On Your Mind With Erin Crown

In this episode of “On Your Mind with Erin Crown,” host Erin Crown, MHS, PA-C, Psych-CAQ, talks with Gus Alva, MD, DFAPA, a California-based psychiatrist and investigational researcher, at a regional psychiatry meeting he created: Jersey City Psychiatry Conference. The conversation is the kind that usually happens in hallways and over dinner, and it covers why clinicians gather, what they gain from one another, and how that exchange ultimately reaches patients.

Asked what is on his mind, Alva describes a sense of excitement about where psychiatry is heading. He sees continuing education as a joy rather than a chore, and he connects it to a principle he applies to clinical care: the guidance clinicians give patients about sleep, nutrition, hydration, and physical and mental activity should apply to clinicians as well.

Crown notes how difficult health care work has become for everyone on the care team, from physicians and nurse practitioners to therapists, case managers, and administrative staff. She says the expectation to keep going persists even as awareness of burnout grows. Alva suggests gratitude as a counterweight. He encourages clinicians to revisit what drew them to the profession and to recognize how much patients in deep suffering can benefit when clinicians come prepared.

The 2 also discuss the role of industry. Alva, who has more than 30 years of experience in clinical research and 13 years in academia, says many groups hold an overly negative view of pharmaceutical sponsors. He points out that industry carries most of the financial risk of drug development, where failed programs are common and costly. Crown adds that conversations with medical science liaisons and peers have made her a more informed prescriber. Both agree that such engagement can be productive without compromising professional or ethical standards.

Crown shares a case that shows why staying informed matters. A new patient told her she had 6 months to help before they would likely attempt suicide. Because she knew esketamine was approaching market, she was able to offer the patient realistic hope until it became available, and the patient eventually remitted.

Alva explains that he started regional meetings to give back after benefiting from mentors himself. He wanted to bring together trusted faculty and focus on practical topics, such as psychedelics, that attendees can act on immediately. Upcoming meetings are planned for South Florida and Southern California.

What psychiatric topic is on your mind? Let us know at [email protected]!

In the second episode of "On Your Mind With Erin Crown," a conversational series from Psychiatric Times built around informal, off-the-cuff conversations among clinicians, host Erin Crown, MHS, PA-C, Psych-CAQ, spoke with Laura Melaro, DNP, APRN, FNP-BC, PMHNP-BC, a psychiatric nurse practitioner who practices integrated psychiatry and primary care in West Tennessee. The discussion centered on the current state of behavioral health integration and what still stands in the way of broader adoption.

Melaro, who became a family nurse practitioner (FNP) in 1988 after growing up in a family of primary care physicians, spent a decade in primary care before moving into community mental health and later earning her doctor of nursing practice (DNP) with psychiatric certification in 2008. She now works at a federally qualified health center (FQHC) that uses a collaborative care model, pairing a behavioral health case manager and primary care team with a psychiatric consultant. She said workforce shortages, not preference, drove that choice: her region has only one university training licensed clinical social workers, and few therapists are willing to work at the pace of primary care.

Both clinicians said cross-training across medicine and psychiatry improves care. Crown, who trained as a PA across the broader medical model, noted that physical conditions are sometimes mistaken for psychiatric symptoms, citing patients presenting with low mood and fatigue who instead have mononucleosis. Malaro said clinicians trained only in psychiatry can struggle to recognize physical illness, a gap she addressed while teaching integrated behavioral health courses at the University of Tennessee, where DNP psychiatric and FNP students worked through shared clinical scenarios.

Melaro also described her years in community mental health, where she continued monitoring patients' physical health, including metabolic effects of second-generation antipsychotics, despite being told to focus solely on psychiatric symptoms. 

"I really want the health of patients with severe mental illness to improve," she said, describing the persistent life-expectancy gap for this population as a personal priority.

Crown's practice takes a different approach, combining psychiatry, primary care, and obesity medicine in one setting. She said the model developed in response to data showing up to 80% of people with severe mental illness lack a primary care provider, along with the transportation and scheduling barriers that keep patients from attending separate appointments.

Asked to describe her ideal integrated care model, Melaro said she wants primary care clinicians to buy into treating behavioral health themselves, or at minimum to maintain active communication with a psychiatric partner rather than treating referrals as a one-way handoff. She emphasized that no single integration model works everywhere, given differences in local workforce and resources, from embedded-therapist models to the case-management approach she uses. "We have to recognize the benefit from it and make it work wherever you are," she said.

Crown closed the conversation by thanking Melaro for her contributions to the psychiatric and primary care community.

Erin Crown, MHS, PA-C, Psych-CAQ, in her first installment of "On Your Mind With Erin Crown," sits down with Psychiatric Times Editor in Chief, John J. Miller, MD. Miller identifies "tribalism in psychiatry" as the main topic on his mind, explaining that it has become a significant issue in various fields, including psychiatry. He compares current tribalism to sports rivalries and how it manifests in psychiatry, and is especially concerned about the increasing division and isolation within the field.

Tribalism can take several forms in psychiatry: including academia vs the pharmaceutical industry, different prescribing subspecialties, and the roles of various health care. Both Crown and Miller advocate for a more integrated and supportive system among all health care professionals to address the epidemic of untreated mental illness.

He believes this tribalism leads to a loss of important information and benefits for patients, colleagues, and the field as a whole. Miller recounts his early experiences with pharmaceutical industry collaborations and how they were integrated into academia and organizations like the National Institute of Mental Health. These collaborations help drive innovation and improve patient care. Both Crown and Miller reinforce the importance of continuous learning and innovation in psychiatry, noting the limited tools available when they started and the advancements made since then.

However, there are increasing administrative burdens for frontline prescribers, which reduce the time available for professional development and collaboration. Staying current with the latest scientific and clinical developments ensure clinicians can provide the best possible care for patients. The fragmentation of the psychiatric field makes this difficult; there is a strong need for better integration and collaboration among different stakeholders, including clinicians, academia, and pharma. 

The psychiatric field needs to work together more cohesively, Miller emphasized, sharing that we need a unified approach among psychiatrists, psychiatric nurse practitioners, and physician assistants to address the mental health crisis effectively. The entire conversation underscores the importance of continuous learning and collaboration in psychiatry.

What psychiatric topic is on your mind? Let us know at [email protected]!