Medical Psychologists on path to getting prescribing privileges, AMA/APA oppose

[Anasazi23]

more like overzealous use of cut & paste...I have a tendency to do that.

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[PublicHealth]

more like overzealous use of cut & paste...I have a tendency to do that.

Of course...I just wanted to use the adjective "Glucksbergian," so it seemed like an appropriate opportunity.

 

[Anasazi23]

You mean this guy?

http://www.princeton.edu/~psych/PsychSite/fac_glucksberg.html

I have a feeling he's not going after prescription privilages.

 

[mdblue]

Psychiatrists are very, very necessary. That's why I'm so irritated about the general mediocrity in the field.

I have great respect for psychiatrists who are physicians in the best sense of the word, but the only one whom I've encountered (sadly not in person) has been the late Jerrold Bernstein, who's *Drug Therapy in Psychiatry* opened my eyes to really TREATING mental illness medically. His references are incredibly exhaustive, and he has whole chapters on how to use the MAOI's, the TCA's, how to safely COMBINE MAOI's and TCA's, use TCA's with SSRI's, use all with lithium--he simply refuses to give up. He even tried using Permax as an augmentor to Parnate in some resistant patients he suspected were responding to elavated dopamine, and noted that over half the patients reported a great or significant improvement in symptoms. He discusses side effects and their management in depth. There are pages of charts with tyramine content of common and exotic foods for MAOI patients.

I have never heard of another psychiatrist who was this attentive and aggressive in helping his or her patients recover.



"decision-making process?", "Your doc know better?"--please; I just ate. You mean prescribing the virtually-untested Zyprexa for every disorder under the sun--to the point that the expense of this drug alone was overwhelming medicaid?

I can't count the number of people I've had to reassure who had been prescribed Zyprexa for depression, anxiety, INSOMNIA, social phobia, etc. who read up on it and thought they had schizophrenia.

The fact that Zyprexa was subsequently shown to cause NMS and TDK, in addition to cool new tricks like orca-grade weight gain, hyperglycemia, and permanent type II diabetes (a stunt even Haldol couldn't pull) seems to have done little to blunt psychiatrists' puzzling enthusiasm for this drug.

You mean dishing out (also virtually untested) Effexor like candy and letting years go by before acknowleding the horrible and disabling withdrawal effects experienced by at least 15% of patients, some of which persisted for more than a year?

You mean ignoring the fact that no study has shown the SSRI's to be effective in MAJOR depression, and that numerous studies show these drugs to have little or no superiority over placebo in treating mild depression?


After 10 years of being a good, crippled patient, I'm afraid I've given up on "Your doc know better." If I still believed that, tomorrow I would obediently take my Effexor and Zyprexa, waddle to the 7-11 for breakfast, and then stare at the TV while waiting for my SSI check.

Instead, I'm popping a couple Parnate and going surfing.

I do think you and me are talking from the same viewpoint. Psychotropic meds are not to be used like candies. SSRI are not the answer to everything. Unfortunately "ask your doc" campaigns minimizes the risks associated w/ these psychotropics. That's why I feel these meds should be prescribed by psychiatrists. These days bulk of the SSRIs and SGAs are prescribed by people who work primarily as PCPs w/o any particular psych experience. The same holds true for stimulants in kids.
The point is it is extremely risky for the untrained to experiment w/ the drugs(be it the pt him/herself, PhDs or no-psych MDs for that matter).
BTW, there are psychiatrists who for whatever reasons restrict themselves to 15-min medcks. If anyone has any experience w/ those sessions they will realize what sub-standard care might creep thru those pt-encounters. This is sub-optimal care of the pt and nothing else. I am afraid w/o addressing the safety issue the PhDs for their own vested interest are arguing for their scripting rights and will provide the same sub-optimal care to the pt(because that's what the 3rd party payors will mandate).
And it's interesting when people have their own interests at heart, how callous they can be to other's safety.
http://pn.psychiatryonline.org/cgi/content/short/39/10/1

 

[sasevan]

You either believe that psychiatric patients are medical in nature or you do not. In medicine, you take the worst case scenario and work downwards in your differential. This is the time-proven logic-driven technique that ensures patient safety.

The safest way to approach this quandry is to assume the worst - that all patients have medical etiologies and comorbidities until proven otherwise. Psychology training programs are looking to skip this step and move straight to psychopharmacological intervention. What might appear to you as dogmatic medical fundamentalism is really a top-down differential approach to the patient as a whole.

Hi Falwell23...ooops...I mean...Anasazi23

In response to your comment as to whether I believe that psychiatric patients are medical in nature, I say

In the words of "Sex & the City's" Mr. BIG:

ABSO-------LUTELY!!!

One of the main reasons why I want to become a psychiatrist is because I highly value the biochemical dimension of mental illness.
I don't see how any mental health provider could possibly purport to dx or tx mental illness unless he/she has a functional knowledge of say, medical conditions that present as mood disorders, medications that may elicit depressive sx, and substance abuse impact on affective state.

One of the best arguments for psychologists gaining RxP is that as mental health providers they must be fully educated and trained in a functional knowledge of the biomedical dimension less they end up trying to assess and intervene with an exclusively psychosocial modality due to ignorance of the biomedical.

HOWEVER, to paraphrase Svas: they are also psychosocialspiritual in nature.

In my opinion, both psych PhD/PsyDs and psych MD/DOs need to be fully ed/trained in both the biochemical and psychosocialspiritual dimensions.
Short cuts, whether due to mangled healthcare pressure or some other pressure, are unethical.

How can a psychiatrist or a psychologist abide by the dictum "DO NO HARM" and at the same time pretend to be able to dx and/or tx mental illness without contextualizing said dx/tx within the biopsychosocialspiritual model????

Do you believe that the BPSS model is just (or mostly) political correctness???
If so, then you may be a medical fundamentalist AND an ideological reductionist.

Seriously, if its really all about patient care, then we should ALL be insisting that psychologists be fully ed/trained in the biochem dim and psychiatrist in the psychosocialspiritual.

There will still be a difference between the two disciplines, with each emphasizing one or the other dimension, but with each also sufficiently prepared to dx/tx in a genuinely comprehensive and caring manner.

Psychology, to its credit, is acknowledging this and insisting on increasing incorporation of the biomedical dimension in its pre-doc as well as its post-doc ed/training models.

FYI, medical psychology ed/training is not just psychopharm (See Following Posts).

P.S. If you prefer, I can affectionately refer to
the little APA
as the APA that came first
Then again, is being premature any better than being small???

 

[sasevan]

Psychology is NOT trying to circumvent appropriate ed/training for RxP.
Proposed medical psychology programs provide appropriate AND adequate ed/training for psychologists to become safe and effective psychopharmacotherapists.


Psychopharmacology Training Program

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The following description of the required courses and the content therein may be subject to changes necessitated by more current needs and/or other factors. The "content areas" listed below are the 10 knowledge-based segments included in the APA Psychopharmacology Examination for Psychologists (PEP)
I. NEUROSCIENCES: Didactic courses in the fields of neuroanatomy, neurophysiology, and neurochemistry are taught by faculty members with appropriate training and experience in these disciplines. Each course is 1.5 credit hours, and the course content is outlined below for each subject.

Neuroanatomy/Neuropathology:

Neuroanatomy:

Will include basic human neuroanatomy, with an emphasis on categorization of tracts by neurotransmitter systems. Categorization by neurotransmitter function will allow an early introduction to pharmacological agents and how they interact with the various anatomical pathways. The anatomy of the brain, spinal cord, and sympathetic and parasympathetic nervous systems will be important to the study of psychopharmacology. Brain regions studied will include cerebral cortex, frontal cortex, hippocampus, basal ganglia, thalamus and hypothalamus, brain stem (with particular attention to locus coeruleus and dorsal raphae nuclei). Involvement of particular anatomical regions in certain mental illnesses and relevant neurological illnesses will be introduced: Including appropriate items from APA Content Area 2

Content Area 2:Neuroscience

Refers to the anatomy, physiology, and biochemistry of the nervous system and its interfaces with other major body systems

0201 Knowledge of the structure and function of nervous system cells

0202 Knowledge of the structure and function of the central and peripheral nervous systems

0203 Knowledge of the major neuronal pathways and their functions

0204 Knowledge of the vascular supply of the brain, and the blood-brain and placental barriers

Neuropathology

The neuropathology section will include cognitive, movement, developmental, and seizure disorders, chronic pain, traumatic brain injury, and other nervous system pathology. Basic neurodiagnostic markers of pathology and mechanisms of extrapyramidal and dysfunction will be included, as well as discussion of the hypothesized neuropathological basis of psychological disorders. Appropriate APA Content Areas will be included

Content Area 3: Nervous system pathology

Refers to disorders of the nervous system resulting in abnormal function or behavioral/mood disruption. Includes biochemical, structural (congenital or acquired), or neurophysiological abnormalities and their impact on other body systems.

0301 Knowledge of etiological factors and diagnoses of dementia, delirium, and other cognitive disorders

03O2 Knowledge of etiological factors and diagnosis of chronic pain, including headache (e.g., differentiation of pain syndromes with primarily nervous, musculoskeletal, and tension-related etiology)

0304 Knowledge of etiological factors and diagnosis of movement disorders (e.g., including Parkinson's, Huntington's, and Tourette's syndromes)

0305 Knowledge of etiological factors and diagnosis of mental ******ation

0306 Knowledge of etiological factors and diagnosis of neurodevelopmental disorders (e.g., fetal alcohol syndrome, pervasive developmental disorders, Fragile-X syndrome)

0307 Knowledge of etiological factors and diagnosis of central nervous system vascular disorders (e.g., cerebral vascular accidents [CVAs], transient ischemic attacks [TIAs])

0308 Knowledge of etiological factors and diagnosis of seizure disorders

0309 Knowledge of traumatic brain injury

0310 Knowledge of other nervous system pathology (e.g., multiple sclerosis, infectious diseases, neoplasms)

0311 Knowledge of neurobehavioral/psychological disorders that have an hypothesized neuropathological basis (e.g., schizophrenia, affective disorders, anxiety, ADHD)

0312 Knowledge of basic neurodiagnostic markers of neurobehavioral disorders (e.g., as found on EEG and diagnostic imaging, and in neuropsychological assessment)

0313 Knowledge of the mechanism of extrapyramidal dysfunction (e.g., dystonic reactions and tardive dyskinesia)

Neurophysiology:

Physiological concepts underlying central and peripheral nervous system function will be presented. Cellular neurophysiology concepts such as the resting potential, action potential and basic ion channel kinetics will be introduced. An integrated view of the electrical functioning of the brain, with an introduction to electroencephalographic concepts, will be introduced. Neurotransmitter receptor function, second messengers and neural plasticity with an introduction to cellular theories underlying learning will be included. Appropriate APA Content Areas be covered

0205 Knowledge of cellular and molecular nervous system biology and regulatory processes and second messenger systems

0208 Knowledge of the endocrine system and the interface of various hormones and other neurotransmitters

0303 Knowledge of etiological factors and diagnosis of sleep disorders as related to the nervous system and psychopathology

0312 Knowledge of basic neurodiagnostic markers of neurobehavioral disorders (e.g., as found on EEG and diagnostic imaging, and in neuropsychological assessment

Update in Neurochemistry and Biochemistry

This course will provide students with a brief review of those aspects of chemistry, organic chemistry and biochemistry which are needed for the study of pharmacology. For instance, in the field of general chemistry the instructor will review the general concepts of chemical compounds and bonds, and atomic theory. In the field of organic chemistry the instructor will review the concepts of organic compounds, bonds and valences. In the field of biochemistry the instructor will review biomolecules of proteins, carbohydrates, nucleic acids and lipids, as well as chromosomal theory and the genetic code, enzymes and metabolism. The assumption will be that all students have had previous coursework in chemistry, but that many students will have taken the courses many years previously. This 2 day course will provide 1 credit.

Professional, ethical, and legal issues:

Informed consent as it relates to prescribing psychotropic medications will be emphasized, including issues of drug side effects such as tardive dyskinesia. Informed consent in drug research protocols. Confidentiality and compliance issues, including involvement of family members in informed consent and treatment sessions. Continuing education requirements. The difficult patient, including the chronically noncompliant patient will be addressed. Second opinions, limitations of practice by psychologists and situations in which referral to psychiatrists or other medical specialists are indicated. Clinical decisions to initiate inpatient versus outpatient treatment with medication. Electroconvulsive therapy, indications and legal/ethical considerations. This course will be approximately 0.5 credits. APA Content Area 10

Content Area 10: Professional, legal, ethical, and interprofessional issues

Refers to knowledge of ethics, standards of care, laws, and regulations relevant to the practice of psychology involving Psychopharmacology.

1001 Knowledge of ethical codes and standards as they pertain to pharmacological practice and research (e.g., the APA Ethical Principles of Psychologists and Code of Conduct, APA Standards for Providers of Psychological Services, AERA/APA/NCME Standards for Educational and Psychological Testing, ASPPB Code of Conduct, Joint Commission on the Accreditation of Healthcare Organizations [JCAHO] Standards)

1002 Knowledge of practice guidelines and standards of care for prescribing psychotropic medications (e.g., documentation requirements, nomenclature for writing prescriptions, written and verbal orders, elements of informed consent, patient education, institutional formulary restrictions, chemical restraints, Agency for Health Care Policy and Research [AHCPR] guidelines, National Institute of Mental Health [NIMH] consensus panel protocols, health care organization rules)

1003 Knowledge of federal and state laws and statutes for prescribing psychotropic medication (e.g., FDA regulations, Medicare, controlled substance laws, specifics of psychologists' licensing laws, patient's rights)
1004 Knowledge of issues involved in collaboration and consultation with other health care providers who are also prescribers and/or psychotherapists (e.g., "ownership' of patients, when to refer or seek consultation, differences in theoretical orientation, triangulation, appropriate levels of disclosure)

1005 Knowledge of provision of psychotropic medications within specific environments (e.g., structured and unstructured environments, classroom and home, correctional institutions. military, substance abuse facilities)

1006 Knowledge of patient's rights (e.g., informed consent, right to refuse treatment, right to treatment within the least restrictive environment, duty to warn, and privileged communication)

1007 Knowledge of issues regarding relationships with pharmaceutical companies (e.g., acceptance of gifts, revealing sources of funding and affiliations)

 

[sasevan]

Note: The complex of factors influencing human functioning noted in Content Area 1, i.e., biological (e.g. genetic, sex, age, disease), psychological (e.g, cognitive, emotional, dynamic, motivational, behavioral), psychosocial (e.g., gender, cultural/ethnicity, interpersonal), and ecological/environmental factors should be considered as they apply across all knowledge areas.

Neurochemistry

This course will emphasize the various neurotransmitter systems relevant to modern psychopharmacological practice. These include but are not limited to: serotonin, norepinephrine, dopamine, acetylcholine, glutamate, GABA, opiods, and Substance P. The interaction of these neurotransmitters with their receptors will be emphasized, as will the mechanism of action of the various receptor systems. The biochemical mechanisms of action of prototypical drugs used in modern psychopharmacological practice will be introduced in this course. Including appropriate APA content areas.

0206 Knowledge of major neurotransmitter and neuromodulator synthesis, storage, release, distribution throughout the brain and the rest of the body, action, reuptake, and degradation

0207 Knowledge of neuropeptides (e.g., enkephalin, endorphin, substance P)

II. CLINICAL AND RESEARCH PHARMACOLOGY AND PSYCHOPHARMACOLOGY:

Approximately ten credit hours will be devoted to courses in general pharmacology, psychopharmacology, developmental psychopharmacology, and chemical dependency and pain management, as outlined below. In addition, review of the general principals involved in the conduct of research on psychoactive substances as itemized in APA Content Area 9

Content Area 9: Research

Refers to the methodology, standards, and conduct of research on psychoactive substances. The knowledge base facilitates research design and implementation, accurate data interpretation and communication, effective utilization of findings, the accumulation of scientific knowledge, and the improvement of the practice of clinical psychopharmacology.

General pharmacology:

This core course, consisting of approximately four credit hours, will cover basic science and clinical concepts fundamental to the subject of general pharmacology. This will be presented to introduce genera! principles (such as pharmacodynamics and pharmacokinetics) which will be expanded upon in the psychopharmacology courses, and to provide students with knowledge of general pharmacological agents used in general medical practice. This will introduce the important concept of drug interactions, which will be reemphasized throughout later course work. General principles including routes of administration, half-life, protein-binding, lipid solubility and the blood-brain barrier will be included. General pharmacology principles will include drugs such as antibiotics, cardiovascular agents, analgesics and drugs affecting the renal, pulmonary, gastrointestinal, and urological systems. Drug interactions will be emphasized in each section. Developmental pharmacology will be covered with special emphasis on pharmacokinetic and pharmacodynamic differences in the very young and very old patients. APA Content Area 7 will be covered

Content Area 7harmacology

Refers to the interactions of drugs with biophysiological systems; encompasses pharmacokinetics, pharmacodynamics, pharmacogenetics, and the epidemiology of various medications such as psychotropics, adjunctive agents, and other medications used in the practice of medicine, as well as substances of abuse, OTC products, and food and dietary supplements. The influence of cultural/ethnic factors, environmental factors, and responses of special populations are considered.

0701 Knowledge of drug classifications for psychotropic and adjunctive medications (e.g., stimulants, sedatives, antidepressants, anticholinergics), other drugs used in the practice of medicine, OTC medications, and substances of abuse

0702 Knowledge of biological factors effecting pharmacokinetics and pharmacodynamics

0703 Knowledge of absorption (e.g., delayed-release preparations, rates of absorption after oral dosing or parenteral injection, area under the curve, timing with food intake)
0704 Knowledge of distribution (e.g., plasma protein binding, influence of lipophilicity)

0705 Knowledge of metabolism (e.g., drug metabolism, understanding of the substrate and inhibitors and inducers of the "family" of P450 enzymes, other enzymes outside the liver)

0706 Knowledge of excretion (e.g., renal filtration rate, clearance of drugs)

0707 Knowledge of importance of biological half-life in determining steady-state drug concentrations, dosing schedules, accumulation

0708 Knowledge of drug properties and characteristics (e.g., therapeutic index, therapeutic blood levels/prescription doses, potency, bioavailability, efficacy, cognitive and behavioral manifestations of toxicity, dose-response relationships)

0709 Knowledge of types of drugs and other agents interacting with receptors(e.g., direct and redirect agonists, antagonists, and inverse agonists)

0710 Knowledge of drug-induced cellular adaptation (e.g., cellular signaling ion channels, second messengers, neurotransmitter release, sensitivity, supersensitivity)

0711 Knowledge of drug effects on genetic expression (e.g., down-regulation)

0712 Knowledge of specific neurotransmitters, receptors, modulators, and neuropeptides

0713 Knowledge of mechanisms of action of a range of therapeutic agents with particular focus on psychotropic and adjunctive medications

0714 Knowledge of theoretical relationships thought to exist between neurotransmitter systems and psychopathological conditions based on known mechanisms of action and clinical observations (e. g., roles of serotonin in depression, dopamine in psychosis and substance abuse)

0715 Knowledge of drug-drug and drug-food interactions for a range of medications as well as substances of abuse, and supplements and other OTC products

0716 Knowledge of drug-induced disease, dysfunction, and adverse reactions (e.g., hepatotoxicity, agranulocytosis, dystonias)

0717 Knowledge of genetic polymorphisms (e.g., ethnic and gender differences, differences in cytochrome P450 isoenzymes in drug metabolism)

0718 Knowledge of familial patterns of drug response and toxicity

0719 Knowledge of pharmacoepidemiology (e.g., epidemiology of psychotropic drug use)

0720 Knowledge of tolerance, dependence, and withdrawal

0903 Knowledge of the FDA drug development process (i.e., Phase I: Human Pharmacology; Phase Il: Therapeutic Exploratory; Phase III: Therapeutic Confirmatory; Phase IV: Therapeutic use)

0908 Knowledge of current status of research regarding specific medications

Clinical Psychopharmacology:

This four-credit core course will cover the general principles underlying the use in modern practice of drugs to treat the major classes of mental illness. This will include antipsychotics (conventional and atypical), antidepressants, anxiolytics, mood stabilizers, and special topics. Mechanism of action, drug interactions, pertinent aspects of differential diagnosis will be discussed. Psychiatric aspects of general medical conditions, with particular attention to the diagnosis and treatment of delirium will be presented. APA Content Area 8 will be covered.

 

[sasevan]

Content Area 8: Clinical Psychopharmacology

Refers to the application of pharmacology to the management of psychological/behavioral disorders. This includes indications, contraindications, dosing, adverse effects and toxicities of psychotropic and adjunctive medications, interactions with other medications (including other drugs used in medicine, for recreational purposes, and available for OTC purchase) as well as the management of adverse reactions, overdoses, and toxicities.

0801 Knowledge of indications, contraindications, and off-label uses of various psychotropic and adjunctive medications

0802 Knowledge of rational for psychotropic medication selection, taking into account target symptoms, patient and family history premorbid personality, demographics, comorbid medical conditions, existing medication regimen and potential for interactions, and differences among medications within classes off drugs

0803 Knowledge of dosing, time course of therapeutic action and adverse effects; and patient factors that influence dose (e.g., weight, gender, ethnicity, age, concurrent disease)

0804 Knowledge of therapeutic monitoring, augmentation strategies, and dose adjustment (e.g., titration, cross-taper, discontinuation)

0805 Knowledge of routes of administration (e.g., oral, intramuscular, intravenous, inhalation) and differential response

0806 Knowledge of specific drug toxicities, management of adverse reactions, including overdose, and indications for referral for appropriate medical care (e.g., acute allergic reaction, extrapyramidal symptoms, hypertensive crisis)

0807 Knowledge of interactions of psychotropic and adjunctive medications with other medications (including other drugs used in medicine, for recreational purposes, and available for OTC purchase)

0808 Knowledge of relapse prevention, maintenance, and prophylaxis (e.g., strategies for sustaining remission of substance abuse, ensuring treatment compliance, preventing recurrence of depression)

0809 Knowledge of drug effects in special populations e.g., developmentally disabled, elderly, pregnant or lactating women)

0810 Knowledge of pharmacological implications for comorbidity of age-related and disability-related disorders (e.g., overanxious disorder comorbid with ADHD)

0811 Knowledge of potential psychological and physiological manifestations of (medications including OTC drugs, supplements, and herbal substances) used for nonpsychological purposes (e.g., beta blockers, steroids)

0812 Knowledge of psychological and physiological manifestations of various recreational substances and treatment of intoxication or addiction, including strategies for assisted withdrawal, maintenance, and relapse prevention.

0813 Knowledge of tolerance, cross tolerance, dependence and withdrawal, sensitization/cross-sensitization with respect to specific medications, and the management strategies used to treat them.

0814 Knowledge of drug-seeking behavior, and potential for abuse of prescription medications.

0815 Knowledge of culturally appropriate educational techniques to inform patients about drug utilization, risks, benefits, potential complications, and alternatives to pharmacotherapy (e.g., procedures to enhance compliance, techniques to teach appropriate attribution and self-monitoring).

Developmental Psychopharmacology:

This 1.5 credit course will supplement the general psychopharmacology course by emphasizing the treatment of disorders of childhood and old age. Disorders in children will include ADHD, anxiety disorders, depression, and others. Differences between the treatment of these disorders in children and adults will be pointed out. Treatment of comorbid conditions in children with conduct disorder, mental ******ation, and learning disabilities will be discussed. In the geriatric population, treatment of dementia and delirium will be emphasized. Common medical conditions presenting with psychiatric manifestations, and the treatment of depression, psychosis, anxiety, and insomnia in the elderly will be topics of discussion. Again, drug interactions will be emphasized.

Chemical dependency and pain management:

Substance abuse and its treatment will be discussed in this 1.5 credit course. Major classes of substances of abuse, including alcohol, cocaine, marijuana, opiates, hallucinogens, stimulants, caffeine, and nicotine will be discussed. Diagnosis, evaluation and treatment of intoxication and withdrawal states will be emphasized. Abuse of commonly prescribed psychotropics and drugs used to treat pain will be topics for discussion. The treatment of chronic pain with opiates, antidepressants, mood stabilizers, and other adjunctive treatments will be discussed

III. PATHOPHYSIOLOGY:

This section consists of one four-credit core course, which covers the following topics fundamental to modern pharmacological practice: Normal physiology and pathophysiology (disease states) of the various organ systems of the human body (cardiovascular. renal, endocrine, gastrointestinal, urological, sex organs, organs of special senses, musculoskeletal.) Psychological manifestations of general medical conditions will be emphasized. Interactions of drugs used to treat general medical conditions with those commonly used in psychopharmacological practice will be discussed. Effects of general medical conditions on drug pharmacokinetics and pharmacodynamics as well as effects of age, sex, and ethnicity will be discussed. This section will include APA Content Area 4

Content Area 4: Physiology and Pathophysiology

Refers to normal physiology and pathophysiology across the life span, and to their impact on psychological functioning and psychopharmacology.

0401 Knowledge of indications for referral to other health care providers for treatment or additional assessment

0402 Knowledge of basic cardiovascular system physiology and pathophysiology across the life span (e.g., rhythm and rate disorders such as prolonged QT interval)

0403 Knowledge of interrelationships between cardiovascular functioning and: psychopharmacology (e.g., EKG changes secondary to TCAs, blood pressure changes secondary to psychotropics, beta blockers, and depression), and psychopathology (e.g., mitral valve prolapse related to panic disorder, tachycardia related to generalized anxiety disorder)

0404 Knowledge of basic pulmonary system physiology and pathophysiology across the life span

0405 Knowledge of interrelationships between pulmonary functioning and psychopharmacology (e.g., theophylline and anxiety, beta blockers and asthma), and psychopathology (e.g., hypoxia versus dementia)

0406 Knowledge of basic renal/genitourinary system physiology and pathophysiology across the life span (e.g., effect of electrolyte imbalance on mental status)

0407 Knowledge of interrelationships between renal/genitourinary functioning and (a) psychopharmacology (e.g., effect of psychotropic substances on urinary/sexual functioning), and (b) psychopathology (e.g., urinary tract infection and mental status change in the elderly)

0408 Knowledge of basic hepatic system physiology and pathophysiology across the life span (e.g., first-pass metabolism, disorders affecting first-pass metabolism)

0409 Knowledge of interrelationships between hepatic functioning and (a) psychopharmacology (e.g., the interaction between psychotropics and liver enzymes, such as the cytochrome P450 system), and b) psychopathology (e.g., metabolic encephalopathy and delirium; carcinoid tumor and anxiety)

0410 Knowledge of basic endocrine system physiology and pathophysiology across the life span (e.g., relationship between thyroid function tests and hypothyroidism and hyperthyroidism)

0411 Knowledge of interrelationships between endocrine functioning and (a) psychopharmacology (e.g., elevated prolactin and antipsychotic medications), and b) psychopathology {e.g., hormonal disequilibrium and perimenstrual dysphoria, depression and Cushing's disease)

0412 Knowledge of basic hematological system physiology and pathophysiology across the life span

0413 Knowledge of interrelationships between hematological functioning and psychopharmacology (e.g., agranulocytosis and clozapine, thrombocytopenia and carbamazepine), and psychopathology (e.g., anemia and depression) 0414 Knowledge of basic muscular/skeletal/dermatologic system physiology and pathophysiology across the life span (e.g., hypercalcemia and depression)

0415 Knowledge of interrelationships between muscular/skeletal/dermatologic functioning and psychopharmacology (e.g., alopecia and valproic acid), and psychopathology(e.g., OCD and trichotillomania)

0416 Knowledge of basic immunologic/rheumatology system physiology and pathophysiology across the life span (e.g., systemic lupus erythematosus (SLE).

0417 Knowledge of interrelationships between immunologic/rheumatologic functioning and (a) psychopharmacology, and b) psychopathology (e.g., SLE and depression, fibromyalgia and depression, AIDS-related dementia)

0418 Knowledge of interface of psychological, physiological, and behavioral factors and their relationship in complex behaviors and processes involving multiple body systems (e.g., psychoneuroimmunology, sexual functioning)

0419 Knowledge of relationship of complex behaviors involving multiple body systems with (a) psychopharmacology (e.g., sleep disruption secondary to antidepressant medication), and (b) psychopathology (e.g., sexual dysfunction and depression)

 

[sasevan]

IV. INTRODUCTION TO PHYSICAL ASSESSMENT, LABORATORY EXAMS & DIFFERENTIAL DIAGNOSIS

This three-credit course will introduce the topics of basic history and physical examination, as they are pertinent to prescribing of medication. The goal of this course will be to allow the practitioner to gain the knowledge necessary to interpret reports of medical histories, physical examinations, and laboratory studies. Laboratory studies will include basic blood chemistry panels, complete blood counts, thyroid and other endocrinological tests, urinalyses, basic radiological studies computed tomography scans, magnetic resonance imaging studies of the brain, electrocardiogram reports, and electroencephalogram reports. The monitoring of psychotropic medications with blood levels where appropriate and required concomitant general laboratory tests (e.g.: liver function tests with Depakote, thyroid function tests with lithium, etc.) will be emphasized. The ability to distinguish between side effects of medication versus signs and symptoms of general medical conditions, as they are manifested in the history, physical exam, and laboratory studies, will be emphasized also. This area will include APA Content Area 5 and Content Area 6

Content Area 5: Biopsychosocial and pharmacological assessment and monitoring

Refers to a range of biopsychosocial (psychological, neurological, behavioral, physical, biomedical) and pharmacological assessment techniques and procedures for baseline and ongoing evaluation of the individual's physical and psychological health status as well as the assessment of therapeutic efficacy, adverse effects, contraindications for usage, drug interactions, and appropriateness for medication continuation, modification, or discontinuation.

0501 Knowledge of psychological assessment and history taking procedures (e.g., comprehensive individual and family mental health history, dietary habits, mental status, and behavioral assessments)

0502 Knowledge of basic physical and neurological examination procedures

0503 Knowledge of normal laboratory values in screening, assessment, and monitoring techniques, and the implication of disease states, sample timing, and medications on those values

0504 Knowledge of laboratory tests and assessment procedures indicated for general assessment (e.g., basic screening panel), appropriate for use with special populations (e.g., females, individuals experiencing first psychotic break), or before prescribing particular medications (e.g., lithium)

0505 Knowledge of medication-specific therapeutic drug monitoring, and indications for monitoring of clinical laboratory values (e.g., TCA levels, renal functioning in lithium use)

0506 Knowledge of behavioral assessment methods (e.g., rating scales, direct observation of behaviors, parent/teacher/self report) in baseline and ongoing monitoring of therapeutic effectiveness, quality of life, and adverse effects of psychopharmacological agents (e.g., tardive dyskinesia with antipsychotics, sexual dysfunction with antidepressants)

0507 Knowledge of techniques for differential diagnosis and indications for referral to other health care providers based on identification by abnormal biopsychosocial or pharmacological evaluation measures

0508 Knowledge of intellectual and neuropsychological assessment as it pertains to aiding diagnosis (e.g., depression versus dementia), indications for medication regimens, and ability to provide informed consent

Content Area 6: Differential Diagnosis

Refers to the use of comprehensive diagnostic information about a patient to establish an accurate diagnosis from among possible medical and psychological diagnoses in order to select appropriate treatment modalities and determine appropriateness of referral to other heath care providers.

0601 Knowledge of medical disorders that present as psychological disorders (e.g., ADHD versus PKU versus autism, anxiety versus Graves' disorder)

0602 Knowledge of psychological disorders that present as medical disorders (e.g., factitious disorders, somatization disorders)

0603 Knowledge of psychological signs and symptoms (e.g., mental status changes, memory dysfunction, depression, psychosis) secondary to substances of abuse, prescribed and over-the-counter [OTC] medications, supplements, and alternative treatments (e.g., St. John's Wort, steroids)

0604 Knowledge of varied presentations of psychological disorders in different populations (e.g., depression versus dementia in the elderly, ADHD versus anxiety in children, mania versus paranoid schizophrenia in African Americans)
0605 Knowledge of the use of psychological testing, physical and laboratory assessment, and medication response to clarify diagnostic dilemmas (e.g., mania versus cocaine abuse versus hyperthyroidism versus theophylline overdose)

0606 Knowledge of psychopharmacological implications for mental health disorders with overlapping symptomatology (e.g., major depressive disorder with psychotic features, anxious depression)

0607 Knowledge of dual diagnosis and co-morbid conditions (e.g., double depression, alcoholism and schizophrenia, depression with Parkinson's disease)

0608 Knowledge of iatrogenic effects of medication versus primary symptoms of disease progression (e.g., akathisia versus anxiety; depression versus negative symptoms of schizophrenia; anticholinergic reactions versus dementia; medication-induced tremor, dystonic reaction, or tardive dyskinesia versus primary movement disorders)

 

[sasevan]

V. SPECIAL ISSUES IN PHARMACOTHERAPEUTICS:

Psychotherapy/pharmacotherapy interactions:

This one credit course will examine the single practitioner model, in which one practitioner provides therapy and medication prescription services, versus a split treatment model in which these functions are divided among two practitioners. Literature studies of synergistic interactions between psychotherapy and pharmacotherapy will be introduced. Will include APA Content Area 1

Content Area 1: Integrating clinical psychopharmacology with the

practice of psychology

Refers to the implementation of clinical practices of biopsychosocial assessment, multiaxial diagnosis, and treatment, including pharmacotherapy, in the context of a complex of factors influencing functioning. These factors include biological (e.g., generic, sex, age, disease), psychological (e.g., cognitive, emotional, dynamic, motivational, behavioral), psychosocial (e.g., gender, cultural/ethnic, interpersonal), and ecological/environmental factors.

0101 Knowledge of biopsychosocial variables as determinants of medication effects (c.g., family history, differential familial medication response, patient belief systems, economics, social support, current environmental circumstances)

0102 Knowledge of relative effects of psychopharmacological and psychological interventions as sole, additive, or interactive treatment, for given disorders

0103 Knowledge of limitations and value of single-treatment modalities, combined interventions (i.e., medication employed alone or ha conjunction with a psychological therapy), and patient perceptions (e.g., attributions of therapeutic and adverse psychological meaning of medication, motivations, treatment expectations)

0104 Knowledge of timing and sequencing of interventions to achieve maximum treatment effectiveness, including importance of patient instruction

0105 Knowledge of practitioner-patient relationship, including its impact on medication adherence, efficacy, adverse effects, and response to side effects, and implications for the relationship when physical and pharmacological interventions are utilized

0106 Knowledge of the development and implementation of a coherent and organized treatment plan of psychological and pharmacological intervention

0107 Knowledge of case and medication management techniques to enhance adherence to treatment plan (e.g., biological and psychological principles relevant to adherence, communication skills, patient education techniques, cultural competence)

0108 Knowledge of pharmacoeconomics/cost issues in treatment planning

Computer based practice aids:

Use of computer databases such as Medline literature searches will be introduced. On-line resources such as the National Library of Medicine database and drug interaction databases will be introduced. Computer networks used to receive laboratory and radiology reports, and to communicate with pharmacies will be covered. This course will consist of one-half credit hour.

Pharmacoepidemiology/Literature review and critique:

This one credit hour course will examine the literature relating to treatment of various disorders with psychotropic medication: for example, the literature on maintenance and discontinuation of antidepressant medication. Literature studies of abuse of prescribed and illicit drugs will be included. Attention to research protocols will be emphasized.

0901 Knowledge of psychopharmacological retrieval systems and databases

0902 Knowledge of research designs and analytic techniques used in psychopharmacological research (e.g., double-blind, drug washout, control groups, dose-response relationships, intent-to-treat analyses, endpoint analyses, within-subject and group designs, cross-over, use of "rescue" medications, and concurrent administration of other drugs [including OTC, and nonpsychotropic medications])

0904 Knowledge of measurement issues in psychopharmacological research (e.g., sample heterogeneity; sample size; random assignment of participants to treatment conditions; drug levels; outcome measures; standard monitoring procedures for side effects, adverse effects, and drug levels; interpretation issues; and interobserver reliability)

0905 Knowledge of community and participatory research strategies to enhance the relevance of studies on ethnic/cultural and other undeserved populations (e.g., use of community advisory boards, community involvement in research planning)

0906 Knowledge of regulatory issues in psychopharmacological research (e.g., FDA regulations, informed consent, research ethics, Institutional Review Board [IRB], safety, abuse liability, follow-up, compassionate care)

0907 Knowledge of how to critically review clinical research data and use the information for making treatment decisions.



--------------------------------------------------------------------------------

Center for Psychological Studies NSU


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This page is maintained by: Eduardo Magalhaes and Diane Karol, Dean's Office.
Copyright 2000. Nova Southeastern University
Revised: March 18, 2003.

 

[PublicHealth]

sasevan,

Do you know if clinical psychologists in Florida are pushing for RxP? If so, how much longer before they obtain them?

Anasazi,

That's him! Be careful. He may actually want to obtain rights to prescribe psychotropics to improve our comprehension of metaphors.

 

[Anasazi23]

Anasazi,

That's him! Be careful. He may actually want to obtain rights to prescribe psychotropics to improve our comprehension of metaphors.

LOL

I don't discount anything anymore....

P.S. For God's sake, you can post links in posts so that you don't have to sort through a mile of spam

 

[sdude]

I do think you and me are talking from the same viewpoint. Psychotropic meds are not to be used like candies. SSRI are not the answer to everything. Unfortunately "ask your doc" campaigns minimizes the risks associated w/ these psychotropics. That's why I feel these meds should be prescribed by psychiatrists. These days bulk of the SSRIs and SGAs are prescribed by people who work primarily as PCPs w/o any particular psych experience. The same holds true for stimulants in kids.
The point is it is extremely risky for the untrained to experiment w/ the drugs(be it the pt him/herself, PhDs or no-psych MDs for that matter).
BTW, there are psychiatrists who for whatever reasons restrict themselves to 15-min medcks. If anyone has any experience w/ those sessions they will realize what sub-standard care might creep thru those pt-encounters. This is sub-optimal care of the pt and nothing else. I am afraid w/o addressing the safety issue the PhDs for their own vested interest are arguing for their scripting rights and will provide the same sub-optimal care to the pt(because that's what the 3rd party payors will mandate).
And it's interesting when people have their own interests at heart, how callous they can be to other's safety.
http://pn.psychiatryonline.org/cgi/content/short/39/10/1

I'm afraid you may be right about the psychologist issue. For me, the whole point of letting trained Ph.D's prescribe would be that patients usually see these doctors much more frequently, which would increase the chance that an adverse psychological (and hopefully physical) reaction might be detected. If psychologists just turned into marginally-trained drug dispensers (which as you say, is what 3rd party payors would demand)--patients would not benefit in the least.

My concern has been that many psychiatrists' medical education isn't doing their ambulatory patients much good in the current practice environment. Your standards appear to be much higher, and I admire that, but "on the other side of the fence"--so to speak--the 15 min. med handout of whatever-the-drug-rep-brought-in-that-day seems to be the way most office physicians (psychiatrists and others) operate.

Ultimately, the ball is still in the psychiatrists' court. Somehow you guys need to demand really good, independent research into drug efficacy and side effects. Drug company research is often quite sketchy--particularly when it comes to side effects. Among other things, doctors and patients need serious studies on treatment for severe, resistant depression. New drugs should be compared not only to placebo, but also to established treatments. (I seriously doubt any SSRI manufacturer would want their flagship to go head to head with a MAOI or Elavil for MDD!)

I also think the strong (and completely undertandable) preference doctors have for "safe" drugs like the SSRI's, Depakote, etc. over "dangerous" drugs like Lithium, MAOI's, TCA's, benzos etc. often acts against patients' interests. It should be difficult to impossible to hold a doctor liable for a patient's misuse of medication. Dangerous diseases sometimes require dangerous drugs--whether the condition is cardiovascular or psychiatric--and tort law should reflect this.

 

[lazure]

Empirical Evidence for Selective Reporting of Outcomes in Randomized Trials: Comparison of Protocols to Published Articles
An-Wen Chan, MD, DPhil; Asbj?rn Hr?bjartsson, MD, PhD; Mette T. Haahr, BSc; Peter C. G?tzsche, MD, DrMedSci; Douglas G. Altman, DSc
JAMA. 2004;291:2457-2465.

Thanks so much for the reference....things are worse than I thought.....how can one insist that doctor knows best after reading such articles is beyond me......as a psychologist in training, I see 'clients' not 'patients' and I prefer it that way. I think of myself as providing a service not 'the right answer'.

On a separate thought, some of the psychiatry folks here are proud medical fundamentalists, others have good grasp of problems in interpreting research, others yet are more concerned with psychiatry neglecting the psychosocial aspects of mental illness (these aren't necessarily exclusive categories). What I'd like to know is whether it is realistic to argue for a 'super' mental health professional who is equally at ease in medical/biological, environmental and empirical aspects of psychopathology? In a sense, that's the image that psychologists who want prescription rights are trying to sell....but again, is that realistic or is there a limit to how much the human brain can do.....

 

[PublicHealth]

What I'd like to know is whether it is realistic to argue for a 'super' mental health professional who is equally at ease in medical/biological, environmental and empirical aspects of psychopathology? [/B] In a sense, that's the image that psychologists who want prescription rights are trying to sell....but again, is that realistic or is there a limit to how much the human brain can do.....

Great point. I think it is less an issue of "how much the human brain can do," as it is a reflection of (mis)managed care. I am sure psychiatrists and psychologists would love to spend more time with their patients in order to understand the myriad medical, psychosocial, and environmental factors that impact their health. Unfortunately, they also have to play by the rules outlined by insurance companies and generate enough paper to pay off school loans, mortgages, and car payments. Increasingly, the healthcare profession as a whole seems to be focusing more on quantity of patients seen, and less on quality of patient care. This is especially true in psychiatry, where over-medication appears to be commonplace, and pharmaceutical companies reign supreme. Why do you think most psychiatrists don't even do psychotherapy any more? As I am sure you know, business runs medicine, not physicians and patients.

"Medical psychologists," if such organisms ever come into form, will likely not be "super mental health professionals." They will be more like "pseudo-psychiatrists," non-physician psychologists who prescribe psychotropic medications and provide psychotherapy. Time will tell whether this will work out with respect to patient safety and treatment effectiveness. Until then, we debate!

 

[sasevan]

sasevan,

Do you know if clinical psychologists in Florida are pushing for RxP? If so, how much longer before they obtain them?

Anasazi,

That's him! Be careful. He may actually want to obtain rights to prescribe psychotropics to improve our comprehension of metaphors.

Medications may be necessary since talking appears not to have done much to reduce limited patterns of thinking; in fact, cognitive errors seem to be spreading...maybe the two of you are getting too close...not that there's anything wrong with that...(as Jerry Seinfeld said).

 

[sasevan]

LOL

I don't discount anything anymore....

P.S. For God's sake, you can post links in posts so that you don't have to sort through a mile of spam

OK, I'll give it to you the way you want it: short and quick

For goodness sake, why do you get so upset by BIG things, i.e., the big APA, big posts,...?

 

[sasevan]

"Medical psychologists," if such organisms ever come into form, will likely not be "super mental health professionals." They will be more like "pseudo-psychiatrists," non-physician psychologists who prescribe psychotropic medications and provide psychotherapy. Time will tell whether this will work out with respect to patient safety and treatment effectiveness. Until then, we debate!

To say that medical psychologists who prescribe will be akin to being "pseudo-psychiatrists" is like saying that academic psychiatrists who do behavioral research are akin to being "pseudo-psychologists."

(Is medication going to be needed for similes as well as metaphors?)

Medical psychologists will be a specialization of clinical psychology. They will not be pseudo-psychiatrists anymore than neuropsychologists are pseudo-neurologists.

Medical psychologists will prescribe medication but this will be based on the psychology model, i.e., psychopharmacotherapy will be an adjunctive intervention. Med psychologists like all psychologists will continue to differentiate themselves from psychiatrists in that their primary tools will be psychological assessments (psychometric instruments) and psychological interventions (psychotherapy and cognitive-behavioral therapy).

For goodness sake, do I have to post the ENTIRE evaluation of the DoD project to once again demonstrate that medical psychologists can be and have been (and continue to be so, BTW) safe and effective prescribers?

 

[mdblue]

Medical psychologists will prescribe medication but this will be based on the psychology model, i.e., psychopharmacotherapy will be an adjunctive intervention. Med psychologists like all psychologists will continue to differentiate themselves from psychiatrists in that their primary tools will be psychological assessments (psychometric instruments) and psychological interventions (psychotherapy and cognitive-behavioral therapy).

WTF?

 

[Anasazi23]

OK, I'll give it to you the way you want it: short and quick

For goodness sake, why do you get so upset by BIG things, i.e., the big APA, big posts,...?

Must have something to do with the way my mother treated me as a child...

Med psychologists like all psychologists will continue to differentiate themselves from psychiatrists in that their primary tools will be psychological assessments (psychometric instruments) and psychological interventions (psychotherapy and cognitive-behavioral therapy).

*Begin Dr. Evil voice*

Riiiiiiiight

 

[Anasazi23]

Oh, and about the DoD study:

First quote (from my old friend Hurt)":

Of note; psychologists who graduated from the 3-year Department of Defense prescribing training program did not earn independent prescribing privileges. These ?pharmacopsychologists? were not allowed to either start or stop a medication without direct supervision from a physician. They were not allowed to even independently monitor any individual with ?concomitant unstable medical conditions,? or those younger than 18 or over 65.

At the conclusion of the study, the Gonvernmental Accounting Office (GAO) stated: ?given PDP?s substantial costs and questionable benefits . . . we see no reason to reinstate this demonstration project.?

Then the public is supposed to be impressed with the lack of adverse effects?
Talk about confounding variables...funny I don't see psychologists complaining about the poor study design of this project.
As if that's not enough, now we're supposed to generalize this to the GENERAL POPULATION with LESS supervision and a LARGER formulary? Wow.

In every medical school curriculum, you take classes in study design and some basic statistics. No, we're not computing MANOVAs by hand. There isn't time. USMLE step I, II, and III incoroprate either direct or implied knowledge of basic medical statistics. During your psychiatry residency, you have multiple lectures, classes, speaking events about interpreting the medical literature, and are often required to publish a clinical study in a peer-reviewed journal yourself. Many psychiatry residencies offer research electives. Required continuing medical education classes offer courses, either basic, refresher, or advanced seminars on statistical design and research literature.

If you're a psychiatrist and don't know how to interpret basic medical literature, it's your own fault. Try coming to most of the psychiatric team meetings I've been to and tell the psychiatrist they don't know how to read medical literature. Good luck. Whenever anyone ever speaks of psychiatrists on this forum who are non (and even are) psychiatrists, they seem to speak only of the worst-case psychiatrist who has no interest in therapy, doesn't know an ANOVA from a hole in the ground, uses about 3 different psychiatric medications indiscriminately, doesn't do ECT, has no idea about general medicine, and can't tell an EKG from an EEG. These generalizations are getting tiresome. The door swings both ways...I know more than a handful of psychology Ph.D.s (never mind PsyDs) from various universities that would be lucky if they could calculate a mean, let alone tear apart minute manipulations in study design, statistical analysis or interpretation.

If we're going to decide now that those that can best interpret clinical studies are the ones that should be treating, I look with worry to the day that mathematical scientists, statisticians, and actuaries are running medicine.

P.S. I saw "The Day After Tomorrow" today, err, yesterday. It was shockingly cool and ridiculously stupid at the same time.

 

[Svas]

At the conclusion of the study, the Gonvernmental Accounting Office (GAO) stated: ?given PDP?s substantial costs and questionable benefits . . . we see no reason to reinstate this demonstration project.?

Anasazi,

Everyone is cherry-picking data. Your quote above reflected an island of information in a sea of data that supported the project. It also ignores that the Navy and Air Force are continuing to train psychologists to prescribe and are commissioning graduates from the already existing programs (rather than sending them through the original DoD program).

For the time being, psychologists will advertise the data they choose, psychiatrists will emphasize the data they like . . . and until we get a large enough data pool, this will be how it goes.

There will be dooms-day sayers that will pose that psychologist will kill hundreds of people with the meds they use. Fear-mongering is a great technique and it's worked for thousands of years. Will the American Psychiatric Association do the honest thing and simultaneously publish the adverse events causes by improper medication use by psychiatrists so that the public can rationally compare the data? Doubtful.

We do have an obligation. We've been prescribing medications for years. Our obligation is to teach, to warn, to inform, and to protect (in addition to continuing to provide care). However, our obligation is not to narrowly interpret reality so that it only reflects that with which we are internally or professionally comfortable. Efforts to do just that have been eroding psychiatry for decades. We don't like something . . . we call it pathology. We don't like something .. . we call it dangerous. These reactions might be reasonable. However, in some situations, the reaction is either paranoid or economically defined turf protection.

What would happen if, instead of fighting this process, we embraced those psychologists with the 2 years of advanced training and assisted them to get licensure laws that enabled limited formulary rights . .. so long as they obtained some form of regular supervision from a board-certified psychiatrist? There is value in this from a patient care perspective AND we won't be wasting so much energy, time, and money fighting a battle that, in the end, isn't going to be that productive. These laws would SAIL through the legislatures, would be hailed as patient-care responsible, would save consumers a vast amount of money, and provide access to broader number of providers. Does all progress need to happen with self-injury?

At least that's my take on what psychiatry would do if it really wanted to take a strong leadership role in this issue.

S

 

[sasevan]

Oh, and about the DoD study:

First quote (from my old friend Hurt)":


At the conclusion of the study, the Gonvernmental Accounting Office (GAO) stated: ?given PDP?s substantial costs and questionable benefits . . . we see no reason to reinstate this demonstration project.?

Then the public is supposed to be impressed with the lack of adverse effects?

I knew you wanted it short and quick BUT I can't give it to you that way because, as obvious from your post, short, quick, and easy answers are also often very wrong.

I hope you don't develope a dx/tx style that follows that pattern.
Complex issues just like patients require painstaiking research and work and humble and honest reporting of the facts.
Please remember: DO NO HARM.

Here then is the ENTIRE GAO report:

Prescribing Psychologists: DOD Demonstration Participants Perform Well
but Have Little Effect on Readiness or Costs (Letter Report, 06/01/99,
GAO/HEHS-99-98).

Pursuant to a legislative requirement, GAO reviewed the Military Health
System's (MHS) Psychopharmacology Demonstration Project (PDP), focusing
on: (1) how PDP graduates have been integrated into MHS; (2) the quality
of care they provide to military personnel and beneficiaries; (3) their
effect on medical readiness; and (4) comparing the costs of the program
graduates to those of other military psychologists and psychiatrists.

GAO noted that: (1) the 10 PDP graduates seem to be well integrated at
their assigned military treatment facilities; (2) the graduates
generally serve in positions of authority, such as clinic or department
chiefs; (3) they also treat a variety of mental health patients;
prescribe from comprehensive lists of drugs, or formularies, and carry
patient caseloads comparable to those of psychiatrists and psychologists
at their same hospitals and clinics; (4) also, although several
graduates experienced early difficulties being accepted by physicians
and others at their assigned locations, the clinical supervisors,
providers, and officials GAO spoke with at the graduates' current and
prior locations--as well as a panel of mental health clinicians who
evaluated each of the graduates--were complimentary about the quality of
patient care provided by the graduates; (5) however, granting drug
prescribing authority to 10 military psychologists cannot substantially
affect the medical readiness of an organization staffed by more than 800
psychiatrists and psychologists; (6) according to military psychiatrists
and psychologists GAO talked to, it is unlikely that the graduates'
prescribing abilities and knowledge of psychotropic drugs would be
needed during wartime because these types of drugs are not generally the
treatment of choice in combat; (7) rather, in treating combat stress,
the preferred course of treatment is adequate rest, counseling, and a
quick return to the front lines; (8) nonetheless, clinic and hospital
officials told GAO that the graduates--by reducing the time patients
must wait for treatment and by increasing the number of personnel and
dependents who can be treated for illnesses requiring psychotropic
medications--have enhanced the peacetime readiness of the locations
where they are serving; (9) GAO projects that the Department of Defense
(DOD) will spend somewhat more on these 10 prescribing psychologists
than it would have spent to provide similar services without the
prescribing psychologists; and (10) primarily because of their high
training costs, GAO estimates that over the course of the PDP graduates'
careers, DOD will spend an average of about 7 percent more (or about
$9,700 annually) per PDP graduate than it would spend on a mix of
psychiatrists and psychologists who would treat patients in the absence
of the PDP graduates.

In conclusion, GAO (like ACNP) concluded that medical psychologists were effective and safe prescribes. The decision not to continue the DoD project was due to the cost of ed/training psychologists (or rather, manipulation of cost figures).

While the DoD project was discontinued, the med psychs were permitted to continue to exercise RxP in the DoD and some still do so to this day. Additionally, last year the DoD accepted to ed/train another psychologist in order to become a prescriber.

For those who can handle it , the GAO report is in the following posts.

 

[sasevan]

--------------------------- Indexing Terms -----------------------------

REPORTNUM: HEHS-99-98
TITLE: Prescribing Psychologists: DOD Demonstration Participants
Perform Well but Have Little Effect on Readiness or
Costs
DATE: 06/01/99
SUBJECT: Health care personnel
Performance measures
Military personnel
Human resources utilization
Medical education
Human resources training
Health services administration
Drugs
Cost effectiveness analysis
Mental health care services
IDENTIFIER: DOD Psychopharmacology Demonstration Project
DOD Medical Readiness Strategic Plan
DOD Military Health Services System

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Cover
================================================================ COVER

Report to the Chairman and Ranking Minority Member, Committee on
Armed Services, U.S. Senate

June 1999

PRESCRIBING PSYCHOLOGISTS - DOD
DEMONSTRATION PARTICIPANTS PERFORM
WELL BUT HAVE LITTLE EFFECT ON
READINESS OR COSTS

GAO/HEHS-99-98

DOD Prescribing Psychologists

(101619)

Abbreviations
=============================================================== ABBREV

ACNP - American College of Neuropsychopharmacology
DOD - Department of Defense
MHS - Military Health System
MRSP - Medical Readiness Strategic Plan
PDP - Psychopharmacology Demonstration Project
USUHS - Uniformed Services University of the Health Sciences
VRI - Vector Research, Inc.

Letter
=============================================================== LETTER

B-280869

June 1, 1999

The Honorable John Warner
Chairman
The Honorable Carl Levin
Ranking Minority Member
Committee on Armed Services
United States Senate

The Military Health System (MHS) provides for the mental health care
needs of the approximately 8 million active-duty members, retirees,
and their dependents. To meet these needs, MHS employed 431
psychiatrists and 430 clinical psychologists in fiscal year 1999.
Some functions of psychiatrists and clinical psychologists overlap.
As physicians, however, psychiatrists are trained in and licensed to
practice medicine and are permitted to prescribe medication for the
treatment of both mental and physical conditions. Because no medical
training is required to practice clinical psychology, clinical
psychologists--whether in the military or the civilian
sector--historically have not been permitted to prescribe drugs. In
1991, however, MHS instituted the Psychopharmacology Demonstration
Project (PDP), which was designed to train and use military
psychologists to prescribe psychotropic medications.\1 By June 1997,
when the project was terminated, 10 psychologists had completed the
training and were subsequently assigned to various Air Force, Army,
and Navy military medical facilities across the country.\2

At the time of our review, 9 of the 10 program graduates were still
treating patients and prescribing medications at military hospitals
and clinics.

The Senate report accompanying the fiscal year 1999 National Defense
Authorization Act directed us to study the results of this program,
including the use and performance of the PDP graduates. Based on the
Senate report and subsequent discussions with your offices, our
evaluation (1) describes how PDP graduates have been integrated into
MHS, (2) provides information on the quality of care they provide to
military personnel and beneficiaries, (3) discusses their effect on
medical readiness, and (4) compares the costs of the program
graduates to those of other military psychologists and psychiatrists.
To address these issues, we talked with all 10 PDP graduates and
other providers and officials at the facilities where the graduates
were practicing or had practiced. Although one graduate left the
military during the course of our review, our evaluation includes
information about this graduate's service as a prescribing
psychologist before leaving the military to reflect the full range of
information available on the performance of the graduates. We also
reviewed the PDP graduates' credentials files,\3 performance reviews,
and relevant reports.

Our work was performed from June 1998 through May 1999 in accordance
with generally accepted government auditing standards. Further
information on our scope and methodology is included as appendix I.

--------------------
\1 These drugs affect psychic function, behavior, or experience.

\2 In April 1997, we issued a report on PDP, Defense Health Care:
Need for More Prescribing Psychologists Is Not Adequately Justified
(GAO/HEHS-97-83, Apr. 1, 1997).

\3 The credentials files contain information on education, licenses,
performance evaluations, and other information, as well as a record
of any quality problems that resulted in adverse outcomes.

RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

The 10 PDP graduates seem to be well integrated at their assigned
military treatment facilities. For example, the graduates generally
serve in positions of authority, such as clinic or department chiefs.
They also treat a variety of mental health patients; prescribe from
comprehensive lists of drugs, or formularies;\4 and carry patient
caseloads comparable to those of psychiatrists and psychologists at
the same hospitals and clinics. Also, although several graduates
experienced early difficulties being accepted by physicians and
others at their assigned locations, the clinical supervisors,
providers, and officials we spoke with at the graduates' current and
prior locations--as well as a panel of mental health clinicians who
evaluated each of the graduates--were complimentary about the quality
of patient care provided by the graduates.

However, granting drug prescribing authority to 10 military
psychologists cannot substantially affect the medical readiness of an
organization staffed by more than 800 psychiatrists and
psychologists. Moreover, according to military psychiatrists and
psychologists we talked to, it is unlikely that the graduates'
prescribing abilities and knowledge of psychotropic drugs would be
needed during wartime because these types of drugs are not generally
the treatment of choice in combat. Rather, in treating combat
stress, the preferred course of treatment according to service
readiness officials and field commanders is adequate rest,
counseling, and a quick return to the front lines. Nonetheless,
clinic and hospital officials told us that the graduates--by reducing
the time patients must wait for treatment and by increasing the
number of personnel and dependents who can be treated for illnesses
requiring psychotropic medications--have enhanced the peacetime
readiness of the locations where they are serving.

We project that the Department of Defense (DOD) will spend somewhat
more on these 10 prescribing psychologists than it would have spent
to provide similar services without the prescribing psychologists.
Primarily because of DOD's higher training costs, we estimate that
over the course of the PDP graduates' careers, DOD will spend an
average of about 7 percent more (or about $9,700 annually) per PDP
graduate than it would spend on a mix of psychiatrists and
psychologists who would treat patients in the absence of the PDP
graduates.

--------------------
\4 As used here, "formulary" refers to the set of prescription drugs
that a provider is permitted to prescribe to patients when treating
illnesses.

 

[sasevan]

BACKGROUND
------------------------------------------------------------ Letter :2

The principal mission of MHS is medical readiness. As defined by
DOD, medical readiness encompasses both wartime and peacetime
components. The wartime mission is primary, according to DOD's
Medical Readiness Strategic Plan (MRSP), requiring MHS to provide
top quality health services, whenever needed, in support of military
operations.\5 In peacetime, according to MRSP, the military medical
departments are to maintain and sustain the well-being of the
fighting forces in preparation for war. Finally, MRSP states that
the military may provide care to dependents or retirees in peacetime,
when not employed in preparation and training for the wartime role.
The Army, Navy, and Air Force all use military and civilian health
care providers to meet their readiness needs.

PDP was established by DOD in response to a conference report dated
September 28, 1988, which accompanied the fiscal year 1989 DOD
Appropriations Act (P.L. 100-463). The report directed DOD to
establish a demonstration pilot training program in which military
psychologists may be trained and authorized to issue appropriate
psychotropic medications under certain circumstances."

This training program began in August 1991 with four participants.
Training for the initial class consisted of 2 years of classroom
training at the Uniformed Services University of the Health Sciences
plus 1 additional year of clinical training. For subsequent classes,
however, the training was modified to consist of 1 year of classroom
training and 1 year of clinical training. PDP participants obtained
their clinical experience on inpatient wards and at outpatient
clinics at Walter Reed Army Medical Center in Washington, D.C., or at
Malcolm Grow Medical Center located at Andrews Air Force Base in
Maryland. During the clinical part of the training, participants
were trained to take medical histories and incorporate them into
treatment plans and to prescribe medication for patients with certain
types of mental disorders.

Two prescribing psychologists graduated from the initial training
class in 1994. The three subsequent graduating classes included 1
prescribing psychologist in 1995, 4 in 1996, and 3 in 1997--for a
total of 10 graduates.\6 These 10 graduates--three women and seven
men\7 --represented each of the three services: 4 from the Navy and
3 each from the Air Force and Army. In 1995, as part of the program,
guidelines were issued on the graduates' roles, including a suggested
drug formulary that they would use, a scope of practice limited to
patients between the ages of 18 and 65, and the level of supervision
or proctoring of graduates for 1 year after graduation.

Several evaluations of the program have been completed since its
inception. The American College of Neuropsychopharmacology (ACNP),\8
under contract to DOD, conducted six annual assessments of PDP and
issued a final report on the program in 1998. In conducting these
assessments, an ACNP evaluation panel interviewed PDP participants
and graduates, program officials, classroom instructors, clinical
supervisors, and others. Vector Research, Inc. (VRI), also under
contract to DOD, conducted an evaluation of the program to determine
its cost-effectiveness and feasibility. VRI's report was issued in
May 1996 and concluded that PDP was cost-effective.\9 In our April
1997 report, we expressed concern about VRI's analysis because in our
view it was based, in part, on unrealistic assumptions.

Additionally, as required by the National Defense Authorization Act
for fiscal year 1996 (P.L. 104-106), GAO conducted a study of PDP,
which included (1) an assessment of the need for prescribing
psychologists in MHS, (2) information on the implementation of PDP,
and (3) information on PDP's costs and benefits. In our resulting
1997 report, we concluded that training psychologists to prescribe
medication was not adequately justified because MHS had not
demonstrated a need for prescribing psychologists, the cost of the
program was substantial, and the benefits were uncertain.

In response to the same act, PDP was terminated in June 1997.
However, those psychologists who had graduated from or were currently
enrolled in the program were permitted by the legislation to continue
prescribing psychotropic medication.

--------------------
\5 See DOD, Medical Readiness Strategic Plan (MRSP) 1998-2004
(Washington, D.C.: Aug. 1998), p. 22.

\6 Three participants left the program during the training.

\7 To safeguard the graduates' privacy, we use only masculine
pronouns in this report.

\8 ACNP is a professional association of about 600 scientists from
disciplines such as behavioral pharmacology, neurology, pharmacology,
psychiatry, and psychology.

\9 VRI, Cost-Effectiveness and Feasibility of the DOD
Psychopharmacology Demonstration Project: Final Report (Arlington,
Va.: May 17, 1996).

 

[sasevan]

PDP GRADUATES ARE WELL
INTEGRATED INTO MHS
------------------------------------------------------------ Letter :3

PDP graduates are well integrated into MHS. They hold positions of
responsibility, such as clinic or department head, and treat a broad
spectrum of patients, including active-duty personnel, retirees, and
dependents. They can prescribe medication from comprehensive drug
formularies and have patient caseloads that are comparable to those
of psychiatrists and other psychologists who practice at their
clinics and hospitals. Although the graduates were initially
supervised closely, all but two have been granted independent status,
meaning that they are subject only to the same level of review as
psychiatrists at their locations. However, although the graduates
are currently well integrated, several experienced early difficulties
being accepted at their locations.

PDP GRADUATES HOLD POSITIONS
OF RESPONSIBILITY, AND MOST
TREAT A MIX OF PATIENTS
---------------------------------------------------------- Letter :3.1

The nine program graduates remaining in the military at the time of
our visits are serving as the chief of a clinic or department,
suggesting the high professional esteem in which they are held. For
example, one serves as the chief of an Army division mental health
clinic, one as the commander of an Air Force mental health clinic,
and another as the chief of a Navy hospital's mental health
department. Serving as clinic or department chief includes
performing administrative duties, such as supervising other mental
health providers and managing the day-to-day operations of the
clinic. The one graduate who left the military did not serve as
clinic or department chief during his year of post-PDP service.

Although PDP guidance limits graduates to seeing patients between the
ages of 18 and 65, most graduates see a mix of patients, including
active-duty personnel, retirees, and dependents. Two graduates serve
in clinics that treat only active-duty personnel, and one serves in a
clinic that treats primarily active-duty personnel but also treats
dependents when mental health providers are available. The remaining
seven treat a mix of active-duty personnel, dependents, and retirees.

PDP GRADUATES PRESCRIBE FROM
COMPREHENSIVE DRUG
FORMULARIES
---------------------------------------------------------- Letter :3.2

To guide medical facilities when granting prescribing privileges to
the program graduates, a suggested drug formulary listing
psychotropic drugs by name was created as part of PDP.\10 Six of the
10 graduates are assigned to facilities that granted the graduates
drug formularies that are at least as comprehensive as the drug
formulary recommended for them. The remaining four graduates have
formularies that lack some drugs listed on the suggested formulary
but contain additional drugs not listed on the suggested formulary.
Although these four graduates' formularies do not include all drugs
on the recommended formulary, none noted that this lack of some drugs
reduced their effectiveness in providing patient care.

Some graduates' authority to prescribe is broader than others'.
While four of the graduates have formularies consisting of lists of
specific drugs they can prescribe, five have formularies listing
classes of drugs from which they can prescribe. Formularies listing
drugs by class, rather than by name, allow the flexibility to
prescribe a new medication if it falls into a class of drugs already
authorized. Otherwise, the graduates have to petition to have the
new drug added to their authorized drug formulary. One graduate's
formulary is even more flexible, granting the graduate broad
authority to prescribe psychotropic drugs and their adjuncts.\11

--------------------
\10 Although all graduates received training in the use of
psychotropic drugs to treat mental disorders in patients, they may
not prescribe medications until granted prescribing privileges by the
medical facility where they are assigned. Each facility is
responsible for establishing the list of drugs, or formulary, from
which providers at the facility can prescribe.

\11 Adjuncts are drugs that are commonly used in the treatment of the
side effects of psychotropic medications.

PDP GRADUATES' AVERAGE
MONTHLY CASELOADS ARE
COMPARABLE TO COLLEAGUES'
---------------------------------------------------------- Letter :3.3

Eight of the 10 graduates' caseloads are comparable to those of
psychiatrists and other psychologists at the same location. (The
remaining two graduates practice at locations without psychiatrists
or other psychologists, so their caseloads could not be compared to
other mental health providers'.) For example, one graduate sees an
average of 47 cases per month--higher than both the average for other
psychologists at the same location (40 cases per month) and the
average for psychiatrists at the same location (30 cases per month).
Another graduate--the chief of the clinic in which he works--sees
between 60 and 70 cases per month. Although this is lower than the
average of 100 cases per month seen by the psychiatrist in the same
clinic, the graduate told us that 30 to 50 percent of his time is
spent on administrative duties associated with his position as chief.

Variation in the graduates' average monthly caseloads--which range
from 40 cases for one graduate to 185 cases for another--results in
part from the graduates' locations and responsibilities. For
example, the graduate with the lowest monthly caseload is stationed
overseas and treats only active-duty personnel and their dependents
who have been screened for suitability for overseas assignment. In
addition, this graduate is the chief of the mental health department
and of the hospital credentials committee and serves on the medical
staff executive committee. Conversely, the graduate with the highest
monthly caseload was the only graduate not serving as a clinic or
department chief, allowing this graduate more time to treat patients.

MOST GRADUATES HAVE BEEN
GRANTED INDEPENDENT STATUS
---------------------------------------------------------- Letter :3.4

Initially, all graduates received close supervision by psychiatrists,
in accordance with guidance issued as part of PDP. For example, each
graduate's supervisor reviewed the graduate's charts for patients
receiving medication. Other elements of supervision varied but
included observing patient sessions or meeting separately with
patients; holding formal weekly meetings to discuss cases; and
requiring written approval for either starting, stopping, or changing
the dosage of medications. The level of supervision was subsequently
reduced for all graduates, seven of whom were granted independent
status--meaning that they are subject only to the same level of chart
review as other providers at their location. Another graduate has
been granted independent status for treating outpatients--the bulk of
the graduate's caseload--but is supervised when treating inpatients.
Granting these graduates full or partial independent status indicates
hospital officials' belief that the graduates need no more
supervision than do other prescribing providers.

The remaining two graduates have not been granted independent status.
Officials stationed at one graduate's location told us that they had
anticipated granting him independent status; however, before
officials reevaluated his status, the graduate was transferred to a
new location.\12 The second graduate serves at a facility that has a
policy requiring continued supervision of all physician extenders
(such as prescribing psychologists, physician assistants, and nurse
practitioners) who prescribe medication, regardless of length of
service or level of performance.

--------------------
\12 According to the graduate, hospital officials at the graduate's
new location have not yet determined whether he will be granted
independent status.

 

[sasevan]

SOME GRADUATES EXPERIENCED
INITIAL PROBLEMS WITH
ACCEPTANCE
---------------------------------------------------------- Letter :3.5

While ultimately well integrated at their locations, some graduates
experienced some initial difficulty in this regard. For example, a
graduate from one of the first PDP classes waited 10 months at his
initial location to receive prescribing privileges and waited another
3 months before treating a patient requiring medication. Another
graduate told us he learned that certain drugs on his formulary had
been eliminated only after being informed by a patient that the
hospital pharmacy had rejected a prescription written by the
graduate. However, both graduates have been reassigned to different
locations, and both have been accepted at their new locations.

Some of the graduates encountered initial skepticism from supervising
psychiatrists, primary care physicians, nurses, and hospital
officials who were uncomfortable with the idea of allowing
psychologists to prescribe drugs. For example, one graduate told us
that a physician at his location was so opposed to giving him
prescribing privileges that the doctor resigned from the credentials
committee after these privileges were granted. One psychiatrist at
another location told us that upon learning that he was assigned to
supervise a PDP graduate, he contacted the American Medical
Association to inquire about the ethical propriety of a psychiatrist
serving as a proctor for a prescribing psychologist. However, nearly
all of the physicians and others we spoke to told us that the
graduates' performance subsequently convinced them that the graduates
were well trained and knowledgeable. Several physicians also told us
that they came to rely on the graduates for information about
psychotropic medications.

GRADUATES ARE REPORTED TO
PROVIDE GOOD QUALITY OF CARE
------------------------------------------------------------ Letter :4

Overwhelmingly, the officials with whom we spoke, including each of
the graduates' clinical supervisors, and an outside panel of
psychiatrists and psychologists who evaluated each of the graduates
rated the graduates' quality of care as good to excellent. Further,
we found no evidence of quality problems in the graduates' credential
files.

The graduates' clinical supervisors have the most extensive knowledge
about the graduates' clinical performance because they have been
responsible for reviewing the graduates' charts, discussing cases
with the graduates, and observing the graduates' interactions with
patients. Without exception, these supervisors--all
psychiatrists--stated that the graduates' quality of care was good.
One supervisor, for example, noted that each of the graduate's
patients had improved as a result of the graduate's treatment;
another supervisor referred to the quality of care provided by the
graduate as phenomenal. The supervisors noted that the graduates
are aware of their limitations and know when to ask for advice or
consultation or when to refer a patient to a psychiatrist. Further,
the supervisors noted that no adverse patient outcomes have been
associated with the treatment provided by the graduates.

External evaluators also provided information on the graduates'
quality of care. In 1998, an ACNP panel composed of board-certified
psychiatrists and licensed clinical psychologists performed a final
evaluation of the graduates--interviewing the graduates, their
supervisors, and other officials, and reviewing a portion of each
graduate's patient charts. In its resulting report, ACNP described
each graduate's location and role, discussed the results of
interviews with the graduates' clinical supervisors and others, and
discussed the results of patient chart reviews. In its report, ACNP
stated that the graduates had performed well in all the locations
where they were assigned, that they had performed safely and
effectively as prescribing psychologists, and that no adverse
outcomes had been associated with their performance.\13

--------------------
\13 During our review, we received allegations regarding certain
graduates' performance from two individuals involved in overseeing or
evaluating the graduates. In all cases, we reviewed available
evidence and held discussions with relevant officials. In all but
one case, we found that there was not sufficient evidence to support
the allegations. In the one case, the hospital's chief of medical
staff considered the issue insignificant.

GRADUATES' EFFECT ON READINESS
IS MINIMAL
------------------------------------------------------------ Letter :5

Although the graduates have been well integrated and have been
reported to provide good care, their effect on DOD's medical
readiness could not be more than minimal. DOD has approximately 400
psychiatrists and 400 psychologists; granting prescribing privileges
to 10 psychologists is unlikely to affect combat readiness. Further,
because psychotropic drugs are not used extensively during combat,
the graduates, if deployed in combat, would likely have little effect
on readiness beyond their role as clinical psychologists. However,
evidence we gathered suggests that the graduates have modestly
enhanced the peacetime readiness of military personnel at their
current locations.

GRADUATES ARE UNLIKELY TO
NEED PRESCRIBING ABILITY IN
WARTIME
---------------------------------------------------------- Letter :5.1

Many officials--including service readiness officials and field
commanders--told us that the graduates would likely have little
effect on readiness in combat because psychotropic drugs are not
generally the treatment of choice in combat and thus prescribing
authority would not be in great demand. Because none of the PDP
graduates have been deployed to a combat zone, however, no data exist
on the actual use of the graduates in wartime situations.

According to many officials with whom we spoke, the preferred course
of treatment for combat stress is adequate rest, counseling, and a
quick return to the front lines. Soldiers who require medication are
generally evacuated to hospitals located away from combat areas.
Psychologists' counseling skills can be valuable front-line tools to
handle stress, although this can be accomplished without the special
training given to prescribing psychologists. A service-level medical
readiness official told us that the most effective techniques to
minimize combat stress are proactive--that is, counseling troops upon
their arrival in the combat zone to reduce their anxiety level before
combat. According to officials, the social workers, psychologists,
and psychiatrists who provide this type of proactive counseling have
a far greater effect on the well-being of the troops in battle than
those who treat personnel after combat stress has set in. This
proactive approach does not require prescribing authority.

 

[sasevan]

GRADUATES CONTRIBUTE TO
READINESS AT THEIR LOCATIONS
---------------------------------------------------------- Letter :5.2

Although the PDP graduates' prescribing skills may not be needed in
combat situations, the graduates reportedly improve medical readiness
at their peacetime locations. According to officials, the graduates
improve readiness by reducing the time that patients must wait for
treatment or by increasing the number of patients who can be treated.

Before the graduates were stationed at their current locations, some
patients requiring mental health care received both psychotherapy
from a psychologist and drug therapy from a psychiatrist because
psychologists had not been permitted to prescribe drugs. Patients
who needed to see two providers for treatment could, according to
officials, wait up to 3 weeks to get an appointment with a
psychiatrist. Prescribing psychologists, however, can treat some
patients needing drugs who otherwise would require an appointment
with a psychiatrist. Since these patients see only one
provider--their prescribing psychologist--the time and effort needed
to receive treatment is reduced.

Other benefits may accrue as well. For example, one official told us
that when only a portion of the units in his division--which is
staffed with a psychologist and a psychiatrist--get an order to
deploy, the division has to consider which providers should remain at
the division's permanent location so that the division as a whole has
adequate medical support. In the past, if the division decided to
deploy its psychiatrist, the permanent location would be without a
prescribing mental health provider. Having a prescribing
psychologist enables the division to deploy one prescribing provider
while keeping another at the division's permanent location.

The graduates may also contribute to medical readiness through the
care of dependents. According to several officials with whom we
spoke, personnel who are worried about whether their family members
are receiving adequate care may be affected in their ability to carry
out their duties. One official told us that the PDP graduate in his
unit--who primarily treats dependents--contributes to readiness in
this manner. Because the facility did not have enough psychiatrists
to care for dependents before the graduate was assigned to this
location, those who needed to see a psychiatrist were referred to
civilian psychiatrists in a nearby city. According to this official,
many dependents did not seek care from these psychiatrists because
they could not afford the copayment. The PDP graduate gives the
facility the additional capability to provide care to dependents
without charging them. The official believes that, consequently,
more dependents seek and receive the care they need and fewer
active-duty personnel worry about their family members' treatment.

PDP GRADUATES ARE MORE COSTLY
THAN TRADITIONAL PSYCHOLOGIST
AND PSYCHIATRIST MIX
------------------------------------------------------------ Letter :6

We project that DOD will spend somewhat more on its 10 prescribing
psychologists than it would have spent on providing mental health
services using the traditional mix of psychologists and
psychiatrists. When all DOD expenditures for various mental health
care providers--including salaries and acquisition, training, and
retirement costs--are averaged over the length of time the providers
are expected to serve, the average yearly cost of a PDP graduate is
about 7 percent higher than that of the combination of psychologists
and psychiatrists who would have provided treatment similar to that
provided by the graduates.\14

Adapting a methodology developed by VRI,\15 we analyzed and compared
DOD's costs for providing salaries, training, retirement pay, and
other career-related benefits to military clinical psychologists,
prescribing psychologists, and psychiatrists. We found that mental
health providers' overall yearly costs to DOD are not identical. Of
the three types of providers we analyzed, the costs for military
psychiatrists are the highest--in part because psychiatrists receive
more yearly pay than military clinical psychologists or prescribing
psychologists. The PDP graduates' costs are the next highest and are
considerably more than clinical psychologists--primarily because the
costs involved in training the graduates and evaluating them
(including evaluations by ACNP and VRI) far exceed the training costs
for clinical psychologists.

Considering all career-related costs, we project that, on average,
the PDP graduates will each cost DOD about $9,700 per year--or about
7 percent--
more than the cost of the combination of psychologists and
psychiatrists that would be used to treat patients in their absence.
Appendix II describes our analysis in more detail.

--------------------
\14 Other physicians--such as family practice and internal medicine
doctors--also prescribe psychotropic medications. However,
psychiatrists are the only physicians included in our analysis.

\15 VRI previously evaluated PDP, under contract to DOD. We updated
VRI's model with more current information.
AGENCY COMMENTS
------------------------------------------------------------ Letter :7

In comments received April 26, 1999, responding to a draft of this
report, the Executive Director of DOD TRICARE Management Activity
stated that DOD agreed with the report and had no further comments.

Copies of this report are being sent to Representative Floyd Spence,
Chairman, and Representative Ike Skelton, Ranking Minority Member,
House Committee on Armed Services; and to the Honorable William
Cohen, Secretary of Defense. Copies will also be made available to
others upon request. If you have any questions about this report,
please call me at (202) 512-7101 or Ronald J. Guthrie, Assistant
Director, at (303) 572-7332. Other major contributors to this report
are Steve Gaty, Sigrid McGinty, and Arthur D. Trapp, Senior
Evaluators; and Timothy J. Carr, Economist.

Stephen P. Backhus
Director, Veterans' Affairs and
Military Health Care Issues

OBJECTIVES, SCOPE, AND METHODOLOGY
OF OUR REVIEW
=========================================================== Appendix I

The objectives of our review were to

-- describe how the 10 Psychopharmacology Demonstration Project
(PDP) graduates have been integrated into the Military Health
System (MHS);

-- obtain information on the quality of care they provide to
military personnel, dependents, and retirees;

-- determine their effect on medical readiness; and

-- assess the cost-effectiveness of the PDP graduates.

To address the first two objectives, we visited the current or former
duty locations of nine of the graduates and contacted the remaining
graduate, who is stationed overseas, by telephone. At the locations
we visited, we also interviewed the graduates' clinical supervisors,
the hospital commander or designee, and various other clinicians and
personnel to obtain information about the graduates' performance and
level of integration.

Lacking a uniform definition of integration, we used several measures
of how the graduates were used in order to assess their integration.
We obtained information on each graduate's current position and role,
scope of practice, drug formulary, average monthly caseload, and
level of supervision received. We also reviewed the graduates'
credentials files and performance reviews. We contacted all the
members of an American College of Neuropsychopharmacology (ACNP)
panel that performed a 1998 review of the graduates to obtain their
views about the quality of care provided by the program graduates.
We analyzed ACNP's May 1998 report and the report's supporting
documentation, as well as prior ACNP evaluations of PDP.

To collect information on the PDP graduates' impact on medical
readiness, we spoke with officials from each of the services and from
the Office of the Assistant Secretary of Defense (Health Affairs), as
well as officials at the graduates' locations. In addition, we
reviewed DOD's Medical Readiness Strategic Plan to determine the role
of MHS in supporting DOD's medical readiness.

To assess the cost-effectiveness of the graduates, we used a model
developed by Vector Research, Inc. (VRI), under contract to DOD.
Using updated data and assumptions, we calculated the life-cycle
costs of the graduates, as well as those of other DOD psychologists,
psychiatrists, and other physicians, and compared the annual
life-cycle costs of these providers to determine the cost of the
graduates relative to that of other providers. Appendix II provides
a more detailed description of the model and the assumptions we used
in calculating life-cycle costs.

 

[sasevan]

ANALYSIS OF PDP GRADUATES' COSTS
RELATIVE TO THOSE OF OTHER DOD
PROVIDERS
========================================================== Appendix II

This appendix presents the methodology, data sources, and principal
assumptions we used to calculate the career costs of military
psychiatrists, psychologists, and prescribing psychologists. It also
discusses how we compared the costs of prescribing psychologists to
those of these other mental health care providers. Our analysis
builds on a 1996 VRI study, in which VRI compared the cost of various
types of military health care providers to the cost of a prescribing
psychologist and assessed the relative cost-effectiveness of training
the psychologists to prescribe medication and having them deliver
this service in MHS.\16

For the purposes of this report, we have updated and extended the VRI
analysis, most notably by

-- revising the figures used by VRI to represent the costs involved
in training the prescribing psychologists and

-- estimating the career length of the graduates who currently
remain in the military, based on their career length to date,
and calculating their career costs.

Except where noted, the data we used--such as military pay rates and
health care costs--were provided by VRI. However, we did not verify
the accuracy of these data.

--------------------
\16 Other tasks in the study included identifying impediments to
integrating prescribing psychologists into MHS and evaluating the
potential roles and functions of prescribing psychologists in DOD.

COST ANALYSIS
------------------------------------------------------ Appendix II:0.1

DOD uses several types of providers to deliver mental health care,
including psychologists, psychiatrists, family practice doctors, and
internal medicine doctors. However, their career-related
costs--including salaries, training, and retirement pay--are not
identical and are generally lower for psychologists than for these
physicians. For example, psychologists are not eligible for all
special payments above salaries that physicians may receive.

We calculated the average career costs of the graduates and other
providers and compared them to one another, using costs based on the
anticipated career length and overall cost to DOD of the PDP
graduates and other providers. Most PDP graduates spent a part of
their military careers as clinical psychologists (before they entered
PDP) and part of their military careers as prescribing psychologists
(after they entered PDP). For comparison purposes, we assumed that
the mental health services provided by PDP graduates as prescribing
psychologists are comparable to those provided by psychiatrists\17
--that is, they are trained to perform a function (prescribing
psychotropic medication) that psychiatrists would have to perform in
their absence.\18

Because a PDP graduate's career, on average, is a combination of the
functions performed by psychologists and psychiatrists, we compared
the portion of a PDP graduate's career spent as a psychologist (that
is, before the graduate became a prescribing psychologist) to the
yearly cost of a military psychologist, and we compared the portion
of a PDP graduate's career spent as a prescribing psychologist to the
yearly cost of a military psychiatrist. For example, one PDP
graduate served about 10 years as a military psychologist before
entering PDP and, since then, has served about 4 years as a
prescribing psychologist--for a total of 14 years. Thus, the
graduate spent 71.4 percent (10 years) of his practicing career in
the military as a clinical psychologist and 28.6 percent (4 years) as
a prescribing psychologist. The yearly cost of the graduate could
then be compared to 71.4 percent of the yearly cost of a psychologist
plus 28.6 percent of the yearly cost of a psychiatrist.

Another PDP graduate served 3 years as a military psychologist before
entering PDP and has served 3 years as a prescribing psychologist,
for a total of 6 years. Thus, 50 percent of his practicing career in
the military was spent as a clinical psychologist and 50 percent was
spent as a prescribing psychologist. As a result, the yearly cost of
this graduate could be compared to 50 percent of the yearly cost of a
psychologist plus 50 percent of the yearly cost of a psychiatrist.

The 10 PDP graduates differed in the length of time they had served
as military psychologists before entering PDP, ranging from not
having served in the military to having served 10 years,\19 with a
mean average of about 4.5 years as military psychologists.
Similarly, the participants can be expected to differ in the length
of time each remains in the military as a prescribing psychologist.
We calculated the average length of their projected careers as
prescribing psychologists, based on the length of their military
service to date and the rates at which DOD psychologists have
historically left the military. Using these data, we project that
each program participant will serve an average of 6 years as a
prescribing psychologist after entering PDP (including service to
date as prescribing psychologists). Thus, we expect the participants
to serve an average combined career total of 10.5 years in the
military as clinical psychologists and subsequently as prescribing
psychologists: an average of 4.5 years (or 43 percent of their
careers) as clinical psychologists, plus an average of 6.0 years (or
57 percent of their careers) as prescribing psychologists. The
average yearly cost of the graduates can thus be compared to 43
percent of the yearly cost of a psychologist plus 57 percent of the
yearly cost of a psychiatrist.

Our estimates of the overall cost of the various types of providers
included

-- acquisition costs that DOD incurs when recruiting someone into
the military;

-- training costs to provide DOD-sponsored training to military
health care providers;

-- force costs, which cover basic pay and allowances (such as
allowances for housing), special pay, miscellaneous expenses,
and health care benefits over the course of an active-duty
career; and

-- retirement costs, which include retirement pay and retiree
health care benefits over the expected life of the retiree.

--------------------
\17 Some--including ACNP and the American Psychological
Association--have pointed out that the graduates are not intended to
replace psychiatrists. ACNP wrote, PDP was not designed to replace
psychiatrists . . . and it did not do so. Instead, the program
products' were extended psychologists with [the] value-added
component prescriptive authority provides.

\18 Other physicians--such as family practice and internal medicine
doctors--also prescribe psychotropic medications. However, their
annual life-cycle costs are higher than those of psychiatrists,
primarily because they serve shorter careers than psychiatrists and,
thus, their overall costs are larger on an annual basis. Because
psychiatrists' costs were the lowest of the physicians' costs
analyzed, we used their costs in order to provide the most
conservative comparison.

\19 Two PDP graduates entered PDP immediately upon joining the
military.

 

[sasevan]

DATA AND ASSUMPTIONS
------------------------------------------------------ Appendix II:0.2

Although our analysis resembles VRI's--and in most cases relies on
VRI's data and assumptions--in several instances we used data or
assumptions that differed from VRI's. These differences reflect our
emphasis on incorporating data that reflect, to date, the actual
costs and experience of the program as it was implemented by DOD,
rather than VRI's projections of how the program might be
implemented. We discussed these changes with a VRI official, who
stated that while he disagreed with our estimate of the cost of
classroom training, the assumptions we used in our calculations were
reasonable given the history of the program. The remainder of this
appendix discusses the major assumptions we made in performing our
analysis and explains where and how our data or assumptions differed
from VRI's.

DIFFERENT SCENARIOS
---------------------------------------------------- Appendix II:0.2.1

In calculating the cost-effectiveness of PDP, VRI used two case
scenarios: start-up and optimal. Costs in the start-up scenario
included the nonrecurring, fixed costs associated with PDP
development and initial implementation, such as the cost of the
external evaluation by ACNP, as well as other costs that VRI believed
would diminish or disappear in the long run.

The optimal scenario represented PDP in a long-term, steady state
during which no nonrecurring costs associated with program start-up
would accrue. In this scenario, VRI set the cost of supplies and
training to levels that indicate long-term efficiency.

In contrast to VRI, we did not project different scenarios because
the program has been terminated. Instead, we used data that reflect,
to date, the actual costs and experience of the program as it was
implemented by DOD.

PRE-PDP SERVICE
---------------------------------------------------- Appendix II:0.2.2

VRI assumed that PDP participants would have at least 6 years of
experience as military clinical psychologists when they entered PDP.
However, we found that although the 10 PDP graduates served an
average of almost 7 years in the military before entering PDP, on
average only about 4.5 of those years were spent as a clinical
psychologist. We did not include nonpsychologist years in our cost
comparison.

VRI assumed that the yearly continuation rates--that is, the
probability that a given provider will stay within a given service
occupation during a given year--for program participants before
entering PDP were identical to those for military psychologists,
including some psychologists who leave the military each year after
the first 2 years of service. In contrast, based on the experience
of the program, we used yearly continuation rates that reflect the
fact that no participants left the military before entering PDP.\20

--------------------
\20 The continuation rate used affects the length of service
calculated by the model. Because annual costs depend in part on this
expected length of service, different continuation rates will result
in different annual costs.

PDP CHARACTERISTICS
---------------------------------------------------- Appendix II:0.2.3

VRI used two different estimates of class size, depending on the
scenario. In the start-up case, VRI assumed that, on average, 3.25
psychologists would enter each PDP class, from which 2.25 prescribing
psychologists would graduate. These numbers were based on the
program experience at the time of VRI's report: 13 psychologists had
entered the program and, according to a VRI official, it appeared
that 9 would graduate. VRI set the retention rate during the program
to reflect the assumption that 9 of 13 participants would graduate.

In the optimal case scenario, VRI assumed that, on average, 8.7
psychologists would enter PDP each year, while 6 prescribing
psychologists would graduate. The continuation rate during the
program was identical to that used in the start-up case.

However, of the 13 participants, 10--not 9--graduated from the four
PDP classes. Consequently, we used an average of 3.25 (that is,
13/4)
psychologists entering PDP each year and 2.5 (that is, 10/4)
graduating. We set the continuation rate during the program
accordingly. Further, in order to reflect the fact that 13
psychologists entered PDP--effectively leaving the services'
clinical psychologist force for cost-comparison purposes--we used a
continuation rate for clinical psychologists that differed slightly
from the historical DOD rate to account for these psychologists.

Our estimates of the cost of training the graduates also differed
from those used by VRI. For its cost model, VRI estimated the
overhead costs associated with the program to be $2,890,343.
However, based on ACNP's annual reports (some of which were not yet
published when VRI conducted its study) and our interviews with the
former PDP training director, we estimated the overhead costs to be
about 14 percent lower at $2,474,578.

While our estimate of overhead costs is lower than VRI's estimate,
our estimate of 1 year of classroom training at the Uniformed
Services University of the Health Sciences (USUHS) is markedly higher
than that used by VRI. VRI estimated the classroom training costs
(which do not include the PDP overhead costs it estimated) for
participants to be $39,969, based on its 1995 study of the costs of
graduate medical education and on a survey of the costs of graduate
medical education in the Washington, D.C., area. However, based on
our previous analysis of USUHS costs,\21

we estimated the classroom training costs to be $110,028--or about
175 percent higher than VRI's estimate.

--------------------
\21 Military Physicians: DOD's Medical School and Scholarship
Program (GAO/HEHS-95-244, Sept. 29, 1995).

POST-PDP SERVICE
---------------------------------------------------- Appendix II:0.2.4

To project how long the PDP graduates could be expected to serve as
prescribing psychologists, VRI assumed no graduates would leave the
military for the 2 years immediately following the program. VRI also
assumed that the rate at which the graduates leave the military
thereafter would be identical to the rate at which other clinical
psychologists leave.

In contrast, our projections of the graduates' post-PDP careers were
based on their actual length of service to date. Because all
graduates completed at least 1 year of post-PDP service, we set the
continuation rate for the first year after the program to 1.
However, the yearly rate for the second year was set to 0.9, because
only 9 of the 10 graduates completed a second year of post-PDP
service. To estimate how much longer the graduates who are still in
the military could be expected to remain in the military, we used
information gathered during our interviews with the graduates (such
as the graduates' future plans for military service) as well as
historical continuation rates for DOD clinical psychologists. Based
on these calculations, we estimate that the participants will serve
an average of about 6 years as prescribing psychologists, including
the productive portion of their training.\22 (We conducted a
sensitivity analysis, described at the end of this appendix, to
determine the effect this estimate had on our final cost estimates.)

VRI also assumed that the PDP graduates posed no more of a
malpractice risk to DOD than any other mental health providers
delivering the same treatment to the same types of patients.
Further, VRI assumed that PDP graduates did not receive the special
pay paid to psychiatrists and other physicians in the military,
assuming instead that the salary for PDP graduates was identical to
that for military clinical psychologists. We also used these
assumptions.

--------------------
\22 In accordance with VRI's estimate, we assumed that PDP
participants were not productive (that is, saw no patients) during
the classroom portion of their training and were 50 percent
productive (that is, were half as productive as fully trained
clinicians) during the clinical portion of their training.

SUPERVISORY TIME
---------------------------------------------------- Appendix II:0.2.5

VRI estimated that the PDP graduates would require 5 percent of a
supervisor's time for the remainder of their careers. However, based
on our fieldwork, we reduced that estimate to zero. Although two
graduates have still not been granted independent status, supervision
of the graduates in general has been reduced significantly. For
example, one graduate required about 1 hour per week (or less than 3
percent) of supervisory time during the first 18 months after the
program; during the subsequent 18 months, this graduate has required
about 0.5 hours per month (or less than 0.3 percent) of supervisory
time. Eight of the graduates currently require less than 1 hour per
week of supervisory time. However, not all supervisors were able to
quantify the amount of time they spent supervising the graduates.
Even when supervisors could quantify this time, it was often less
than 1 percent, and as a result we used an estimate of zero to
provide a conservative estimate of the cost of the graduates. Had we
used a percentage larger than zero, our estimate of the PDP
graduates' costs would have been higher. (We conducted a sensitivity
analysis, described at the end of this appendix, to determine the
effect this assumption had on our final cost estimates.)

 

[sasevan]

RETIREMENT COSTS
---------------------------------------------------- Appendix II:0.2.6

Based on DOD figures, VRI calculated pension rates based on an
average service time for military retirees of 22.5 years. However,
our estimates of the graduates' expected length of service yield an
average service time for retirees in this group of 23.8 years. In
other words, the graduates who serve at least 20 years in the
military--and are thus eligible to earn a pension--will likely have
served an average of 23.8 years. We calculated retirement costs
accordingly.

Further, since only some of the graduates' years of service before
entering PDP were spent as military clinical psychologists and
because some of the retirement costs for the graduates are associated
with service as neither clinical psychologist nor prescribing
psychologist, we believe it is not appropriate to include this
portion of retirement costs in our cost comparison. As a result,
retirement cost estimates for the graduates were reduced.

UPDATED COSTS
---------------------------------------------------- Appendix II:0.2.7

The data used in VRI's earlier calculations were in 1996 dollars.
For our analysis, we updated the figures to 1999 dollars using the
most recent estimates of the DOD medical consumer price index.\23

--------------------
\23 Neither we nor VRI discounted the costs included in these
calculations. Discounting determines the present value of an amount
of money that will be spent in the future. For example, a dollar
paid by the government today is more costly than a dollar paid at
some future date because it increases the burden of making interest
payments on the national debt. See Office of Management and Budget,
Guidelines and Discount Rates for Benefit-Cost Analysis of Federal
Programs, Circular A-94 (Washington, D.C.: Office of Management and
Budget, Revised Oct. 29, 1992).

RESULTS OF ANALYSIS
---------------------------------------------------- Appendix II:0.2.8

Table II.1 shows the results of VRI's calculations and our
calculations.

Table II.1

VRI's Cost Estimates and GAO's Cost
Estimates

Yearly life-cycle cost
per full-time
equivalent (1999
dollars)
----------------------
Provider group VRI total GAO total
---------------------------------- ---------- ----------
Psychiatrist $188,472 $188,472
Psychologist 96,819 92,703
Psychologist and psychiatrist 136,895 147,532
combination
Prescribing psychologists (start- 133,942 \a
up case scenario; graduating
class size set to 2.25)
Prescribing psychologists (optimal 120,463 \a
case scenario; graduating class
size set to 6)
PDP graduates (based on program \a 157,226
experience)
----------------------------------------------------------
\a Not applicable.

VRI's estimates for the annual cost of the prescribing psychologists
in both the start-up case ($133,942) and the optimal case ($120,463)
were less than that of the combined psychologist and psychiatrist
cost ($136,895). VRI concluded that the program was cost-effective.
On the other hand, our estimate of the annual cost of prescribing
psychologists ($157,226) was higher than that of the combined
psychologist and psychiatrist cost ($147,532), by about $9,700.

Our estimate of the cost of the graduates is higher than VRI's
because of the different data and assumptions we used, our estimate
of the cost of the psychologists is lower than VRI's because we
adjusted the psychologist continuation rate slightly, and our
estimate of the combination of psychologist and psychiatrist costs is
higher than VRI's because our estimates of the length of time the
graduates served as military clinical psychologists and will serve as
prescribing psychologists differ somewhat from VRI's estimates.
Because the combination of psychologist and psychiatrist costs
depends on the proportion of time the graduates spend as clinical
psychologists and prescribing psychologists, differences in these
proportions will result in different estimates for the combination of
psychologist and psychiatrist.

SENSITIVITY ANALYSIS
---------------------------------------------------- Appendix II:0.2.9

To assess the influence that our assumptions of length of service and
supervisory time had on the results of our calculations, we performed
a sensitivity analysis on each of these assumptions. To perform each
analysis, we varied our assumptions about length of service or
supervisory time while holding all other values constant.

First, we performed a sensitivity analysis on our projections of the
length of time the graduates can be expected to remain in the
military. Using DOD's historical continuation rate for
psychologists, we projected that the participants will serve for
about 6 years as prescribing psychologists, including service to
date. This resulted in our estimate that the annual cost of the
graduates is about $9,700 more than the combined psychologist and
psychiatrist costs used for comparison. If the participants were to
serve for 7 years as prescribing psychologists, the estimated cost
differential between the PDP graduates and the combined psychologist
and psychiatrist costs is reduced to about $6,300. Projecting an
average length of service of 8 years as prescribing psychologists
reduces that differential to about $3,800; 9 years, to about $2,100;
and 10 years, to about $800. Thus, given this program's experience,
the graduates would not be less expensive than the combined
psychologist and psychiatrist unless they served as prescribing
psychologists for an average of more than 10 years.

In addition, because we could not precisely quantify the amount of
supervisory time required by the graduates, we assumed in making our
calculations that the supervisory time was zero. To determine the
effect that this assumption had on our final cost estimates, we
performed a sensitivity analysis using other estimates of supervisory
time. First, we used VRI's estimate that the graduates would require
5 percent of a supervisor's time throughout their career. This
assumption raised the estimated differential between the cost of the
graduates and the combined psychologist and psychiatrist cost from
$9,700 to about $11,800. Assuming 3 percent of a supervisor's time
raised the estimated cost differential to about $11,000 per year;
assuming 1 percent of a supervisor's time raised the estimated cost
differential to about $10,100 per year.

*** End of document. ***

 

[lazure]

Great point. I think it is less an issue of "how much the human brain can do," as it is a reflection of (mis)managed care. I am sure psychiatrists and psychologists would love to spend more time with their patients in order to understand the myriad medical, psychosocial, and environmental factors that impact their health. Unfortunately, they also have to play by the rules outlined by insurance companies and generate enough paper to pay off school loans, mortgages, and car payments. Increasingly, the healthcare profession as a whole seems to be focusing more on quantity of patients seen, and less on quality of patient care. This is especially true in psychiatry, where over-medication appears to be commonplace, and pharmaceutical companies reign supreme. Why do you think most psychiatrists don't even do psychotherapy any more? As I am sure you know, business runs medicine, not physicians and patients.

While we don't have managed care in Canada, that might not last very long given the current legislative changes

Another relevant issue here is one that was brought up by a psychiatrist that visited one of my psychopathology classes. The current focus in psychiatry is not to cure patients but to significantly improve their condition so that they can function. They are not one and the same.... will we ever have a treatment that will restore mental health? whether it's pharmacological and/or talk therapy?

 

[sasevan]

LOL

I don't discount anything anymore....

P.S. For God's sake, you can post links in posts so that you don't have to sort through a mile of spam

For goodness' sake, climb down from that ledge, put aside those pills (self-prescription? ) and sit down with a FL margarita or NY cosmopolitan and read the ENTIRE GAO report. It's not spam, it's information. It may change your entire perspective on this whole issue.

For my sake I'm taking Memorial Day off.
Posting the entire GAO report wore me out.
Hopefully you'll read it or at least stop citing it if you don't.

 

[Anasazi23]

As usual, Sasevan attempts to use gobs of "data," which by the way, reads less like science and more like a communist propaganda release, to overwhelm and convince readers that his is the only way. (can you say Fundamentalism?) As predicted, the highlighted red area stating that psychologists are "safe prescribers" is presented with no retort to the above variables I mentioned. Namely, that the oversight was so strong, the formulary so limited, and the patients so "pure," that generalization to the general population is impossible.

Island of data? Sure, but don't accuse just me of doing this. I didn't post the additional comments on military record delineating why many of the Rxp psychologists dropped out (to go to med school, dissatisfaction with the program, etc) - but I forgot.....only psychiatrists are the scientists publishing data that is convenient to them.

Here's the funny thing....I wouldn't be that against psychologists prescribing if it weren't for the underhanded and offensive way in which they approach the request. Svas keeps stating that we should embrace them and live happily ever after. I've stated numerous times that the psychologists DO NOT WANT OUR OVERSIGHT. As evidenced in their original bills, and by the opposition to the pleas for increased oversight, they want only completely autonomous practicing rights with an unlimited formulary, to be held responsible to a different (some say incompetent by definition) level of care by their OWN governing body, and the ability to take their practice to any area they want - not the "underserved areas" as they blatently lied about in order to for these bills to reach the legislature. Then they can't imagine why psychiatrists and other branches of medicine are upset at the underhanded techniques with which they procure these rights.

I'm not sure why any psychiatrist or other physician would put their necks on the line in Louisiana where psychologists have to (over the phone if they like), present their patient to the attending in order to secure medications for them. Any insuing lawsuit would bring not only the psychologist, but also the attending physician into the suit with them. How you could possibly defend yourself as a physician in this type of trial would be beyond me.

Svas correctly asserts that psychologists will publish data after some time claiming that their prescribing practices are safe. He then also states that psychiatrists should publish similar data in order to compare. Problem is....and contrary to the dearth of erroneous beliefs held in this forum, psychologists will publish data that is beneficial to THEM. At best, statistics will be manipulated in order to show no statistical difference in practice safety comparing the two groups. I've taken enough statistics and research design classes to know how this occurs. Psychiatrists are busy seeing patients, and by the nature of their profession, will publish less data and spend less time hemming over choosing the right multivariate stat possibly to its own detriment. This will be an unfortunate occurance.

 

[mdblue]

For the time being, psychologists will advertise the data they choose, psychiatrists will emphasize the data they like . . . and until we get a large enough data pool, this will be how it goes.
Dr. Svas how to prevent adverse outcome in the process? If there is a psychiatrist overseeing the scripting process how radically it's going to change the current system and how much savings of resources will happen at the end? And I am not bringing up the issue of malpractice.

There will be dooms-day sayers that will pose that psychologist will kill hundreds of people with the meds they use. Fear-mongering is a great technique and it's worked for thousands of years. Will the American Psychiatric Association do the honest thing and simultaneously publish the adverse events causes by improper medication use by psychiatrists so that the public can rationally compare the data? Doubtful.
The same holds true for PhDs too.
Efforts to do just that have been eroding psychiatry for decades. We don't like something . . . we call it pathology. We don't like something .. . we call it dangerous. These reactions might be reasonable. However, in some situations, the reaction is either paranoid or economically defined turf protection.
Unless and until there is enough protection for the pt inbuilt in the system majority of the docs will be sceptical about it. Docs by nature are conservative and rightfully so because they have to conserve the most precious thing- a human life
What would happen if, instead of fighting this process, we embraced those psychologists with the 2 years of advanced training and assisted them to get licensure laws that enabled limited formulary rights . .. so long as they obtained some form of regular supervision from a board-certified psychiatrist?
Why is it necessary for an exceptionally trained "med Psychologist" to seek supervision if they supremely confident about their training? And if they are trained for this only one task they should be able to perform it by their own. There is no half-way in it. If you challenge the basic med model coming up w/ an alternative idea, it's you who have to face the music. You can't belittle the MD model and ask them for help at the same time.
These laws would SAIL through the legislatures, would be hailed as patient-care responsible, would save consumers a vast amount of money, and provide access to broader number of providers.
Are are that naive to belive that it's so simple. All it'll need is a single -ve outcome and a smart-ass lawyer to get these "non-MD providers scripting these mind-altering horrible drugs" out of the playground. People are not that altruistic and being a capitalistic society all of us are after $$. That's the issue here and not "broader access to pt-care." The PhDs are threatened by MSWs and college grads and they want to get a piece of the cake. There is no harm in trying, but why we should tolerate lowering the standard?
Will you feel comfortable in taking your loved ones to these "med PhDs" for tx-I wouldn't . If not why should I refer others to them?
At least that's my take on what psychiatry would do if it really wanted to take a strong leadership role in this issue.S[/QUOTE]
We are competitors, so by definition question of LEADING the team is not there. Why I've to take the risk of supervising "med PhDs" when I can see my pts w/o them? What's my incentive for that? And plz don't give me those altruistic ideas of pt care in the current US helath environment.
I do appreciate your concern about the sub-standard care provided by "SOME" psychiatrists, but I guess they are not the norm. And let's keep it that way.

 

[DrFocker]

Quoted from Svas:

For the time being, psychologists will advertise the data they choose, psychiatrists will emphasize the data they like . . . and until we get a large enough data pool, this will be how it goes

Good point, I wonder when "the big" APA will propose studies comparing the efficacy of using Social workers, Bachelor Psychs, or Chiropractors from performing "medical psychology"? After all, there isn't enough data out there to suggest they can't perform on par with the physician. Psychologists want expanded access to patient care, right? When, will the Psychologists stop this fundamentalism and demand social workers be trained in RXP?

 

[Svas]

Quoted from Dr. Focker:

"Good point, I wonder when "the big" APA will propose studies comparing the efficacy of using Social workers, Bachelor Psychs . . ."

It's been done AND reported. IT wasn't particularly supportive of needing doctoral level training to perform psychotherapy well.

S

 

[Anasazi23]

I think he meant the efficacy of psychiatric social workers and bachelors psychs prescribing.....(hence the "medical psychology" comment)

 

[sasevan]

As usual, Sasevan attempts to use gobs of "data," which by the way, reads less like science and more like a communist propaganda release, to overwhelm and convince readers that his is the only way. (can you say Fundamentalism?) As predicted, the highlighted red area stating that psychologists are "safe prescribers" is presented with no retort to the above variables I mentioned. Namely, that the oversight was so strong, the formulary so limited, and the patients so "pure," that generalization to the general population is impossible.
SEE BELOW

Island of data? Sure, but don't accuse just me of doing this. I didn't post the additional comments on military record delineating why many of the Rxp psychologists dropped out (to go to med school, dissatisfaction with the program, etc) - but I forgot.....only psychiatrists are the scientists publishing data that is convenient to them.
UNBELIEVABLE!!!

Here's the funny thing....I wouldn't be that against psychologists prescribing if it weren't for the underhanded and offensive way in which they approach the request. Svas keeps stating that we should embrace them and live happily ever after. I've stated numerous times that the psychologists DO NOT WANT OUR OVERSIGHT. As evidenced in their original bills, and by the opposition to the pleas for increased oversight, they want only completely autonomous practicing rights with an unlimited formulary, to be held responsible to a different (some say incompetent by definition) level of care by their OWN governing body, and the ability to take their practice to any area they want - not the "underserved areas" as they blatently lied about in order to for these bills to reach the legislature. Then they can't imagine why psychiatrists and other branches of medicine are upset at the underhanded techniques with which they procure these rights.
YOU'RE RIGHT ABOUT THIS ONE; CRITICAL THINKERS DON'T WANT TO BE UNDER FUNDAMENTALISTS! However, mutual consultation/collaboration between psychologists and psychiatrists is welcomed as is even temporary supervision.

I'm not sure why any psychiatrist or other physician would put their necks on the line in Louisiana where psychologists have to (over the phone if they like), present their patient to the attending in order to secure medications for them. Any insuing lawsuit would bring not only the psychologist, but also the attending physician into the suit with them. How you could possibly defend yourself as a physician in this type of trial would be beyond me.
UNBELIEVABLE!!!

Svas correctly asserts that psychologists will publish data after some time claiming that their prescribing practices are safe. He then also states that psychiatrists should publish similar data in order to compare. Problem is....and contrary to the dearth of erroneous beliefs held in this forum, psychologists will publish data that is beneficial to THEM. At best, statistics will be manipulated in order to show no statistical difference in practice safety comparing the two groups. I've taken enough statistics and research design classes to know how this occurs. Psychiatrists are busy seeing patients, and by the nature of their profession, will publish less data and spend less time hemming over choosing the right multivariate stat possibly to its own detriment. This will be an unfortunate occurance.
AGAIN, UNBELIEVABLE!!!

WOW!!!
You didn't read the full GAO report but still alluded to it.

I believed that your mind was already made up and you didn't want to be confused by the facts but your above statements provide evidence of this even beyond what I had expected.

BTW, the retorts to your points were ALL in the full GAO report. That's why I posted it.

You didn't find them. Why?

Three possibilities:

1. You're intellectually challenged,

2. You're lazy, and/or
3. You're being disingenuous.

I'm leaning to the latter two, given that:

1. You actually earned a masters degree in a psychology program so your actions cannot be excused under you being intellectually challenged.

2. However, you found that program to be boring and repetitive. Maybe what you consider "boring" was learning critical thinking skills and "repetitive" the routine application of those skills. I can see why you prefered the Asclepian model (look it up). But it's unfortunate if you believed that since a mind is a terrible thing to waste.

3. By contrast, you may actually be using your brain but in a destructive as opposed to a constructive way: you continue to make outrageous claims and when these are rebutted you then simply move on to making new ones. Maybe then, I should say a terrible mind, what a waste.

I'm now convinced that you're still intentionally contributing misinformation to this discussion making any attempts at genuine dialogue absurd. That's sad.

Anyway, I wish you the best in your upcoming residency. I hope you genuinely take good care of yourself and your patients.

 

[lazure]

what is it with the people on this thread that they take these internet discussions so damn personally? you have a right to disagree but don't take away from your previous thoughtful posts by posting personal attacks ..... these simply fuel the fury and don't accomplish anything...

And yes, the DoD study is promising. But at this point it is just one study and as such, it requires replication by independent researchers. I do not compromise research standards when examining psychologists' work either

 

[sasevan]

Hi Lazure,
Thanks for the advise. I appreciate it.
Usually I try to avoid characterizations but at times the evidence precludes any other course.
If you read through the >200 posts here you may come to similar conclusions.
I genuinely attempted to engage in a dialogue but was finally dissuaded from continuing to do so with those who consistently gave evidence that they weren't seeking common ground.
It's unfortunate because I initially thought that both a common background in psychology and a future in psychiatry would have facilitated such dialogue.
That wasn't the case so I've chosen to recognize reality and cut my losses by ending any further discussion.
Oprah Winfrey once said something to the effect that: when someone says something negative about themselves, believe it the first time; don't make them have to repeat it a second time.
I regret that I did not follow her counsel when I first came upon the infamous quotation in the signature.
Peace.

 

[Anasazi23]

I will not attempt to continue any negative dialogue. Believe it or not, it was not my intention. We agree to disagree. I think that's about the end of it. As a final point, though, you should take a sincere look at your own intentions. Yes, I gave up psychology because I found it unfulfilling. I don't blame others for this. It was my own experience. If others find this insulting, then frankly, so be it. I recognized that the medical model was more in alignment with what I think is proper treatment of patients, and was simply more interesting to me.

After reading the DoD report years ago and more recently, I agree that to psychologists, the study is promising. But as a scientist, it is one tiny baby step in the "proof" that psychologists are so desparately seeking stating that they are as competent prescribers as physicians.

Sasavan, I bet that if we had a beer together at the local Irish pub, it would actually be quite fun and that we'd get along great. Unfortunately, I think the internet (particularly web boards) have a way of making what are often innocuous words seem more hostile and sarcastic. And, also allow people to say things that would be deemed socially inappropriate. In those respects, I may be a victim or such propagation.

I flew to visit my parents yesterday here in Florida and as chance would have it, sat next to a clinical psychologist on the plane - a very nice woman who is a professor at a small liberal arts college in the south. I asked her her opinion about prescription privilages....she stated, "Oh, I think that what psychologists and the APA are doing is inappropriate. If people want to be the best prescribers, they certainly should go to medical school." I can see people cringing in their computer chairs from here, but the salient point is this: Despite research that may or may not be generalizable, despite the fact that NPs or PAs may be prescribing, etc, there is a non-quantifiable component to healthcare in general, and psychiatric practice in particular. Lots of psychiatrists or prescribing psychologists can give medication and not hurt, but many not help much either. In these qualitative respects, people can disagree, and that's OK.

The fact that you're seeking medical school to pursue psychiatry after your PhD (congratulations, btw), tells me, and other readers, something. Perhaps after some time off and soul-searching, you'll find that you prefer the medical model as well, or will see the astounding complexities and information overload experienced in medical school to be eye-opening. You may see that to read about diseases in a book to be informative, but to SEE these same conditions on your clinical rotations and their subtle manifestations is actually disconcerting. Or perhaps not.

Either way, I wish you luck. We all have our passions and are willing to stick up for them. This same enthusiasm should serve our patients well, as long as they don't become dogmatic and destructive.

p.s. And as for my signature, I never intended it to bring so much angst to so many people. I explained myself more fully in another post, but suffice it to say that I'm simply a fan of the show, that's it.

 

[lazure]

To Sasevan,
glad you liked my response Good luck in med school and I'm sure you'll make a wonderful combined MD with great respect for psychology....I'll be happy to refer clients to you


To Anasazi23,

I fully aggree with the right to disagree line. And yes it is extremely easy to freak out about what someone posted given the lack of physical, emotional cues (and the icons here don't help either). Perhaps that's why psychotherapy should never be conducted over the internet .......

 

[sasevan]

Sasavan, I bet that if we had a beer together at the local Irish pub, it would actually be quite fun and that we'd get along great. Unfortunately, I think the internet (particularly web boards) have a way of making what are often innocuous words seem more hostile and sarcastic. And, also allow people to say things that would be deemed socially inappropriate. In those respects, I may be a victim or such propagation.

Anasazi23,
Cool...but no discussion of guild issues.
Peace.
P.S. That woman on the plane will be hunted down...LOL

 

[Anasazi23]

Anasazi23,
Cool...but no discussion of guild issues.
Peace.
P.S. That woman on the plane will be hunted down...LOL

She said she was a member of APS....maybe you could start there

 

[PublicHealth]

http://pn.psychiatryonline.org/cgi/content/full/39/10/1

Louisiana Lawmakers Hurriedly Pass Psychologist-Prescribing Law

Jim Rosack

Even though the new law calls for no specific medical oversight, state officials apparently didn?t believe patient safety was at stake.

On May 6 the state of Louisiana became the second state in the country to authorize psychologists to prescribe psychotropic medications to people with mental illness. The state joins New Mexico, which enacted psychologist-prescribing legislation in March 2002 (Psychiatric News, April 5, 2002).

APA?s reaction was swift and condemning. "[Louisiana] HB 1426 is a rush to judgment that puts politics above patients? lives and safety," said APA President Michelle Riba, M.D. "By enacting it, Gov. [Kathleen Babineux] Blanco and the Louisiana legislature have codified a dangerous, substandard level of care as legally acceptable in Louisiana. HB 1426 puts Louisiana well outside the medical mainstream in the United States and will jeopardize patients struggling with mental illnesses."

While "the lessons to be learned from Louisiana are far from clear" at this time, Riba emphasized that APA plans to undertake "a careful review" as a "key part of continuing to block such reckless laws." (See "From the President" on page 3.)

Blanco, a Democrat, signed HB 1426 after concerted efforts by APA, the Louisiana Psychiatric Medical Association (LPMA), the American Medical Association, and the Louisiana State Medical Association, along with local chapters of the National Alliance for the Mentally Ill and the Depressive and Bipolar Support Alliance, strongly urged the governor to veto the hastily passed legislation.

The original psychologist-prescribing bill was introduced on April 7, sponsored by Louisiana House Speaker Joe Salter (D). An identical bill was introduced on April 13 by Senate President Donald Hines, M.D. (D), who maintains a family practice while the legislature is not in session. With little discussion or debate and only minor amendments, the bill was passed by the House on April 19 by a vote of 62-31.

The next day the Senate received the House bill, and declaring it to be a duplicate of the Senate version, Hines deftly moved the House bill through the Senate chamber. On April 21 Hines used procedural privileges as Senate president to suspend the normal rules for considering legislation in an orderly manner.

When the president pro tempore, Diana Bajoie (D), attempted to offer an amendment that would have prohibited psychologists from prescribing to children, Hines dismissed the effort. He noted that as a physician himself, he could write prescriptions for children for the very medications in question, and he wasn?t required to have a master?s degree in psychopharmacology.

Hines called for a vote, and the measure passed the Senate by a vote of 21-16. In the end, only minor editorial changes and clarifying amendments were passed.

The bill went back to the House immediately, and, again with the rules suspended, representatives voted on it without any conference committee consideration. The House passed the bill by a vote of 68-30.

The final bill was signed by Salter on Thursday, April 22, and by Hines on the following Monday, April 26, starting a 10-day countdown for the governor?s action. In Louisiana the governor may sign passed legislation, veto it, or allow it to go into law without a signature.

Lobbyists for the state medical society and LPMA were so dismayed that they left the legislative chambers silently, shaking their heads.

No Regard for Patient Safety

In the ensuing 10 days, efforts were made with "warp speed," noted LPMA legislative representative Dudley Stewart Jr., M.D. The lobbyists, Stewart, and LPMA President Patrick O?Neill M.D., called in AMA President Donald Palmisano, M.D., who is from Louisiana, to advise the governor?s office of the significant patient-safety concerns that the legislation raised.

The new Louisiana statute will allow a "medical psychologist" to prescribe and distribute "agents related to the diagnosis and treatment of mental and emotional disorders." A "medical psychologist" is loosely defined as a "psychologist who has undergone specialized training in clinical psychopharmacology and has passed a national proficiency examination in psychopharmacology approved by the [psychologist examiners?] board and who holds from the board a current certificate of responsibility."

The only medications that the law specifically exempts are narcotics.

Blanco asserted in a prepared statement that she was "assured by the proponents [of the legislation], including the speaker of the House and the president of the Senate," that the new law?s "tight controls" and "tough" regulations she expects the board of psychologist examiners to promulgate will protect patients? safety. She noted that those who "do not abide" by the provisions of the law could lose their prescribing privileges and "face misdemeanor charges." Yet no such "tough rules" or any regulations are codified by the statute. In fact, complete oversight of psychologist prescribing is granted to the Board of Psychologist Examiners, and it is that same board that the law entrusts to create regulations and procedures to implement the law.

To be eligible to prescribe, applicants must hold a current license to practice psychology and must have "successfully graduated with a postdoctoral master?s degree in clinical psychopharmacology from a regionally accredited institution or equivalent to the postdoctoral master?s degree as approved by the board."

The law?s language describing educational requirements is vague, but it appears to be patterned after the American Psychological Association?s preferred curriculum for prescribing psychopharmacology.

The law requires a prescribing psychologist to "prescribe only in consultation and collaboration with the patient?s primary or attending physician and with the concurrence of that physician." However, Riba noted, "Bluntly, the vaguely defined consultative requirements cited by the governor as a safety measure do not pass muster: there is nothing in the law to ensure that a physician will ever lay eyes on the patient."

Patients Opposed Legislation

Riba said that patient advocacy groups and patients themselves were adamantly opposed to the legislation, and she had urged Gov. Blanco to protect them and their loved ones by vetoing the bill.

"[Psychotropic] medications," Riba emphasized, "impact the whole patient, not just the patient?s mental or emotional disorder, as the governor suggests." These "potent medications," she continued, "may interact with other medications and may impact other medical conditions. As behavioral scientists, psychologists are simply not trained for the medical complexities faced by psychiatrists and other physicians when they prescribe medications."

Riba stressed that APA?s focus must be on "action." As part of an action plan, she added, APA must "review how we respond to these assaults. We will undertake this review quickly, but we should not?unlike the Louisiana legislature?rush to judgment without the benefits of the facts."

Such an examination?determining what was successful in some states and what was unsuccessful in Louisiana?"is a key part of continuing to block such reckless laws," she continued.

 

[sasevan]

Louisiana grants psychologists prescriptive authority
Louisiana psychologists' persistence pays off, and their state becomes the second to pass RxP legislation.

BY JENNIFER DAW HOLLOWAY
Monitor Staff

In a major victory for professional psychology, the Louisiana legislature voted in April to grant prescription privileges to trained psychologists.

The bill passed 62-31 in the Louisiana House and 21-16 in the state's Senate. And then on May 6, Governor Kathleen Blanco (D) signed the bill into law, making Louisiana the second state--New Mexico became the first in 2002--to give specially trained psychologists the authorization to prescribe certain drugs related to the diagnosis and treatment of mental health disorders.

Fueling the bill's passage was legislators' overall sense that it would boost mental health care while providing cost savings--a message communicated through strong relationships psychologists had forged with key politicians, observers say. The president of the Senate, Donald E. Hines, MD (D), and the speaker of the House, Joe R. Salter (D), sponsored the bill. In fact, Hines--a physician--spoke out before the vote in support of the training psychologists must receive in order to prescribe, noting that the 50 current Louisiana psychopharmacology graduates had gone to school every other weekend for two years to obtain their postdoctoral master's degree in psychopharmacology. He also pointed out that many primary-care or family physicians already refer patients to psychologists and that the bill would ensure greater coordination of care.

Applauding such support is James Quillin, PhD, president of the Louisiana Academy of Medical Psychologists (LAMP)--a group of 50 psychopharmacology graduates that has worked hand in hand with the Louisiana Psychological Association (LPA) on RxP issues. He explains the reason behind his praise: "As in most states, front-line treatment of psychological disorders is currently managed by nonpsychiatric physicians who largely welcome the role of psychologists in assisting in the management of these conditions."

In that spirit, the law requires consulation and concurrence between psychologists and physicians.

For example, if a physician refers a patient to a psychologist, and the psychologist determines that the patient is depressed and recommends an antidepressant, the physician and psychologist must agree on the course of treatment, and then the psychologist can write the prescription. This provision, says John Bolter, PhD, LAMP's treasurer, reduces what opponents of the bill often bring up--medical risk. "And it improves patient care because it creates a collaboration. Patients benefit from that," he adds. Echoing Bolter's point that patient care is the major winner is Russ Newman, PhD, JD, APA's executive director for professional practice: "Another state is now poised to improve access to care by enabling qualified psychologists to prescribe." Newman adds that Louisiana's achievement is important because it lays to rest any sense that New Mexico's victory was a fluke. "While two laws may not constitute a critical mass, the groundbreaking ones tend to be the most difficult ones to pass," he explains.

Steady progress

Indeed, Louisiana psychologists laid the groundwork for this success for years. To be exact, they first began the push for prescription privileges in 1995 and introduced their first bill in 1997. In fact, this victory marks their fourth RxP bill introduction. "It's been a multiyear process. Nothing was done in one year--this is a cumulative effect," says Bolter. Adds Quillin, "This has been an issue of educating legislators and you have to stick with it."

And the national RxP movement wasn't built overnight. Advocates base their efforts on the belief that with appropriate training, psychologists can improve patient services by providing psychological psychopharmacological care and by collaborating with primary-care providers, especially in states like Louisiana, where much of the territory is rural and access to services is a problem. So far, 18 states have introduced RxP legislation. In 1999, Guam passed legislation and then in 2002, New Mexico gave prescribing authority to trained psychologists. Combined with these earlier developments, the Louisiana win could pave the way for additional states to gain RxP victories, some observers speculate.

"The more laws we achieve, the more it may help invigorate other states that are advocating for prescriptive authority," Newman points out.

The fact that Louisiana is such a conservative state makes this victory even more stunning, adds Bolter. "It should raise the bar of hope for everyone else," he says.

Building support

Indeed, Louisiana can serve as a model for other states, says Michael Sullivan, PhD, associate executive director for state advocacy in APA's Practice Directorate. Cathy Castille, PhD, president of LPA, adds that the keys to success were "a combination of strategic lobbying, very dedicated and hardworking psychologists and grassroots efforts." The prescriptive authority bill enjoyed the strong support of the consumer advocacy organization known as Louisiana Families for Access to Comprehensive Treatment (LaFACT), a diverse group of families and individuals from all over the state. According to Bolter, LaFACT members were very active during critical periods leading up to the bill's passage.

"It's hard to get people to talk to legislators," he says. But LaFACT made it easy; the group put members in touch with their legislators. So why did so many consumers care enough to join LaFACT? Access to mental health services is a major issue in Louisiana, which has an extreme shortage of psychiatrists. In fact, there are only 518 psychiatrists in the entire state to meet 4.5 million people's needs--that equals about one psychiatrist for every 9,000 citizens, says Quillin. The state ranks 48th in the United States in social services. And to make matters worse, many of the psychiatrists have opted out of the state's Medicare and Medicaid systems. "So there are enormous wait times for an appointment and those who can't pay for services suffer," says Bolter.

As a result, properly trained psychologists can fill an unmet need in Louisiana, he says.

At the same time, these psychologists could even save the state money. According to Bolter, the state contracts for private psychiatric services at a large cost. "So this would be a way for psychologists who are accustomed to working in state hospitals to provide additional services," he says.

Indeed, the bill's benefits to health-care costs and quality were impossible for legislators to pass up, Quillin believes. "It's hard to argue against a bill that represents good, quality health care," says Quillin. "This [will] allow us to begin to address the problem of inadequate access. The alternative is to allow the powerful medical lobby to dictate all policy while they reject safe and meaningful alternatives that could address the present health-care needs."
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PsychNET?
? 2004 American Psychological Association

 

[rpost3]

Just out of curiousity, would you guys still be against it if Ph.D candidates were required to take the necessary pharmacolology and biochem classes and have a residency incorporated into their graduate training? I can't tell, because it really seems that some of you are more worried about medical school losing its percieved "right of passage" status than anything.

I was a Psych. major who has decided on med school instead of graduate school. The problem is it seems like anyone can prescribe lately Chiropractors (sp?), Nurse Practitioners, podatrists, optometrists...you get the picture. There are already too many people who don't go thorugh medical school who can prescribe medicine. But going to medical school shouldn't be the issue. Sufficient pharmocological training should be the issue here. After all, they call it "medical school" not "psychopharmacology school."

Then there's the reasons I'd support it. First off, it's pretty damn hard to get into a Clinical Psych. Ph.D. program. I'm talking around 3.8 - 4.0 for a decent program. So it's not like these people aren't smart enough. Second, according to the head of Pitt's Clinical Psych. admissions committee, there's a huge wait (4-6 months?) to see a Psychiatrist for medication unless we're talking participating as a subject in clinical trials or being an inpatient.

The only way I'd support prescribing rights for Ph.D's is if they went through what would amount to at least a year (straight through) of the necessary pharmacology and biochem classes that medical students go through, and a 6 month - 1 year residency involving the obvious patient contact and clinical application of prescribing the meds that psychiatry residents experience. Those conditions are what were outlined to our class as probable minimum training, so I'm surprised at the utter lack of vigorous training that would be included in the Louisianna bill.

Funny thing is, the average Clinical Psychologist goes through 6-7 years of graduate school. 1.5 - 2 more years training for prescribing rights equates to more schooling than psychiatrists go through! So what you would be looking at is the Ph.D's who already are practicing going through the extra schooling so they can prescribe, and everone else who would have gone that route would just go to medical school for psychiatry instead because it would take less time. So even if the bill passes, in 20 years there would be nobody taking advantage of it 'cause they'd all be in medical school working towards psychiatry anyways. More money, less time...think about it.

 

[PublicHealth]

The only way I'd support prescribing rights for Ph.D's is if they went through what would amount to at least a year (straight through) of the necessary pharmacology and biochem classes that medical students go through, and a 6 month - 1 year residency involving the obvious patient contact and clinical application of prescribing the meds that psychiatry residents experience. Those conditions are what were outlined to our class as probable minimum training, so I'm surprised at the utter lack of vigorous training that would be included in the Louisianna bill.

Medical psychologists in Louisiana are required to complete a program such as the following, which is similar to the program you described in your post.

"The curriculum includes 395 hours of university-based didactic course work with an appropriately interspersed 200 additional hours of supervised clinical practicum. The program is completed in two years. Classes are usually held once per month on Friday, Saturday and Sundays for nine months. Practica are arranged individually during the summer months for training at the Nova Southeastern University Community Mental Health Center and other approved sites. Students upon completion of their practica will have had contact with a minimum of 100 patients who are on medication."

http://www.cps.nova.edu/programs/PostdocMasterPsychopharmC7.html

 

[lazure]

Dear rpost3,
good post and interesting ideas....but you'll get eaten on this thread ......