Department of Psychiatry Newsletter, Summer 2025

DEPARTMENT

PSYCHIATRY

EMBEDDING MENTAL HEALTH

CARE WHERE IT’S NEEDED MOST

Many people with chronic gastrointestinal (GI) diseases suffer in silence.

“GI conditions are often stigmatized” in a way that other conditions may not be, says clinical psychologist and researcher Jessiy Salwen-Deremer, PhD, director of behavioral medicine at the Walter and Carole Young Center for Digestive Health at Dartmouth Health’s Dartmouth Hitchcock Medical Center (DHMC). “It’s socially appropriate for someone with insomnia to say, ‘I’m exhausted because I didn’t sleep well,’ but with GI, it’s not the same. People don’t say, ‘I’m exhausted because I got up six times with diarrhea last night.’”

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Our department is energized by the muchneeded attention given to this health crisis, and we’re using our strengths to catalyze change in many ways.

Until recently, Dartmouth’s motto, “a voice crying in the wilderness,” resonated with those of us working to increase timely access to quality psychiatric care—society as a whole had not yet turned toward psychiatric disorders with a seriousness of purpose and intensity proportional to the suffering they cause. However, attitudes are shifting and people are discussing mental health more openly.

Our department is energized by the much-needed attention given to this health crisis, and we’re using our strengths to catalyze change in many ways.

First, we’re expanding inpatient treatment capacity with new child and adolescent beds at Dartmouth Hitchcock Medical Center, a wing for crisis care in the emergency department, and five new involuntary adult beds. We’re partnering with other departments to embed psychiatric resources in settings where people are already seeking care. We also extended our longstanding partnership with New Hampshire Health and Human Services to lease Hampstead Hospital, the state’s only child and adolescent psychiatric hospital.

We’re also tackling the workforce shortage, which limits care availability. Using our deep well of experience, we’re now training psychiatric nurse practitioners and licensed independent clinical social workers.

Finally, we’re committed to advancing psychiatric research to improve the care we provide. Among many scientific endeavors, we’re studying ways to enhance care with technology, and we’re exploring the underlying causes of these sometimesdevastating illnesses.

These efforts require time, energy, and money. We’re grateful for the generosity of donors who help us shape the future of psychiatry. This newsletter provides a glimpse of where we’re headed. We invite you to join us.

William C. Torrey, MD, D ’80, RES ’85-89

Chair,

Department of Psychiatry

Raymond Sobel Professor of Psychiatry

Geisel School of Medicine at Dartmouth and Dartmouth Health

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Embedding Mental Health Care

But in Salwen-Deremer’s gut-directed group hypnotherapy sessions, it is not only appropriate but encouraged to share those details because the patients understand one another’s struggles.

“For some folks, they have never talked about their symptoms before, but in this group, everyone gets it.”

She and her team developed these and other disease- and symptom-specific treatment sessions as part of a complete redesign of the Gastrointestinal Behavioral Health Program she leads at Dartmouth Health, supported by a one-year, $300,000 award from the Susan and Richard Levy Health Care Delivery Incubator in 2022 and a philanthropic gift from a grateful patient.

The redesigned GI behavioral health program is just one of many initiatives across Dartmouth Health to increase access to highquality mental health care for adult and pediatric patients. There are now psychiatrists, psychologists, behavioral health clinicians, advanced practice registered nurses, trainees, and other mental health providers embedded within 13 different services across Dartmouth Health, including primary care, pediatric sleep medicine, the cancer center, and women’s health, among others.

“When you refer a patient to general psychiatry, they don’t know who they’re going to see, and some patients never come,” says Christine Finn, MD, medical director and vice chair for clinical services in the Department of Psychiatry at Dartmouth Health and an associate professor of psychiatry at the Geisel School of Medicine at Dartmouth. “But when we’re part of the primary care team [for example], it gives us a different relationship with the patient. Their primary care doctor can say, ‘I want you to see Dr. Finn; her office is just down the hall.’ That’s reassuring to the patient.”

From primary care to specialty care

Psychiatric clinicians were first embedded into primary care settings when Finn helped establish a collaborative care model in 2009. Its success in primary care led Finn and others to use the model to embed psychiatric care into subspecialty settings, too. Not only does embedded care within host departments increase access to psychiatric care, but it also increases patients’ willingness to engage with their medical care. For example, if anxiety or pain is interfering with a patient’s medication adherence, a disease-specific behavioral health clinician can help manage those issues.

“We do targeted work, helping to treat the primary medical condition by treating the behavioral health factors influencing

When we’re part of the primary care team, it gives us a different relationship with the patient.

Christine Finn, MD Medical Director and Vice Chair for Clinical Services and For Education in the Department of Psychiatry at Dartmouth Health and an Associate Professor of Psychiatry at the Geisel School of Medicine at Dartmouth

Think about GI disease as an octopus: The disease is the head with the main symptoms, but the tentacles reach into and get stuck on so many other areas of your life.

Jessiy

Director

Salwen-Deremer,

PhD

of Behavioral Medicine at the Walter and Carole Young Center for Digestive Health at Dartmouth Hitchcock Medical Center, and Assistant Professor of Psychiatry and of Medicine at Geisel School of Medicine at Dartmouth

the patient’s ability to participate in their care,” says Sivan Rotenberg, PhD, assistant professor of psychiatry at Geisel, clinical health psychologist at Dartmouth Cancer Center, and director of the specialty side of embedded care in the Department of Psychiatry. “Taking your medications, improving your diet, whatever the component is—that’s all health behavior change. Our team addresses those factors so the patient can be part of their own care.”

Embedded care also creates more touchpoints between patients and providers so that no one falls through the cracks. If a medical specialist or primary care physician prescribes an antidepressant, for example, the doctor might not see the patient again for three months. But if the patient has a bad side effect and quits taking the medication, “it’s better to know they stopped taking it after two weeks rather than three months later,” Finn says. A mental health care clinician embedded within a specific department can check up on the patient in the meantime and “can give redirection if we know what’s going on. With more information, we can incorporate that into the patient’s treatment plan.”

Specialized care to treat the whole person

Ultra-specialized clinical providers like Salwen-Deremer, who focuses specifically on behavioral health care for people with inflammatory bowel disease, are still rare. But programs like hers have made it easier to serve more patients using streamlined processes, group therapy approaches, and new patient-provider communication tools.

For example, the redesigned GI behavioral health program offers a host of virtual small-group classes where patients meet with Salwen-Deremer or another clinician for behavioral health therapy to address a variety of GIspecific problems. These sessions offer patients a range of treatments for the disease symptoms themselves and the additional challenges that stem from them. Patients can access therapy to manage chronic pain associated with GI symptoms, develop a personal plan to manage food avoidance, and learn cognitive-behavioral techniques to manage stress and anxiety, among other offerings.

“Think about GI disease as an octopus: The disease is the head with the main symptoms, but the tentacles reach into and get stuck on so many other areas of your life,” says SalwenDeremer, who is also an assistant professor of psychiatry and of medicine at Geisel. “The relationship between the GI disease and mental health then goes both ways. For example, depression and stress are pro-inflammatory, so we look at those as both outcomes of the disease, and also contributors to the symptoms and disease experience.”

And because the redesign of the GI behavioral health program allows Salwen-Deremer and her team to provide therapy to approximately five to 10 people at a time, the group treatment sessions have dramatically reduced delays for GI patients seeking mental and behavioral health care, shortening a months-long wait to just a few weeks. The group sessions have resulted in an uptick of more than 90% in the number of appointments per year and a more than 70% increase in individual patients treated per year.

“It’s not that we could see more patients because people were getting less treatment, but instead people are actually getting more treatment with this new model,” SalwenDeremer says. “We’re increasingly learning that people with chronic conditions have a better quality of life when they get complex, multidisciplinary care. It makes sense to care for patients this way.”

Psychiatric Care is Now Embedded In...

• Dartmouth Cancer Center

• Walter and Carole Young Center for Digestive Health

• Sleep Disorders Center

• Center for Pain and Spine

• Infectious Disease and International Health

- HIV Program

• Pediatric Endocrinology

• Pediatric Gastroenterology

• Neurology

• Bariatric Surgery Program

• Obstetrics and Gynecology

• Dermatology

• Interdisciplinary Child Development Program

• Primary Care

We do targeted work, helping to treat the primary medical condition by treating the behavioral health factors influencing the patient’s ability to participate in their care.

Sivan Rotenberg, PhD

Clinical Health Psychologist at Dartmouth Cancer Center, Director of the specialty side of embedded care in the Department of Psychiatry at Dartmouth Hitchcock Medical Center, and Assistant Professor of Psychiatry at Geisel

Closing the Gap

Dartmouth Health training empowers master’s-educated clinicians to tackle mental health care workforce shortage

When Deb Fournier, MHCDS, MSN, APRN, PMHNPBC, ANP-BC, the lead advanced practice provider (APP) for the Department of Psychiatry, was looking to hire additional psychiatric-mental health nurse practitioners (PMHNPs) to care for Dartmouth Health (DH) patients, she found very few whose training met her high standards. She decided to find out why.

“Students in most PMHNP programs have to find their own clinical rotations” to complete their master’s degree, says Fournier, who is now the chief APP officer for Dartmouth Health. “The quality of those training experiences is highly variable, and many students are then not prepared to successfully transition to clinical practice when they graduate.”

So Fournier and her colleague, Laura Kelliher, MPP, MSN, APRN, CPNP-PC, PMHNP-BC, decided to develop a focused program for PMHNP clinical training within the Department of Psychiatry. Although Geisel doesn’t have PMHNP or master’s in social work (MSW) degree programs, DH has offered clinical hours for these master’sprepared students from other institutions in the past in an ad hoc fashion. But now, these clinical experiences are offered as formal educational programs for PMHNP students, pre-licensure MSW students, and post-master’s social workers seeking licensed independent clinical social worker (LICSW) credentials.

Fournier’s hiring standards for PMHNP practitioners are being fully satisfied by students completing the program.

“Of the last eight open positions, we’ve filled six with our own trainees,” Fournier says. And “since we design their experience and support our preceptors, they receive high-quality training.” Hiring these trainees has also decreased onboarding time, getting new clinicians into action faster.

These programs not only expand the qualified mental health care workforce in northern New England, but they also help to alleviate the national shortage of mental health care clinicians. Healthcare systems across the country are working to hire more providers, including PMHNPs and LICSWs, to meet the increasing demand for mental health care services. Although the skills these master’s-prepared clinicians have learned are different from medically trained psychiatrists and doctoral-trained psychologists, these providers are qualified to offer many kinds of mental health treatment and, in turn, reduce the long waiting lists for people in need of care.

Seeing a need, meeting a need

DH has long been helping to mitigate the gaps in clinical training for PMHNPs, MSW students, and LICSWs by providing proactive students and trainees with high-quality clinical experience. But the hospital system had no formal programs.

“Students can get their master’s degree online from a school anywhere in the country, but those schools don’t always arrange clinical exposure for them. So, students sometimes reach out to us to ask for clinical hours,” says Julia Frew, MD, MED ’05, RES ’10, the vice chair of psychiatry education in the Department of Psychiatry and an associate professor of psychiatry, of obstetrics and gynecology, and of medical education at Geisel. After years of providing clinical experience for these students on a case-by-case basis, “we asked ourselves: ‘How can we use what we’ve learned about education and clinical training for medical students and residents, and apply that to train other professionals?’”

The Department of Psychiatry launched its formal PMHNP training program in 2020, creating an avenue for interested learners to complete an application and go through an interview process— similar to what potential physician residents would do for clinical training. Accepted students progress through their rotations under the supervision of PMHNPs in the department. In fact, every PMHNP employed at DH who is eligible to serve as a clinical educator or preceptor is now engaged in teaching students, increasing DH’s capacity to provide these clinical experiences.

“We quadrupled our capacity to accept students” since formally launching the program, Fournier says.

In 2022, the clinical training program expanded to include MSW and LICSW students. In addition to training learners from other institutions, DH also offers training for its own non-clinical social workers who want to earn a clinical license. These DH employees can enter the post-master’s program, in which trainees practice one-on-one therapeutic interventions with patients. Together, these new clinical training programs are expanding the psychiatry department’s capacity to treat patients—even before the learners have completed their program.

“If a patient comes in with depression, a [post-master’s] clinical trainee can provide 15 sessions of cognitive behavioral therapy, which is the same treatment they might receive at a community mental health center,” explains Lucy Pilcher, LICSW, director of education for social work and mental health and a psychiatry instructor at Geisel. She helped establish the training programs for MSW students and LICSWs.

Promoting interprofessional collaboration

Now that the programs are formalized at DH, MSW students, LICSW candidates, and PMHNP trainees practice clinical skills at Dartmouth Hitchcock Medical Center (DHMC) and several associated clinics. The nurse practitioners can also train at New Hampshire Hospital, where the psychiatry department recently opened a collaborative space called the Lori Shibinette Interprofessional Education (LIFE) Center, named after a former New Hampshire Hospital CEO in honor of her commitment to behavioral health workforce training.

We asked ourselves:

‘How can we use what we’ve learned about education and clinical training for medical students and residents, and apply that to train other professionals?’

Julia Frew, MD, MED ’05, RES ’10 Vice Chair of Psychiatry Education in the Department of Psychiatry, and Associate Professor of Psychiatry, of Obstetrics and Gynecology, and of Medical Education at the Geisel School of Medicine at Dartmouth

All graduate-level trainees—PMHNP students, psychiatric residents, and others—learn and work together in the LIFE Center.

“Interprofessional practice means [different clinicians] understand each other’s models and ways of talking about problem-solving,” says Jeff Fetter, MD, chief medical officer at New Hampshire Hospital and assistant professor of psychiatry at Geisel. “You not only avoid misunderstandings, but you also are leveraging each other’s strengths. When we put our heads together, we’re more than the sum of the parts.”

Frew adds, “In the real world, all the care we provide takes place in teams, so it’s really important to learn what the different roles are and their training background. Getting to know one another during training will set the students up to work well in teams, wherever they end up.”

Gift supports research on neuroimmune psychiatric disorders

At age 19, Alexandra “Alex” Manfull developed a strep throat infection. She then suddenly developed signs of mild obsessive-compulsive disorder and other neuropsychiatric symptoms—anxiety, weight loss, and sleep difficulties—which she and her family attributed to the pressures of college life and being a full-time athlete.

Over the next several years, Alex and her parents searched for a doctor who could help her. Unfortunately, the help Alex needed came too late to save her life.

“Most doctors aren’t familiar with neuropsychiatric disorders triggered by infections, inflammation in the brain, and dysregulation of the immune system,” says Susan Manfull, Alex’s mother. “No physician asked the right question about the source of her symptoms: ‘Have you had an infection recently?’”

As executive director and co-founder of The Alex Manfull Fund, Manfull is now dedicated to supporting research and education into the potential medical causes of neuroimmune psychiatric disorders.

Manfull’s foundation has made a $225,000 commitment to establish The Alex Manfull Neuroimmune Psychiatry Program Fund at Dartmouth Hitchcock Medical Center (DHMC), which supports three years of funding for an education and research coordinator job in the Department of Psychiatry. The position is responsible for facilitating faculty, residents, medical students, and other learners participating in research in the Neuroimmune Psychiatric Disorders (NIPD) program, led by Juliette Madan, MD, MS, MED ’00, professor of psychiatry, of pediatrics, and of epidemiology at the Geisel School of Medicine at Dartmouth.

In the NIPD, a translational research-based clinic, Madan studies PANDAS (pediatric acuteonset neuropsychiatric disorders associated with streptococcus) and the broader category of PANS (pediatric acute-onset neuropsychiatric syndrome), which is linked to infections such as flu or COVID-19. Although PANS and PANDAS are most commonly diagnosed in children, Madan says young adults like Alex Manfull, who died at age 26, can also develop these conditions, making them an important group to study and care for as well.

“The Manfulls are funding this position so we can have a fellowship to train more experts to diagnose and treat children and young adults who may have neuroimmune psychiatric conditions,” Madan says. “We need more physicians trained to evaluate and treat patients quickly and correctly.”

Manfull is eager to contribute to research that will help others who develop these conditions. “We feel privileged to work with this top-notch group; they’re going to make a difference,” she says. “Our vision is to have no more deaths due to PANDAS and PANS—and no more years wasted looking for a diagnosis and treatment.”

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