From the perspective of a former APA President who decided to observe from afar, rather than continue to participate in the association’s governance activities, organized psychology has become a steadily maturing profession – although in all candor, at times one wishes that some of our colleagues on the division’s list-serve would “get a life.” Those who have had the opportunity to be personally involved in shaping our nation’s health and educational policies have long come to appreciate the importance of the recommendations made by respected independent “think tanks” such as the Institute of Medicine (IOM). The IOM was established in 1970 by the National Academy of Sciences (NAS) to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the nation. It acts under the responsibility given to the NAS by its congressional charter granted by the Congress in 1863, to be an advisor to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. At this year’s annual APA convention, Ellen Garrison hosted a special event honoring the 30th anniversary of the APA Congressional Science Fellowship program which has now sponsored 92 psychologists for a year on Capitol Hill; an additional four psychologists having been selected to serve during the second session of this Congress. Seven psychologists have been selected as Robert Wood Johnson Health Policy Fellows; Danny Wedding serving as their first psychologist in 1989-1990. We are becoming increasingly involved in the public policy process. Accordingly, it has been particularly rewarding to see the increasing Monitor coverage of IOM events, thereby providing the membership with a glimpse into the future. The key question: How do we facilitate practitioners becoming involved?

Having worked closely with our APA President-Elect Gerry Koocher for well over two decades, I am personally looking forward to his year. Gerry has always been on the cutting edge of our nation’s healthcare and social policy agendas and truly appreciates the critical importance of practitioners working closely with scientists and educators for the common good. He understands the importance of psychology becoming actively engaged in (and thereby helping to shape) national policy agendas. His health psychology expertise will nicely build upon the impressive foundations established by former Presidents Joe Matarazzo, Charlie Spielberger, Norine Johnson, and Ron Levant. Gerry appreciates the critical importance of having psychology visually involved in those policy agendas that have taken on a life of their own, often pursuant to IOM reports and media coverage. For full-time practitioners this becomes a major challenge. How can our colleagues who are already extraordinarily busy earning a living and staying on top of the newest clinical advances, also find the time and venue to participate in evolving societal priorities? Yet, from a public policy perspective there can be no question that they must. We are one of the “learned professions” and this is our societal responsibility. This is the challenge for the 21st century that must be met. As but one example, I would not be surprised if under Gerry’s leadership practitioners increasingly take responsibility for shaping their own continuing education (CE) agendas. Historically, CE has primarily been the responsibility of the education community. However, given its importance to practitioners and state associations, we would rhetorically ask: Is this really the most appropriate home?

The IOM Report: Preventing Childhood Obesity: Health In The Balance – In 2001, the U.S. Surgeon General issued a Call To Action to stimulate the development of specific agendas and actions targeting what was rapidly becoming a major public health problem of childhood obesity. The charge to the IOM was: “To develop a prevention-focused action plan to decrease the prevalence of obesity in children and youth in the United States. The primary emphasis of the study’s task force was on examining the behavioral and cultural factors, social constructs, and other broad environmental factors involved in childhood obesity and identifying promising approaches for prevention efforts.... Since the inception of this study, the committee recognized that it faced a broad task and a complex problem that has become an epidemic not only in the United States but also internationally.... Children are highly cherished in our society. The value we attach to our children is fundamentally connected to society’s responsibility to provide for their growth, development, and well-being. Extensive discussions will need to continue beyond this report so that shared understandings are reached and support is garnered for sustained societal and lifestyle changes that will reverse the obesity trends among our children and youth.” New elected IOM member Kelly Brownell was one of the participants. Highlights of the IOM findings:

Despite steady progress over most of the past century towards ensuring the health of our country’s children, we begin the 21st century with a startling setback – an epidemic of childhood obesity. Prevention of obesity in children and youth should be a national public health priority. Over the past three decades the prevalence of childhood obesity has more than doubled for preschool children aged 2 to 5 years and adolescents aged 12 to 19 years, and it has more than tripled for children aged 6 to 11 years. Presently, approximately nine million children over 6 years of age are considered obese. Childhood obesity involves immediate and long-term risks to physical health. For children born in the United States in 2000, the lifetime risk of being diagnosed with diabetes at some point in their lives is estimated at 30 percent for boys and 40 percent for girls if obesity rates level off. Young people are also at risk of developing serious psychosocial burdens related to being obese in a society that stigmatizes this condition. The national health care expenditures related to obesity and overweight in adults alone have been estimated to range from approximately $98 billion to $129 billion after adjusting for inflation and converting estimates to 2004 dollars.

Obesity prevention requires an evidence-based public health approach to assure that recommended strategies and actions will have their intended effects. Such evidence is traditionally drawn from experimental (randomized) trials and high-quality observational studies. However, there is limited experimental evidence in this area, and for many environmental policy, and societal variables, carefully designed evaluations of ongoing programs and policies are likely to answer many key questions. For this reason, the committee chose a process that incorporated all forms of available evidence – across different categories of information and types of study designs – to enhance the biological, psychosocial, and environmental plausibility of its inferences and to ensure consistency and congruency of information.

Because the obesity epidemic is a serious public health problem calling for immediate reductions in obesity prevalence and in its health and social consequences, the committee believed strongly that actions should be based on the best available evidence – as opposed to waiting for the best possible evidence. However, there is an obligation to accumulate appropriate evidence not only to justify a course of action but to assess whether it has made a difference. Therefore, evaluation should be a critical component of any implemented intervention or change.

Government at all levels should provide coordinated leadership for the prevention of obesity in children and youth. The President should request that the Secretary of the Department of Health and Human Services (DHHS) convene a high-level task force to ensure coordinated budgets, policies, and program requirements and to establish effective interdepartmental collaboration and priorities for action. An increased level and sustained commitment of federal and state funds and resources are needed.

Community actions need to encourage child- and youth-centered organizations, social and civic organizations, faith-based groups, and many other community partners. Health-care professionals, including physicians, nurses, and other clinicians, have a vital role to play in preventing childhood obesity. As advisors both to children and their parents, they have the access and influence to discuss the child’s weight status with the parents (and the child as age appropriate) and make credible recommendations on dietary intake and physical activity throughout children’s lives. They also have the authority to encourage action by advocating for prevention efforts. Henry Tomes will soon be retiring as Executive Director of the APA Public Interest Directorate. Probably more than any other colleague that I have known, Henry understood psychology’s potential for utilizing this societal authority and the association’s ability to effectively utilize its public “convening power.” We should appreciate that the key to addressing our nation’s childhood obesity epidemic are the behavioral sciences and psychology in particular. How can Division 42 increase practitioner involvement in this effort?

The Prescriptive Authority Agenda – In our last column we reported that: “During the last legislative session, the Hawaii Psychological Association, in collaboration with the Hawaii Primary Care Association, nearly obtained prescriptive authority (RxP) for their members working within federally qualified community health centers. The resulting legislatively mandated RxP Task Force was a major accomplishment.” Louisiana Psychological Association President Jim Quillin stressed that: “the ‘medical’ in medical psychology is an adjective that modifies rather than defines who and what we are – psychologists.” Ray Folen is a member of the Hawaii RxP Task Force. His report on their first meeting this October:

“The first meeting of the legislatively mandated RxP Task Force started with a parking lot encounter with the anti-RxP psychiatrist assigned by organized psychiatry to represent them during the discussions. He greeted me with an obvious dig – ‘So what do you guys do? Testing, right?’ I didn’t offer him the courtesy of a reply as we walked to the State Capital for our meeting with the legislators chairing the task force. One thing was clear, though: he was feeling threatened. My colleagues and I knew he confided in others that it was only a matter of time before psychologists had prescriptive authority. His job was to stave off the inevitable as long as possible. I might have felt some sympathy for his situation, were it not for the fact that he had little to offer in the face of the desperate need for mental health services in our state. We, like most areas of the country, have a critical shortage of psychiatrists, particularly in rural and underserved areas and we have a desperate need for pediatric psychiatrists in particular. Inpatient adolescent units have had to close due to a lack of psychiatrists.

“Is there any chance they will be able to improve this situation in the future? The answer is a resounding ‘No.’ Psychiatry residencies have to pull 40% of their residents from foreign countries due to a lack of U.S. applicants. Only three percent of psychiatry graduates have plans to work in rural or underserved areas. Hawaii psychologists, on the other hand, can be found in almost all areas of the state. A large percentage are providing psychological services to children. Psychologists are found in most of the federally-designated community health centers (CHCs), whose charter is to provide services in underserved areas. The CHC psychologists work collaboratively with the primary care physicians to provide their patients with appropriate therapy and adjunctive pharmacological interventions when needed.

“Prescriptive authority is only meaningful in appropriate context, and the primary care psychology model is one that makes the most sense to us. Primary care psychologists work in a primary care clinic. They provide traditional behavioral health services (e.g., treatment of depression, anxiety, substance abuse), as well as more specialized behavioral medicine services (e.g., treatment of obesity, high blood pressure, diabetes, headache). In our experience, family practitioners welcome psychologists in their clinics. These psychologists not only provide an opportunity for the immediate referral of the distressed patient, but also provide truly comprehensive treatment in the primary care environment. The patients welcome the seamless continuity of their overall health care and appreciate the lack of stigma that has been historically associated with behavioral health care. Additionally, insurance companies are beginning to realize that services provided in this manner are leading to a reduction in overall healthcare costs.

“Many primary care psychologists (almost all of those in Hawaii) have received additional training in psychopharmacology. This is particularly valuable as psychologists are often the sole behavioral health provider in our rural clinics. Over the last several years, the primary care providers, with an average of six weeks of mental health training and limited formalized psychopharmacologic education, have come to rely on our expertise and that of nurse practitioners in this area. It is noteworthy that the CHC medical directors wrote a letter to the state legislature endorsing prescriptive authority for psychologists last legislative session.

“This scenario could be repeated in other places. Federally-qualified CHCs can be found in every state. Primary care psychologists have clearly demonstrated their proficiency in this venue and it is imperative that we continue to do so. As more psychopharmacology-trained psychologists provide services in the primary care environment, it will offer an increasingly convincing argument for the value this expertise provides to our patients and our communities alike. Unlike some of our psychiatric colleagues, we have begun to respond to the behavioral health care crisis by ‘walking the walk, not simply talking the talk.’”

Our sincerest congratulations to Jill Oliveira-Berry and Robin Miyamoto for their success in obtaining and maintaining active support throughout the legislative process from each of the health center medical directors, the Hawaii Primary Care Association, and a number of other “interested parties.” Access to high quality health care has been psychology’s fundamental stance. Accordingly, it is quite interesting to note that upon the convening of the RxP Task Force by the legislator co-chairs, the University of Hawaii Department of Psychiatry offered the health centers: “one psychiatric resident (with attending) available to give each neighbor island health center ½ day/month of psychiatric consultation and follow-up. After the first visit to the health center, follow-up will be available by VTC. In ½ day/month the psychiatric resident can follow-up with 2-3 patients and/or do consults and in-service education with clinicians.” This approach by psychiatry geared to undercut psychology’s access argument is very familiar to Elaine LeVine and Mario Marquez after their experiences in New Mexico. Hopefully this time, however, the medical community will actually follow through on its offer and at least some of Hawaii’s underserved citizens will receive the care that they require.

Aloha

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