Why Appropriately Trained Psychologists Should Have Prescriptive Authority in Tennessee

1
Why Appropriately Trained Psychologists Should
Have Prescriptive Authority in Tennessee

• Executive Summary and
• Response to the Opposition

2
Today we will show
3
Today we will show

• Why This Bill is Important

4
Today we will show

• Why This Bill is Important
• Five Key Facts About our Bill

5
Today we will show

• Why This Bill is Important
• Five Key Facts About our Bill
• The Extensiveness of Prescribing Psychologists
  Training

6
Today we will show

• Why This Bill is Important
• Five Key Facts About our Bill
• The Extensiveness of Prescribing Psychologists
  Training
• Why Prescribing Psychologists training is much
  more extensive than that of a nurse
  practitioners

7
Today we will show

• Why This Bill is Important
• Five Key Facts About our Bill
• The Extensiveness of Prescribing Psychologists
  Training
• Why Prescribing Psychologists training is much
  more extensive than that of a nurse
  practitioners
• That the citizens of Tennessee need Integrated
  Mental Health Care

8
Today we will show

• Why This Bill is Important
• Five Key Facts About our Bill
• The Extensiveness of Prescribing Psychologists
  Training
• Why Prescribing Psychologists training is much
  more extensive than that of a nurse
  practitioners
• That the citizens of Tennessee need Integrated
  Mental Health Care
• Why Prescribing Psychologists are Safe

9
1. Why This Bill is Important
10
Psychiatry has not disputed many of our
arguments, including that
Importance
11
Psychiatry has not disputed many of our
arguments, including that
Importance

• The unmet need for mental health services in
  Tennessee is tremendous (and failing to treat
  mental health disorders is tremendously costly)

12
Psychiatry has not disputed many of our
arguments, including that
Importance

• The unmet need for mental health services in
  Tennessee is tremendous (and failing to treat
  mental health disorders is tremendously costly)
• There is a severe shortage of psychiatrists in
  Tennessee, and nationally that is not going to
  change

13
Psychiatry has not disputed many of our
arguments, including that
Importance

• The unmet need for mental health services in
  Tennessee is tremendous (and failing to treat
  mental health disorders is tremendously costly)
• There is a severe shortage of psychiatrists in
  Tennessee, and nationally that is not going to
  change
• A recent independent state-wide survey documents
  patients lack of access to Tennessee
  psychiatrists

14
Psychiatry has not disputed many of our
arguments, including that
Importance

• The unmet need for mental health services in
  Tennessee is tremendous (and failing to treat
  mental health disorders is tremendously costly)
• There is a severe shortage of psychiatrists in
  Tennessee, and nationally that is not going to
  change
• A recent independent state-wide survey documents
  patients lack of access to Tennessee
  psychiatrists
• For BC/BS patients average wait is 6 weeks (and
  almost 25 are not taking new patients)

15
Psychiatry has not disputed many of our
arguments, including that
Importance

• The unmet need for mental health services in
  Tennessee is tremendous (and failing to treat
  mental health disorders is tremendously costly)
• There is a severe shortage of psychiatrists in
  Tennessee, and nationally that is not going to
  change
• A recent independent state-wide survey documents
  patients lack of access to Tennessee
  psychiatrists
• For BC/BS patients average wait is 6 weeks (and
  almost 25 are not taking new patients)
• For Medicare patients average is 7 weeks (and
  almost 1/3 are not taking new patients)

16
Psychiatry has not disputed many of our
arguments, including that
Importance

• The unmet need for mental health services in
  Tennessee is tremendous (and failing to treat
  mental health disorders is tremendously costly)
• There is a severe shortage of psychiatrists in
  Tennessee, and nationally that is not going to
  change
• A recent independent state-wide survey documents
  patients lack of access to Tennessee
  psychiatrists
• For BC/BS patients average wait is 6 weeks (and
  almost 25 are not taking new patients)
• For Medicare patients average is 7 weeks (and
  almost 1/3 are not taking new patients)
• For TennCare patients, the median state-wide wait
  is almost 3 MONTHS (82 days) (and a full 40
  percent of psychiatrists are not taking new
  TennCare patients)

17
Psychiatry has not disputed many of our
arguments, including that
Importance

• Primary care physicians, who prescribe the
  majority of psychotropic drugs, are overburdened
  and unfairly expected to treat all the patient's
  mental health problems, and it is unreasonable to
  ever expect them to be able to do so effectively.

18
Psychiatry has not disputed many of our
arguments, including that
Importance

• Primary care physicians, who prescribe the
  majority of psychotropic drugs, are overburdened
  and unfairly expected to treat all the patient's
  mental health problems, and it is unreasonable to
  ever expect them to be able to do so effectively.
• As an inevitable consequence of this situation,
  medications end up being over-utilized and other
  treatments end up being under-utilized, leading
  to out of control pharmacy costs. Care is often
  fragmented, and therefore inadequate, and
  therefore much more costly

19
A Key Fact
Importance

• Non-psychiatric physicians prescribe 85 of the
  psychotropic medications in Tennessee.

20
Importance

• In medical school, these non-psychiatric
  physicians have had, on average

21
Importance

• In medical school, these non-psychiatric
  physicians have had, on average
• A total of just 99 contact hours of training in
  all of pharmacology, including psychopharmacology
  
• (Source www.AAMC.org)

22
Importance

• In medical school, these non-psychiatric
  physicians have had, on average
• A total of just 99 contact hours of training in
  all of pharmacology, including psychopharmacology
  
• A total of just 6.8 weeks of training in the
  diagnosis and treatment of mental disorders
• (Source www.AAMC.org)

23
Importance

• Psychiatry is in fact very concerned about
  Primary Care Physicians lack of training to
  prescribe psychotropic medications

24
Importance

• Psychiatry is in fact very concerned about
  Primary Care Physicians lack of training to
  prescribe psychotropic medications
• Quotes from a recent Wall Street Journal article
  entitled
• Should Family Doctors Treat Serious Mental
  Illness?

25
Importance

• Psychiatry is in fact very concerned about
  Primary Care Physicians lack of training to
  prescribe psychotropic medications
• Quotes from a recent Wall Street Journal article
  entitled
• Should Family Doctors Treat Serious Mental
  Illness?
• General doctors often lack specialized knowledge
  on how to diagnose the most severe types of
  mental illness, and

26
Importance

• Psychiatry is in fact very concerned about
  Primary Care Physicians lack of training to
  prescribe psychotropic medications
• Quotes from a recent Wall Street Journal article
  entitled
• Should Family Doctors Treat Serious Mental
  Illness?
• General doctors often lack specialized knowledge
  on how to diagnose the most severe types of
  mental illness, and
• Psychiatrists argue that general-practice
  physicians dont have enough specific training to
  dispense drugs to people with serious mental
  illness.

27
Our Bottom Line 1 With Tennessees
skyrocketing psychotropic drug costs, and with
Tennessee 1 in the country in prescriptions per
capita, there is a critical need for clinicians
who will provide Integrated Mental Health
Care Treatment which combines
psychotherapeutic, behavioral, and lifestyle
intervention with judicious medication use
hence,Tennessee needs Prescribing Psychologists
Integrated Care
28
2. Five Key Facts about our Bill
29
1. The bill does not pertain to all
psychologists only to those psychologists who
have gone on to complete the FIVE YEARS of
additional postdoctoral training to become
Prescribing Psychologists.
30
2. Prescribing Psychologists seek prescriptive
authority only for those drugs, laboratory tests,
etc., rational to the practice of psychologywe
are not seeking prescriptive authority for an
unrestricted formulary.
31
3. Prescribing Psychologists will not treat any
patients who do not have an established
relationship with a primary care physician.
32
Even after completion of all training, practicum,
and two years of collaborative practice with a
physician, the Prescribing Psychologist must
still, permanentlyestablish and maintain
effective intercommunication with a physician to
make provision for the diagnosis and treatment of
medical problems
33
Note This provision simply reiterates a
statute that already applies to all
psychologists, and which has worked well for over
52 years.
34
Similar bills authorizing Prescribing
Psychologists have already been passed in New
Mexico and Louisiana, and currently 7 other
states have bills pending.
35
3. The Extensiveness of PrescribingPsychologists
Training
36
Regrettably, and predictably, organized
psychiatry has relentlessly opposed all other
professions efforts to expand their scope of
practice, because (to quote the Pew Health
Professions Commission) organized medicine
has no institutional incentive to compromise

Resistance to Change
37
Regrettably, and predictably, organized
psychiatry has relentlessly opposed all other
professions efforts to expand their scope of
practice, because (to quote the Pew Health
Professions Commission) organized medicine
has no institutional incentive to compromise
Psychiatry recently appears to be to shifting
the focus of their opposition to the issue of
relative amounts of biomedical training,
(including undergraduate), among prescribing
professionals
Resistance to Change
38
Resistance to Change
Apparently, heres their argument
Equivalent Years of BIOMEDICAL Education and
Training for Prescribing Practitioners
Prescribing Psychologists (Per our calculations)
39
BUT Our assertion is that this near-exclusive
focus on biomedical training contributes to the
problem of over-prescribing (when all you have
is a hammer, everything looks like a nail)--it
does not promote what is needed in this state
more access to Integrated Mental Health Care.
Resistance to Change
Apparently, heres their argument
Equivalent Years of BIOMEDICAL Education and
Training for Prescribing Practitioners
Prescribing Psychologists (Per our calculations)
40

• Recall that in medical school, the average
  non-psychiatric physician has had, on average
• A total of just 99 contact hours of training in
  all of pharmacology, including psychopharmacology
  
• A total of just 6.8 weeks of training in the
  diagnosis and treatment of mental disorders
• (Source www.AAMC.org)

41
An obvious fact To adequately treat Mental
Health problems and avoid over-prescribing, a
prescribing professional MUST have adequate
training in BOTH1. Biomedical issues AND 2.
Mental Health Care In other words, they must
have training in Integrated Mental Health Care
Lets look at the facts
The Solution to Over-Prescribing
42
The Facts about the TPA-Endorsed Post -Doctoral
Masters Degree in Clinical Psychopharmacology,
administered by Fairleigh Dickinson University
43
The University

• Fairleigh Dickinson University is accredited by
  the Middle States Association of Colleges and
  Schools
• Two campuses in New Jersey and one in England
• App. 10,000 students, 35 graduate

44
The School of Psychology

• APA-accredited Ph.D. Program in Clinical
  Psychology
• New Psy.D. Program in School Psychology
• Two other masters degrees
• Undergraduate programs in psychology and sociology

45
The Program

• 2000 Created as a certificate program by the
  Department of Psychology at University of Florida
• Developed by Dr. Anita Brown, a DoD graduate
• Eliminated unnecessary portions of DoD Program

46
The Program

• 2000 Created as a certificate program by the
  Department of Psychology at University of Florida
• Developed by Dr. Anita Brown, a DoD graduate
• Eliminated unnecessary portions of DoD Program
• 2000 Moved to FDU when Floridas Department of
  Psychiatry pressured the university to close the
  program (i.e., moved due to political pressure)

47
The Program

• 2000 Created as a certificate program by the
  Department of Psychology at University of Florida
• Developed by Dr. Anita Brown, a DoD graduate
• Eliminated unnecessary portions of DoD Program
• 2000 Moved to FDU when Floridas Department of
  Psychiatry pressured the university to close the
  program (i.e., moved due to political pressure)
• 2002 Converted to a Masters program after
• Year-long internal review
• Review by all institutions of higher education
  in NJ
• Is also authorized as a Masters degree program
  in Tennessee by Tennessee Higher Education
  Commission, and reviewed by them annually
• (and the THEC does not authorize mail order
  diplomas)

48
The Program
49
The Program

• Is approximately two years in length

50
The Program

• Is approximately two years in length
• Provides a Post-Doctoral Masters Degree in
  Clinical Psychopharmacology

51
The Program

• Is approximately two years in length
• Provides a Post-Doctoral Masters Degree in
  Clinical Psychopharmacology
• Is accredited by the Middle States Association of
  Colleges and Schools, through FDU

52
The Program

• Is approximately two years in length
• Provides a Post-Doctoral Masters Degree in
  Clinical Psychopharmacology
• Is accredited by the Middle States Association of
  Colleges and Schools, through FDU
• Has had 4 of the 10 original Dept. of Defense
  Prescribing Psychologists involved as faculty,
  including Dr. Anita Brown, who wrote the
  curriculum

53
The Program

• Is approximately two years in length
• Provides a Post-Doctoral Masters Degree in
  Clinical Psychopharmacology
• Is accredited by the Middle States Association of
  Colleges and Schools, through FDU
• Has had 4 of the 10 original Dept. of Defense
  Prescribing Psychologists involved as faculty,
  including Dr. Anita Brown, who wrote the
  curriculum
• Requires that students pass the national
  Psychopharmacology Examination for Psychologists
  in order to actually be awarded the M.S. degree.

54
The Program

• The Program includes emphases on

55
The Program

• The Program includes emphases on
• Clinical application of academic training
• Weekly on-line 1-2 hour case conferences
• Face-to-face meetings for those skills best
  addressed in a hands-on manner, e.g., physical
  exams

56
The Program

• The Program includes emphases on
• Clinical application of academic training
• Weekly on-line 1-2 hour case conferences
• Face-to-face meetings for those skills best
  addressed in a hands-on manner, e.g., physical
  exams
• Academic rigor
• Faculty from top-tier institutions, including
• City University of New York
• University of Georgia
• University of Tennessee Knoxville

57
The Program

• And the FDU training program covers all necessary
  areas of medical science, including

58
The Program

• And the FDU training program covers all necessary
  areas of medical science, including
• Physiology/pathophysiology of organ systems,

59
The Program

• And the FDU training program covers all necessary
  areas of medical science, including
• Physiology/pathophysiology of organ systems,
• Mechanisms of drug action, absorption,
  distribution, metabolism, and excretion.

60
The Program

• And the FDU training program covers all necessary
  areas of medical science, including
• Physiology/pathophysiology of organ systems,
• Mechanisms of drug action, absorption,
  distribution, metabolism, and excretion.
• Pharmacology of major classes of non-psychotropic
  drugs,

61
The Program

• And the FDU training program covers all necessary
  areas of medical science, including
• Physiology/pathophysiology of organ systems,
• Mechanisms of drug action, absorption,
  distribution, metabolism, and excretion.
• Pharmacology of major classes of non-psychotropic
  drugs,
• Current practice in the pharmacological treatment
  of common physical (not mental) disorders (e.g.,
  hypertension, ischemic heart disease, diabetes)

62
Course Contents

• Pathophysiology 1 Covers Basic Cellular
  Concepts, Respiratory System, Cardiovascular
  System, Genitourinary System

63
Course Contents

• Pathophysiology 1 Covers Basic Cellular
  Concepts, Respiratory System, Cardiovascular
  System, Genitourinary System
• Pathophysiology 2 Covers Hematology and
  Immunology, Gastrointestinal System, Endocrine
  System, Musculoskeletal System, Reproductive
  System

64
Course Contents

• Pathophysiology 1 Covers Basic Cellular
  Concepts, Respiratory System, Cardiovascular
  System, Genitourinary System
• Pathophysiology 2 Covers Hematology and
  Immunology, Gastrointestinal System, Endocrine
  System, Musculoskeletal System, Reproductive
  System
• Neuroscience Covers anatomy and physiology of
  Central Nervous System, beginning at the cellular
  level

65
Course Contents

• Pathophysiology 1 Covers Basic Cellular
  Concepts, Respiratory System, Cardiovascular
  System, Genitourinary System
• Pathophysiology 2 Covers Hematology and
  Immunology, Gastrointestinal System, Endocrine
  System, Musculoskeletal System, Reproductive
  System
• Neuroscience Covers anatomy and physiology of
  Central Nervous System, beginning at the cellular
  level
• Neuropharmacology Covers neurotransmitter
  systems (serotonin, norepinephrine, etc.) and an
  introduction to the different classes of
  psychotropic medications

66
Course Contents

• Pathophysiology 1 Covers Basic Cellular
  Concepts, Respiratory System, Cardiovascular
  System, Genitourinary System
• Pathophysiology 2 Covers Hematology and
  Immunology, Gastrointestinal System, Endocrine
  System, Musculoskeletal System, Reproductive
  System
• Neuroscience Covers anatomy and physiology of
  Central Nervous System, beginning at the cellular
  level
• Neuropharmacology Covers neurotransmitter
  systems (serotonin, norepinephrine, etc.) and an
  introduction to the different classes of
  psychotropic medications
• Clinical Pharmacology Covers major classes of
  NON-psychotropic drugs and their uses in common
  medical (NOT mental) disorders.

67
Course Contents

• Professional Issues and Practice Management
  Covers standards of care, legal and ethical
  issues, informed consent, documentation,
  interprofessional relationships

68
Course Contents

• Professional Issues and Practice Management
  Covers standards of care, legal and ethical
  issues, informed consent, documentation,
  interprofessional relationships
• Treatment Issues Series (4 courses) Covers
  biological basis, drug classes, treatment
  guidelines and issues, special populations,
  integrating psychotherapy with medication in

69
Course Contents

• Professional Issues and Practice Management
  Covers standards of care, legal and ethical
  issues, informed consent, documentation,
  interprofessional relationships
• Treatment Issues Series (4 courses) Covers
  biological basis, drug classes, treatment
  guidelines and issues, special populations,
  integrating psychotherapy with medication in
• Affective Disorders Major Depression, Dysthymia,
  etc.

70
Course Contents

• Professional Issues and Practice Management
  Covers standards of care, legal and ethical
  issues, informed consent, documentation,
  interprofessional relationships
• Treatment Issues Series (4 courses) Covers
  biological basis, drug classes, treatment
  guidelines and issues, special populations,
  integrating psychotherapy with medication in
• Affective Disorders Major Depression, Dysthymia,
  etc.
• Psychotic Disorders Schizophrenia, Bipolar
  Disorder, Acute Agitation, etc.

71
Course Contents

• Professional Issues and Practice Management
  Covers standards of care, legal and ethical
  issues, informed consent, documentation,
  interprofessional relationships
• Treatment Issues Series (4 courses) Covers
  biological basis, drug classes, treatment
  guidelines and issues, special populations,
  integrating psychotherapy with medication in
• Affective Disorders Major Depression, Dysthymia,
  etc.
• Psychotic Disorders Schizophrenia, Bipolar
  Disorder, Acute Agitation, etc.
• Anxiety Disorders Panic Disorder, Generalized
  Anxiety Disorder, Obsessive-Compulsive Disorder,
  etc.

72
Course Contents

• Professional Issues and Practice Management
  Covers standards of care, legal and ethical
  issues, informed consent, documentation,
  interprofessional relationships
• Treatment Issues Series (4 courses) Covers
  biological basis, drug classes, treatment
  guidelines and issues, special populations,
  integrating psychotherapy with medication in
• Affective Disorders Major Depression, Dysthymia,
  etc.
• Psychotic Disorders Schizophrenia, Bipolar
  Disorder, Acute Agitation, etc.
• Anxiety Disorders Panic Disorder, Generalized
  Anxiety Disorder, Obsessive-Compulsive Disorder,
  etc.
• Other Disorders Childhood Adolescent Disorders
  (ADHD, etc), Weight Disorders, Dementia, Chronic
  Pain, Sleep Disorders, Substance-Abuse Disorders,
  Personality Disorders, etc.

73
Here is a list of currently required texts for
the program
Required Texts
74
Here is a list of currently required texts for
the programThe American Psychiatric Press
textbook of psychopharmacology. (Schatzberg, A.
F., Nemeroff, C. B., Eds., 2004).
Required Texts
75
Here is a list of currently required texts for
the programThe American Psychiatric Press
textbook of psychopharmacology. (Schatzberg, A.
F., Nemeroff, C. B., Eds., 2004). Clinical
handbook of psychotropic drugs.
(Bezchlibnyk-Butler, K. Z., Jeffries, J. J.,
Ed., 2002).
Required Texts
76
Here is a list of currently required texts for
the programThe American Psychiatric Press
textbook of psychopharmacology. (Schatzberg, A.
F., Nemeroff, C. B., Eds., 2004). Clinical
handbook of psychotropic drugs.
(Bezchlibnyk-Butler, K. Z., Jeffries, J. J.,
Ed., 2002). Essential psychopharmacology
Neuroscientific basis and practical applications.
(Stahl, S., 2000).
Required Texts
77
Here is a list of currently required texts for
the programThe American Psychiatric Press
textbook of psychopharmacology. (Schatzberg, A.
F., Nemeroff, C. B., Eds., 2004). Clinical
handbook of psychotropic drugs.
(Bezchlibnyk-Butler, K. Z., Jeffries, J. J.,
Ed., 2002). Essential psychopharmacology
Neuroscientific basis and practical applications.
(Stahl, S., 2000). Pathophysiology The
biologic basis for disease in adults and
children. (McCance, K. Huether, S., 2002).
Required Texts
78
Here is a list of currently required texts for
the programThe American Psychiatric Press
textbook of psychopharmacology. (Schatzberg, A.
F., Nemeroff, C. B., Eds., 2004). Clinical
handbook of psychotropic drugs.
(Bezchlibnyk-Butler, K. Z., Jeffries, J. J.,
Ed., 2002). Essential psychopharmacology
Neuroscientific basis and practical applications.
(Stahl, S., 2000). Pathophysiology The
biologic basis for disease in adults and
children. (McCance, K. Huether, S., 2002).
Mosbys guide to physical examination. (Seidel,
H., Ball, J., Daines, J., Benedict, G., 1999).
Required Texts
79
Here is a list of currently required texts for
the programThe American Psychiatric Press
textbook of psychopharmacology. (Schatzberg, A.
F., Nemeroff, C. B., Eds., 2004). Clinical
handbook of psychotropic drugs.
(Bezchlibnyk-Butler, K. Z., Jeffries, J. J.,
Ed., 2002). Essential psychopharmacology
Neuroscientific basis and practical applications.
(Stahl, S., 2000). Pathophysiology The
biologic basis for disease in adults and
children. (McCance, K. Huether, S., 2002).
Mosbys guide to physical examination. (Seidel,
H., Ball, J., Daines, J., Benedict, G., 1999).
Concise text of neuroscience. (Kingsley, R.,
1999).
Required Texts
80
Here is a list of currently required texts for
the programThe American Psychiatric Press
textbook of psychopharmacology. (Schatzberg, A.
F., Nemeroff, C. B., Eds., 2004). Clinical
handbook of psychotropic drugs.
(Bezchlibnyk-Butler, K. Z., Jeffries, J. J.,
Ed., 2002). Essential psychopharmacology
Neuroscientific basis and practical applications.
(Stahl, S., 2000). Pathophysiology The
biologic basis for disease in adults and
children. (McCance, K. Huether, S., 2002).
Mosbys guide to physical examination. (Seidel,
H., Ball, J., Daines, J., Benedict, G., 1999).
Concise text of neuroscience. (Kingsley, R.,
1999). Neuroscience. (Purves, D., Augustine, G.
J., Fitzpatrick, D., Eds., 2001).
Required Texts
81
Here is a list of currently required texts for
the programThe American Psychiatric Press
textbook of psychopharmacology. (Schatzberg, A.
F., Nemeroff, C. B., Eds., 2004). Clinical
handbook of psychotropic drugs.
(Bezchlibnyk-Butler, K. Z., Jeffries, J. J.,
Ed., 2002). Essential psychopharmacology
Neuroscientific basis and practical applications.
(Stahl, S., 2000). Pathophysiology The
biologic basis for disease in adults and
children. (McCance, K. Huether, S., 2002).
Mosbys guide to physical examination. (Seidel,
H., Ball, J., Daines, J., Benedict, G., 1999).
Concise text of neuroscience. (Kingsley, R.,
1999). Neuroscience. (Purves, D., Augustine, G.
J., Fitzpatrick, D., Eds., 2001). Modern
pharmacology with clinical applications. (Craig,
C., Stitzel, R., 2004).
Required Texts
82
Here is a list of currently required texts for
the programThe American Psychiatric Press
textbook of psychopharmacology. (Schatzberg, A.
F., Nemeroff, C. B., Eds., 2004). Clinical
handbook of psychotropic drugs.
(Bezchlibnyk-Butler, K. Z., Jeffries, J. J.,
Ed., 2002). Essential psychopharmacology
Neuroscientific basis and practical applications.
(Stahl, S., 2000). Pathophysiology The
biologic basis for disease in adults and
children. (McCance, K. Huether, S., 2002).
Mosbys guide to physical examination. (Seidel,
H., Ball, J., Daines, J., Benedict, G., 1999).
Concise text of neuroscience. (Kingsley, R.,
1999). Neuroscience. (Purves, D., Augustine, G.
J., Fitzpatrick, D., Eds., 2001). Modern
pharmacology with clinical applications. (Craig,
C., Stitzel, R., 2004). Principles of neural
science. (Kandel, E., Schwartz, J.H. Jessell,
T.M.)
Required Texts
83
Here is a list of currently required texts for
the programThe American Psychiatric Press
textbook of psychopharmacology. (Schatzberg, A.
F., Nemeroff, C. B., Eds., 2004). Clinical
handbook of psychotropic drugs.
(Bezchlibnyk-Butler, K. Z., Jeffries, J. J.,
Ed., 2002). Essential psychopharmacology
Neuroscientific basis and practical applications.
(Stahl, S., 2000). Pathophysiology The
biologic basis for disease in adults and
children. (McCance, K. Huether, S., 2002).
Mosbys guide to physical examination. (Seidel,
H., Ball, J., Daines, J., Benedict, G., 1999).
Concise text of neuroscience. (Kingsley, R.,
1999). Neuroscience. (Purves, D., Augustine, G.
J., Fitzpatrick, D., Eds., 2001). Modern
pharmacology with clinical applications. (Craig,
C., Stitzel, R., 2004). Principles of neural
science. (Kandel, E., Schwartz, J.H. Jessell,
T.M.) Pharmacotherapy A pathophysiologic
approach. (DiPiro, J.T., Talbert, R.L., Yee,
G.C., Posey, L.M., Eds., 1999).
Required Texts
84
Question Which subject that is essential to
prescribing is not covered in one or more of
these texts and courses?
85
Distance Education (Non-) Issues

• International Virtual Medical School Will offer
  the first two years of medical school entirely
  on-line. 30 partners around the world, including
• Brown University, University of Florida,
  University of Miami, Wake Forest, and West
  Virginia University.

86
Distance Education (Non-) Issues

• International Virtual Medical School Will offer
  the first two years of medical school entirely
  on-line. 30 partners around the world, including
• Brown University, University of Florida,
  University of Miami, Wake Forest, and West
  Virginia University.
• Allen et al. (2004) A review of the literature,
  involving 71,000 participants, concluded
  distance education course students slightly
  outperformed traditional students on exams and
  course grades.

87
Distance Education (Non-) Issues

• International Virtual Medical School Will offer
  the first two years of medical school entirely
  on-line. 30 partners around the world, including
• Brown University, University of Florida,
  University of Miami, Wake Forest, and West
  Virginia University.
• Allen et al. (2004) A review of the literature,
  involving 71,000 participants, concluded
  distance education course students slightly
  outperformed traditional students on exams and
  course grades.
• Florida offers doctorates in pharmacy and
  audiology completely on line.

88
Distance Education (Non-) Issues

• Vanderbilt Bridge Program Many of the
  programs in the School of Nursing do not require
  all course content to be delivered in a
  face-to-face traditional classroom environment.
  Instead, the content is delivered in a modified
  learning format viaonline conferencing, and
  digital videoIn addition, clinical placement can
  be arranged in the students home area.

89
Distance Education (Non-) Issues

• Vanderbilt Bridge Program Many of the
  programs in the School of Nursing do not require
  all course content to be delivered in a
  face-to-face traditional classroom environment.
  Instead, the content is delivered in a modified
  learning format viaonline conferencing, and
  digital videoIn addition, clinical placement can
  be arranged in the students home area.
• UT College of Medicine CME Program To maximize
  learning opportunities, a wide range of
  activities are offered which include video
  conferences/distance learning and innovative
  technologies such as web-based learning
  activities for personal skill development in
  medical procedures and teaching competence.

90
Prescribing Psychologists Biomedical Training A
Graphic Summary
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• So by the time they have completed the required
  training, Prescribing Psychologists

104

• So by the time they have completed the required
  training, Prescribing Psychologists
• Will have already had an average of 7 years of
  doctoral training in mental disorders just to
  become psychologists

105

• So by the time they have completed the required
  training, Prescribing Psychologists
• Will have already had an average of 7 years of
  doctoral training in mental disorders just to
  become psychologists
• Will have then gone on to complete
• an additional two year, 450-480 contact hour
  post-doctoral training program in
  Psychopharmacology

106

• So by the time they have completed the required
  training, Prescribing Psychologists
• Will have already had an average of 7 years of
  doctoral training in mental disorders just to
  become psychologists
• Will have then gone on to complete
• an additional two year, 450-480 contact hour
  post-doctoral training program in
  Psychopharmacology
• a 1 year long patient practicum, 100 supervised
  by an MD

107

• So by the time they have completed the required
  training, Prescribing Psychologists
• Will have already had an average of 7 years of
  doctoral training in mental disorders just to
  become psychologists
• Will have then gone on to complete
• an additional two year, 450-480 contact hour
  post-doctoral training program in
  Psychopharmacology
• a 1 year long patient practicum, 100 supervised
  by an MD
• two years of collaborative practice with a
  physician

108

• So by the time they have completed the required
  training, Prescribing Psychologists
• Will have already had an average of 7 years of
  doctoral training in mental disorders just to
  become psychologists
• Will have then gone on to complete
• an additional two year, 450-480 contact hour
  post-doctoral training program in
  Psychopharmacology
• a 1 year long patient practicum, 100 supervised
  by an MD
• two years of collaborative practice with a
  physician
• the national Psychopharmacology Examination for
  Psychologists.

109
Total Pharmacology and Mental Health Training
Average Physician vs. Prescribing Psychologist
110

• Which leads to some bottom line questions
• Who would you rather see?
• Who would you rather your parent or your child
  see?
• Dont the citizens of Tennessee deserve more
  Integrated Mental Health Care?

111
On December 12, 2003, the Tennessee House
Professional Practice Subcommittee held hearings
on Prescriptive Authority for Psychologists. At
these hearings, two of our highly respected
psychiatric colleagues, Dr. Cliff Tennyson, and
Dr. James Gillespie, gave public testimony on
behalf of the Tennessee Psychiatric Association.
Here are some selected excerpts from their
testimony
112
Psychiatry (In response to direct questioning
about the TPA-Endorsed Psychopharmacology
training program) The program IS much more
extensive than a nurse practitioner program.
113
Psychiatry If psychologists went through
the Bridge Program Vanderbilt Universitys 2
year part-time program for nurse practitioners,
theyd be incredible providers.
114
So, to restate, Tennessee psychiatry has
acknowledged in their public testimony that1.
Even if psychologists just completed a nurse
practitioner program, they would be incredible
providers, and2. The TPA-Endorsed
Post-Doctoral Psychopharmacology training program
is indeed much more extensive than a nurse
practitioner program.
115
4. Why the TPA-Endorsed Training Program is in
fact much more extensive than a nurse
practitioner program--e.g., Vanderbilts Bridge
program
116
First, How do the Prerequisites to enter the two
different programs compare?
Comparison of prerequisites
117
First, How do the Prerequisites to enter the two
different programs compare?
Comparison of prerequisites

• Bridge program 78 semester hours of college
  credit prior bachelors degree is not required
  prior degree in nursing is not required minimal
  biomedical prerequisites required

118
First, How do the Prerequisites to enter the two
different programs compare?
Comparison of prerequisites

• Bridge program 78 semester hours of college
  credit prior bachelors degree is not required
  prior degree in nursing is not required minimal
  biomedical prerequisites required
• FDU program A bachelors degree (120 hours)
• An additional 7 years of training in psychology
  including biological bases of behavior
• A year-long, 2000 hour clinical internship
• Another year of postdoctoral supervised practice
• Successful passing of written and oral licensing
  exams to become a Psychologist/Health Service
  Provider

119
Bottom Line The FDU Programs prerequisites
HUGELY exceed those of the Bridge program.
Comparison of prerequisites
Years
120
How does the core biomedical and pharmacology
coursework compare?
Comparison of Biomedical Training

• Bottom Line FDU program has 3 TIMES AS MUCH
  core biomedical and pharmacology coursework as
  does the Bridge Program
• (9 vs. 27 credit hours)

121
Mental Health Training Bridge Program
Graduates vs. Prescribing Psychologists

• Bridge Program
• NO courses required in the diagnosis of mental
  disorders
• NO courses or practicum specifically in
  psychotherapy
• But are 4 courses in related subjects that appear
  to include a component of these areas (15
  Semester hrs)

122
What is the other coursework in the Bridge
program?
123
What is the other coursework in the Bridge
program?

• Since the program assumes that incoming students
  may have no clinical background (have never seen
  a patient professionally), the focus of the
  entire second year is on clinical practicum

124
What is the other coursework in the Bridge
program?

• Since the program assumes that incoming students
  may have no clinical background (have never seen
  a patient professionally), the focus of the
  entire second year is on clinical practicum
• Since the program assumes that incoming students
  know essentially nothing about the health care
  system or research, the program includes several
  courses in these areas already intimately
  familiar to psychologists.

125
And YET As soon as they graduate with their
MSN, Bridge program students can potentially be
prescribing for almost ANY of the gt4,000
medications in the PDR. By contrast,
Prescribing Psychologists are seeking authority
for a much smaller formulary (less than 100
medications)
126
5. The Citizens of Tennessee Need Integrated
Mental Health Care
127
The Bottom Line Question What training and mode
of practice will best help solve the mental
health crisis in this state?
128
The Bottom Line Question What training and mode
of practice will best help solve the mental
health crisis in this state?

• The Bottom Line Answer
• Integrated Mental Health Care A combination of
  psychotherapy and other behavioral/lifestyle
  interventions with judicious use of medication

129
The Bottom Line Question What training and mode
of practice will best help solve the mental
health crisis in this state?

• The Bottom Line Answer
• Integrated Mental Health Care A combination of
  psychotherapy and other behavioral/lifestyle
  interventions with judicious use of medication
• Integrated Care has been shown repeatedly, in
  multiple studies, to be the most effective, and
  most cost-effective, treatment for most mental
  disorders

130
The Bottom Line Question What training and mode
of practice will best help solve the mental
health crisis in this state?

• The Bottom Line Answer
• Integrated Mental Health Care A combination of
  psychotherapy and other behavioral/lifestyle
  interventions with judicious use of medication
• Integrated Care has been shown repeatedly, in
  multiple studies, to be the most effective, and
  most cost-effective, treatment for most mental
  disorders
• Lets look at how well prepared these different
  professions are to provide this

131
Biomedical Training Non-Psychiatric Physicians,
Bridge Program Graduates, Prescribing
Psychologists
132
Mental Disorders Training Non-Psychiatric
Physicians, Bridge Program Graduates,
Prescribing Psychologists
BridgeProgram
133
Total Training to Provide Integrated Mental
Health Care Non-psychiatric Physicians,
Bridge Program Graduates, Prescribing
Psychologists
134
The Conclusion Prescribing Psychologists are by
far the best-trained of these three groups of
professionals to provide the Integrated Mental
Health Care which is so sadly lacking, and so
urgently needed, in our state
135
Prescribing Psychologists are S A F E

• 6. Prescribing Psychologists are S A F E
• by which we mean
• Safe
• Accessible
• Freedom of Choice-Promoting
• Economical

136
Prescribing Psychologists are S A F E
Prescribing Psychologists are Safe

• The United States Surgeon General has said, If
  we can demonstrate that psychologists have the
  training to prescribe, then they should be
  allowed to prescribe.
• (Hon. David Satcher, M.D., Ph.D., United States
  Surgeon General, 8-8-2000)

137
News Flash The Changing Face Of Health Care
The federal government and outside evaluators
concluded that the Dept. of Defense
psychologists were indeed trained to provide safe
pharmacological care.
138
Prescribing Psychologists are S A F E

• Prescribing Psychologists in the Department of
  Defense (DoD) have been providing Integrated
  Mental Health Care for over 10 years--including
  active duty service members and retirees as well
  as their family members.
• These Psychologists, with the freedom to
  prescribe, nevertheless have been found to
  prescribe medications for only 10 to 30 of their
  patients, vs. a prescribing rate of almost 100
  for psychiatrists treating the same patient
  groups.

139
Prescribing Psychologists are S A F E

• And, because the DoD program was so politically
  controversial, over 2 million was spent
  evaluating this program. The bottom line (from
  the GAO Report)

140
Prescribing Psychologists are S A F E

• And, because the DoD program was so politically
  controversial, over 2 million was spent
  evaluating this program. The bottom line (from
  the GAO Report)
• Overwhelmingly, the officials with whom we
  spokeincluding each of the graduates clinical
  supervisors who were psychiatristsrated the
  graduates quality of care as good to excellent,

141
Prescribing Psychologists are S A F E

• And, because the DoD program was so politically
  controversial, over 2 million was spent
  evaluating this program. The bottom line (from
  the GAO Report)
• Overwhelmingly, the officials with whom we
  spokeincluding each of the graduates clinical
  supervisors who were psychiatristsrated the
  graduates quality of care as good to excellent,
• The supervisors noted that the graduates are
  aware of their limitations,

142
Prescribing Psychologists are S A F E

• And, because the DoD program was so politically
  controversial, over 2 million was spent
  evaluating this program. The bottom line (from
  the GAO Report)
• Overwhelmingly, the officials with whom we
  spokeincluding each of the graduates clinical
  supervisors who were psychiatristsrated the
  graduates quality of care as good to excellent,
• The supervisors noted that the graduates are
  aware of their limitations,
• The DoD met its goal to train Psychologists to
  prescribe drugs, and,

143
Prescribing Psychologists are S A F E

• And, because the DoD program was so politically
  controversial, over 2 million was spent
  evaluating this program. The bottom line (from
  the GAO Report)
• Overwhelmingly, the officials with whom we
  spokeincluding each of the graduates clinical
  supervisors who were psychiatristsrated the
  graduates quality of care as good to excellent,
• The supervisors noted that the graduates are
  aware of their limitations,
• The DoD met its goal to train Psychologists to
  prescribe drugs, and,
• It is more cost effective to train Psychologists
  to prescribe than to use a combination of
  psychologists and psychiatrists to provide the
  same mental health care.

144
Prescribing Psychologists are S A F E
Prescribing Psychologists are Safe

• Further, other non-physicians have been safely
  prescribing medication in Tennessee for years
  (including, Dentists, Optometrists, Podiatrists,
  Nurse Practitioners, and Pharmacists in our VA
  system).
• And multiple studies analyzing the prescribing
  practices between non-physician prescribers and
  physicians have shown that there are no
  significant differences in safety or
  effectiveness of prescribing practices.

145
Prescribing Psychologists are S A F E

• Further, the risk of a prescriber harming a
  patient is actually very precisely defined by
  insurance industry actuaries, and insurance
  premiums for health care providers very precisely
  reflect these assessed risks.

146
Prescribing Psychologists are S A F E

• Further, the risk of a prescriber harming a
  patient is actually very precisely defined by
  insurance industry actuaries, and insurance
  premiums for health care providers very precisely
  reflect these assessed risks.
• And in fact, liability rates for psychiatrists
  are the lowest of any major medical specialty

147
Prescribing Psychologists are S A F E

• Further, the risk of a prescriber harming a
  patient is actually very precisely defined by
  insurance industry actuaries, and insurance
  premiums for health care providers very precisely
  reflect these assessed risks.
• And in fact, liability rates for psychiatrists
  are the lowest of any major medical specialty
• For Optometrists, and for nurse practitioners
  (even in states where they practice
  independently), they remain low, even after years
  of prescriptive privileges.

148
Prescribing Psychologists are S A F E

• Further, the risk of a prescriber harming a
  patient is actually very precisely defined by
  insurance industry actuaries, and insurance
  premiums for health care providers very precisely
  reflect these assessed risks.
• And in fact, liability rates for psychiatrists
  are the lowest of any major medical specialty
• For Optometrists, and for nurse practitioners
  (even in states where they practice
  independently), they remain low, even after years
  of prescriptive privileges.
• Another bottom line The objective data from the
  experts in risk management does not support the
  allegation of increased risk from prescribing.

149
Prescribing Psychologists are also Accessible
Prescribing Psychologists are S A F E

150
Prescribing Psychologists are also Accessible
Prescribing Psychologists are S A F E

• In Tennessee, there are over twice as many
  psychologists as psychiatrists (1,113 vs. 532)

151
Prescribing Psychologists are also Accessible
Prescribing Psychologists are S A F E

• In Tennessee, there are over twice as many
  psychologists as psychiatrists (1,113 vs. 532)
• And in Tennessee, a recent survey found that 84
  of all psychologists in the state support
  Prescribing Psychologists

152
Prescribing Psychologists are also Accessible
Prescribing Psychologists are S A F E

• In Tennessee, there are over twice as many
  psychologists as psychiatrists (1,113 vs. 532)
• And in Tennessee, a recent survey found that 84
  of all psychologists in the state support
  Prescribing Psychologists
• National surveys indicate that up to 40 of
  psychologists plan to take psychopharmacology
  training.

153
Prescribing Psychologists are also Accessible
Prescribing Psychologists are S A F E

• In Tennessee, there are over twice as many
  psychologists as psychiatrists (1,113 vs. 532)
• And in Tennessee, a recent survey found that 84
  of all psychologists in the state support
  Prescribing Psychologists
• National surveys indicate that up to 40 of
  psychologists plan to take psychopharmacology
  training.
• And nationwide there are approximately 1,000
  psychologists who have already completed or are
  completing postdoctoral training programs in
  psychopharmacology.

154
Prescribing Psychologists are Freedom of
Choice-Promoting
Prescribing Psychologists are S A F E

• Integrated Mental Health Care is more than just
  being able to prescribe medication
• its also the ability to unprescribe
  inappropriate or unnecessary medications.

155
Prescribing Psychologists are Freedom of
Choice-Promoting
Prescribing Psychologists are S A F E

• Integrated Mental Health Care is more than just
  being able to prescribe medication
• its also the ability to unprescribe
  inappropriate or unnecessary medications.
• The power to prescribe is also the power to
  unprescribe

156
Finally, Prescribing Psychologists are Economical
Prescribing Psychologists are S A F E

• In an HMO context, a study was conducted in which
  8,000 psychologists took over managing patients
  mental health care

157
Finally, Prescribing Psychologists are Economical
Prescribing Psychologists are S A F E

• In an HMO context, a study was conducted in which
  8,000 psychologists took over managing patients
  mental health care
• Psychologists received lt200 hours of training in
  psychopharmacology

158
Finally, Prescribing Psychologists are Economical
Prescribing Psychologists are S A F E

• In an HMO context, a study was conducted in which
  8,000 psychologists took over managing patients
  mental health care
• Psychologists received lt200 hours of training in
  psychopharmacology
• They managed nearly one million patient contacts

159
Finally, Prescribing Psychologists are Economical
Prescribing Psychologists are S A F E

• In an HMO context, a study was conducted in which
  8,000 psychologists took over managing patients
  mental health care
• Psychologists received lt200 hours of training in
  psychopharmacology
• They managed nearly one million patient contacts
• Number of adverse effects 0

160
Finally, Prescribing Psychologists are Economical
Prescribing Psychologists are S A F E

• In an HMO context, a study was conducted in which
  8,000 psychologists took over managing patients
  mental health care
• Psychologists received lt200 hours of training in
  psychopharmacology
• They managed nearly one million patient contacts
• Number of adverse effects 0
• Medication use rate at outset of study 68

161
Finally, Prescribing Psychologists are Economical
Prescribing Psychologists are S A F E

• In an HMO context, a study was conducted in which
  8,000 psychologists took over managing patients
  mental health care
• Psychologists received lt200 hours of training in
  psychopharmacology
• They managed nearly one million patient contacts
• Number of adverse effects 0
• Medication use rate at outset of study 68
• Medication use rate at end of study 13

162
We feel this study conclusively demonstrates
that, given the chance, Prescribing Psychologists
can provide Integrated Mental Health Care which
significantly reduces medication use while
maintaining good clinical outcomes.
Prescribing Psychologists are S A F E
163
Today we have shown that
In Conclusion
164
Today we have shown that
In Conclusion

• There is a mental health crisis in this state,
  involving both lack of access and
  over-prescribing

165
Today we have shown that
In Conclusion

• There is a mental health crisis in this state,
  involving both lack of access and
  over-prescribing
• Integrated Treatment is the best solution for
  this problem

166
Today we have shown that
In Conclusion

• There is a mental health crisis in this state,
  involving both lack of access and
  over-prescribing
• Integrated Treatment is the best solution for
  this problem
• There are not enough, and are not going to be
  enough, psychiatrists to provide this

167
Today we have shown that
In Conclusion

• There is a mental health crisis in this state,
  involving both lack of access and
  over-prescribing
• Integrated Treatment is the best solution for
  this problem
• There are not enough, and are not going to be
  enough, psychiatrists to provide this
• Primary care physicians cannot provide this

168
Today we have shown that
In Conclusion

• There is a mental health crisis in this state,
  involving both lack of access and
  over-prescribing
• Integrated Treatment is the best solution for
  this problem
• There are not enough, and are not going to be
  enough, psychiatrists to provide this
• Primary care physicians cannot provide this
• Prescribing Psychologists can provide this, and
  safely

169
Today we have shown that
In Conclusion

• There is a mental health crisis in this state,
  involving both lack of access and
  over-prescribing
• Integrated Treatment is the best solution for
  this problem
• There are not enough, and are not going to be
  enough, psychiatrists to provide this
• Primary care physicians cannot provide this
• Prescribing Psychologists can provide this, and
  safely
• And again, Tennessee Psychiatric Association has
  acknowledged, in public testimony

170
Today we have shown that
In Conclusion

• There is a mental health crisis in this state,
  involving both lack of access and
  over-prescribing
• Integrated Treatment is the best solution for
  this problem
• There are not enough, and are not going to be
  enough, psychiatrists to provide this
• Primary care physicians cannot provide this
• Prescribing Psychologists can provide this, and
  safely
• And again, Tennessee Psychiatric Association has
  acknowledged. in public testimony
• that our training program is comprehensive, and

171
Today we have shown that
In Conclusion

• There is a mental health crisis in this state,
  involving both lack of access and
  over-prescribing
• Integrated Treatment is the best solution for
  this problem
• There are not enough, and are not going to be
  enough, psychiatrists to provide this
• Primary care physicians cannot provide this
• Prescribing Psychologists can provide this, and
  safely
• And again, Tennessee Psychiatric Association has
  acknowledged. in public testimony
• that our training program is comprehensive, and
• that Psychologists who completed even a lesser
  training program would make terrific providers.

172
Today we have shown that
In Conclusion

• There is a mental health crisis in this state,
  involving both lack of access and
  over-prescribing
• Integrated Treatment is the best solution for
  this problem
• There are not enough, and are not going to be
  enough, psychiatrists to provide this
• Primary care physicians cannot provide this
• Prescribing Psychologists can provide this, and
  safely
• And again, Tennessee Psychiatric Association has
  acknowledged. in public testimony
• that our training program is comprehensive, and
• that Psychologists who completed even a lesser
  training program would make terrific providers.
• We therefore respectfully request your support
  for this bill