Date: May 9, 2019 at 8:11:49 AM GMT-3
To: "Pat" <patdeleon@verizon.net>
Subject: Division 55 column
LOOKING BACK -- MOTIVATION FOR MOVING FORWARD
In September, 1985 APA published A Women's Mental Health Agenda, under the editorship of Nancy Felipe Russo, following up on a conference to assess the status of women's mental health needs, identify priority areas, and create an interdisciplinary network to facilitate implementation of their recommendations. Participating in the conference were former APA Presidents Florence Denmark and Bonnie Strickland; as well as Angie McBride, a nurse-psychologist who served as Dean of the Indiana University School of Nursing and is one of nursing's Living Legends. Those interested in psychology's prescriptive (RxP) authority quest should seriously consider whether significant progress has really been made in our nation's mental health delivery system over the past three decades. Highlights of their visionary report:
Research, education and training, and prevention programs were seen as tools for change. Increasing the participation of women at all levels in the mental health delivery system – as providers and as policymakers – was seen as the first step. That participation was considered a necessary condition for eliminating sex bias and sex role stereotyping in the delivery of mental health services. Developing appropriate diagnosis, treatment, rehabilitation, and prevention strategies requires recognition of the impact of the social context on women's mental health, a position that challenges traditional intrapsychic, biomedical approaches to mental disorder. The call for strong interdisciplinary collaboration foretells today's emphasis on Interprofessional Education (IPE), a personal priority of former APA President Susan McDaniel, as well as reflecting her focus on integrated care.
Women were more likely than men to use mental health services, particularly outpatient services, but men were more likely to be seen by mental health professionals. Nearly one-half of women's mental health visits were made in the general medical sector, suggesting that primary physicians play a disproportionate role in the treatment of women's mental health problems as compared to men's. More than two-thirds of all prescriptions for psychotropic drugs were for women. Although women made up 58% of all visits to physicians' offices, they received 73% of all prescriptions written for psychotropic medications (and 90% when the prescribing physician was not a psychiatrist). Although twice as many women as men were treated for depression, the depression literature suggests that it is the men rather than the women who benefit most from the antidepressant drugs.
In June, 1998 the National Center on Addiction and Substance Abuse at Columbia University released their report Under The Rug: Substance Abuse and The Mature Woman. Relevant Highlights: The destructive relationship between depression and alcohol abuse is particularly strong among women. At any age, alcoholic females are twice as likely as non-alcoholic females to be depressed and almost four times likelier than male alcoholics to be depressed. Inappropriate prescribing is common and can contribute to abuse and addiction. One out of six Medicare beneficiaries (3.5 million mature women) receives at least one inappropriate prescription. For many psychologists, social justice, by ensuring that the highest quality of care will be provided, has always been the critical vision behind RxP.
Prescriptive Authority (RxP): "It was 19 years ago now that we first developed the Fairleigh Dickinson Clinical Psychopharmacology program to provide training in preparation for prescriptive authority completely online. In 2002 we converted it to a Master's program, making it the second distance program offering a degree after Alliant University, the same year New Mexico became the first state to pass RxP legislation. When Louisiana passed its legislation in 2004, we saw the dominoes starting to fall and thought the critical mass would come soon. We had no idea how long it would be till the third state (Illinois) would join the club in 2014, which we owe to the great work done by Beth Rom-Rymer. Despite the long dry spell, the program has enrolled a new class every year for almost 20 years. I finally stepped down as Director in 2015, with Anne Farrar-Anton carrying the torch since then, though I still provide backup in my role as the Director of the School of Psychology. The program continues to evolve: our latest challenge has to do with how we would deal with the unique medical rotations requirement in the Illinois law, and we're working on the solution right now. The recent addition of Iowa and Idaho to the club tells us that maybe the critical mass is finally here, and we look forward to continuing to help psychologists from all over the country prepare themselves for that day" (Bob McGrath).
Maturing Successes: Iowa -- "As part of the legislation for prescriptive authority for psychologists in Iowa, we needed to create the administrative rules jointly with the Board of Medicine (BOM). In September, 2016 members appointed by the BOM and members appointed by the Board of Psychology (BOP) met for the first time to determine rules each group could support to their larger boards respectively. From September, 2016 until April, 2018 this sub-committee met regularly. There was considerable discussion regarding the training required. The fact that the post-doctoral master's degree programs are not yet accredited was difficult for our medical folks to understand. Conversations with APA about the process of accreditation compared to designation were held and Cathi Grus was very helpful in creating a comparison hand-out for the BOM members to visualize the similarities in each process. Once consensus on the degree program was reached, the practicum and supervision years were discussed. While this did not present as much of a challenge, there were still some intense conversations about who could be a training physician, a supervising physician, and a collaborating physician. In the end, the sub-committees reached consensus in April, 2018 and the rules as proposed were sent to the full Boards. At the June, 2018 BOM meeting they voted to notice the proposed rules for public comment and the BOP did the same.
"The public hearing was held August 21, 2018. At the hearing, the same concerns and suggestions from the opposing medical groups were heard. These were the same suggestions for amendments heard during the legislative sessions. Over the course of the BOM meetings in September and October, a couple of amendments were made to be more clear about releases of information and which physician involved with the training of the psychologist was responsible for what activity. On December 14, 2018 the BOM voted to adopt the rules as amended and on December 21, 2018 the BOP voted the same. These adopted rules were then filed by December 26th for notice on January 16th, 2019. The notice period of 20 days was concluded February 5th and the Administrative Rules Review Committee (ARRC) of the legislature met on February 8, 2019. The week prior to this meeting, some members of the ARRC were approached by the lobbyist of the Iowa Psychiatric Society who was requesting a session delay on the rules. There was some quick action taken to summarize the events of the past 2.5 years for the committee and ultimately, the rules were adopted without fanfare on February 8th. This was a long and challenging process and would not have been accomplished without the help and support of many, many people" (Bethe Lonning).
Connecticut -- "RxP is rolling along in the cold and snowy State of Connecticut early in March, 2019! You might recall that last year we were granted a Request for Review of Scope of Practice by the CT Department of Public Health (DPH). After a series of meetings with DPH and health care organizations (e.g., MDs, APRNs, Hospital Association, etc.), we engaged in 'discussions' and DPH reported on it all to the legislature. Since then, we have continued to advocate. In early February we had a 'Speed-Dating for Advocating' meeting with the Co-Chairs, a Vice Chair, and a Ranking Member (a physician) of the Public Health Committee (PHC), all of whom were knowledgeable and open to conversation.
"Then, later in the month, we received great news! The PHC of the CT State Legislature agreed to sponsor a bill, SB 966 An Act Concerning The Prescriptive Authority of Psychologists. The Public Hearing has not yet been scheduled, but will be within the next few weeks. We are proud and excited that CT is willing to take this step. We've still got a long way to go, that's for sure. But for now, get the snow mobile going!" (Barbara Bunk, Co-Chair).
Florida -- "In Florida we now have multiple sponsors and cosponsors in the Florida House and Senate. Legislative Day will occur in a few weeks and our Florida Psychological Association (FPA) members will meet with their local legislators to drum up support. We continue to gather information and answer questions for our legislators. We are very encouraged by the progress we've made to date and the support we're receiving from our elected representatives who tend to see this as a 'freedom of choice' issue. The White House released a report at the end of 2018 entitled Reforming America's Healthcare System Through Choice and Competition authored by the Secretaries of the Departments of Health and Human Services, Treasury, and Labor. It states in part:
"'As health care spending continues to rise, Americans are not receiving the commensurate benefit of living longer, healthier lives. Health care bills are too complex, choices are too restrained, and the insurance premiums and out-of-pocket costs are climbing faster than wages and tax revenue. Health care markets could work more efficiently and Americans could receive more effective, high-value care if we remove and revise certain federal and state regulations and policies that inhibit choice and competition…. Reduced competition among clinicians leads to higher prices for health care services, reduces choice, and negatively impacts overall health care quality and the efficient allocation of resources. Government policies have suppressed competition by reducing the available supply of providers and restricting the range of services that they can offer. This report recommends policies that will broaden providers' scope of practice [SOP] while improving workforce mobility, including telehealth, to encourage innovation and to allow providers more easily to meet patients' needs…. States should consider changes to their scope-of-practice statutes to allow all healthcare providers to practice to the top of their license, utilizing their full skill set.' It seems to me that we psychologists are on the right side of history. The times they are, indeed, changing" (Steve Ragusea).
Illinois – "At the Illinois Sixth Biannual Prescriptive Authority Networking event on Saturday night, February 2nd, I had the great honor and privilege of being given recognition as an 'Outstanding Leader' from the CEO of AMITA Health, one of our most important partners in the implementation of our Prescriptive Authority legislation in Illinois. With over 92 people, that included 20 students, interested in pursuing training to become prescribing psychologists; four of the 10 graduate students who are pursuing the joint degree in Clinical Psychopharmacology and Clinical Psychology; 15 of the more than 50 licensed psychologists who are currently doing their didactic training to become prescribing psychologists; five of the 10 psychologists who are currently doing their medical rotations; and the psychologist who is just a few months away from receiving his prescribing license; it was an exciting, electric evening.
"To begin the evening's program, we had two inspiring and dynamic keynote speakers, who very well articulated the connection between the needs of the most vulnerable and underserved populations in our society and the burgeoning presence of prescribing psychologists: a great community partner, Mark Ishaug, President and CEO of Thresholds, the largest and oldest social service agency in Illinois, that works with the most seriously mentally ill population in our state; and a wonderful psychologist colleague, Morgan Sammons, retired Navy Captain, in the first cohort of military psychologists who were trained as prescribers in 1992, formerly Dean of CSPP, Alliant International University, and now Executive Officer of the National Register of Health Service Psychologists.
"Following our keynote speakers, the practicing psychologists spoke about their training in Clinical Psychopharmacology (CP); then, the graduate students talked about the incredibly broadening experience of their training in CP at the pre-doctoral level. Finally, the large group of 20 graduate students talked about their interest in studying CP and their reasons for wanting to become prescribing psychologists. What we most heard was that these young students wanted opportunities to work, more effectively, with communities who have been chronically underserved. Since this was our Sixth Prescriptive Authority Networking event. Illinois psychologists, interested in pursuing Prescriptive Authority, came to renew and create important collegial relationships. It's not unusual for our psychologists to find long lost friends and colleagues at our events!
"Our APA Convention will be in Chicago this summer! I am, therefore, scheduling our Prescriptive Authority Networking event for August 11th, the Sunday of Convention, and extending our welcome to include psychologist participants from all around the country! Our Prescriptive Authority Movement has partnered with powerful community healthcare systems, like AMITA Health, and associations that serve the most underserved populations in our State, including Thresholds and NAMI. On August 11th, our APA CEO, Arthur Evans, will speak, as will our APA President Rosie Phillips Davis. In addition, we will have our Illinois community partners; our state legislative champions; our prescribing psychologists; our young graduate student trainees and older, practicing prescribing psychology trainees speak. I am thrilled to demonstrate, to our larger community, how Illinois psychologists are training for the future!" (Beth Rom-Rymer).
Reflections: "Talk about memory lane. The WMHA conference was an outgrowth of the work of the Subpanel on the Mental Health of Women of President Carter's Commission on Mental Health. Being co-chair of that Subpanel with psychiatrist Elaine Carmen, I met and learned from the 'stars' of the women's health movement across the health professions and applied those lessons in my role as Head of the Women's Programs Office at APA and Chair of the National Coalition for Women's Mental Health.
"1. The 'facts' are only the beginning. After completing our work documenting the impact of women's roles and circumstances on their mental health, the word got back to us that the entrenched power structure of the NIMH basically patronized and dismissed social determinants of women's behavior; the biomedical model reigned. It was not to be borne. I obtained a conference grant from the Ittleson Foundation and we were off and running.
"2. Clear goals and the power to achieve them are essential for a conference to produce actual social change. With the Subpanel report, we didn't need yet another research conference. What we needed was to build an advocacy framework and unified message to get our allies in prevailing power structures (e.g., professional associations and women's advocacy groups) on board to push for specific changes. The formula to constructing a conference leading to actual change was having the right mix of leaders, a leadership structure for follow-up, and a bit of sleight of hand – and we pulled it off. The WMHA was crafted and the National Coalition for Women's Mental Health was born.
"3. The conference's inclusive selection process was a key component for long term success. Having diverse voices at the table when discussing women's roles and circumstances is essential for the perspective-taking needed to generate effective prevention and intervention strategies. In constructing the conference, we not only had a separate working group focusing on special populations, we had individuals (professionals and advocates) from such populations represented in all the groups. The cross fertilization of ideas across the disciplines and life experiences was energizing. We weren't agonizing, we were organizing! We were individuals who shared core values who recognized that women's roles and life contexts were not conducive to mental health -- of women or men" (Nancy).
"You brought me back in time. The mental health agenda we proposed has given birth to some positive changes – women included in earlier stages of drug testing to see if effective, violence against women taken more seriously, PTSD enlarged as a concept to include the rape experience and other traumas likely to affect women. But there remain topics that we raised that still affect women's mental health – the role of stress of combining work and family (much less combining leadership and family) without social supports, the stereotype that shapes whether we see women as authority figures, how clinicians respond to women's and men's same presenting symptoms differently. My best to my partners of 1985" (Angela). Aloha,
Pat DeLeon, former APA President – Division 55 – March, 2019
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