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Apr2010

  1. 1. NAPPP NATIONAL ALLIANCE of PROFESSIONAL PSYCHOLOGICAL PROVIDERS April 2010 Volume 5 No. 4 The Clinical Practitioner From the Executive Director NAPPP Continues the Advocacy Tradition Jerry Morris, Psy.D., MBA, MSPharm. In the history of practice advocacy great leaders and Wright, Melvin Gravits, Ernie Lawence, Gene Shapiro, leadership have cyclically emerged. In our historical Bob Weitz, Bryant Welch, Donna Daley, Pat Deleon, memory these seminal leadership victories and Anita Brown, Morgan Sammons, Deborah Dunivan, issues include the Virginia Blues Group (Resnick & Stuart Wilson, Stephen Berger, Larry Blum, Gary Morris, 1997) which began the process of confronting Boulter, Cory Fox, Steven Frankel, Lisa Pomeroy, psychologist exclusion from health insurance payment, Carleton Purviance, James Quillin, John Bolter, the California CAPP vs. Rank folks (CAPP v, Rank,1990; John Courtney, Mario Marquez, Elaine Levine, Sam capp@nappp.org) who really set the Feldman, Matt Necetti, Al Gruber, hospital privileges movement into a SJ (Terry) Soter, James Childerson, forward thrust, and the dirty dozen John Caccavale, Howard Rubin, The War on David Reinhardt, Michael Enright, (Dorken et al, 1986). Psychotherapy has Bob Resnick, and many others come Practice advocacy continued with the hospital movement in psychology and sought to establish to mind as leaders in the practitioner JCAHO inclusion for psychologists medications as the movement. I have been privileged to (Elefant, 1985), the Medicare “first line” approach work personally on projects in various aspects of the practitioner movement inclusion and Medicaid EPSD rules to the treatment of allowing psychologists to treat with many of these psychologists, and mental disorders. there are many more that have taken the poor’s children and families (Onibus Budget Reconciliation Act, up the mantel to move the practitioner 1988), state licensure of healthcare movement forward. psychologists and establishment of doctorate only laws, The War on Psychotherapy has sought to the RxP movement (Fox, et al., 2009), and the mental establish medications as the “first line” approach to health parity movement (H.R. 1424, 2008) the treatment of mental disorders. (Morris, 2009) Now the Integrated Care movement looms large in It has used marketing rather than science to brand our fight to secure an independent ability to diagnose, medications as the stand alone treatment for mental prescribe treatments, to treat without supervision, and illness. This approach has left the mentally ill in to act as the Primary or Attending Doctor for patients. America without adequate diagnoses, with partial and affect and behavior control rather than true change, and Names such as Nick Cummings, Jack Wiggins, Rogers has hidden what top scientists Continued on Pg. 2 In this issue... Dr. Morris: The next step in the Practitioner Movement Pg. 1; Dr. Caccavale: NAPPP Public Awareness Campaign Pg. 3; Dr. Reinhardt: Mental health needs to detach from Big Pharma Pg. 5; Dr. Morris decares a Golden Era in Practice Pg. 7; Dr. Reinhardt asks if your patients are being treated like dogs Pg. 12; Dr. Padovar discusses client variables Pg. 17; NEJM reports on drug safety Pg. 19; FDA updates Pg. 20; From JAMA: Eroding Trust in Psychiatry Pg. 20: Science notes Pg. 22; Submission guidelines Pg. 27; C.E. Credits for April Pg. 28; CE courses, Pg. 29 A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 1
  2. 2. April 2010 Vol. 5 No. 4 Advocacy continued from Pg. 1 Contents: know, “that the environment is what triggers and manifests gene expression NAPPP Continues the Advocacy Tradition by Jerry Morris ....... Pg. 1 triggering many mental disorders and affecting brain function”. Making And Fighting The Good Fight NAPPP is starting another major page in the by John Caccavale .................Pg. 3 history books of practitioner movement advocacy. Mental Health Care Must Detach This spring, NAPPP will unfold a major national from Big Pharma NAPPP is starting campaign funded by practitioners to combat the by David Reinhardt .................Pg. 5 War on Psychotherapy. another major The Practitioner Movement’s Golden Era by Jerry Morris .................Pg. 7 NAPPP will start a national advertising campaign page in the history Is Your depressed patient being that will take America back to the science, back books of practitioner Treated Like A Dog? to appropriate and comprehensive treatment by David Reinhardt .............. Pg. 12 for mental disorders that utilizes behavioral movement advocacy The contribution of client variables and psychotherapy approaches as the first Pt. 2 by Gary Padovar ......... Pg. 17 line treatment and medications as adjunctive World View: The Missing Voice of techniques for the treatment of mental disorders. Patients in Drug-Safety Reporting Dr. Caccavale describes this campaign in his article Making And Fighting The Good by Ethan Watters ................. Pg. 19 Fight. This campaign represents the next step in the advancement of the Psychology FDA Update ......................... Pg. 20 Practitioner Movement and psychology’s advocacy for the public. I strongly urge Eroding Public trust in Psychiatry you and your colleagues to get involved. You will learn how NAPPP is standing up by Caroline Cassels............. Pg. 20 for practitioners and how practicing psychologists can stand up for their patients, Science Notes ..................... Pg. 22 the public, and the U.S. Healthcare System. Please join us! How to Write a Brilliant Submission by Dave Reinhardt and Elle Walker (Sumbission Guidelines)...... Pg. 27 References April CE Credit By Richard Blackburn .......... Pg. 28 CAPP v, Rank, 51 Cal.3d 1, 793 P:2d 2 (1990). Continuing Education Course Dorken , H., Stapp, J., & VandenBos, G. (1986). Licensed psychologists: A decade List ...................................... Pg. 29 of major growth. In H. Dorken & associates (Eds.), Professional psychology in Executive Editor transition: Meeting today’s challenges (pp.3-19). San Francisco: Jossey-Bass. Dave Reinhardt Ph.D. Elefant, A. B. (1985). Psychotherapy and assessment in hospital settings: Ideological Editors Jerry Morris, Psy.D. and professional conflicts. Professional Psychology: Research and Practice, 16, 55- Gary Padovar, Ph.D. 63. Richard Blackburn, Ph.D. Fox, R. E., DeLeon, P. H., Newman, R., Sammons, M. T., Dunivan, D. L., Baker, Elle Walker, Psy.D. D. C. (2009). Prescriptive Authority and Psychology: A Status Report. American Past Issues Psychologist, May-June, American Psychological Association, Washington, D. C. http://nappp.org/backissues. (pp. 257-268). html Submissions H. R. 1424-117 (2008). Payl Wellsone and Pete Domenici Mental Health Parity and Editor. Addiction Equity Act of 2008. U.S. House of Representatives, Washington, D.C. TheClinicalPractitioner@ Morris, J. A., (2008). The War on Psychotherapy. The Clinical Practitioner. gmail.com National Alliance of Professional Psychology Providers, vol. 3, number 2, Feb., p. NAPPP on the Web www.NAPPP.org 3-6. MoNAPPP Chapter Omnibus Budget Reconcilliation Act of 1988, Sec. 4201-4206, 4211-4216, 101 Stat www.monappp.nappp.org 1330-160 through 1330-220, 42 U.S.C. Sec. 1395i-3(a)-(h) [Medicare] and 139r (a)- NAPPP Executive Board (h) [Medicaid] 1992). John Caccavale, Ph.D. Resnick, R. J., & Morris,J. A. (1997). The History of Rural Hospital Psychology. In Nick Cummings, Ph.D. Jerry Morris, Psy.D. Morris, J. A. (Ed.), Practicing Psychology in Rural Settings: Hospital Privileges and David Reinhardt, Ph.D. Collaborative Care. Washingtion, D.C.: American Psychological Association (pp. Howard Rubin, Ph.D. 1-18). Jack Wiggins, Ph.D. A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 2
  3. 3. Making And Fighting The Good Fight By John Caccavale, Ph.D., MSPharm. Psychology practitioners are on the edge consist of full page ads in major newspapers, such as of the mental health care system. In a matter the New York Times, Washington Post, and Wall Street of perhaps 15 years, we have descended from being Journal. A copy of the first draft ad can be read at the premier providers of mental health services to http://nappp.org/draftad.pdf. being replaced by any number of providers including The goals of the first phase of this program non-doctoral level providers, nurse practitioners, and are as follows. A PowerPoint Presentation of the goals primary care physicians. The shift of mental health can be read and downloaded at http://nappp.org/goals.pdf care to primary care has been dramatic. Moreover, 1 as primary care physicians have become the first line Informing the public that medications should not providers of mental healthcare, so has the overall mental be their first line treatment for depression, anxiety health budget, which now accounts for about 4% of total and other psychological conditions. Before medications healthcare expenditures. This is down from 8% over the should be considered, the standard of care requires last decade. an evaluation by a doctoral level psychologist who can Real Healthcare Reform Is Not On The provide a correct diagnosis and an appropriate treatment Horizon. In getting involved in healthcare reform, plan. Should medications become part of the treatment psychology practitioners had much to be excited about. plan, the standard of care requires that these patients be The initial proposals held so many good things for mental followed by a doctoral level psychologist. health justifying that excitement. However, the future for psychology practitioners is now less clear. It is likely that the shift to primary care will continue and the use of non-doctoral level providers will expand. Recognizing 2 NAPPP will provide practitioners and the public with information sheets detailing the questions they must ask primary care providers before agreeing this, many professional schools of psychology are to accept a medication only treatment plan. Just as becoming professional schools of non-doctoral level pharmaceutical companies have encouraged the public counselors. Although this scenario dims the prospects of to request specific medications from their physician, we psychologists, NAPPP is preparing to make the good fight will provide the public with the standards of care that are and has a plan to confront and reverse these trends. required but are not now being followed. 3 Making The Good Fight. For over two decades NAPPP will take on the misrepresentations of the many psychologists have called for a massive and focused drug companies who have consistently misinformed public awareness campaign to elevate doctoral level the public about the efficacy of medications, such as anti- practice and the superiority of the services we provide. depressants. We are developing fact sheets with the most Dr. Nicholas Cummings, one of the most persistent and relevant research to support our assertions. The public visionary proponents of psychology practice, tried to needs to know the truth and, while some physicians do get APA to take on this type of campaign two decades not tell them, we will. Moreover, we are able to support ago but was shunted aside and lambasted for being our claims. These will be available on our website. “too assertive” and being a ”Chicken Little.” Clearly, Dr. 4 Cummings was correct then as we are correct now. If we NAPPP will contact and work with physician fail to reverse the currents trends, psychology providers groups to support our efforts. Many physicians will literally disappear into the maze of the lessor skilled are just as disappointed with the current system as we mental health workforce. We cannot let this happen! are. By accepting NAPPP guidelines for evaluations and The NAPPP Public Awareness Campaign correct diagnosis before prescribing medications, these For Psychology Practice. The NAPPP Executive physician groups will be adhering to the standard of care Committee has retained the services of a Washington and this will make for better outcomes in the treatment DC consulting group to help us design and implement a of their patients. major public awareness program. The program will be implemented in stages and will continue until we have reached our goals. The first phase of the program will Go to Table of Contents A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 3
  4. 4. Public Awareness Campaign continued from Pg. 3 5 The public must be made aware of the differences between a doctoral level psychologist and non- doctoral level provider. Referring to others as “master fair way of funding the program. It will then be up to every practitioner to demonstrate their commitment to practice and their profession. If the program does level counselors” also gives an incorrect perception to not receive the level of support that it deserves and the public. To most, a “master” connotes superiority. needs, we will not go forward. We all must be part of In the case of mental health providers, the value the success when we succeed or failure if we do not act. and designation of doctor must be appreciated and Sitting on the sidelines may not be an option we are understood. Only doctoral level psychologists have the prepared to accept. scope of practice, training, and experience to provide We look forward to making this program a success with the evaluations and appropriate diagnoses required your help and support. under the standard of care for patients receiving mental health services. The NAPPP Executive Committee 6 Insurance Panels. The public must be made aware that they are being denied the appropriate standard of care when insurers restrict psychologists from their panels of providers. The public will be educated and we will show them how to rightfully The NAPPP Executive Committee demand and get access to doctoral level psychologists. Non-doctoral level providers are being utilized outside has authorized significant their scope of practice by insurers who do so simply funding for the campaign but to cut costs and increase profits. This needs to be individual practitioners must also addressed and stopped. share in the costs How Will The Plan Be Implemented And Funded? Clearly, this type of campaign will be costly. However, the costs will be small in comparison to what we will receive. The NAPPP Executive Committee has authorized significant funding for the campaign but individual practitioners must also share in the costs. We can no longer be enablers and ask a small number of concerned and committed Review our Goals at psychologists to bear the burden for the profession. It http://nappp.org/goals.pdf is not right or ethical and we will not do it. NAPPP will utilize a pledge system to obtain the needed funding. We will not ask anyone to contribute any money until we reach funding pledge goals. The budget for each View our draft ad at aspect of the program will be posted on the NAPPP website along with a “pledge” page where practitioners http://nappp.org/draftad.pdf can pledge a contribution and can see the present amount contributed. There will be no suggested amount to be pledged by individual practitioners. Each of us will need to set the value that we place on Get Involved! our practice and profession. Typically, contributions http://www.nappp.org to a public education and awareness campaign are tax deductible. When the funding goal is reached, only then will we ask for those pledges to be honored. NAPPP will contribute the first significant pledge along with paying the consultants. We believe this to be a Go to Table of Contents A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 4
  5. 5. From the Editor Mental Health Care Must Detach from Big Pharma David Reinhardt, Ph.D., MSPharm. Psychiatrists seem to be genuinely flummoxed This hardly is a surprise to anyone that has read at what to do with all of the recent evidence proving through a medical journal and noticed the source of antidepressants are a sham treatment (for all except the funding. It has been shown that there is overwhelming most severe depression, and even that is under fire for bias in choosing studies to be included in journal lack of evidence). How can their profession be caught content. Cochrane Collaboration has studied this issue with such surprise? I believe the fault lies in the conduct and states “trials with positive findings are published of medical journals and the reliance on drug companies more often, and more quickly, than trials with negative to provide MD education and continuing education. findings” (3) Medical journals are an extension of a Simply put, doctors are being crippled by the process of corrupted medical education system. becoming and remaining doctors. A significant amount of medical school funding is A study published in the March 10 issue of JAMA found paid by Big Pharma. A survey by NPR found that “for that in medical journals, consideration of non-drug 2003-2004, up to 16% of medical schools’ budgets were and comparative medication strategies received short paid by the drug industry.” (4) shrift. “Approximately one-third of studies evaluating Given a choice, how many doctors choose to pay for their medications were CE (Comparative Effectiveness) continuing education, and how many choose to take studies. Of these studies, only a minority compared advantage of free classes, often involving all expense pharmacologic and nonpharmacologic therapies, few paid junkets? focused on safety or cost, and most were funded by noncommercial funding sources.”(1) The rest were An article in the Milwaukee Journal Sentinel stated either aimed at bringing a new therapy to market or “Drug company funding of continuing medical education simply compared a medication with for doctors has become one of the most a placebo. Whether the therapy was lucrative ways for pharmaceutical firms to promote and sell their products, better or worse than other treatments Have you ever been adding to the enormous cost of health was simply not addressed. to a doctor’s office care in the United States, according Drugs within a class are seldom that was free of to testimony Wednesday before a U.S. compared against each other. An Senate hearing...”CME (continuing article published in the LA Times bags, pens, mugs or medical education) has become (3/10/10) found that of the few posters from drug an insidious vehicle for aggressive comparative studies, 87% were promotion of drugs and medical not funded by drug companies but companies? devices,” said Steven Nissen, chairman were funded entirely or in part by of cardiovascular medicine at the noncommercial sources, such as Cleveland Clinic. “CME has largely nonprofit foundations or government institutions. evolved into marketing, cleverly disguised as education.” Over 90% of studies comparing medications with (5) non-pharmacologic therapies (such as psychological or lifestyle changes) were funded by noncommercial Drug companies exert their influence in other sources, as were 94% of studies comparing different ways as well. There are highly refined strategies that are medication strategies (such as different blood sugar used in marketing drugs. “Food, flattery and friendship targets in patients with diabetes). Over 90% of studies are all powerful tools of persuasion, particularly when comparing the safety profiles of medications were not combined.” (6) Have you ever been to a doctor’s office funded by drug companies. Noncommercial sources that was free of bags, pens, mugs or posters from drug funded virtually all studies comparing the cost- companies? effectiveness of different treatments, “though only 2% of Drug companies do their best to influence doctors the studies we reviewed included such analysis.” (2) through the patients directly, who are told to ask for inappropriate chemicals, Continued on Pg. 6 A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 5
  6. 6. Mental heath care must detach continued from Pg. 5 such as the ads promoting Abilify when the antidepressants (not suprisingly) don’t cure their depression. This practice is limited in other countries due to its corrupting influence. Psychologists have never been seen as a fertile ground for pushing drugs. Psychologists are uniquely treated in statistics and study design. We are not as easily fooled by marketing hype. Psychologists, like most healthcare professionals, don’t rely on others to pay for our continuing education. NAPPP leaders have agreed to reject the influence of Big Pharma and make psychologists answerable to science alone. As Dr. Morris states in his article NAPPP Continues the Advocacy Tradition, branding medications as the stand alone treatment for mental illness has left the mentally Have you considered ill in America without adequate diagnoses, with partial and affect and behavior control rather than true change. Practice Accreditation? NAPPP is making plans to do something about it! NAPPP is starting a program aimed at educating psychologists, psychiatrists, other health care professionals and the public on the facts of mental National Institute of Behavioral Health Quality health care. If we are to be successful we need all Accrediting Educational Programs and Professional Psychologists to get involved. Please see Dr. Caccavale’s article Making And Fighting The Good Fight on page 3. Practices in Behavioral Healthcare (1) http://jama.ama-assn.org/cgi/content/ Accreditation can provide your practice with pres- abstract/303/10/951 tige and lets everyone know that the way you prac- (2) www.latimes.com/news/opinion/commentary/la- tice conforms to the highest quality in behavioral oe-hochman10-2010mar10,0,3812725.story health care. (3) http://www.cochrane.org/reviews/en/mr000006. Find out about the benefits of practice accreditation html and how to get your practice accredited by NIBHQ (4) http://www.npr.org/templates/story/story. today! php?storyId=4696316 (5) http://www.jsonline.com/news/wiscon- sin/52008087.html http://nibhq.org/ (6) Moynihan, R. Who pays for the pizza? Redefining the relationships between doctors and drug companies. Review our Goals at http://nappp.org/goals.pdf View our draft ad at http://nappp.org/draftad.pdf Get Involved! Go to Table of Contents A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 6
  7. 7. The Practitioner Movement’s Golden Era Jerry Morris, PsyD, MBA, MS(Pharm) I have written about the War on Psychotherapy The pharmaceutical companies have directly (Morris, 2008) and about the house of cards of attacked the problem of convincing the public that organized medicine and the pharmaceutical houses “drugs are the answer to mental illness”. In 1998 efforts to convince the public that “medication only University of Chicago scientists found that except for approaches” are a sufficient and even “first line” situations involving intense physical and emotional treatment of mental disorder. As a result of this War symptoms of going crazy most subjects would be on comprehensive treatment, increasingly, mental unwilling to take a medication (Crogan, et al., 2003). patients (and especially children) are being given drugs Nearly four in ten in this study said they would refuse only instead of following “best practice guidelines” by a psychiatric medication for any condition, and providing psychotherapy and medication interventions nearly half said they would not take a medication (Norton, 2005). Recent science has been prolific for depression. One in four viewed medications for and has vindicated and illuminated our position that psychological problems as harmful to the body and medicine alone is not a first line or even adequate over one third believed that these drugs would interfere treatment for mental illness (Morris, 2009; Kirsch et with daily functioning. Europeans were even more al., 2008; Turner et al., 2008; Antonuccio et al., 1999). realistic about these drugs with fewer than half (46%) Financial consideration and profit motive rather than believing that antidepressants were effective treatments science have driven much of the healthcare and mental for depression and nearly one third indicating that health service system design of the past (Antonucio antidepressants had no real positive effect at all (PayKel et al., 2002; Morris, 1996). Drug companies et al., 1997). Their insight has been vindicated in recent have supported prescription of science (Moncrieff, & Kirsch, 2005). psychoactive medications in primary The drug company recognized care centers (their main drug Primary care the problem and launched extensive delivery system for their business) physicians and marketing campaigns to increase the and as first line treatments because nurse prescribers, patient and physician acceptance general medical personnel do not unlike prescribing of drugs as the first line treatment have the training and expertise, the of mental disorders (PayKel et psychologists, must time, or the interest to deliver more al., 1997; Jackson, 2005; Breggin, complex psychological interventions rely heavily on drugs 2008). They were successful and for mental illness (Kirschenbaum, as their dominant many people have adopted the 1996; Kroenke, & Mangelsdorff, intervention philosophy that medications are a 1989; Kunen, et al., 2005). treatment for mental illness with Primary care physicians and not one scientific study showing nurse prescribers, unlike prescribing psychologists, that any psychotropic medication ever did any more must rely heavily on drugs as their dominant than control a minority of symptoms of a minority of intervention. Considerable numbers of psychologists, mentally ill patients. The Federal Drug Administration psychiatrists, and physicians have recognized (FDA) and the pharmaceutical houses have repeatedly the paucity of science driving the growing use of demonstrated inability to rapidly and honestly alert medications as first line treatments for mental disorder, the public to the dangers and harmed public, and and have chronicled the science indicating that these the FDA has been described by some physicians and drugs only work with a minority of patients, have psychologists as a “toothless watchdog that hadn’t dangerous and concerning risk/reward patterns, and even growled” (Breggin, 2008). The chicanery and that they are considerably over sold and marketed downright suppression of science and truth from the (Jackson, 2005; Hobson & Leonard, 2001; Stein, 1999; drug companies in an effort to keep the Brand of Drugs Schaefer, 2003, Volpicelli et al., 2001; Glasser, 2003; as a First Line Treatment of mental disorder has been Healy, 2004; Cohen, 1993; Szasz, 1976). well chronicled (Jackson, Continued on Pg. 8 A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 7
  8. 8. Golden Era continued from Pg. 7 2009; Goozner, 2004; Goldberg, 2002; Esherlick, approach, and has great potential for long term harm 2004; Cornwell, 1996). to the patient, their relatives, the public, and the The state of affairs in the treatment of mental healthcare economy. disorders is becoming unmistakably clear. Drugs are After years of being left to the drug company marketing, not the first line treatment for mental illness, and the FDA’s inadequacies, and the insurance companies primary care physicians are not equipped to provide need to have quick, simple, and inexpensive solutions the appropriate diagnosis and appropriate multi- to “symptom control” and avoidance of treatment component treatment plans needed for effective and of mental disorders, the current administration in modern treatment of the mentally ill patient. Washingtion, the federal legislature, and health Psychiatrists, generally seeing 3-6 patients per hours economists have hit upon Integrated Care (moving and focusing mainly on medication management have behavioral treatment and prevention into the primary fallen prey to what many of their early colleagues care centers) and laws guaranteeing mental health warned against, excessive bioreductionism of mental parity with physical treatment in insurance and illness (Glasser, 2003; Cohen, 1993; Szasz, 1976). They corporate healthcare payer systems. These moves have lost their skills and place in any but “drug delivery have occurred because of courageous psychologists, systems” as agents of the pharmaceutical companies. psychiatrists, and research scientists like those General physicians, willing to learn and collaborate, chronicled in this paper, because of political change that but busy with 40-60 patients a day in multiple settings separated healthcare corporations and the Government, and the coverage of over 3,000 diagnoses, have and because of maturing and a growing body of science generally been seduced by massive and well funded about the effects and limited outcomes related to drug marketing and relational marketing programs (drug treatments of mental illness. detail salespersons armed with perquisites) into A Golden Era of Practice is emerging for over simplifying mental illness and applying overly Psychologists. The maturation of science, treatment simplistic, palliative, and partial symptom control providers, policy makers, and the mental health focused treatments industry has allowed for a more mature and complex (Kirschenbaum, conceptualization of mental illness and related Psychology is 1996). They, above treatment needs of the mentally ill (Schaefer, 2003). all, have been the most This has allowed for the beginning of a new era of entering the duped into wasting opportunities for psychologist practitioners. their great intellects, Doctors of psychology have never been in more demand Golden Era of scientific training, and and in a more leveraged position to negotiate movement branded authority and into primary care systems and hospitals. These systems Practice leadership position and need to qualify for the incentives, requirements, and to have been lulled into acquire the expertise to implement advanced diagnoses becoming a basic “drug and behavioral and treatment programs in psychology. delivery system” with accompanying contrived and They will also need specialty diagnosticians in serious supplied rationalizations that do not stand the test of and persistent mental illness, neuropsychology, lifestyle science. and habit modification, etc., in order to compete in Scholars and scientists have cautioned that the coming era of integrated care. They will need help we must stop blaming the brain for mental illness and with breaking down the hoax brand of pharmaceutical learn to read and understand the scientific literature products and helping their practitioner’s transition (Scott, 2006, Valenstein, 1988). They explained from “medication only” approaches to the treatment repeatedly, clearly, and convincingly that medications of mental illness. They will need practitioners trained are not an effective treatment for most people with in the dissemination of the research, demonstration mental illness. Their multidisciplinary research, and supervision of behavioral techniques and lifestyle writing, and summarization of the scientific literature management and resiliency programs, and who can makes it clear that simply describing a feeling as if it is a assimilate into the medical and primary care culture. diagnosis of mental illness (anxiety, depression, anger, etc.) and prescribing a medication is not a scientific Continued on Pg. 9 A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 8
  9. 9. Golden Era continued from Pg. 8 Psychology is entering the Golden Era of Practice; carry the message and to do follow-up educational the best opportunities I’ve seen since the start of the presentations and workshops with local medical staffs, psychiatric hospital building era are unfolding! with allied healthcare disciplines, with community Action is Required. Organizational action, leaders, and with the local media. NAPPP will lead including practitioner organizations getting their the nation in debunking the hoax related to the use of practitioners ready (in mind set and assertiveness, as psychoactive medications as the first line treatment well as regarding techniques and science assimilation) of mental illness and as a consequence of poor and for Integrated Care will be needed. misdiagnoses and deliberately misleading information (Reinhardt, 2010). NAPPP has been doing that for over a year. We have written about the need for a new mind set of We must model for practitioners what can assertiveness and a new culture of effectiveness that be done and the things I outlined in my book on knows our friends from our enemies and detractors hospital leadership and practice in psychology (Morris, (Caccavale, 2009). In addition, we are about to roll 1997). In that vein, I have taken a look at my overly out a national marketing campaign that highlights comfortable position many of the things elucidated in this article. Clearly, as the owner and developer of a multi-site we will expose the drug hoax, and attempt to educate Only practitioners the public, embolden psychology practitioners to assert and multidisciplinary themselves and psychological interventions, and we community mental can save the will attempt to leverage Governmental Agencies into health center and healthcare and assertive and rapid response. extended myself to negotiate a merger behavioral health NAPPP will organize, assist practitioners with funding, with a regional hospital systems and will coordinate a national campaign to move the system with multiple national practitioner association to an increasingly primary care centers. active leadership position to bring the treatment I have decided, like I of the mentally ill out of the hoax approach on did during the state licensure movement, psychiatric antidepressants, tranquilizers, mood stabilizers, and hospital development movement, the psychologist amphetamines as stand alone, first line, and substantive hospital privileges movement, and the RxP movement treatments for mental illness that has harmed so many. to take very specific and aggressive personal actions NAPPP will stand up and do something when the to move the psychology cause forward. In doing so, only other psychological society doing so has been the I have obtained an agreement that will position me American Board of Medical Psychology’s leadership. and a regional hospital and multiprimary care clinic NAPPP will attempt to get the FDA to oppose Chief of Medical Staff to develop a comprehensive medication only approaches on psychoactive drug Integrated Care System using their medical and my labels and fact sheets. We will publish scientifically community mental health facilities. I have spent validated protocols with specialty diagnoses, behavioral the last month educating their medical staff and and psychotherapies, and lifestyle change as first line administration and my clinical staff about the stages treatments, and will move medications to adjunctive of integration, the anxieties and potential roadblocks, or second line treatments. We will publish these best and the effort required to accomplish comprehensive practices protocols and encourage their use by the integrated care during the next year. On Wednesday, public when asking for and evaluating their care, for the March 10th I took this important position and medical third party payers, and for governmental adoption. staff responsibilities to design and implement a two A Time for Personal Leadership. NAPPP’s organization wide integrated care system. leadership will only be effective if practitioners in While this will eat up my time and life for the next NAPPP become engaged and contribute to the national couple of years, I think that we must model for marketing campaign and other NAPPP initiatives. Only practitioners how to take advantage of these Integrated practitioners can save the healthcare and behavioral Care and Golden Era of Psychology opportunities. health systems (Caccavale, 2010). Their contributions Unfortunately, this commitment will be quite time can be at the financial, and at the action level. Their consuming and I have been actions can include rallying local practitioners to Continued on Pg. 10 A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 9
  10. 10. Golden Era continued from Pg. 9 forced to examine my priorities and make some difficult primary care and hospital systems that will be pressed decisions. to move toward Integrated Care. Their operations, I have notified the NAPPP board that I must continued growth, participation in multiple incentive resign my function as the Executive Director of NAPPP pay and grant systems, and need to respond to the effective the first week in May. I have indicated that emerging and compelling science and related change I will continue on the board, assist with transition to in public demand will move their motivations toward the new director, and remain steadfastly committed to increasingly favorable dispositions toward doctors of the mission and functions of the national practitioner psychology. They are doctoral practitioner oriented association. I will continue, in that way, to be one of systems, and will naturally look toward psychologists the staunchest proponents of the national practitioner who have significant advantages over psychiatrists in movement and NAPPP’s leadership role in that implementing new healthcare paradigms and refining movement. I will endeavor to model what can be and growing systems. done by practitioners in the budding Golden Era of Psychologists should immediately ask for Psychology Practice and the move to Integrated Care. meetings with hospital administrators, Medical I will endeavor to traverse the dangers and political Directors, and primary care personnel. They should intrigue of medical systems to establish a model discuss the emerging literature about the limitations approach that can be replicated of medications with the mentally and used in part or whole by our ill and the need for combined care. practitioners nationally. I will I must resign my You should not be confined to one continue to support the psychology presentation and despair if you are practitioner movement with the function as the turned down, and like the professional passion, shared practitioner vision, Executive Director of salesman you should understand and concerted effort that I have had NAPPP effective the probabilities and numbers and meet for 35 years. During my final two with several primary care systems months as the Executive Director first week in May until you achieve a match of your of NAPPP, I will work with our need and their need. You should plan tireless board to find a suitable and to capitalize on the education and highly effective director to continue incentives that they are getting from the important vision and thrust of this important the Government and their professional organizations organization. and the coming Integrated Care Model. In addition to designing an Integrated Care Above all, you should be positive, flexible, accurate but System, I will be collaborating with my good friend respectful of their job within the healthcare system, and John Caccavale, PhD, MS on a book that delineates you should be confident that you have something that the various hoaxes related to first line medication and they need. medication only treatments of mental illness, faulty Antonuccio, D. O., Burns, D. D., & Danton, W. G. (2002). Antidepressants: assumptions that primary care centers are staffed A triumph of marketing over science? Prevention & Treatment, 5, Article and prepared to treat mental illness, that the nation’s 25. medical surgical and even psychiatric hospitals are appropriately organized and staffed with the proper Antonuccio, D. O., Danton, W. G., DeNelsky, G. Y., Greenberg, R. P., models of leadership to treat mental illness. This & Gordon, J. S. (1999). Raising Questions about Antidepressants. task has begun with several chapters nearly finished, Psychotherapy and Psychosomatics, 68, 3–14. and is increasingly demanding and time consuming. Breggin, P. R. (2008a). Medication Madness: The Role of Psychiatric However, we must have such substantive literature and Drugs in Cases of Violence, Suicide, and Crime. St. Martin’s Griffin science reviews, thoughtful analysis, and meaningful Publisher, New York, NY. delineation of remedies and models for the NAPPP Breggin, P. R. (2008b). Medication Madness: The Role of Psychiatric marketing campaign and the psychology practitioner movement to move forward. Drugs in Cases of Violence, Suicide, and Crime. St. Martin’s Griffin Publisher, New York, NY. Page 36. You must do the same thing in light of the opportunities which are emerging to initiate conversations with Go to Table of Contents Continued on Pg. 11 A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 10
  11. 11. Golden Era continued from Pg. 10 Caccavale, J. (2010). Only Psychologists Can Save Behavioral Health. bmj.331.7509.155 The Clinical Practitioner, vol. 5, number 3, March 2010. Morris, J. A., (2009). Sneaky Science. The Clinical Practitioner. National Caccavale, J. (2010). Psychology is Mired in a Culture of Dysfunction. Alliance of Professional Psychology Providers, vol. 4, number 2, Feb., p. 9. The Clinical Practitioner, vol. 5, number 1, January 2010. Morris, J. A., (2008). The War on Psychotherapy. The Clinical Practitioner. Cohen, C. I. (1993). The biomedi-calization of psychiatry: A critical over National Alliance of Professional Psychology Providers, vol. 3, number 2, view. Community mental Health Journal, 29, 509-521. Feb., p. 3-6. Cornwell, J. (1996). The Power to Harm: Mind, Medicine, and Murder on Morris, J. A. (Ed.)(1997). Practicing Psychology in Rural Settings: Trial. Viking Penguin Books, New York, NY. Hospital Privileges and Collaborative Care. Washington, D.C.: American Crogan, T. W., Tomlin, M., Pescosolido, B. A., Schnitter, J., and Martin, Psychological Association. J. (2003). American Attitudes Toward and Willingness to Use Psychiatric Morris, J. A. (1996). The history of managed care and its impact on Medications. The Journal of Nervous and Mental Disease, 191: 166-174. psychodynamic treatment. In Barron & Sands (Eds.), Impact of Managed Glasser, W. (2003). Warning: Psychiatry can be Hazardous to Your care on Psychodynamic Treatment. (pp. 203-218). Mental Health. HarperCollins Publishers, New York, NY. Norton, A. (2005, November 24). Child antidepressant use increases. Goldberg, R. (2002). Taking Sides: Clashing Views on Controversial Issues Retrieved in Drugs and Society. McGraw-Hill/Dushkin, Gilford Connecticut. November 25, 2005, from Reuters Web Site http://go.reuters.com/ Goozner, M. (2004). The $800 Million Pill: The Truth Behind the Cost of printerFriendlyPopup.jhtml?type=healthNews&storyID=10394002 New Drugs. The University of California Press, Berkley and Los Angelas, Paykel, E. S., Tylee, A., Wright, Priest, R. G., Rix, S., and Hart, D. (1997). Calif. The Defeat of Depression Campaign: Psychiatry in the Public Arena. Healy, D. (2004). Let Them Eat Prozac: The Unhealthy Relationship American Journal of Psychiatry 154: 59-65. Between the Pharmaceutical Industry and Depression. New York Reinhardt, D. (2010). Time for Psychology to Reclaim the Science. The University Press, New York, NY. Clinical Practitioner, vol. 5, number 3, March. Hobson, J. A., & Leonard, J. A. (2001). Out of Its Mine: Psychiatry in Schaefer, P. (2003). Medicating the Ghost in the Machine. In Prosky, P. Crisis. A Call for Reform. Perseus Publishing, Cambridge, Mass. S., Keith, D. V. (2003). Family Therapy as an Alternative to Medication: An Jackson, G. E. (2005). Rethinking Psychiatric Drugs: A Guide for Informed Appraisal of Pharmland. Brunner-Routledge, New York, NY. Consent. Authorhouse, Bloomington, Indiana. Scott, T. (2006). America Fooled: The Truth About Antidepressants, Jackson, G. E. (2009). Drug-Induced Dementia: A Perfect Crime.. Antipsychotics and Howe We’ve Been Decieved. Argo Publishing, Victoria Authorhouse, Bloomington, Indiana. Texas. Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Stein, D. B. (1999). Ritalin is not the Answer: A Drug-Free, Practical Johnson 1 BT. Initial severity and antidepressant benefits: a meta Program for Children Diagnosed with ADD or ADHD. Jossey-Bass Publishers, San Francisco, Calif. -analysis of data submitted to the Food and Drug Administration. Szasz, T. (1976). Schizophrenia: The Sacred Symbol of Psychiatry. Basic PLoS Med 2008;5:e45. Books, New York, New York. Kirschenbaum, D. S. (1996). Helping Physicians Make Useful Turner EH, Matthews AM, Linardatos E, Tell RA, Rosenthal R. Selective 2 Recommendations About Loosing Weight. In, Resnick, R. J., & Rozensky, publication of antidepressant trials and its influence on apparent efficacy. N R. H., Health Psychology Through the Life Span: Practice and Research Engl J Med 2008;358:252-60. Opportunities. APA Books, Washington, D.C. Valenstein, E. S. Blaming the Brain: The Truth About Drugs and Mental Kroenke, K., & Mangelsdorff, A. D. (1989). Common symptoms in Health. The Free Press, New York, NY. ambulatory care: Incidence, evalua-tion, therapy and outcome. Ameri-can Journal of Medicine, 86, 262–266. Volpicelli, J. R., Pettinati, H. M., McLellan, T. A., O’Brien, C. P. (2001). The Guilford Press, New York, NY. Kunen, S., Niederhauser, R., Smith, P., Morris, J. A., & Marx, B. (2005). Raced disparities in psy-chiatric rates in emergency depart-ments. Journal of Consulting and Clinical Psychology, 73 (1), pp. 116-126. Moncrieff, J., Kirsch, I. (2005). Efficacy of Antidepressants in Adults. British Medical Journal. 331:155-157 (16 July), doi:10.1136/ Go to Table of Contents A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 11
  12. 12. Is Your depressed patient being Treated Like A Dog? David Reinhardt, Ph.D., MSPharm. The Psychologist’s role in Collaborative Health Care is an interesting one. We are uniquely trained to listen and can serve as a vital conduit between the patient and all other health care professionals. Yet in the traditional mental health system, the psychiatrist, who (according to most definitions) is responsible for determining which if any symptoms have physical causes and which are emotional, usually sees the patient first. This does not seem to be working out very well for our clients! I’ve started working on the NAPPP Collaborative Health Care Protocol for Depression and am looking for alternatives to this flawed traditional model. Psychologists appear to be the specialists best trained to be the First Responders. Before we volunteer to take on this role we must be sure we are knowledgable in more than just psychological issues. I came across an article that seems to lay out a productive approach. Interestingly, it is written for veterinarians, and is on treating dogs that are apathetic and exhibit “exercise intolerance.” These symptoms seem have a close parallel to human depression. How veterinary science handles exercise intolerance might be useful in developing our Depression Protocol. The veterinary article focuses on identifying the conditions associated with exercise intolerance in retrievers. I have omitted certain genetic investigations that apply only to dogs. Lets see how things compare! Excerpts from Exercise Intolerance in Retrievers The Science of Depression Veterinary Medicine Feb 1, 2010 (1) Selected quotes History Taking History Taking A complete history investigating abnormalities in According to Sommers-Flanagan (2): “Before initiating every body system is important. Whenever possible, counseling, psychotherapy or psychiatric treatment, a veterinarian should observe the dog while it is it’s usually necessary and always wise to conduct manifesting what the owner perceives as exercise an intake interview. Intake interviews are designed intolerance. to answer a number of critical questions, which typically include: Is the client suffering from a mental, Careful physical examination may detect abnormalities emotional or behavioral problem? If so, are his or her that lead to a diagnosis. Complete respiratory, mental, emotional, or behavioral problems sufficient cardiovascular, musculoskeletal, and nervous system to require treatment? What form of treatment should examinations should be performed, as well as be provided to the client? ho should provide treatment thorough abdominal palpation. A complete patient and in what setting?” history, physical examination, and routine laboratory evaluation should be used to help establish a diagnosis. Seems our brothers are given less comprehensive guidance… Conditions associated with Exercise Intolerance Conditions associated with Depression 1. Lack of conditioning or obesity: Obesity is 1. Obesity has a bi-directional link to depression, common in dogs, especially retrievers, and can according to studies. Patients presenting with be associated with a variety of medical disorders symptoms should be assessed for obesity and related and orthopedic problems that can lead to exercise chronic diseases. “The presence of psychosocial and intolerance. Obese retrievers have also been lifestyle risk factors as well as obstructive sleep apnea shown to have small airway collapse during should be considered and managed, particularly given expiration, limiting their ability to exercise. the possibility of weight gain with antidepressants. Weight loss in obese dogs with hip osteoarthritis Physical activity is well established as an effective substantially improves their gait and their ability treatment for depression, obesity, and related chronic to exercise. diseases including type 2 diabetes.” (3) Continued on Pg. 13 A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 12
  13. 13. Depression continued from Pg.12 2. Bone and joint disorders: Discomfort from 2. Bone and joint disorders: In a study of patients with abnormalities of the bones or joints causes reluctance polyarthritis, “thirty-six per cent of the patients were at to exercise. Inflammatory disease affecting multiple risk of depressive symptoms. Women had significantly joints, termed polyarthritis, causes joint pain and higher levels of depression and anxiety than men. reluctance to exercise in dogs. Regression analyses showed that pain and (low) illness acceptance predicted levels of depression.” (4) 3.Infectious diseases: Tick-borne infectious diseases 3. Infectious diseases: “Depressive states among may result in exercise intolerance (e.g. ehrlichiosis, patients with late Lyme disease are fairly common, Lyme disease, granulocytic anaplasmosis, bartonellosis, ranging across studies from 26%-66%. A broad Rocky Mountain spotted fever). Diagnosis requires range of psychiatric reactions have been associated arthrocentesis with cytology and bacterial culture. with Lyme disease including paranoia, dementia, schizophrenia, bipolar disorder, panic attacks, major depression, anorexia nervosa, and obsessive- compulsive disorder.” (5) 4. Cardiovascular disorders: Dogs with cardiovascular 4. Cardiovascular disorders: “Depression is disorders will typically exhibit physical evidence of prevalent (approx. 20% to 35%) in populations with cardiac failure at rest, including tachycardia, cough, cardiovascular disease, is predictive of developing weak femoral pulses, crackles on lung auscultation cardiovascular disease, and is predictive of adverse from pulmonary congestion or edema, and perhaps outcomes among patients with existing cardiac cyanosis and a murmur. disease.” (6) 5. Respiratory and other disorders: Abnormalities 5. Respiratory and other disorders: “Parental of the respiratory system can impair exercise major depression is associated with a significantly tolerance. Further diagnostic tests to evaluate the increased likelihood of respiratory illness in youth. respiratory system should be performed as necessary This association persists after adjusting for age, sex, to reach a diagnosis. Routine screening blood tests, parental prenatal smoking, parental respiratory thoracic radiography, and a complete nervous system disease, and parental functional impairment.” (7) examination should always be performed. 6. Anemia: Chronic anemia can result in classic 6. Anemia: The “Invecchiare in Chianti” (Aging in signs of exercise intolerance. Chronic anemia is most the Chianti area, InCHIANTI) study, a prospective often seen with low-grade gastrointestinal or urinary population-based study of older people living in bleeding, neoplasia, chronic hemolysis, or bone marrow the community, found “Depressive symptoms are disease. Perform a complete blood count in all dogs associated with anemia in a general population of older with exercise intolerance. persons living in the community.” (8) 7. Hypoglycemia: Hypoglycemia is an important 7. Hypoglycemia: “Depressive symptoms were cause of weakness and exercise intolerance in dogs. positively associated with BMI, fasting insulin, systolic In adult dogs, hypoglycemia is most likely caused by blood pressure, caloric intake, physical inactivity, insulin-secreting neoplasms, other tumors, liver failure, and current smoking. In prospective analyses, after hypoadrenocorticism, or sepsis. Low blood sugar as a adjusting for age, race, sex, and education, individuals cause of exercise intolerance is best documented during in the highest quartile of depressive symptoms had a an episode of weakness or when repeated hourly blood 63% increased risk of developing diabetes.” (9) glucose samples are evaluated during fasting. Continued on Pg. 14 A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 13
  14. 14. Depression continued from Pg. 13 8. Hypoadrenocorticism: Primary hypoadrenocorticism 8. Hypoadrenocorticism: “Psychiatric symptoms (Addison’s disease) is a clinical syndrome resulting in patients with severe or long standing adrenal from a deficiency of cortisol and aldosterone. Clinical insufficiency can include depression in 20 to 40%, signs of hypoadrenocorticism are typically related manifested by apathy, poverty of thought, lack of to fluid and electrolyte imbalance, circulatory initiative, social withdrawal, irritability, negativism, insufficiency, and abnormal carbohydrate metabolism. poor judgment, agitation, hallucination, paranoid Lethargy, vomiting, and diarrhea are common. delusion or catatonic posturing. These psychiatric manifestations occur early in the disease and may predate other physical finding, making diagnosis of the cause difficult.” (10) 9. Mineralocorticoids: Hyponatremia, hyperkalemia, 9. Mineralocorticoids: “Patients with major and increased blood urea nitrogen concentration depression show high functional activity of the MR are common findings in dogs with mineralocorticoid (mineralocorticoid receptor) system. Paired with the deficiency. Suggestive laboratory findings in body of evidence regarding decreased sensitivity to GR cortisol-deficient dogs may include hypoglycemia, (glucocorticoid receptor) agonists, these data suggest hypoalbuminemia, and the absence of a stress leukon. an imbalance in the MR/GR ratio. The balance of MR Definitive diagnosis requires confirmation with an and GR is known to affect brain serotonin systems ACTH stimulation test. and may play an etiologic role in serotonin receptor changes observed in patients with major depression.” (11) 10. Hypothyroidism: Hypothyroidism is common in 10. Hypothyroidism: “The relationship between the retriever breeds and can be associated with obesity, hypothyroidism and depression is well known... T3 is lethargy, and exercise intolerance. Laboratory testing superior to T4 as adjuvant therapy in the treatment of thyroid function, including measurement of serum of unipolar depression. CONCLUSIONS: Depressed total thyroxine (T4), free T4 by equilibrium dialysis patients should be screened for hypothyroidism.” (12) (ED), and thyroid stimulating hormone (TSH), is recommended in all dogs with exercise intolerance. 11. Cerebral arteriosclerosis: Central nervous system 11. Cerebral arteriosclerosis: “Psychoses With atherosclerosis and thromboembolic events may Cerebral Arteriosclerosis...Cerebral physical symptoms, be responsible for acute and chronic neurologic headaches, dizziness, fainting attacks, etc., are nearly syndromes in dogs. always present and usually signs of focal brain disease appear sooner or later (aphasia, paralysis, etc.)... Pronounced psychotic symptoms may appear in the form of depression (often of the anxious type), suspicions or paranoid ideas, or episodes marked by confusion.” (13) 12. Polymyositis: Polymyositis is a generalized 12. Polymyositis: According to The Lupus Foundation inflammatory myopathy presumed to have an immune- of America, “Depression may occur as a direct result mediated basis. Elevated serum creatine kinase (CK) of the physical effects the disease produces on your activity is seen in most affected dogs at rest, and body...Some of the medicines that are prescribed even more dramatic increases are common following to control lupus are known to play a role in causing exercise. Attempts should be made to rule out tick- depression...Depression may be a result of the related diseases, systemic lupus erythematosus, continuous series of emotional and psychological Toxoplasma gondii, and Neospora caninum using stresses and strains associated with coping with a serology. chronic illness.” (14) Continued on Pg. 15 A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 14
  15. 15. Depression continued from Pg. 14 13. Metabolic myopathies: Metabolic myopathies 13. Metabolic myopathies: “A definite tendency can be broadly characterized as either glycolytic toward depression was evident among MMD patients. pathway defects or defects of oxidative metabolism. A similar tendency was noted in the small LGS group. Clinical findings may include weakness, muscle The progressive and disabling nature of the disease atrophy, exercise intolerance, and muscle cramping. appears to be the major reason for depression in MMD Affected dogs have persistently elevated serum alanine patients.” (15) aminotransferase (ALT) and alkaline phosphatase (ALP) activities and variable increases in CK activity. Pre- and post-exercise serum lactate and pyruvate concentrations should be measured in exercise- intolerant dogs. 14. Neurologic disorders: Idiopathic epilepsy is a 14. Neurologic disorders: “In general, when standard- common. Exercise, excitement, and hyperventilation ized methods are used, about 29 percent of people with can all serve as triggers for seizures in affected dogs. epilepsy have a major depressive disorder. Research also shows that people with epilepsy who are depressed often are not diagnosed. About 50 percent of the time, they are never treated for the problem.” (16) 15. Acquired spinal cord disease: Progressive 15. Acquired spinal cord disease: “Depression is weakness or incoordination can result in reluctance to even more common in the spinal cord injury ( SCI ) EXERCISE. Perform a complete screening neurologic population-about 1 in 5 people. Estimated rates of examination in all dogs with a history of exercise depression among people with SCI range from 11% to intolerance. Weakness and ataxia resulting from 37%.” (17) chronic spinal cord compression can worsen with exercise, particularly if compression exists in the cervical region where excessive motion occurs during walking and running. 16. Pain: Pain may cause the reluctance to exercise in 16. Pain: “Depression is the most common emotion some dogs. associated with chronic pain. It is thought to be 3 to 4 times more common in people with chronic pain than in the general population. In addition, 30 to 80% of people with chronic pain will have some type of depression. The combination of chronic pain and depression is often associated with greater disability than either depression or chronic pain alone.” (18) 17. Polyneuropathies: Polyneuropathies result in 17. Polyneuropathies: “Doctors believe that multiple muscular weakness that may manifest as reluctance sclerosis depression can be caused by the illness itself. to exercise or exercise intolerance. Chronic Apparently the scar tissue, or myelin plaques, can form polyneuropathies can be seen in association with in areas of the brain that control emotions.” (19) metabolic disorders such as hypothyroidism and diabetes mellitus. Demyelinating polyneuropathies with no known etiology and no effective treatment also occur. Continued on Pg. 16 A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 15
  16. 16. Depression continued from Pg. 15 18. Nutritional deficiency anemias develop when 18. “Deficiency and excess of many nutrients have micronutrients needed for RBC formation are not been shown to alter brain function and lead to present in adequate amounts. Anemia develops depression, anxiety, and other mental disorders. gradually and may initially be regenerative, but Nutrient deficiencies can have a profound influence on ultimately becomes nonregenerative. Starvation causes the brain and mood.” (20) anemia by a combination of vitamin and mineral deficiencies as well as a negative energy and protein balance. Deficiencies most likely to cause anemia are: iron, copper, cobalamin (B12), B6, riboflavin, niacin, Several contributors to depression in humans are not vitamin E, and vitamin C (only important in primates covered in the veterinary article. Please see the May and guinea pigs). issue for a more complete list. If Psychologists are to assume a role as First Responders for Collaborative Mental Health Care, we must be prepared for all that entails. We must make sure our patient’s concerns and symptoms are accurately heard and acknowledged by other Team members. As Medical (and in particular as Prescribing) Psychologists, we must do all that we can to set the stage for the Psychiatrist and other physicians to do their jobs. Psychologists have an obligation to make sure, within our power, that our patients are treated at least as well as dogs. How does this compare to what you’ve seen? Next month’s issue will examine additional contributions to depression and the the specific symptoms that Psy- chologists must be aware of in order to fulfill a role of “First Responders” in collaborative mental health. 1) J Veterinary Medicine Feb. 1 2001 http://veterinarymedicine.dvm360.com/vetmed/article/articleDetail.jsp?id=656960&sk=&date=&pageID=11 2) Clinical Interviewing, John Sommers-Flanagan and Rita Sommers-Flanagan, 2003, Wiley and Sons, new Jersey ISBN 0-471-41547-2 http://books. google.com/books?id=pTS_eAcJaXEC&pg=PA167&lpg=PA167&dq=psychiatric+intake+interview&source=bl&ots=sOqtMXOXtb&sig=KvG0SMiSZt82ypl kTgkddS8k_eY&hl=en&ei=0MemS-K6EZPQsgOnxP28BA&sa=X&oi=book_result&ct=result&resnum=8&ved=0CCoQ6AEwBw#v=onepage&q=psychiatr ic%20intake%20interview&f=false 3) British Medical Journal (BMJ) http://www.bmj.com/cgi/content/full/339/oct06_2/b3868 4) Rheumatology, http://rheumatology.oxfordjournals.org/cgi/content/full/44/9/1166 5) Amer. J. of Psychiatry http://stason.org/TULARC/health/lyme-disease/2-17-Can-Lyme-disease-cause-depression-or-other-psychiatric.html 6) Circulation, http://www.circ.ahajournals.org/cgi/content/full/111/3/250 7) Arch. of Ped and Adol Med http://archpedi.ama-assn.org/cgi/content/abstract/161/5/487 8) J Gerontol A Biol Sci Med Sci. http://www.ncbi.nlm.nih.gov/pubmed/16183958 9) Diabetes Care http://care.diabetesjournals.org/content/27/2/429.abstract 10) .Ind J of Med Sci http://www.indianjmedsci.org/article.asp?issn=0019-5359;year=2003;volume=57;issue=6;spage=249;epage=251;aulast=Kaushik 11) Arch Gen Psychiatry http://www.ncbi.nlm.nih.gov/pubmed/12511169 12) Ann Pharmacother http://www.biopsychiatry.com/hypothyroidism.htm 13) “Manual Of Psychiatry”, by Aaron J. Rosanoff ISBN-13: 978-1406733556 14) Lupus Foundation of America, http://www.lupus.org/webmodules/webarticlesnet/templates/new_learnliving.aspx?articleid=2256&zoneid=527 15) Arch Phys Med Rehabil. http://www.ncbi.nlm.nih.gov/pubmed/3800615 16) Epilepsy Foundation, http://www.intranet.efa.org/answerplace/Medical/related/Depression/epilepsy.cfm 17) U.W. School of Medicine http://sci.washington.edu/info/pamphlets/depression_sci.asp 18) ACA Today http://www.acatoday.org/content_css.cfm?CID=2187 19) Suite 101.com http://neurologicalillness.suite101.com/article.cfm/ms_depression__what_causes_it_ 20) International Clinical Nutrition Review,http://www.vitasearch.com/get-clp-summary/9375 Go to Table of Contents A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 16
  17. 17. The Contribution of Client Variables to Psychotherapy Outcomes Part II: Therapeutic Techniques Which Allow for Client Contributions to Drive Change Gary Padover, Ph.D., MP Most practicing psychologists would likely gained the blessings of the insurance carriers. Although agree that the client is the driver of change in treatment. this leads to greater uniformity and reliability, it may The traditional psychotherapy session is a fifty minute compromise the importance of client variables such as microcosm of life in which the client attempts to solve interests and motivation. his or her problems. Clients may present as reactive, School psychologists and clinicians treating children impulsive, reflective, or with a low frustration tolerance, and adolescents in both schools and outpatient settings but the client is there to tell his or her story. The client’s utilize varied forms of cognitive behavioral approaches. role and sense of personal agency in the change process The acronym “STOP and GO” is frequently employed in would be diminished by therapist over-involvement and treating adolescents in a group therapy setting: “Slow judgment. down, think, consider options, pick the positive option While seasoned clinicians provide the structure and go to your goal.” While such manualized acronyms and boundaries for clients, the most effective first are not insight oriented, they do provide an effective line treatments may be those therapies which allow treatment option for more concrete thinking adolescents clients to define their own topics. From a professional in residential centers who may not be interested in standpoint it may be true that “the light bulb must want longer term or abstract reasoning processes, but seek to change”, but it may equally be true that “the light immediate and concrete solutions to problems. Not bulb also knows the direction in which it wants to turn.” all children and adolescents, however, fit the mold for As professionals, we owe it to our clients to use the which this modality is targeted. approach that works best for them. Client or person centered therapies allow more Certain therapeutic techniques emphasize for client contributions to evolve within a therapeutic this client role more than others. environment of unconditional positive Cognitive behavioral, rational-emotive, regard, acceptance, attunement, client centered, and gestalt therapies validation and empathy. Effective Client centered are among them. The premises of client centered therapies emphasize cognitive behavioral and rational- therapies allow for a more neutral, accepting therapist emotive behavioral therapies are well who is present but less involved. The clients to define goals established. With them clinicians experience of the client is the focus of facilitate client growth by encouraging for themselves treatment. This approach facilitates them to explore the negative self the uncovering of client motivations, statements, demands, beliefs, and perceptions and styles and drive the expectations which distort events and change process. result in greater anxiety and depression. The client is Client centered therapies allow for the client to define encouraged to replace his or her faulty logic with more goals for him or herself. Positive self acceptance rational thoughts and behaviors. facilitates authentic client growth. More reactant clients, Cognitive behavioral therapy is an empirically threatened by their perception that others may become supported treatment for specific disorders, most notably obstacles in their paths, are likely to prefer this approach depression and anxiety. The techniques of CogB are as it emphasizes the client’s choices. often manualized (there is a set protocol of actions; if Gestalt psychotherapeutic approaches you follow the series of steps then a particular result can emphasize client perceptions, demands and be expected.) This concept is appearing in more cases to expectations. I utilize the “empty chair” technique for handle many social and psychological maladies and has Continued on Pg. 18 A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 17
  18. 18. Variables continued from Pg. 17 many clients, as they attempt to resolve splits within their relationship, as well as potential legal problems. themselves and conflicts with others. The notion of This technique can also help an angry, middle-age male “top dog” and “bottom dog” enables clients to explore client resolve feelings of worthlessness and poor self how they are placing demands upon themselves and esteem, by imaginatively placing a deceased father on others. the empty chair as the client works through his hurt and With the Gestalt approach clients may effectively anger, thereby becoming more capable of dealing with a explore their emotions and take responsibility for critical employer in his present everyday life. their role in creating conflicts with family members, A new client driven therapy, “Method of Levels peers, employers, significant others, and in their own Therapy” is premised on theories of reorganization and self-critical judgments. The client explores his or her homeostasis. It is gaining popularity in Australia and feelings while the therapist remains in the background. the UK and gradually being introduced to the US. The He or she takes on a more active role, with a keener client takes on the role of “explorer” and the therapist sense of personal agency in the safety of the session. is the “guide”. I have found this technique very useful The client is able to reorganize perceptions and with families. Working with youngsters, I have found reactions and effectively make adaptations in problem that they know the topics they wish to discuss, and if solving strategies. they are allowed to define foreground and background I have found empty chair is more suitable for adult issues a process similar to the gestalt notion evolves. than teenage clients, but it can be very effective for both For example, if a 15-year old youngster with a physical children and adolescents as they explore their anger defect is reporting in therapy that he is being teased by and hurt feelings. I have seen clients effectively work peers, I ask him what comes to mind when describing on issues such as perceived unfair treatment through the teasing. He begins to talk about this technique. For example, middle how his father always is there for him, school youngsters, trusting the empty so the client has begun to drive the chair process, may imaginatively place “Method of Levels change process. If I then ask, “What a classmate on the empty chair and Therapy” is premised comes to mind when you talk about tell him or her how hurtful it feels to your father?” and the client answers, be teased for being overweight. Over on theories of “I worry about my father’s health,” time, the client then integrates this reorganization and the client has shifted to a higher level therapeutic experience with some topic, previously more hidden in his additional role playing during therapy homeostasis background thoughts and now gaining and learns how to enter into age awareness. appropriate peer play without acting overly timid or aggressive. The important point is the client is driving the change, by presenting topics of concern. He knows where Some clients are not comfortable talking to an he wants to go in the therapy session; all he needs empty chair and perceive it as “crazy” and may need is a guide while he does the exploring. The client normalization and some explanation of the process. has the capacity to reorganize and reduce his error Highly reactant and resistant clients are likely to avoid or disturbance once he is able to access the topics attempting to explore their experiences through this previously in his background thoughts. process. Likewise, the empty chair technique likely is contraindicated for clients with ego disturbances. In training new practitioners I encourage them to look at the numerous psychotherapeutic approaches Similarly, I have seen middle aged male clients in and critically examine how these therapies may demeaning relationships with their respective spouses utilize the notion of the client as the driver of change. learn to appropriately define and express their hurt Seasoned clinicians are adept at providing structure and feelings by imaginatively placing their spouse on boundaries for clients, and the most effective first line the empty chair in the therapy session. The client is treatments may be those therapies which allow clients then more capable of returning home without angry to define their own topics, without therapist over- outbursts toward his spouse. He can avoid adverse involvement or viewing client perceptions, expectations, and negative consequences, including damaged trust in and styles skeptically. Go to Table of Contents A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 18
  19. 19. World View... The Missing Voice of Patients in Drug-Safety Reporting From The New England Journal of Medicine January 2010 by Ethan Basch, M.D. A patient wants to know about symptoms she in controlled trials could be used. may have from a prescription drug she is taking. Such methods might have resulted in earlier Consulting the label’s “Adverse Reactions” section, she detection of some serious adverse events that have finds a wealth of data. Little does she realize that this been widely publicized, including suicidal ideation information, largely collected during clinical trials, related to the use of selective serotonin-reuptake is based almost entirely on clinicians’ impressions of inhibitor antidepressants in younger patients and severe patients’ symptoms — not on patients’ own firsthand constipation and ischemic colitis associated with the use reports of their experiences with the drug. of the 5-hydroxytryptamine type 3 receptor antagonist The current drug-labeling practice for adverse alosetron, which resulted in temporary withdrawal of events is based on the implicit assumption that an the drug from the market. accurate portrait of patients’ subjective experiences Why isn’t the reporting of such events by patients a can be provided by clinicians’ documentation alone. standard component of drug evaluation? Although Yet a substantial body of evidence contradicts this safety evaluation once predominated over efficacy assumption, showing that clinicians systematically evaluation in the regulatory review of drugs, over time downgrade the severity of patients’ symptoms, that the comprehensiveness of efficacy measurement has patients’ self-reports frequently capture side effects progressed, while safety screening has remained largely that clinicians miss, and that clinicians’ failure to note dependent on ad hoc and retrospective reporting. It is these symptoms results in the occurrence of preventable in this context that the current clinician based approach adverse events. to adverse symptom reporting has evolved. The prospective collection of data directly from patients This model remains in place largely because about symptoms they have while taking a drug (so- of inertia — but today’s patients are vocal partners in called adverse symptom events) is an alternative decisions about their own care, and there are commonly approach that could add valuable information to current available technologies that permit reliable collection practice. Self-reports are more sensitive to underlying of information from them. Optimizing tactics for changes in patients’ functional status than are clinicians’ collecting this information is especially important reports and tend to identify symptoms earlier during because adverse symptom events are common: a course of treatment. Current methods for detecting symptoms account for a large proportion of the adverse adverse events in clinical trials are acknowledged to reactions listed in drug labels... lack sensitivity, and worrisome symptoms might well come to light earlier in the drug-development cycle if The limitations of current safety-reporting mechanisms reporting by patients were standard practice. are well documented and have led the FDA to develop its recently announced Safe Use Initiative to reduce Before a drug has received marketing approval preventable harm from medicines. Patient self- from the Food and Drug Administration (FDA), direct reporting offers one solution that would enhance the reporting by patients could be used in phase 2 trials capture of subjective elements of safety information. to screen for unexpected reactions and then in phase 3 trials to follow up on any detected signals and to Given the clinical and scientific value of patient- characterize the incidence and severity of additional reported adverse symptom events as well as the potential adverse symptom events... Although other feasibility of collecting this information, one can make inherent limitations of preapproval safety evaluations, an ethical argument that patients are entitled to know such as narrow eligibility criteria and limited follow-up, the impressions of their peers — and that scientists, would persist, the ability to detect adverse symptom regulators, and clinicians should have access to those events among study participants would improve. After impressions when evaluating drugs. Such a change FDA approval, both general screening to detect signals would lend all of us extra confidence when we reach into in observational cohorts and more targeted assessments the medicine cabinet. Go to Table of Contents A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 19

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