Grady Memorial Hospital

The Department of Psychiatry at Grady Memorial Hospital functions as The Central Fulton Community Mental Health Center, providing mental health care to chronic and severely mentally ill patients in central Fulton County. Additionally, we provide emergency psychiatric services and referrals for patients residing throughout Fulton and Dekalb Counties in our role as the psychiatry department of Grady Memorial Hospital, which provides medical services to the bi-county area, as well as surrounding parts of the State of Georgia.

There are approximately thirty full time Emory faculty and one Morehouse School of Medicine full time equivalent to oversee the work of approximately thirty residents, several psychology predoctoral interns and postdoctoral fellows, medical students, social work students and various other trainees. The service is approximately 85% outpatient and community outreach services. We provide 40 inpatients beds made up of 24 regular beds with an average length stay of three to four weeks, 8 temporary observation beds with the length of stay of 23 hours or less, and 8 crisis and stabilization beds with an average length of stay of five days. The service is among the most comprehensive community mental health programs in the country, providing adult, adolescent and children services in a large number of venues. The department is an integral part of the State of Georgia mental health system, functions as the psychiatry department of a large community general hospital, and is integral to the Department of Psychiatry and Behavioral Sciences of the Emory University School of Medicine. It provides approximately 65% of all psychiatric residency training for the department and additionally is a major training site for the Morehouse School of Medicine Psychiatry training program.

The Grady department has service contracts with the Atlanta School System through its MERIT and Adolescent Substance Abuse Programs, the City Jail through its jail diversion program, a part of the Psychiatry and Law Service, as well as training associations with Georgia State University, Emory University and the University of Georgia for the training of psychologists, and several other universities whose trainees participate in our programs.

Our Inpatient Service, directed by Andrew Furman, MD, Assistant Professor, consists of a 24 bed inpatient unit staffed by two full time attendings, a part time psychologist, Nadine Kaslow, PhD, four 1st year psychiatric residents and a 4th year chief resident in psychiatry who directs the day to day clinical activities of the unit. Each resident carries approximately six patients on the unit, four residents being on service at any one time. Additionally there are one psychology intern, one psychology postdoctoral fellow, many medical students and other trainees. Preference for admission to this unit is given to patients experiencing first psychotic episodes, patients with complex medical problems in addition to psychiatric problems that are beyond the capabilities of other parts of the state mental health system, patients followed in our outpatient clinics and research subjects in our many ongoing studies. The patients are treated with multiple modalities, almost invariably including psychopharmacologic agents, individual and group psychotherapeutic efforts, as well as family treatment whenever possible.

The service also runs an 8-bed crisis and stabilization unit, treating severely and chronically mental ill patients known to our system who have become destabilized and who need reintegration into our ambulatory programs as well as immediate treatment.

The service runs the only 24-hour Psychiatric Emergency Service in the region. This is a full service psychiatric emergency program separated in space and structure from the hospital emergency service. It is staffed by full time faculty, 1st year, 3rd year and 4th year psychiatric residents, psychology trainees and a large number of mid level providers. It is directed by Barbara D’Orio, MD, Assistant Professor, and is intimately integrated with our 8-bed temporary Observation Unit and the Crisis Stabilization Unit, which are immediately adjacent to it. The emergency room sees approximately1430 patients per month.

The department maintains a Consultation and Liaison Service led by Charles Raison, MD, Assistant Professor. This service provides acute consultation throughout the hospital as well as specialty liaison services to many parts of the Grady Health System. Perhaps the largest is our Infectious Disease Program Mental Health Service, which is staffed by psychiatrists and psychologists and various trainees. This service has approximately 1000 patients enrolled in the program and averages 420 visits per month and provides acute evaluation and short term ongoing treatment to patients with emotional difficulties associated with HIV disease. The Consultation Service in the hospital sees 100 patients per month. It is staffed by two full time equivalents, three PGY-II residents, and often a PGY-IV resident on an elective basis.

By far the largest of our services is the Adult Ambulatory Service. This is comprised of many subservices to be described below. The Central Program is our Adult Ambulatory Outpatient Program housed in Florida Hall, immediately adjacent to the general hospital. This service is run by Palitha Vidaganama, MD, Assistant Professor and staffed by three additional full time equivalent faculty. It sees 1630 patients per month. These are primarily chronically and severally mentally ill patients who are seen for thirty-minute ongoing appointments for medication management, supportive psychotherapy and other managerial interventions. This program is the primary training site for PGY-III psychiatric residents as well as many other trainees. Associated with this program is our Evaluation and Brief Treatment Program, which provides more intensive evaluation and ten-session brief treatment for patients in the ambulatory division who are then followed in a less intensive manner in our general outpatient program. This program is headed by Jennifer Wootten, MD and Keith Wood, PhD, both Assistant Professors, and described in more detail below. The department maintains two Day Treatment programs, one a psychosocial rehabilitation program directed by Katharine Porter, MD, Assistant Professor, which follows severely ill patients, often for years, in a rehabilitative mode, both psychiatric and vocational. On average 80 to 100 patients per month attend this program four to five days per week. A sub-program has been developed in the past two years, our Focus Program, a more acute and intensive day treatment program directed by Karen Hochman, MD, Assistant Professor, which follows 15 to 20 patients who stay for three weeks. This treatment program deals with both psychotic level illnesses and associated substance abuse. This program serves as a training site for 4th year residents on elective as well as for medical students, psychology postdoctoral trainees and other students.

The department has extensive community outreach programs directed by Rosalind Mance, MD, Associate Professor. We provide psychiatric services to homeless shelters, supportive living facilities, geriatric living facilities, and other community based programs serving patients who are unable or unwilling to come to Grady Memorial Hospital on a regular basis for mental health care. All PGY-III residents rotate through this service and many 4th year residents take electives in various clinical venues that are part of our outreach services.

The department provides adult opiate substitution (methadone) service as part of the Central Fulton Community Mental Health Center. The Drug Dependency Unit is directed by Neil Johnston, MD, of the Morehouse School of Medicine and serves approximately 200 individuals per year. Morehouse School of Medicine also provides a part-time faculty member who supervises two residents in addition to providing individual psychotherapy and medication management services to consumers. Plans to include the addition of an Addiction Psychiatry Fellowship program beginning in July of 2002 are in place, and renovation of a building adjacent to the Outpatient program that will continue to provide methadone services to this expanding population is also likely.

The department has a comprehensive Child and Adolescent Program overseen by Sandra Sexson, MD, Associate Professor and Interim Chief of Child and Adolescent Psychiatry at Grady. The central parts of this program are the Child and Adolescent Ambulatory Clinic, directed by Arden Dingle, MD, Associate Professor, our Child and Adolescent Consultation Services headed by Arden Dingle, MD, our Adolescent Merit Program providing services within the school system to severally mental ill children and our Adolescent Substance Abuse Program associated with the Merit Program, both directed by John Griffin, MD, Professor. These programs provide training for child residents, adult residents on elective, psychology pre and postdoctoral trainees and other interested students. A comprehensive description of these Child and Adolescent services are described in detail later in this section.

The department includes the Psychiatry and Law Service, directed by Peter Ash, MD, Associate Professor. This program has two full time equivalent faculty members, one or two psychiatric forensic fellows per year as well as other trainees in psychology and other disciplines. It provides services to courts, to the jail system, to the state mental health system and to other community agencies.

Evaluation and Brief Treatment Service

The Evaluation and Brief Treatment Service was created to provide a thorough evaluation of new adult patients to the Grady Psychiatry Service and offer brief treatment if appropriate. The service receives referral from the psychiatric emergency service, stress management service, Diabetes clinic, and from child psychiatry for the parents of patients. Patients that benefit most from the service are new patients to the Grady system, requiring outpatient evaluation of their illness. The evaluation takes place over 2-3 sessions and a determination for brief treatment is made at the end of this time. Brief treatment lasts from 8-10 sessions.

This service offers a rapid turn around time as new patient appointments are available within the week of their initial contact psychiatric emergency services. Patients are then evaluated and offered a plan for treatment that may include brief treatment, outpatient medication management at the local mental health center, psychotherapy, day treatment, intensive outpatient (FOCUS), or no further treatment. Generally patients fall in the depressive disorders spectrum of diagnosis although character pathology and some psychotic disorders are represented as well.

The service is staffed by the PGY-3 residents on their outpatient rotation, a clinical nurse specialist, a postdoctoral fellow in psychology, a psychology intern, and a medical director. Due to limited staff, the service is not currently available to all new patients at Grady, but that is a goal for a more integrated intake system.

Child and Adolescent Psychiatry Clinical Programs

The child and adolescent psychiatry service provides psychiatric services to children, adolescents, and families in its clinic, in other areas of the hospital, and in the community. The past 5 years has seen a marked expansion of services both on-site and in the community. Services include evaluations, psychotherapy (individual, group, family), medication management, classroom observation, parenting groups, classes for staff, a family evaluation clinic, psychological testing, milieu activities, and liaison with other agencies (school, pediatrics, child protective services, juvenile justice). Community services include on-site consultation and treatment at City of Atlanta Schools, Fulton County Juvenile Court, and after-school programs as well as two programs based at a City of Atlanta High School: an adolescent day treatment program (MERIT) and an adolescent substance abuse program (DATE). Services are provided both by individual providers as well as teams (family evaluation clinic, outpatient evaluations, school services, and some pediatric clinics). The service also participates in a number of liaison activities with pediatrics (grand rounds, abuse team), the City of Atlanta schools, Fulton County, Fulton County Juvenile Justice and Fulton County Department of Family and Children Services. Additionally, the service is a primary training site for a variety of trainees and has several clinical research projects. Clinical services include:

The Child and Adolescent Psychiatry Consultation Service
This program provides psychiatric evaluations, triage, crisis intervention, behavioral management, supportive psychotherapy, and psychopharmacological consultations within the Grady Health System for children, adolescents and their families. Additionally education and liaison services to the medical and nursing staff is an integral part of the program. Approximately 40 patients are seen monthly. Consultations are provided at Grady Hospital (General Psychiatry Emergency Room, Burn Unit, Medical and Surgical Units) and Hughes Spalding Children’s Hospital (the children’s hospital of Grady Health Systems). At the Children’s Hospital, consultations come from the general pediatrics inpatient service, the pediatric emergency room, and the medical specialty clinics (i.e. asthma clinic, sickle cell clinic, adolescent clinic, etc.). The Emory Child and Adolescent Psychiatry Call Service (child and adolescent psychiatry residents and attendings) provide evening and week-end back-up call to both the Grady Psychiatric Emergency Room and the Hughes Spalding Pediatric Emergency Room.

Specific specialty programs include:

1. Regional Burn Unit Consultation Service -- Automatic consults occur on all children and adolescents admitted to this unit. Consultation and liaison efforts work continually to address the medical (pain management), the psychological issues (coping with severe burns), and the social issues (support for families, assessment of potential abuse, etc.).

2. Specialty and Satellite Clinic Services -- Another specialty program links specific clinicians with pediatric specialty clinics (i.e. asthma, endocrine, adolescent) to provide continuity of service to the children and families served in these clinics. Issues related to psychological influences on the medical illness, medical contributions to psychological problems and compliance with medical treatment are commonly addressed in these clinics.

3. Hospital Child Abuse Team - The C/L service participates actively as the mental health representative to the multidisciplinary team that reviews all cases of abuse seen within the hospital system. Assessment, disposition, and longer term treatment planning may be a part of this service.

4. Sickle Cell Pediatric Mental Health Services - Georgia Comprehensive Sickle Cell Center. This program is responsible for the provision of psychological services for pediatric patients diagnosed with sickle cell disease and their families. Specific services provided include psychological assessment, individual and family psychotherapeutic services, and outpatient and inpatient psychiatric consultations. Approximately 50-60 new evaluations are done annually, 10-20 families are receiving ongoing psychotherapy services at any one time, and approximately 10 inpatients consultations are done monthly. In the fall of 1998 a new psychoeducation and support group for adolescents with sickle cell disease was initiated. A number of research and training programs are integral to this clinical service.

5. Pediatric/Adolescent Infectious Disease Program (IDP) - Mental Health Program. This service provides psychological evaluation, intervention, and psychological testing to children, adolescents, and families living with HIV disease. Therapeutic modalities include individual, family, and group therapies. HIV-infected children receive annual psychological assessments. The program provides early intervention/school liaison and advocacy services as well as consultation to the multidisciplinary team of health care providers. Over 400 families are followed in the clinic, with approximately 150 children and 50 adolescents being HIV infected. Mental health is well integrated into the comprehensive services children and families receive at the Pediatric IDP. A number of research and training programs are integral to this clinical service.

Child and Adolescent Psychiatry Outpatient Clinic

The Child and Adolescent Outpatient Clinic (CAPOC) serves as the child psychiatry outpatient component for Grady Health Systems as well as a community mental health center (part of the county/state system) for Fulton County. Clinical services are provided on-site using a typical outpatient clinic model, providing comprehensive evaluation and treatment of children and adolescents with a variety of emotional and behavioral disorders. Although psychopharmacology, behavioral interventions, and supportive psychotherapy are the predominant treatment modalities, individual, family and group therapies, case management and parenting classes are also available. Specific programs that have been developed over the past five years include the following:

1. The Family Evaluation Clinic -- a multidisciplinary team lead by Marianne Celano, Ph.D. that assesses a family in an extended evaluation. This Clinic provides training in family assessment for child and adolescent and general psychiatry residents and psychology interns, post-docs and practicum students.

2. Trauma Program - Although children who have been traumatized by rape or sexual abuse have always been evaluated and treated at CAPOC, under the leadership of Shannon Croft, M.D. a reorganization of these services focusing evaluation, treatment and training more specifically for these children, adolescents and their families has been accomplished. Currently a team consisting of an attending child and adolescent psychiatrist, two social workers and a general psychiatry resident evaluates these cases with both FEC and more typical techniques. Plans to include other Grady professionals involved in the treatment of sexually abused children and research on trauma will be implemented in the near future. The planned research components will be coordinated with a similar program at Georgia State. Attempts to establish liaison programs with City of Atlanta Police Department, Department of Family and Children’s Services (Child Protection Agency) and other existing agencies are in progress.

3. Parent/Child Group Intervention Program - During the past year Drs. Croft and Dingle along with CAPOC social workers have developed a group intervention program for parents and children. Medical students and general psychiatry residents participate in the actual interventions. These paired groups were established to address the growing number of parents who are struggling to manage their children who have emotional and behavioral problems often in the context of developmental delays. After reviewing the failures of previous group treatments in the Clinic, the team decided to emphasize the supportive elements of group therapy, facilitating discussion, group member support and providing incidental parent education. A concomitant child group teaches social skills, uses behavioral techniques for behavioral disturbances, and provides an opportunity for direct observation of peer interactions for diagnosis and treatment of these children who may be receiving individual services within the Clinic. Children are age 4 through 11 with diagnoses of MR, ADHD, ODD and depression. Twelve children and their families participate in this program at any one time.

An additional program under development is a sexual offender program.

Grady CAPOC provides community services including membership on a number of community agency committees and boards that influence greatly the mental health delivery for children and adolescents in both Fulton and DeKalb counties as well as the state of Georgia.

COMMUNITY BASED SERVICES

The MERIT/DATE Program is a combination of two programs. The MERIT Program (Meaningful Education through Responsive Integrative Treatment) is a joint venture between Atlanta Public Schools, Grady Health System, and the Fulton County Regional Board. Since 1978 MERIT has provided services to adolescents with moderate to severe mental health problems including psychotic illnesses but excluding severe conduct disorders. Although this program is located in Washington High School, an historic central city Atlanta high school near the main campuses of the five predominantly African American colleges, students from any City of Atlanta high school may qualify for services in this program. Typically 16-18 students are served at one time. Students remain in the program until graduation from high school or until their mental health problems resolve sufficiently to allow return to mainstream or other special education classes. Space issues are problematic for both of these programs and new space is being sought.

The DATE (Drug Abuse Treatment and Education) Program was established in 1998 to help meet the substance abuse needs of inner city adolescents in Atlanta. The program uses the same space as the MERIT program after the MERIT school day ends. The after school programming runs weekly Monday through Friday. It provides intensive outpatient services with students attending five times each week until their progress warrants less frequent visits. Progress is monitored by objective measurements including school attendance, legal difficulties, and onsite drug testing. Treatment modalities include the Twelve Steps Program as modified for adolescents, group therapy, family therapy, recreational therapy and individual therapy. Approximately 14-18 students attend each afternoon. Because of the utilization of the MERIT space, the funding can be used primarily for staffing and programmatic expenses. The following is the text of the brocure that we distribute concerning the DATE program:

Drug and Alcohol Treatment and Education (DATE) - a 5-day after-school intensive outpatient program for high school-aged adolescents with substance use problems (located on a high school campus).
MERIT'S DATE program is a substance use intervention service which aids the development of high school aged teenagers who are at high risk for, or who are currently experiencing substance use problems. Such problems frequently interfere with academic, personal, and social functioning. Services are provided at Booker T. Washington High School through a cooperative agreement between Atlanta Public Schools and Central Fulton Community Mental Health Center at Grady Health System.
PHILOSOPHY
DATE counselors view adolescent substance use, abuse, and chemical dependency as a progressive individual and family problem, which interferes with healthy development. DATE interventions integrate the unique developmental needs of the adolescent, the needs of the family, and the changes that must take place to move from a dysfunctional to a functional, healthy lifestyle. Confidentiality of participants and records is assured.

PROGRAM
DATE participation involves meeting several times a week. Interventions include:
- intensive group counseling - parent groups - drug screens
- individual counseling - multi-family groups - psychological evaluations
- fancily counseling & education - recreational activities - medical evaluations
- education & relapse prevention - 12-step meeting participation

STAFF
DATE program staff include substance abuse and social counselors, a recreational therapist, a registered nurse, a clinical psychologist, a psychiatrist, and an administrator.

REFERRALS
The DATE program welcomes referral from students (self-referrals), parents and guardians, school personnel, and other community agency personnel.

Over the past five years subsequent to Dr. Sexson’s negotiation of a Medicaid waiver that facilitates service delivery off-site along with Dr. Dingle’s and Ms. Simmons’ aggressive seeking of resources from the Fulton County Community Service Board, community outreach programs and services have rapidly expanded. Additional staff positions funded by these resources include five social work positions and two part-time child and adolescent psychiatrists.

Additional programs include:

1. School Consultation Programs and School-Based Clinics -- Facilitated by the Medicaid waiver and support from the Fulton County Regional Board a school outreach program has been established that provides both traditional school consultation services to the school administrators and teachers and additionally offers onsite clinic services to students and their families. A team of mental health professionals including a child psychiatrist, a psychiatric social worker and trainees (both general and child psychiatry residents) provide evaluations, ongoing therapy, group therapies, classroom observations, teacher education and teacher consultation/liaison on a weekly basis. The program started in 1995, in three City of Atlanta elementary schools and has now expanded into 13 public, urban elementary schools and one alternative middle school and one middle school. Requests for services to other schools has created a waiting list limited by staffing and funding availability. In the fall, 1999, the service expanded into the preschool arena with the implementation of the services in a local Headstart program. In the 1999-2000 school year the number of visits for children and families in these programs was 1922.

2. Juvenile Justice Consultation Clinic/Service - Facilitated by a grant from the Fulton County Regional Board, services are now being provided to the juvenile justice system in a similar team format as that used in the school-based programs - psychiatric social worker, child and adolescent psychiatrist, and general and child and adolescent psychiatry trainees. Clinical services include evaluations, triage and consultation. Services are provided to approximately 3 - 5 juveniles weekly.

3. CHAMPS - CHAMPS is a partnership of community agencies serving children/adolescents and families in Fulton County. The partnership offers a continuum of services including behavior aids, case management, mental health evaluations and treatment, weekend respite care, therapeutic foster care and therapeutic group home care, and a therapeutic after school program. The newest additions to these services are the Mental Health Crisis Respite beds funded through the Regional Board and provided through a partnership of three CHAMPS agencies – Grady Child and Adolescent Psychiatry, Creative Communities Foster Care and Georgia Parent Support Network. Services offered are respite care for up to two weeks in a therapeutic foster home for children seen in the Grady Psychiatric Emergency Room who do not need immediate hospitalization but do need out-patient mental health treatment and temporary care while plans are developed for the child. Families of children seen in the ER who return home are contacted and visited by a social worker/case manager who coordinates resources present in the community and facilitates linkage of the family with these resources. This program began in May 2001 and has served 16 children for the two-week respite thus far.
4. A program with child protective services (DFACS-Department of Family and Children’s Services) has been negotiated and will begin as soon as an additional therapist is recruited and DFACS completes their current reorganization. This program aids adolescents in long term foster care.

Overall, the Grady Child and Adolescent Outpatient Services logged almost 6700 visits during 2000, demonstrating an annual increase for each of the past 5 years with a projected increase for the year 2001.