Perspectives

Here comes the sun

Former division president Patrick DeLeon, PhD, reflects on the current state of psychotropic medication prescription.

By Patrick H. DeLeon, PhD

I recently had the opportunity of meeting with graduate students and several faculty members at Purdue University where I obtained my doctorate. Long-time RxP supporters Chuck Faltz and former APA president Jack Wiggins are also Boilermakers, as is APA journal editor extraordinaire Michael Roberts. My sincerest appreciation to Don Lynam and Chris Agnew for making this visit possible. It was truly special to be able to visit once again with Cliff Swensen, my major professor. Two of the messages which I shared with our next generation were that every one of the prescribing psychologists that I have met has been very pleased with their decision to obtain this extra training even though, almost without exception, it was at their own personal expense. And, that in my judgment, almost all of those colleagues who are adamantly opposed to psychology obtaining this clinical responsibility do not work with those patient populations who would benefit from our expertise—especially in ensuring that appropriate medications and dosages are utilized. Providing quality care has always been the underlying issue.

Far from being the “public health hazard” that organized psychiatry predicted, our prescribing colleagues in New Mexico, Louisiana, and the federal system have done an outstanding job. Former APA and division president Ron Fox notes: “As of Dec. 31, 2013 when I was chair of the APA Insurance Trust, I can attest to the fact that prescribing psychologists do not have to pay higher premiums for professional liability insurance as the Trust deemed an increase unnecessary; and, because the Trust policy provides insurance to cover expenses related to licensing board complaints I know that there have been no complaints or actions taken by state licensing boards regarding prescribing abuses by appropriately trained psychologists.” Another visionary former Division President, Bob McGrath, who is spearheading the New Jersey RxP legislative effort, estimates that 1750 colleagues have already completed their advanced psychopharmacology training. Working at the Uniformed Services University of the Health Sciences (DoD), we would be particularly interested in having those veterans who have completed their RxP training share their experiences with APA’s Heather Kelly, who is working on a relevant VA agenda.

SAMHSA

During its deliberations on last year’s budget for the Substance Abuse and Mental Health Services Administration (SAMHSA), the Senate Appropriations Committee expressed its concern regarding the current utilization of psychotropic medications for children. “The Committee has become increasingly concerned about the safe, appropriate and effective use of psychotropic medications and children; particularly children in foster care settings. According to a December 2012 GAO report, an alarming 18 percent of foster children are prescribed psychotropic medications, compared with 4.8 percent of privately insured children. The Committee strongly encourages SAMHSA to establish meaningful partnerships with Medicaid, the foster care program, medical specialty societies, and treatment centers to develop new strategies for treating this vulnerable population. The Committee would like an update in next year’s congressional justification on the steps SAMHSA has taken to promote the most effective and appropriate treatment approaches, including the use of evidence-based psychosocial therapies instead of, or in combination with, psychotropic medications.”

During this year’s budget justification, SAMHSA reported: “SAMHSA has taken a significant leadership role to address the safe, effective and appropriate use of psychotropic medication in children and youth. The agency has collaborated extensively with the Administration on Children and Families (ACF) and the Centers for Medicare & Medicaid Services (CMS) to address this issue for children in foster care; has partnered with professional groups to create more stringent guidelines related to prescribing and medication oversight practices; and has worked closely with parents and youth to improve consumer decision-making with regards to the use of medications. Below reflect a number of activities and developments that SAMHSA has been engaged in to address the issue.

“SAMHSA supported the American Academy of Child and Adolescent Psychiatry’s (AACAP) development of guidelines on issues that community agencies should address when prescribers are considering the use of psychotropic medications. Titled, ‘A Guide for Community Child Serving Agencies on Psychotropic Medications for Children and Adolescents,’ this document provides information to community agencies about safely and effectively prescribing psychotropic medications, describes the phases in treatment when medication could be considered part of an overall treatment plan, and provides information about the use of community based alternatives that child serving systems and agencies should consider in addition to psychotropic medications. SAMHSA has also collaborated with AACAP to support a Child and Adolescent Psychiatry Fellow at SAMHSA one day a week (20 percent FTE). For the past four years each Fellow has undertaken a project to improve psychiatric service delivery, connect with community agencies and organizations, and identify evidence-based treatment strategies. Perhaps one of the most significant advances SAMHSA has helped to support has been the development of a Youth Advisory Group at AACAP that provides advice, guidance and information about medication use and empowers youth to make their own informed decisions regarding using medications. One accomplishment supported through this youth group was the development and expansion of the AACAP website as a resource to youth and families. Via a simple click on the ‘families and youth’ toolbar on the AACAP homepage, youth and families can obtain a wealth of resources that include a section on how to choose a child and adolescent psychiatrist; ‘Facts for Families’ on a wide range of topics; a patient education section that provides information about mental health conditions; and an entire section dedicated to youth resources. Going forward, SAMHSA will be continuing its efforts to address the importance of using psychotropic medications safely and effectively in collaboration with AACAP.

“In addition to the work with AACAP, SAMHSA has also supported efforts by the Center for Health Care Strategies of the Robert Wood Johnson Foundation to provide technical assistance on strategies to improve oversight of psychotropic medication use in foster children. The technical assistance has included a webinar series, ‘Psychotropic Medication Use among Children in Foster Care: Technical Assistance Webinar Series.’ As part of this series, in September of 2013, a webinar was held titled, ‘The Use and Financing of Non-Pharmacologic Evidence-Based Practices: Alternatives to Psychotropic Medications.’ Evidence-based psychosocial interventions were identified that may offer a more comprehensive and cost-effective means of addressing behavioral health and social challenges experienced by children and youth in foster care, as well as other child populations with significant behavioral health challenges. SAMHSA also supported the Center for Health Care Strategies recently released ‘Faces of Medicaid Analysis,’ which identified areas to improve behavioral health treatment, including the use of psychotropic medications and alternative approaches.

“SAMHSA was also one of the sponsors of an Administration on Children, Youth and Families conference and dialogue about the appropriate use of psychotropic medication for foster children. SAMHSA provided training to nearly 100 early career child and adolescent psychiatrists on community and public sector psychiatry, systems of care and youth and family engagement. As part of SAMHSA’s ongoing commitment, SAMHSA will maintain its meaningful partnerships with other federal agencies, guilds and organizations to further the important agenda to address psychotropic medication use in America’s children and youth.”

There can be no question that SAMHSA’s efforts to be responsive to the Committee and to the needs of our nation’s children, including those placed in foster care, is highly commendable. We would ask, however: Where is psychology’s voice/presence? We are confident that those colleagues who specialize in serving children and who have completed their RxP training could contribute significantly to addressing this national need. Yet, one of Hawaii’s most rural, and perhaps smallest, federally qualified community health center (FQCHC) on the island of Lanai recently applied for a HRSA behavioral health integration grant which would, among other needed services, provide for part-time child and adolescent psychiatry services utilizing telehealth/telemedicine, at the request of their psychology staff, estimating that approximately 10 patients a year will need these services. If psychology is unwilling to focus upon national and pressing local priorities, others will; especially as President Obama’s Patient Protection and Affordable Care Act (ACA), with its emphasis upon integrated care, is systematically implemented. Long time health psychology visionary Susan McDaniel reports: “I had a nice surprise last week. As part of promoting psychology as essential to health, I have done two episodes on the nationally-syndicated PBS show on health called ‘Second Opinion.’ The directors are very in tune with a whole person approach to health, and always have a multidisciplinary group of professionals along with a patient, focused on some specific health problem. I’ve done one on Grief, and then one 5-minute spot on the show on Teen Depression. The show heard last week that this episode on Teen Depression won a Telly award (a national award for the best in television programming).”

Meaningful Journeys

“Reflections of a Peace Corps Volunteer—A Decade Later. Tempus fugit, time indeed seems to have the habit of proceeding on a logarithmic path. Could it really be almost a decade since I completed Peace Corps service in Guatemala? Yes, it is so, time to reflect once again on that experience. Many questions come to mind. How did I get there? What was it like? What do I tell other people about the Peace Corps?

“I had been retired from 37 years active duty in the U.S. Army. The last 20 years of my Army career was as an operational psychologist. For five years I had a great retirement, crewing on sailboats in Hawaii, Mexico and the Caribbean and backpacking in Europe and New Zealand. I thought about how fortunate I have been in life. I decided maybe it was a good time to give to others for the many blessings I have received. I was around when John F. Kennedy founded the Peace Corps. I greatly admired the idea of the Corps. I went online and applied.

“I was in Washington, D.C. on Sept. 11, 2001, when the terrorists crashed into the Pentagon. I watched the smoke from the roof of my condo. Then and there I resolved to do my enlistment in the Peace Corps. I knew at age sixty-six, the Army would probably not allow me back on active duty. I decided the best thing I could do for my country and for others was to accept the invitation I had received from the Peace Corps to serve in a Healthy Schools Project in Guatemala.

“Thirty-nine of us gathered in Miami to process and to travel to Guatemala to begin fourteen weeks of training for the Peace Corps. Of the 39 volunteers, 29 completed the full two year tour. Each volunteer had to live with a local family during training to learn Spanish and to learn the culture. I was blessed to live with a wonderful family, with whom I maintain contact. I have returned to Guatemala to visit them. The Peace Corps does an excellent job in training volunteers in language, technical skills and cultural interaction. The Peace Corps nurse clinicians do a superb job in teaching individual preventive care and self-care. They impressed upon us that you are to a great extent responsible for your own health. If any of us required definitive care, the Peace Corps ensured the best doctors in Guatemala treated us. After completing training, we took the Oath of Service from U.S. Ambassador John Hamilton.

“I was fortunate in being assigned to Santiago Atitlan, a Mayan village on the shore of Lake Atitlan. An awed Aldous Huxley described the Lake as ‘too much of a good thing.’ As Lonely Planet states: ‘Simply put, Lago de Atitlan is one of the world’s most spectacular locales, period.’ The grinding poverty of many of the people is in sharp contrast to the surrounding beauty. The Mayan people of the Central Highlands probably suffered the most during the tragic 36 year civil war in Guatemala.

“As a psychologist, I really appreciated the behavioral objectives of our Healthy Schools program. The major objective was to have the children practice good health habits in school on a daily basis. For example, we strove for at least 80 percent of the students brushing their teeth after the school snack. And yes, we had to figure out little games to teach the kids how to brush properly. For some students, it was the first time in their lives that they had a tooth brush. If a school met the long list of behavioral objectives, it would be certified as a ‘Healthy School.’ This certification increased the school’s prestige in the community. In addition, it also helped in obtaining international assistance. We started out teaching and we trained the teachers in instructing health material. We encouraged them to adopt experiential learning techniques as opposed to straight lecture. We conducted workshops, where teachers would create their own material and games. Another dimension of our job was to work with the parents, local authorities, and nongovernmental organizations (NGOs) to improve sanitary conditions in the schools and in the village. We ended up with one of the few rural schools in Guatemala that has running potable water, clean bathrooms and even toilet paper. The kitchen now has a propane stove instead of a wood fire with the dangerous emission of smoke.

“Most days were good. And then there were the other days. I remember a day of stumbling over my Spanish words, hoping the children could understand me. At the same time, I was trying to unobtrusively scratch my flea bites and hoping to control the diarrhea until recess. That was the day at long last when I could consider myself a real Peace Corps volunteer. Fortunately days like that were rare. Most days you were happy to be doing what you were doing. Living in the village and becoming part of the community was a great experience. The Mayan people have respect for the family, especially the elderly. At times, the life of a volunteer could be frustrating, but most of the time it was as they say in Spanish vale la pana, very worthwhile. In many ways, for someone trained in psychology, a tour in the Peace Corps becomes a living laboratory. You can see the results of schedules of reinforcement and what modeling and role play can accomplish. You learn a lot about group dynamics and cross-cultural communications. And you learn a lot more about others and yourself and what you value.

“This January’s Monitor had an excellent article about retirement. The Peace Corps could be a great experience for any psychologist during retirement. Also for a young man or woman who just finished their undergraduate work, the Peace Corps could provide the opportunity to serve others and to mature. One of the best things that happened to me during my tour was that many of the younger volunteers asked me for assistance in planning their future. Every volunteer, who wanted to return to school for an advanced degree, got accepted into a program. Most universities are very Peace Corps friendly. We had an electrical engineer who was in the environmental protection program and who is now a physician. Another volunteer from the Healthy Schools program went back to law school and specialized in international law. She is now assisting indigenous people world-wide. The young volunteers I had the privilege of working with were just what John F. Kennedy had in mind, when he founded the Peace Corps. My advice about the Peace Corps—if you are thinking about doing it, just do it” [Ernie Lenz].

Retired VA psychologist and now psychology historian and sage fiction writer, Rod Baker: “When you mentioned the person in retirement who said that he thought he still had something to pass on, I remembered one of my favorite stories an elderly gentleman passed on to me was his lament: ‘Now that I know all the answers, no one asks me the question.’ Looking forward to seeing you at APA.” It is all right. Aloha.