Medical Psychology: Definitions, Controversies, and New Directions PDF

 Chapter 1 MEDICAL PSYCHOLOGY Definitions, Controversies, and New Directions What’s in a name? —Juliet Capulet Bret A. Moore Mark Muse...

 Chapter 1 MEDICAL PSYCHOLOGY Definitions, Controversies, and New Directions What’s in a name? —Juliet Capulet Bret A. Moore Mark Muse The field of medical psychology includes the specialties of health psychology, reha- bilitation psychology, pediatric psychology, neuropsychology, and clinical psychophar- macology, as well as subspecialties in pain management, primary care psychology, and hospital-based (or medical school-based) psychology. Yet the term “medical psychol- ogy” is an umbrella term: it encompasses the multiple specialties that make up health- care psychology, embracing the biopsychosocial paradigm of mental/physical health and extending that paradigm to clinical practice through research and the application of evidenced-based diagnostic and treatment procedures. By adopting the biopsychosocial paradigm, the field of medical psychology has recognized that the Cartesian assumption that the body and mind are separate entities is inadequate, representing as it does an arbitrary dichotomy that works to the detri- ment of healthcare (Burns, Mueller, & Warren, 2010). The biopsychosocial approach reflects the concept that the psychology of an individual cannot be understood with- out reference to that individual’s social environment (Steele & Price, 2007). For the medical psychologist, the medical model of disease cannot in itself explain complex health concerns any more than a strict psychosocial explanation of mental and physi- cal health can in itself be comprehensive (Miller, 2010). Rather, the specialties that constitute medical psychology strive to integrate the major components of an indi- vidual’s psychological, biological, and social functioning and are designed to contrib- ute to that person’s well-being in a way that respects the natural interface among these components. The biopsychosocial paradigm (Engel, 1977)—or, more aptly, the psychobiosocial paradigm (LeVine & Orabona Foster, 2010)—argues not so much for the standard, multidisciplinary division of a person into discrete parts as for the integrated care of the whole person by a professional who is trained to assess and treat all these functional components within his or her specialty area. Indeed, the whole is greater than the sum of its parts when it comes to providing comprehensive and sensible behavioral healthcare. 1 c01.indd 1 07/03/12 8:06 AM  2 Medical Psychology DEFINITION OF MEDICAL PSYCHOLOGY The idea that psychologists should be allowed to integrate psychopharmacology and the principles of traditional behavioral science into their clinical practice has been met with considerable controversy. From the perspective of its proponents, progress toward this goal has been slow but steady. Over the past two decades, the debate over whether medication management should be within the purview of psychologists—that is, their right to have prescriptive authority—has taken place at professional conferences, in the pages of professional journals (Julien, 2011), before state boards of psychol- ogy and medicine, and within academic and legislative halls throughout the country. Although this debate has reflected mainly the opinions of organized psychiatry versus psychologists (Muse & McGrath, 2010a), it has not been exclusively so. One point of contention within professional psychology itself is how the term “medical psychol- ogy” should be defined, as well as which areas of applied psychology should have the right to adopt it. For example, Division 38 (Health Psychology) of the American Psychological Association (APA) has taken the stance that the terms “medical psychology” and “medical psychologist” should not be equated with prescriptive authority exclusively (American Psychological Association Division 38, 2010). In a position statement, Division 38 makes the case that the term medical psychology has a long history within the profession and has not been traditionally associated with the right of psychologists to prescribe medication. In agreement with the concern raised by Division 38 about use of the term medical psychology to mean exclusively the authority to prescribe medication, the Academy of Medical Psychology supports an inclusive definition, by which medi- cal psychology is viewed as a specialty within psychology that requires training at the postdoctoral level and utilizes the skills of professionals in clinical psychology, health psychology, behavioral medicine, psychopharmacology, and medical science. This point of view is most consistent with the definition put forth by Division 55 of the APA, the American Society for the Advancement of Pharmacotherapy, which states that “[medical psychology] is that branch of psychology that integrates somatic and psychotherapeutic modalities into the management of mental ill- ness, substance-use disorders, and emotional, cognitive, and behavioral disorders” (American Psychological Association Division 55, 2007). This view is also in keeping with the inclusive definition offered 30 years ago by Prokop and Bradley (1981) in the first cogent treatise on the subject entitled “Medical Psychology: Contributions to Behavioral Medicine.” Although these authors believed that medical psychol- ogy in the 1980s emanated primarily from psychologists housed within schools of medicine, they also foresaw the overlapping of various emerging disciplines, such as health psychology and behavioral medicine. Much of the concern of Division 38 and other specialties that have traditionally used the term medical psychologist stems from a recent legislative statute in the State of Louisiana in which the term refers specifically to those psychologists licensed by the Louisiana State Board of Medical Examiners to prescribe medications. This stat- ute builds upon the definition issued by the U.S. Drug Enforcement Agency (DEA), which recognizes that the term medical psychologist refers to a mid-level provider/ practitioner who has prescriptive authority. The DEA definition notwithstanding, the problem with legislating at a state level the exclusive use of the generic term “medi- cal psychologist” by those psychologists who can prescribe psychotropic medication is that it makes it illegal for other medical psychologists to use the term when referring to themselves within such a jurisdiction. In our opinion, this unfortunate consequence c01.indd 2 07/03/12 8:06 AM  Prescribing Medical Psychology and the Prescriptive Authority Movement 3 can be avoided by writing future prescriptive authority laws in such a way as to distin- guish those medical psychologists who prescribe from those who do not prescribe. PRESCRIBING MEDICAL PSYCHOLOGY Since the editors of this volume wish to highlight the integration of clinical psycho- pharmacology within the psychobiosocial paradigm of medical psychology, we will herein treat the field of medical psychology as a generic one, from which springs the discipline of prescribing medical psychology, and define it as follows: Medical Psychology is a postdoctoral specialty within applied psychology that integrates evidence-based psychological principles with medical science for the purpose of diagnosing and treating emotional, cognitive, behavioral, and psycho- somatic disorders. Pharmacologically trained medical psychologists can prescribe, in concert with psychobiosocial interventions, psychotropic medications or advise patients and other professionals about the use of such medication. Nothing in this definition prevents health, rehabilitation, or pediatric psycholo- gists or neuropsychologists, or any other subspecialty of psychology, such as pain management or primary care psychology, from using the term medical psychology or medical psychologist. The definition does, however, specifically identify a subgroup of medical psychologists who are competent in medication management. Such pro- fessionals are referred to here as “prescribing medical psychologists” and are under- stood to be engaged in the practice of prescribing medical psychology. In the editors’ view, the term prescribing medical psychology most aptly conveys the complexities of this emerging field and captures the rigors of training and clini- cal practice inherent in integrating psychopharmacology within the psychobiosocial model of health and disease. To refer to individuals who have been trained to be pro- ficient in managing psychotropic medications simply as “prescribing psychologists” does not do justice to their extensive instruction in all aspects of the psychobiosocial model. The individual chapters of this text cover each of the 10 content areas that constitute the subspecialty of prescribing medical psychology and attest to the com- plex integration of the sciences of psychology and medicine in the preparation of psychologists to prescribe medication. PRESCRIBING MEDICAL PSYCHOLOGY AND THE PRESCRIPTIVE AUTHORITY MOVEMENT Because of the broad scope of this subject and space constraints, it would not be prudent to offer a comprehensive review of the history of prescribing medical psy- chology and the prescriptive authority movement at this juncture.1 For our purposes 1 The biopsychosocial orientation within psychology has a long and continuous history. The experimental area of psychopharmacology dates back to Emil Kraepelin, a figure pivotal in bridging psychology and psy- chiatry, who completed studies on the effects of common psychotropic agents such as alcohol in Wilhelm Wundt’s psychophysics lab in the 19th century (Müller, Fletcher, & Steinberg, 2006). Early 20th-century psychopharmacologists, such as Harry Hollingsworth (Benjamin, Rogers, & Rosenbaum, 1991), were largely experimental psychologists (Schmied, Steinberg, & Sykes, 2006) who carried out double-blind trials c01.indd 3 07/03/12 8:06 AM  4 Medical Psychology here, it is more appropriate to highlight the core issues and arguments that propel prescriptive authority within the greater context of medical psychology. These essen- tial arguments illuminate the importance of medical psychology in general and pre- scribing medical psychology in particular, as well as the reasons why the profession of clinical psychology hinges on the success of this branch of clinical practice. PROFESSIONAL PSYCHOLOGY IN CRISIS Professional psychology—that is, the practical application of the science of psychol- ogy in the clinical domain—is in danger of becoming obsolete or obviated by other burgeoning professions such as clinical social work and professional counseling. This is due to a multitude of factors, including the shorter preparation time required for the latter groups to pursue their career, preferential contracting by third-party insur- ance because of the inherently lower costs/reimbursement rates for their services, and effective legislative lobbying by other behavioral health providers to gain competen- cies that once were reserved for psychologists. Clinical psychology can no longer hold itself out to the public as the sine qua non of psychotherapy. It is, quite literally, being overrun by competitors and ignored by payers. In the eyes of any accountant, this turn of events spells trouble. Clinical psychology has, indisputably, bona fide differences from other disciplines that offer behavioral health services; traditionally, these differences were founded on this discipline’s respect for science and evidence-based approaches, as well as on its development and practice of psychometric-based diagnostic techniques. Still, these differences are largely ignored by third-party payers whose business plan is based on reduced costs rather than on the excellence of a product or outcome. At the same time, large third-party insurers have shifted reimbursement and emphasis from psycho- therapy to psychiatric treatment (i.e., psychotropic medication) for an array of condi- tions that have traditionally been effectively managed with psychotherapy (Olfson & Marcus, 2010). Medical psychology, on the other hand, not only creates and applies evidence- based diagnostics and interventions, but it does so in an area of practice that is hard to replicate in disciplines with shorter career paths because of the extensive training needed to round out the practitioner in both the psychosocial realm and the biomedi- cal arena. It is the contribution of the medical psychologist in the areas of health, rehabilitation, primary care, and psychopharmacology/substance abuse that sets the profession apart from the typical psychotherapist, who is trained mainly, if not exclu- sively, in descriptive diagnosis (according to the Diagnostic and Statistical Manual of Mental Disorders —fourth edition [DSM-IV ]) and psychotherapeutic technique. It also involving different psychoactive substances, such as caffeine. Among the 20th-century academicians who contributed significantly during the early stages of prescribing psychopharmacology is the husband-and- wife team of Louis and Ann Marie Pagliaro (Pagliaro & Pagliaro, 1979, 1983, 1986, 1996, 1998a, 1998b, 1999a, 1999b). Clinical involvement of psychology in the practice of prescribing psychopharmacology began in 1986, when the Indian Health Service (IHS) trained a psychologist and granted him prescrip- tive authority (Jennings, 2010). More recently, pharmacologically trained psychologists have achieved autonomous status as psychobiosocial clinicians with the enactment of various state laws allowing for pre- scriptive authority and with the simultaneous recognition of prescribing competence for properly trained psychologists by various branches of the federal government, including the Department of Defense (DOD), the IHS, and the Department of Health and Human Services (DHHS) (Dittman, 2003). c01.indd 4 07/03/12 8:06 AM  Support for Prescriptive Authority 5 sets the prescribing medical psychologist apart from the contemporary psychiatrist (Carlat, 2010a), whose training is based preferentially on the medical model (with its emphasis on “bio”) and almost exclusively on the use of a single treatment modality (i.e., medication management). The addition of prescriptive authority to the arma- mentarium of the medical psychologist will result not only in better-integrated care for his or her clientele, but also in economic viability and solvency, which is the foun- dation of professional autonomy and sovereignty (Johnson, 2009). SUPPORT FOR PRESCRIPTIVE AUTHORITY Filling a Healthcare Gap Since psychologists began their efforts to incorporate pharmacotherapy into their treatment inventory, the main thrust of their endeavor has been to meet the needs of vulnerable populations. Whether they are treating the underserved (e.g., Native Americans), those in need of targeted and immediate care (e.g., veterans and active- duty military), or those who live in remote areas and are difficult to reach (e.g., resi- dents of rural and frontier communities), psychologists are acutely aware of the millions of people who either go without behavioral healthcare or receive substan- dard care (Moore, 2010; Moore & McGrath, 2007; Muse & McGrath, 2010b). Unfortunately, the practice of psychiatry has not adequately met the needs of the most vulnerable and underserved in the population. One need only look at the situ- ation in California to fully appreciate this deficiency. Recent testimony before the California Senate highlighted two alarming facts: approximately 20% of the counties have no practicing psychiatrists, and another 30% are served by five or fewer psychia- trists. As Romney (2007) pointed out, psychiatrists are fleeing remote practice areas in favor of urban and more financially lucrative settings. Although some prescribing medical psychologists may also choose to pursue positions in such settings, most are probably less likely to do so, since the facts show that (a) psychologists already out- number psychiatrists by about 4 to 1 in rural settings (Hartley, Bird, & Dempsey, 1999) and (b) over half the psychologists who have been trained in pharmacotherapy and are practicing in New Mexico and Louisiana are already serving disadvantaged patients. Improving Quality and Continuity of Care Proponents of prescriptive authority for psychologists believe that as the number of psychologists who can effectively integrate pharmacotherapy into psychobioso- cial interventions increases, quality of care will also increase. In one respect, this is due to increased access to care in general. Nonetheless, just as important is the fact that those psychologists who choose to add pharmacology training to their knowl- edge base will emerge as consummate mental health professionals. This is not meant to demean or dismiss the training of psychiatrists, physicians’ assistants, psychiatric nurse practitioners, social workers, professional counselors, or psychologists who are not trained in pharmacotherapy. It is, however, meant to highlight the breadth of skills offered by prescribing medical psychologists. Patients who consult a prescrib- ing medical psychologist receive integrated services—that is, diagnostic, consultative, and psychobiosocial care (including pharmacological treatment)—from a single pro- vider rather than fragmented services from multiple providers. Furthermore, the vast majority of prescriptions for psychotropic medications are currently written by non- psychiatric physicians (i.e., family physicians, internists) who have limited training c01.indd 5 07/03/12 8:06 AM  6 Medical Psychology in psychopharmacology and no training in evidence-based psychosocial treatments, so that as the number of prescribing medical psychologists increases, more effective behavioral health services will become inevitable. RECENT PROFESSIONAL ADVANCES IN PRESCRIBING MEDICAL PSYCHOLOGY Practice Guidelines Over the past decade, the specialty that integrates pharmacotherapy with psycho- biosocial interventions has undergone many positive changes. One of the most significant professional developments has been the establishment of practice guide- lines for pharmacologically trained psychologists. “Practice Guidelines Regarding Psychologists’ Involvement in Pharmacological Issues,” a document published in 2009 by the APA’s Division 55 Task Force on Practice Guidelines (APA, 2011), is the first attempt to address and clarify the professional and ethical issues faced by those psy- chologists who have incorporated psychopharmacology into their clinical repertoire, whether at the level of (a) actual prescribing of medication, (b) actively collaborating in medication decision making, or (c) providing general information. (See Table 1.1.) Clarifying a professional practice through the development of guidelines or standards is a necessary part of any applied area of psychology. In formulating the guidelines described above, Division 55 has provided a framework for the integra- tion of pharmacotherapy and psychobiosocial interventions as a distinct specialty instead of relying on professional practice guidelines designed for other disciplines, such as psychiatry, medicine, and nursing. Expanded Credentialing As of February 2009, each of three service branches of the U.S. Armed Forces (Army, Navy, and Air Force) had developed its own unique credentialing guidelines for pharmacologically trained psychologists. Although the credentialing section and the commanding general of each military treatment facility must authorize prescription privileges for each prescribing medical psychologist, clear guidance is available to assist them in making informed decisions. The credentialing of prescribing medical psychologists has also gained momentum in the U.S. Public Health Service, as well as in the Indian Health Service. In 2010, at least three psychologists were credentialed to provide psychopharmacological services to Native Americans at their respective service units, and Earl Sutherland became the first IHS prescribing medical psychologist to be granted a national DEA prescriber number, independent of the state-based DEA prescribing numbers issued in New Mexico and Louisiana. According to all estimates, the number of psychologists cre- dentialed to prescribe within the IHS should increase exponentially in the near future. SPECIALTY CERTIFICATION Another developmental milestone in the evolution of most areas of applied psychol- ogy is specialty certification. The Academy of Medical Psychology allows appro- priately trained psychologists to earn the distinction of “Board Certified Medical c01.indd 6 07/03/12 8:06 AM  Table 1.1 American Psychological Association Practice Guidelines Regarding Psychologists’ Involvement in Pharmacological Issues Relevant Activities Providing Prescribing Collaborating Information General Guideline 1. Psychologists are encouraged to con- X X X sider objectively the scope of their competence in pharmacotherapy and to seek consultation as appropriate before offering recommendations about psychotropic medications. Guideline 2. Psychologists are urged to evaluate X X X their own feelings and attitudes about the role of medication in the treatment of psychological dis- orders, as these feelings and attitudes can poten- tially affect communications with patients. Guideline 3. Psychologists involved in prescribing X X or collaborating are sensitive to the developmen- tal, age and aging, educational, sex and gender, language, health status, and cultural/ethnicity factors that can moderate the interpersonal and biological aspects of pharmacotherapy relevant to the populations they serve. Education Guideline 4. Psychologists are urged to identify a X X X level of knowledge concerning pharmacotherapy for the treatment of psychological disorders that is appropriate to the populations they serve and the type of practice they wish to establish, and to engage in educational experiences as appropriate to achieve and maintain that level of knowledge. Guideline 5. Psychologists strive to be sensitive to X X X the potential for adverse effects associated with the psychotropic medications used by their patients. Guideline 6. Psychologists involved in prescribing X X or collaborating are encouraged to familiarize themselves with the technological resources that can enhance decision-making during the course of treatment. Assessment Guideline 7. Psychologists with prescriptive author- X ity strive to familiarize themselves with key proce- dures for monitoring the physical and psychological sequelae of the medications used to treat psycho- logical disorders, including laboratory examinations and overt signs of adverse or unintended effects. Guideline 8. Psychologists with prescriptive X authority regularly strive to monitor the physi- ological status of the patients they treat with medication, particularly when there is a physical condition that might complicate the response to psychotropic medication or predispose a patient to experience an adverse reaction. (continued ) c01.indd 7 07/03/12 8:06 AM  8 Medical Psychology Table 1.1 (Continued) Relevant Activities Providing Prescribing Collaborating Information Guideline 9. Psychologists are encouraged to X X X explore issues surrounding patient adherence and feelings about medication. Intervention and Consultation Guideline 10. Psychologists are urged to develop X X X a relationship that will allow the populations they serve to feel comfortable exploring issues sur- rounding medication use. Guideline 11. To the extent deemed appropriate, X X psychologists involved in prescribing or collabo- rating adopt a biopsychosocial approach to case formulation that considers both psychosocial and biological factors. Guideline 12. The psychologist with prescrip- X tive authority is encouraged to use an expanded informed consent process to incorporate addi- tional issues specific to prescribing. Guideline 13. When making decisions about the X use of psychological treatments, pharmacother- apy, or their combination, the psychologist with prescriptive authority considers the best inter- ests of the patient, current research, and, when appropriate, the needs of the community. Guideline 14. Psychologists involved in prescrib- X X ing or collaborating strive to be sensitive to the subtle influences of effective marketing on pro- fessional behavior and the potential for bias in information in their clinical decisions about the use of medications. Guideline 15. Psychologists with prescriptive X authority are encouraged to use interactions with the patient surrounding the act of prescribing to learn more about the patient’s characteristic pat- terns of interpersonal behavior. Relationships Guideline 16. Psychologists with prescriptive author- X ity are sensitive to maintaining appropriate relation- ships with other providers of psychological services. Guideline 17. Psychologists are urged to maintain X X X appropriate relationships with providers of bio- logical interventions. Copyright © 2009 by the American Psychological Association. Reproduced with permission. The official citation that should be used in referencing this material is American Psychological Association Council of Representatives. (2009). Practice guidelines regarding psychologists’ involvement in pharmacological issues. Washington DC: Author. Available at www.apa.org/practice/guidelines/pharmacological-issues.pdf c01.indd 8 07/03/12 8:06 AM  Future Directions 9 Psychologist” if they are deemed eligible through a peer-review process. In addi- tion, in 2010, a committee of APA’s Division 55 applied to the American Board of Professional Psychology to have Clinical Psychopharmacology designated a spe- cialty. The American Psychological Association has also developed a strict procedure for reviewing and awarding official designation to postdoctoral training programs in clinical psychopharmacology (APA, 2009). At this writing, three university-based training progams have achieved APA designation in psychopharmacology: The M.S. Program in Clinical Psychopharmacology at Fairleigh Dickinson University, the Interdisciplinary Master of Arts in Psychopharmacology at Southwestern Institute for the Advancement of Psychotherapy/New Mexico State University (SIAP/NMSU), and the Clinical Psychopharmacology Postdoctoral M.S. Program at the California School of Professional Psychology. SUPPORT FROM PROMINENT PHYSICIANS To the consternation of organized psychiatry as well as some members of organized psychology, a number of prominent psychopharmacologists, psychiatrists, and non- psychiatric physicians have openly acknowledged their support of prescriptive author- ity for prescribing medical psychologists (Carlat, 2010b; Julien, 2011). It remains to be seen how quickly such support will help prescribing medical psychologists become accepted into the mainstream; however, at a minimum, sanction from respected indi- viduals in parallel camps does provide a degree of credibility. Moreover, when crit- ics within psychology who initially—and perhaps reflexively—opposed prescriptive authority (Heiby, 2010) take a less biased look at the training required for prescrib- ing medical psychology and its practice, they will begin to appreciate the rationale for promoting this new and inspiring movement. FUTURE DIRECTIONS Prescribing medical psychology is one of the most exciting and professionally relevant areas of psychology today. It has matured considerably over the past few decades and has the potential to shape the future of professional practice, not only with respect to the delivery of services to the traditional mental health population, but also within the medical setting, in which medical psychologists are becoming essential primary care providers (McGrath & Sammons, 2011). Prescribing psychopharmacology has created greater access to care for the most underserved and vulnerable of our society and is responsible for producing some of the most well-rounded health practitio- ners in the country. It is the editors’ hope that these trends will continue. With that in mind, the following three steps need to be taken if prescribing medical psychology is to advance. Dispense With the “Mid-Level Provider/Practitioner” Mentality To gain true parity among doctoral-level providers, those psychologists trained in psychopharmacology must dispense with the “mid-level provider/practitioner” mentality. For too long psychologists have been relegated to a status within health- care that does not recognize their skills and abilities. This is compounded 10-fold for prescribing medical psychologists. Accepting lower reimbursement rates from c01.indd 9 07/03/12 8:06 AM  10 Medical Psychology insurance companies and contract agencies, or agreeing to oversight by a physician when the state law doesn’t require it, may be the path of least resistance, yet it is a path that will eventually lead to a dead end. Be Professionally Honest No doubt some psychologists are interested in gaining prescribing privileges for rea- sons that are less than altruistic, and to ignore this fact is to risk the sincerity of those who wish to see this specialty develop and succeed. Proponents of prescribing psychopharmacology are concerned about the lack of timely and appropriate psy- chiatric services to the underserved and vulnerable, believing unequivocally that the power to prescribe is also the power to not prescribe or to unprescribe. Nevertheless, it would be counterproductive to dismiss claims by opponents of prescribing medical psychology that the financial incentive is what makes some psychologists pursue the goal of prescribing. The truth is that at some point prescribing medical psycholo- gists will be remunerated for their investment in training, their competence, and their service to society. Yet, keep in mind that, to date, approximately 1,500 prescribing medical psychologists have undergone training and have received little or no finan- cial reward (Ax, Fagan, & Resnick, 2009). In fact, the first generation of prescrib- ing medical psychologists invested considerable sums of money and many hours of training to pave the way for future psychologists who may, parenthetically, earn more than their contemporary colleagues who have opted for a shorter career path.2 There is no need to justify these outcomes, for they are laudable and reflect incen- tives found in every positive movement within society. The financial incentive for a psychologist to pursue training in prescribing medical psychology is no different from the financial incentive for a researcher to pursue research funding, for a stu- dent to choose a specialty track in a medical psychology specialty such as neuropsy- chology or health psychology, or for a clinical psychologist to enter private practice. Doing something valuable for society and doing something valuable for oneself are not mutually exclusive pursuits (Moore, 2010). Unify Resources Although the past decade has witnessed great strides in the area of prescriptive author- ity, one wonders how much more successful the granting of prescriptive authority would be had there been greater unity among those working to achieve this goal for the betterment of the field. Let us hope that the legendary turf battles between psychiatrists and psychologists do not foreshadow the rise of jealousies among factions of psycholo- gists. If not, perhaps we will end up being “our own worst enemies.” It may be inevita- ble that those who planted the flag—those first intrepid prescribing psychologists—will become the ones who work the hardest to defend the territory gained by limiting mobility of other qualified RxP psychologists. Alternatively, our specialty, which has been honed by the most courageous mental health professionals, might be in a posi- tion to address reciprocity for medical psychologists across juridicitions and in a variety 2 According to a recent survey of 17 prescribing medical psychologists in private practice in Louisiana and New Mexico, the “the medium income increase from a prescribing practice is minimally about $20,000 per year” (p. 9). LeVine, E., Wiggins, J., and Masse, E. (2011). Prescribing psychologists in private practice: The dream and the reality of the experience of prescribing psychologists. Archives of Medical Psychology, 2, 1–14. c01.indd 10 07/03/12 8:06 AM  Chapter 1 Key Terms 11 of federal venues, thus circumventing any tendency toward insular jurisdictions. Is it reasonable to limit the scope of practice of one’s fellow colleagues when they are fully qualified to exercise their competencies? Can organizations and groups more effectively work together for the common goal of expanding the reach of prescribing medical psychology? Maybe such questions are naïve, but they need to be raised. Let us hope that the answers will lead to a stronger, more committed group of providers. CHAPTER 1 KEY TERMS Academy of Medical Psychology: Membership organization that provides board certification, training, and advocacy for medical psychologists. American Society for the Advancement of Pharmacotherapy: Division 55 of the American Psychological Association (APA), having the primary purpose of enhanc- ing psychological treatments combined with psychopharmacological medications. Behavioral medicine: A broad, interdisciplinary approach dedicated to understanding physical health and illness through the knowledge and techniques of behavioral science. It seeks to address prevention, treatment, and rehabilitation of illness through incor- porating research and practices from psychology, psychiatry, sociology, epidemiology, anthropology, health economics, public health, general medicine, and biostatistics. Biopsychosocial paradigm: Healthcare approach that stresses the concept that bio- logical, psychological, and social factors all play a significant role in human func- tioning within the context of disease or illness. (See also Psychobiosocial paradigm.) Clinical psychopharmacology: Science and practice of utilizing pharmacological agents in addressing disorders of mood, sensation, thinking, and behavior. Drug Enforcement Agency (DEA) prescriber number: A number assigned to a health- care provider that allows him or her to write prescriptions for controlled substances. This number is used primarily to track patterns of prescribing and to ensure that only appropriate/qualified individuals are involved in prescribing such substances. Evidence-based practice: Preferential use of mental and behavioral health interven- tions for which systematic, empirical research has provided evidence of their statisti- cally significant effectiveness as treatments for specific problems. Health psychology: Area of applied psychology concerned with understanding how biological, psychological, environmental, and cultural factors are involved in physical health and the prevention of illness. Healthcare psychology: General term used to describe the application of clinical psy- chological services in the amelioration, elimination, or prevention of psychological, behavioral, and substance-use problems. Hospital-based psychology: Practice of psychology in a hospital or other medical set- ting (e.g., medical school). Medical model of disease: Traditional approach to the diagnosis and treatment of illness as practiced by physicians in the Western world. According to this model, the physician focuses on the defect or dysfunction within the patient, using a cause-and- effect diagnostic orientation and problem-solving therapeutic approach. Medical psychology: A postdoctoral specialty within applied psychology that inte- grates evidence-based psychological principles with medical science for the purpose c01.indd 11 07/03/12 8:06 AM  12 Medical Psychology of diagnosing and treating emotional, cognitive, behavioral, and psychosomatic dis- orders. Pharmacologically trained (prescribing) medical psychologists can prescribe psychotropic medications (in concert with psychobiosocial interventions) or advise patients and other professionals about the use of such medication. Mid-level provider/practitioner: Healthcare provider who is not a physician but is licensed to diagnose and treat patients, generally under the supervision of a physi- cian. This physician-driven definition is not accurate for medical psychology but is perpetuated by the DEA classification. Neuropsychology: Discipline within applied psychology that combines neurology, neuroscience, and psychology to study the relationship between the functioning of the brain, cognitive processes, and behavior. Pain management: Branch of clinical health science that employs an interdisciplinary approach designed to ease the suffering and improve the quality of life of those liv- ing with pain. A typical pain-management team includes medical practitioners, clini- cal psychologists, physiotherapists, occupational therapists, and nurse practitioners. Pediatric psychology: Discipline within applied psychology concerned with the phys- ical health and illness of children and the relationship of psychological and behav- ioral factors with health, illness, and disease. Practice guidelines: Systematically developed statements to assist practitioners and patients in making decisions about appropriate healthcare for specific clinical circumstances. Prescribing medical psychology: That subspecialty which adds pharmacotherapy to the array of psychobiosocial diagnostic and therapeutic approaches of medical psy- chology. (See Medical psychology.) Prescriptive authority for psychologists: Political effort to give prescribing rights to pharmacologically trained medical psychologists, enabling them to prescribe psycho- tropic medications to treat patients who have mental or emotional disorders. Primary care psychology: Discipline within applied psychology concerned with pro- viding healthcare and mental health services in the primary care setting. It includes the treatment and prevention of disease and the promotion of healthy behaviors in individuals, families, and communities. Psychobiosocial paradigm: Healthcare approach that is similar to the biopsychosocial model of healthcare delivery but places greater emphasis on the psychological aspect of human functioning within the context of disease or illness, especially mental health. Rehabilitation psychology: Discipline within applied psychology concerned with assist- ing a person who has an injury or illness (e.g., chronic, traumatic, and/or congenital) to achieve optimal physical, psychological, and interpersonal functioning. Chapter 1 Questions 1. The term “medical psychologist” is a legal/official term for which organization/ state/agency? a. New Mexico b. Louisiana c. Drug Enforcement Agency c01.indd 12 07/03/12 8:06 AM  References 13 d. Both b and c e. None of the above 2. What is the ratio of psychologists to psychiatrists in rural settings? a. 1 to 1 b. 2 to 1 c. 4 to 1 d. 10 to 1 e. 20 to 1 3. Which organizations have specific credentialing guidelines for allowing psy- chologists to prescribe? a. United States Army b. United States Navy c. United States Air Force d. Indian Health Service e. All of the above 4. Which of the following is not one of the reasons why some believe that the field of clinical psychology is becoming less relevant in healthcare? a. Lower reimbursement rates for providers with master’s degree b. Expansion of scope of practice by social workers and professional counsel- ors into roles traditionally occupied by psychologists c. Decline in training standards in psychology d. Resistance to prescriptive authority for psychologists Answers: (1) b, (2) c, (3) e, and (4) c. REFERENCES American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV ). Washington DC: Author. American Psychological Association. (2009). Designation criteria for education and training pro- grams in preparation for prescriptive authority: Approved by APA Council of Representatives. Washington, DC: Author. American Psychological Association. (2011). Practice guidelines regarding psychologists’ involvement in pharmacological issues. American Psychologist, 66, 835–849. American Psychological Association Division 38. (2010, January 23). Division 38 statement on the use of the term “Medical Psychology.” Retrieved from www.healthpsych.org/ MedPsych.cfm American Psychological Association Division 55. (2007, October 18). Minutes of Division 55 board meeting. Ax, R. K., Fagan, T. J., & Resnick, R. J. (2009). Predoctoral prescriptive authority training: The rationale and a combined model. Psychological Services, 6, 85–95. Benjamin, L., Rogers, A., & Rosenbaum, A. (1991). Coca-Cola, caffeine, and mental defi- ciency: Harry Hollingsworth and the Chattanooga trial of 1911. Journal of the History of Behavioral Science, 27, 42–55. Burns, D., Mueller, K., & Warren, P. (2010). A review of evidence-based biopsychosocial laws governing the treatment of pain and injury. Psychological Injury and Law, 3, 169–181. c01.indd 13 07/03/12 8:06 AM  Chapter 2 INTEGRATING CLINICAL PSYCHOPHARMACOLOGY WITHIN THE PRACTICE OF MEDICAL PSYCHOLOGY Mark Muse Bret A. Moore Integration is the defining characteristic of medical psychology,1 which purports to integrate the psychobiosocial2 aspects of human functioning within the diagnosis and treatment of mental health disorders, syndromes, and conditions. One aspect of the practice of medical psychology is clinical psychopharmacology, or the manage- ment of pharmacokinetics and pharmacodynamics in the treatment of psychologi- cal disorders. Clinical psychopharmacology is not engaged in as the sole approach or treatment within medical psychology but is integrated within multidimensional analyses of behavior and multimodal treatment strategies. Not only are the aspects of human psychology (e.g., behavior, cognition, affect), biology (e.g., genetics, age, sex, race, health/disease), and social context (e.g., family-gender-cultural/ethnic asso- ciations, political-economic environment) assessed and weighed for their respective influences on a given individual, they are also integrated within the medical psychol- ogist’s orientation and thinking, allowing a holistic approach to understanding and responding to the patient/client. When engaged in clinical psychopharmacology, the medical psychologist is aware of multiple factors (over and above any particular drug’s chemical makeup) that may contribute to a given patient’s response. For example, the family history may reveal inherited tendencies in patients with schizophrenia or bipolar disorder (Berrettini, 2000), and if a patient’s family member has previously responded positively to a par- ticular medication used to treat the same condition as the patient’s, one can predict with some confidence that this same drug can be safely and efficaciously prescribed to the patient (O’Reilly, Bogue, & Singh, 1994). 1 We support integration at the level of the individual practicing professional, as suggested by Daniel Carlat (2011), rather than the fragmented attempt at “integration” among professionals who practice piecemeal specialties. To us, the latter is a multidisciplinary rather than integrated approach. 2 While medical psychology currently emphasizes the psychobiological aspects of diagnosis and treatment, the social/cultural aspect of clinical analysis and intervention is also acknowledged and may become pro- gressively more important as evidence-based diagnostic and therapeutic strategies are developed in the areas of clinical anthropology, clinical sociology, and social-clinical psychology (McNally, 2011; Steele & Price, 2004; Rebach & Bruhn, 1991; Rush, 1996, 1999). To the extent that the science and the practice of clinical social interventions are developed, it will become incumbent upon medical psychologists to integrate this type of psychobiosocial intervention within their practice (McDaniel, Hepworth, & Doherty, 1992). 17 c02.indd 17 07/03/12 8:07 AM  18 Integrating Clinical Psychopharmacology Within the Practice of Medical Psychology Other factors that should be considered in determining the proper role of phar- macotherapy are the patient’s belief system (Makela & Griffith, 2003), social support structure, and economic and environmental situation (Roy et al., 2005). For example, the medical psychologist must weigh the benefits of treating a hospitalized patient with the latest, most expensive medication against that patient’s ability to afford the prescribed treatment after discharge. A homeless schizophrenic patient who becomes stable while being treated in the hospital with a costly drug that requires strict dose compliance and frequent laboratory monitoring will find it difficult to maintain this regimen upon returning to his or her former indigent lifestyle; a better option would be to initiate treatment in the hospital with a low-cost parenteral preparation that can later be administered and monitored once every 2 to 3 weeks (e.g., haloperidol decanoate, fluphenazine decanoate). In his writings, Morgan Sammons explicitly describes how medical psychologists can integrate treatment options for an array of emotional disorders by discerning whether it would be better to apply medication or psychotherapy as a stand-alone treatment or to combine the two modalities (Sammons & Levant, 1999; Sammons & Schmidt, 2001). Here are just three of his conclusions: 1. In the treatment of obsessive-compulsive disorder (OCD), research indicates that a single-treatment modality (behavioral therapy) is more effective than a combination-treatment modality (medication-behavioral therapy) when symp- toms are primarily compulsive, whereas the reverse is true when symptoms are primarily obsessive. 2. For most other conditions, single-treatment modalities should be attempted before combined treatments are implemented. 3. Not all single-treatment approaches are equal: For example, pharmacotherapy is less effective than psychotherapy as a single-treatment approach when treat- ing a patient who has chronic depression with an Axis II disorder. Contemporaneous with Sammons’ work has been Robert Julien’s effort to ferret out differential indications for drug therapy versus talk therapy in his seminal book A Primer of Drug Action, now in its 12th edition (Julien, 2005; Julien, Advokat, & Comaty, 2011). Among Julien’s conclusions regarding the integration of psychotherapy with pharmacotherapy are the following: 1. In the treatment of phobias (e.g., agoraphobia, simple phobia, and social phobia), cognitive-behavioral therapy (CBT) is more consistent than medications and pro- vides longer-lasting effects; 2. In the treatment of obsessive-compulsive disorder, posttraumatic stress disor- der (PTSD), and generalized anxiety, medical and behavioral approaches are equally effective; 3. Psychotherapy (cognitive-behavioral) and medical therapy (selective serotonin- reuptake inhibitors [SSRIs], tricyclic antidepressants, benzodiazepines, and monoamine oxidase inhibitors) are equally effective in the acute treatment of panic disorder, but in this case combining behavioral therapy and medication is superior to either of these monotherapies; 4. In the treatment of major depression, CBT and antidepressant medication are equally effective and display additional efficacy when combined; and 5. In the treatment of eating disorders, CBT is superior to an SSRI. c02.indd 18 07/03/12 8:07 AM  Integrating Clinical Psychopharmacology Within the Practice of Medical Psychology 19 Prior to the work of both Sammons and Julien, attempts by other investigators to answer the question of when to medicate, when not, and when to combine medi- cation with psychosocial interventions drew equivocal results with conflicting conclu- sions (Weissman, 1981). Fisher and Greenburg (1989) noted what they considered to be an overreliance on drug therapy and concluded that in many of the studies they reviewed the practice of adding medication to psychotherapy yielded no improve- ment in outcomes. In a later book, Fisher and Greenburg (1997) further argued that pharmacological agents in the treatment of mental disorders are, in general, no more effective than placebo. More recent arguments have been proposed to explain phar- macotherapy’s positive clinical results (Moncrieff & Cohen, 2009) by considering psychotropic drugs as nonspecific agents, reminiscent of the common factors theory explanation of psychotherapeutic effectiveness (Imel & Wampold, 2008). These agents induce a complex, global response, analogous to the pervasive healing effect of empathy as a nonspecific agent across psychotherapies (Riess, 2010), thus yielding a sense of subjective improvement. The fact that most psychotherapies are of equal efficacy when compared in meta- analyses—the so-called Dodo-bird effect (Wampold et al., 1997)—has led to a search for possible underlying mechanisms, one of which is described in the Wampold hypothesis (Sammons, 2010). This view is contrary to the reigning biological para- digm, which assumes that each psychiatric condition has a specific underlying neuro- logical mechanism and that drugs are effective because their respective mechanisms of action differentially address specific imbalances inherent in the disorder being treated. In contrast to this strict biological model, the alternative view suggests that whether one treats depression with norepinephrine or serotonin, cognitive-behavioral or psychodynamic therapy, or pure placebo, it is the interpersonal relationship with a provider and the patient’s ensuing expectation for positive change that is largely driv- ing improvement, aided somewhat by the nonspecific psychobiosocial effect inherent in all these treatment approaches. This new line of reasoning complements Stanley Schachter’s earlier, experimentally derived two-factor theory of emotion (Schachter, 1964; Schachter & Singer, 1962), in which the observer (patient) derives specific meaning from general subjective emo- tional arousal according to the context in which it occurs. Thus, a specific antidepres- sant effect might be attributed to SSRIs because it is present when a patient taking these drugs recovers from depression, although a more parsimonious interpretation might be that most therapeutic agents effect positive subjective changes regardless of the specific intervention employed or the condition being treated. On the other hand, other investigators have proposed differential recommenda- tions for specific disorders.3 In one of the earliest studies on combining treatment modalities, Hogarty, Goldberg, & Schooler (1974) concluded that a combination of medication and psychosocial interventions prevented relapse in schizophrenic patients. Rush and Hollon (1991) suggested that pharmacotherapy, cognitive ther- apy, or a combination of both was equally effective in treating nonbipolar and nonpsychotic depression, while pharmacotherapy appeared to be indispensable in 3 Although not a comparison of different biopsychosocial therapies, one meta-analysis of studies of phar- macotherapy in patients with personality disorders may be of interest here. Duggan, Huband, Smailagic, Ferriter, and Adams (2008) acknowledge serious methodological limitations to their study, but after reviewing 35 trials that focused on the use of various drugs to treat a limited sampling of personality disorders, they concluded that anticonvulsants appear to reduce aggressive behaviors while antipsychotics reduce emotional volatility in patients with predominantly borderline personality disorder. c02.indd 19 07/03/12 8:07 AM  20 Integrating Clinical Psychopharmacology Within the Practice of Medical Psychology treating bipolar disorder and major depression with psychotic features. With respect to agoraphobia, Mavissakalian (1991), on reviewing six contemporary studies, found that imipramine tended to be as effective as exposure therapy in treating panic, whereas exposure approaches are somewhat more effective in treating phobic behav- ior; a combination of both approaches appeared to offer some advantage in the treatment of patients who had panic disorder with phobic avoidance. Nevertheless, approximately one fourth of patients who experienced agoraphobia responded equally well to placebo, where about one fourth did not respond to the combination of both pharmacotherapy and exposure psychotherapy. Mavissakalian also indicated that the sequencing of pharmacotherapy—initially for 8 weeks, followed by 16 weeks of imipramine plus exposure therapy—tended to enhance the initial effect achieved with drug treatment alone. Large-scale studies, as well as expert consensus projects such as the TMAP (Kashner et al., 2003), have attempted to shine light on the specific impact of vari- ous treatment interventions on particular disorders. Examples of such trials are the STAR*D (Fava et al., 2004; Gaynes et al., 2005) and STEP-BD (Kogan et al., 2004; Sachs et al., 2003) trials conducted by the National Institute of Mental Health (NIMH); the TADS; the CATIE (Lieberman et al., 2005); the CUtLASS (Jones et al., 2006); and the MTA (MTA Cooperative Group, 1999a, 1999b)—all of which are discussed in detail later in this chapter under “Major Studies and Algorithms.” Although subtle differences among treatments have been detected, the fact that no substantial, clinically significant differences were found is more impressive. Although the use of combined therapies has long been assumed to be the gold standard in psychiatric treatment (Conte et al., 1986; Kraly, 2006; Riba & Balon, 2005), Beitman and Blinder (2003) more recently revised such thinking by propos- ing that combined therapies are not necessarily more effective than their constituent monotherapies and should therefore be avoided, unless specific evidence of their com- parative effectiveness outweighs the additional cost and potential for an increase in negative side effects (Healy, 2004) of combined treatments. Notwithstanding the undisputed benefits of pharmacotherapy in a subset of disorders, including bipo- lar disorder, schizophrenia, and major depression with psychotic features, psycho- therapy, in addition to its being indicated as a stand-alone approach in an array of other conditions, is generally helpful in supporting the use of medication, since it tends to improve overall compliance (Guo et al., 2010). More to the point, according to Beitman and Blinder (2003), monopsychotherapy has been shown to be effective in patients with major (nonbipolar) depressive disorder, dysthymia, panic disorder, obsessive-compulsive disorder, social phobia, generalized anxiety disorder, bulimia, and primary insomnia; we might suggest that adding medication to the treatment of these conditions is best reserved for those cases in which the potential for side effects is justified by the lack of adequate response to psychotherapy. In mild-to-moderate depression, combined therapy adds little, whereas in severe depression, a combina- tion of medication and psychotherapy appears to increase positive outcomes. In summary, Beitman and Blinder found that the following specific treatments were preferable for particular conditions: family therapy for major depression, CBT for bulimia nervosa, CBT with occasional antidepressant medication for panic disorder, and behavioral exposure for obsessive-compulsive disorder. Previous research has raised many questions that only recently have yielded answers, with the potential for directing clinical practice. The most recent research (Fournier et al., 2009) indicates that patient variables may influence outcomes within diagnostic categories; for example, if a patient is married, unemployed, or experiencing c02.indd 20 07/03/12 8:07 AM  Integrating Clinical Psychopharmacology Within the Practice of Medical Psychology 21 significant life events, cognitive therapy is likely to result in a better response than anti- depressant medication would be for treating moderate or severe depression. Also, the severity of a given condition such as depression may determine whether there is any advantage at all to medication rather than placebo (Fournier et al., 2010). Similarly, recent findings point out the subtle interference of medication on the long-term effect of psychotherapy. For example, in the case of sleep disorders, the intermittent use of zolpidem in conjunction with CBT for chronic insomnia (Morin et al., 2009) tends to reduce the effectiveness of CBT, which is more effective sin- gly than when “aided” by as-needed (pro re nata, or PRN) medication. When one attempts to determine the usefulness of combining therapies for the treatment of depression, however, contradictory findings continue to be the theme. March and Vitiello (2009), for example, indicate that the combination of CBT and fluoxetine is superior to the use of either of these agents singly in adolescents with severe to mod- erate depressive disorders, whereas Kocsis and colleagues (2009) found no advantage to adding psychotherapy to pharmacotherapy for the treatment of chronic depres- sion, and Blier et al. (2009) found that combining fluoxetine with a second antide- pressant medication was more effective than fluoxetine alone. Indeed, combining multiple medications has become increasingly common, but there is scant evidence that such polypharmacy provides superior results. Mojtabai and Olfson (2010) con- clude that these trends “put patients at increased risk of drug–drug interactions with uncertain gains for quality of care and clinical outcomes” (p. 26). Dobson et al. (2008) have pointed out the importance of psychotherapy’s effectiveness beyond the treatment stage; in their study, patients who were treated with CBT until remis- sion were only about half as likely to relapse following termination of therapy than patients who were treated with medications until remission. Studies in attention deficit–hyperactivity disorder (ADHD) tended to con- firm the effectiveness of analeptic medication in ameliorating behaviors such as distractedness and hyperactivity, but combination therapy is consistently found to be superior to monopharmacotherapy (Jensen et al., 2005); yet uniformity is lack- ing with respect to how medication effectiveness is assessed across studies (Faraone et al., 2006), and bias can be ruled out only when variability in study design is more adequately controlled. On the other hand, recent research has indicated that behav- ioral approaches are unequivocally effective in treating Tourette’s syndrome and appear to be as effective as medication (Piacentini et al., 2010). Apart from clinical research into the differential use of various biopsychosocial interventions in the treatment of emotional distress, psychosocial orientations promul- gate theoretical considerations that question the appropriateness of across-the-board medication as first-line treatment in the majority of mental health cases (Crystal et al., 2009). Such theoretical stances propose that there are genuine life issues involved in most cases of emotional disturbance and that it is best to treat the disturbance through resolving the issues rather than suppressing symptoms. It is the patient’s adjustment to life issues, intrapersonal as well as interpersonal, that defines positive change, and the improvement of symptoms reflects this growth process, which is more likely to occur when the precocious suppression of symptoms by psychotropic drugs has not preempted personal adaptation. A symptom of anxiety does not necessarily imply an anxiety disorder, just as there is a functional side to nearly all emotions (May, 1950), and many symptoms of distress have an adaptive value that can be lost if elimi- nating symptoms is the only clinical goal in the rush to eradicate a “disorder.” The trend over the last 10 to 15 years has been to increase the role of psycho- tropics for the suppression of symptoms while reducing the role of psychotherapy c02.indd 21 07/03/12 8:07 AM  22 Integrating Clinical Psychopharmacology Within the Practice of Medical Psychology (Olfson & Marcus, 2010). Medical management alone, however, is far more likely to treat symptoms alone without delving into their cause, not only because medica- tions are aimed at symptoms but because they are, by and large, prescribed by clini- cians other than mental health professionals (Mark, Levit, & Buck, 2009) who have little or no expertise in evaluating a case beyond the presenting problem (Muse & McGrath, 2010). In contrast to prescribers who are not mental health professionals and to psychiatrists who have specialized in pharmacotherapy to the relative aban- donment of psychotherapy (being “motivated by financial incentives and growth in psychopharmacological treatments in recent years” [Mojtabai & Olfson, 2008]), the medical psychologist who can integrate multimodal evaluation and treatment when caring for a patient with an emotional disorder is more likely to concede that a cer- tain amount of “distress” will tend to motivate that patient to make the effort needed for growth. Premature suppression of emotional symptoms runs the risk of delaying or aborting personal adaptation through new learning. When seen in this light, dis- comfort is a requirement for therapeutic change (Rogers, 1961). Although we have limited our discussion here to psychotherapy, the larger ques- tion concerns the use of psychosocial interventions (with psychotherapy being a sub- set of such interventions) versus pharmacotherapy and how these two approaches are best integrated. Another question in the same vein is whether medication can, by its nature, ever be a stand-alone treatment or whether it should be an integral part of psychosocial interventions. Unless a drug is dispensed from a vending machine, with no human contact involved, there is bound to be some form of engagement between the patient and the dispensing professional. Such rapport is the basis of most psy- chotherapy (Wampold, 2001). How, then, can the true, stand-alone effectiveness of a drug ever be measured when its use is inevitably bound up with the expectations, possible placebo effects, and transference issues inherent in the patient-professional relationship (Busch & Sandberg, 2007; Norcross & Goldfried, 2003)? A related issue is that of the temporal nature of any research findings, findings which give the impression that even substantiated trends discovered today may be ephemeral, and vanish with time. Case in point is the fact that placebo effect is grow- ing within the present mental health treatment zeitgeist (Silberman, 2009), with pharmacological agents acquiring increasing potency as people have come to expect more from them through massive advertisement campaigns that “sell” the product. If the present “biological explanation” of emotional disorders, with its implied need to medicate, were to fall into disrepute or relative disuse (that is, if psychotherapy were to become more popular for whatever reason), some of the research discoveries about the relative effectiveness of one treatment over another may flip, as the pla- cebo effect associated with drugs decreases as a result of generalized skepticism and, perhaps, a parallel re-engendered belief in psychotherapy invests the psychosocial modality with greater placebo. One approach to circumventing such culturally determined fluctuations in the placebo effect is rooted in the relative immutability of established principles of learn- ing and the application of conditioning for therapeutic effect. Medical psychologists are in a unique position to integrate the effect of conditioned learning that parallels the dispensing of medication so as to reinforce desired therapeutic directions by inte- grating pharmacotherapy within the behavioral principles of learning. Not only does this create a synergistic therapeutic intervention that enhances the effectiveness of pharmacologic agents, it reduces the acquisition of learned, undesirable secondary effects. Consider these examples of potential applications of behavioral principles in the administration and management of pharmacotherapy: c02.indd 22 07/03/12 8:07 AM  Summary 23 In chronic pain syndromes, behavioral therapy (Wolpe, 1969) and behavior modification (Skinner, 1974) can be reinforced by pharmacotherapy within the operant paradigm for motivating patient compliance and efforts toward reha- bilitation (Fordyce, 1976). Medication schedules can be managed to avoid positive and negative reinforcement contingencies that promote reliance on and addiction to analgesics (Muse, 1994). The medication effect can be used as an unconditioned response for pairing with the conditioned stimulus within the respondent paradigm for countercon- ditioning of phobias (Muse, 2007). Aversive substances can be employed as unconditioned stimuli in pairings with the conditioned response of sexual arousal to achieve a Garcia effect–like extinction in the treatment of pedophilia (Muse, 1999; Muse & Frigola, 2003). A drug-induced, state-dependent learning paradigm can be enlisted to acceler- ate relearning in PTSD (Muse, 1984). Drug therapy can be prescribed as an initial mitigator of subjective units of dis- tress (SUDs) attached to hierarchical items in the systematic desensitization of severe vaginismus (Muse, 2010a). The placebo effect, thought to account for about 70% of the response to anti- depressant medications (Rief et al., 2009), can act as a booster in stalled stages of psychotherapy to reinforce previous efforts and to facilitate renewed positive expectations in the patient-professional relationship. SUMMARY Table 2.1 summarizes what has been covered thus far in our review of past and pres- ent attempts to devise differential interventions in the treatment of psychological conditions to achieve optimal results. This summary is not intended for use by the medical psychologist as a decision tree or algorithm when formulating treatment rec- ommendations; it has been designed merely for heuristic purposes to illuminate trends apparent in the myriad results of research. Clearly, it does not take into account patient variables (e.g., gender, age, race, or ethnicity) or transient contributory factors (e.g., life events), nor does it address the issue of integrating reinforcement contingen- cies of behavioral therapy within pharmacotherapy. In short, Table 2.1 represents all the current limitations inherent in the attempt to force generalized treatment recom- mendations into the dichotomous choice between “drugs” and “therapy.” Major Studies and Algorithms In order to make heads or tails out of the vast array of treatment options available in the field of mental health, it is incumbent upon the medical psychologist to keep abreast of developments in the science of psychology, as well as to remain current in the field of clinical psychopharmacology. This is not a small task, and for this reason continuing education is far more extensive for medical psychology than for any other subspecialty within applied psychology or perhaps even medicine. To analyze the studies available, medical psychologists must draw upon their expertise in research and consult primary resource material whenever possible. Each study—whether it be a meta-analysis, a randomized clinical trial, or a case study in the area of psychopharmacology (Muse, 2010b)—has the potential to provide the c02.indd 23 07/03/12 8:07 AM  24 Integrating Clinical Psychopharmacology Within the Practice of Medical Psychology Table 2.1 Monotherapy Versus Combined Therapy in Psychobiosocial Treatment of Mental Health Conditions Research 1. Medication efficacy is hard to calculate, since the greater part of a drug’s effect is placebo. This placebo effect also accounts for the greater part of psychotherapy’s effect and appears to be culturally bound, thus fluctuating over time as a function of cultural beliefs. 2. Research designs have been inadequate in identifying and separating out effects of medica- tion and psychotherapy on various disorders. 3. Side effects of medication, which are demonstrably greater than with psychotherapy, are not adequately weighed as (negative) outcomes in research that compares this modality with psychotherapy. Treatment 1. Medication is important (albeit not always effective/efficacious) in: a. Treating positive signs of schizophrenia, with clozapine preferred for treatment-resistant symptoms. b. Treating mania in bipolar disorder. c. Treating depression with psychotic features. d. Treating attention deficit–hyperactivity disorder (ADHD), especially the hyperactive type. 2. Medication is of comparable importance to psychotherapy (no better outcome) in: a. Treating major depression. b. Treating depressive end of bipolar disorder. c. Treating panic disorder. d. Treating Tourette’s syndrome. 3. Medication is of secondary importance to psychotherapy (poorer outcome) in: a. Treating negative signs of schizophrenia (second-generation antipsychotics no more effective than first-generation in treating negative symptoms). b. Treating depressions other than major depression (adjustment disorder, depression not otherwise specified [NOS]). c. Treating obsessive-compulsive disorder. d. Treating eating disorders. 4. Medication is generally not indicated (interferes with more effective psychotherapy) in: a. Treating simple phobias. b. Treating dysthymia. c. Treating chronic insomnia. 5. Combining both medication and psychosocial therapy might be indicated for: a. Schizophrenia, in which neuroleptics are augmented with systemic, family, or milieu therapy for overcoming the poor social integration involved in negative symptoms and for reducing discontinuation of therapy. b. Bipolar disorder with hypomania/mania, in which mood stabilizers are augmented by cognitive-educational approaches intended to help the patient gain insight into the advantage of medication compliance. c. Major depression, especially with adolescents, in which medication is augmented by cognitive-behavioral therapy (CBT) approaches in an effort to increase engagement and activity level. d. ADHD, in which analeptic medication is paired with CBT approaches aimed at time management, impulse control, and executive functions. e. Panic disorder, in which CBT approaches emphasize tolerance of anxiety while selective serotonin-reuptake inhibitors (SSRIs) raise the threshold for manifest panic. f. Obsessive-compulsive disorder with a strong obsessive component, in which obsessive symptoms may be adjunctively treated with SSRIs or tricyclic medication while compul- sive components are simultaneously treated with behavioral approaches. c02.indd 24 07/03/12 8:07 AM  Summary 25 Table 2.1 (Continued) Limitations 1. Current research is dominated by attempts to match diagnosis with treatment modality, paying little attention to subject variables and life event interplay. 2. Little research has been done to optimize the behavioral administration of medications in an effort to integrate medication into behavioral approaches. 3. CBT is overrepresented in controlled studies, leading to the question of how effective are psychosocial interventions in general when only a limited sampling of such interventions is compared to placebo and medication. 4. The medical model has emphasized symptom reduction, reducing the value of emotional distress as a motivator for therapeutic change. Conclusions 1. Medication is overused in medical practice, given its limited efficacy, its potential for del- eterious effects, and the availability of alternative psychosocial treatments of proven value with significantly less side effect profiles. 2. Much more research is needed in the differential effects of medication and psychotherapy on various diagnoses, patient populations, and presenting/underlying life issues before specific, empirically based, authoritative statements can be made with any degree of confidence as to which treatment or combination of treatments might be preferentially recommended. Table adapted from Muse (2010a). key to treating a group of patients or, indeed, a particular individual. With an esti- mated 10,000 randomized, controlled trials being published every year (DeLeon, 2010), the practicing clinician can never commit all relevant studies to memory; therefore, an essential part of the practice of medical psychology is to cultivate the habit of both consulting and revisiting the literature on an ongoing basis, while also relying on certain landmark studies as general points of reference. Major studies that have been particularly influential in the field of clinical psychopharmacology should be familiar to the medical psychologist and should serve as a general knowledge base. By the same token, certain algorithms may prove useful as guides when one is faced with the complex task of tailoring treatment to specific patients (Fawcett et al., 1999). Several of these major studies and algorithms are summarized in Table 2.2 and are discussed next.4 STAR*D Study (Sequenced Treatment Alternatives to Relieve Depression) This NIMH-funded study was the largest and longest study ever conducted to deter- mine the effectiveness of different treatments for patients with major depression. Over a period of 7 years, the researchers enrolled more than 4,000 outpatients, 18 to 75 years of age, who had not responded to initial therapy with an antidepressant. The study was carried out by psychiatrists and primary care physicians in both pri- vate practice and public clinics to reflect the treatments patients typically receive in community settings. This was not a true randomized study with control groups; 4 One large study worth mentioning, but perhaps not as influential as those cited in Table 2.2, is the SMILE (Standard Medical Intervention and Long-term Exercise) study (Hoffman et al., 2011) in which 202 sedentary adults with major depressive disorder were randomly assigned to either sertraline or aerobic exercise. At the end of this 4-month study, as well as at the 1-year follow-up, antidepressant medication and exercise both proved to be effective but neither was superior to the other. c02.indd 25 07/03/12 8:07 AM  26 Integrating Clinical Psychopharmacology Within the Practice of Medical Psychology Table 2.2 Summary of Medication Efficacy in Large Studies and Algorithms In the STAR*D study, medication efficacy in treating major depressive disorder in adults ranged from about 1/3 to 1/4 to 1/5 for each of three successive attempts; a fourth attempt with treatment-resistant nonresponders yielded a remission rate of less than 10%. With multiple medication switches or augmentation, the cumulative remission rate increased to approximately 60% overall; 40% remained nonresponders, despite up to four successive medication trials. For depressed persons who failed to respond to an antidepressant in the first trial, adding cognitive therapy resulted in the same probability of remission as did switching from one antidepressant medication to another. In the STEP-BD study, treatment-resistant bipolar patients did not significantly improve when lamotrigine, inositol, risperidone, or antidepressant medication was added to a mood stabilizer, whereas patients who received psychotherapy in addition to medication showed enhanced treatment outcomes for bipolar disorder. In the TADS study, short-term efficacy in treating depression in children and adolescents was greatest for combined therapy (fluoxetine plus cognitive-behavioral therapy [CBT]) than for either pharmacotherapy or psychotherapy alone. In the long term, combination therapy and CBT monotherapy proved more effective than fluoxetine alone, with CBT somewhat superior to combination therapy on measures of sustained improvement. In the CATIE and CUtLASS studies, no difference in efficacy was observed between the newer atypical antipsychotic agents and the older neuroleptics, and patients with schizo- phrenia were relatively noncompliant regardless of which antipsychotic was prescribed. Clozapine was found to be more efficacious than other second-generation antipsychotics in treatment-resistant subjects in the CUtLASS-2. In the TMAP, some evidence has been presented that treating certain groups of patients according to an algorithm may lead to better recovery results than relying on practitioners’ individual decision-making without the structure of consensually developed algorithms. In the MTA study of children with attention deficit–hyperactivity disorder (ADHD), chil- dren placed on medication, either alone or in combination with behavioral approaches, initially showed greater improvement than those treated with behavioral approaches or commuity-based support alone. However, long-term follow-up indicated that medication differences were no longer significant at 3 and 8 years after the initial treatment. In the SOFTABS on adolescent depression, the great majority of patients recovered from depression within 2 years, yet half of those suffered a relapse within 5 years. Recurrent rates for female adolescents were greater than for male adolescents. In the GLAD-PC Guidelines for treating adolescent depression in the primary care setting, the expert panel recommended, among other things, that interviews be augmented with standard questionnaires, treatment be based on a collaborative relationship and include evidence-based treatment protocols, and referral be made to mental health professionals as needed, with follow-up reassessment and encouragement to work with these professionals. indeed, there were no placebo conditions, and patients were allowed to choose among treatment modalities, although the medications within each treatment cate- gory were randomly assigned. Four levels of treatment were used, and treatment at each level could continue for up to 14 weeks. All participants began at Level 1, and were treated with citalopram. Participants who did not become symptom-free or who could not tolerate side effects from citalopram were encouraged to progress to the next level (Level 2), where new treatment choices would be available. Level 2 offered seven different treatments; four of these options “switched” the citalopram participants to either a new medication or talk therapy, and the other three options “augmented” citalopram treatment by adding a new medication c02.indd 26 07/03/12 8:07 AM  Summary 27 or talk therapy to the citalopram they were already receiving. If participants pro- gressed to Level 2, they agreed to have their treatment selected randomly from among the approaches available. Those who joined the “switch” group were randomly assigned to sertraline, bupropion-SR, or venlafaxine-XR, while those who joined the “add-on” group were prescribed either bupropion-SR or buspirone. Participants could also switch to, or add on, cognitive psychotherapy. In Level 3, participants again had the option of either switching to a different medication or adding on to their existing medication. Those who chose to switch their medication were randomly assigned to either mirtaza- pine or nortriptyline for up to 14 weeks. In the Level 3 add-on group, participants were randomly prescribed either lithium or triiodothyronine (T3) to add to the medication they were already taking. Finally, in Level 4, participants who had not become symp- tom-free in any of the previous levels were taken off all other medications and randomly switched to one of two treatments: tranylcypromine or the combination of venlafaxine and mirtazapine. After each level, those participants whose depression did not respond to the treat- ment were encouraged to go on to the ne