Professional Practice: Comparing Standards

Benefits of combined psychotherapy/pharmacotherapy provided by mental health doctors are compared with usual mental health services of non-psychiatric physicians in office based practices. Targeted psychotherapy/pharmacotherapy provides value-added treatment outcomes for depression, and other mental disorders, over usual mental health services provided in general medical care as measured by improvements in functionality, cost-effectiveness, relapse rates, and safety. To meet public health standards for mental health care, a substantial increase in the use of these value-added treatments combining psychotherapy with pharmacotherapy is required. To achieve these goals public policy must be amended to provide citizens access to this value-added psychological/pharmacological care.

Introduction

This article challenges a public misperception that most mental health treatment is provided by mental health specialists with the bulk of the psychopharmacological therapy prescribed by psychiatrists. It examines current standards of mental health practices rather than evaluating the question of the effectiveness of psychotherapy versus pharmacotherapy. The benefits of combined psychotherapy/ pharmacotherapy provided by mental health doctors are compared with usual mental health services delivered in offices of non-psychiatric doctors.

Current Standards of Care

In recent years, US business, as well as, the federal and state governments have increasingly relied on prepaid managed care organizations to provide services for the mentally ill. The tacit acceptance of managed care restricting specialty care created a de facto standard of mental health practice in general medicine without specialty training in mental health care. Schulberg and Burns (1998) found that of the mental disorders treated in the United States, this “de facto mental health system” in primary care treated 70% of all mental disorders without the aide of a mental health specialist.

Rogers et al (1993) report that the share of depressed patients treated in psychiatry was 12-16 percentage points lower under prepaid plans compared with fee-for-service. More than half of this shift was to general medical care and the remainder to “nonphysician” therapists. One out of four patients seen in primary care, over 25%, has a diagnosable mental condition (Schulberg and Burns, op. cit.). Perez-Stable, Munoz, and Ying (1990) reported that most of the mental health disorders of patients in primary care are never detected or treated. Yet, detected mental conditions -- most commonly depression and anxiety -- comprise a significant portion, 15% or more, of the practices of primary care physicians (Campbell et al 2000). In addition to the treatment of depression and anxiety , alcohol and substance abuse, post traumatic stress disorders (PTSD) and schizophrenia and over 300 other mental diagnoses are treated in general medicine. Mental disorders, either as the principal diagnosis or a comorbid condition, constitute up to 80% of the patient load in primary care (De Leon 1999, Kroenke and Mangelsdorff, 1989).
The Agency for Healthcare Research and Quality (AHRQ), formerly the Agency for Health Care Policy and Research(AHCPR), attempted increase access to treatment and reduce health care costs by substituting less costly primary care services for the use of more expensive specialty services. It targeted the treatment of depression for reducing health care costs by having primary care physicians prescribe psychotropic medications. In 1993, its Depression Guideline Panel which in 1993 published standards in the form of guidelines for treating major depression in primary care practice. Schulberg, Katon, Simon, and Rush (1998) reviewed research on the effects of these guidelines on primary care practices. They found that both antidepressant pharmacotherapy and time-limited depression-targeted psychotherapies are both efficacious. They conclude; “Studies to date suggest that improving treatment of depression in primary care requires properly organized treatment programs, regular follow-up, monitoring of treatment, and a prominent role for the mental health specialist as educator, consultant, and clinician for the more severely ill. Future research should focus on how guidelines are best implemented in routine practice, since conventional dissemination strategies have little impact.” Nathan (1998), in an understatement, notes that the guidelines’ potential to improve patient outcomes and reduce practice variation was not totally fulfilled.

Currently, primary care providers prescribe over 70% of all of the psychotropic prescriptions written ( Beardsley,et al., 1988). This pattern of prescribing psychotropics constitutes the de facto community standard of mental health services. The use of psychotropics increased nearly 40% from 1985 to 1994 as newer psychotropic medications became available (Pincus et al., 1998). The use of equally effective psychotherapies declined with the managed care forcing beneficiaries to use pharmacotherapy instead of psychotherapy to save costs. Yet, a combination of psychotherapy and pharmacotherapy is often the treatment of choice and more effective in the treatment of depression or other mental health conditions. Sturm and Wells report, “ More appropriate care for depression (increased counseling, use of appropriate antidepressant medications, or avoidance of regular minor tranquilizer use) improves functioning outcomes. Although this approach increases total costs of care, it also improves the value of care because each dollar spent on care now provides more benefits in terms of health improvements. In contrast with the effects of more appropriate care for depression, the trend away from mental health specialty care and toward general medical provider care under current treatment patterns reduces costs, worsens outcomes, and does not increase the value of health care spending in terms of health improvement per dollar.” … “ The best strategy for making care for depression more cost effective is through quality improvement, not through changing specialty mix.”… To realize this potential, however, substantial quality improvement of care for depression is necessary in general medical practice.”

The “Consensus Statement on the Undertreatment of Depression” by the National Depressive and Manic-Depressive Association (NDMDA) gives a vivid example of some of the problems in the “de facto” standards of mental health practice. The NDMDA assembled a cross section of mental health experts from many disciplines and reviewed the information on the identification, treatment, and outcomes of depressive disorders (Hirschfeld, R. M. et al 1997). The experts’ consensus report concluded that the continuing and pernicious undertreatment of depression was due to patient and provider factors, as well as, barriers in the mental health system itself. NDMDA posits: “Patient-based reasons include failure to recognize the symptoms, underestimating the severity, limited access, reluctance to see a mental health specialist due to stigma, noncompliance with treatment, and lack of health insurance. The provider factors include poor professional school education about depression, limited training in interpersonal skills, stigma, inadequate time to evaluate and treat depression, failure to consider psychotherapeutic approaches, and prescription of inadequate doses of antidepressant medication for inadequate duration.” NDMDA also recommended “enhancing collaboration among provider subtypes (e.g., primary care providers and mental health professionals.”

Meeting Public Health Needs for Mental Health Care

US Surgeon General Satcher declared in his 1999 Mental Health Report that “mental health is fundamental to health” and that “mental disorders are real health conditions.” The societal costs of the disabling effects of under treatment mental conditions are more expensive than the costs of treatment of these conditions. Society must plan and develop standards for the effective care of mental conditions or suffer the consequences of the unwanted behavior and disabilities of those with mental illnesses.

Murray and Lopez (1996) , despite their initial skepticism, found that psychological depression will be the second leading cause of disability from all health conditions by the year 2020. Heart conditions are projected to be number one, having ranked fifth in 1990. Depression ranked fourth in 1990. The incidence of the first four of the top five of the non-fatal health conditions in 1990 were psychological disorders: depression, alcohol dependence, obsessive-compulsive disorder, and panic. Conclusions similar to those made by NDMDA for depressive disorders can be made for other mental conditions. Mojtabai, Nicholson and Carpenter (1998) reviewed the effects of psychosocial management of schizophrenia with somatic treatments. Their findings demonstrated the additive and supplementary effects of psychosocial treatments and the durability of these effects. Patients with more chronic illness appeared to be more responsive to psychosocial treatments.

Shortages Effect Patient Care

If the de facto standards of mental health care are not supplying the necessary mental health services and are not responsive to treatment guidelines, how will the public health needs for mental health services be met? How can public access to effective combined psychotherapy/ pharmacotherapy treatments for mental conditions? Psychiatry has been unable to fill its residency training positions for many years. Unable to attract sufficient United States medical graduates to its training programs, psychiatry has turned to importing international medical graduates who now comprise 44% of the filled residency positions ( Borenstein). Psychiatry has become more of a biologically based profession as a result since it was difficult to teach psychotherapy and psychosocial interventions to doctors whose second language is English. Psychiatry had the same shortcomings and similar results to primary care physicians in a study of clinical practice in the use of antidepressant medications (Simon, G.E., von Korff, M., Rutter, C.M., & Peterson, D.A. 2001) The practice pattern of infrequent consultation and brief medication checks fostered by managed care reimbursement incentives for mental services does not permit evaluation and treatment of psychosocial aspects of the patients’ condition.

Nursing has attained prescriptive authority in all 50 states and advanced nurse practitioners have independent prescribing authority in at least 30, at last count. Advanced nurse practitioners have been employed as less-costly physician substitutes by managed care because of their ability to write prescriptions for psychotropic medications. Demand for advanced nursing services in primary care is currently high. Therefore, additional training in psychotherapy to provide a standard of mental health care using combined psychosocial/pharmacological treatments is unlikely to be a high priority for many nurses with advanced training in medicine.

The Split Treatment Model of Care: Only a Stopgap

Psychology is the most likely profession to expand its training to meet the public health needs in combined psychotherapy/pharmacotherapy standards of mental health care. Social work has thus far shown little interest in psychopharmacology ( Piotrowski and Doelker, 2001). Psychologists have been involved in every aspect of the development of pharmacological treatment of mental disorders. Psychological practice has included, research, training, evaluation, treatment, consultation, monitoring, etc. Doctors of psychology have been collaborating with doctors of medicine for the treatment of mental disorders for the past 40 years. This pattern of practice began when primary care doctors, without mental health specialty training, requested consultation from knowledgeable psychologists on medications, dosages, and for treatment recommendations. Psychologists turned to their medical colleagues to prescribe psychotropic medications for their own patients. The pattern of the primary care prescribing psychotropic medications for the patients of psychologist and psychologists providing the necessary psychotherapy and monitoring the effects of the medication for patients of general medical practitioners became known as “the split treatment model” of mental health care. This “split treatment model” of care has been a necessary stopgap measure but is inconvenient for the patient. It highlighted the inefficiencies in coordinating care between medical and psychological doctors who were practicing in different offices.

As the public and de facto mental health systems have failed to meet the public health care needs for the mentally ill through managed care, psychology has not been idle. Psychologists organized psychopharmacology continuing education programs in the 1980’s to improve inter-professional communication, provide better continuity of care, and afford greater convenience for their patients.. Patient-centered psychopharmacological training programs have been established to prepare psychologists for their evolving roles in public health services. As a result, the questions of the convenience for patients, and whether psychotherapy or pharmacotherapy is more beneficial for patients, have been laid to rest. The value added by employing a combination of psychotherapy and pharmacotherapy is now recognized as a treatment of choice over usual services for many mental conditions. In authorized settings, psychologists trained in psychopharmacology have written prescriptions for mental disorders safely and effectively for nearly a decade. Psychology has determined its methods of providing this combined care are value-added services to current standards of mental treatment. The value-added combination mental treatments are not readily available in most American communities . Thus, it is in the public interest that psychologists, trained in psychopharmacology, seek statutory authority to provide the combined treatment using modern psychosocial treatment interventions along with their expertise in pharmacotherapy .

The Training of Psychologists in Pharmacotherapy

It might be asked, “How are psychologists appropriately trained to deliver the high quality combined psychotherapy and pharmacotherapy treatments?” Psychologists become licensed doctors after four or more years of studying both normal and abnormal mental processes and treating patients who both suffer significant psychopathology and exhibit disturbed behavior. In addition, to apply for a license, psychologists undertake significant pre-doctoral practical training, a one year internship plus advanced postdoctoral experience. During graduate training psychologists’ principal focus is on psychotherapy and other psychological interventions.

The American Psychological Association (APA)recognized psychopharmacology a domain of psychology in 1967. The APA guidelines for training in prescribing pharmaceuticals as an organized postdoctoral training experience requiring 300 hours of didactic education in the same areas that medical doctors receive their pharmacology training. In addition, prescribing psychologists are required to treat 100 or more patients as the prescribing doctor in a collaborative relationship with a doctor licensed to prescribe psychotropic medications. This postdoctoral training is approximates having a Master’s Degree in psychopharmacology. Psychologists’ postdoctoral psychopharmacological training compares favorably with 114 hours of pharmacological training of medical students, 95 hours for optometrists, 83.6 for dentists, 75 for nurse anesthetists and 6 for podiatrists (California Psychological Association 1994). Further, to receive a credential in the practice of prescribing psychoactive medications, psychologists are required to pass a national examination in ten areas of psychopharmacology. Prescribing psychologists clearly receive specialty training in both psychotherapy and pharmacotherapy.

Prescribing psychologists include: 1.) licensed psychologists trained by the Department of Defense to prescribe in the military, and 2a.) licensed doctoral psychologists who are also trained as advanced nurse practitioners or physician assistants and reside in jurisdictions where advanced nurse practitioners or physician assistants are authorized to prescribe or 2b.) practice in public institutions where they can be awarded credentials to prescribe. Currently, there are fewer than 1000 prescribing psychologists by this definition, although there are over 1200 qualified to do so according to their credentials.

Practice Standards of Prescribing Psychologists Compared with Usual Mental Health Care in Medical Settings

Treatment effectiveness can be judged by improvements in functioning, relief of symptoms and minimizing problematic side effects of medication. The decade-long effort to improve treatment services for depression in primary practices is well documented. Depressive conditions serve as a benchmark to compare the treatment practices of doctors in psychology trained in pharmacotherapy with the usual mental treatment practices of primary care. Table 1. presents data regarding similarities, differences, typical treatment protocols, outcomes of treatments, cost-effectiveness and safety. These data provide a platform that illuminates the differences between the psychological approach to prescribing psychotropic medication with usual mental health services seen in primary medical care.

Comparison of Prescribing Psychotropic Medications by Doctors of Psychology with Usual Mental Health Services in Primary Care

Similarities of Practice

1. The official US diagnostic codes for mental disorders are used by prescribing psychologists and for usual mental health services in primary care are those of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), of the World Health Organization. The tenth revision of this manual will be available later in 2001. Diagnostic criteria of the Diagnostic and Statistical Manual IV, Text Revision of the American Psychiatric Association are also used .

2. Standard U.S. treatment codes are employed by prescribing psychologists and for usual mental health services in general medicine. The standard treatment codes used in the US are those of the Current Procedural Terminology 2001 published by the American Medical Association and include psychotherapy codes with medication management developed by the Health Care Financing Administration (HCFA) for use in Medicare billing.

3. Both psychology and general medical care use standardized outcome measures. There are many outcome measures in use today resulting in an ongoing dialogue among researchers and clinicians as to which is the most representative of progress in treatment. Some are simply a priori descriptions with face validity. Others have been standardized by using them in outcome research and measure specific characteristics.

4. Both prescribing psychologists and general medical practitioners use a “biopsychosocial” orientation.

In general the mental health community subscribes to the biopsychosocial model of diagnosis and treatment. However, each profession has its on interpretation of this model. Medical training tends to emphasize the biological and ; primary care providers have limited training regarding the use of psychosocial factors in treating mental conditions. Psychological training places the most emphasis on psychosocial factors and integrates postdoctoral psychopharmacological training with the biological aspects of graduate training.

Differences in Practices

5. Prescribing psychologists use a patient behavior centered approach, whereas, general medicine is focused on disease to a greater extent. A major tenet and focus of study in psychology is that of the effects of individual differences on health and behavior. These individual differences in functioning require patient-centered treatments for effective behavioral change. Medicine tends to focus on physiological causality and its correlates of clusters of consequences or symptoms leading to physical interventions such as medication to eliminate a disease. Both strategies play an important role in treating mental conditions but often result in different methods of treatment.

6. Medication is a treatment option by specialists trained in psychotherapy , whereas, medication is the principal treatment in general medicine. As cited earlier, 44% of psychiatrists trained in the last few years are international medical graduates (Borenstein, 2001). International medical graduates have limited experience in dealing with the psychosocial factors of the American public. Because of language difficulties of their trainees many psychiatric residency programs switched to biological psychiatry emphasizing medication treatments and restricting training in psychotherapy. It is estimated that less that half of the graduates of psychiatric residencies in the last decade have traditional psychotherapy training. Most primary care providers are not prepared by their medical training to treat mental conditions with psychosocial interventions. De Gruy describes it this way, “But contemporary primary medical care is structured so that even the conscientious, sympathetic, psychologically minded primary care physicians (PCPs) have an extraordinary difficult time expanding their scope of practice to include the full biopsychosocial range of their patient’s problems s part of normal business.”

7. The goal of the prescribing psychologist is to improve patient functionality through self-management. The goal in medicine is to alleviate symptoms and overcome disease. In a clinic where patients were randomly assigned to a prescribing psychologist or to psychiatrists, it was found the prescribing psychologist placed 13% of his patients on psychotropic medications while the psychiatrists placed 61% to 68% of their patients on psychotropic medications. ( Sexton, personal communication.)

8. Prescribing psychologists try to create a therapeutic alliance with the patient and their families as a partners. In primary care the practice model relies on provider determined treatments. Campbell et al (2000) found that “primary care physicians with higher proportions of recorded mental health diagnoses generate significantly lower panel member costs, and their patients may be less likely to be admitted for avoidable hospitalization conditions.” The savings were 9%.

9. Prescribing psychologists teach patients self-management, thereby reducing costs, whereas, in primary care, medical authority is used to achieve compliance of medication use.

10. Wiggins and Cummings (1998) review of 1 million mental health episodes in which psychotropic medications were managed by psychologists found that 68% of the patients had been prescribed psychotropic medications by primary care or non-psychiatric doctors before they presented for mental health treatment. At termination of psychotherapy and behavioral training only 13% remained on a maintenance dose of psychotropic medication. Cummings and Wiggins (2001) found similar reductions in the use of psychotropic medication in pre-school and school age children following psychological intervention.
10. Prescribing for mental disorders is by psychologists who specialize in mental health. Doctors in general medicine may have little training in modern mental health methods of diagnoses and treatment.

The AHCPR Depression Guidelines and the Minnesota Consensus Guidelines (1996) clinical indicators for mental health specialty care are: severe symptoms; comorbid medical, psychiatric, or substance abuse disorder; and failure to respond to treatment.

11. Prescribing psychologists are specialists in psychotropics. Primary care physicians use many medications for a variety of health conditions.

The pharmacotherapy training in psychology specializes in psychotropic medications ( APA Guidelines (1995). Primary Care doctors use a wide array of medications and tend not to specialize in the use of psychotropics. Specialization tends to reduce errors in prescribing and more accurate titration of doses of medication required for effective treatment. In Arizona primary care physicians were not permitted to prescribe psychotropic medications to patients in the state Medicaid program (AHCCCS) until 1999.

Typical Treatment Protocols

12.Prescribing psychologists can provide ongoing psychotherapy and pharmacotherapy in 40-50 minute treatment sessions. In usual care, the prescription is written in the initial consultation followed by 10-15 minute medication check appointments.

Schulberg et al (1996,1997, 1998) found “when prescribed antidepressant medication, the usual-care group averaged only 4 visits during 8 months.” “ Katon et al (1995,1996) and Simon et al (1996) determined patients in a health maintenance organization seen monthly during the acute-phase pharmacotherapy had high rates of attrition and low rates of recovery.” “The AHCPR (Depression- ed.) Panel recommended that more severely depressed patients be seen weekly and those with less severe illness every 10 to 14 days during the initial 6 to 8 weeks of pharmacotherapy… However, this schedule far exceeds routine primary care practice and would require significant additional resources,” Katon et al write.

Outcomes

13. Katon et el (1995,1996) demonstrated that collaboration between psychologists and primary care doctors significantly improved clinical outcomes over the generalist’s usual care.

Lin et al found the improved physician prescribing practices and improved patient outcomes achieved by Katon and coworkers’ Collaborative Care programs faded upon withdrawal of the mental health specialist and the systematic monitoring of treatment. Goldberg et al (1998). Dowrick and Buchan (1995), Callahan et al (1994) found that training of primary care physicians in the depression guidelines had no significant impact on recognition of depression, appropriateness of pharmacotherapy, or clinical outcomes. Paykel et al reports, “Previous studies indicate that depressed patients with partial remission and residual symptoms following antidepressant treatment are common and have high relapse rates in depression… In this difficult to treat group of patients with residual repression who showed only partial response despite antidepressant treatment, cognitive therapy produced a worthwhile benefit.” Cognitive therapy reduced relapse rate for acute major depression and persistent severe residual symptoms from 47% in the management control group to 29% in the management control group receiving cognitive therapy.

Cost-Effectivenes

14. Psychotherapy is a value-added treatment improving functionality of patients with lowered relapse rates while medication alone does not necessarily lead to increased levels of functioning. Medical cost-offset studies show that targeted psychotherapy for mental conditions reduces overall medical costs. Unrecognized and/or untreated mental conditions increase medical utilization and costs. Reduced costs of medical care following targeted focused psychotherapy was first demonstrated by Follette and Cummings in 1967. These cost savings have been studied by numerous researchers for over 35 years (Wiggins, 1976; Jones and Vishi, 1979; Mumford et al, 1984; Cummings et al, 1993; Cummings, N.A., Cummings, J. and Johnson, J.N., 1997 ). Repeatedly, these “medical cost-offset” studies have shown significant cost savings even when including the costs of targeted focused psychotherapy. This psychotherapy is particularly effective in reducing the use of costly hospital care.

Campbell’s ( 2000) study illustrates mental health symptom recognition and intervention reduces avoidable hospital care. Simon et al (1995) found that total health care costs for a six month period associated with patients depressive and anxiety disorders had higher baseline costs of $2,390 compared with costs patients with sub-threshold disorders of $1,098 and those with no depressive or anxiety of $1,397. Cost differences reflected higher utilization of general medical services rather than higher mental health treatment costs. Von Korff et al (1998)analyzed data from Katon et al and found that additional expenditures of $250 to $450 on psychosocial interventions increased the likelihood of treatment response from 40% to 70%. Lave et al (1998) analyzed Schulberg et al’s 1996 data of the 12 month study and determined that guideline-based pharmacotherapy produced 58 more depression free days and psychotherapy 49 more free days than usual care provided by internists and family physicians. The costs beyond usual care per additional depression-free day were $13 for standard pharmacotherapy and $22 for psychotherapy.

Sturm and Wells (1995) calculated the usual care of the current system spends more than $5000 to remove one functional limitation. The cost of removing one functional limitation with improved depression treatment was between $1,000 and $2,000. This provided a cost-effectiveness Ratio of 2 to 5 times added benefit per dollar spent. They report that reduction of one functional limitation is associated with an increase of $2,000 to $3,000 in annual earned family income. If the family paid $1,000 to $2,000 of this difference in cost over usual primary care it would be net monetary gain for the family as well.. From the public health policy perspective the additional tax revenues would offset the cost of removing the functional improvement and reduction in medical utilization in about two years. They describe this as “value-added treatment.”

Sturm and Wells also reported treatment of depression by other “mental health specialists”, e.g., psychologists. Their data revealed that “other mental health specialists” were as effective as psychiatrists in reducing functional limitations when their patients had access to appropriate antidepressant medications at a cost of $2,900. The value added treatment by other mental health specialists was similar to psychiatry.

Safety

15. Prescribing psychologists have a history of prescribing with the patient’s safety in mind. The Government Accounting Office (GAO) report on psychologists prescribing in the military supports the conclusion that psychologists prescribe safely. (For the Executive Summary of the GAO report of 06/01/99 (GAO/HEHS-99-98) go to http://www.apa.org/ divisions/div55). The American College of Neuropsychopharmacology, the independent evaluator organization hired by the Department of Defense to provide external monitoring and assessment of the demonstration project training psychologists to prescribe gave its endorsement of the safety of psychologists prescribing in its final report of the project. (Lasagna, L. et al 2000). Newman,R, et al also report psychologists can be trained to provide safe high-quality pharmacological care. The increased safety of the newer SSRI antidepressants and other psychotropic medications of the past decade has resulted in a 40% increase in the use of psychotropics in primary care (Pincus et al 1998). Recently, there have been reports about adverse drug events (ADEs) in hospitals resulting in 770,000 in injuries and deaths each year (AHRQ,2001). Most of these untoward events occur in Intensive Care Units (ICUs) when the patient is not cognitively intact and can not comprehend or respond to health status inquiry. No cause/effect relationship has been established between ADEs and age, comorbidity, or the number of medications received. It must also be noted that ADEs leading to hospitalization are not included in this report and ADEs can not be predicted by drug type. Antidepressant and antipsychotic drugs account for less than 1% of ADEs.

The safety of prescribing psychotropic medications can also measured by how the side effects of medications are handled. The National Depressive and Manic Depressive Association Survey (2000) explored management of major depression in primary care settings. “ The survey reveals a significant communications gap between primary care doctors and patients about treatment and side effects, and differences in perceptions about what should be tolerated regarding side effects.” The side effects of drugs are a frequent reason cited for discontinuing treatment. Wiggins and Cummings (1998) report an 80% reduction in the use of medications over the course of treatment when psychologists managed both the psychotherapy and pharmacotherapy. Since the frequency of side effects, such as sexual dysfunction and weight gain occur in 20% or more of patients, this reduction in use of medications by psychologists using psychotherapy adds to the safety of the treatment. Another measure of the safety of prescribing psychotropic and other medications is from professional liability rates assigned to this risk by liability insurance companies. Advanced Psychiatric Nurse Practitioners who prescribe psychotropic, as well as other pharmaceuticals independently without medical oversight paid $702 for $2 Million/$4 Million coverage in 1999. Similarly, Optometrists, who also prescribe independently, paid an annual premium of $355 for their liability coverage of $1 Million/$3 Million or $415 for $2 Million/$4 Million in 1999. These low professional liability rates indicate the safety and relatively low risk in prescribing medications.

Another risk variable in safety of prescribing is that of undertreatment and underprescribing. Clinical depression which afflicts 20 million Americans each year can be fatal if proper care is not sought. It is estimated that 15% of those that suffer severe depression but do not seek help commit suicide. Eaton et al (1996) conclude from their study that major depressive disorder signal increased risk for onset of Type II diabetes. Similarly, Brenda et al (2001) found “depression increases the risk for cardiac mortality in subjects with and without cardiac disease at baseline. The excess mortality risk was more than twice as high for major depression as for minor depression.” Undertreatment of depression as occurs in usual care for mental conditions in general medical care and even medication only psychiatric care can be of significant risk to life and health. The risk of non-treatment or undertreatment of depression typical appears to be greater that the risk of treatment of depression by non-MDs using psychotropic medications. This is perhaps true for the treatment or non-treatment of other mental conditions as well. Search of the literature does not reveal studies to support the added risk of prescribing psychoactive medications by non-MDs trained in psychopharmacology. Thus, the valued added to treatment of depression by prescribing psychologists using combined psychotherapy/pharmacotherapy outweighs any safety risks documented in the literature.

Summary and Conclusions

The standards of care for mental disorders in primary care and general medical practice fall short of the recommendations for appropriate mental health care. The value-added treatment of targeted focused psychotherapy combined with pharmacotherapy provides significant improvements in outcomes, relapse rates, costs of care, and safety over the usual services for mental disorders provided in general medical care. If the public health standards for mental health care are to be met, there must be a substantial expansion of these value-added treatments combining psychotherapy with pharmacotherapy. Psychologists trained according to the standards of the American Psychological Association Guidelines prescribe safely and effectively for mental health conditions. These psychologists treat depression and other mental disorders with a broad array of psychosocial skills and behavioral interventions, as well as, applying critical clinical judgments in prescribing psychotropic medications. With proper statutory authorization these psychologists can provide safe value-added mental treatments that improve human functioning, are cost-effective and relapse resistant. Prescriptive authority for psychologists with the necessary training in psychopharmacology can be of major assistance in meeting the standards of care recommended by mental health experts. Public policy needs to be amended to authorize citizens access to this value-added psychological/ pharmacological care.

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