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The Implications of Public Policy Development

I was recently reminded by Barbara Van Horne of the seeming timelessness nature of the public policy process, particularly for those colleagues who are not intimately involved. Barbara was preparing her first Presidential Message for the Association of State and Provincial Psychology Boards (ASPPB) and noted that their Certificate of Professional Qualifications (CPQ) has now been accepted by 29 American and Canadian jurisdictions, with an additional 16 boards in the process of seriously considering its adoption. Soon, she predicted, there would be 45 jurisdictions in which licensure mobility would be a reality. Reflecting, I realized that my April 2000 Presidential Monitor column had stressed the critical need to move aggressively towards this goal. At that time, 17 jurisdictions had accepted the CPQ, although it had been operational for only 18 months. That year, our Council of Representatives endorsed licensure mobility. From afar, one can clearly see mobility is rapidly becoming a priority for a number of senior colleagues and newly licensed professionals. Telehealth and the unprecedented advances occurring almost daily within the communications and technology fields will make this particular policy agenda extraordinarily important for our profession in the future.

When President Bush signed the Health Care Safety Net Amendments of 2002 (P.L. 107-251) in October 2002, licensure mobility became a national, as well as local (i.e., state) issue. “It is the sense of Congress that... States should develop reciprocity agreements so that a provider of services... who is a licensed or otherwise authorized health care provider under the law of 1 or more States, and who, through telehealth technology, consults with a licensed or otherwise authorized health care provider in another State, is exempt, with respect to such consultation, from any State law of the other State that prohibits such consultation on the basis that the first health care provider is not a licensed or authorized health care provider under the law of that State.” For five years the Secretary of the Department of Health and Human Services was to have the authority to: “make grants to State professional licensing boards to carry out programs under which such licensing boards of various States cooperate to develop and implement State policies that will reduce statutory and regulatory barriers to telemedicine.”

It has been our observation that substantive policy changes usually evolve within the health care arena only after deliberative discussions, over a prolonged period of time, by credible health policy “think tanks” and extensive Congressional public hearings. Accordingly, it should not be surprising to learn that in October 1998, the Pew Health Professions Commission, chaired by former Senate Majority Leader George Mitchell, had seriously questioned the professional licensure status quo. And, had recommended that: Congress should enact legislation that facilitates professional mobility and practice across state boundaries. As health care markets become national, a federal role in consumer protection is more warranted.... Telepractice is a compelling justification for a more centralized and better integrated regulatory system as practitioners can “virtually” practice across physical and political boundaries and may pursue a career in several states. Current state licensure laws do not facilitate interstate movement or telepractice; nor do they offer sufficient redress to consumers in the event of substandard telepractice from outside their jurisdiction. We would suggest that substantive changes in our daily professional lives will occur as a direct result of ongoing national public policy deliberations, even, as we have noted, if the process may appear to be slow and methodical for some, or if the ultimate outcome may seem somewhat diffuse at first. Professional psychology must be involved if we are to shape our own destiny.

During the Summer of 2002, the Institute of Medicine (IOM) released its report: Reducing Suicide: A National Imperative. Several leading psychologists were involved in the IOM deliberations, including Edwin Shneidman, Kay Jamison, Jane Pearson, and Tom Joiner. Psychology has long been on the cutting edge in addressing the complex issues surrounding suicide and the tenor of the IOM report is quite interesting, notwithstanding one’s professional treatment and/or causation orientation. The underlying questions for the readership are: What will we collectively do in response to this public policy challenge? Will psychology become proactive change agents or remain passive observers? Will we evolve from our traditional, silo-oriented isolated training and treatment models and effectively embrace interdisciplinary collaboration and provider accountability, as the 21st century will undoubtedly require? Ultimately, Will we seek to control our own destiny? A glimpse at the IOM report:

Introduction: Suicide is a complex process. If ever a condition begged for an integrated understanding that takes into account biological, clinical, subjective, and social factors, this is it. This report reflects different perspectives and levels of analysis. It embodies tensions between medical and social analyses of suicide that date back at least 100 years. Suicide is a medical issue; but it is also an economic, social relational, moral, and as September 11's tragic global spectacle of suicide terrorist attack made clear, a political issue as well. Suicide prevention, in turn, holds medical, social, psychological, economic, moral and political significance.

Suicide represents a major national and international public health problem with over 30,000 deaths in the United States and 1,000,000 deaths in the world each year. Approximately 650,000 people annually receive emergency treatment after attempting suicide in the United States. Thirteen percent of the population makes a suicide attempt during their lives. The rates of suicide are exceptionally high among certain populations: white males over 75 years of age, Native Americans, and certain professions, including dentists. The rates among youth are rising, especially in African American males. The estimated cost to this nation in lost income is 11.8 billion dollars per year. There is every reason to expect that a national consensus to declare war on suicide and to fund research and prevention at a level commensurate with the severity of the problem will be successful and will lead to highly significant discoveries as have the wars on cancer, Alzheimer’s disease, and AIDS.

Suicide is the twelfth leading cause of death for all ages in the United States and the third leading cause of death among adolescents. Suicides in this country outnumber homicides by a third. During the period of the Vietnam War, four times the number of Americans died by suicide than died in combat. Six times the number of United States citizens committed suicide than died in the 9/11 terrorist attack. 200,000 more people died of suicide than died of AIDS in the past 20 years. These figures do not capture the intense suffering of the suicidal patient. Much has been learned about the risk factors contributing to suicide, biological changes that are associated with suicide, links between childhood trauma and suicide, and the impact of social and cultural influences, medical and psychosocial interventions. But a fundamental understanding of the suicide process remains unknown, and national prevention efforts have not been successful.

Risk and Protective Factors: Biological, psychological, social, and cultural factors all have a significant impact on the risk of suicide. There is a need for an integrated understanding of their influence. Over 90 percent of suicides in the United States are associated with mental illness and/or alcohol and substance abuse. Yet, as many as 10 percent of people who complete suicide do not have any known psychiatric diagnosis. This percentage appears higher still in non-Western societies such as China where it is estimated that less than half of suicides have a correlation with mental illness. Over 95% of those with mental disorders do not complete suicide. The relationship between suicide and mental illness is a conundrum. Suicidality, although clearly overlapping the symptomatology of the associated disorders, does not appear to respond to treatment in exactly the same way. Depressive symptoms can be reduced by medicines without reduction in suicidality; psychotherapy can reduce suicide without significant changes in affective symptoms. Over 30 years of research confirms the relationship between hopelessness and suicide across diagnoses. Biological changes are associated with completed and attempted suicides. Childhood trauma has emerged as a strong risk factor for suicidal behavior in adolescents and adults. Social support is a protective factor. Those who enjoy close relationships cope better with various stresses, including bereavement, job loss, and illness, and enjoy better psychological and physical health. At both the individual and collective levels, the suicide rate has long been understood to correlate with cultural, social, political, and economic factors. Despite the extensive knowledge that research has provided regarding these risk and protective factors, we are still far from integrating them to understand how they work in concert to evoke suicidal behavior or to prevent it. Why is it that significant proportions (20-49 percent) of maltreated children do not display suicidal symptoms or why the majority of individuals affected with mental illness do not complete suicide? We also need to understand the large numbers of people who commit suicide in the absence of pathology, how suicide varies with social and cultural forces, and how it relates to individual, group, and contextual experiences.

Treatment: Suicidality can be treated. Medications alone are not sufficient for treating mental disorders or suicidality, nor are treatments equally effective across individuals and diagnoses. Psychotherapy provides a necessary therapeutic relationship that reduces the risk of suicide. Cognitive-behavioral approaches that include problem-solving training seem to reduce suicidal ideation and attempts more effectively than “treatment as usual” or nondirective therapy. Psychological autopsy studies reveal that only 6-14 percent of depressed suicide victims were adequately treated and only 8-17 percent of all suicides were under treatment with prescription psychiatric medications. Yet significant opportunities to deliver adequate care exist since over 50-70 percent of those who complete suicide have contact with health services in the days to months before their death. However, suicide risk is difficult to assess. Barriers to receiving effective mental health treatment exist. About two-thirds of people with diagnosable mental disorders do not receive treatment. Primary care has become a critical setting for detection of the two most common risk factors for suicide: depression and alcoholism. According to the AMA, a diagnostic interview for depression is comparable in sensitivity and specificity to many radiologic and laboratory tests commonly used. Yet, currently only 30-50 percent of adults with diagnosable depression are accurately diagnosed by primary care physicians. Treatment of depression in primary care is associated with reduced rates of completed suicide as shown by an ecological study on the Swedish Island of Gotlaund. Substance use disorders are especially important in suicide among young adults. Substance abuse and mood disorders frequently co-occur, with 51 percent of suicide attempters having both. In primary care, numerous professional groups recommend routine screening for problem drinking in all patients.

Prevention: A number of prevention programs have been explored to reduce the incidence of suicide and suicidal behaviors. At multiple levels (universal, selective, and indicated) interventions attempt to address risk factors and to enhance protective factors. Programs that integrate prevention at multiple levels are likely to be the most effective. The Air Force’s prevention program [in which psychology’s leadership role was highlighted in the APA Monitor] is one example of an integrated program that appears to have effectively reduced suicide rates in the community by removing barriers to treatment; increasing knowledge, attitudes, and competencies within the community; and increasing access to help and support with a consequent decrease in suicide rates. While there are promising programs that have been implemented, long-term assessments and rigorous evaluation of their effectiveness are unavailable. Education of the media regarding appropriate reporting of suicides can limit imitation effects and thereby reduce suicide rates. Lack of longitudinal and prospective studies are a critical barrier to understanding and preventing suicide.

Of particular interest to the readership would be the section on General Barriers to Treatment -- Managed Care: In the past two decades, managed care has grown from relative obscurity to cover almost 72 percent of Americans with health insurance in 1999. Managed care’s emphasis on treatment of mental health problems in primary care is potentially advantageous for certain populations, such as older people and minorities, which are less inclined towards use of specialty mental health care. Managed care’s potential pitfalls are poorer quality of care, denial of needed care, under-treatment, and disruption in the continuity of clinician-patient relationships. The impact of managed care on mental health services has been profound in terms of cost. One study finding there was a 50 percent reduction in the mental health portion of total health care costs paid by employer-based insurance. Whether this has lowered access to, and quality of, mental health services for people who need them is a critical topic for research, but one for which answers have been elusive. The impact of managed care expressly on detection or treatment of suicide has been largely unstudied. Another study found that: (1) patients with suicidal ideation did not receive higher rates of treatment than did patients without suicidal ideation (using measures of process and quality) and (2) patients with both depression and alcohol abuse – which places them at higher risk of suicide – were not given more specialty referrals, as recommended by treatment guidelines. While the study did not assess outcomes of care, it did conclude that patients with suicidal ideation and other “silent,” yet serious, symptoms are at particular risk for not receiving appropriate treatment by managed care organizations.

In light of the IOM report, we were particularly pleased (but not surprised) to receive e-mails from former APA President Nick Cummings and former HPA President Ray Folen describing their efforts to move psychology into primary care, particularly within our nation’s community health centers (CHCs) which are the “safety net” for many Americans. Nick is one of our nation’s true visionaries and in Toronto received the APF Gold Medal Award for his Lifetime Contributions to Practice. He has recently been working to develop a “psychologist as primary care provider” curriculum. “Bill O’Donohue is in Hawaii and along with looking at the data of Hawaii Project II, he has had a good series of meeting at the University of Hawaii and Ray Folen at Tripler Army Medical Center. You will be pleased to know that the three CHCs came in with 29% medical cost offset in ONLY 12 months. This is good news, as medical cost offset usually begins to accelerate in 18 to 24 months. You will recall this project has psychologists co-located in the primary care setting.... Forest Institute next month is graduating their first doctorates in this track, and Bill, Dot, and I will be attending the graduation. Eastern Michigan University and Wyoming University are instituting programs. Interesting, once things start moving, they move faster than I had predicted....”

Reflecting upon the Native Hawaiian scholars, Ray: “We’ve got Kamana`O Crabbe working in Hana with the center, Jill in Moloka`i with the system there, John at the Waianae center, Lisa Kaneshiro at Bay Clinic and at Kalihi-Palama. I’m going to work with the new Argosy President to introduce a primary care psychology track into the curriculum. It will better prepare the students for placement in the community health centers. Bill O’Donohue from the University of Nevada at Reno is collaborating with us at Tripler and in the community. He will be providing the research manpower to demonstrate that primary care psychology reduces health care costs (he can also use Argosy students to do outcome studies for their dissertations). John, by the way, reports a significant reduction in ER visits following his involvement at Waianae. Waianae has also developed the business plan demonstrating that the primary care psychologists are financially viable within the CHC. I expect that the insurers will soon begin to look at the increasing CHC psychology billings – that is when Bill’s data will become necessary.” And, from a former CHC executive director: “Training within CHCs. Now this is where it gets exciting. One of the biggest problems that we had at Waikiki was that we just did not have the magnitude of money needed to hire the ideal staffing pattern that could include psychologists, MDs, APRNs and so forth so we had to do a lot of stuff hit and miss. The Reno, Nevada model of having a psychologist work side by side with an MD is beautiful if you have the money to pay for it all.... In Waikiki’s case the MD worked well with the psychologist and essentially took their pharmacological recommendation and then the MD did the prescribing.... I think the key is where you talk about psychologists seeing themselves as part of the health care team and not an exclusively mental health professional.” We are making progress. In this regards, I want to congratulate John Bolter and Jim Quillin. Some time ago they started the LaFact support network, which is a consumer/public citizen “grass roots” organization sympathetic to the psychology RxP- agenda. They received clearance from the APA ethics committee and as of this Summer, they enrolled in excess of 3500 members, surpassing NAMI of Louisiana. Aloha,

Pat DeLeon is a former APA President.

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