Professional Issues in Pharmacotherapy for Psychologists: An Update

1
Professional Issues in Pharmacotherapy for
Psychologists An Update

• Robert E. McGrath, Ph.D.
• Fairleigh Dickinson University

2
Where We Are

• Two psychologists approved to prescribe in LA
• Three psychologists approved to prescribe in NM
• At least six DoD graduates continue to prescribe
  for the military, two as heads of mental health
  services
• 40 more psychologists in the pipeline

3
Professional Issues

• Update on Legislation
• Program Recognition
• Practice Guidelines

4
Legislation

• 8 states submitted enabling bills
• CT MO
• GA OR
• HI TN
• IL WY
• NM submitted clarifying bill
• 2 (TN and HI) passed out of committee in one
  body, only 1 (HI) voted on

5
Lessons Learned

• Must be ready for an intensive, multi-year
  campaign
• Must develop relationships with legislators
• Must be ready to start from scratch each time
• Two issues
• Access
• Safety (Wiggins Cummings, 1998)

6
Program Recognition

• NR/ASPPB, not APA
• Limited contact with program directors
• Requiring formal practicum before masters
  degree/certificate
• No one will sign on
• Ultimately, all programs will be masters programs

7
Practice Guidelines (Div. 55)

• Task Force on Practice Guidelines
• Robert E. McGrath (chair)
• Stanley Berman
• Elaine LeVine
• Elaine Mantell
• Beth Rom-Rymer
• Morgan Sammons
• Wendy Stock
• Div. 18 consultant Robert Ax

8
Representativeness of Task Force

• Three program directors
• Two DoD prescribers
• One state-licensed psychologist (a second
  resigned)
• Four members of Div. 55 BoD
• Two members of minority status

9
Understanding Practice Guidelines

• Ethical Standard vs. Practice Guidelines
• Ethics are minimum acceptable behavior,
  guidelines are aspirational
• Ethics are mandatory, guidelines are recommended
• Treatment Guidelines vs. Practice Guidelines
• Treatment guidelines are specific, practice
  guidelines are general
• Treatment guidelines are (ideally) algorithmic,
  practice guidelines are principles

10
Target Populations

• Prescribing psychologists
• Direct collaborators provide input to
  prescribers
• Indirect collaborators refer for medication,
  discuss medication with patients/physicians
• VandenBos Williams (2000)
• 43 of current patients receive meds
• 94 of psychologists have suggested changing
  medication
• 87 have been involved in decision-making

11
DRAFT Guidelines
Draft

• General Guidelines

12
Guideline 1.
Draft

• The degree to which psychologists participate in
  pharmacotherapy should be based on an impartial
  evaluation of the scope of their competence based
  on appropriate education, training and ongoing
  continuing education regarding the use of
  medications and their integration into the
  psychotherapeutic process.

13
Guideline 2.
Draft

• Prescribing psychologists recognize that
  pharmacotherapy is most effectively provided in
  the context of an ongoing therapeutic
  relationship, and endeavor to provide services in
  this context wherever possible.

14
Guideline 3.
Draft

• Psychologists are encouraged to evaluate their
  own feelings about the role of medication in the
  treatment of mental disorders, as they can
  potentially affect communications with patients.

15
Guideline 4.
Draft

• Psychologists will seek to act in a manner
  consistent with best practice standards
  regardless of the mechanism of interaction with
  individuals served.

16
Guideline 5.
Draft

• Psychologists should be aware of population and
  cultural factors that can moderate both the
  interpersonal act of prescribing and the
  pharmacokinetics and pharmacodynamics of
  medication.

17
Draft

• Medical conditions common within specific ethnic
  groups that can masquerade as psychological
  disorders.
• Culture-bound syndromes
• Biological correlates of cultural status
• Psychosocial factors that influence prescribing
  practice

18
DRAFT Guidelines
Draft

• Education Guidelines

19
Guideline 6.
Draft

• Psychologists are encouraged to identify a level
  of knowledge concerning pharmacotherapy that
  takes into consideration the needs of the
  populations they serve and the type of practice
  they wish to establish, and engage in educational
  experiences as appropriate to achieve and
  maintain that level of knowledge.

20
Guideline 7.
Draft

• Psychologists strive to be critical consumers of
  information they receive about psychotropic
  medications, recognizing that much of that
  information at least has the potential to be
  biased.

21
Draft

• Guidelines
• No direct support to CME presenters
• Gifts to prescribers should be related to
  practice, and of limited value (100). No cash or
  equivalents.
• No strings should be attached to the giving of
  gifts.
• Psychologists know even small presents can
  influence behavior.
• Non-sponsored education

22
Draft

• When interpreting the results of sponsored
  trials, psychologists pay particular attention
  to
• changes in enrollment or principal outcomes that
  may have occurred after the trial was initiated
• whether the outcomes measures were appropriate to
  answer the research questions at hand
• how closely the trial conditions and outcomes
  mirror real-world experiences and patient
  outcomes
• whether the trial has met criteria for systematic
  review
• whether the trial has been registered in a
  database designed to assure professionals and the
  public of the integrity of the data that were
  used as the basis for the findings.

23

• Examples of Methods for Pharmaceutical Companies
  to Get the Results They Want from Clinical Trials
• Conduct a trial of your drug against a treatment
  known to be inferior.
• Trial your drugs against too low a dose of a
  competitor drug.
• Conduct a trial of your drug against too high a
  dose of a competitor drug (making your drug seem
  less toxic).
• Conduct trials that are too small to show
  differences from competitor drugs.
• Use multiple endpoints in the trial and select
  for publication those that give favourable
  results.
• Do multicentre trials and select for publication
  results from centres that are favourable.
• Conduct subgroup analyses and select for
  publication those that are favourable.
• Present results that are most likely to
  impressfor example, reduction in relative rather
  than absolute risk.
• R. Smith (2005).

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Guideline 8.
Draft

• In keeping with the previous two guidelines,
  prescribing psychologists are aware of
  technological resources that are available as
  aids in the course of treatment.

25
DRAFT Guidelines
Draft

• Assessment Guidelines

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Guideline 9.
Draft

• Prescribing psychologists should strive to
  develop and maintain competence in monitoring
  both the physical and the psychological sequelae
  of the medications used to treat psychological
  disorders, including laboratory examinations and
  monitoring treatment effectiveness.

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Guideline 10.
Draft

• Prescribing psychologists are responsible for
  assessing and documenting the basic physiological
  status of patients treated with medications,
  particularly when they are aware of a physical
  condition that might complicate the response to a
  psychotropic or predispose a patient towards an
  adverse reaction.

28
DRAFT Guidelines
Draft

• Consultation Guidelines

29
Guideline 11.
Draft

• Consultation for purposes of prescribing
  medication should occur in the context of a full
  biopsychosocial evaluation of the patient.

30
Draft

• Referral from another professional for
  pharmaceutical treatment does not create an
  obligation to prescribe, or to restrict one's
  focus to the physical aspects of the disorder.

31
DRAFT Guidelines
Draft

• Intervention Guidelines

32
Guideline 12.
Draft

• All psychologists involved in the practice of
  pharmacotherapy, whether as collaborators or
  prescribers, should be aware of the potential for
  adverse events associated with the use of
  medication.

33
Guideline 13.
Draft

• A biopsychosocial model requires consideration of
  the psychosocial (risk factors, the sequelae of
  chronic conditions, maintaining factors) as well
  as biological factors.

34
Guideline 14.
Draft

• Pharmacotherapy from a biopsychosocial
  perspective is a collaborative and interpersonal
  activity to the extent the patient is capable.

35
Guideline 15.
Draft

• A prescribing psychologist recognizes that
  adherence to a medication regimen, and the
  patients desires or intentions regarding
  continued use of a medication, must be addressed
  throughout the treatment process.

36
Guideline 16.
Draft

• Adequate prescribing practice require appropriate
  informed consent, that addresses at a minimum the
  agent to be used, the target symptoms, the
  expected duration of treatment, potential adverse
  events and expected benefits, the cost of the
  treatment, and alternative therapies Prescribing
  psychologists assume the role of consultant
  rather than director of treatment, and as such
  they recognize that informed consent is a dynamic
  process and must be revisited throughout the
  treatment course.

37
Informed Consent
Draft

• Medication risks, benefits, common and serious
  adverse effects, and medication/nonmedication
  alternatives
• Contraindications and drug interactions
• Adverse effects that require immediate response
• Potential for titration when indicated
• In combined psychotherapy-pharmacotherapy, an
  effort is made to describe the framework by which
  the sessions are structured.
• Time to pharmacotherapeutic effect
• Patients are afforded an explanation that is
  congruent with their level of education, their
  ability to understand the language, and
  individually tailored with regard to any
  disability which might impair their ability to
  give full informed consent.

38
Guideline 17.
Draft

• Clinical decisions must be made in recognition of
  the subtle influences of effective marketing on
  professional behavior.

39
DRAFT Guidelines
Draft

• Relationships Guidelines

40
Guideline 18.
Draft

• Serving as both prescriber and psychotherapist
  creates a new potential for multiple
  relationships. The psychologist is aware of the
  potential impact of such relationships on the
  process of treatment.

41
Guideline 19.
Draft

• The psychologist must consider the importance of
  appropriate relationships with other
  professionals surrounding the use of medications.

42
Draft

• Feldman and Feldman (1997, p. 2) "potential
  problems with two-therapist integration always
  exist, such as miscommunication, conflict, and
  competition between therapists ... and as a
  result the patient may receive contradictory
  messages about their diagnosis or treatment.
  Therapists must avoid competing for the role of
  primary treatment provider because it interferes
  with the collaborative process, and by extension,
  optimal patient care.

43
Guideline 20.
Draft

• The psychologist who prescribes to individuals
  with whom the psychologist has a personal
  relationship has an increased obligation to
  ensure that medication decisions are based on a
  full and objective evaluation of the recipient's
  needs.

44
DRAFT Guidelines
Draft

• Monitoring Guidelines

45
Guideline 21.
Draft

• Even if not prescribing, psychologists tend to
  have the most consistent contact with patients of
  any professionals involved in the patient's care.
  With this contact comes an increased
  responsibility to monitor side effects,
  compliance, and feelings about medication.

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FDU Psychopharm Program

• M.S. Program in Clinical Psychopharmacology
• 10 course sequence
• Masters degree awarded upon completion of the
  PEP exam
• www.rxpsychology.com