Palo Alto VA Psychiatry
Clinics and Services
Inpatient Psychiatry Wards and Services
The Palo Alto Health Care System is one of the largest and most complex VA facilities in the nation, providing high quality, compassionate healthcare to a large service area containing more than 540,000 veterans. Department of Veterans Affairs Palo Alto Health Care System (VAPAHCS) is a three-campus facility with several additional clinics. The main campus is approximately four miles southeast of Stanford University in Palo Alto. A second campus is three miles away in Menlo Park. The third campus is 40 miles away in Livermore. VAPAHCS also operates a full-service outpatient Clinic 25 miles to the south in San Jose and a primary care-limited subspecialty clinic and a drug and alcohol rehabilitation unit 90 miles south at Ford Ord on the Monterey peninsula. New access points are scheduled to open in Modesto and Stockton in 1997. VAPAHCS operates a total of 1,020 beds, including 205 medical-surgical beds at Palo Alto, 145 psychiatry beds at Palo Alto and Menlo Park, a 100-bed homeless domicilary at Menlo Park, and 379 nursing home beds at Livermore and Menlo Park. VAPAHCS is home to a variety of special regional treatment centers, including a Spinal Cord Injury Center; a Comprehensive Rehabilitation Center; a Traumatic Brain Injury Center; the Western Blind Rehabilitation Center; a Geriatric Research, Educational and Clinical Center; a Homeless Veteran Rehabilitation Program; and the National Center for Post Traumatic Stress Disorder (PTSD). Many of these programs are active teaching sites for Stanford students, housestaff and fellows. In all, VAPAHCS has more than 3,500 employees and has an annual budget in excess of $280 million.
Each psychiatry intern can expect to spend the majority of their year at the Palo Alto VA. There are four acute psychiatry wards at the Palo Alto VA main campus. Each ward holds a maximum of 20 patients, for a total possible inpatient census of 80 patients, plus four overflow beds. Also there are 20 acute-geropsychiatry beds at the Menlo Park VA which we admit to. While interns are only assigned to wards 5C4 or 4B2, you will need to interact and admit to all psychiatry wards and interact with most services at the hospital. Below you will find a summary of the inpatient psychiatry wards, as well as associated services.
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Highest Acuity (Ward 5C4)
John Brooks M.D., Ph.D.
Lisa Large MD
Robert Zeiss, Ph.D.
Peter Berman, Ph.D., ABPP
Ward 5C4 is a 20 bed all-male locked unit equipped to handle the most acutely critical psychiatric patients. Operating at nearly 100% capacity at all times, this unit provides acute care to a 60% non-white patient population who present with severe, often chronic and refractory, AXIS I pathologies: (70% Psychotic, 30% Affective Disorder, 50% Substance Abuse/Dependence, 25% Suicidal, 45% Assaultive and 12% Demented.) It receives patients in crisis directly from affiliated clinics (i.e. San Jose, Stockton, Monterey, Modesto, Capitola, Palo Alto, Menlo Park, and Livermore) as well as transfers from locales throughout the Palo Alto Division's extensive cachment area. Care for these patients is divided between two interdisciplinary treatment teams. Each team comprises an attending psychiatrist, psychologist, psychiatric resident, psychology intern as well as a full complement of supporting staff including nursing, social work, occupational/physical/recreational therapists.Residents spend the majority of their time managing, on a pragmatic basis, the acute crises that have brought the patients into the hospital. Such management typically involves diagnostic evaluation, '>psychopharmacologic and supportive therapies, legal processing and acting as a liaison with patient families and other hospital services. Because of the short length of stay on the unit, crisis management is a primary focus. Once patients are stabilized they are transferred to one of the less acute inpatient units (see below). One exception to this short length of stay are a subset of extremely refractory patients, many of them with histories of repeated violence or medical complications, are placed on Clozaril therapy while on the unit. This requires both an extended length of stay and sophisticated pharmacologic and behavioral management. Of note, since nearly all patients are admitted on involuntary civil commitments residents obtain substantial experience interfacing with the legal system and learning the intricacies of California mental health law. These experiences include weekly legal "Probable Cause" Hearings to extend detainment, obtaining conservatorship of more severely ill patients, and consultation with guardians, public defenders, and county counsel.
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Open Unit/Acute Detox (4B2)
Selma Kahn MD
David Ringo M.D.
William O. Faustman, Ph.D
Unit 4B2 is a 20 bed inpatient program for male veterans. The unit serves as the only open male inpatient psychiatry unit. The ward is a teaching unit of the Department of Psychiatry and Behavioral Sciences at Stanford University Medical School. The staff includes two attending psychiatrists, one full-time psychologist, two psychiatry residents from Stanford, medical students, one recreation therapist, a social worker, and nursing staff. The program has traditionally served a research protocols are currently active on the unit. These studies include investigations of schizophrenic patients using event related potentials, clinical neuropsychology, and clinical psychopharmacology.
The program has numerous formal and informal didactic training opportunities. Jim Moses, Ph.D., provides a review of clinical and research issues in neuropsychology on a weekly basis. Clinical and academic faculty from Stanford conduct clinical teaching rounds and weekly seminars cover a broad range of topics in clinical and biological psychiatry. The treatment program employs a range of treatment approaches, including group and individual psychotherapy, milieu therapy, and psychopharmacological treatment. Most patients attend one or more therapy groups each day. Therapy groups are diverse and span the range of level of functioning of the patients. Interns frequently serve as a co-leader of these groups. Interns typically carry several individual cases in which they provide case management, family, and individual psychotherapy. A strong emphasis is placed on diagnostic assessment, documentation of psychopathology, and development and provision of treatment which addresses the psychopathology and psychosocial issues. Interns can become familiar with a broad range of clinical assessment tools used in psychiatric research. Since the unit has a strong program in psychopharmacology, interns can become quite familiar with the appropriate use of psychiatric treatment medications.
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Moderate Acuity (5B3)
Susan Sanfilippo, M.D., Medical Director,
Mary Margaret Flynn, M.D.
S. Katz, Ph.D.
Palo Alto Ward 5B3 is a short term locked male unit with twenty beds. Professionals from a number of services, provide comprehensive treatment. Core staff works together as an interdisciplinary team in developing a treatment plan for each patient, making treatment decisions and in coordinating treatment interventions. Patients have acute symptoms at time of admission, although the underlying conditions may be chronic. A wide range of conditions is to be found on the unit, including disorders of mood, anxiety, post-traumatic stress, personality, psychoses, and cognitive impairment. Many patients have alcohol and/or drug problems, either in conjunction with other disorders or as a primary condition. Some patients have physical medical problems, as well as psychiatric. Patients on this unit are expected to be in sufficient control to benefit from the moderate level of structure. Every effort is made to maintain a safe unit, and patients are supported in keeping their behavior under sufficient control so that the environment is therapeutic for all members.
The approach to treatment is biopsychosocial. Each patient meets daily with his treatment team to evaluate progress, address problems, and to review the treatment plan. Careful attention is paid to medications, psychosocial factors, interpersonal behavior on the unit, medical problems, and practical circumstances. Patients participate in three group therapy meetings per week co-led by the psychologist and intern. There are also opportunities for brief therapy with selective patients. There are two community meetings weekly led by patients with staff guidance. Also, there are classes daily dealing with such topics as stress management, understanding mental conditions, medications, addiction treatment, and discharge planning.
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Coed Intensive Treatment Unit (4B3)
John Dorfmann M.D.
Donna Horn, Ph.D.
This is an acute treatment unit for both men and women, with a capacity for 22 patients; the number of women and men vary by need. Psychiatry, psychology, social work, and nursing staff function as a multi-disciplinary team. Our objective is to help patients attain their highest level of independent functioning before returning to the community. The patient population has varied in age from 18 to 89. Patients contain representatives from all diagnostic groups, with the most common being character disorder, major affective disorder, and psychotic disorder. Well over 50% of the patients have concurrent substance abuse problems. The therapeutic community is the principle focus of treatment; community meetings, groups, and individual treatment revolve around this concept. Psychology interns are integral members of the treatment team. As treatment team members, they participate in twice weekly community meetings, three times weekly group psychotherapy, daily progress reviews with individual patients, and daily ward report as their schedule allows. Additionally, each intern can carry 1-2 individual psychotherapy patients with varying diagnoses. Interns who are interested have opportunities to work with families or to supplement diagnostic interviews with psychological assessment procedures. The rotation is half time for six months.
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Psychiatric Consultation Service
Lisa Large M.D.
Walton T. Roth M.D.
The inpatient consultation/liaison service provides neuropsychiatric evaluation of patients on all medical and surgical services, as well as specialized centers for spinal cord injury, traumatic brain injury, renal dialysis and blind rehabilitation. The patient population is 90% male, mostly drawn from lower socioeconomic strata. About half are white, non-Hispanics, one sixth are Hispanic and one sixth are African-American. Ages range from 20 to 90, but most patients are older than 40. Approximately one third of consults are to evaluate acute changes in mental state, 20% medically acute inpatients requiring management of their chronic psychiatric illness, 20% management of polysubstance abuse and detox., evaluation of an untreated anxiety or depressive disorders in the setting of an acute medical illness, 15% for assistance in determining patients capacity for medical decision making. Major treatment modalities include crisis intervention, psychopharmacology and supportive psychotherapy as well as managing legal aspects of treatment, such as involuntary holds and conservatorship applications. New consults seen by the on-call resident are reviewed within 24 hours by an attending psychiatrist.
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The Mental Health Emergency staff evaluates patients presenting to the PAVA emergency department during regular hours. This staff comprises one full time psychiatrist and two mental health social workers.. All other times residents are primarily responsible for the service with back-up from sixteen full-time psychiatrists who attend on a rotating basis. The clinical population presenting for evaluation at the VA is approximately 95% male, mostly in the lower socioeconomic strata, with many homeless patients.. Diagnoses are of wide variety. Major Axis I psychiatric diagnoses, including schizophrenia and major affective disorders, account for the primary presentation in two-thirds of cases. The remaining one-third of cases present with a primary diagnosis of PTSD and/or Axis II pathology. Co-morbid diagnoses are the standard presentation, with concurrent alcohol or substance abuse the most commonly seen.
Residents spend their time evaluating patients, providing brief psychotherapy as appropriate, initiating appropriate pharmacologic treatments, and arranging disposition plans. On average 4-8 patients are evaluated per call shift by the resident on-call. Residents learn to screen patients' medical status while completing psychiatric evaluations and arriving at diagnoses. Evaluations are done in the context of collaboration with other medical professionals, as well as patients' family and friends, community support services, and law enforcement officers. Supervision takes place on a case-by-case basis, either at the time of the evaluation or the end of the call shift with the on-call attending. An additional teaching round is held with the Chief Resident and on-call attending the next morning. Attending psychiatric staff are available at all times for phone supervision. The Chief Resident and a system of senior residents is also set up for additional supervision. In addition, residents attend clinically based teaching rounds held every weekday morning from 8AM to 9AM with the on-call attendings and VA Chief Resident. Topics discussed range from triage, diagnoses, treatments (pharmacological, psychotherapeutic, case management), disposition issues, management issues, interdisciplinary collaboration issues, legal issues, and research issues. (Also see Call duties ).
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Comprehensive Rehabilitation Center (Ward 2C2)
Supervisor: Harriet Katz Zeiner, Ph.D.
The Comprehensive Rehabilitation Center (CRC) is a 24 bed Rehabilitation Medicine Service inpatient unit. This unit provides multi-disciplinary evaluation and treatment services to patients suffering from cognitive, sensory and motor problems that are the result of medical and /or neurological conditions. The patient population served is approximately 60% neurological (e.g., CVA, traumatic brain injury, anoxic/hypoxic injury, tumor, Parkinson's, MS, Dementia), 30% pain patients, (both acute and chronic) and 10% with other medical etiology (e.g., post surgical deconditioning and diabetic amputation). The objective of the CRC is to increase the patient's functional independence and quality of life. The multidisciplinary team consists of psychologists, physicians (physiatrists), nurses, occupational therapists, physical therapists, kinesiotherapists, speech and language pathologists, a social worker and case manager.
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Brain Injury Rehabilitation Unit (2B2, Palo Alto)
Supervisor: William Lynch, Ph.D., ABPP, Program Director
The Brain Injury Rehabilitation Unit (BIRU) began in July 1969 as a pilot study for the comprehensive rehabilitation of traumatically brain-injured veterans. Presently located in modular building MB2B in Palo Alto, the BIRU has a permanent staff of 4: program chief, clinical coordinator, staff nurse and a secretary. The BIRU is an outpatient Day Hospital model program that operates from 8AM - 4:30 PM, five days a week. Diagnoses include head trauma, cerebrovascular diseases, anoxia, tumor, infections, and multiple sclerosis. The programs emphasis is upon rapid intervention, evaluation, problem identification, and treatment planning.
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Spinal Cord Injury Center (7E1 and 7F1, PA)
Supervisor: Michael Dunn, Ph.D.
The Spinal Cord Injury Center is a 47-bed facility located in a newly constructed building at the Palo Alto Division. The SCI Center is internationally recognized for providing excellent, state-of-the art care to newly injured veterans as well as long-term follow-up. A team composed of physicians, nurses, physical and occupational therapists, psychologists, social workers, and dietitians, working in an interdisciplinary therapeutic milieu, staffs the Center.
Although spinal cord injury is a serious medical condition, people often become more functionally and socially active as a result of their rehabilitation experience. SCI rehabilitation patients are often hospitalized for a number of months, and the staff has an opportunity to get to know them and their families quite well.
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Western Blind Rehabilitation Center (48, PA)
Supervisor: Laura Peters, Ph.D.
Consultant: Gregory Goodrich, Ph.D.
The Western Blind Rehabilitation (WBRC) is recognized internationally as a leader in rehabilitation services, training, and research. WBRC is a 30 bed residential facility that provides intensive rehabilitation to legally blind veterans learning to adjust to and manage sight loss. It is staffed by 50 specialists and over 200 veterans go through the program each year.
The typical client is approximately 66 years old and is legally blind due to some progressive, age-related disease, although the age range is from the 20's through the 90's. The individual whose vision becomes impaired often must face a variety of losses. Those with legal blindness, as opposed to those who are totally blind, often must learn to live with a "hidden disability" -one that is not readily identifiable by others. Such hidden disabilities often elicit suspicion and discomfort in others, and lead to interactions in which the visually impaired individual is "tested". Finally, many of the individuals who are admitted to WBRC, in addition to losses and changes associated directly with vision loss, face losses associated with retirement from employment and from chronic illness. Fortunately, losses and changes experienced by those with vision impairment are offset by the acquisition of adaptive skills and personal reorganization.
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Geriatric Primary Care Clinic (5C2 GRECC Palo Alto)
Supervisor: Jon Rose, Ph.D.
This is a primary medical care program run by our Geriatric Research Education and Clinical Center. While we strive to serve older veterans with a variety of outpatient medical care needs, most of our patients have multiple chronic and acute medical problems that require the services of an interprofessional team for optimal treatment. A team consisting of Geriatric Medicine, Social Work, Nursing, Pharmacy and Psychology cares for patients. Clinic hours are Wednesdays from 8 a.m. to 1 p.m.. Follow-up is done at times convenient to the intern. Some home visits are made.
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Home Based Primary Care
Supervisor: Steven Lovett, Ph.D.
The Home Based Primary Care (HBPC) program provides medical and psychosocial services to veterans in their homes whose chronic medical problems place them at risk for hospitalization or institutionalization. HBPC is an interdisciplinary team that includes medicine, nursing, social work, occupational therapy, pharmacy, and psychology. A wide variety of psychological services are provided to HBPC clients by the psychology staff. These services include: 1) neuropsychological screenings and psychological assessments of patients and caregivers, 2) individual and family therapy for depression, anxiety, caregiver stress, and other forms of emotional distress, 3) training in basic pain management, weight management, and smoking cessation techniques, 4) consulting with other program staff about methods of enhancing client adherence to treatment regimens.
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Other Units & Programs
Geriatric Research & Education Center (GRECC)
The Geriatric Research Education and Clinical Center is active in research, education, and clinical care. Its mission is to improve medical, phychological, and social services for older veterans, to advance scientific knowledge through geriatric and gerontological research, to train health personnel in the care of older individuals, and to develop improved models of clinical services.
Research Focus
Basic Biomedical Research
Molecular aspects of the decline in steroid hormone production during aging, cell processing of lipoprotein derived cholesterol and cholestery esters and molecular pharmacology of adrenergic receptors.
Applied Clinical Research
Emphasis on endocrinological and metabolic diseases of the elderly. Effect of chronic disease on cognitive pharmacologic interventions to modify body composition, use of psychological interventions to treat depression and related mental health problems, biomechanics of mobility patterns, exercise effects in the elderly, regulation of bonemass, acquisition of bone, osteoporosis, IGF - I and II (insulin like growth factor I and II) and ethnic contributions to skeletal health.
Health Services Research
Advanced care directives; cost-effective programs for low vision elders; family caregiving issues; the relationship between preference-weighted (utility) measures and health status measures, with focus on functional status and implementation of clinical practice guidelines using computer-generated patient-specific recommendations, with focus on hypertension.
Education Focus
Education programs are targeted for medical postgraduate education. Hosts a Physician Geriatric Fellowship Program, a Residency training rotation in Geriatrics and a VA Headquarters sponsored postdoctoral Psychology fellowship in geriatric mental health. Has an Interdisciplinary Team Training and Development program (ITT&D). Hosts one to two annual conferences. Has multiple, specialized VA Headquarters sponsored traineeships in social work, psychology, pharmacy and other affiliated health professions such as nursing
Clinical Programs
Outpatient Geriatric Clinic VA and Stanford, Extended Care Special Care Center, GEM units (Palo Alto VA), Division of Vision and Aging, HBPC, Older Adult and Family Research and Resources Center, hypertension Clinic, Bone Clinic and Andrology Clinic.
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Sierra-Pacific Mental Illness Research, Education and Clinical Center (MIRECC)
The Sierra-Pacific Network has chosen as its overall theme for the MIRECC the matching of treatments for mental illnesses to the personal characteristics of the individual veteran patient. Given the extensive array of behavioral and biological treatments now available for mental illness, the VISN will emphasize how matching specific treatments to individual veterans can improve the quality of care afforded our veteran patients with mental illness. Focusing first on patients with Post-traumatic Stress Disorder (PTSD) and behavioral problems associated with Alzheimer's Disease and related dementias, MIRECC investigators will build a wide network across Hawaii, Northern California and Nevada to conduct studies matching patients to the best treatment. The characteristics of patients will be assessed using a broad range of neurochemical, neuroimaging and psychosocial measures.For more information you can either select an overview of MIRECC activities or go to the (MIRECC) web site.
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