Feature Article

Practicing in rural South-Central New Mexico

The author reflects on his 10 years as a medical and neuropsychologist with prescriptive authority in New Mexico.

By Tommy Thompson, PhD

Living at the intersection of poverty, low education, poor self-care, chronic physical disease and the burdens of mental health: What a neighborhood to live and work in as a  medical/prescribing psychologist!

Tommy ThompsonI am reflecting at this time on my past 10 years as a medical and neuropsychologist with prescriptive authority in New Mexico. This reflection is sparked by many things including arriving at the age of 68 this summer, contemplating having been licensed as a psychologist for over 41 years and acquiring postdoctoral training in neuropsychology and medical psychology over a course of years, as well as a request from Michael Tillus, PsyD, for a submission. This is a natural time for reflection. The inquiry from Tillus came at an opportune time for me. I hope the following reflections will be of use to others.

I have practiced for the past 10 years at a rural critical care hospital with an attached community mental health center (CMHC) in Sierra Vista Hospital located in Truth or Consequences, New Mexico. That's right, the town that changed its name to a game show back in the 50s. What the change explains I will not speculate upon at this juncture. This year, on June 24, I ended my tenure having moved from a position of contract consultation to full time medical director for behavioral health with full medical staff privileges.

I was privileged to help rebuild the CMHC. In the process, I learned enormously from the chief medical officer, James Malcolmson, MD, internists and other members of the medical staff. Together we worked to build an integrated service. Not because it would become the new professional buzzword, but because survival in a poor, rural and underserved area depends on everyone covering everyone else's back. As a result of this need to survive, integration was a natural and worked well, which is why I suspect it has become a new goal nationally. The influential and bidirectional interaction of rural health medical staff and behavioral health staff resulted in a tremendous amount of learning on the part of everyone involved. As part of the medical staff, I was fortunate to help the CMHC develop expanded consultation services to the emergency room, to the rural health clinic and to the acute medical floor and even to the county detention center.

Fortunately, my educational background as a medical-prescribing psychologist included heavy exposure to family medicine. During training at New Mexico State University, I was able to spend almost two years with the Southern New Mexico Family Medicine Residency Program at Memorial Medical Center. Working side by side with residents and faculty, I learned to assemble both a physical and medical picture of the patient. We learned to pay attention to the physical presentation of the patient, vital signs, our examination, the medical history and findings over time.

I began to integrate an expanded level of understanding of physical medicine and pathophysiology with my years of experience in clinical and neuropsychology. As a result, the doors to a larger universe, the bidirectional universe of the comorbidities that exist between physical and mental disorders opened wide. The ability to conceptualize, understand and treat a patient population with enormous need began to take on an increased clarity. This was a patient population with exposure to multiple risk factors associated with family, social, educational, vocational and health hardships. I remember one faculty member saying if you go into community health programs these are the patients you will see. While many of us had experience with this population in our practices as psychologists, the words of this faculty member were exactly on target, in fact, on occasion, an understatement.

For me and one other postdoctoral prescribing psychology resident, Robert Mayfield, LCP, MD, PhD, the exposure and training were further enhanced when we began working with mothers and children at La Casa, the domestic violence residential program in Las Cruces, New Mexico. Assisted by a caseworker and encouraged by a faculty member, we developed a weekly clinic for both these vulnerable mothers and children. We practiced what we had been trained to do performing basic physical assessment and screening with vital signs as well as developmental and mental health assessment. We would then refer the majority of these patients to the Residency Program Clinic or other community agencies where evaluations associated with developmental disabilities and assessment could be provided.

With faculty support, Mayfield and I moved beyond the idea that as medical prescribing psychologists in training we would see our patients for therapy and prescribe for them.

Being up close and personal with this group of vulnerable mothers and children underscored the necessity that we be prepared to assume the heavy lifting that much of psychiatry had been doing. Not that psychiatry wanted us to assume these responsibilities. It was the need of the underserved. It was reflective of the current Zeitgeist. For Mayfield and me as well as for some others, the tremendous unmet needs of the underserved, poor, at risk and vulnerable populations cried out for the medical prescribing psychologist to step up and assume this role and carry our weight in collaboration with the other medical practitioners on this frontier.

As we emerged from training and initial licensing periods, our roles expanded. We encountered a much greater degree of involvement in the treatment of individuals for whom the spectrum of mental and physical disorders was highly complex. With the initial licensing of psychologists with prescriptive authority, at the conditional level and unconditional level, many of us became even more active in our new roles treating populations in which greater degrees of comorbidity, complexity and histories of multiple adversities were present. The training and supervision which we had received resulted in an increased skill sets, exponentially so. We emerged to work and participate with other medical professionals in those areas where there was a dire need, a need that surrounds us in southern New Mexico and New Mexico as a whole.

The Challenge

Most of New Mexico is categorized as an area of persistent poverty by the U.S. Department of Agriculture (USDA). This designation means an area has a poverty rate higher than 1 out of every 5 people. This is an extreme degree of poverty which extends back many decades and is not unique to New Mexico. Across the nation, 82 percent of persistent poverty occurs in rural counties especially in isolated rural areas commonly designated as frontier, which is the classification for Sierra County. As a concrete reflection of the dire circumstances, the state of New Mexico refunds up to $5,000 on individual state taxes if you are a full-time medical worker in one of these areas.

The national and state data are very clear. This population is complex secondary to many problems. These problems relate to physical health, personal care and comorbid behavioral/mental disorders. In Sierra County, heart disease, cancer, chronic lower respiratory disease, cerebrovascular disease and diabetes are the leading causes of death, in that order. In the patients I began seeing, everyone had at least one if not more of these conditions. If they were younger, the health and personal care practices and risk factors were such that if they did not then have these disorders, they certainly had the potential for developing these conditions, which would soon complicate their lives even more so.

Recent 2012 Sierra County statistics noted heavy drinking rates for females (25 percent) and males (50 percent) was the worst for all counties in New Mexico. That rate had risen in females from 2005 to 2012. Similar findings were noted for binge drinking rates and for smoking with only obesity not significantly increasing. However, given obesity's degree of occurrence in all comorbid disorders the latter result was not particularly outstanding.

Poverty, for both males and females, was in the worst 10 percent of all counties in New Mexico and had increased over an approximate 10-year time span. One of the last figures in 2006 showed the per capita income in Sierra County at slightly over $22,000 and noted a poverty rate for children under eighteen of 44 percent. Data in 2012 also showed an increase to 59 percent of young children or almost 100,000 children in low-income families which was defined as an income 200 percent below the federal poverty level. In sparsely populated (rural) New Mexico, at least 150,000 children live in poverty and nearly 80,000 in extreme poverty.

In 2007, the New Mexico Indicator Based Information System (NM-IBIS) reported poverty in the early years of a child's life, more than at any other time, has an especially harmful effect on continuing healthy development and well-being including both developmental delays and infant mortality. Quality of well-being complications in later childhood, such as teen pregnancies, substance abuse and educational attainment are also influenced by the early experience of childhood poverty. Children born into poverty are less likely to have regular health care, proper nutrition or opportunities for mental stimulation and enrichment.

I was able to capture my experiences and evolution of thinking in a presentation before the New Mexico Prescribing Psychologists in 2013. The presentation, “The Intersection of Poverty, Low Education, Poor Self-care, Chronic Physical Disease and the Burdens of Mental Health: The Problem of Patient Complexity and the Larger Problem of Preventing Patient Complexity” was a continuing attempt on my part to formulate what I had encountered as well as what I knew others were encountering.

The presentation also reflected a recognition of how extremely fortunate I was to be able to provide care side by side with physicians, nurse practitioners and other providers. The opportunities for both learning and contributing to the learning of others were invaluable. As with all disorders in this population, and generalizing to other rural, urban and Native American/Indian country, these were disorders in which comorbidity was the norm and in which the bidirectionality of that comorbidity was a defining feature. Certainly it was a defining feature in the training I received and is a defining feature for those medical prescribing psychologists who move to participate in care for these underserved and at-risk populations.

One of the advantages of preparing the presentation was my ability to access the research and practice of others that supported my thinking. We are all part of the Zeitgeist. I found other articles in which individuals had done a very nice job of articulating their experience and thinking. In a slide presentation by Shim (2012) Figure 1, she articulated the high prevalence of mental disorders occurring among the chronic medical conditions seen in primary care. In that presentation, she emphasized the interaction and bidirectional nature of the relationship of these comorbidities. When an individual has a mental disorder, they are at risk for developing a chronic physical condition and the opposite is equally true. Indeed, this was my experience.

Figure 1

Comorbidity of Medical and Mental Disorders

Chronic Medical Condition Percent with depression/anxiety Percent treated for depression/anxiety
Arthritis     32.3 7.1

Hypertension

30.5 5.5
Chronic pain 61.2 5.9
Diabetes Mellitus 30.8 5.2
Asthma 60.5 6.8
Coronary arrtery disease 48.2 5.7
Cancer 39.8 5.7

A complex bidirectional risk pathway creates an enormous burden for the patients we treat. Not only does it create painful costs in the lives of these patients, it creates an enormous cost on the health care system itself. The failure to recognize this reality is now very obvious, even publicly so. Also exposed is the enormous failure at a national and state level to adequately fund behavioral health and the resulting failure to integrate factors which have been known for decades.

With the skill set that we bring to the table where are other medical colleagues were already working, Medical-Prescribing Psychologist, could work to help to treat the current need and try to participate in the reduction the long-term comorbidities/risk factors. In concert with our medical colleagues we bring treatment of mental disorders and modification of lifestyle behaviors to the table. As the old saying goes, this is something that is biting us in the derrière. It has been, and will continue to be until dealt with in a serious straightforward and realistic manner without the political one-liners, promises and double talk that characterize much, if not most, of what flows downhill from on high. There is still a wish at the level of state government in New Mexico that each pronounce of system change, new organization involvement, etc., will finally result in the fairy godmother appearing and turning the pumpkin into a coach and the mice into horses and footman. I'm sure this is not unique to New Mexico.

Figure 2

The bidirectionality of risk factors and comorbid medical and mental disorders

 The bidirectionality of risk factors and comorbid medical and mental disorders

[Research Synthesis Report NO. 21-The Robert Wood Johnson Foundation-mental health disorders and medical comorbidity, page 6]

The National Comorbidity Survey, 2001-2003, cited in the Robert Wood Johnson Foundation (RWJF) report, found 25 percent of adults had mental disorders. In this group with mental disorders, 68 percent had coexisting medical conditions. These facts are a small reflection of how long we have been aware of this data.

The disparity in quality and years of life are painfully obvious in rural southern New Mexico and in many other underserved rural, urban and reservation areas. The tremendous burden of the impact on the quality of life, as well as the quantity, is reflected in multiple research and discussions. The knowledge is so common it appeared in a USA Today article (2007). The author reported the data in the 1990s reflected a 10- to 15-year decrease in life span among the mentally ill. The author goes on to note that at the time she was writing this article the disparity had increased to 25 years. In addition, among individuals with the most serious of mental disorders almost half of the population has their daily functioning limited by at least one chronic illness. In addition, it is much more probable that those with mental disorders are having multiple physical illnesses and that these illnesses will become or are chronic.

The patient population, in Sierra County, is a population very much characterized by the above data. The patients are characterized by a large number of individuals who are exposed to many of the risk factors noted in Figure 2. A large number of these individuals present with low social economic status, poverty, low educational achievement and low and insecure vocational achievement or status. The population in which these risk factors, Figure 2, operate are multigenerational and include poverty, unstable family leadership and patterns, poor health, poor models for self-care and family levels of dysfunction that continue to maintain and exacerbate this cycle. Comorbidity is the Norm and certainly this reality is what I encountered in Sierra County.

From the RWJF report, I note two of the conclusions, which are pervasive in the patient population I have been treating.

Exposure to early traumas and chronic stress may be a risk factor for both mental and medical disorders:

  • Results from the Adverse Childhood Experience study, a survey of approximately 10,000 adults in a health maintenance organization from 1995 to 1996, indicated a strong graded response between the level of exposure to childhood abuse or household dysfunction and poor health outcomes.
  • People who experience more adverse exposures during childhood are more likely to report depression, suicide attempts and chronic medical conditions.
  • Chronic stressors, such as lack of money for basic needs, caregiving responsibilities, conflict in relationships or dealing with long-term medical conditions, are particularly strong predictors of depression.

Social economic factors, such as low income and poor educational attainment, are associated with mental disorders and medical conditions: 

  • Low social economic status reduces available resources, such as social support, and increases the chance of exposure to adverse environmental conditions.
  • Individuals with low social support consistently report higher levels of depressive symptoms; this relationship can be found among the general population and among people with various chronic diseases.
  • People of low social economic status are more likely to engage in adverse health behaviors such as eating a poor diet, smoking, and not exercising, which in turn contribute to the development of chronic medical conditions.

(Druss, B.G., &  Walker, E.R. Research Synthesis Report No. 21, The Robert Wood Johnson Foundation, Mental disorders and medical comorbidity Febuary, 2011)

Implementing Solutions

At the hospital and mental health clinic I encountered as I began work in Sierra County, the impact of these factors on patients was a constant and was related to treatment and the coordination of treatment with physicians, nurse practitioners and other providers. It was a system where there were more patients than we, at the current level of staffing and funding, could ever hope to systematically and adequately treat either now or in the foreseeable future.

One of the fundamental tasks I had to address was the training and education of staff to a new model. The current staff possessed limited understanding of the impact of risk factors and stressors on the development of behavioral and physical disorders. Meaning no disrespect, I would describe the clinical view as one which would have been held much earlier, perhaps 20 or 25 years ago. The staff had yet to be guided by current thinking regarding the patient as a whole system and the bidirectional nature of risk factors for behavioral and physical health. In addition, they had not recognized the movement toward an integration of neuroscience. It was a staff in which counselors and therapists had never been trained and were not attuned to paying attention to the patient's physical presentation and functioning and really at some level continued to hold the old mind-body duality. I suspect this was not unusual for professionals of 10 years ago who came to a clinic setting. Likely this situation continues to be present among clinical staff far more than we would like to believe. The situation is one where evidenced-based therapies were not common and still have not become common.

The term stress in these settings is frequently used in notes, reports and communications when referring to patients. Stress is a ubiquitous term in the popular press and has been so overused that the real essence in the patient populations we treat has become fairly meaningless. This is true at some level for both mental health staff as well as medical staff. The significance of stress as it is experienced in these populations is something very different. It is the occurrence of an event, really a series of events, constant to the point it becomes background noise in the lives of these patients. Stress has been and continues to be quite toxic to the body holding the physical and mental disorders.

For these individual patients, their stressful experiences frequently become inescapable and extend from the beginning to the end of life. Stress begins at critical times of development and is toxic to the long term functioning of the body. As this occurrence is multigenerational, it has a huge impact. Stress is toxic in the prenatal mom and negatively impacts the nature of in utero and later development. In the expectant mothers in this population it is frequently a toxic compound of circulating cortisol, nicotine, poor nutrition and sadly other teratogenic substances that bathe the developing fetus.

The impact on child and adolescent development is critical. As adults, these individuals cannot adequately cope with many of the stressors they encounter because their entire system has never adequately developed in a manner allowing toleration and coping with a wide range of stressors. While we use the term and condition of posttraumatic stress disorder (PTSD), it is hard to know if the designation is accurate as most of these individuals have never really left the “battlefield.” One might even say their PTSD is developmental and ongoing to a point no longer recognizable as such. At least, this is the challenge I encountered in this underserved population.

I also found the work of Raabe and Spengler (2013) adding insight to my understanding and teaching of what occurs in the lives of these patients. I have intertwined and cobbled these images together in my work in a manner that has been very useful. While presenting these concepts to therapists and other staff, I have found Figure 3 to be useful in helping conceptualize the complexities of their patients. In addition, I have found it strikingly useful in teaching patients about what has happened to them and what will need to be done to help form the foundation of their treatment.

Figure 3

Raabe & Spengler, Frontiers in Psychiatry

[Raabe & Spengler, Frontiers in Psychiatry]

Child Teen-Adult Middle-Older

(Toxic-CNS development combo) (Toxic-long term ANS-Sympathetic) (Toxic-long term ANS-Sympathetic)

Pre-perinatal risk Low Ed/Voc/Poor$$ More of the same failure of attachment PTSD, Depression, Behavior More of the same Maternal depression Drugs, EtOH, Nicotine More of the same maltreatment, neglect Poor self care More of the same Domestic Violence More of the same CAD,PAD,CVD,COPD Genetics and family Violence (Perp-Vic) OSA,HTN,MI,DM-II environment Legal-Jail-Prison Decreased life Span

Figure 3 illustrates an enormous amount of what our patients are confronting from childhood through adulthood and on into older age. Along with Figure 2, the images visually explain the enormous impact occurring in the development of behavioral and physical disorders and the bidirectional manner in which both become chronic and magnified. These images are variations on the lives of many. As noted in Figure 3, the lightning of adversity, results in an overrepresentation of teen-adult with educational disruption, increasing mental health disorders and representation in jail in the legal system. Thompson (2009) noted that this is an “Extremely vulnerable group with high-risk for early and ongoing failures of developmental adaptation. They are over represented as failing in the educational system, in the mental health system and juvenile justice referral systems” (p. 2). Figures 1, 2 and 3 illustrate how we as medical prescribing psychologists are just one piece of the puzzle or mosaic, if you will. These pieces desperately need a large, diverse and integrated team to move them in the direction of a clear and coherent image of treatment.

These images reflect the state in which the systems for our brain and our body are established. In the development of the brain, it is the laying down of systems for the regulation of stress, abstract thought, executive functioning, emotion and everything in between that will be characterized by dysfunctional interactions. The multi lightning strikes of adversity negatively impact the development and later capacity for learning, coping and interpersonal relationships. This is not to say there is not a factor of resiliency or that all experiences are destructive. However, the transgenerational repetitive cycle takes its toll across a genetic, epigenetic and experiential background creating complexity and interactive comorbidity.

My experience, when teaching patients as well as staff, suggests that if used right, the images move the individual away from the idea of a duality of mind and body. A duality where the repetitive beliefs around “not being good enough” and all of the other “not enoughs” continually run the automatic programs of thoughts, feelings and behavior populating the lives and worldviews of patients. For me, this is a key piece to any psychopharmacological treatment of complex patients with multiple comorbidities or less complicated patients for that matter.

I continue to use these conceptualizations and images as a way of helping therapists understand the complexity they are encountering. They also argue for evidenced-based therapies (EBTs) for patients. Without the latter, the success of medication treatment is an uphill battle that will never help as much as is possible. I have found that this conceptualization helps bring an understanding of the difficulties these patients have modifying cognition and behavior, something that staff must understand and which also informs the need for EBT. It also helps to further the understanding of how they as therapists and we as prescribers and teachers can become very frustrated in the bumpy road of therapy and medication compliance in these populations.

In addition, these figures provide a way of conceptualizing how patients with these developmental experiences and comorbidities can go rapidly from attempts at new problem-solving , new cognitions, and alternative behaviors into a repetitive pattern of old behaviors. Because the experience of risk factors (lightning strikes of adversity) occurs in interpersonal development, the potential for stimulus generalization of perceived threat with people and situations they encounter is not only enormous, it is ubiquitous. To use a term often associated with psychosis, there is a rapid decompensation into old repetitive patterns of faulty/inaccurate conceptualization and ways of coping that result in behaviors that continue to complicate the lives of the patients as they perceive the present through the eyes of the past. At its roots, all therapy is “response extinction.”

The skill sets which we as medical/prescribing psychologists bring to these setting are invaluable. They provide us with the ability to conceptualize complexity and guide psychopharmacological treatment as well as supervise and train therapists to conceptualize their patients in the complex context of treatment. The task of medical prescribing psychology in the integration of treatment and training includes working with behavioral health staff but also medical staff. Very frequently medical staffs tend to think of behavioral health issues in a non-brain-based developmentally biological fashion. This requires us to bring our ability to provide integrated education to our staff and educate the other medical practitioners with whom we work. It is an approach that works to bridge the divisions in the way in which people conceptualize and communicate with each other about the issues and complexities of treatment in these populations were comorbidity is the norm.

As a medical prescribing psychologist, one of the most troubling situations I encountered when I came to the CMHC clinic was the lack of vital signs with reference to medical problems in any of the behavioral health charts. This had occurred, for whatever reasons, even when the clinic had previously had earlier MD and CNP prescribers. In fact, for a brief period of time the clinic continued to have a part-time psychiatrist with whom I overlapped. Having come from a family practice residency program, I was amazed there were no vital signs or references to medical problems. This was something that could not and would not continue.

I was fortunate to have a very mature, talented and experienced rural health and mental health nurse join me. Together, we began to organize the treatment of our patients in a way that integrated the bidirectional complexities of medical and mental comorbidities. Between us, we established regular medical monitoring of patients. This included regularly scheduled labs, random blood sugars in certain patients, vital signs, which always included height, weight, temperature, blood pressure, pulse, pulse ox and pain, with every consultation. I have been extremely fortunate to have had two such nurses over the past 10 years. As a result, I was able to work with them to provide health related behavior education and interventions that were never available before.

We began to train a staff, primarily counselors of the old school where patient's medical conditions had not been a focus, recognized or discussed. We moved to shift this view of the patient to one that integrated the multiple behavioral and medical factors present. The expectation we were teaching was one in which the discussion of patient's problems must be predicated upon multiple aspects of medical and behavioral data that are equally important. In fact, if you do not have the medical data you have over looked the first question. What is going on in the body and what is the early and later developmental context to which the brain was exposed? Without that, you have no idea where you are and what is occurring.

While I understood old-school thinking, it became mandatory during case staffing that the so-called psychological problems needed to be accompanied by information from medical and developmental history including vital signs, labs, communications with the PCP and imaging, if necessary. My question and my question to staff are always, “What do we know about the status of this individual brain developmentally and now?” In this context I always remember the quote from Greenough and Black, (1992), “A basic assumption of this work is that the brain and the mind really are the same thing. Few readers would probably challenge this point, but there is a difference between believing this and actually thinking it all the time. When you really think this way, you recognize that studying what is going on in the brain can actually help to tell you what is going on in the mind.” (p. 156)

One of the first patients I saw during that early phase was a prime teaching example to the staff. The patient, a woman in her mid-50s, was referred because of depression. When she entered I noticed the immediate smell of necrotic tissue. No one in behavioral health had paid any attention before to her diabetes. On the day I saw her, there was an old dirty bandage on her right leg and underneath that she had a full thickness diabetic/neuropathic ulcer. As a result, I pointed out to the behavioral health staff that had referred her that this was not medication consultation day. The patient needed to go to the emergency room and her PCP needed to be immediately notified. How could she be referred for medication when the essentials had been overlooked? How well could her brain function in psychotherapy? How could she not be depressed even if nothing else had happened to her? The stage was set from there on out.

The majority of patients I treated at the clinic ranged in age from latency to older adults. A large number of these were then followed by licensed counselors and licensed social workers for therapy and other staff for case and community management. The majority of these complex patients presented with comorbid disorders. The older the patient the more medical disorders and the more chronic they had typically become. Insulin and non-insulin-dependent type II diabetes, various stages of COPD-emphysema, obesity, hypertension and hyperlipidemia running the full spectrum of these disorders were present. In the older adult patients, cognitive changes secondary to vascular issues were present. In younger patients, those in their 40s and moving into their 50s, we saw new patients who had never been evaluated for OSA when it is clearly a factor. Frequently, by asking for the ordering of an overnight oximetry, a relatively simple assessment, the need for later overnight sleep studies were confirmed as well as the need for nighttime oxygen.

The task is always one of working to appropriately educate the patients with regard to behavioral factors involved with both their chronic behavioral and medical disorders and to the effects, side effects and interactions of the medications. The success rate at this varies enormously. Some of the patients that we saw had been the recipients of the multigenerational lightning/adversity strikes and presented with long histories of nicotine addiction, poor self-care, poor healthcare, histories of alcohol abuse and difficulties regulating blood sugars, hypertension, etc. The behavioral pattern was long and complicated. In addition, the majority of these patients had not had the benefit of quality behavioral health treatment and medical/prescribing psychology consultation and intervention. Most had never had support in identifying problems such as OSA or support in dealing with these.

The second and equally important task was to encourage current staff in learning models related to EBT through workshops, my teaching, online classes, independent reading, etc. This was successful to varying degrees. It did not really become successful until we were able to hire a licensed independent social worker (LISW) with a very good background in cognitive behavioral therapy. She was able to attract other younger staff that was eager to learn and train. As you can imagine, education in that setting had a steep learning curve and required people who were eager to learn and work hard. We were eventually successful. The process of transformation at the clinic took a while, and some people were able to make the transition and transformation; many others were not. Those who did and those who came on board learned that a solid integration of important medical and pathophysiology concepts had to be integrated with EBT for proper treatment to occur. You needed to listen to and look at the patient for the comorbidities that presented. It became a working system where no staff member would watch a patient come down the hall ambulating themselves, using a walker or in a wheelchair without people paying attention to the person's physical presence, gait, balance and smell and no one would sit and only rehash and regurgitate the past with their patients.

Final Thoughts

As a medical prescribing psychologist, I do not think or suggest that my implementation of solutions was original. As always, I believe we are part of the Zeitgeist of our times. Part of that Zeitgeist for medical prescribing psychology has been in the evolving model. As we are increasingly working in rural and urban settings with the underserved and with Native peoples in Indian country, we have been evolving that model. That model has similarities to what we were initially exposed to and debated and it has enormous differences.

My sense of the emerging model in the Zeitgeist is one that has moved from a focus on the consultation room and prescribing for individual therapy patients to that of community health in areas where there is great need in which are greatly underserved. In this evolving model, medical prescribing psychologists are moving in to settings as prescribers of medication, medical directors and teachers/trainers for staffs that will provide EBT and case management. As medical prescribing psychologists the skill sets we have and the services we are able to provide and coordinate necessitate this shifting/evolving role.

Implicit in the discussion of my experience over the past 10 years is a model in which we as medical prescribing psychologists are able to make contribution, both short-term and long-term, to these very large problems of comorbid medical and mental disorders present throughout our health care systems. I encourage those of us who are medical prescribing psychologists, those who are in training and those who run training programs to listen to the Zeitgeist, understand this evolving model and the tremendous need of our fellow citizens, rural, urban and Native peoples.

Druss, B.G., &  Walker, E.R. (2011, February). Research Synthesis Report NO, 21. The Robert Wood Johnson Foundation, Mental disorders and medical comorbidity. Princeton, NJ, (RWJF).

Greenough, W.T., & Black, J.E. (1992). Induction of brain structure by experience: Substrates for cognitive development. In M.R. Gunnar & C.A. Nelson (Eds.), Developmental behavior neuroscience (Vol.   24, pp. 155-200). Hillsdale, NJ: Erlbaum.

Miller, C. (2013). Child poverty in New Mexico: Our communities need more than crumbs. Counter Punch . Retrieved from: http://www.counterpunch.org/archives

New Mexico's Indicator-Based Information System (NM-IBIS). Retrieved from https:/ibis.health.state.nm.us/Indicator/important_facts/NM

Raabe, J.B., & Spengler, D. (2013). Epigenetic risk factors in PTSD and depression. Frontiers in Psychiatry , 4 , 80. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3736070

Shims, R. Co-Management of Chronic Physical Conditions and Chronic Behavioral Health Conditions. 2012 SAMSHA Primary and Behavioral Health Care. Power Point Slides. Retrieved from: http://www.integration.samhsa.gov/pbhci-learning-community/Primary_Care_Breakout.pptx

Sierra County Community Health Profile. Community United for Quality Living Health Council. updated May 2009.

Thompson, T. A. (2009). Neuroscientifically informed approach to the understanding and conceptualization of disorders of affect, violence, and substance abuse among high-risk preteen, early adolescents and young adults with histories of neglect and abuse. Unpublished manuscript.

United States Department of Agriculture Economic Research Service 2010 Frontier and Remote Area (FAR) Codes. Retrieved from: http://www.ers.usda.gov/topics/rural-economy-population/rural-classifications