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JOURNAL OF THE ACADEMY OF MEDICAL PSYCHOLOGY

ARCHIVES

of MEDICAL PSYCHOLOGY

VOLUME 2, ISSUE 1 July 2011

J o u r n a l o f t h e A c a d e m y o f M e d i c a l P s y c h o l o g y

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July 2011 • Volume 2, Issue 1

Managing Editor Jack G. Wiggins, PhD, PsyD Associate Editors John L. Caccavale, PhD, ABMP James K. Childerston, PhD, ABMP Alan Gruber, DSW, PhD, MD, ABMP Jerry A. Morris, PsyD, MBA, MS Pharm, ABPP, ABMP, ABBHP Matthew B.R. Nessetti, PhD, MD, ABMP John L. Reeves II, PhD, MS, ABPP Gilbert O. Sanders, EdD, ABMP Soterios J. Soter, PhD, MD, ABMP Editorial Consultants William Bernstein, PhD Jeffrey Cole, PhD Alan D. Entin, PhD, ABPP James M. Meredith, PhD, ABMP, ABPP Mark Muse, EdD, ABPP, ABMP

Editorial Statement The Archives of Medical Psychology is a peer-reviewed journal published electronically that is dedicated to the practice of Medical Psychology. The rapidly emerging field of Medical Psychology in the evolving new healthcare delivery system requires prompt dissemination and documentation of these developments. Therefore, The Archives is using this electronic format to deliver this information to practitioners for the well being of their patients. Articles are published when they have met the standards of the review process and are determined to have potential merit for practitioners when providing healthcare services to their patients. Subscribers will be notified electronically as articles are posted on the Archives of Medical Psychology web site for their viewing. Articles submitted to the Archives for publication will be considered for review as long as they are pertinent to the practice of Medical Psychology as defined below.


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July 2011 • Volume 2, Issue 1

Archives of Medical Psychology

Table of Contents Volume 2, Issue 1

Masthead ......................................................................................................................... i Table of Contents............................................................................................................ ii Prescribing Psychologists in Private Practice: The Dream and the Reality of the Experiences of Prescribing Psychologists ........................................ 1 Elaine S. LeVine, Jack G. Wiggins and Erin Masse Imagery Rehearsal Therapy May Be Better than Prazosin for the Treatment of Nightmares in the Deployed Setting .............................................................................. 15 Bret A. Moore Report of the Fort Hood Massacre Findings .................................................................. 19 Academy of Medical Psychology

Archives Author and Reader Information Author and reader information about the Archives of Medical Psychology, the Academy of Medical Psychology (AMP) and the American Board of Medical Psychology (ABMP) appear at the beginning of Issue I of Volume I. The Masthead, Table of Contents of Issue I, Editorial Statement, Definition of Medical Psychology, Introduction to the Archives of Medical and Editorial Policy are listed in the section on pages with roman numerals.


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Prescribing Psychologists in Private Practice: The Dream and the Reality of the Experiences of Prescribing Psychologists

Elaine S. LeVine Jack G. Wiggins

Erin Masse Private Practice Las Cruces, NM

Abstract An open-ended “depth” survey of psychologists now prescribing was conducted to learn how prescriptive authority laws for psychologists were implemented. Prescribing psychologists were proudly collaborating with medical healthcare professionals and found their prescribing practices financially rewarding. The major practice obstacle found was the Louisiana law required mandatory agreement between the prescribing “Medical Psychologist” and the prescribing medical doctor. This concurrence clause resulted in an amendment placing “Medical Psychologists” under the regulation of the Louisiana Medical Board. A “concurrence” clause is not in the New Mexico law. NM Prescribing Psychologists and LA Medical Psychologists agreed in their survey responses despite differences in prescribing laws. Responders stated their RxP training goals were achieved preparing them to prescribe safely and effectively. Practices and incomes increased substantially. Prescribing Psychologists treated patients with mental and physical conditions from previously underserved populations. Responders were optimistic about the future of prescribing psychology as a way to better serve their patients. A survey dealing with the use of vital signs, physical examinations, clinical laboratories, and dual diagnoses was mailed to NM Prescribing Psychologists in March 2011. There was a significant increase in Prescribing Psychologists over two the past two years, especially in the public sector. This represented increased acceptance of Prescribing Psychologists by the public, healthcare facilities and other healthcare professionals. This suggests that the chronic shortage of mental health specialists could be overcome by public funding of prescriptive authority training of licensed psychologists.

Introduction: The Emergence of Prescriptive Authority for Psychologists Through the Independent Practice Movement

This article describes the implementation of a long-term dream of many psychologists to make the practice of psychology a “full-service health profession.” Public recognition of psychology in healthcare health dates back over 60 years when the Department of Veterans Affairs began training clinical psychologists as specialists in mental healthcare. Unmet public needs for mental health specialists to diagnose and treat behavioral disorders with both psychological and physical interventions became the challenge to clinical psychology. Leaders in clinical psychology advocated psychologists treat mental and behavioral disorders with a broad array of treatment techniques including the use of _________________________________ Correspondence Address: Elaine S. LeVine, PhD, ABMP Through the Looking Glass 1395 Missouri Ave. Las Cruces, NM 88001 email [email protected]


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psychotropic medications. Dr. Elaine LeVine was instrumental in the passage of the historic New Mexico law that granted prescriptive authority to psychologists trained in psychopharmacology to prescribe psychotropic medications for mental and behavioral conditions. This law required breaking down long-standing legal and medical barriers to the practice of psychology. She was also a primary author of the required regulations implementing the New Mexico law into practice. Dr. LeVine conducted two surveys of how licensed prescribing /medical psychologists implemented their skills into their practices. She chose private practice as being the most representative of professional psychologists operating under their own aegis unfettered by facility protocols. She recognized prescribing psychologists serve as a benchmark as full-service health care profession. She asked that a historical background be included to highlight the magnitude of this struggle and significance of psychology’s achievement as a prescribing profession. The following overview of development of prescriptive authority for the profession is offered to honor Dr. Levine and her colleagues that made this achievement a reality.

I. Historical Basis for Prescriptive Authority for Psychologists (1) The private practice of psychology is an outgrowth of the healthcare legislation to deal with returning veterans readjusting to civilian life following World War II. The war effort had created a pent-up unmet demand for medical services in the civilian population that were aggravated further by the return of veterans of military service. There was no plan for how to overcome the healthcare shortages and to pay for the needed “medical services.” The Taft-Hartley Act of 1947 attempted to deal with these health issues by making healthcare a tax-deductible benefit of workers. This Act also created union–based Trusts that would use tax-exempt corporate healthcare funds for unions to organize and provide healthcare for their members. Unions negotiated health plans with insurers for their members and set the tone of the post-war healthcare market that private practitioners of psychology hoped to enter.

Pre-paid healthcare was a bonanza for general healthcare but not for mental health. Nervous and mental disorders, alcoholism and tuberculosis were the three chronic health conditions exempted from standard health insurance contracts. Tuberculosis became a covered condition by insurance with the development of penicillin and other antibiotics. However, there were no effective medications for mental disorders or alcoholism. It was not until 1958 when the US Government began to include “nervous and mental disorders” and “alcoholism” in its insurance contracts for federal employees that private practice of psychology began to flourish. Prior to this time the bulk of psychologists were employed primarily in public schools and in state or federal hospitals. The expansion of postsecondary education had provided some opportunities for both the teaching and the practice of psychology.

From the end of the Civil War to the end of World War II care for the mentally ill and mentally retarded had become a responsibility of states. State operated facilities had become the dumping grounds for unwanted relatives or non-self-supporting citizens. A major treatment problem was to separate the mentally ill from the mentally retarded. Psychologists were hired to use their psychometric skills to accomplish this cost-saving diagnostic task. However, states had few if any standards. States did not comply with federally required reporting systems for mental conditions. The diagnostic system was inadequate and the DSM-I was just coming into use. Dorothea Dix’s optimistic dream for


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humane public healthcare for the insane had become a costly nightmare to states and to the federal government.

During the general healthcare boom of the 1950’s the public rejected state operated mental hospitals for the care and treatment of their loved ones. Public demand for rehabilitation of WW II veterans with mental conditions had required the Department of Veterans Affairs (VA) to expand its services for mental health specialists. The VA then created a doctoral level program to train clinical psychology as mental health specialists. The demand for these trained doctoral level psychologists by state hospitals outstripped the supply. Dr. Karl Heiser anticipated this supply/demand issue and in 1946 codified the doctoral standard in the first law certifying psychologists. This began the 30-year struggle for statutory recognition of psychology by licensure in all 50 states. Demand for improved standards of care for outpatient treatment of those with mental conditions overwhelmed the meager supply of doctors willing to treat and manage these conditions. Psychiatrists in working in state hospitals began to develop lucrative private practices and recruited psychologists to assist them in their practices.

Enterprising psychologists realized they were providing the same services as psychiatrists and found opportunities to set up their own outpatient practices for diagnostic testing and psychotherapy. Psychiatrists began treating mental conditions with newly marketed psychotropic medications, such as Thorazine and the benzodiazepines as they became available. Although there was a growing market for psychological treatments, psychologists were not included in pre-paid health insurance plans. Mental disorders were considered to be medical conditions and reimbursement for diagnosis and treatment was restricted to medical doctors. The rapid increase in the availability of insurance coverage for mental disorders made it clear that the private practice of psychology for had little future in the diagnosis and treatment of mental conditions had little future unless payments for their patients could be reimbursed by insurance. The major objections to insurance coverage of psychological diagnosis and treatment were: 1. Psychologists could not provide a full range of care for those requiring hospitalization and 2. Psychologists could not prescribe medications.

If psychologists provided the same services as psychiatrists in the diagnosis and psychotherapeutic treatment of patients, psychologists asked themselves, “why shouldn’t patients requiring mental care be entitled to seek services from whomever that was legally qualified to provide those services?” In 1967 Drs. A. Eugene Shapiro and Morris Goodman of New Jersey obtained passage of the first “freedom of choice” law in New Jersey that required insurers to reimburse patients of psychologists for the diagnosis and treatment of mental conditions. Insurers complied with this law by simply defining licensed psychologists as “physicians” under the terms of their health insurance contracts. This ignited psychological practitioners to seek licensing laws with a “defined scope of practice” rather than certification acts that merely protected the title of psychologist. This movement was bolstered by Dr. Nicholas Cummings’ seminal findings that proper treatment of mental and behavioral conditions using psychotherapy could result in significant cost savings in medical treatments that more than offset the cost of the psychotherapy.

The APA Committee on Health Insurance (COHI) was established to expand insurance coverage of psychological healthcare treatments. The success of COHI obtaining inclusion of psychological services in many private and state group insurance contracts


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for outpatient services did not remove the barriers of prescribing medications and hospital privileges for psychologists. Union Trusts were exempt from state “freedom of choice” laws and psychology was not enumerated as a health profession in Section 1861 (r) of Medicare or in federal Medicaid requirements for the states to provide mental health services for the medically indigent. Consumer rights for mental care that were granted by state “freedom of choice” insurance laws were then abolished by the federal Employee Retirement Income Security Act of 1975 (ERISA). ERISA gave business corporations similar rights to form insurance trusts that labor unions had gained under the Taft-Hartley Act. Thus, ERISA became the legislative foundation for managed care corporations of the insurance industry. The APA Committee on Health Insurance was “discontinued” as being no longer necessary. Several years of advocacy for private and public practice were lost before healthcare advocacy was re-established as the APA Practice Directorate.

The hospital treatment of the mentally ill had remained the private preserve of psychiatry except for some private consultation for psychological testing and delegated duties assigned to psychologists who were employees of the hospitals. The American Medical Association’s Joint Commission for the Accreditation of Health Organizations (JCAHO---formerly JCAH) had been given “deemed status” of a government agency under Medicare to regulate hospital care. Hospital staff privileges of admission, “attending” status, transfer, and discharge, were denied to psychologists who were classified as Allied Professionals in JCAHO regulations. However, the Commission for the Accreditation of Rehabilitation Facilities (CARF), a multi-disciplinary peer organization to JCAHO, did permit staff privileges for psychologists. Dr. Jack Wiggins persuaded the Ohio Psychological Association and the Ohio Attorney General to sue JCAHO on antitrust grounds that JCAH regulations were a restraint of trade on the practice of psychology. After a 3 year struggle JCAHO signed a consent decree to abide by state laws regarding the hospital practice of psychology. Then, psychologists lobbied states to enact laws authorizing hospitals to include psychologists on their medical staffs and give them appropriate privileges to care for their patients in hospitals.

Prescriptive authority remained as one of the last scope of practice barriers for psychological practitioners in order to make psychology a full-service healthcare profession once hospital practice was attained. Psychologists in New Mexico and Louisiana with psychopharmacology training have achieved prescriptive authority despite difficult, prolonged legislative battles. Now, it is time to learn about how prescriptive authority is the viewed from the standpoint of the experiences and attitudes of colleagues prescribing as professional psychologists. Dr. LeVine, continued her advocacy by conducting a survey of how prescribing psychologists incorporated their skills of psychopharmacotherapy into their private practices. She believed that private practice, unfettered by healthcare facilities, would be the best measure of psychology as a prescribing healthcare profession.

II. The Current Status of Prescribing Practices of Psychologists in New Mexico and Louisiana

A person-to-person survey was deemed necessary to learn the exigencies of prescribing psychologists in private practice in New Mexico and Louisiana. Lists of Prescribing Psychologists were obtained from the New Mexico Board of Psychologist Examiners and Medical Psychologists from the Louisiana Board of Psychologist Examiners. The prescribing/medical psychologists in private practice were identified by asking


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colleagues that knew who were the prescribing psychologists in their state. Of the 18 Prescribing Psychologists in New Mexico in the fall of 2008, 9 were identified as maintaining a part- or full-time private practice. Of the 41 medical psychologists in Louisiana at the time, only 14 were identified as maintaining a part- or full-time private practice. Each of the prescribing/medical psychologists identified to be in private practice were emailed a request for their participation in a telephone interview and asked for a time when it might be possible to talk. An open-ended oral interview format was used so that the range of independent practice approaches could be fully explored. Twenty-seven interview questions were designed to explore the psychologist’s views on the relevance and appropriateness of their training, changes in relationships with colleagues, practical and financial aspects of practice related to prescribing, and the perceived advantages and disadvantages of being able to prescribe. Possible differences in response patterns between New Mexico and Louisiana psychologists were examined statistically for 10 questions1. The results of the analyses suggested that it was not necessary to reject the null hypothesis and that the populations are the same. Upon completion of all interviews, the answers were placed in logical categories. Survey questions are categorized as follows:

A. Goals and results in RxP training B. Description of use of psychopharmacology in practice C. Inter-professional relationships as a prescribing/medical psychologist D. Financial aspects of practice from prescribing E. Changes in practice associated with prescribing F. Advantages and problems of prescribing in practice

A. Goals and results of RxP training category questions included: Q1. What prompted you to decide to take RxP training? Q2. What did you expect from RxP training? Q3. Has RxP training prepared you for independent practice as a medical/prescribing psychologist?

Psychologists interviewed had expressed a desire to increase their expertise. These psychologists believed their RxP training and practica met their goals for training and prepared them to prescribe safely and effectively (17/17). Also, they (17/17) are optimistic about their own future and that of psychology as a prescribing are optimistic about their own future and that of psychology as a prescribing health profession to meet the needs of underserved populations. B. Description of use of psychopharmacology in practice questions were:

Q4. What is the nature of your private practice? Q5. How long have you been prescribing? Q6. How many patients do you treat a week? Q7. For what percent of your private practice population are you prescribing? Q8. Of these, what percent are you seeing for psychotherapy and medication management combined?

1Chi-square analyses by the Monte Carlo method were employed on questions: Q. 4, 5, 6, 7, 8, 9, 18, 22, 23 and combined. None of these scores were significant. However, it must be recognized that the lack of detection of difference from the null hypothesis may reflect the low power due the small sample size. The authors thank Dr. David Daniel of the Business Statistics Department of New Mexico State University for his assistance in research methodology.


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Q9. What percent are you seeing for medication management alone? Q10. Has the nature of your patient population changed since you have been prescribing?

The majority of these practitioners were in solo practice (14/17) with three in partnership practices and most (13/17) had been prescribing for two or more years. Their practices were increasing with new practice opportunities in psychiatric hospitals, nursing homes, underserved prisons, rural clinics, military facilities and other public agencies. They were receiving more referrals from primary care physicians (PCPs). Most of those interviewed (9/17) were treating 30 or more patients a week, 4 treated 20 patients or more and 3 were new in their practices. The percent of patients that were prescribed for ranged from 31% to over 91%with the median between 71% and 80%. Psychotherapy combined with medication was being provided for over 90% of the patients seen by 9 of 13 psychologists responding to this question. Similarly, 9 of 14 of those responding were treating 10% or less of their patients on mediations alone. One psychologist in an extremely rural area was so inundated with patients requiring medication that he had little time to treat with psychotherapy. Most (13 of 17) reported that their practices were more varied and had changed since they added prescribing to their practices. They were seeing more seriously disturbed patients and more patients with comorbid psychological and medical conditions. They also reported seeing more Medicaid patients and patients that had been misdiagnosed. C. Inter-professional relationships as a prescribing /medical psychologist. Questions were:

Q11. Have any PCP’s refused to allow you to prescribe the medication you felt was most appropriate? Q12. If so, how did you handle this situation? Q13. What do you see as the benefits of this collaborative relationship? Q14. Do you see any drawbacks to it? Q19. What is your relationship with pharmaceutical companies? Are you being

visited by pharmaceutical representatives? If so, how much time do you spend with them? Do they leave you samples? Are they giving you gifts? Please describe. Q25. How do you describe your relationship with pharmacists? Are they responsive, respectful?

Questions related to collaboration provided interesting commentary on the increased interactions between psychologists and physicians, as well as, interactions with pharmacists. The increased collaboration physicians and pharmacists substantiated that prescribing/medical psychologists were well received by the healthcare community in a short period of time. The survey questions were not directed toward psychologists’ relationships with nursing or social work and little information about interactions with these professions was obtained. Of particular interest were the responses to Question 11 “Have any PCPs refused to allow you to prescribe the medication you felt was the most appropriate? The answer was a clear “no” for 10 of the 17 responding who reported that PCPs “really appreciated the calls.” Of the 7 reporting some difficulty it was less than 10% of the time. This occurred more frequently (7/8) in Louisiana where collaboration with a prescribing physicians is mandatory and the psychologist must obtain “concurrence” from the collaborating physician before prescribing. When “concurrence” of the medication


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prescribed was not attained by 4 responders, the treatment plan was disrupted. Thus, the requirement of “concurrence” collaboration in the LA law became a source of contention in the collaboration relationship between psychologists and physicians. It must be noted here that this survey was conducted prior to the RxP law in Louisiana being changed placing Medical Psychologist” under the regulation of the Medical Board without a requirement that they maintain their license as a psychologist. The lack of oversight requirement by the Board of Psychologist Examiners in LA is now a source of contention within the practice of psychology. Thus, great care in specifying the nature of collaboration is essential in the drafting of collaboration language in scope of practice legislation. In New Mexico, psychologists must collaborate with the primary care physician before prescribing medication unless the patient’s need for a psychotropic medication is critical (in which case, there is a 48-hour period in which to contact the primary care physician after prescribing) or in a disaster area (in which case, the on-call physician can serve in the role of the primary care physician). The New Mexico law or regulations do not specify that the collaborating physician must agree with the psychologist’s recommendation. New Mexico regulations allow for the psychologist to present an overall plan to the collaborating physician rather than to contact the physician about each specific change in medication. Prescribing/medical psychologists saw many benefits in collaborating with other healthcare professionals. However, there can also be seemingly unnecessary frustrations associated with the required mandatory collaboration with the primary care physicians. Part of this may be due to a physician’s lack familiarity with psychologists as a profession or not having had the opportunity of working with a specific psychologist. Responders cited two circumstances where the specifics of collaboration may become a practice issue:

1. Medicaid regulations for nursing homes state that only the admitting physician can prescribe medications. Consulting Psychologists, just as Consulting Psychiatrists, cannot prescribe without the permission of the patients’ attending physician. This regulation is designed to prevent aged and debilitated patients from being over medicated. This regulation places psychology and psychiatry on the same status in nursing homes but does not require the attending doctor to have specialty training or continuing education in prescribing or monitoring psychotropic medications when prescribing them.

2. When consulting in hospitals, prescribing/medical psychologists may be called in

to see patients where the attending physician does not have an ongoing collaborating arrangement with the psychologist and may be uncomfortable co-signing prescriptions of the psychologist.

Despite the difficulties in collaborating encountered as described above, prescribing/ medical psychologists see great value in collaborating with other healthcare professions. They (16/17) used their relationship skills and professional contacts in the community so that any difficulties in the collaboration with another health professional did not interfere with the overall care of the patient. Collaboration resulted in better integration of clinical care was cited (12/17), PCPs appreciating consultations were noted by (5/17) and consultation was seen as a practice building opportunity (3/17).


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Drawbacks of collaboration understandably listed time required (15/17), overburdened PCPs were not interested in collaborating, looking at more laboratory records, or PCPs giving pro forma agreements. Despite the time required for consultation on medications and inconveniences in making contact, one practicing psychologist said s(he) would do it anyway when appropriate even if it were not mandated. Question 19 is multi-factored regarding representatives of pharmaceutical companies. Most prescribing psychologists (13/17) reported “drug detail” representatives of pharmaceutical companies were not interested in marketing their medications to them. The other 4 were left drug samples and/or token gifts such as pens/ prescription pads, etc. Free drug samples to start patients on medication were appreciated but not sought by psychologists. Relationships between psychologists and pharmacists were described as being excellent (17/17). Psychologists saw pharmacists as courteous, responsive, and helpful in monitoring medications and excellent sources of information. Frustrations with insurance companies appear to stem in part from the term “Prescribing Psychologist” is a term of art in NM. (The redundant term “medical/psychologist” used in the paper to note inclusion of LA prescribing psychologists.) NM medical/prescribing psychologists must work with medication formulary limitations, which are designed to keep down the cost of medication. The current formulary can limit providing the most efficacious medication to a patient. One psychologist described experiences dealing with a particular managed care company to obtain prior authorization to prescribe medication not on a formulary as “surrealistic.” After being referred to several offices and finally speaking to the correct administrator, the administrator only wanted to know the identifying data of the insured. Therefore, the entire authorization process was perfunctory for purpose of discouraging the use of off-formulary medications rather than an authentic review of the appropriateness of medications. Another psychologist reported a large state managed care company tried to force her into practice within the traditional medical model. Payments for psychotherapy with medication management for several chronically depressed patients with bipolar disorder were denied. Instead, reimbursement was restricted to 15 minutes or 30 minutes for medication management checks. D. Financial aspects of practice from prescribing questions were:

Q15. Are you able to charge more per session? Please describe. Q16. What new costs have you incurred? Q17. Has supervision by managed care changed? If so, in which ways? Q18. Are you using health and behavior codes? Are you getting reimbursed through them?

Responders to the survey reported varying degrees of difficulty in getting paid by managed care companies. Most found little change in supervision by insurers as a result of prescribing (9/17). Health and Behavioral Codes were rarely used (2/17). This lack of use of Health and Behavioral codes is surprising since most prescribing psychologists reported they were treating more patients with medical as well as behavioral conditions. Insurers refused to reimburse for prescriptive services of Conditional licensed RxP trained psychologists regardless of codes used according to reports by all nine of the New Mexico respondents!


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All (17/17) of the prescribing/medical psychologists reporting stated they were able to increase their fees. Over half (9/17) reported they were making “considerably” more money because they were able to discontinue managed care contacts and provide only fee-for-service care or simply raise rates. Some were able to obtain contracts that paid a similar rate as psychiatry. However, 2 of 17 reported losing money on Medicaid patients. Half (8/17) of private practitioners who were serving patients drawn from the managed care pool reported only a slight increase in fees of about $10 to $15 per session. Even so, these “slight increases” on an annualized basis can amount from $15,000 up to $22,500 of increased income. Thus, it is estimated that the median income increase from a prescribing practice is minimally about $20,000 per year. Increased costs of practice were cited as drawbacks to practicing as a prescribing/ medical psychologist. Increased costs mentioned were: Liability insurance costs increased 15%. (This 15% increase could typically translate into about $150 in increased costs. Ed.) The initial cost of the federal DEA license to prescribe and dispense medications was $500.00 with an annual renewal fee of $51. Some purchased software programs to assist them in accurate record keeping of prescriptions written. Some reported added record keeping and “unbillable” time reviewing clinical laboratory reports was problematic as a function of prescribing.2 Some said they were attending more expensive CE courses dealing with RxP. The reported income increases gained from prescribing more than offset any increased costs related to prescriptive authority they cited as drawbacks! E. Changes in practice associated with prescribing questions were varied by practitioner

and lacked a central theme for practice. They were treated as separate items.

Q20. How do you cover telephone calls from patients on a 24-hour basis? Prescribing/medical psychologists still tend to handle their telephone messages through an answering service (10/17), although some (6/17) take calls by their cell phone or have special cell phone arrangements. About 1/3 had a telephone coverage arrangement with another prescribing psychologist, nurse practitioner or physician.

Q21. What provisions do you make to assure the accuracy of your prescriptions?

Duplicate prescription pads were used by (9/17) of the prescribers. Online prescribing services and dictated prescribing in front of the patient were mentioned. Giving the patient the prescription and having them read it back was also cited.

Q22. Are you using an online pharmacy prescribing service that monitors

medication usage and interactions? Only 3 prescribers of the 14 responding stated they were using such an online pharmacy prescribing service and 11 said they were not.

Q23. How often do you run computerized drug interaction studies?

Six of the 16 responding reported they ran a computerized medication check on every patient and six did not, unless multiple medications were involved. Only one reported doing medication checks by to textbooks.

2 The importance of laboratory findings was not addressed in the original survey. A second survey on use of clinical laboratory testing by psychologists appears in Addendum III of this article.


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Q24. Has RxP changed your record keeping practices? More extensive note taking was reported by (8/17) of the prescribers. Four were having their patients co-sign prescriptions written by them. Five were using computers more to assist them in office practices and/or scanning in laboratory reports. Two were using symptom-rating scales with their RxP patients. Informed consent forms were mentioned as being problematic by four responders although the consent forms apply to all patients and are not a function of RxP requirements. Prescribing/medical psychologists still tend to handle their telephone messages through an answering service (10/17), although some (6/17) take calls by their cell phone or have special cell phone arrangements. About 1/3 of the respondents had a telephone coverage arrangement with another prescribing psychologist, nurse practitioner or physician.

F. Advantages and problems of prescribing/medical psychologists questions were

presented as in a direct but non-leading open-ended format: Q26. What do you see as the greatest difficulties and hindrances of becoming a prescribing/medical psychologist? Q27. What do you see as the greatest advantages of becoming a prescribing/medical psychologist?

Psychologists opposing prescriptive authority have emphasized the potential hazards of prescribing medications including a change of attitudes or behavior of psychological practitioners to become “junior psychiatrists.” Those suggested hazards appear to be political fear tactics. These fears have not materialized as far as the prescribing/medical psychologists surveyed. Survey respondents were forthright when stating their complaints, as well as, the advantages of prescribing in their practices. Two of the 17 spontaneously mentioned the need to remember, “we are psychologists first” and “one does not over-prescribe.” The difficulties or hindrances they do report are the broadened oversight in patient care and concerns about medication effects (10/17). The increased sense of responsibility of prescribing was offset by satisfactions from practice and the feeling of empowerment RxP providers gained from providing a more integrated, better quality of care (15/17). They believe the care they provide is more timely, thus, less expensive for the patient (6/17). Part of this satisfaction from practicing as a prescriber came from reducing rampant over-prescribing from polypharmacy, that is using multiple medications of the same class of medications to treat a single diagnosed condition of the patient (5/17). Time considerations due to collaboration requirements and increased record keeping were also mentioned as hindrances (9/17). One unexpected complaint of RxP prescribers was the amount of time required to read clinical laboratory test results. There were no complaints that their increased incomes from prescribing did not adequately compensate them for obtaining RxP training or practicing as a prescribing/medical psychologist! Several comments of responders add a personal flavor to the data obtained. Problems with insurers regarding reimbursement persisted for prescribing/ medical psychologists just as they do for other prescribing professions (3/17).


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Some felt that patient expectations from medications were too high (2/17). Two were also concerned about the possibility of increased liability insurance risks. Two prescribers reported greater patient trust and better patient treatment compliance when medications were used in treatment. Another responder stated prescribing enabled him to have a greater impact on the seriously mental ill. One complained they could not treat all referrals that needed help. While another felt prescribing offered more consulting opportunities to expand help to treatment centers.

III. Addendum of Behavioral and Medical Practice Issues in New Mexico Presentations (2,3) of the original RxP survey data raised more curiosity regarding how prescribing/medical psychologists practice. There has been significant interest in obtaining more detailed information about how the connections between physical and behavioral conditions were addressed in the practices prescribing/medical psychologists’ practices. The low usage of Health and Behavior codes were of particular concern to some since this might suggest psychologists were not treating patients with primary medical conditions. On the other hand, there were spontaneous comments by prescribing/medical psychologists regarding clinical laboratory reports being time consuming even though the survey questions did not address issues of clinical laboratory findings. Therefore, a follow-up survey was contemplated. Amendments to the Louisiana law and regulations were adopted and negated the utility of repeating the original survey. Yet, the interplay of physical and mental health issues of patients of prescribing psychologists still required further investigation. The following 5-item questionnaire was mailed in March 2011 to licensed psychologists in New Mexico authorized to treat with psychotropic medications as Prescribing Psychologists.

Survey Questions March 2011 Please estimate how often you do this each week:

1. Take one or more set of vital signs (blood pressure, weight, height, etc.)? 2. Conduct a physical examination? 3. Order laboratory testing? 4. Treat someone with a dual diagnosis—medical condition, as well as, a

psychological condition? 5. Treat someone with psychotropics who has a medical condition

affecting their psychological condition?

Responses were received from 22 of the 29 licensed prescribing psychologists for a response rate of 72%. Their data was recorded separately for their primary and secondary work sites.

The results indicate that Prescribing Psychologists working in federally qualified health centers, as well as, mental and general hospitals are taking vital signs, conducting some physical examinations and ordering laboratory tests according to protocols of the facility. This represents a significant difference in the practices of Prescribing Psychologists when working in a medical facility than when they work as private practitioners. This finding supports LeVine’s view that private practice best describes the prescribing practice patterns of psychologists that resulted in her choice of prescribing in private practice survey. When these same psychologists provide their services in private practice, it appears that they rely upon a collaborating medical practitioner to conduct physical examinations. This underscores that these prescribing psychologists understood the boundaries of practice and abided by them!


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Prescribing Psychologists working in medical facilities and private practice both diagnose and treat many complicated cases. Prescribing Psychologists working in private practice settings are treating and medicating patients with dual diagnoses—psychological and medical conditions. They are ordering clinical laboratory tests to help manage the care of their patients in the use of prescribed and “unprescribed” psychotropic medications, such as alcohol and psychoactive substances. In underserved areas where medical sources are scarce or unavailable licensed prescribing psychologists may take vital signs of patients as they are trained to do.

The number of Prescribing Psychologists licensed in New Mexico increased from 18 to 29 (62%) in the two years since the completion of the original survey. There were 8 psychologists were prescribing in private practice at the end of 2008. Now, there are 11 prescribing psychologists in at least part-time private practice but only 5 are still solely in private practice. Growth in numbers of prescribing psychologists in public facilities has tripled in this same time period. This growth indicates that prescriptive authority of psychologists is increasing access for all population sectors and not just to those who can afford insurance coverage for mental disorders. This highlights that the shortage of behavioral care specialists in public facilities can be overcome by public financing of RxP training of licensed psychologists. Prescribing psychologists in public facilities, as well as in private practice, in New Mexico have demonstrated they are willing to treat complicated cases where their patients have “dual-diagnosed” multiple psychological and medical needs.

Where indicated these prescribing psychologists expand clinic facilities by taking vital signs of patients and even do partial physical examinations according to the protocols of the facility. Only a psychologist consulting in nursing homes did not do vital signs, order laboratory tests or treat dual-diagnosed patients.3 Most of the Prescribing Psychologists performed vital signs and ordered clinical laboratory tests according to facility protocols and evaluated clinical laboratory results for the benefit of their patients. Most Prescribing Psychologists diagnosed and treated patients with dual-diagnoses. Only in a military facility was the psychologist restricted by regulation from treating dual-diagnosed patients. The frequency of occurrence of dual-diagnosed patients varied markedly according to the facility. Thus, the variety and flexibility of clinical skills that Prescribing Psychologists possess has been welcomed and sought after in rural areas, military facilities, understaffed community clinics, Indian reservations and by medical practitioners. In brief, –Prescribing Psychologists have been welcomed both by the public and serve as an important functional addition to the New Mexico healthcare community!

Summary and Comment The NM /LA survey documents the consensus of positive attitudes of prescribing/ medical psychologists in private practice regarding prescriptive authority. For these RxP-trained psychologists, prescribing medications for their patients has become a satisfying way to practice as a licensed psychologist. Legislated authority to prescribe psychotropic medications by RxP-trained psychological practitioners gave the public access to needed treatments for underserved people who would have remained untreated otherwise. This new added access to psychological services was well received by the public, medical doctors and other health practitioners. 3 Medicaid regulations restrict prescriptive authority to the attending physician of the patient in skilled nursing facilities (SNF).


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Collaboration between RxP trained psychologists and other prescribing professionals required by law worked to increase public access to specialists in mental and behavioral healthcare. However, unnecessary restraint imposed by requiring a “consensus” in collaboration was a major impediment to RxP trained psychologists prescribing as practitioners in Louisiana. Mandated “consensus” creates an imbalance in discussions unless both parties have the right to agree or disagree in the decision making process. Without this provision for collegiality collaboration was only “conditional practice authority” of physician agency extension. New Mexico legislated prescriptive authority had negotiated a two year limitation to its Conditional Authority licensure supervision provision clause. The two-year Conditional Authority prescribing period remains an insurance reimbursement problem in New Mexico but has become less of a problem as prescribing health professionals become more familiar with Prescribing Psychologists. The “conditional authority to prescribe” for Louisiana Medical Psychologists resulted amending their LA prescribing law to be regulated by the Louisiana Medical Board without oversight by the Louisiana Board of Examiners of Psychologists. This amended legislation for Medical Psychologists as prescribers versus licensed psychologists regulated by the Louisiana Board of Psychologist Examiners has created major conflicts among psychologists in Louisiana. Board Certification by the American Board of Medical Psychology requires diplomates to agree to regulations of state licensing Boards of Psychologist Examiners. Thus, psychologists with American Board of Medical Psychology diplomates desiring prescribing under the Louisiana Medical Psychologist license provisions must retain their psychology license in addition to their Medical Psychology license in order to satisfy ABMP requirements. Needless to say, this confusion in professional titles and practices has created public confusion, as well. This Louisiana RxP licensing amendment has also limited the value of the survey data obtained to the time period prior to the enactment of the amendment for transferring regulation of prescription authority to the Louisiana Medical Board. It is precisely for this reason that a re-analysis of any differences in survey data between these two states was undertaken and is reported here. Although the original statistical analysis found no significant statistical differences between New Mexico and Louisiana survey responder’s replies, legislative approaches and outcomes are strikingly different. The lack of statistically significant differences was attributed to the small size of the sample. Over-analysis of small sample data is always a research danger, yet the importance of the questions asked regarding “collaboration” among health professionals begged for a second look at the data at hand. Conditional Licensure for a stipulated period of time may be an important legislative strategy for passage of RxP legislation but does not achieve an increased access to specialty care for underserved people. Instead, it creates another “medical extender” category under the control of prescribing health professions that are already overburdened in their practices and lack time to collaborate. Further, many medical practitioners have self-imposed limits to their practice and therefore lack continued education training in behavioral health treatments or specialty training in the prescribing of psychotropic medications.


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Implications and Recommendations Healthcare reform is inadequate without a strong behavioral care component. The current mental health system in the United States and worldwide is in disarray due to a shortage of medical mental health specialists whose expertise is primarily the prescription of psychotropic drugs rather than psychosocial interventions. The numbers of these medical mental health specialists are so few that they cannot even provide sufficient psychotropic services required to meet current demands nor treat the psychosocial components that are an integral part of the rehabilitation of mental and behavioral disorders. Medicating behavioral conditions has been turned over to primary care physicians (PCP) whose principal interest is physical diseases without any requirement they be trained or even have continuing educations requirements for prescribing of psychotropic medications. PCPs are well intended but are already overburdened treating patients physical conditions they were trained to provide care. It is an unrealistic expectation to extend the practices of PCPs further by collaborating in treatment of behavioral disorders that require added time to deal with the psychosocial aspects of patients’ conditions. Patients expecting medications provided by PCPs to cure their problems are not receiving the benefits of specialty care they require. We must incorporate the psychological expertise of that is currently available in the community to deal with the crisis of a shortage behavioral care for our underserved civilian population and the returning military service men and women. Prescribing Psychologists in public facilities, as well as in private practice in New Mexico have demonstrated they are willing to treat complicated cases where their patients have “dual-diagnosed” multiple psychological and medical needs. Enactment of prescriptive authority for psychologists in these two states and practicing effectively in federal services has proven RxP-trained psychologists provide the necessary increased access to behavioral care, as well as, prescribe the psychotropic medications required for comprehensive healthcare reform. Data presented indicates that prescriptive authority of psychologists increases access for all population sectors and not just to those who can afford insurance coverage for mental disorders. This suggests that the shortage of behavioral care specialists in public facilities can be overcome by public financing of psychopharmacology training of licensed psychologists.

References 1. Wiggins JG. A History of the Reimbursement of Psychological Services: The

Education of One Psychologist in the Real World. In Wright R & Cummings N (eds) The Practice of Psychology: The Battle for Professionalism. 2001, Zeig, Tucker & Theisen, Phoenix AZ.

2. LeVine E & Wiggins J. Prescribing in a Private Practice Setting. Independent Practitioner 2009, 29 (1), 30-32.

3. LeVine ES & Wiggins JG. In the Private Practice Setting: A Survey on the Experiences of Prescribing Psychologists. In Mcgrath R & Moore B (eds) Pharmacotherapy for Psychologists: Prescribing and Collaborative Roles. 2010, Am Psychol Assn, Washington, DC.


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Imagery Rehearsal Therapy May Be Better than Prazosin for the Treatment of Nightmares in the Deployed Setting

Bret A. Moore

Warrior Resiliency Program-Brooke Army Medical Center San Antonio, TX

Abstract Research on the medication Prazosin and the cognitive-behavioral intervention Imagery Rehearsal Therapy has shown promising results in treating service members suffering from nightmares in both deployed and non-deployed settings. However, due to potential side effects of Prazosin, Imagery Rehearsal Therapy may be a better intervention for treating nightmares in the combat environment.

Introduction Nightmares are a common occurrence after exposure to a variety of traumatic experiences.1 Frequent occurrence of nightmares is particularly true for those suffering from posttraumatic stress disorder (PTSD). Considering the multiple combat traumas that many service members are exposed to during deployment there has been an increasing number of service members being diagnosed with PTSD. Thus, nightmares have become a relatively common clinical complaint in this population. Often associated with PTSD, nightmares are seen as a symptom of the disorder but are rarely targeted specifically. Generally, it is assumed that if the PTSD is treated effectively by such treatments as exposure or cognitive processing therapy, the nightmares will decrease or disappear altogether.2 Unfortunately, for many service members, nightmares remain long after other core symptoms of PTSD have remitted. Emerging research supports the medication Prazosin and the cognitive-behavioral intervention Imagery Rehearsal Therapy (IRT) as promising treatments for nightmares in the deployed setting.

The Use of Prazosin in the Deployed Setting Prazosin is a sympatholytic medication used to treat hypertension. It is an alpha-adrenergic antagonist, which lowers blood pressure by relaxing blood vessels. Specifically, prazosin inhibits the postganglionic functioning of the sympathetic nervous system and is selective for the alpha-1 receptors on vascular smooth muscle. It is this action which is responsible for the anti-hypertensive effects of Prazosin. Note: The opinions or assertions contained herein are the private views of the author and are not to be construed and as official or reflecting the views of the Army, Department of Defense or United States. Correspondence Address: Bret A. Moore, PsyD, ABPP. 25822 Coronado Ridge, San Antonio, TX 78260


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The use of Prazosin has gained considerable popularity in treating service members suffering from nightmares in the deployed setting. Much of this popularity has been spurred by research on combat veterans stateside by Raskind and colleagues.3 A recent study by Raskind and colleagues found that service members being treated for nightmares with Prazosin in Iraq tolerated the medication well (i.e., no dizziness or fainting) and was effective in eliminating nightmares.4 Two notable limitations of the study are the small sample size of 13 soldiers and the lack of a control group. The latter is of great importance because nightmares tend to resolve on their own in a substantial portion of individuals, particularly those of an acute nature. In general, the accumulating evidence for Prazosin is promising. The medication is not, however, without limitations. First, results seem to support the fact that nightmares return after the medication is stopped. Second, and more critical in the deployed setting, Prazosin can potentially cause significant negative clinical and operational/occupational outcomes. Specifically, due to its alpha-1 blockade, Prazosin may cause dizziness and fainting, particularly orthostatic hypotension. Generally, this effect is most prominent with the first dose due to the phenomenon of the “first dose response.” Obviously, these are serious side effects for service members in the combat environment.

The Use of Imagery Rehearsal Therapy in the Deployed Setting

Imagery Rehearsal Therapy (IRT) has a number of variations that have been described in the literature. The most widely used model is a two-factor cognitive-behavioral treatment, which can be applied individually or in a group format. The first factor views nightmares as a learned behavioral disorder, such as insomnia. The second factor is associated with damaged, disabled or malfunctioning imagery capacity5. The most common differences among the different variations of IRT application relate to the number of sessions, which typically range from one to four, time course in which treatment is applied, and the degree to which exposure, whether intentional or not, is included in the treatment protocol. A comprehensive model has been put forth by Krakow & Zadra that includes four group sessions, approximately 2 hours in duration5. The first two sessions focus on the connection between nightmares and insomnia. The primary goal during these sessions is to help the patient understand how nightmares can become a learned behavioral disorder that requires treatment independent of other symptoms or disorders. The last two sessions focus on how IRT can reduce the frequency or eliminate nightmares through a process not unlike cognitive restructuring. First, due to the need to acclimate the patient to the process, the patient is asked to select a nightmare that evokes only a moderate level of psychological distress. Second, the patient is instructed to “change the nightmare anyway you wish.” This is important because it allows the patient ownership of the content and maximizes self-efficacy. Last, the patient is instructed to rehearse the “new dream” through imagery while disregarding any content from the original nightmare that intrudes into the patient’s thoughts. IRT has been shown in numerous clinical trials with civilians to not only decrease the frequency and intensity of nightmares, but also improve sleep quality and reduce global symptoms of PTSD.6, 7 Similar results have been found in military samples, although fewer studies are reported. The most recent study utilizing IRT with veterans consisted of 15 males with PTSD and trauma-related nightmares. Although results showed no immediate improvement initially at post-treatment, follow-up at three months showed a decrease in nightmare frequency and improvement in PTSD symptoms.8


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In the deployed environment, one study of IRT has shown success in treating acute nightmares in combat soldiers serving in Iraq. In a case series of 11 soldiers suffering from acute posttraumatic nightmares (i.e., onset within thirty-days of traumatic event), IRT showed significant reductions in nightmare frequency and severity, insomnia, and global PTSD symptoms immediate following treatment and at one-month follow-up.9 Not unlike the Prazosin study completed in Iraq, this study also had several limitations including the small sample size and the fact that nightmares spontaneously remit in many trauma survivors. There were no evident side effects or adverse events reported related to the treatment.

Is One Better than the Other?

The preliminary evidence for the use of IRT and Prazosin in the deployed setting is promising. However, in this author’s opinion, IRT is likely the better choice until further evidence of Prazosin’s safety in combat is provided. This recommendation is primarily based on the potential negative side effects such as fatigue, drowsiness, headaches, and dizziness that may occur due to alpha-1 blockade. Again, this is not related to issues of the medication’s efficacy, but the potential dangerous consequences in the combat environment from the typical side effects. Consider the following two hypothetical case examples:

1. An Infantry Soldier who is part of a Quick Reaction Force and is required to respond to emergencies in hostile areas at all hours. During a call in the middle of the night, the Soldier quickly jumps from the bed to immediately find him/herself lying on the floor after passing out from a quick drop in his blood pressure. Consequently, the unit’s team is delayed in providing support to another unit in need.

2. A Marine’s outpost takes incoming mortars and he quickly rises from bed to take cover. He experiences dizziness and disorientation due to a drop in his blood pressure. Consequently, he is left exposed for several seconds while his fellow service members scramble for cover.

The preliminary evidence supporting the effectiveness of IRT in the deployed setting combined with the lack of negative treatment side effects, leads this author to believe IRT should be the first-line choice when specifically targeting nightmares in the combat setting is warranted. In addition, IRT has several other general advantages over Prazosin in treating nightmares in service members. First, IRT is a short-term treatment, which is desirable considering that long-term treatment is often times impractical in the deployed setting. Moreover, IRT seems to provide a “cure” whereas the nightmares tend to reoccur once Prazosin is discontinued. Second, in general, service members tend to be solution-oriented with a high degree of self-efficacy. IRT is an easy to understand approach to eliminating nightmares and requires the service member to do work outside of the clinician’s office. A service member may resist taking a medication because he or she becomes a passive bystander and must rely on the medication to solve the problem. And last, there is a general misunderstanding about the mechanisms of action and effects of medications used in the treatment of psychiatric symptoms and disorders. This misunderstanding perpetuates an already tremendous stigma in the military regarding mental health. Once again, this may be an obstacle for the service member with regard to fully “buying in” to taking the medication.


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Conclusion Although limited, available data supports the use of IRT with service members suffering from nightmares. Specifically, due to rebound of symptoms and side effects related to Prazosin, IRT is likely a better choice in the deployed setting IRT potentially has the added benefit of reducing global symptoms of PTSD and insomnia; however, more research in this area is needed. Future studies should include head-to-head studies of IRT and other cognitive-behavioral treatments and dismantling protocols to delineate the effective components of the treatment.

References

1. Barrett D. Trauma and Dreams. Cambridge, MA: Harvard University Press 1996. 2. Moore BA, Krakow B. Imagery rehearsal therapy: An emerging treatment for

posttraumatic nightmares in veterans. Psychol Trauma 2010; 2: 232-238. 3. Raskind M, Peskind E, Kanter E, et al. Reduction of nightmares and other PTSD

symptoms in combat veterans by Prazosin: A placebo-controlled study. Am J Psychiatry 2003;160: 371-373

4. Raskind M, Calohan J, Peterson K, et al. Prazosin reduces trauma nightmares and severe sleep disturbance in soldiers deployed in Iraq. Mil Health Res Forum, MedScape Sep 3 2009.

5. Krakow B, Zadra A. Clinical management of chronic nightmares: Imagery rehearsal therapy. Behav Sleep Med 2006; 4: 45-70.

6. Krakow B, Hollifield M, Johnston, L, Koss, M, Schrader, R, Warner, T, et al. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: A randomized controlled trial. JAMA 2001; 286: 537-545.

7. Krakow, B, Johnston, L, Melendrez, D, Hollifield, M, Warner, T. D, Chavez-Kennedy, D, et al. An open-label trial of evidence-based cognitive behavior therapy for nightmares and insomnia in crime victims with PTSD. Am J Psychiatry 2001; 158: 2043-2047.

8. Lu M, Wagner A, Van Male L, et al. Imagery rehearsal therapy for posttraumatic nightmares in U.S. veterans. J Trauma Stress 2009; 22: 236-239.

9. Moore BA, Krakow B. Imagery rehearsal therapy for acute posttraumatic nightmares among combat soldiers in Iraq. Am J Psychiatry 2007; 164: 683-684.


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Report of the Fort Hood Massacre Findings Academy of Medical Psychology

The Academy of Medical Psychology investigated the Fort Hood massacre due the tragic death Major Eduardo Caraveo, PhD, a colleague and a prescribing medical psychologist. Dr. Eduardo Caraveo was killed attempting to “rush” Major Nidal Hasan in order to draw fire from Hasan to protect other unarmed mental health personnel. Hasan’s classmates during his psychiatric residency had questioned his competence as a psychiatrist and fitness for duty during his psychiatric residency long before his catastrophic treachery. Therefore, there was ample time for the Army to dismiss Major Hasan from the Army and possibly prevent his treasonable acts upon his unarmed comrades on the military base. Our investigation was not able to obtain sufficient information to rule on Hasan’s motivations for his acts. However, we were able to document that the shortage of psychiatric services in the armed forces increases the vulnerability of our troops to untreated Post Traumatic Stress Disorders (PTSD) incurred in military service. Therefore, our investigation focused on ways to provide necessary mental care for current and future military personnel. Nidal Hasan’s behavior deviated significantly from military and psychiatric protocols. Yet, Hasan was not discharged from the Army and was promoted Captain to Major in April 2009. Medical doctors are typically promoted to Major, as was Hasan, when they finish their medical training. Physicians, nurses, lawyers and chaplains are treated differently under Title 10 than other officers by the military officers classification codes. Hasan could have been discharged promptly had he been a line officer in the Infantry, Armored Divisions or even doctoral level medical psychologists, such as, Major Eduardo Caraveo, Ph.D. who provide health care services but are not listed Health Care Practitioners under Title 10. Military Officers, such as physicians, lawyers and chaplains, covered under Title 10, have several levels of appeal of discharge orders available to them that can prolong discharge actions for up to 2 years. Hasan had appealed to courts to try to avoid assignment to Afghanistan. If discharge was not used to remove an unsatisfactory officer, it can be asked, “Did the Army take any corrective measures regarding Hasan to assure patient safety and care?” We found that Hasan had been removed from patient care as a psychiatrist by assigning him to public health training where he could be de-classified as a Healthcare Practitioner under Title 10. This was judged as an attempt by military authorities to take corrective action within the Army system. This administrative measure was obviously insufficient and other measures are required. The Army and the Department of Veteran Affairs have actively recruited mental health personnel due to shortage of psychiatrists. There still remains a critical shortage of psychiatrists in the military. (See addendum - ed.) The Army has also created a psychiatric residency program at Walter Reed Army Hospital and the Bethesda Naval Hospital for graduates of the Uniformed Services University of Health Sciences (USUHS). But, obviously this is not enough to deal with shortage of psychiatrists if medical graduates, such as Nidal Hasan, are allowed to continue in the military.


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The Department of Defense (DoD) recognized the shortage of psychiatrists over 20 years ago. It established a training program for clinical psychologists already trained as mental health specialists to prescribe psychotropic medications. This program was initiated at USUHS and carried out at Walter Reed Hospital. This training in medical psychology taught psychologists to prescribe psychotropic medications safely and effectively in less time than required for medical doctors to complete their residencies in psychiatry. The DoD program in medical psychology was abandoned due to Congressional "budgetary cuts" and political pressure by the American Medical Association and the American Psychiatric Association to protect their professional interests. Nevertheless, 10 licensed clinical psychologists completed this DOD training program and demonstrated its success by prescribing safely and effectively during their military careers. The success of this DOD demonstration project in medical psychology is the least-costly model to overcome psychiatric shortages promptly in the military services! Clinical psychologists have been offering private postdoctoral training programs in psychopharmacology since 1993. It is estimated that over 1500 licensed clinical psychologists have been trained to prescribe psychotropic medications at their own expense. Two states have passed laws where psychologists with this special training in medical psychology can prescribe psychotropic medications for the mentally ill. The Academy of Medical Psychology was formed in 1998 to register clinical psychologists knowledgeable in psychopharmacology. The Academy then formed the American Board of Medical Psychology (ABMP) for its Board Specialty Certification for psychologists qualified in Medical Psychology who are trained in psychopharmacology and collaborate with primary care physicians in treating chronic health disorders and co-morbid mental conditions. Some ABMP Board Certified Medical Psychologists are presently employed in DoD hospitals to prescribe to military personnel with mental disorders.

Barriers to ending psychiatric shortages in the military The Academy of Medical Psychology has identified certain barriers must be overcome in order to deal with psychiatric shortages that have existed in the United States for the past 40 years. The primary barrier has been one of funding. A second obstacle has been archaic Federal Regulations and State Laws. The opposition of organized psychiatry to psychologists prescribing psychotropic medications has been a third issue. A fourth obstacle is the limited training in psychopharmacology in doctoral training in clinical psychology. Licensed psychologists already trained as mental health specialists still must pay for postdoctoral training in the Specialty of Medical Psychology out of their own earnings due to the lack of government funded residency programs such as those that are available in psychiatry. These barriers can be overcome promptly with the political will to solve the unaddressed mental health issues of our military and the nation due to the long-standing shortages psychiatrists. The Fort Hood massacre provides the emotional energy for the political will to resolve the shortage of mental health specialists that denies the military access to essential mental healthcare. The Academy of Medical Psychology offers the following actions to resolve psychiatric shortages in the military:


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1. Funding Post-doctoral training in Medical Psychology through Graduate Medical Education (GME) funding can effectively overcome to the shortage of psychiatrists. No additional funding is required. Redistribution of GME and other funds to Medical Psychology programs in primary care would accelerate the growing trend to integrate mental health specialists with Family Medicine at the training level. This would facilitate ongoing practice relationships between primary care physicians and medical psychologists in the management of nervous and mental disorders. This would also enhance the treatments of chronic diseases where co-morbid mental conditions are part of the necessary treatment.

2. Federal Regulations and State Laws

Federal regulations dealing with the practice of psychology have not kept pace with these developments in State Laws authorizing the practice of psychology for the treatment of mental conditions. Defining Medical Psychology as a specialty shortage category under Title 10 of federal regulations will provide essential mental health treatments in the military to deal with personnel shortages. State laws are not a barrier to Medical Psychologists prescribing in federally operated facilities. Federal laws supersede state laws in dealing with healthcare in publicly operated facilities. State statutes in Medical Psychology that authorize psychologists to prescribe medications appropriate for the treatment of their specialty are already in place in New Mexico and Louisiana. Several other states are introducing legislation for prescriptive authority (RxP) for psychologists.

3. Medical and Psychiatric opposition.

Medical opposition to psychologists with special training in psychopharmacology has subsided markedly with the advent of the newer psychiatric drugs that are commonly prescribed by non- psychiatric physicians. Primary care doctors are not trained in the newer mental health treatments and are routinely requesting collaborative assistance from psychologists for use of psychotropic medications and psychological treatments. Family physicians, especially, have already incorporated mental health as an integral part of their residency programs. Licensed clinical psychologists can be trained to prescribe safely and effectively in as short a time as one- year hospital based residency program. Training licensed clinical psychologists in psychopharmacology does not require even a three or four year training program. Even the DOD demonstration program did not require this length of time.

4. The value of expansion of psychopharmacology training in clinical psychology graduate curricula The events at Fort Hood can provide the fulcrum to make needed changes in training clinical psychologists. The Department of Defense and the US Public Health Service provide internship and postdoctoral training for psychologists in their hospitals and other facilities. These military services can institute training and experience programs in medical psychology in their hospitals and health facilities at minimal cost by following the model established by the American Board of Medical Psychology.


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Student loan reduction programs for those trained in Medical Psychology working in mental health shortage areas designated by the Health Resources and Services Administration (HRSA) could quickly eliminate these shortage areas. The Department of Veterans Affairs (VA) also provides funding for graduate training in clinical psychology. Funding for such training could be restricted to graduate programs that offer an expanded curriculum in psychopharmacology. Hospital services in primary care could then be expanded with new skills provided by Medical Psychologists.

Summary and Conclusions

The scope of the investigation of the Academy of Medical Psychology did not determine motivations of Nidal Hasan for his treacherous acts at Fort Hood. The Academy did find that the shortage of psychiatrists probably contributed to the massacre at Fort Hood because of the lack of dismissal of Hasan from military service. Further, we found that the shortage of psychiatrists unnecessarily exposes military personnel to greater vulnerability to Post Traumatic Stress Disorders because of lack of resources for treatment. We found that the Army is not responsible for its shortage of psychiatrists. However, the Department of Defense must take additional action to provide the full range of mental treatments in order to reduce this vulnerability of our troops. The Academy of Medical Psychology recommends the Department of Defense take the following actions to rectify its shortage of psychiatric personnel promptly:

1. Bolster DoD policies already in place by reallocation of existing GME funds to hire and train clinical psychologists in Medical Psychology under Title 10.

2. Use federal hospitals and facilities to implement the training and the

application of the skills of Board certified Medical Psychologists.

3. Integrate Medical Psychologists into primary care to serve a broader range of health conditions with co-morbid mental disorders.

4. Use the expanded role of Medical Psychologists under Title 10 in the military as

a model for training of clinical psychologists and serve as a recruitment inducement to overcome healthcare shortages in uniformed services.

Submitted 12-13-2010 Jack G. Wiggins, Secretary

Addendum (March 2011) Psychiatry has learned to live with its shortages since such shortages assure continued government funding for Graduate Medical Education (GME) training programs and keep bonus payments for psychiatrists in medical shortage areas. The federal Human Resources Service Agency (a required “interested government agency”) allows medicine to import foreign medical personnel trainees under “J-1” Waiver provisions of the foreign visitors program. Psychiatry uses J-1 waivers to fill 44% of its training slots and then qualify to be “doctors” in various states. Once these trainees are licensed in a state they are considered physicians eligible to provide services under Medicare and Medicaid regardless of academic training degree they may have received.

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