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Dr. Sherin,

1. How can LA County better address substance use problems, especially among our homeless? I've had to acquiesce to vague primary diagnoses like "Mood NOS" even when I knew a patient's biggest immediate impediment was their massive meth or alcohol use. We had several ED high utilizers--people who smoked meth, become paranoid/agitated in the community, and routinely get brought into the hospital by the police. At times, when I tried to focus treatment on problematic substance use in the chart, I've been told by administrators that the substance use was "not a mental illness". 

2. What is going to be done about emergency room overcrowding? On rare busy mornings, I've literally had to walk over patients sleeping on the ground. At some point, so many patients in a locked environment has to be a safety hazard. Also, are there any new approaches to managing people who come in expressing suicidality for secondary gain?

3. Residency location plays a role in a physician's decision on where to practice. Is anything being done to make up for the lost Cedars Sinai and MLK training slots? 

4. What are the major barriers to better integrating medical and mental health care? Especially with regards to the electronic medical record and colocating medical/mental healthcare? The level of coordination between LA County's medical and mental health services is a large contrast to my experiences at Kaiser and the VA. 

For sure, there is a large amount of comorbidity between substance use disorders and disorders like GAD, MDD, BPD or whatnot.

On the other hand, in the County clinic, it is sometimes difficult to tease out an underlying mental illness if most of a patient's encounters are in the context of inebriation or withdrawal. Doing CBT in that situation is likewise difficult.

It would be wonderful if all the county clinicians worked outside their silos. Can you tell us more about the integration efforts?