果冻影院

Consistent with ACCME policy, faculty for all 果冻影院 continuing education programs must disclose all relevant financial relationships with commercial organizations. 果冻影院 has a mechanism in place to identify and resolve conflicts in advance of the DCSI.

The 果冻影院 is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The 果冻影院 designates each five-day session of this live activity for a maximum of 15 AMA PRA Category 1 Credits^TM and each two-day session for a maximum of 8 AMA PRA Category 1 Credits^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Hours of Participation for Allied Health Professionals
The 果冻影院 designates each week-long session of this live activity for up to 15 hours of participation for continuing education for allied health professionals and each two-day session for a maximum of 8 hours of participation for continuing education for allied health professionals.

National Association of Social Workers Credit Statement
This program is approved by the National Association of Social Workers (Approval #886840778-6400) for 57 continuing education contact hours.

Psychology CE Credit Statement
The 果冻影院 is approved by the American Psychological Association to sponsor continuing education for psychologists. The 果冻影院 maintains responsibility for this program and its content.

This activity contains content or processes that may be potentially stressful.

Special Needs
Please contact us via email (summerinstitute@mcw.edu) at least two weeks in advance of any session if you have special needs.

Tuition and Refunds
Tuition pricing will be announced later. Tuition for graduate students, medical students, and resident physicians will be offered at a discounted rate, with a letter from their training director. If you are an 果冻影院 faculty member, please reach out to Caimen Masterson (camasterson@mcw.edu) to inquire about pricing. 

Early Bird Pricing
Early Bird pricing will be made available, with pricing announced later. More details will be announced. 

Please note that 果冻影院 accepts payment by Visa, MasterCard, and Discover.

If you do not already have an EthosCE account, select Create Account in the upper right-hand corner and enter all the required information. You will need to access this account again to complete a course evaluation and print your CE certificate, so please make a note of your username and password.

**The deadline for claiming 2024 credit is November 30, 2024, after which you will not be able to obtain your credits**

Register and Pay for a Session
Log in to your newly created or existing Ethos account, then select:

• Specialties > Psychiatry & Behavioral Health > The 38th Door County Summer Institute > Click on session(s) you want to register for
• Go to the Register tab on the session
• Choose your attendee type (Physician, Psychologist, APPs, etc.)
• Click Checkout to pay or Continue Shopping to add another session

Registration Fees
More information will be announced later.

July 22-26, 2024 | 9 a.m. – 12:15 p.m.
Donald Meichenbaum, PhD and David Meichenbaum, PhD

Donald Meichenbaum, PhD, is a Distinguished Professor Emeritus from the University of Waterloo in Ontario Canada, from which he took early retirement just over 28 years ago. Since that time, he has been Research Director of the in Miami. He is one of the founders of Cognitive Behavior Therapy, and in a survey of clinicians he was voted "one of the ten most influential psychotherapists of the 20th century." He has received a Lifetime Achievement Award from the Clinical Division of the American Psychological Association and was Honorary President of the Canadian Psychological Association. He has presented in all 50 U.S. states as well as internationally, and he has published extensively. His latest book is entitled "Roadmap to Resilience" and he just completed a 10 CEU Legacy Course titled “Getting Better Results: The Core Tasks and Skills of Expert Psychotherapists.”

David Meichenbaum, PhD, is a New York State licensed clinical psychologist specializing in the diagnostic evaluation and treatment of developmental and mental health disorders. For 20 years, Dr. Meichenbaum has worked at The Summit Center in Amherst, NY, where he is both the Clinical Director of Summit’s Behavioral Pediatrics Clinic and the Director of Community Consulting and Clinical Services. He is a highly sought-after consultant for school districts, offering practical behavioral and educational strategies that focus on the social, emotional, adaptive, and behavioral development of students with autism spectrum and disruptive behavior disorders. Dr. David Meichenbaum graduated with his doctorate in Clinical Psychology from the State University of New York at Buffalo, and he completed his clinical internship at Duke University Medical Center. He is returning to present at the Door County Summer Institute for the second consecutive summer.

Course Description
This workshop is designed to prepare educators AND mental health professionals who will be working with individuals considered to be at "high-risk" for having challenges this coming school year. Lectures, case examples, group discussions, and activities will center around children and adolescents who are at-risk because of having experienced adverse childhood experiences and/or having been identified with a developmental disability (e.g., Autism), disruptive behavior disorder, and/or mental health challenge (e.g., Anxiety and Depression). Our focus will be on highlighting means to adapting cognitive-behavioral and other evidence-based strategies for practical use across school, home, and community settings. We will highlight a collaborative process, and provide the participants with tools, that will support skill acquisition and generalization across settings.

Learning Objectives
Participants who engage in this education intervention will be able to:

• Identify students who are at-risk of adverse outcomes.
• Identify instructional, environmental, and behavioral techniques to facilitate inclusive programming and to reduce adult supports.
• Identify the role of team and plans in developing adaptive alternative behaviors to reduce behavior challenges.
• Describe evidence-based treatment strategies for helping children/adolescents with mental health challenges.
• Identify interventions for developing flexible thinkers and building resilience.
• Explain what “expert” teachers do.
• Explain critical components and means for fostering the generalization of skills.

Monday

• Assessing and Identifying Who Is “At-Risk”
• Understanding the Role of Individual, Parent, School, and Community Factors
• Defining Ecological-Based Interventions

Tuesday

• Utilizing Proactive and Multi-Tiered Solutions to Set Up Students, Teachers, Parents, and Clinicians for Success
• The Power of “It” – Methods for Developing Rapport and a Therapeutic Alliance
• Building a Team to Address Skill Acquisition, Fluency, and Performance Deficits
• Inclusive Programming Strategies for “High-Risk” Students

Wednesday

• Redefining Consequences: Key Considerations and Strategies for Addressing Dysregulation and Challenging Behaviors
• Means for Increasing Flexible, Positive, and Social-Thinking Skills
• Strategies for Increasing Child-Driven Goal Attainment

Thursday

• Understanding Why the Smart Keep Getting Smarter and Other Students Fall Further Behind
• Keys to Developing Expert Teachers
• How to Build a Resilient Mindset in Students, Teachers, and Parents
• Interventions for Responding to Neurodivergence and for Building Executive Functioning Skills
• Building Skills vs. Doing Skills: Strategies for Fostering Independence and Reducing Adult Supports

Friday

• Trauma-Focus Interventions
• Ways to Bolster Resilience in Students and Families
• Guidelines for Increasing the Generalization of Skills
• Processes for Anticipating and Overcoming Barriers
• Putting It Altogether

July 22-26, 2024 | 9 a.m. – 12:15 p.m.
Fred Heide PhD and Lee Becker

Frederick J. Heide, PhD, is Professor Emeritus at the California School of Professional Psychology at Alliant International University in the San Francisco Bay Area. There he was a member of the core faculty for 37 years and won both the Master Teacher and Teacher of the Year Awards. He earned his doctorate in clinical psychology from Pennsylvania State University in 1981 and has co-presented with Lee Becker at 果冻影院’s Door County Summer Institute for 25 continuous seasons. Dr. Heide received the Outstanding Research Contribution Award from the Association for Advancement of Behavior Therapy (AABT) for his foundational work on relaxation-induced anxiety and has published in the Journal of Consulting and Clinical Psychology, Psychophysiology, Mindfulness, Journal of Psychotherapy Integration, Behavior Research and Therapy, Psychology of Aesthetics, Creativity and the Arts, Psychotherapy: Theory, Research, Practice, Training, Journal of Psychoactive Drugs, and elsewhere. He also served as associate editor of the APA journal PsycCRITIQUES. Dr. Heide co-founded and has performed for five decades with Northern Sky Theater, which has received the Wisconsin Governor’s Award for Arts, Culture and Heritage. He has recorded three albums, published a book of 55 original songs (2022’s Tangled in Wonder), and co-authored almost two dozen shows including Belgians in Heaven and its prequel Hell’s Belgians (both with Lee Becker and James Kaplan), and the deer-hunting musical Guys & Does (with Lee Becker and Paul Libman). Dr. Heide studied improvisation with The Second City’s founding director Paul Sills and created several shows with him, including Moon of the Long Nights, Tales of the Midnight Sun, and Ya Ya You Betcha. In 2023 he received the Winifred Boynton Creative Spirit Award for his significant and enduring contributions to Door County.

Lee Becker began improvising over 35 years ago with ComedySportz while attending UW Madison. He helped found ComedySportz NYC, and worked with the group in Milwaukee, performing and running workshops in all three locations. He is a core member of Northern Sky Theater where he is a performer, musician, and playwright. Lee was a founding member of Door Shakespeare in Door County, WI, and has also performed and written for First Stage Children’s Theater in Milwaukee. Along with Doc Heide, he has been a workshop facilitator for DCSI for over 20 years, providing trainings using role play and Spolin theater games. He has done similar work as a guest teacher at Alliant University’s CA School of Professional Psychology.

Course Description
Recently a movement spearheaded at Northwestern University’s Feinberg School of Medicine has begun using improvisational acting exercises to teach physicians, psychotherapists, and other healthcare professionals the ability to respond flexibly in the face of change. This approach, termed “medical improvisation”, has shown promise in promoting a wide variety of communication skills, including empathy, affirmation, collaboration, and authenticity. Although the title of the approach implies that it is medically oriented, its methods apply to any setting involving human interaction. A recent classification of medical improv skills (Fu, 2019) breaks them into three categories: Attunement, Affirmation, and Advancement. This year’s seminar will focus on the second category, Affirmation, or validation of self and others (e.g., agreement, appreciation, cooperation, comfort with uncertainty/risk, and encouragement). While the effects of practicing medical improv can often be humorous, participants do not need to be “funny” to do it. The leaders of this largely experiential workshop will draw on their close collaboration with Paul Sills, founding director of Chicago’s Second City, who used improvisation to train renowned actors such as Alan Arkin and Alan Alda. After an overview of current research and theory in medical improvisation and affirmation skills, the bulk of the week will be devoted to engaging in and discussing a series of simple and entertaining improv exercises in a safe, highly supportive atmosphere. No previous experience with improvisation or medical improvisation is required.

Learning Objectives
Participants who engage in this education intervention will be able to:

• Identify the importance of spontaneity and improvisational ability in medicine, psychotherapy, pharmacy, and other health-related fields
• List and describe Fu’s (2019) three categories of medical improvisation’s goals and core skills: (a) Attunement (knowledge of self and others), (b) Affirmation (validation of self and others), and (c) Advancement (enrichment of self and others)
• Demonstrate core affirmation skills including acceptance, agreement, and appreciation
• Demonstrate comfort with uncertainty/risk and failure

Monday

• What is medical improvisation?
• Definitions
• The critical role of spontaneous adaptability in healthcare
• Overview of Fu’s (2019) classification of the goals and benefits of medical improvisation
• Literature documenting the critical role of provider-patient communication in improving outcomes and increasing patient satisfaction
• Evidence for the effectiveness of practitioner affirmation skills, including acceptance, support, empathy, and agreement
• Basic principles of medical improvisation
• Warm-up exercises

Tuesday

• Affirmation Skills 1

Wednesday

• Affirmation Skills 2

Thursday

• Affirmation Skills 3

Friday

• Summary and conclusions
• Wrap-up exercises

July 22-23, 2024 | 8:30 a.m. 鈥� 12:35 p.m.
Thomas Heinrich, MD and Harold Harsch, MD

Thomas Heinrich, MD, Professor of Psychiatry and Family Medicine at the 果冻影院 (果冻影院), completed a combined residency in psychiatry and family medicine, followed by a fellowship in consultation psychiatry at Massachusetts General Hospital. He is board-certified in family medicine and general adult psychiatry and holds subspecialty certification in consultation-liaison psychiatry and neuropsychiatry. Clinically, Dr. Heinrich remains active in consultation psychiatry, working on a busy academic psychiatric consultation service at Froedtert Hospital. This quaternary care academic medical center serves as 果冻影院鈥檚 primary teaching hospital. Administratively, Dr. Heinrich currently serves as Director of the Division of Consultation-Liaison Psychiatry and Executive Vice-Chair in the Department of Psychiatry and Behavioral Medicine at 果冻影院. In addition, he is the Medical Director of Behavioral Health at Froedtert Hospital and the Physician Lead for implementing Froedtert & the 果冻影院鈥檚 multidisciplinary behavioral health strategic plan. He has collaborated with multiple stakeholders in these roles to develop and implement several innovative cross-disciplinary and inter-institutional clinical programs.

Harold H. Harsch, MD, is a Professor of Psychiatry and Behavioral Medicine at the 果冻影院 (果冻影院). Dr. Harsch attended medical school at the 果冻影院, completed an internship in internal medicine at the University of Texas at Galveston, and completed his psychiatric training and behavioral medicine fellowship at Stanford University Medical Center in California. He has been board certified in adult psychiatry, geriatric psychiatry, and psychosomatic medicine.

Dr. Harsch has been involved in over 100 clinical trials of new drug development. He has been a consultant to most major pharmaceutical companies. He has been involved with brain stimulation procedures for treatment resistant depression. He currently teaches Advanced Psychopharmacology to psychiatric residents at the 果冻影院. Currently he supervises residents and fellows at the Froedtert/MCW Geropsychiatry clinic, the 果冻影院 resident psychiatry clinic, and the Froedtert Consultation-Liaison Program.

Course Description
Delirium is a syndrome of neuropsychiatric signs and symptoms that can accompany severe medical conditions. It is an independent risk factor for increased morbidity and mortality and is associated with increased lengths of stay and costs of care. Despite this, it frequently goes unrecognized, and debate continues about the best prevention and treatment strategies. We will review the current best practices for identifying, preventing, and treating delirium to improve outcomes and minimize adverse events. Substance Use Disorders (SUDs) represent a public health crisis. Medical admissions for this at-risk patient population are increasing. Unfortunately, administrative hurdles, legal challenges, and associated stigma complicate the assessment and treatment of SUDs in the inpatient medical setting. We will outline various identification and management options for alcohol and opioid use disorders commonly encountered in the hospital setting. Challenging patient interactions are present in all types of healthcare settings. Addressing the patient's needs, managing staff distress, and identifying our feelings are essential to safe management and resolving these demanding situations. Adverse effects of psychiatric medications vary from those that may be a nuisance to more severe and potentially life-threatening adverse events. We will review the diagnosis, pathophysiology, and treatment of neuroleptic malignant syndrome and serotonin syndrome. Awareness of these possible adverse effects is essential because they are associated with physical morbidity and mortality.

Last year, a paper stating that there is no evidence regarding serotonin deficiency in major depression brought about a new controversy in the field of psychopharmacology. We will reexamine the monoamine theory of depression and newer concepts in the neurobiology of major depression. We will look at the antidepressants available now. There have been six medications approved by the FDA in the last 15 years for treatment of major depression. These include three new mechanisms 鈥� NMDA receptor antagonism, GABA 鈥� A receptor modulators and 5HT-1 receptor agonism. We will look at these mechanisms and the data behind them.

Thorazine was the first widely used anti-psychotic and its structure gave rise to almost half of the psychoactive agents we now have available. In the last 15 years, four new antipsychotics have been approved by the FDA. We will discuss these in detail. Exciting potential antipsychotics are being tested based on the muscarinic system and the Trace amine-associated receptor 1 (TAAR1). We will critique where these mechanisms may be beneficial. Finally, we will scrutinize Alzheimer鈥檚 disease and the new anti-amyloid treatments and the FDA鈥檚 approval of brexpiprazole for agitation in Alzheimer鈥檚 disease means for clinical practice.

Learning Objectives
Participants who engage in this education intervention will be able to:

• Identify the mechanisms of action of newer antidepressants
• Identify the mechanisms of new and potential antipsychotics
• Describe anti-amyloid therapies and their place in geropsychiatry
• Describe various management techniques to address challenging patient interactions in a healthcare setting

Monday

• Review of Antidepressants and Major Depression
  • Serotonin controversy
  • Serotonin deficiency to the neurobiology of major depression
  • Antidepressants 鈥� the beginning
  • Some newer antidepressants in detail
  • New mechanisms and very new agents
• Delirium: Identification, management, and prevention
• Serotonin syndrome and neuroleptic malignant disorder

Tuesday

• Review of Antipsychotics and the dopamine hypothesis
  • Thorazine and where has it taken us
  • Some newer antipsychotics in detail
  • New potential antipsychotics and new mechanisms
• Update in Geropsychiatry
  • Alzheimer鈥檚 disease review
  • Treatments for Alzheimer鈥檚 today
• Substance use disorders in the general medical hospital
• Managing challenging patient interactions in a medical setting

July 25-26, 2024 | 8:30 a.m. – 12:35 p.m.
David Mintz, MD

David Mintz, MD, is a graduate of the University of Miami School of Medicine and the Cambridge Hospital/Austen Riggs Center Combined Residency Program. He completed a Fellowship in Psychodynamic Psychotherapy at the Austen Riggs Center, where he remained on staff as Treatment Team Leader, Director of Psychiatric Education, and Associate Director of Training in the Fellowship in Psychotherapy and Adult Psychoanalysis. At the Austen Riggs Center, Dr. Mintz’s clinical work focuses on complex, multiple co-morbid, and “treatment-resistant” patients. To optimally engage such patients, Dr. Mintz and colleagues have developed a patient-centered, psychodynamically informed approach to leveraging the pharmacotherapeutic alliance and addressing psychological resistance to the healthy use of treatment. His book Psychodynamic Psychopharmacology: Caring for the Treatment-Resistant Patient, and over a dozen other papers, explores these principles. Dr. Mintz is also the recent past leader of the Psychotherapy Caucus of the American Psychiatric Association.

Course Description
The history of psychiatry is a pendulum that swings between the biological and psychosocial poles. The psychodynamic perspective that held sway for most of the 20th Century gave way to the “Decade of the Brain,” and a privileging of biomedical perspectives. Though psychiatry benefited from an increasingly evidence-based perspective and a proliferation of safer and more tolerable treatments, psychiatric outcomes have not substantially improved. Treatment resistance remains a serious problem across psychiatric diagnoses. One likely reason is that the systems within which mental health practitioners are working often create pressures to adopt biologically reductionistic frameworks, limiting meaningful integration of biological and psychosocial perspectives across the treatment team.

This course will review the historical and theoretical tensions between bio- and psychosocial psychiatry and will explore possibilities of integration. We will examine the evidence base connecting meaning, medications, and outcomes, and will explore the dynamic meaning of medications and common dynamics contributing to pharmacologic treatment-resistance. We will review psychodynamic concepts relevant to the practice of psychopharmacology and explore a model (Psychodynamic Psychopharmacology) that aims to enhance pharmacotherapy outcomes through the integration of psychodynamic attitudes and skills. We will focus on techniques for fostering a patient-centered pharmacotherapeutic alliance and will consider necessary skills for identifying and addressing psychological and interpersonal interferences with the healthy use of medications. More broadly, we will consider approaches to optimize the integration of pharmacotherapy and psychotherapy, in both combined and split treatments.

Learning Objectives
Participants who engage in this education intervention will be able to:

• Cite aspects of the evidence base demonstrating that how one prescribes may affect outcomes as much as what one prescribes
• Recognize and formulate common psychodynamics interfering with optimal pharmacotherapy outcomes
• Develop a patient-centered alliance that supports the patient’s ability to make healthy use of medications
• Use psychodynamically-informed interventions to address dynamics driving treatment-resistance

Thursday

• Bio-Psychiatry and Psychodynamics: Conflict and Integration
• The Science of the Art of Pharmacotherapy
• Exploring the Meanings of Medication
• Clinical Exercise / Discussion

Friday

• Integrative Approaches to Pharmacotherapy with Complex Patients
• Forging the Alliance with the Difficult-to-Treat Patient
• Addressing Psychological and Interpersonal Drivers of Treatment-Resistance
• Clinical Exercise
• Bringing It Back Home: Clinical Applications and Impediments

July 29-August 2, 2024 | 9 a.m. – 12:15 p.m.
Francis G. Lu, MD, DLFAPA

Francis G. Lu, MD, DLFAPA, is the Luke & Grace Kim Professor in Cultural Psychiatry, Emeritus, at the University of California, Davis. As a Distinguished Life Fellow of the American Psychiatric Association (APA), Dr. Lu has contributed to the areas of cultural psychiatry including the interface with religion/spirituality, psychiatric education, diversity/inclusion, mental health equity, and psychiatry/film. He has presented at every APA Annual Meeting since 1984. He was awarded APA Special Presidential Commendations in both 2002 and 2016 for his contributions to cultural psychiatry, and in 2020, he received the APA Distinguished Service Award. In 2008, the Association for Academic Psychiatry awarded him its Lifetime Achievement in Education Award. In 2020, the Society for the Study of Psychiatry and Culture awarded him the Lifetime Achievement Award. In 2021, the American College of Psychiatrists awarded him its Distinguished Service Award. He has led or co-led 37 film seminars at Esalen Institute, Big Sur, CA, since 1987 and has led seven film seminars at DCSI.

Course Description
“We must learn to live together as brothers and sisters–or perish together as fools.” – Martin Luther King, Jr.

Through mindful viewing of five feature films – today’s vehicles of myth – participants will open their hearts to the quality of belonging with others and belonging to others that is so important in our time. We will trace how cinema’s greatest directors have depicted intolerance and ways of eventually embracing the other through compassion, love, and recognition of our interdependence as humans. This seminar aims at a mindfulness experience through viewing 5 feature films from Japan, the United States, and the United Kingdom in which inspiring characters embody belonging as a way to resilient well-being for the purpose of renewing these qualities in the lives of the seminar participants and in our work with patients. On each of the five mornings, one film is shown via Blu-ray video projection and six loudspeakers with an introduction and centering process to begin the session and processing after the film focusing on the participant's own experience of the movie including silent reflection, journaling, dyadic sharing, and group discussion. Supplementary optional films (non-CME) will be shown on two evenings (Monday and Thursday). Films take on an exquisite cumulative power when shown over five days at the DCSI in a group setting that is truly remarkable and unforgettable.

Learning Objectives
Participants who engage in this education intervention will be able to:

• Identify how film characters embody compassion as a way to resilient well-being so as to identify these strengths in themselves and in their patients.
• Develop skills and practice techniques of viewing of films from a mindfulness perspective in which inspiring characters embody compassion as a means to resilient well-being for the purpose of renewing these qualities in their lives.
• Describe the essential role of developing compassion as a way to resilient well-being.
• Explain to patients to help them view films from a mindfulness perspective in which inspiring characters embody compassion as a means to resilient well-being for the purpose of renewing these qualities in patients’ lives.

Monday

• “Our Hospitality,” 1923, directed by Buster Keaton
• “Intolerance,” 1916, directed by D.W. Griffith (Part 1)
• Bonus evening film: “Far From Heaven,” 2002, directed by Todd Haynes

Tuesday

• “Intolerance,” 1916, directed by D.W. Griffith (Part 2)

Wednesday

• “The Burmese Harp,” 1956, directed by Kon Ichikawa

Thursday

• “Long Night’s Journey Into Day,” 2000, directed by Deborah Hoffman and Frances Reid (excerpt)
• “Invictus,” 2009, directed by Clint Eastwood
• Bonus evening film: “Won’t You Be My Neighbor?” 2018, directed by Morgan Neville

Friday

“Pride,” 2014, directed by Matthew Warchus

July 29-30, 2024 | 8:30 a.m. 鈥� 12:35 p.m.
Jeremy Miner, MA

Jeremy T. Miner, MA, is associate director of pre-award at the University of Wisconsin-Milwaukee. In addition to developing and administering proposals to public and private grantmakers, Jeremy has served as a reviewer for federal and state grant programs and helped private foundations streamline their grant application guidelines. He has taught grant writing workshops regionally, nationally, and internationally. His successful grant writing techniques have generated millions of grant dollars for many nonprofit education, health care, and social service agencies.

Course Description
Whether a government agency requires a 100+ single-spaced page grant application or a private foundation requires three (3) double-spaced pages, common elements appear in nearly every grant proposal. Micro case studies will be used to illustrate writing pitfalls and stimulate discussion about ways to improve sections of the narrative. You will see resources for identifying public and private sponsors and learn a process to help pick the ones that have the highest probability of funding your projects.

Learning Objectives
Participants who engage in this education intervention will be able to:

• Identify public and private sponsors
• Match their needs with sponsor funding priorities
• Describe the primary elements in grant proposals
• Avoid common grant proposal writing mistakes

Monday

• Identify public and private sponsors
• Understand sponsors鈥� 鈥渧alues glasses鈥�
• Match your needs with sponsor funding priorities

Tuesday

• Describe the primary elements in grant proposals
• Recognize the types of details that sponsors expect
• Avoid common grant proposal writing mistakes

July 29-30, 2024 | 8:30 a.m. – 12:35 p.m.
Kathleen Koth, DO, DFAACAP

Kathleen A. Koth, DO, DFAACAP, is an Associate Professor of Psychiatry and Behavioral Medicine at the 果冻影院 and the Director of Neurodevelopmental Disabilities in the division of Child and Adolescent Psychiatry where she provides clinical services to individuals with intellectual developmental disorder, autism spectrum disorder, and genetic conditions with co-occurring psychiatric disorders and severe behavioral issues. Dr. Koth is a member of the Autism and Intellectual Disability Committee of the American Academy of Child and Adolescent Psychiatry where she is the Chair of the Intellectual Developmental Disorder Subcommittee and Co-Chair of the Education and Training Working Group. She enjoys working with her colleagues on the committee in increasing the education of clinicians caring for individuals with neurodevelopmental disorders. Her work includes speaking, research, and developing teaching materials, some of which may be found at the . Locally she plays an active role on the Wisconsin Council of Child and Adolescent Psychiatry’s executive committee as a past president and current Member-At-Large and is involved in increasing the diagnosis of autism spectrum disorder in primary care through a grant from Advancing a Healthier Wisconsin and partnership with Marquette University.

Course Description
During this 8-hour course we will use active case-based discussion to take a closer look at the care and treatment of individuals with neurodevelopmental disorders (NDD). Day one will focus on diagnosis of autism spectrum disorder and intellectual developmental disorder including using DSM-5-TR criteria, controversies surrounding the diagnosis, current recommendations for genetic testing, and how genetic testing results can be used in clinical practice. The first day will conclude with discussion of the difficult diagnosis of co-occurring psychiatric disorders. Day Two will continue with the topic of co-occurring psychiatric disorders and then cover therapeutic and pharmacologic treatments both specific to and adapted for those with NDD. Finally, we will discuss some key factors for transitions both from adolescents to adulthood and beyond that can promote health and well-being for the individual and the family.

Learning Objectives
Participants who engage in this education intervention will be able to:

• Review the DSM-5-TR diagnosis for autism spectrum disorder and intellectual developmental disorder focusing on changes and relevance to clinical practice
• Explore genetic testing with neurodevelopmental disabilities including how this is relevant to clinical practice now and in the near future
• Discuss the complexities of diagnosing co-occurring psychiatric illness in individuals with neurodevelopmental disabilities
• Discern therapeutic interventions for neurodevelopmental disabilities for behavioral issues and co-occurring psychiatric disorders
• Recognize and review the complexities of pharmacologic management for individuals with neurodevelopmental disabilities
• Analyze the components of transition to adulthood that can help adolescents and young adults be successful and these principles can be used to support the individual across the lifespan.

Monday

• Diagnosis of autism spectrum disorder
• Genetic testing
• Applying genetic testing results in clinical practice
• Discussion on the difficulty of diagnosing co-occurring psychiatric disorders

Tuesday

• Co-occurring psychiatric disorders
• Therapeutic treatments
• Pharmacologic treatments
• Factors for transitions from adolescence to adulthood and beyond

August 1- 2, 2024 | 8:30 a.m. – 12:35 p.m.
Rebecca Anderson, PhD and Sarah Trost, PhD

Rebecca Anderson, PhD, is a retired Professor in the Department of Anesthesiology and Director of Integrated Mental Health in Pain Management Center at 果冻影院. She is the author of over 70 peer-reviewed articles, six book chapters, and two books. She served as Secretary of the WI Examining Board. Clinically she was a member of a comprehensive pain management program where she utilized CBT, mindfulness, use of apps, imagery recordings, and biofeedback as part of an integrated approach to address adjustment and improve function and quality of life for patients. Dr. Anderson has presented frequently locally, regionally, and nationally on topics related to pain medicine. She has conducted webinars related to pain management and has conducted research in pain management. Dr. Anderson is the psychologist who established an Integrated Pain Management program at 果冻影院.

Sarah Trost, PhD, is a clinical psychologist with a specialty in health psychology. She earned her MA and PhD in Clinical Psychology from the University of Arizona, where she examined how couple-level variables relate to health outcomes. She completed a clinical internship with the UW-Madison Department of Psychiatry and post-doctoral training in clinical health psychology at the 果冻影院. She had concurrent faculty appointments within the Department of Transplant Surgery at 果冻影院 and at Cardinal Stritch University, where she taught a range of courses in clinical psychology for over a decade. She joined the Department of Anesthesiology and the Pain Management Program in 2016 and has been utilizing psychosocial interventions in her work with individuals who experience chronic pain. She has expertise in CBT, motivational interviewing, solution-focused therapy, systemic couples therapy, and pain reprocessing therapy.

Course Description
Join Drs. Anderson and Trost for a presentation that will address an overview of the challenges and opportunities for a mental health provider working with patients/clients experiencing chronic pain conditions. Cases, didactics, and experiential learning opportunities in pain management will be provided for the participants.

Learning Objectives
Participants who engage in this education intervention will be able to:

• Apply pain management strategies to identified patients and pain conditions.
• Learn the most common pain-related conditions, medications utilized in pain management, and medical procedures used to address specific pain-related problems.
• Identify cognitive behavioral strategies and variations used in pain management.
• Explore common assessment tools used in pain management.

Thursday

• Introduction
• Overview of pain conditions and behavioral approaches
• CBT for chronic pain
• Assessing the patient
• Pain and comorbid mental health issues
• Cases and experiential learning

Friday

• Multi-disciplinary approach to pain management
• Medications and procedures used to manage pain
• The Opioid Crisis: The patient, the prescriber, and the mental health provider
• Technology in pain management
• Cases and practice

August 1-2, 2024 | 8:30 a.m. – 12:35 p.m.
Joseph Goveas, MD and Makenzie Hatfield Kresch, MD

Joseph Goveas, MD, is Professor (with Tenure) of Psychiatry and Behavioral Medicine, and the Institute for Health and Equity at the 果冻影院 (果冻影院). Dr. Goveas is the Vice Chair and Director of Geriatric Psychiatry at the 果冻影院. Dr. Goveas has received several awards including being selected every year since 2009 as one of the Best Doctors in America and is an elected member of the American College of Psychiatrists and the Society of Biological Psychiatry. He is a recipient of the 2011 Investigator of the year award from the Alzheimer’s Association of Southeastern Wisconsin and was selected as one of the promising junior investigators in Alzheimer’s disease by the 2013 Charleston Conference on Alzheimer’s Disease. He is a past scholar of the NIMH/Weill Cornell Advanced Research Institute in Geriatric Mental Health. He serves as an ad hoc reviewer for NIH study sections and has several peer-reviewed publications in high-impact medical journals, written book chapters, and has given national and international presentations related to bereavement and grief, and late-life depression and Alzheimer’s disease and related disorders.

Makenzie Hatfield Kresch, MD, is an 果冻影院 Clinical faculty member who specializes in adults and seniors (65+). She attended medical school at Marshall University Joan C. Edwards School of Medicine. She then completed five years of postgraduate training, including a residency program in Psychiatry at the 果冻影院; the first year of the Child and Adolescent Psychiatry Fellowship at Children’s Wisconsin (a 2-year program); and then transitioned to the Geriatric Psychiatry Fellowship at the 果冻影院, which she completed in 2023. Dr. Hatfield supervises and teaches at the Veterans Administration in the Geriatric Psychiatry clinic for 果冻影院 Psychiatry Residents. She is Board Certified in General/Adult Psychiatry and Board Eligible in Geriatric Psychiatry. She specializes in mood and psychotic disorders, neurocognitive disorders (dementia), ADHD (child and adult), and “Seasons of Life” changes.

Course Description
This course provides an evidence-based update on three common late-life psychiatric disorders: Geriatric Depression, Geriatric Anxiety Disorders, and Behavioral and Psychological Symptoms of Dementia. We will discuss the latest research, pharmaceutical, and behavioral options for the geriatric population.

Learning Objectives
Participants who engage in this education intervention will be able to:

• Describe how to evaluate depression and anxiety among older adults.
• Develop a treatment plan for depression and anxiety among older adults, incorporating the most recent evidence base.
• Describe how to evaluate behavioral and psychological symptoms of dementia (BPSD).
• Discuss the elements of a plan to manage BPSD, including non-pharmacological interventions.

Thursday

• Epidemiology of Geriatric Depression and Anxiety
• Clinical Features and Evaluation of Depression and Anxiety
• Clinical Features and Evaluation of Behavioral and Psychological Symptoms of Dementia in Older Adults

Friday

• Evidence-Based Treatment Update of Depression and Anxiety
• Evidence-Based Treatment Update of Dementia in Older Adults

August 5-9, 2024 | 9 a.m. – 12:15 p.m.
Beth Shaw, PhD and Jessica Brumm-Larson, PhD

Beth Shaw, PhD, is an Assistant Professor in the Department of Psychiatry and Behavioral Medicine at 果冻影院 specializing in the treatment of adults with disorders of emotional dysregulation. She is the team lead of the Dialectical Behavior Therapy (DBT) program at the 果冻影院 Tosa Health Center and provides clinical training and supervision to medical students and residents with an emphasis on DBT and Cognitive Behavioral interventions. Dr. Shaw received her PhD in Clinical Psychology from Marquette University and is a member of the Wisconsin Institute of Neuroscience.

Jessica Brumm-Larson, PhD, (she/her) is an Assistant Professor for the 果冻影院 and a Licensed Psychologist with Children’s Wisconsin. Dr. Brumm-Larson provides therapy, assessment, and psychological evaluations to families, adolescents, and school-age children. She facilitates a DBT skills-only group for adolescents and caregivers at Children’s Wisconsin. With specialized training in cognitive-behavioral therapy (CBT) and dialectical behavioral therapy (DBT), she has experience in clinical, academic, and school-based settings. In addition to her clinical contributions, Dr. Brumm-Larson has over ten years of experience training graduate-level students and mentoring early-career psychologists. She is trained in mind-body skills and leads a mind-body group for medical providers at Children’s Wisconsin. Dr. Brumm-Larson is passionate about supporting identity development and self-care practices for providers. She attained her PhD at the University of Wisconsin-Milwaukee in Educational Psychology in 2011.

Course Description
This workshop will provide a broad overview of comprehensive Dialectical Behavior Therapy (DBT) including major theoretical concepts, treatment structure and strategy, and research supporting the efficacy of DBT. Participants will gain increased knowledge and familiarity with DBT skills of mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness along with stylistic approaches to manage challenging clinical presentations. The workshop will include discussion about adolescent and family considerations, adaptations of DBT in different settings (e.g., outpatient, schools), and populations indicated for DBT treatment. The course is designed for practitioners with basic or little experience with DBT.

Learning Objectives
Participants who engage in this education intervention will be able to:

• Describe key DBT concepts including dialectics, validation, and biosocial theory
• Explain the DBT skill mindfulness and demonstrate three examples of mindfulness practice
• Identify the main differences between emotional regulation and distress tolerance with the ability to explain strategies for employing each skill
• Demonstrate the use of DEARMAN as an interpersonal effectiveness skill

Monday

• Introductions
• Rationale for mindfulness practice and mindfulness exercise
• Overview of comprehensive Dialectical Behavior Therapy
• Dialectics
• Borderline Personality Disorder and the Biosocial Theory

Tuesday

• Mindfulness exercise
• Modes of Treatment
• Structuring treatment
• Key differences between DBT and CBT
• Goals and structure of skills training
• Mindfulness Module with skill practice and demonstration

Wednesday

• Mindfulness exercise
• Distress Tolerance Module with skill practice and demonstration
• Emotion Regulation Module with skill practice and demonstration

Thursday

• Mindfulness exercise
• Emotion Regulation (continued)
• Interpersonal Effectiveness Module with skill practice and demonstration
• Walking the Middle Path – aka family/adolescent skills and considerations
• Skills wrap-up and review

Friday

• Tools and strategies for individual sessions
• Dialectical Strategies
• Change strategies
• Managing suicidal and self-harm behaviors
• Wrap-up

August 5-6, 2024 | 8:30 a.m. – 12:35 p.m.
Sheldon Benjamin, MD, DLFAPA, FANPA, FAAN

Sheldon Benjamin, MD, is Professor of Psychiatry and Neurology at the University of Massachusetts T H Chan School of Medicine (UMass Chan), where he has served as Director of Neuropsychiatry since 1986. He served as Interim Chair of Psychiatry from 2017-2020, Director of the UMass Chan Neuropsychiatry Fellowship since 1989, founding director of the Combined Neurology/Psychiatry Residency Program from 1997-2020 (now associate director), and co-director of the UMass Chan Fellowship in Adult Neurodevelopmental Disabilities. In 2020 he stepped down after 25 years as Psychiatry Program Director and is now Vice Chair for Education and Associate Program Director. He had the pleasure of serving as Visiting Professor in Neuropsychiatry at Kings College Institute of Psychiatry, Psychology, and Neuroscience from March-August 2023.

A graduate of the University of Cincinnati College of Medicine, he completed psychiatry residency training at Tufts New England Medical Center, neurology residency training at Tufts and Boston University, and a fellowship in Behavioral Neurology at the Boston University/Boston Veterans Administration Hospital. He is board-certified in both Psychiatry and Neurology (ABPN) and in Behavioral Neurology and Neuropsychiatry by the United Council on Neurological Subspecialties. Dr. Benjamin is currently one of the Psychiatry Directors of the American Board of Psychiatry and Neurology. He has served as President of the American Association of Directors of Psychiatry Residency Training (AADPRT) and President of the American Neuropsychiatric Association (ANPA). He is a Distinguished Life Fellow of the APA, a Fellow of the American Academy of Neurology, and a Fellow of ANPA.

Dr. Benjamin has been selected as the recipient of the Outstanding Educator Award by the Massachusetts Psychiatric Society, The UMass Chan Lamar Soutter Lifetime Achievement Award in Education, the UMass Chan Chancellors Medal for Distinguished Teaching, the American Neuropsychiatric Association’s Gary J Tucker, MD Lifetime Achievement Award in Neuropsychiatry, and the AADPRT Lifetime Service Award in Psychiatric Education.

A specialist in the evaluation of behavioral problems at the interface of psychiatry and neurology, he teaches clinical neuroscience and neuropsychiatry; and has published and presented widely on neuropsychiatry, clinical neuroscience training of psychiatrists; neurocognitive and neuropsychiatric examination techniques; educational technology; residency training issues; and the history of neuropsychiatry. He is co-author of The Brain Card®, a guide to comprehensive bedside neuropsychiatric examination; a coauthor of the ACGME-ABPN Psychiatry Milestones; a co-author of the APA Guidelines for the Treatment of Schizophrenia, and a co-author of the forthcoming revision to the APA Guidelines for the Treatment of Borderline Personality Disorder.

Course Description
Neuropsychiatry is a potentially complex field of study encompassing the psychiatric and clinical neurosciences relevant to the evaluation of brain-behavior relationships. This week, however, we are going to keep it practical and clinically oriented. I hope you will feel free to ask questions, bring forward case material from your practice, try out new cognitive assessment techniques and immerse yourself for 2 to 4 days in the exciting world of neuropsychiatry. What could be more fun? *

*"There is probably no pleasure equal to the pleasure of climbing a dangerous Alp; but it is a pleasure which is confined strictly to people who can find pleasure in it” – Mark Twain

Learning Objectives
Participants who engage in this education intervention will be able to:

• Identify the major frontal behavioral syndromes
• Describe executive function, its importance in rehabilitation, and how to assess it at the “bedside”
• Predict behavioral sequelae of traumatic brain injury by using a pathophysiologic approach
• Utilize practical neuropsychiatric assessment techniques to assess frontal and executive function

Monday

• The Frontal Lobes: A Users Guide for Clinicians
• Why Mental Health Professionals Should Care About Executive Function
• Frontal syndromes and executive function made clear and understandable, with focus on the importance of executive function to psychosocial rehabilitation
• Bedside neuropsychiatric assessment techniques & Case discussion

Tuesday

• Neuropsychiatric Sequelae of Traumatic Brain Injury
• Predicting behavior from TBI pathophysiology
• Clinical approach to brain-injured patients
• Growing Up Without Frontal Lobes: The Story of JP
  (JP, reported by Ackerly and Benton in 1948, was born with massive bifrontal damage and grew up to be a gentleman car thief incapable of sustaining relationships. Dr. Benjamin’s team set out to find out what happened to JP in adulthood and to see if his brain could be located for clinical-pathological correlation.)

August 5-6, 2024 | 8:30 a.m. – 12:35 p.m.
Cecilia Hillard, PhD and Todd Stollenwerk, MD, PhD

Cecilia J. Hillard, PhD, grew up in the suburbs of Milwaukee and credits her high school chemistry teacher for starting her on the journey to be a scientist. Dr. Hillard received her undergraduate degree in Chemistry from the University of Virginia and PhD in Pharmacology from the 果冻影院. Dr. Hillard is currently a Professor of Pharmacology and Toxicology, Director of the Neuroscience Research Center, and Associate Dean for Research at the 果冻影院. Her laboratory has long-standing interests in the pharmacology of the cannabinoids and biochemistry of endocannabinoid signaling. Her laboratory has explored the roles of endocannabinoid signaling in many aspects of brain function, including emotional regulation, addiction, and neuroinflammation. She and her colleagues have reported seminal findings regarding the role of endocannabinoids in preclinical models of schizophrenia, depression, and anxiety.

Recently, she has been collaborating with others to explore changes in circulating endocannabinoids in humans, with the goal of using this as a translational measure of endocannabinoid tone. Her work has been funded continuously by NIH since 1987, and she has published over 270 peer-reviewed, original papers. Dr. Hillard received the 2011 Mechoulam Award for outstanding research in the area of cannabinoids and endocannabinoids and the 2017 Lifetime Achievement Award, both from the International Cannabinoid Research Society. A long-time faculty member at the 果冻影院, Dr. Hillard has won many awards for teaching and was awarded “Mentor of the Year” by the Graduate School in 2010 and the Distinguished Service Award in 2011.

Todd Stollenwerk, MD, PhD, is a first-year resident in the combined Internal Medicine and Psychiatry residency program at the 果冻影院. He completed MD-PhD training at the 果冻影院 in 2024. He obtained his PhD in the lab of Cecilia Hillard, PhD, where he studied endocannabinoid signaling in the brain. His dissertation research used a mouse model of schizophrenia to study the effects of maternal immune activation and adolescent stress and THC exposure on the development of behavioral abnormalities. During his training, he lectured in the pharmacology and physiology courses for first-year medical students and was extensively involved in the medical student tutoring program.

Course Description
We will describe cannabis and hemp with a focus on the molecules in those preparations that have been used as pharmaceuticals and nutraceuticals. We will discuss the health effects of using cannabis-derived products. We will present the brain's endocannabinoid system and discuss its role in the regulation of brain function.

Learning Objectives
Participants who engage in this education intervention will be able to:

• Identify the targets of the cannabinoid, THC, in the brain
• Apply understanding of the endocannabinoid system to psychiatric disorders
• Compare the effects of THC and cannabidiol (CBD) on the brain, focusing on differences in molecular targets
• Critique the claims of beneficial effects of the cannabinoids by the public

Monday

• Basics of the cannabis plant and the cannabinoids (THC and CBD)
• Basics of the brain endocannabinoid signaling system

Tuesday

• Positive and negative effects of cannabis-derived molecules in Psychiatry
• Potential therapeutic effects of drugs that target the endocannabinoid system

August 8-9, 2024 | 8:30 a.m. – 12:35 p.m.
Sheldon Benjamin, MD, DLFAPA, FANPA, FAAN

Sheldon Benjamin, MD, is Professor of Psychiatry and Neurology at the University of Massachusetts T H Chan School of Medicine (UMass Chan), where he has served as Director of Neuropsychiatry since 1986. He served as Interim Chair of Psychiatry from 2017-2020, Director of the UMass Chan Neuropsychiatry Fellowship since 1989, founding director of the Combined Neurology/Psychiatry Residency Program from 1997-2020 (now associate director), and co-director of the UMass Chan Fellowship in Adult Neurodevelopmental Disabilities. In 2020 he stepped down after 25 years as Psychiatry Program Director and is now Vice Chair for Education and Associate Program Director. He had the pleasure of serving as Visiting Professor in Neuropsychiatry at Kings College Institute of Psychiatry, Psychology, and Neuroscience from March-August 2023.

A graduate of the University of Cincinnati College of Medicine, he completed psychiatry residency training at Tufts New England Medical Center, neurology residency training at Tufts and Boston University, and a fellowship in Behavioral Neurology at the Boston University/Boston Veterans Administration Hospital. He is board-certified in both Psychiatry and Neurology (ABPN) and in Behavioral Neurology and Neuropsychiatry by the United Council on Neurological Subspecialties. Dr. Benjamin is currently one of the Psychiatry Directors of the American Board of Psychiatry and Neurology. He has served as President of the American Association of Directors of Psychiatry Residency Training (AADPRT) and President of the American Neuropsychiatric Association (ANPA). He is a Distinguished Life Fellow of the APA, a Fellow of the American Academy of Neurology, and a Fellow of ANPA.

Dr. Benjamin has been selected as the recipient of the Outstanding Educator Award by the Massachusetts Psychiatric Society, The UMass Chan Lamar Soutter Lifetime Achievement Award in Education, the UMass Chan Chancellors Medal for Distinguished Teaching, the American Neuropsychiatric Association’s Gary J Tucker, MD Lifetime Achievement Award in Neuropsychiatry, and the AADPRT Lifetime Service Award in Psychiatric Education.

A specialist in the evaluation of behavioral problems at the interface of psychiatry and neurology, he teaches clinical neuroscience and neuropsychiatry; and has published and presented widely on neuropsychiatry, clinical neuroscience training of psychiatrists; neurocognitive and neuropsychiatric examination techniques; educational technology; residency training issues; and the history of neuropsychiatry. He is co-author of The Brain Card®, a guide to comprehensive bedside neuropsychiatric examination; a coauthor of the ACGME-ABPN Psychiatry Milestones; a co-author of the APA Guidelines for the Treatment of Schizophrenia, and a co-author of the forthcoming revision to the APA Guidelines for the Treatment of Borderline Personality Disorder.

Course Description
Neuropsychiatry is a potentially complex field of study encompassing the psychiatric and clinical neurosciences relevant to the evaluation of brain-behavior relationships. This week, however, we are going to keep it practical and clinically oriented. I hope you will feel free to ask questions, bring forward case material from your practice, try out new cognitive assessment techniques and immerse yourself for 2 to 4 days in the exciting world of neuropsychiatry. What could be more fun? *

*"There is probably no pleasure equal to the pleasure of climbing a dangerous Alp; but it is a pleasure which is confined strictly to people who can find pleasure in it” – Mark Twain

Learning Objectives
Participants who engage in this education intervention will be able to:

• Explain the neuroscientific basis of memory
• Identify several amnesias and hypermnesias
• Demonstrate ability to diagnose common dementias
• Identify autoimmunity and molecular mimicry as a possible cause of psychiatric syndromes, including autoimmune limbic encephalitis
• List modern lessons of at least 2 classic neuropsychiatry cases

Thursday

• Memory and Its Disorders
• Forgetting to Remember, Remembering to Forget: A Neuropsychiatrist Thinks About Memory
• A Practitioners Guide to Common Dementias

Friday

• Molecular Mimicry and Memorable Maladies
• Molecular Mimicry in Psychiatry (from Encephalitis Lethargica to Autoimmune Encephalitis)
• The 6 Neuropsychiatry Cases All Mental Health Clinicians Should Know (Phineas Gage, Tan Tan, Frau D, S, JP, and HM)

August 8-9, 2024 | 8:30 a.m. – 12:35 p.m.
Laura Miller, MD

Laura J. Miller, MD, is a Professor of Psychiatry at Loyola Stritch School of Medicine and the Medical Director of Reproductive Mental Health for the Veterans Health Administration. She has developed nationally award-winning women’s mental health services and educational programs and has participated in numerous women’s mental health policy initiatives. She has authored or co-authored more than 90 articles and book chapters related to women’s mental health. She has devoted her career to improving the mental health of women through clinical care, education, and research.

Course Description
Female reproductive cycle stages can affect the expression, course, and treatment of psychiatric disorders. In this course, we will discuss clinically relevant updates about premenstrual, perinatal, and perimenopausal mental health conditions and interventions.

Learning Objectives
Participants who engage in this education intervention will be able to:

• Define the three main types of premenstrual mental health conditions.
• Weigh perinatal risks of untreated symptoms against perinatal risks of psychotropic medications for common psychiatric conditions.
• Describe how perinatal loss can affect mental health.
• Explain factors that can influence the likelihood of depression during perimenopause.

Thursday

• The menstrual cycle and mental health
• Perinatal depression
• Perinatal bipolar disorder
• Perinatal anxiety disorders and sleep disorders

Friday

• Perinatal ADHD
• Perinatal loss and mental health
• Perinatal eating disorders and OCD
• Perimenopause, midlife, and mental health