It was extraordinarily satisfying to learn from Beth Rom-Rymer that the Illinois Psychological Association (IPA) was successful in enacting your prescriptive authority (RxP) legislation this past June. It has been a decade since Louisiana achieved their startling success, during which time leaders in the RxP movement have been steadily working to develop a "critical mass" of postdoctoral trained psychopharmacology clinicians. Bob McGrath, Director of the Fairleigh Dickinson University Clinical Psychopharmacology training program, estimates that today there are 1750 graduates. As vigorous as your opposition has been, it was impressive from a public policy perspective to see that, in the end, the Illinois Psychiatric Society and the Illinois Medical Society conceded that psychologists can prescribe. Clearly this was a concession that only came after a hard-fought battle. It was the perseverance and the determination of your IPA leaders, looking after the interests of the most vulnerable and at-risk residents in Illinois, that ultimately won the day. And, as you now move quickly to implement your RxP legislation, with the drafting of the rules and regulations of the law and the signing up of various training facilities and universities and colleges throughout the state to train Illinois's prescribing psychologists, undoubtedly you will find that achieving the collaborative partnership of psychiatrists and medical directors has been greatly facilitated by your eleventh hour negotiated bill. Congratulations!
Our collective RxP discussions frequently refer to the successes of New Mexico (2002), Louisiana (2004), and colleagues in the Department of Defense (DoD) and U.S. Public Health Service (particularly, the Indian Health Service [IHS]). Few seem to appreciate that the first state to pass RxP legislation was actually Indiana (1993, thanks to Mike Murphy), which was followed by Guam (1998, thanks to Mamie Balajadia). Neither of these states has implemented their statutes to date; although progress has been reported in Guam. Interestingly, Floyd Jennings was prescribing in the IHS back in 1988-1989 under the authority of the Santa Fe Indian Hospital bylaws. Former APA President Ron Fox: "As of December 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."
Having been an informed observer throughout psychology's RxP quest, I was particularly pleased that your legislation recognizes, for the first time, the importance of encouraging pre-doctoral training. This is an educational policy position that had been urged by practice visionary Gene Shapiro from the beginning and most recently by APA Past President Bob Resnick. The initial requirement for postdoctoral training was a reasonable political compromise, addressing the sincere concerns of those who feared that our next generation of colleagues might never appreciate what psychological expertise could contribute to our patients' quality of life. Their view was that otherwise "we would take the easy way out and become junior psychiatrists; substituting medication for therapy." Over the years, the evidence has clearly not supported that contention. In fact, our prescribing colleagues frequently report significantly modifying previously ordered medication protocols. "The power to prescribe is the power to unprescribe," as New Mexico's Mario Marquez has stated on numerous occasions.
The 1992 report submitted to the APA Council of Representatives by the ad hoc Task Force on Psychopharmacology, chaired by Mick Smyer, clearly appreciated the long term significance of "the importance of developing a subspecialty of psychology with comprehensive knowledge and experience in psychopharmacology. Practitioners with combined training in psychopharmacology and psychosocial treatments can reasonably be viewed as a new form of health care professional, expected to bring to health care delivery the best of both psychological and pharmacological knowledge. The contributions of this new form of psychopharmacological intervention have the potential to improve dramatically patient care and make important new advances in treatment." And, as you have successfully demonstrated, the Task Force then focused on "the potential impact of the proposed training on two important concerns of consumers: (1) meeting unmet need for mental health services, and (2) effectively serving special populations." Anita Brown was one of the APA staff liaisons to the Task Force. She subsequently became one of the DoD prescribing psychologists.
During his 2009 APA Presidency, James Bray hosted a Presidential Summit on the "Future of Psychology Practice." One of the major themes presented was that "mental health care cannot be divorced from primary medical care, and that all attempts to do so are doomed to failure." The enumerated Summit Principles were * Expand the focus of traditional psychological practice. * From mental health to health care providers: Integrated health care. * Integrating technology into practice. * Meeting the needs of our diverse society. And, * Apply basic and applied scientific evidence in our practice. Shortly after the signing of your historic legislation James noted: "To stay as a viable profession psychology needs to take advantage of new opportunities in health care and business, otherwise we are likely to continue to financially decline. Reimbursement rates for traditional mental health services have decreased in the past 10 years, while health care insurance premiums have seen double digit increases – Why is this? Psychologists are being replaced by Masters level trained clinicians who will work for less and provide many of the same services. We need to evolve into new positions of clinical leadership, consulting with business and gaining prescriptive authority where our services of doctoral trained psychologists will be rewarded. If we don't step up now, other professions will and we will continue to see our incomes and opportunities drop."
President Obama's landmark Patient Protection and Affordable Care Act (ACA) provides many opportunities for non-physicians with vision. Combined with the recently enacted Mental Health Parity legislation this represents the largest expansion of health insurance coverage, particularly for behavioral health, in the history of our nation. It provides a priority for prevention, wellness care, and services which are high quality and cost-effective, and aims to move our health care system towards a population health-based system. The ACA affirmatively calls for the development of integrated, interdisciplinary systems of patient-centered care which will be transformational. Chief among them is the integration of behavioral health and medical health care systems. Under the law mental health and substance use treatment are deemed "essential health benefits." The foundation now exists for the steady integration of the advances occurring within the communications and health information (HIT) technology fields into the health care environment. From this perspective alone, your success in obtaining the support of the American Nurses' Association-Illinois chapter and the Illinois Society for Advanced Practice Nursing for your RxP legislation is extraordinarily futuristic.
Substantive change always take time; often far longer than one expects. Throughout today's discussions regarding the appropriateness and cost-effectiveness of integrating behavioral health/mental health within primary care settings, the high incidence of depression among patients is frequently noted. The Agency for Health Care Policy and Research (AHCPR) was established by the Omnibus Budget Reconciliation Act of 1989 to enhance the quality, appropriateness, and effectiveness of health care services and access. Among its responsibilities was facilitating the development and updating of clinical practice guidelines to assist practitioners in the prevention, diagnosis, treatment, and management of clinical conditions. More than two decades ago (April 1993), AHCPR issued its guideline on Depression in Primary Care: Detection and Diagnosis – then-APA's Deputy Executive Director for Professional Practice, Russ Newman, was involved in ensuring that psychology's voice would be heard.
"Depression was selected as a topic for guideline development because: * Depressive disorders are commonly encountered in primary care, as well as in other treatment settings. * Most depressed patients seek care from primary care practitioners. * A range of effective treatments are available and commonly provided for these conditions. * There is a large body of scientific evidence on which to base these guidelines. * Practice surveys indicate that improvements are needed in primary care practitioners' ability to recognize and treat depressive disorders. * Depressive disorders result in significant morbidity and mortality. (And) * Depressive disorders have a high prevalence in the general population…. Despite the high prevalence of depressive symptoms and full major depressive episodes in patients of all ages, depression is underdiagnosed and undertreated by primary care and other nonpsychiatric practitioners, who are, paradoxically, the most likely to see these patients initially…. The social stigma surrounding depression is substantial and often prevents the optimal use of current knowledge and treatments. The cost of the illness in pain, suffering, disability, and death is high…. Clinically significant depressive symptoms are detectable in approximately 12 to 36 percent of patients with another nonpsychiatric, general medical condition…. " More than two decades ago…. GOOD DAY SUNSHINE. Aloha,
Pat DeLeon, former APA President – Illinois Psychological Association – September, 2014
