THE TABLET: Newsletter of Division 55 American Society for the Advancement of of the American Psychological Association Pharmacotherapy (ASAP)

http://www.division55.org/TabletOnline.htm Volume 11, Issue 3 Editor: Laura E. Holcomb, Ph.D., MSCP November 2010

SPECIAL DOUBLE EDITION Water Buffalo Theology and RxP LCDR Michael Tilus, Psy.D., MSCP

Kosuke Koyama‘s covered that there is much in the Bible position ourselves as Koyama describes delightful book about water! He theologized that God the people of Thailand did during the called Water Buf- rules from a place above the rains and monsoon season, as hiding under some falo Theology re- the floods. (Koyama‘s God stays dry.) room, avoiding the rain, as if ―watching

flects on the late At the close of his little book, Koyama God‘s rain out there.‖ Above others, Japanese-American theologian‘s experi- generalized on the method he had been away from others, or in the rice paddy ence of being sent early in his mission- using in his efforts to understand what with the water buffalo- these images ary career by his Japanese church to he believed the Bible has to say to the inform our thinking about culture, and Northern Thailand. Up to that point, culture of northern Thailand. Missionar- our theologizing about culture, our psy- Koyama had spent most of his life in a ies, he reported, must find a place chologizing (my word) about theology, fairly comfortable urban setting, but where they are ―sandwiched between‖ and maybe even our own RxP Culture. now suddenly found himself in a place of the Bible and the culture to which God Strict biological reductionism keeps thousands of rice paddies. As he rode has called them. He continues on to say ―God dry‖ by insisting that its postulates around his new ―parish‖ on his motor they must then engage in a two-way are irrefutable and immutable. Psychia- scooter, Koyama discovered that most exegesis, working at two interpretive try holds the DSM in a god-like fashion, of the people he saw spent all their days exercises: They have to interpret the by verse and criterion, with determi- standing in shallow rice water, alongside questions and answers of the culture in nants that push people into that preor- massive water buffalos. During the on- which they find themselves, and they dained box. RxP may fall into the same slaught of the monsoon season, these all must bring those questions and answers two-way exegesis of being another holy day work schedules were usually fol- to the Bible, in order to interpret anew tablet that has its ―above‖-like refer- lowed with periods of more rain, during what God has to say about such mat- ence, feels no rain, and knows no peo- which everyone had to find some way of ters. ple. Or it can be the brief, 10-minute staying dry. I think I understand Koyama‘s interpre- visit ―away from‖ others who are in the Koyama made a decision to read the tative questions and the ―sandwich‖ rain, practicing their science from a cul- Bible as if he were standing alongside his metaphor, as they appear to highlight tural position which is ―god-like above parishioners, in a rice paddy, trying to my sense of what psychology, psychia- the rain,‖ never allowing themselves or maneuver that behemoth water buffalo. try, religion, and sometimes, RxP, do to their thinking (theologizing, psychologiz- He reports that suddenly passages of some degree. However, as opposed to ing, RxP-izing) to ―get in the rice paddy scripture and visual images leaped out at Koyama‘s theological need to have a with the farmer and his water buffalo.‖ him that he had never really considered ―God that stays dry,‖ I want a ―God that (continued on pg. 6) before. Koyama reported that he dis- gets wet.‖ Theologically, we could also Page 2 THE TABLET: Newsletter of Division 55

SPECIAL DOUBLE EDITION Table of Contents

SPECIAL FEATURE SECTION: RXP IN THE INDIAN HEALTH SERVICE ASSISTANT EDITOR– LCDR MICHAEL TILUS, Psy.D., MSCP

Water Buffalo Theology and RxP Mike Tilus, Psy.D., MSCP 1

Suicide Prevention at Spirit Lake Health Center Antonette Halsey, BS, MMgt 14

How a Medical Psychologist Enhances Teamwork and Patient Care LuAnn J. Stromme, DNP, FNP-BC 16

An Model of Collaboration Around Adolescent Asperger's Deb Hanson, LICSW 18

Combining Western Medicine and Traditional Native Healing Marissa Taylor, RN, BSN 20

The Perspective of a Northern Plains Dakota Elder and Social Worker Joanne Streifel, LICSW 23

A Pharmacy Director‘s View of Collaboration with a Prescribing Psychologist Cynthia Gunderson, R.Ph. 26

A Tag Team Approach with a Family Practice PCP and a Medical Psychologist Candelaria Martin, M.D. 27

My Experience as a Prescribing Psychologist at the Fort Peck Unit Bret Moore, Psy.D., MSCP, ABPP 30

A Prescribing Psychologist‘s Quest to Provide Culturally-Sensitive Care Mimi Sa, Psy.D., MSCP 32

Medical Psychologist to the Passamaquoddy Tribe Jack Martinez, Psy.D., MSCP, CCS 36

Journey to RxP at Fort Thompson Johna Hartnell, Ph.D. 38

Standing Rock and Other Motivations for Becoming a Medical Psychologist Anthony Tranchita, Ph.D. 40

My Tenure as a Psychologist for the Indian Health Services Vincent Barnes, Ph.D. 42

GENERAL CLINICAL ARTICLES AND COLUMNS

From the Editor– Passing the Torch Laura Holcomb, Ph.D., MSCP 3

President‘s Column Owen Nichols, Psy.D., MBA 4 Interview with Robert M. Julien, M.D., Ph.D. Judith Julien, Ph.D. 45

Threats Within the Ranks: Violence Across the Deployment Cycle Robert Younger, Ph.D., MP, ABPP 49

Antipsychotics in Geriatric Patients: The Risk of Early Death G. Channing Harris 52

Psychiatric Taxonomy, Psychopharmacology and Big Pharma Lisa Cosgrove, Ph.D. 60

A Glimpse at an Evolving Practice Environment Pat DeLeon, Ph.D., JD, ABPP 64

Molecular Nutrition: A Missing Link in Pediatric Pharmacotherapy? Susana Galle, Ph.D., MSCP 68

The Self-Medication Question in Response to Stimulant Medication for ADHD: Brian J. Bigelow, Ph.D., C. Psych., 74 Who is at Risk for Addiction? ABPP Remembering Scott Borrelli Beth Rom-Rymer, Ph.D. 80

2011 Division 55 Midwinter Conference Information 81

Congratulations (to PEP Passers, Election Winners, Award Winners) 82-83

The Tablet, November 2010 Volume 11, Issue 3 Page 3

From the Editor– Passing the Torch Laura E. Holcomb, Ph.D., MSCP [email protected]

You may have In addition to the wonderful articles ners, PLLC in Cedar Hill, TX, that pro- noticed that about the IHS, there were also enough vides professional mental health and this issue is a submissions of other types of informa- organizational behavior training, busi- bit larger than tive articles to fill an entire issue of The ness consulting, and psychological as- usual (OK, Tablet, with a range of fascinating clinical sessments. He is an APA Accreditation that‘s an un- topics. A special thanks to Mark Muse, Site Visitor, and has been a director of derstatement!). Credit is due largely to Ed.D., MP, ABMP for facilitating an inter- APA-approved psychology internships the vision and initiative of Mike Tilus, view with Dr. Robert Julien, author of and APPIC postdoctoral fellowships in who proposed a special feature section the recently updated (12th edition), A the past. on RxP in the Indian Health Service Primer of Drug Action, led by his wife Dr. Dr. Calvert will be assisted by Nicholas (IHS), and was willing to serve as Assis- Judith Julien. You won‘t want to miss Patapis, Ph.D., MSCP, who will serve as tant Editor for this section of this issue Dr. Julien‘s pre-conference workshop Associate Editor. Dr. Patapis completed in order to make this possible (Thank and presentation at the Division 55 Mid- his master‘s in clinical psychopharmacol- you, Mike!). You may have noticed the Winter Conference in DC in March, ogy in 2009 at Fairleigh Dickinson Uni- announcements of multiple awards he 2011 (see pg. 81). versity. He is in private practice in Phila- has received for his work with the IHS, This issue ends my 2 year tenure as edi- delphia, specializing in clinical psychology in prior issues of The Tablet. Please read tor of The Tablet. I have enjoyed having and forensic neuropsychology, and is a his article, Water Buffalo Theology and this opportunity to contribute to Divi- psychologist at Wordsworth Academy. RxP, to learn the inspiring ―back-story.‖ sion 55 and the RxP cause. He has authored numerous book chap- Thanks to all of the dedicated and de- ters and peer-reviewed publications on In 2011, your new Tablet editor will be termined professionals who have con- forensics and substance abuse. He was a James Calvert, Ph.D., MSCP. He com- tributed articles to the special feature National Institute on Drug Abuse Clini- pleted the master‘s in clinical psy- section on RxP in the Indian Health Ser- cal Research Fellow at the Treatment chopharmacology in 2007 at Fairleigh vice. Your stories paint a rich picture of Research Center, Department of Psy- Dickinson University. He is a licensed the spirit and needs of the Native chiatry, University of Pennsylvania Medical Psychologist in Louisiana. He is American people, and of the work you School of Medicine. a Board-Certified Diplomate-Fellow in are doing to deliver care to them under Psychopharmacology by the Prescribing Please welcome James and Nicholas by often challenging circumstances. I hope Psychologists‘ Register (PPR) and the submitting lots of articles for The Tablet that more psychologists with RxP train- International College of Prescribing Psy- in 2011. Thanks to all who have submit- ing will consider bringing expertise and chologists. He teaches graduate psy- ted articles during my tenure in 2009 talents to the IHS. This is an opportu- chopharmacology courses at Southern and 2010. It has been a pleasure to nity to further the RxP movement while Methodist University in Dallas, TX, and work with you. giving back in a very meaningful way. Texas A & M University in Texarkana, TX. He is the president of Calvert Part-

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President‟s Column: Owen T. Nichols, Psy.D., MBA, NHA, ABPP, ABMP

It is hard to be- agenda that is devoted to our goal of the other members of the Convention lieve, but my year prescriptive authority for appropriately Program Committee devoted a great as President of trained psychologists in every venue. deal of attention to the needs and op- Division 55 is His efforts to advance our movement portunities that exist within Indian nearly over, and are already well underway with the Health Services. The tribal self- this will be my planning of the 2011 Mid-Winter Con- governance allows for independent deci- last column as ference that will occur in conjunction sion making regarding the issue of pre- President. It has been an incredible pro- with the State Leadership Conference scriptive authority for appropriately fessional experience that I have truly of the American Psychological Associa- trained psychologists. Significant behav- enjoyed immensely. As an organization, tion (APA). ioral healthcare needs currently exist we are blessed with some of the best within the tribal communities. A significant highlight of my tenure as and brightest that our profession has to President of Division 55 was the 2010 As has been the history of the prescrip- offer. The energy, creativity, and passion Division 55 program offerings at the tive authority movement thus far, un- for the professional practice of psychol- 118th Convention of the American Psy- derserved populations such as can be ogy within Division 55 cannot be de- chological Association (APA), which was found in the military, rural states, and scribed as anything other than abso- truly outstanding. Dr. Massi Wyatt, the tribal communities provide a unique lutely remarkable. As I look around at Convention Program Chair, did a won- opportunity for prescribing psycholo- our Board of Directors and member- derful job putting together a well- gists to offer valuable services, while ship, I see true leadership that I hope balanced selection of continuing educa- demonstrating the efficacy of allowing will advance within the governance of tion programs and symposiums which psychologists to prescribe. This is an- the American Psychological Association were well attended by our membership other win-win for Division 55, because (APA) and lead our national organiza- and many other participants. Dr. Wyatt there is a definite need that our mem- tion in a direction that further advances was especially creative at finding new bership has the skills to safely and effec- the practice of psychology, and pro- and different ways to entice early career tively meet, which can further demon- motes the betterment of our society psychologists to select Division 55 pro- strate our commitment to service and through our professional skills as health- grams during the 118th APA Conven- our willingness to go where the needs care providers. tion. His dual role of serving as Mem- exist, while providing quality care. One such individual on our Board of bership Committee Chair and Conven- I remain convinced that doing the right Directors that brings his heart and tion Program Chair was definitely a win- thing for the right reasons will always gifted mind to the service of our organi- win for Division 55 this year. produce success! I am also hopeful that zation and profession is the incoming For those of you who were able to at- as our nation embarks upon the journey Division 55 President, Dr. Glenn Ally. tend the Division 55 programs during of modernizing our healthcare delivery Dr. Ally will have my full support as the the APA Convention, it should have system, we will find ourselves in the Past-President, as I continue my service been fairly obvious that Dr. Wyatt and position of seeing increasing opportuni- to Division 55, while he promotes an

The Tablet, November 2010 Volume 11, Issue 3 Page 5

Owens, President’s Column, continued ties for psychologists, especially those tions were the top-selling class of drugs. scription opioids, sedatives, and tran- with training in psychopharmacology. Yes, the pharmaceutical industry has quilizers in the U.S. has now surpassed expanded the patent of many of the motor vehicle crashes as the leading There is a need for all psychologists to atypical antipsychotics to encompass cause of unintentional injury and death. become more educated about the im- ―mood stabilizing,‖ but do we really pact that the use and misuse of pharma- The public healthcare delivery system think that these drugs are being cor- ceutical agents has had upon our health- will remain an appropriate venue for the rectly prescribed, when the volume of care delivery system, our national econ- prescriptive authority movement be- sales has reached the current level? omy, and society as a whole. But cause of the overwhelming needs that greater still, there is a need for psy- exist in many underserved areas; how- “Psychologists should learn chologists to become more involved in ever, we must also begin to think more to prescribe in order to be the judicious practice of medication a part of changing how globally about how to apply the skills we management. Our basic training teaches healthcare is delivered in possess as both psychologists and us that the majority of health-related this country, and to prevent ―psychopharmacologists.‖ We all sup- problems have significant contributory the inappropriate port prescription privileges for appro- behavioral components and, likewise, utilization of psychoactive priately trained psychologists, to expand the best treatment of many medical drugs in high risk our scope of practice and to better problems involves significant behavioral populations.” serve our patients, but there is a signifi- components. cant need for psychologists to get more Pharmacy expenditures are the single involved at a health care policy level Psychologists should learn to prescribe fastest-growing area of all healthcare related to pharmaceutical utilization, to in order to be a part of changing how related costs, growing by at least 5% per protect and better serve the public. Our healthcare is delivered in this country, year, and sometimes as much as 20% skills in evaluating research are espe- and to prevent the inappropriate utiliza- per year. The U.S. spends more per cially relevant, given the current over- tion of psychoactive drugs in high risk capita on prescription drugs than any utilization of prescription medications populations, such as the elderly, chil- other country in the world. Prescription and the modern healthcare reform ac- dren, developmentally disabled, and the drugs account for about 13% of the to- tivities, in designing a preventive system addicted population. In 2009, the U.S. tal cost of healthcare in the U.S. of care that has great potential to be- spent over $300 billion on prescription come more behaviorally-based. drugs, with over 3.9 billion prescriptions Because of the overutilization of pre- written. During the same time period, scription drugs in the U.S., there has Dr. Owens is the CEO/President of NorthKey Community Care in Kentucky. the U.S. spent $15 billion on antipsy- been a dramatic increase in accidental chotic medications. This $15 billion is poisonings. The number of individuals equal to every family that lives in the hospitalized due to poisoning, related to U.S. paying $150 per year for antipsy- prescription medications, increased by chotic medications. As a result of this 65% between 1999 and 2006. The rate spending in 2009, antipsychotic medica- of unintentional poisoning from pre-

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Tilus, Water Buffalo Theology..., continued

(continued from pg. 1) are forming and are being in-formed/ Mental Health specialty program from shaped by? What is the method of our the University of California at San Fran- … In my experience, any clinician prac- integration? Why is that important? To cisco (this was that unique program in ticing this way in Indian Country will be me, it started in my first assignment as a the 1970s that integrated psychology, relationally impotent. newly minted Doctor of Psychology, social work, medicine, and psychiatry Simply having an RxP prescription pad stationed in the far northwest corner of with medical rotations and RxP training) does not dispose a prescriber in Indian Washington State, working with a small, Trained to prescribe, provide psycho- Country to a god-like reverence above isolated, medically underserved Quileute dynamic therapy, and provide critical the water buffalo culture. Being ―above Tribe in La Push, WA. Barely a square social work intervention in a multidisci- the rain‖ positions the RxP provider on mile dense, this tribe of approximately plinary professional setting, I experi- top of the Indian culture, reflective of 650 had centurion roots on this Pacific enced Dr. Birch as one of the finest the years of the dominant culture inflict- Coast landmark that they traced back to equipped psychologists, most well- ing self-righteous judgments and as- an ice age exploration from the Eastern rounded human beings, and most ex- sumptions about what they knew was side of what is now Russia. traordinary supervisors I had ever had, right ―for them.‖ Practicing RxP this way period. I brought her a question that This particular job had not been filled is dismissing the culture. As a practitio- was haunting my soul one day, and she for years. Previous therapists had been ner, I haven‘t even found the rice paddy, reminded me to, ―Hear the voice of the hired, and fired, for a multitude of politi- the farmer, or the water buffalo yet. child.‖ cal reasons. This Indian Health Service Some RxP prescribers ―watch the rain (IHS) region had been unsuccessful in This child was a clearly struggling 9-year from afar‖; sheltered from the Monsoon recruiting anybody for this position. So, -old who was having serious difficulties downpour, they observe the farmer and as one official informed me, ―You (Public in school with truancy problems, ques- the water buffalo, making assumptions Health Service Psychologist) were our tionable medical conditions, malnutri- about that culture ―from afar.‖ These last option! We didn‘t want a PHS Offi- tion, anger, behavioral disruptions, and RxP providers in Indian Country tend to cer, but you‘re the only one that would undiagnosed learning disabilities. His insulate and isolate themselves from the come.‖ Interesting welcome! Fetal Alcohol Syndrome features were impact of the culture they are attempt- I began traveling an hour west to Port remarkable, as was his silly smile and ing to be ―health care providers‖ of. Angeles to complete my Post Doctoral love of basketball. We immediately be- Theoretically inclined, emotionally insu- Supervision with a psychodynamically gan ―basketball therapy,‖ and during our lated, they tend to see and use RxP as charged supervisor, Marian Birch, DMH once a week ―therapy session,‖ we ―an intervention‖ for ―the depressed walked to the gym and had sporting (Doctor of Mental Health), whose spe- culture‖ out there. They don‘t feel the games of H.O.R.S.E. and one-on-one. cialty was in child mental health. Inter- monotony of rice planting, tending the He loved beating me to the hoop! esting that this supervisor‘s relationship water buffalo, or the scarcity of life this with me would be one of the tag points His grandmother was an honored matri- culture exists in. along my RxP career, as she was one of arch of the century-plus year-old Shaker How do we think theologically and psy- the last psychologists trained in the in- church established in the mid 1800s. As chologically about the RxP Culture we novative program of the Doctor of an ordained Pentecostal minister and

The Tablet, November 2010 Volume 11, Issue 3 Page 7

Tilus, Water Buffalo Theology..., continued chaplain, I was very interested in this go on the waiting list.‖ A visiting psy- won‘t they let me see the doctor?‖ I had Indian church that had somehow inte- chiatrist came through our part of the no words. My supervisor advised me to grated a pre-Pentecostal, German emi- county once a week, for one day, so the listen to the child‘s voice. That supervi- grant, experiential religious movement waiting list was long. I had no idea how sory encounter, coupled with that into their personal Quileute culture. long that was. child‘s request, stirred within me the

Exuberant singing and dancing, and My basketball buddy and I waited for desire to do something. And I was mad! ―shaking‖ were both normal religious three and a half years to make it up that Mad at the clear racial prejudice that customs of the Shakers and this Native list. When I finally left that duty station was accepted as the norm! American Shaker Church. Grandma had after almost four years, I was 100% suc- One day my little buddy‘s grandmother requested my 9-year-old basketball cessful in not getting a single one of my dropped by to see me, and announced wanna-be to be taken to the church and Native American patients referred to herself at the front desk as ―an elder‖ ―brushed off‖ [a religious ceremony see the psychiatrist, including my little who wished to see ―the big white Doc- where a group of believers use prayer, bud. Racism had a nine-year-old face tor in the uniform.‖ She graciously dis- dance, ringing individual bells, and would now. cussed her hopes and fears for her put the child in the middle and ―brush grandson, her sadness at her daughter‘s I grew to understand there was still off the evil presences‖ (spirits) that alcohol problems, and the bewilderment great animosity and racial discrimination were encumbering his spirit]. I gladly of what kind of path her grandson with the dominant Caucasian culture supported this as a wonderful, family would take, given his ―suffering‖ (her and this small Indian tribe. The hardened and cultural intervention, and sent my word). Before leaving, she honored me and tough logging industry had gone prayers along with them as well. This with an invitation for my wife and I to away, but left much of that culture would be a closed spiritual ceremony, attend an upcoming, special religious around. Racism was very much alive so I would not be allowed to participate with malignant effect. After two years of service. As is custom, all the families or observe. waiting, I went to my supervisor and would bring something for the potluck As we began to build our therapeutic discussed this case, the cultural and po- (my word). For them, the eating to- relationship, I knew this young man litical scenario, and my clinical dilemma. gether was as symbolic and vital as the needed some psychiatric care for his Repeatedly calling brought no results. I sharing of communion in my church. impulsive anger outbursts. Our little feared losing the little collaboration I Here, this Shaker church shared the Tribal medical clinic had one PA, two was hoping to build with the only other nutrition of the earth, the sea, and the nurses, one dentist, one psychologist mental health practitioners in my area, family of relatives and relationships. It (me), and one drug and alcohol coun- was a day of ―good medicine‖ and rich but the excuses kept coming: ―The list selor. After consulting with our PA, he learning for my wife and me. About that was lost; he‘s number #35; we had said I needed to start the referral proc- time, I discovered the RxP program some other emergent people and now ess to get this young man to our local through Alliant International University; he‘s number #54.‖ My little basketball community mental health facility that discovered that it was being video con- buddy had finally cornered me after was about 12 miles away. I was in- ferenced live; discovered I could… waiting for almost two years and asked formed by this clinic that ―his name will me, ―What‘s wrong with me? Why (continued on pg. 8)

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Tilus, Water Buffalo Theology..., continued

(continued from pg. 7) and medicine, I called into the 800 line ble Psychopharmacology Examination for my weekend training. I was so ex- for Psychologists (PEP), but life here was ... drive to Portland, Oregon some four cited about the opportunity of working too hard. I was becoming overwhelmed and a half hours away for a long, hard with many professionals of various disci- with the turmoil and internal chaos. My weekend; discovered I would not get the support of the my federal supervi- plines, and bringing my neophyte RxP psychopharmacology degree was com- sor; discovered the fact that this was skills to the table. pleted, but I had no energy left for in- not going to be easy; discovered the fact However, cultures clashing was the tense study. that I loved the learning and the RxP sound of this arena, as this grand experi- Here, some were demonizing psycho- peers I met; discovered the fact that ment found mountains of disagreements tropics as ―bad‖ and reifying them as the there were a lot of people outside my between how, when, and who does the epitome of evil western medicine. small world that knew a lot about psy- ―integration.‖ I, with my Pentecostal Other professionals were calling on chopharmacology and were willing to heritage and my Zen Buddhist leanings, their use as ―best practice‖; the ques- teach me; discovered that this was going met practitioners who were Navajo by tion was always raised, ―By whom? Who to be a lifelong commitment of learning. birth but practiced their social work determined this as best practice for us?‖ duties as a Mormon or a Catholic or in If a culturally-approved Native provider What I also discovered was my Physi- a traditional way. Other Pakistanian/ believes that his sweat ceremony with cian Assistant (PA) that I worked with Indian psychiatrists practiced medicine herbal water is curative for psychiatric every day began immediately consulting from their Hindu tradition. Our Navajo illness, who can dispute that? Which with me about medications, side-effects, traditional practitioner (a staff member) bible do you swear by? And contrarily, if and drug-drug problems. I was only a held sweats and other ceremonies held a psychiatrist or psychologist believes year plus into my AIU RxP program, but in high regard for their healing efficacy. that this bipolar adolescent needs inten- the clinical need for informed decision making on psychopharm was intense Traditional herbs and medicines were sive dialectical behavioral therapy (DBT) and real. I found myself in the rice administered to the adolescents with three times a week and a trial on lith- paddy, and the water buffalo was laugh- concurrence from their parents. Our ium, who determines this as culturally ing at me. mornings were started with the burning appropriate? of sage or cedar, smudging and prayers, This clash of cultures seemed to come I continued traveling to Portland for a and good words given to each other to a head when a patient‘s care and year and a half until my new duty assign- both patients and staff. And in this mix, treatment became polarized between ment came. My wife and I then packed it seemed like everyone was attempting treatment communities. The western up and went to Four Corners region, to integrate their thinking about healing, medicine trained members wanted this working in Navajo country. While help- medicine, wellness, and family with young man with paranoid schizophrenia ing establish the first ever IHS inpatient other treatment members‘ beliefs. I wish to continue in weekly psychotherapy psychiatry, adolescent locked unit that I could say it was a success, but to me, and to take his prescribed atypical antip- specifically attempted to integrated these two years were profoundly dis- sychotic. The patient began skipping western medicine with the Navajo heal- turbing and personally destructive. I had therapy sessions and refusing to take his ing and wellness ceremonies, teaching, hoped to start my study for the damna- medication. The traditional provider

The Tablet, November 2010 Volume 11, Issue 3 Page 9

Tilus, Water Buffalo Theology..., continued believed he needed a special Navajo ment team would witness the miracle these themes had personal biological ceremony, and that that this patient did and thank the Creator for it… and he family images that my counter transfer- not need to go back to therapy, since he would still continue in therapy and with ences could not avoid, and some had resolved (healed) his problems in a psychopharm. Culture clash was now brought back combat chaplain feelings recent sweat ceremony. The patient personified and, in the end, my patient and memories that were charged with also had an unfortunate trauma history was told he did not need to continue in primitive feelings as well. and someone, somehow, decided he therapy or take his medication. Staff was In the midst of these cultural, religious, needed to surface everything, all at polarized and sides were drawn. Soon, I and personality enmeshed battles, I once, during his sweat. As the Acting was removed from my Acting Position wore out. One day feeling high anxiety clinical Director, I was aghast at this and assumed the regular duties of the with some chest pressure from a now seemingly justified decision. With great Senior Psychologist. Not my best hour. growingly hostile work environment, I angst, I confronted the alleged provider Within this RxP trail, the question decided to get myself checked out by who both denied the charge, and re- gradually became clearer that it was the Army ER doc who ran our ER de- turned my anger with his anger. What a more important ―who‖ was saying what, partment. My father had a triple heart mess… from what ―authority‖ and ―credential‖ bypass when he was in his 60s, so I It appeared the clinical question of the base, and where the theology was going knew I might have some genetic loading care for this young man had gotten to come from. In my mind‘s eye, our for such. And I had noticed that since twisted into a politically dangerous team needed a ―God that stays dry,‖ coming to this high desert, my strength agenda, as opposed to a truly qualifying that is, above the situation, above the and stamina while running and working clinical answer. By that I mean, when rain, and who is sovereign. Sovereign out with my kettle bells had diminished. does the question become one of ‗I‘m edicts have power and efficiency but, in I chocked it up to stress at work. After the doctor and I know best/most,‖ or, my experience, usually the clinicians a short nitro trial, I was shipped down ―I‘m the cultural professional and this is who press for their authority ―from on to Albuquerque. Three days later and a how the cultural/religion knows best/ high‖ are the ones I don‘t want my fam- triple-valve bypass due to coronary ar- most?‖ Choosing this bipolar question ily receiving care from. And if your pro- tery disease, I got thirty days of vacation always pushes away a Likert scale an- fessional provider espoused his or her free recovery time at home. My respite swer because there is only a ―yes‖ or remedy as ―the true way‖ or ―the evi- sparked a renewal of the desire within ―no,‖ or ―right‖ or ―wrong‖ answer, dence-based way,‖ and the adolescent me to complete my RxP training, but with hell to pay on either side. must subscribe to ―their way of healing,‖ not here or in this place. My soul felt the ultimate end was reification such like I had been assassinated, and my I strongly reinforced the treatment plan that only ―God‖ could argue. Since no heart was vengeful. I needed to re- that this young man would continue one was God, the discussion was over. group. with therapy, taking his medications as And, if someone places themselves as prescribed, and receiving the traditional Sometimes this RxP journey has mo- God, they usually need a Satan. I sought teachings, ceremonies, and prayers, like ments that stall us out, cull our… consultation, supervision, and spiritual all the other patients. And if he was in- (continued on pg. 10) direction through this rift, as many of deed ―healed,‖ then the entire treat-

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Tilus, Water Buffalo Theology..., continued

(continued from pg. 9) on my thinking, my sleep disturbance, their madness. My body was no differ- my quick reactions, my existential angst ent. I was no different. My PEP reading ... emotional and spiritual resources, and and anger, my marital relationship, and during my recovery days was real, not leave us begging. The RxP factor that my professional impact. Reading a DSM theoretical. gets side-swiped by some of the RxP community is the value of RxP friend- for criteria really didn‘t make much Neurobiological reductionism, as I un- ships and professional colleagues. If not sense, as my body already told me what derstand it, seems to haunt most cul- for a few of these connections, I may was present. But I was different this tures that have some sort of ―free will‖ have stopped my RxP journey at that time. I respected the neuronal surges theology (as I do). To some degree, this point. But I‘m not good at giving up! (I and bouts of ―infection of unknown RxP adventure is challenging some of also noticed that, as a common charac- sources‖ and ―fevers of unknown this epistemological free will argument. teristic of most of the RxP psychologists sources.‖ Combat nightmares got By that I mean there is a freedom I have met anywhere- we are a tena- blurred with the intensity of conflict at ―from‖ (a wide variety of real or imag- cious bunch of hounds, that once we get this recent cultural crisis. Night sweats ined) constraints, and a freedom became a norm. My biological heart the scent we just don‘t give up!) ―to,‖ (i.e., to pursue the good, to act for was healing, while my emotional heart reasons, to develop one‘s character, or Like a process theologian, or a marriage was bleeding. to inhibit one‘s propensities for action). and family therapist who is monitoring I knew why when I went to McDonalds When one acquires a psychiatric diagno- the ―living system,‖ I think these times with my wife on an occasional Saturday sis, like I did with PTSD, are the neuro- of setback and recovery are important morning date, I needed to sit with my biological deterministic features of neu- parts of the RxP journey, where we back to the wall, facing the room, with rons making me do something? Do I still consolidate our growing internal and every exit door scanned and available. have sufficient free will to act on my professional identity. During my heart surgery recovery, it was my spouse, my This subtlety also was noticed to sub- own? Is this neurobiology impairment family, close RxP peers, and PHS offi- side when my PCP put me on a beta disturbing my mind to such a degree cers, who called, noticed, encouraged, blocker for my heightened blood pres- that I can be impoverished? Illusions, prayed, and reminded me to get out of sure. Physiological arousal was a living delusions, or realities about our human bed and back in the game. Good people! dynamic, a part of my faith, a measure of nature? To me, these are RxP questions, Old Posttraumatic Stress Disorder my person, not just a criterion. I theolo- as the experiences we never forget are (PTSD) signs and symptoms from my gized about it, argued with God about it, shaping and informing to even our cellu- combat chaplain experience in the first and minimized it to my PCP. I embel- lar level. lished it with my wife, if I felt it would Gulf War that were moderately con- Enthusiasm, burnout, and finally despair get me some care. And I gradually grew trolled for years began resurfacing. An- is often the path that I, and many mental to see it as my body responding to ger, fear, and depression were all old health professionals, find in serving the trauma. My body. I had worked with friends that were now living with me IHS. I suspect most of it is due to the many veterans at multiple VA hospitals, more than I had wanted, but had their fact that the IHS is, and has been histori- where they seemed to find a measure of place at the table. This time, I began to cally, underfunded, under-staffed, under- wellness when they found their sanity in notice the effect my hypervigilance had resourced, and over-utilized. Indian

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Country is truly a third world country conferences in Missouri, and in New nary gestures to help me get to that within the USA. This fact cannot be Mexico. I met like-minded professionals conference, and also spent another 10 overstated. There is always more need of many persuasions from all over the minutes with me which were life chang- than there are resources. Always. In globe, who were open-hearted, highly ing. She moved me. My now friend and many ways, it‘s a systemic set up for motivated, and extremely bright. The mentor, Captain Kevin McGuinness, and vicarious PTSD. What is also true, from conferences were good but the relation- I met for the first time after having mul- my perspective, is that most clinicians ships were far more important. I was tiple telephone consultations during aren‘t surprised when their patient acts struggling, personally and professionally, distressing duty times. He became a crazy and self destructive. But when the to find my place within a newly growing brother in arms, and my friend. He ex- organization itself is too sick and dys- field, feeling my need for serious profes- emplified the best of the Public Health functional, (mirroring the alcoholic fam- sional mentoring and consultation, desir- Service! RxP had faces now. ily system), clinicians often get sick ing professional friendships. I had a few, I am a relational theologian and a rela- themselves, work harder to become tional psychologist who values the mo- ―saviors‖, or play out their own biologi- “Indian Country is truly a ments we get when we actually connect cal family roles. Like my experience, third world country within with another human being in an experi- most clinicians leave IHS because of the the USA. This fact cannot ence that actually changes us, and con- organizational pain and sickness, not the be overstated. There is nects us with memories that we will not patient care. always more need than forget. My pastoral father would call However with very few exceptions, the there are resources. that a ―born again moment.‖ My mental health providers, and especially Always. ” psychodynamic supervisors called it the the RxP psychologists who work to get ―significant emotional encounter.‖ My small coffee talks with what I know now into IHS, are people who are reflective, family system supervisors called it ―the are key national RxP leaders, who virtu- compassionate, highly skillful, and have positive feedback loop.‖ I know that ally shifted my direction. Mario some sense of ―inner call‖ to do this these RxP psychologists showed great Marquez, then President of Division 55, work. They are committed to working respect and great trust to me. They was the most approachable psychologist in the public sector and to communicate ―came along side,‖ in a living-faith way I had ever met. He graciously shared his hope. They want to be a part of some- that to me has become the nature of heart and hard-earned wisdom. He was thing larger than themselves. They sacri- most of the RxP psychologists who are a man of integrity. Patrick DeLeon ze- fice, work harder, work smarter, and in this movement. They are people who there is still, at the end of the day, more roed in on me following a few com- are intentionally pouring out their lives need than resources. Cultural integra- ments I made one evening. His candor, and shouldering the mission of bringing tion is expensive and not easy. I still wisdom, and open heart immediately RxP to the public sector. I would not be think it‘s worth it. Cultural clash can be, touched my heart where it needed to in the RxP movement today without… and usually is, devastating. be. We spent maybe ten minutes to- (continued on pg. 12) gether, but that was sufficient. He also Two turning points for me during those stood tall. Elaine Levine made extraordi- years were attending the APA Div 55

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Tilus, Water Buffalo Theology..., continued

(continued from pg. 11) four nurses, one psychologist (me), and sullen. Maybe this was just beyond my one social worker. By one federal staff- abilities. I shared my doubt with my ... the unexpected encounters I had with ing protocol, my behavioral health de- wife who again, encouraged me to keep these ―sent people.‖ (I think the Crea- partment ―should‖ have four psycholo- on- ―stay the course‖. From anyone tor finds unconventional places to bring gists, four social workers, two case else, those would have been cheap people into our lives for unique mo- managers, and 1 office assistant. words. From her, they registered faith ments or turning points, as much as I to me, and in me. Sometimes when we believe that occurs in therapy as well.) Psychiatric care was generally con- tracted to our local state human re- don‘t believe in ourselves, we have the I left Navajo country physically stitched source center, and the wait time was gracious gift of others believing and sup- up, ready to find a new place to serve, generally three months for new patients. porting us. That is a part of the RxP searching to find a new, safe, work If we needed to get psychiatric care story for me and others who are in the home. I assumed the Behavioral Health faster, we may have to try and get an process. Director position at Spirit Lake Health appointment at Grand Forks, 90 miles Regrouping, I took an additional one and Center, at Ft. Totten, North Dakota. away or Fargo which was more than a half years to study, involving all week- Both my wife and I were feeling beat up 150 miles away. Either would take two end, almost every weekend with few by our previous duty assignments and months or so to get someone seen. So, exceptions, and often three to four needed a quiet place to recover. We from the get go, my PCP and I began nights a week. I grew to appreciate the talked in earnest about the require- consulting on psychopharm. Our Chief complexity of the material and the intri- ments I needed to complete to get this of Pharmacy became a strong supporter cate biological design of these bodies we magical prescription pad- pass the PEP, of RxP as she saw me talk and educate carry, and developed immense respect and get the 80-hours of medical intern- about the Medical Psychology model of my medical peers for their effort. ship and 400-hours of preceptorship. being integrated into the primary care However, I found myself growing more We discussed the investment we had treatment team. With a few exceptions, and more cautious, then honestly appre- made personally in the past 5 years, the entire medical staff supported my hensive, of being a capable, safe, and academically and personally. I frankly training, and welcomed me to complete responsible provider, given the enormity wasn‘t sure I was up to the task. We and get the NM Conditional Prescribing of the pure book knowledge I was at- decided that we, or I, needed to get it License. What a nice change! tempting to master. done now. Over the course of the next three This fear led to a conversation with Di- Spirit Lake Health Center was the Indian years, I studied to pass that damn PEP rector Elaine LeVine concerning her Health Service‘s one-stop-shop clinic (said very respectfully). I found the program in Las Cruces. The nine-month serving the Dakota tribe here, of some mountain of material to study over- evidence-based medicine and patho- 6800 registered Indian family members, whelming. My first attempt at the PEP physiology course work sounded like not including other Indians simply living proved my worst nightmare, as I scored exactly what I needed. Soon, I began on the reservation. Our clinic has two five points below the passing mark. Af- flying down to Las Cruces monthly, physicians MDs, one Doctor of Nurse ter studying for more than 18 months while continuing my regular duties at Practitioner, one podiatrist, one dentist, for this event, I felt defeated and grew Spirit Lake Health Center. I found this

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Tilus, Water Buffalo Theology..., continued medically-oriented training immensely SD, after being deployed there recently I hope that RxP Culture and RxP psy- pragmatic and informative, with hands for a mental health disaster response, chologists ―get wet.‖ Watching from the on physician-supervised skill training. and my own Service Unit at Spirit Lake outside under the roof is silo practice. My confidence and ability began to Health Center in Ft. Totten, ND. I took Watching above in a god-like fashion is grow. At the end of these trainings, I almost seven years to complete my en- paternalistic and delusional practice. I began my 80-hour supervision training tire academic and clinical training in psy- hope our RxP culture continues to build within my own clinic under our clinical chopharmacology. This is a lifelong a water buffalo theology that puts RxP Director Dr. Candelaria Martin, M.D., a learning commitment, which to me con- psychologists‘ right smack in the rice Navajo family practice physician. This tinues to push my sense of integration. paddy with the water buffalo, letting intensive two weeks was a capstone to Thinking theologically about psychology, everything we do and think get wet, the Las Cruces training. and thinking psychologically about theol- relating to our patient, so that our biol-

Completing the nine months of course ogy, both impact our ability to think ogy, psychology and theology all have work, I immediately began my year-long biologically. the intentional design of being saturated in the culture we serve. We need to preceptorship with Dr. Martin, meeting A living practice, such as what I hope- crawl in and get ―sandwiched.‖ If getting weekly for supervision. Labs, reviewing fully have tried to describe here, in- the prescription pad sets us apart, medical records, taking vitals- all initially volves the ongoing dialogues between above, and distant, then we have gained were both overwhelming and exciting. ―living human documents‖ (using Anton nothing. The clinical training is so vital to estab- Theophilus Boisen‘s words) of both pa- lishing the actual knowledge base, that I tient and doctor. The use of RxP lan- I often wonder what happened to my wish I had more time and opportunity guage and training, like medical or psy- little, now grown, basketball buddy who to practice this on a daily basis. Skills chological diagnoses, needs to be an- played H.O.R.S.E. therapy so well. I not practiced clearly diminish, so cur- chored in the concrete data of living would like to tell him that I kept my rently I continue to do a mini-physical human experience. The depth experi- promise, and now he can get some and take vitals on all of my patients, do a ence of human suffering, in their medi- meds.

Review of Systems (ROS), conduct a cal, psychological, or spiritual contexts, LCDR Michael R. Tilus, Psy.D., MSCP serves as thorough medical record review, and demands the same respect and sacred- the Director of Social Services and Mental review labs (with all of my books on the ness as do the historic texts from which Health Programs at Spirit Lake Health Center in Fort Totten, North Dakota. He is a Conditional side as references). I talk to my PCPs the foundation of the medicine, psychol- Prescribing Psychologist in New Mexico, and has daily, and can‘t imagine practicing any ogy, pharmacotherapy, or Judeo- full prescribing privileges with the Indian Health other way. Christian faith (my bias) are drawn. Re- Services. He has chosen to serve in isolate, re- mote, medically underserved populations as the flecting on this living person, with their My New Mexico RxP application was focus of his Public Health Service Career. Mike living narrative, demands a sense of wa- served in the U S Army for 12 years as a Chap- submitted for four months before I re- ter buffalo theology- getting intimately lain and is a combat veteran of the first Gulf ceived my Conditional License. Since War of 1991. shaped by knowing the rice farmer, get- then, I have been credentialed and privi- ting in the rice paddy, riding the water leged for full RxP scope of practice at buffalo, in the rain. Standing Rock Reservation in ND and

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Suicide Prevention at Spirit Lake Health Center Antonette Halsey, MMgt

Spirit Lake Res- The 2005 North Dakota Suicide Plan ity was to become a trained community ervation en- reported that North Dakota suicide that could help at risk youth and com- compasses rates for ages 5-14 were 175% higher munity members. Meetings were held to 245,000 acres than the national rates, and 49% higher form a suicide prevention plan for Spirit in northeastern for ages 15-24. The ten-year suicide rate Lake Tribe. A draft is in the state of North Dakota for Native Americans was 174% higher revision. The Spirit Lake Tribe Suicide in Benson, than for their white counterparts. Dur- Prevention Plan will be completed and Ramsey, Nel- ing the ten-year period, the region of approved during the project period. son and Eddy counties. According to the North Dakota including Spirit Lake Res- Because a base of operations was 2002 Bureau of Indian Affairs Labor ervation had the highest suicide rate of needed for the effort, an initial applica- Force report, the total population of the the eight regions in the state, with 19.2 tion was submitted for the North Da- Spirit Lake Tribe (Mni Wakan Oyate) deaths attributable to suicide. According kota State/Tribal Suicide Prevention was 6,339. Of this total, 5,086 were grant in May 2007, and an award of Spirit Lake enrolled members; 350 were $42,500 was received in September American Indians from other tribes; and “The ten-year suicide rate 2007. This was seed money to begin 903 were non-Indians. The age distribu- for Native Americans was development of culturally specific mate- 174% higher than for their tion of the Native population, as com- white counterparts.” rials, and to provide community training. pared to the State, identified a very This led to a successful application for young population with 50% of the popu- the SAMHSA Garrett Lee Smith grant, lation under age 18: to the Spirit Lake Indian Health Services on behalf of the Spirit Lake community (IHS) Mental Health Program (2006), 48  Under 18—tribal population 49.6%, and many partnering agencies. The Spirit State 23.2% mental health assessments were com-  18 to 64—tribal population 47.6%, Lake Suicide Prevention Coalition serves pleted. Twenty-nine of the 48 patients State 62% as the advisory body for the grants, and or 60% were ages 10-24; and the re- The poverty rate on the reservation is will continue in that capacity for any maining 40% or 19 patients were in the documented by a variety of economic future funding. We emphasize the inte- age ranges of 8-13 and 25-63. During indicators: gration of the Dakota culture into all 2006, there were two suicide comple-  47% of the population lives below project activities with the approval and the poverty level (12% statewide) tions, six attempts, and twenty-five pa- blessing of tribal elders, who serve as  59.9% are unemployed (Bureau of tients with ideation and five exhibiting Indian Affairs, Labor Force Report consultants and coalition members. 2002) suicidal gestures. According to the National Strategy for  Median household income is $21,857 ($35,590 for North Da- The Spirit Lake Suicide Prevention Coa- Suicide Prevention commission (NSSP), kota) lition was formed in May 2005 for the culturally competent services are, ―the  95% of K-12 students were eligible common mission of saving lives that (2003-04) for free and reduced delivery of services that are responsive meals (Four Winds Community could be lost due to suicide, and helping to the cultural concerns of racial and School report) survivors of suicide recover. The prior-

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Halsey, Suicide Prevention..., continued ethnic minority groups, including their educators, and care providers missioner (later 1990s/early 2000s), Dr.  Goal 4- Strengthening the Commu- language, histories, traditions, beliefs, Mala assisted in developing the State's nity and values‖ (United States Public Health  Goal 5- Increased awareness of suicide prevention plan. Service Office of the Surgeon General, suicide prevention I serve as the Wiconi Ohitika Project 2001). Further, the Commission encour-  Goal 6- Evaluate the Wiconi Ohitika Project Coordinator, in addition to Vice Presi- ages collaborative efforts to recruit mi- The core of this project is based upon dent of Community & Library Services nority and bilingual professionals, the culture, language, values and history at Cankdeska Cikana Community Col- develop curricula addressing the impact of the Spirit Lake Dakota (Mni Wakan lege. Because of my dedication to the of culture, race, and ethnicity on mental Oyate) which promotes positive self- Spirit Lake Dakota Nation, where I am health and service use, and train and identity, increased self-esteem, and an enrolled citizen, I have made it my research programs/services for multicul- knowledge of Dakota cultural compe- personal mission to work jointly with tural populations. We feel this initiative tency. We recognize that once students other agencies, so we can combine re- supports the project we developed to acquire basic knowledge of their culture, sources and effectively improve services meet the needs of our community. history, and spirituality, they become offered. As a community, I believe we The Wiconi Ohitika ―Strong Life‖ Pro- more confident and willing to make can set our minds to accomplish any- ject is a federally funded Garrett Lee positive choices that will lead to health- thing! Through the Wiconi Ohitika pro- Smith suicide prevention project, serving ier lifestyles. ject, community partnerships have been the Spirit Lake Dakota Nation in Fort built and existing collaborations Cynthia Lindquist Mala, PhD, President Totten, North Dakota. It is based on strengthened. of Cankdeska Cikana (Little Hoop) the Dakota culture, and provides suicide Community College, which serves the A critical element to the success of the prevention services to Spirit Lake com- Spirit Lake Dakota community (her project is community ownership and munity members, ages 10-24. We are home reservation), brings great exper- continuity of coalition support. Our currently in year two of a three-year tise to her role as Project Director. Dr. coalition membership has been greatly grant. Our project purpose is to edu- Mala earned a master‘s degree in public enhanced through the consistent partici- cate and strengthen the Spirit Lake administration, with an Indian health pation and support of Dr. Michael Tilus. Tribal community to prevent the loss of systems emphasis, and a PhD in educa- Cankdeska Cikana Community College loved ones due to suicide. tional leadership. During her tenure as recently honored Dr. Tilus for his ef- The Wiconi Ohitika Youth Suicide Pre- Spirit Lake Tribal Health Director/ forts in attaining his Medical Psycholo- vention Project has six goals: Planner in the 1980s, she was a member gist certification. The basic premise of  Goal 1- Project Implementation and medical psychology is recognizing that Community Engagement of the Tribe's interagency working  Goal 2- Partner with Four Winds group for suicide prevention. At that body and mind are one. This is in align- Middle and High School, Warwick time, Spirit Lake Tribe had only one ment with Dakota thought and philoso- Middle and High School, and Minne- waukan to provide suicide preven- mental health social worker, and docu- phy, of harmony and living in balance. tion support mented three to four suicide attempts Traditional healing is "holistic,‖...  Goal 3- Implement suicide preven- tion training to the community, per week. As ND Indian Affairs Com- (continued on pg. 16)

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Halsey, Suicide Prevention..., continued

(continued from pg. 15) the coalition by expanding and recogniz- that when times get tough, they are ing our circle of providers including resilient enough to stand up to the chal- … dealing with the total individual in- Mercy Hospital and Lake Region Human lenge. stead of focusing on diseases or condi- Services Center. His contributions to tions. Dr. Tilus‘ active involvement and Antonette “Swadeau” Halsey serves the Spirit Lake Dakota community as Vice President of support of the project is evident our effort are immeasurable and invalu- Community & Library Services at Cankdeska able. through his regular attendance at Cikana Community College. She is the coordina- monthly coalition meetings, willingness Through Wiconi Ohitika project, we tor for the Wiconi Ohitika “Strong Life” suicide prevention project. As an enrolled citizen of to assist in providing gatekeeper training encourage and provide activities that Spirit Lake Nation, she lives and works to im- for the community, sharing of appropri- will strengthen our youth and families prove services and develop needed programs for ate resources including articles and through learning about where we come, her community. She is proud of her Arikara and Hidatsa ancestry, carrying her American Indian books and, most recently, collaboration from elders who are willing to share name of “Swadeau,” which means “Dakota on a summer camp for area youth that their stories and wisdom. We empha- Girl” in the Arikara language. focuses on building social skills and pro- size education about the Dakota way of References viding opportunities for service learning life: spirituality, beliefs, cultural values, United States Public Health Service Office of the Surgeon General (2001). Mental projects. He is dedicated to assisting us traditions, history, music, sacred rites, Health: Culture, Race, and Ethnicity: A in building our community suicide pre- and perpetuation of our language so that Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: De- vention plan and crisis protocol. Dr. our youth will gain a positive self iden- partment of Health and Human Ser- vices, U.S. Public Health Service. Tilus has brought new membership to tity and a strong sense of self worth, so

How a Medical Psychologist Enhances Teamwork and Patient Care LuAnn J. Stromme, DNP, FNP-BC

I was born North Dakota, I practiced at Carrington the ―heart‖ of Fort Totten, which is and raised on Health Center with clinical, hospital and home to the Dakota Sioux Spirit Lake a farm in ru- emergency room experience. When a Tribe. I provide general medical care to ral North full-time position as a medical provider all individuals, from prenatal to the Dakota. I was offered at Spirit Lake Health Center "Golden Years" of the elders. Diabetes, completed a (SLHC) in Fort Totten, ND in August heart disease, arthritis, asthma, infec- Doctorate in 2009, I relocated to be closer to home tions, allergies, childhood illnesses, and Nursing Prac- and family. My husband operates a grain pain management are the primary medi- tice (DNP) degree as a family nurse farm northeast of Devil‘s Lake. Both of cal conditions treated. Depression, Practitioner at North Dakota State Uni- us are of German-Norwegian heritage, anxiety, chemical/ substance abuse, ne- versity, after being challenged by 20 and together we have three children, all glect and suicide prevention are the years as a registered nurse in neuro and attending colleges in Minnesota. primary psychiatric conditions identified cardiac intensive care, long term care, and treated. Spirit Lake Health Center is located in and dialysis. As the first DNP from

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Stromme, How a Medical Psychologist..., continued

Patient care at SLHC is coordinated thematous/irritated/ itching/draining in addition to ongoing medical collabo- among three mental health providers, eyes for several days. He had recently ration with me. Gradual improvement five medical providers, nursing staff, dia- lost his job. He admitted that he had not continued for this patient. Within three betes educators, lab, radiology, dietician, taken his medication for depression and months, he was able to secure a new and support staff. Dr. Michael Tilus, sleep for two to three months. He had job and was a regular attendee at a clinical and Medical Psychologist, is the relocated to the Fort Totten area to live health facility. This was a very positive director of the mental health facility with family, as his wife had left him and step for this patient in rebuilding his life, which is a part of SLHC. Patient care is he was without finances. He admitted to self esteem, and ongoing, positive men- regularly coordinated to include both struggling with his depression. As the tal health. His major depressive disor- medical and behavioral health aspects to patient was a ―walk-in,‖ providers are der, hyperlipidemia, hypertension, and accomplish holistic goals. Collaboration asked to only address the immediate chronic psoriasis continue to be moni- among the providers is a very necessary concern during this visit. The conjuncti- tored monthly, with adjustments to his reality for positive patient care. Dr. Ti- vitis would be treated, and the antide- medication regimen as appropriate. lus and the mental health staff share pressant would be prescribed. The pa- What a rewarding experience for not their documentation, following patient tient had labs completed (CBC, UA, P8, only the patient, but also for the provid- behavioral therapy, with differential diag- TSH, Liver, Lipids) and his hypertension ers, when collaboration gives results like nosis, recommendations, and medical was recognized. He was scheduled to this! care requests. Each patient is then re- be evaluated by mental health staff I can only speak positively of how suc- ferred to his/her primary care provider ASAP, and to return to me for a health cessful a medical psychologist working to rule out other organic or metabolic maintenance exam and lab results. so closely with the medical providers causes for their behavioral symptoms. Within the two weeks following this has been for countless patients! With An example of how collaboration be- initial visit, Dr. Tilus had evaluated this Dr. Tilus having prescriptive authority in tween medical and behavioral health patient with a recommended admission Indian Country, his wealth of experience professionals can be the true key to as an inpatient for psychiatric evaluation in behavioral health will continue to be positive patient outcomes came with a and treatment for his severe, vegetative even more valuable for positive patient 45 year-old Native American male who physiological depression. Upon his hos- care outcomes. presented to the SLHC as a ―walk-in‖ pital release, this patient continued with LuAnn J. Stromme, DNP, FNP-BC has been patient. I saw him for evaluation. This psychological therapy and psychophar- a Family Nurse Practitioner at Spirit Lake gentleman presented with bilateral ery- macotherapy monitoring with Dr. Tilus, Health Center since August, 2009.

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The Tablet, November 2010 j Page 18 THE TABLET: Newsletter of Division 55

An RxP Model of Collaboration Around Adolescent Asperger‟s Deb Hanson, LICSW

Author’s Note: The Anglo Saxons migrated in and home- 1995. I currently work with adolescents opinions expressed in this article are steaded. The Welsh retained much of at Four Winds School three days a the personal opin- their dark and swarthy complexion. My week, and for the last year have con- ion of the author, and do not reflect father had black hair and looked Native tracted at Indian Health Services Mental those of the Indian American, much like I do. Once when I Health two days a week under Mike Health Service or the United States was about eight years old and riding in Tilus, Psy.D. I have found collaborating Public Health Service. the back of the station wagon with my with all mental health workers within My name is Deb Hanson and I am a li- siblings, a man came to my tall father the community vital to serving the peo- censed clinical Social Worker; LICSW. and asked him if he had adopted a child ple. As a native North Dakotan, I was raised from Spirit Lake Nation. He later told I remember when I first started in 1995, north of Devil‘s Lake on a farm and cur- me this story, and said I should be being asked if I had any experience rently live west of Minnewaukan with proud of this. To this day Native Ameri- working with teens. I said I loved work- my husband. We used to farm but lost cans and White Americans will ask me if ing with teens, as I had worked with a much of our land in 1986 during the I am Native (It does make me proud). few, but wondered if I would be any farm crisis, about the same time I My personal family culture is an example good working with them on a full time started back to school. I was 36 and of the typical landscape for many local basis. I loved it from the moment I be- pregnant when I started attending the North Dakotan‘s, who both live and gan. The youth were so honest and University of North Dakota. I graduated work here in and around Indian country. kind, and willing to talk and keep them- in 1993 with a bachelor‘s degree in So- Within Indian country, religious and selves safe, if offered the chance. cial Work, and in 1999 with a master‘s cultural beliefs, practices, and ceremo- in Social Work. I continue trying to do my best for a nies are critical to understand, appreci- I returned to school because I believe proud nation and their youth, who will ate, and support. My religious back- individuals and families who live in rural be the future of the Spirit Lake Nation. ground includes being baptized Congre- communities deserve qualified profes- My Intro to Social Work class at Cank- gational, brought up in the Presbyterian sional counselors. I wanted to expand deska Cikana Community College is Church, confirmed Episcopalian, and the skills I had to help with the work I another way I can give back to the com- married and reconfirmed in the Lu- was already doing as a home visitor at munity and those who have helped me theran Church. I use spirituality in my Head Start, and later at Four Winds along the way. Five women took the therapy; listening and being respectful of School. class and all did well, hopefully beginning everyone‘s beliefs. This background the next generation of Social Workers Culture is very important here in the helps me understand differences in be- from within Spirit Lake Nation. Northern Plains. My culture both colors liefs, including those of Native Ameri- One of the first things we ―outsiders‖ and enhances my professional behavior cans. here in Indian country. My father‘s often do when starting to work within I feel privileged and honored to have Welsh people were forced to the Spirit Lake is to try to do too much. A worked at the Spirit Lake Nation since Northern Plains when the dominant wise friend, who is a pastor from Spirit

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Hanson, An RxP Model of Collaboration..., continued

Lake, took me aside and said, ―Slow being a medical psychologist, was able to rule out any organic reason for Joe‘s down or you will never last.‖ His wis- perform a mini physical exam in his of- behavioral difficulties with a full physical dom and generous support have helped fice, and was able to recommend she be examination, with laboratory, ECG, and me maintain continuity for the people brought to the emergency room for MedTox. Based upon all of the informa- here. detoxification, referred for a drug and tion gathered, Dr. Tilus diagnosed Joe alcohol evaluation, and that she return with Asperger‘s Syndrome. He then One story of a mother‘s struggle to to see me for counseling. We have made recommendations for behavioral raise her family demonstrates how avail- never had this level of behavioral health skills training. He also coordinated ser- ability of a medical psychologist can be provider in our isolated Indian Country vices with the high school educational helpful in this remote, frontier town. I who would be able to assess her active psychologist, to update Joe‘s current first met Mary when she was 35, and suicidal thinking and drug-induced mood cognitive status. trying to keep her family together after disturbance, as well as to then collabo- the suicide attempt of her husband. I Being a medical psychologist, Dr. Tilus rate with the Emergency Room physi- was working as a family therapist for was qualified to suggest an antidepres- cian for an emergent detoxification and Village Family Services. Mary and her sant for Joe‘s anxiety. Having then re- transfer to an inpatient substance abuse five children were understandably trau- ceived full prescribing authority here in treatment facility. matized. The family was battling sub- our clinic, Dr Tilus has continued to stance abuse, domestic violence, depres- Another example of how availability of a monitor this medication and is gradually sion and anxiety. medical psychologist has been helpful is increasing the dosage to achieve maxi- in the case of an adolescent referred by mum benefits. This has been a great Mary‘s mother had left her with her Four Winds Special Education. Joe of- asset to Joe‘s care, as the IHS clinic is grandparents as a young child but later ten arrived to our sessions flat and un- short-staffed, and Joe‘s primary care returned with an adopted daughter. emotional. He appeared to be an aca- provider has been on sick leave for a Her father would return to the home demically bright young man but strug- month. The primary care physicians now periodically, and physically abused her. gled with making age-appropriate rely on Dr. Tilus‘s judgment, both on The historical trauma interfered with friends, was often socially awkward and diagnosis and medication recommenda- her ability to learn the tools to keep occasionally behaved inappropriately. I tions. herself and her family healthy. referred him to Dr. Tilus, after he be- Because he is a medical psychologist, Nearly ten years later, a police officer haved inappropriately with me. Dr. Tilus was able to provide a large brought 45 year-old Mary to the Indian Dr. Tilus reviewed his medical chart range of psychological and medical ser- Health Service Behavioral Health De- history, conducted a full battery of psy- vices to this young man. We are so partment office for a suicide assessment, chological tests, consulted with his spe- happy now that Dr. Tilus recently was after stopping her for driving erratically. cial education director and principal, and granted full prescribing authority here in Mary‘s husband had moved out of the interviewed Joe and his mother on mul- our clinic. This fact alone will make our home, and she was struggling to raise tiple occasions. He coordinated care treatment options more available… another young child with a new boy- with Joe‘s Primary Care Physician to friend who had just left her. Dr. Tilus, (continued on pg. 20)

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(continued from pg. 19) out to a psychiatrist, with local wait Joe‘s continued therapy we me has also times of two months or with travel to improved because Dr. Tilus and I can … and immediate, allow for face to face Grand Forks, Minot, or Bismarck, with work together as a team toward giving collaboration between health care pro- wait times of two to three months. Joe‘s this young man the support he needs for fessionals, and save our clinic contract mother could not have afforded the a better life. I am proud to be a visitor health dollars. cost of this kind of care. This process for a brief time within this fine commu- Without a medical psychologist on this took almost two and a half months. But nity and to be able to work as part of case, Joe would have, no doubt, been given the legal problems that Joe was the mental health team at Sprit Lake IHS referred to an outside clinical psycholo- potentially facing, Dr. Tilus wanted to Mental Health. gist for testing, with a wait period of 6 ensure that everything that could be Deborah, Jones Hanson, LICSW is Vice President weeks and increased cost to the IHS done was done, for Joe‘s best care. of North Dakota’s National Association of Social Workers. Deborah works for Country Counsel- clinic. He would also have been referred ing & Consulting, INC and contracts with Indian Health Services and Four Winds High School.

Combining Western Medicine and Traditional Native Healing Marissa Taylor, RN, BSN

My name is Ma- home for the Navajo, where I worked saying the words and sentences on our rissa Taylor, RN, for a little over a year. break times. Even Dr. Tutt (Navajo MD) BSN. I have been a also was happy to say a few Navajo My first three month assignment was in healthcare pro- words with me. the Family Care Clinic. In this clinic, I vider for 30 years. worked with great people. I met Mary- My experience in the clinic was wonder- I would like to ann, a Navajo RN with whom I worked ful, but I wanted to be able to connect share with you my closely. She gave me an excellent orien- more with the patients, so when I was experience in working with the Navajo, tation to my duties and responsibilities. recruited to be part of the first Psychiat- Zuni, and Apache peoples. It has always She seemed a reserved but very caring ric Adolescence Care Unit (ACU), as a been my wish to work with the Native person. She is liked and respected by all staff registered nurse (RN), I accepted American peoples. I am fascinated with staff and patients that worked with her. the position. I was the first RN to be the spiritual aspect of health and their hired, and also the first RN who had Working in the clinic, I had very limited mindfulness. My own personal beliefs experience in Adolescent psychiatry. time to talk to the patients, so my learn- are that healing is within us, that our Our initial staff was composed of an ing of the culture was limited. When I brain is the most powerful organ of our administrator, also our nurse practitio- started expressing my desired to learn body, and that there is a relationship ner, a psychiatrist, a traditional practitio- Navajo, my co-workers started teaching between our body, mind, and spirit. So, ner (Shaman), a school teacher, an art me. We had a chalk board in the clinic, when the opportunity came to me, I teacher, RNs, and a mental health tech- and every day they would write words accepted a travelling assignment to go nician (MHT). I was, at first, surprised and then short sentences. I practiced to Ft. Defiance, Arizona. This is the that there was a Navajo medicine man

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Taylor, Combining Western Medicine..., continued on staff. I quickly realized, though, that Sweat Lodge there is no light; I was in- while western medicine helped heal he was an integral part of the staff, and formed that the lack of one sense (sight) their body. Although he was held in much respected by the patients and staff makes the other senses more alert and very high regard, and was much re- members. He performed many ceremo- allows the body to feel the spirits, and spected as a practitioner, some of our nies, and even held some sweat lodge feel itself healing. The sweat lodge patients expressed to me that they did ceremonies while I was there. Navajo represents the universe. not want to talk to him. The Navajo patients told me that they use both tra- Traditional Navajo healing focuses on children seemed to be very afraid to ditional and western medicines when the mind, body, and spirit. As such, I talk about their trauma. Some of the they become ill. believe that all three are connected, and children told me that they are con- As we went through numerous training that an imbalance in one can cause an fused, and that at times they don‘t like sessions and meetings, I became fasci- imbalance in the other two. With the being a Navajo, while other times they nated and more interested in Navajo Navajo, I was able to observe healing are proud of their culture. culture. I learned of many of the cere- ceremonies that lasted for days. I came Working with the adolescents and the monies performed (i.e. sweat lodge), to understand that the beliefs of the parents was very challenging, especially and other traditional remedies used to Navajo and Zuni were similar to my when the patient needed psychotropic help cleanse the body and take out the own, from my upbringing in the Philip- medication. Getting consent from the impurities. I learned that the Navajo pines. It was not uncommon during my parent, usually the mother, was very people believe in the power of spirits to childhood, that a ―Quack‖ doctor would difficult. I remember one time when heal from within. be called to cure an illness or injury with our psychiatrist asked for my help in herbal therapy. The surprising thing is talking to the mother, and trying to get One of the traditional therapies used by that often the cures worked. her approval for a mood stabilizer for the Navajo that I was most fascinated with was the use of the Sweat Lodge. I Our age group at the ACU was thirteen the patient. I had already developed a learned that the Ta‘che‘e‘h (Sweat to seventeen years old. Caring for those good rapport with this mother, and the Lodge) ceremony is spiritual, but not in in age group with mental issues is always patient would only talk to me, with the the structured sense of religion. It is a challenge. Many of these adolescents exception of one MHT. The mother used to rid the body of toxins, and to be suffered from addictions to alcohol and refused for her son to take this medica- one with the prayer and environment to drugs. They also suffered from emo- tion numerous times. I spoke to the allow the body to heal. It is the first tional, physical, and sexual abuse. These mother and the son separately, and ceremonial structure built by Talking adolescents needed someone who then both together. I patiently and carefully explained why the medication God (Navajo deity) to teach the Navajo would sincerely care for them, and care was needed. I also informed the the four seasons and the four stages of about them. They wanted structure and mother of my own personal observa- life, which are infant, adolescent, adult, they wanted to feel loved. tions of the patient since he was admit- and elderly. During the ceremony, the The medicine man on our staff was very ted. I asked her to give it a try, and if patient will enter and exit the sweat helpful, and sincerely wished to help the after 2 weeks if there were no… lodge four times to represent the four children. He helped heal their spirit, seasons and four stages of life. Inside the (continued on pg. 22)

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Taylor, Combining Western Medicine..., continued

(continued from pg. 21) talking to the patient and family. There the psychiatric ARNP and other medical were also periods that we did not have providers in the hospital. With a pre- ... changes, then we would revisit the a psychiatrist at all, and this often cre- scribing medical psychologist, patients treatment. I also promised to update ated a setback in providing treatment didn‘t have to wait for the arrival of the her daily about the patient‘s progress. The mother finally agreed, and we both for the patients. psychiatrist, or to accept the limited talked to the patient, who in turn fol- The arrival of Dr. Michael Tilus, Psy.D., treatment resources of healthcare pro- lowed what his mother told him. MSCP, a clinical and Medical Psycholo- viders not experienced in psychophar- gist was eventful. He brought knowl- macology. Integration of psychology For the most part, the Navajo adoles- edge, experience, and expertise to the and psychopharmacology provided a cent is very respectful of the adults/ clinical setting. He raised the treatment higher quality of care for all mental elders, and never did I hear them say of the adolescent patients to a higher health patients and their families. curse words to us, unlike where I had level of care. He increased the training My husband and I met some very good worked before, where the adolescents for the staff, and implemented new and people during my time with the Navajo. would curse at the staff when they were innovative treatments for the patients. My experience working with the Navajo angry. What is so amazing in caring for He organized our patient‘s treatment is something I will always cherish and these patients is that once you had de- plans and activities. His leadership and will never forget, because I learned so veloped trust, it was easy for to imple- support quickly gained the respect of all much and loved working with these ment their treatment plan. I felt a sense the staff, the patients and the manage- children. I was also fortunate to have of relief, accomplishment, and happiness ment. He instituted a physical fitness worked with very talented people like that I made a difference in their lives. program for our patients which corre- Dr. Tilus, from whom I learned so It was important to carefully incorpo- sponded with the Navajo traditional much. (Until that time I had never heard rate both the Western and traditional belief of running in the morning. He of a medical psychologist.) I hope some- Native medicines into an individualized coordinated with clergy and priests day, after completing my master‘s De- plan of care for each patient. One bar- from outside the hospital to come to gree in Nursing, that I will again have rier we had faced was the lack of a staff our inpatient unit and provide religious the opportunity to work with the Na- psychiatrist. The management attempted services to any willing teenager. He es- tive American people. There is so much to fill this gap with a contract psychia- tablished practice standards for our in- to learn from them and their culture, trist. This presented another barrier, tegrated, behavioral health staff with which for me is fascinating. And, I hope since the contracts were for a one scope of practice modeled after sepa- to work with other medical psycholo- month period, causing a lack of continu- rate licensing agencies. Dr. Tilus was gists like Dr. Tilus who, in my opinion, ity of care for our patients, since the known to drop in and visit staff, and are the best trained and equipped to be psychiatrist changed every month. This check on the patients during the swing the behavioral health leaders in cultur- setup resulted in a lack of trust from the or graveyard shift. ally diverse populations like Indian coun- patients, plus a loss of credibility. This is try. When we had no psychiatry support, one of the reasons why I was always Dr. Tilus reviewed the teenager‘s psy- Marissa Taylor, RN, BSN is pursuing a master’s asked by our psychiatrist to assist in Degree in Nursing from Walden University. chotropic medications, consulting with

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The Perspective of a Northern Plains Dakota Elder and Social Worker Joanne Streifel, LICSW

Author’s Note: with both psychological and prescriptive them again until a new crisis arises. If a The opinions expressed in skills, in our office every day! psychiatric evaluation is needed for help this article are in establishing an accurate diagnosis, the the personal Being in a rural community and on a lack of a readily available psychiatrist or opinion of the reservation, resources have been scarce author and do psychologist makes it difficult to develop not reflect those to almost non-existent. Having limited an effective treatment plan in a timely of the Indian resources in our local communities im- Health Service manner, and we run the risk of losing or the HHS. pacts how effective we can be with our the patient. I am an enrolled member of the Spirit treatment. Our local general practice Lake Nation here in Fort Totten, North physicians feel that to prescribe anti- This has changed dramatically since Dr. Dakota. I continued my education away psychotic medications is out of the Tilus arrived. We now have a Medical from the reservation, and obtained my scope of their practice, so a referral Psychologist who not only evaluates our master‘s in Social Work in San Antonio, must be made to a prescriber with ex- patient‘s medications and has prescrip- Texas. I returned to my home in 1981, pertise in this type of medication. When tive authority, but assists us in our more and have been employed with a number difficult cases with psychological testing of social work type agencies on the res- and differential diagnosis consultation. “… the wait may be ervation for the past 29 years. All of my We have established a system where my anywhere from three to six patients who are seeing me for therapy post graduate experience has been in weeks for an appointment follow up with Dr. Tilus for their psy- the mental health field. with a psychiatrist, if we are chotropic medication management, to At the present time, I am a clinical social lucky, and two months or get their lab values reviewed, and to worker for the Indian Health Services more if we have to look to have a hands on mini-physical screening (IHS). During these past 20 plus years, I our surrounding area.” with all their vitals taken and reviewed. have worked alone in a mental health My patients have been extremely happy office much of the time, though some- we need to arrange for psychiatric ser- with this arrangement, and we are now times with a psychologist or occasionally vices for outpatients, or for medication seeing a significant increase in patient with another social worker. The work follow-up after the patient is discharged adherence to both coming to therapy has been rewarding, but very challenging from inpatient psychiatric care and re- and taking their medications as pre- at times. I have never had the opportu- turns to the community, the wait may scribed. nity to work with a psychiatrist on a be anywhere from three to six weeks reservation, and have only recently had The lack of adequate alcohol and drug for an appointment with a psychiatrist, if the last three plus years to have a Medi- treatment in local Indian communities we are lucky, and two months or more cal Psychologist as my supervisor and adds another tremendous problem in if we have to look to our surrounding Director of the Behavioral Health Pro- working with individuals having a dual area. Much of the time, patients will gram here at Spirit Lake. What a bless- diagnosis. Our people have to… come for help only in an emergency, and ing to have this level of professional, (continued on pg. 24) once the crisis is over we will not see

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Streifel, The Perspective of..., continued

(continued from pg. 23) drug use) and their prescribed medica- an appropriate professional to help us. tions. Another of my patients appeared ... travel hundreds of miles outside of When this patient returned to the com- to be suddenly slipping into a new major the community for some of the neces- munity, Dr. Tilus, our DNP (Doctoral depressive episode and was having sary alcohol and drug treatment, leaving level Nurse Practitioner) and I collabo- problems thinking. While in consultation their family, school, and community sup- rated about his integrated treatment with Dr. Tilus, we discovered she had port. This complicates the treatment plan. The results have been astounding, relapsed in her alcohol misuse and had plan, and typically family involvement both for us as a treatment team and for not been taking her diabetic medications never happens because of the distance our patient. My patient continues to as prescribed by her physician. Her glu- and expense. Once patients discharged make progress in individual psychother- cose levels were extremely high, and from substance abuse treatment return apy with me. Dr. Tilus administered a she was getting more and more de- to the community, the proper support is battery of psychological tests, per- pressed, while drinking more and more then not there to help them maintain formed a religious and spiritual inven- alcohol. This is the kind of care we are sobriety. So the revolving door swings tory assessment, reviewed his current now providing together, as a team with back and forth, as we try to provide psychotropic regimen, and collaborated a Medical Psychologist on staff. Having adequate treatment. directly with our DNP in monitoring his prescribing psychologists available for other medical conditions of obesity, With the promise of prescribing psy- our people will mean they will receive edema, and high blood pressure. Our chologist services, the services to the much needed services in a timely man- DNP conducted a full physical examina- people (Oyate) are improved greatly. ner. With timely assessments and treat- tion, got him caught up on all his labs, Now, with a prescribing psychologist on ment comes faster recovery. did a baseline ECG, and consulted with staff, needed services of evaluation, diag- Another particular patient of mine both Dr. Tilus and I regularly about his nosis, and treatment with psychotropic comes to mind as another example. Just other medical care. Dr. Tilus also sees medications can begin almost immedi- before Christmas, a 45 year-old male him once a month, and reviews his ately, rather than having to refer out to presented with severe, vegetative, psy- medications, recently gradual tapering psychiatrists, with patients going on long chotic depressive symptoms and signs, his previously prescribed sleeping medi- waiting lists. Almost all of our patients with an acute suicidal plan. After a ten cation and benzodiazepines, with the who have drug or alcohol problems also day stay as an inpatient, he returned goal of stopping them as soon as it is suffer from some anxiety, mood disor- home and began counseling twice a clinically viable. Our patient has re- der or trauma. We now have the spe- week with me. He had been started on turned to work, received a promotion, cialized ability to help our people who antidepressant, anti-anxiety, antipsy- lost weight, started working out again, suffer with dual diagnosis problems. chotic, and sleep medications at the improved his diet, renewed his child- I recently had one of my patients sent to hospital. Our local physicians were not hood Catholic faith, been compliant on the emergency room by Dr. Tilus be- comfortable monitoring or prescribing his psychotropics, and is mending and cause they were having a ―drug-drug‖ all these medications, which in the past establishing new healthy boundaries interaction problem between their alco- has puts us and our patients in some with family members that he was never hol, amphetamine (or some other illicit jeopardy as we scrambled trying to find able to before. When I was stumped as

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Streifel, The Perspective of..., continued to what to do, all I had to do is walk strong leaders. Those of us who believe psychologists who come to Indian coun- across the room and consult with Dr. in the strength of our way of life con- try will be true healers who practice Tilus. This type of collaboration and tinue to teach and help our younger from a good heart! support between professionals helps us generations learn and hold sacred our Joanne A. Streifel, LICSW is a member of to use our individual areas of expertise way of life, in spite of sometimes over- the Spirit Lake Nation at Fort Totten, North to the fullest, while reducing job stress. whelming odds. This resiliency and faith Dakota. Her Indian name is Wakagege sa of the Indian families is what holds us winyan(woman who likes to sew). She has I can‘t help but think of the years when I been with IHS for the past 6 years. together. We rely on one another for tried to get help from, and have the hope and faith that tomorrow will be patient monitored by, a psychiatrist at better. I hope and pray that the medical the State regional center in a nearby town. It was always so difficult to share information about the patient‘s pro- gress, ask questions, or to have time to Division 55 really talk about my concerns for the Board of Directors for 2010 patient, being in separate agencies sepa- rated by miles. I cannot emphasize President– Owen Nichols, Psy.D., ABPP, MP, ABPP enough how wonderful it is to have a prescribing psychologist on board in the President Elect– Glenn Ally, Ph.D., MP facility where I work. Past President– Morgan Sammons, Ph.D., ABPP If the challenges were hopeless, not Secretary– Arlene Giordano, Ph.D. many of us would hang around Indian Treasurer– Mark Skrade, Psy.D. Country. But our people have continued to survive and thrive through major Members at Large: difficulties down through the centuries. The history of our people is fraught Jeff Matranga, Ph.D., MSCP, ABPP with trauma after trauma, as we have Earl Sutherland, Ph.D., MSCP striven to hold on to our traditions and Robert Younger, Ph.D., MP, ABPP to grow from our efforts to maintain our culture and way of life, even in the APA Council Reps: midst of the influence of the mainstream culture impacting us from every side. Elaine LeVine, Ph.D., ABMP But the resiliency of the Native culture Beth Rom-Rymer, Ph.D. is what holds the fabric of life and mean- ing for us. Our traditions have been APAGS Representative– Audra Schulman handed down to us from wise and

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A Pharmacy Director‟s View of Collaboration with a Prescribing Psychologist Cynthia Gunderson, R.Ph.

Ever since I can remember, I have had pharmacy consultation services, provi- tations do not always afford psychiatric an interest in helping people. I decided sion of adult vaccinations, and involve- referral for medication management to pursue a career in pharmacy to be on ment in countless special projects within services. It is timely to illicit novel ‗the front lines‘ as a patient advocate. the Spirit Lake Health Center. strategies to address these needs in the Even as a young pharmacy student, I was provision of quality patient care. involved in public health through my I once again find myself in an era of “Utilizing a prescribing involvement with multiple indigent clin- change with a unique opportunity to psychologist is one example ics serving greater Omaha, Nebraska. It enhance services on the reservation. I of creative problem-solving was through this rewarding interaction have had the pleasure to interact with a that I decided to pursue a career in pub- that optimizes patient outcomes and maximizes psychologist pursuing prescriptive au- lic health, more specifically with the budgetary expense.” thority. Our collaboration has been re- Indian Health Service (IHS). Working warding and has improved medication with the pharmacist recruiter for IHS, I management for multiple patients. isolated a great need for pharmacists in We have been able to accomplish these We utilize a simple multidisciplinary North Dakota. After much prayer, I felt improvements and establish an exem- referral process, whereby a patient will a calling to serve the people of the Spirit plary department through progressive be referred from any of our direct care Lake Nation near Devil‘s Lake North thinking and priority placement of the patient departments for psychologist Dakota. patient and his/her needs. I have person- evaluation. A patient may be referred I arrived at the Spirit Lake Health Cen- ally observed a great need for qualified back to primary care for further testing ter… my first day on the job as a brand behavioral health professionals in Indian and diagnosis, following the initial behav- new pharmacist with the ink still wet on Country. The high rates of suicide, co- ioral health appointment. Often, the my license. The sole pharmacist working morbidities, and poly-substance abuse prescribing psychologist will make rec- at the clinic informed me that he has alone warrant the expansion of psychiat- ommendations to alter pharmacother- submitted his two week notice. Since ric services on the reservation. As a apy, to improve patient outcomes. The that first day, I have developed as a per- pharmacist, I appreciate the many nu- recommendation is screened by phar- son, a confidante, a pharmacist, and a ances of psychotropic therapy, and real- macy for appropriateness and drug in- clinician. We have built our pharmacy ize the limitations of primary care and teractions. Any pharmacy recommenda- program to become a model within the budgetary constraints. The myriad of tions are communicated to the prescrib- Aberdeen Area. I have recruited and antidepressants, mood stabilizers, and ing psychologist at this time. All commu- retained two exceptional clinical phar- antipsychotics mandate great care with nications are secured in the Electronic macists. Together we provide services prescribing and patient monitoring. Medical Record. to approximately 4,000 patients annu- Often, these subtleties are overlooked A multimodal approach aligns patient ally. We have expanded pharmaceutical in primary care, as progress is unable to treatment plans, to place the patient at services to include management of sev- be quantified by a lab test. Additionally, the center of his/her medication regi- eral direct patient care clinics, enhanced service unit policies and budgetary limi-

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Gunderson, A Pharmacy Director’s View..., continued men. This multi-disciplinary management without a corresponding line item in- Cynthia (Cindy) Gunderson is the Pharmacy Director at the Spirit Lake Health Center in rural has proven beneficial to the patient, the crease. Utilizing a prescribing psycholo- North Dakota. She is a 2004 graduate from provider, and the clinic flow, resulting in gist is one example of creative problem- the University of Nebraska, Medical Center improved patient outcomes, reduced solving that optimizes patient outcomes College of Pharmacy. time to optimal treatment, and reduced and maximizes budgetary expense. I side effects. look forward to continued collaboration

It has been my experience in IHS that between the prescribing psychologist we are constantly asked to ‗do more‘ and the pharmacist.

A Tag Team Approach with a Family Practice PCP and a Medical Psychologist Candelaria Martin, M.D.

I was born on a other provider, then came to me in June nosed as panic attacks from venlafaxine Navajo reserva- 2009 for headaches, while on venla- withdrawal. She responded well to tion, and grew up faxine. She was being treated for de- lorazepam given in the ED. I then pre- in New Mexico. I pression with excessive anger, and had scribed a small supply of lorazepam to come from a long just gotten up to a therapeutic dose of use while increasing the fluoxetine. line of traditional 150mg per day. She rated her headache Consult was made at this time with Dr. healers; I am the pain as a 7/10. She had a history of mi- Tilus to assist with management of what first to practice western medicine. My graines but reported this headache was I thought I was treating as depression. father tells me that growing up, all I ever different. It was located in the parietal At follow up, she brought in old pills to wanted to be was a doctor. My mother and temporal lobe area on the right, but be discarded, including hydrocodone, tells me that in traditional custom you was most severe in the forehead and clindamycin, clarithromycin, and do not choose to be a healer, it is more eyes, feeling like an expanding water cyclobenzaprine. She had a history of that you are chosen for it. When com- balloon just before it pops. She experi- being sensitive to medications, and had ing to a new Indian reservation in North enced nausea, tingling when she turned several listed intolerances. Dakota, I was fortunate to meet Dr. her head, and sparkling lights in her right She reported that she was crying a lot, Mike Tilus, our clinical and medical psy- visual field, similar to her migraines. But and was easily triggered. These symp- chologist, who enjoys collaborative care then the migraine did not develop. The toms used to occur about every other of patients. decision was made to taper off the month and had some association with venlafaxine and start fluoxetine. Despite While working with Dr. Tilus, I encoun- menstrual cycles, but now they were her mood issues, she was looking into tered a patient that exemplified why more frequent, almost daily. Her hus- getting pregnant again. knowledge of psycho -pharmaceuticals is band reported that she kept emotions... so important. My patient was a 35 year- Next, she was seen in the emergency (continued on pg. 28) old female who was being seen by an- department (ED) for what was diag-

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Martin, The Tag Team Approach..., continued

(continued from pg. 27) time use. Divalproex (Category D) had in the evening to discuss this emergent possible weight loss as a benefit, but situation. We believed the patient ... bottled up, then dwelled on things would need to be weaned off of before needed emergent psychiatric hospitaliza- which would trigger sad/upset emotions pregnancy due to potential neural tube tion due to her clearly manic episode. at random times. She felt she did better defects, neonatal liver disease, polycystic almost immediately when she started That same night, she was admitted to a ovarian disease and menstrual irregulari- the venlafaxine, then it seemed like it psychiatric hospital for inpatient man- ties. She was anxious to get her mood was losing its effect. After coming off agement. After a short two day hospi- symptoms under control, so divalproex the venlafaxine, the patient and family all talization, the discharge diagnosis from was started. She admitted at that time agree she was worse than before she the attending psychiatrist was Major that she had a prescription for phenter- started the venlafaxine. There was not Depressive Disorder with agitation. mine for weight loss that she had not yet improvement with the fluoxetine. Both Dr. Tilus and I expressed concerns used yet, and was advised not to use it, She soon went to the ED a second time, about this differential diagnosis, follow- as it could trigger a manic episode. Our and was diagnosed with labyrinthitis. She ing this clearly manic episode. The at- first goal was emergent mood stabiliza- was given lorazepam, ondansetron, a tending psychiatrist continued fluoxet- tion. Following that, we recommended liter of normal saline, ziprasidone and ine, lamotrigine, and trazadone, and biweekly individual psychotherapy, with hydroxyzine. She was tired, and had added quetiapine for sleep and anger additional weekly family therapy ses- vertigo in a clockwise direction. symptoms. After discharge, it was noted sions. Patient and family were in agree- that the quetiapine 50mg was helping In consultation with Dr. Tilus, after his ment. with sleep and not ―knocking her out,‖ direct clinical interview of the patient The following day after clinic hours, the but she felt a little foggy the next day. and her husband, our working diagnosis patient's husband contacted me to dis- She had stopped taking trazodone be- then changed to a rule out of bipolar cuss urgent hospitalization. Since seeing cause it made her too sleepy, and she disorder. The patient‘s mother was a her the day before, her symptoms had felt like a zombie the next day. She was professional Licensed Addiction Coun- worsened. She had been unable to sleep taking Compazine, as needed, for irrita- selor who had a history of alcoholism, for more than five to ten minutes at a ble bowel symptoms. She was still on and successful treatment for bipolar time, and was desperate to sleep. She the fluoxetine. She reported feeling like disorder. We decided to discontinue was constantly cleaning and working on she needed to be doing something all the fluoxetine. Dr Tilus and I discussed the computer. Her family expressed the time. options, including lithium (Category D); their increasing concern for potentially weight gain was the limiting factor for The next month, I spoke with her. She harmful behavior. Although she was not the patient, as well as needing to stop it reported she had not slept since noon violent, her irritability was worsening. before pregnancy. Lamotrigine the day before. Her daily routine was Her husband found her burning sage, in (Category C) would be slower to take not being kept, and she felt her meds much greater quantity than usual. The effect, but more compatible with her were not working well. She was advised family was afraid to leave her alone, or desires for pregnancy. Quetiapine to go back to her routine schedule, and to sleep themselves, for fear she might (Category C) was considered for bed- take quetiapine 100mg at bedtime. The burn the house down. I called Dr. Tilus

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Martin, The Tag Team Approach..., continued next day, she reported she had been ported a positive therapeutic alliance was only taking the quetiapine and Bena- able to sleep, only getting up 2-3 times with her new psychologist, who be- dryl. After about another 2 weeks, she during the night, and was feeling better. lieved, as the attending psychiatrist had, stopped all medications on her own in Dr. Tilus and I felt the fluoxetine trig- that she did not appear to be suffering pursuit of pregnancy. She continues to gered the manic symptoms, because the from a bipolar spectrum mood disorder have mild mood symptoms, but no full bipolar was not yet adequately con- but was experiencing an agitated de- relapse yet. trolled. She continued to be very driven pressed state due to childhood trauma. This is a case where two minds were to get things done, in excess of normal “As a family physician who definitely better than one in thinking (house cleaning, completing work as- also does obstetrics, I have through her drug intolerances, fear of signments on the computer from home, to be a jack of all trades. side effects, differential diagnosis dis- washing the cars, prolonged conversa- There is no way for me to crepancies, pregnancy concerns and her tions on the phone). She was fighting keep up on all the latest and greatest in self-adjustment of medications. Dr. Tilus sleep, despite objectively being noted to psychopharmacology. was there every step of the way. He have slurred speech and feeling like she Although I thought I was recommended treatment choices, and had been drinking. The plan was to stop pretty good with reviewed the pros and cons of each, the fluoxetine, and increase quetiapine psychiatric issues, I found out how useful having a taking into account that this patient re- to 150mg. We also continued the la- resource for ported many side effects to medications, mogrotine and restarted the valproic psychopharmacology like and was very fearful of side effects, mak- acid that had not been continued after Dr. Tilus is, in the rural ing treatment more difficult. He took her hospitalization. She was also to start setting we work in.” my calls after hours to assist in coordi- weekly couple‘s therapy and individual At the next follow up, she was taking nation of hospitalization, and to discuss therapy. the quetiapine 50mg at bedtime but the treatment options. Dr. Tilus always Before the next visit, she decreased her there had been days that she stayed kept the patient‘s long and short-term quetiapine to 50mg at bedtime, and was home due to being too tired to function. plans in mind. having less hangover effect. She also cut Her lamotrigine was still being increased As a family physician who also does ob- back due to concern about the weight to the therapeutic dose of 200mg a day, stetrics, I have to be a jack of all trades. gain side effects. She continued to and her mood was more stable. About There is no way for me to keep up on slowly titrate up on the lamotrigine. Her one week later, she called the ED to all the latest and greatest in psychophar- family was watching her closely and report a rash that was gradual in onset macology. Although I thought I was worried about hypomania, based on with rough texture, with red areas on pretty good with psychiatric issues, I witnessed activities such as taking out her back, and was starting to spread. found out how useful having a resource the trash while doing laundry. She had She denied hives, but had blister-like for psychopharmacology like Dr. Tilus begun individual therapy with an outside lesions above her buttock. The ED is, in the rural setting we work in. psychologist, as Dr. Tilus wanted to phone recommendation to her was to Candelaria Martin, M.D. is the clinical Director keep the couple‘s therapy separate from take Benadryl and to stop the medica- of the Spirit Lake Health Center. the patient‘s individual work. She re- tions. She stopped the lamotrigine, and

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My Experience as a Prescribing Psychologist at the Fort Peck Unit Bret Moore, Psy.D., MSCP, ABPP

Prior to beginning Although he tried to prepare me for solid foundation related to understand- my training in where I would be working, not even ing psychotropic medications and were clinical psy- Hemingway could adequately describe well-rounded physicians with an impres- chopharmacology, the remoteness and desolation of the sive fund of medical knowledge. I had little reason area. The level of medical comorbidities, lack to believe that After a few conversations with MassI, it of compliance, and rampant substance two years later I became evident that something great abuse and dependence were my great- would find myself tucked away from the was about to happen within the Indian est obstacles during my training. Many rest of the world in Poplar, Montana. I Health Service, and at this service unit in of my patients were either diabetic or was very content with my current posi- particular, with regard to RxP. The prediabetic, had a history of high blood tion at the time, as an active duty Army groundwork for a formal preceptorship pressure and/or kidney dysfunction, psychologist. However, as we can all had been laid. The Chief Medical Officer were active or past users of alcohol and/ attest, things unexpectedly change. was supportive of prescribing/medical or drugs, and were on a list of medica- During my second year of training at psychologists, as was the area behavioral tions as long as my arm. In retrospect, I Fairleigh Dickinson University, I decided health consultant. All that was needed think I took more time looking up possi- that I would leave the Army for several were a few warm bodies looking to ex- ble medication interactions and medical reasons. I had spent 27 months in Iraq. pand the breadth of psychiatric care at diagnoses than I spent talking with my The Army did not have any formal pol- the service unit. patients (contrary to what you learn in icy in place to allow properly trained class, but often times necessary in prac- psychologists to prescribe. Also, it was “… the model of tice). likely that I would be placed in a super- collaboration between Over the next year, my confidence as a visory position which would not allow prescribing/medical prescriber grew. I hadn‘t killed anyone, me the opportunity to prescribe. psychologists and non- and it seemed like many of my patients As the end of my tenure in the Army psychiatric physicians is one were getting better. And I did all of this neared, I began the mad dash to find that works.” with the closest psychiatrist being three work that was consistent with my ca- and a half hours away in Canada! Point reer goals and suitable to my personal- Other than a few small bumps in the being that the model of collaboration ity. Fortunately, an ―old Army buddy,‖ RxP highway, the training went well. I between prescribing/medical psycholo- MassI Wyatt, encouraged me to con- saw 5-6 patients a day for medication gists and non-psychiatric physicians is sider working with him at the Ft. Peck management, and met weekly with ei- one that works. Service Unit of Indian Health Service in ther a general practitioner or internist Sometime in the early part of this year, I Poplar, MT. At the time, I knew little for supervision. `Neither one of my su- completed my preceptorship. Subse- about Indian Health Service and nothing pervisors were anything close to psy- quently, I have been fortunate enough to about Ft. Peck and Poplar, Montana. chopharmacologists, but they did have a successfully navigate the paperwork

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Moore, My Experience as a Prescribing Psychologist..., continued process, and update my privileges at my clinical psychologist so difficult. Many of some of the most difficult areas in the service unit. As of April 1, 2010 my patients have multiple problems, live country. Thank you! (assuming this was not an elaborate in abject poverty, have suffered emo- Bret A. Moore, Psy.D. completed his doctorate in April Fools‘ joke), the New Mexico tional, physical, and sexual abuse as chil- clinical psychology at the Adler School of Profes- Board of Psychologist Examiners offi- dren, and see little hope for a brighter sional Psychology and the postdoctorate Master of Science degree in clinical psychopharmacology cially recognized me as a Conditional future. Ft. Peck, like many reservations from Fairleigh Dickinson University. He is li- Prescribing Psychologist. in the Northern Plains area, is not the censed as a conditional prescribing psychologist place for the faint of heart. by the New Mexico Board of Psychologist Exam- In mid-July of this year, my request for iners and board-certified in clinical psychology by privileges to order my own medications the American Board of Professional Psychology. He is the author and/or editor of four books, and labs without the co-signature of a “My experience as a including Living and Surviving in Harm's Way, physician was approved by the medical prescribing psychologist Wheels Down: Adjusting to Life After De- governing body of my service unit. Al- ployment, Pharmacotherapy for Psycholo- within the Indian Health gists: Prescribing and Collaborative Roles though this is not an IHS wide policy, it Service has been (recently released and co-edited with Bob does set a precedent for future service outstanding…. The future McGrath, Ph.D.), The Veterans and Active units within IHS, and provides guidelines Duty Military Psychotherapy Treatment of RxP within Indian Health Planner and Handbook for the Treatment of for other psychologists who are looking Service is bright.” PTSD in Military Personnel. He also writes a to prescribe. biweekly newspaper column entitled “Kevlar for the Mind,” which is published by Military Times. Today, I provide psychotherapeutic ser- His views and opinions on clinical and military The future of RxP within Indian Health vices to most of my patients, and have psychology have been quoted in/on USA Today, Service is bright. There are some very become more popular with the medical New York Times, Boston Globe, NPR, BBC, smart and dedicated people moving this and CBC. He writes a Psychology Today blog staff due to my becoming a new referral called The Camouflage Couch at collaborative effort forward. We are source for their ―psych‖ patients. I now http://www.psychologytoday/blog/the- fortunate to have psychologists within know what it‘s like to be a prescribing/ camouflage-couch Division 55, such as Beth Rom-Rymer, medical psychologist, and I like it. Better Kevin McGuiness, Robert McGrath, and yet, my patients like it. Steve Tulkin, supporting this effort, as My experience as a prescribing psy- well as those in the ―trenches,‖ such as chologist with the Indian Health Service Earl Sutherland, who is with the Crow has been outstanding. Not a day goes by Agency outside of Billings, MT, LCDR that I am not intellectually challenged by Mike Tilus, who is at Ft. Totten in the complex cases I see. However, my North Dakota, and Dr. Robert Chang, time at the Indian Health Service has who occupies an office next to me here been emotionally and psychologically at Ft. Peck. Both groups are important trying. The aspects that make being a players in this effort, but I believe the prescribing psychologist so rewarding latter need extra thanks for pushing this are the same ones that make being a movement forward while serving in

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A Prescribing Psychologist‟s Quest to Provide Culturally-Sensitive Care Mimi Sa, Psy.D., MSCP

Author’s Note: The tween the three entities. All of the grandmother was raised in Michigan opinions expressed in this article are the per- tribes I spoke with asserted that West- during a time when it was shameful to sonal opinion of the ern illnesses should be treated with be Native, so she fiercely denied her author and do not reflect those of the Western medicine (i.e., strep throat), heritage, cut her hair short and dressed Indian Health Service but that spiritual illness must be treated Western. As a result of this shame, I or DHHS. with traditional medicine. They also all was raised in the Western culture in It was during graduate school in Minne- agreed that a spiritual illness could cause Minnesota. However, stories of our sota that I first became acquainted with mental or physical symptoms, and vice heritage, pictures of our relatives, and the notion of cross-cultural psychology. versa, and urged me to be cautious the proximity with many Ojibwe and I heard about a young Mexican girl living when treating indigenous patients. Dakota tribes has helped keep my heri- in Minneapolis who was put on Zyprexa tage alive for me. and hospitalized for several months, because she told the psychologist she “I became particularly Although raised Christian by my sees the spirit of her deceased grand- interested in the crossroads mother, which has given me Christianity mother, and even speaks with her. This between psychosis and as a strong base, I have studied and young girl reportedly had no negative spirituality, and was practice traditional Native American symptoms of a thought disorder, and passionate about ensuring ways of the Northern Plains and Wood- was otherwise functioning normally. that an individual not be land Indians. This belief system has al- labeled as thought- lowed me to communicate with and It was at that moment that I decided to disordered for displaying understand my Native American col- dedicate the focus of my clinical work in culturally-normative leagues who are healthcare providers, as psychology to striving toward culturally- spiritual practices.” well as my Native patients. Often when I sensitive care, and to do my part to meet my patients for the first time, they ensure that the above-mentioned sce- are only prepared to meet with a West- nario would never occur again. I became Clearly, a clinician‘s own background ern provider and discuss merely West- particularly interested in the crossroads can affect her perception of the presen- ern diagnoses. However, assessing for between psychosis and spirituality, and tation of a patient, as well as treatment level of acculturation and personal belief was passionate about ensuring that an decisions. Therefore, some of my per- systems of my patients is one of the individual not be labeled as thought- sonal background is provided here as a initial tasks I perform as part of the diag- disordered for displaying culturally- reference. I am the descendant of the nostic process. Sometimes after realiz- normative spiritual practices. This pas- Blackfoot Tribe from the Saskatchewan ing my willingness to discuss Native sion drove the focus of my dissertation, area of Canada, via my great- spirituality, a patient will tell me that and led me to Native American tribes in grandmother. She was given a Catholic they personally do not believe they have Brazil, Costa Rica and Minnesota to ask name and married a French Canadian, an organic mental illness, but that their their elders about spiritual, physical and which is making genealogy and enroll- symptoms are being caused by some mental health, and the relationship be- ment for me quite difficult. My own other external source. The differential

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Sa, A Prescribing Psychologist’s Quest..., continued diagnosis at this time is critical, and I It was a dark winter day in February, sota, and share with the family doctors have developed some specific hallmarks when I received a colorful brochure in the area. Although it was a slow proc- to assist in that process. from Nova Southeastern University in ess for the physicians to learn to trust Ft. Lauderdale, Florida for a bi-monthly, my input, after about two years of col- Given my interest in cross-cultural psy- fly-in program in psychopharmacology laboration, they did come to accept chology, my first job after graduate for doctoral-level psychologists. I saw many of my suggestions for medications. school was at the Grand Portage Chip- the program not only as a wonderful Some of the physicians began sending pewa Reservation in Northern Minne- opportunity to get out of the frigid me every case note from doctor visits sota. Grand Portage has a small clinic weather, but also to combat my profes- my patients had with them, which was where the physicians from the local sional isolation and gain knowledge in immensely helpful. town come once per week. I established psychopharmacology that I could bring a working relationship with the physi- After much thought, I decided to ex- back to our small community. cians, who soon asked if I could see non pand my professional horizons by pursu- -Native patients. I started the program at Nova in the fall ing prescription privileges in New Mex- of 2004. My practice almost instantly ico. In accordance with my professional After three years of working directly benefited from the information I gained experience, I applied to the Indian and only for the tribe, I decided to leave in the program. I was able to start edu- Health Service, and was offered a job in the reservation and open a private prac- cated discussions with my patients about Taos, NM. The service unit was very tice in order to service the entire their psychotropics, such as what a excited to get a psychologist with RxP county, including the reservation. My medication was meant to do (some pa- training who wanted to pursue the abil- rapport continued with the five family- tients said they did not know why they ity to prescribe. practice physicians in the county. How- were taking a medication!), and what ever, I saw a serious gap in the provision The staff in Taos consisted of several action it was taking on their brain and of psychotropic medications (Minnesota family physicians, a physician assistant body. I was also able to answer many of reportedly has only one pediatric psy- and many contracted specialists, includ- the ever-important questions about side chiatrist for the Northern half of the ing a psychiatrist who came two times effects. state, making wait times for both chil- per month. The psychiatrist was gra- dren and adults as much as six to nine My first practicum for the psychopharm cious and supportive of me privately, months!). My knowledge of psychotrop- program was with a family practice phy- but warned me that his colleagues in ics at the time was cursory (the course- sician in southern Minnesota, who had New Mexico were vehemently opposed work provided in our doctoral program such a knack for psychotropics that his to RxP. at Argosy University in Minneapolis), but practice had become about 90% psychi- Working at the clinic was a wonderful even so, I often encountered patients atric. His patients raved about him, and opportunity to be in a primary care set- whose medication regime was concern- said he had helped them when no other ting and have nearly full access to a pa- ing (i.e., polypharmacy with serious side doctor had. I was able to take the in- tient‘s medical information, as part… effects and very little symptom relief). valuable knowledge I gained from this (continued on pg. 34) physician back up to Northern Minne-

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Sa, A Prescribing Psychologist’s Quest..., continued

(continued from pg. 33) tients with anxiety who were taking  Are there psycho-social factors in chronic benzodiazepines. They were the home that would make it diffi- ... of my decision making process for cult for this patient to follow a also required to make regular mental prescribing. The medical staff was very regular medication regimen? health appointments. Most of these pa- pleased to have a mental health provider  Does this patient need a referral to tients were able to wean off of chronic available at all times (we were often a physician or a spiritual healer? benzodiazepine use through behavioral pulled over to the medical side of the  Is this patient going to participate in health techniques or alternative psycho- clinic when patients began to cry, or cultural activities that could inter- they asked for our services), and I was tropics such as gabapentin. The medical fere with medication consumption, grateful to be able to ask their opinions staff was relieved, and the patient ulti- metabolism, or absorption? and collaborate with them dozens of mately benefited.  Will the patient be taking non- times throughout the day. We had staff prescription substances that could adversely interfere with the psycho- meetings three times per week that “Most of these patients tropic (i.e., peyote)? allowed the behavioral health and medi- were able to wean off of Of greatest importance, however, in my cal departments to update each other chronic benzodiazepine use practice of prescribing medications for on critical patients. through behavioral health Native American patients has been rap- One of the most useful collaborations techniques or alternative port, and taking time to understand the between our two departments was psychotropics…” presenting concerns of the patient as working with patients with chronic pain. they see them. The ultimate decision The staff decided that ALL patients with about a medication trial needs to be While there are many factors to take chronic pain would be made to sign a mutual between the provider and the into consideration when prescribing pain contract, and that one of the re- patient, with much consideration given quirements would be regular behavioral psychotropic medications, I have found to possible side effects, health, family, health appointments. I would take the the following particularly important and cultural factors. When the decision opportunity with these patients to fully when treating Native American patients: is mutual, I have found the patient to be explain the dangers of opiates, and work  Is there a substance abuse history more willing to take partial responsibil- on alternative methods of pain manage- with the patient or anyone in the ity for negative outcomes to medica- ment, including psychotropic options family? tions, and to have a greater willingness such as Cymbalta. In several cases, we  Is the patient overweight? to try alternative medications/ were able to wean the patients com-  What is the patient‘s blood glucose? treatments. pletely off pain medications. If patients What about family members? During my tenure at Taos, I completed missed behavioral health appointments  Is there family opposition to psy- all of the practicum requirements and without a valid reason, they were dis- chotropics due to cultural reasons? the PEP requirement for New Mexico continued from their pain contract.  Are there financial stressors in the family that may lead to medication licensure as a Conditional Prescribing Another helpful collaboration between diversion? Psychologist, and obtained the license in the two departments focused on pa- September of 2009 (along with a DEA

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Sa, A Prescribing Psychologist’s Quest..., continued license). Once I was fully up and run- ment for moral, not professional, rea- ioral Health Director for Mescalero, my ning, the collaboration at Taos and the sons. opinion on the clinical needs of the ability to use the EHR (electronic health community was met with strong opposi- Mescalero is a very different service unit record) system made the prescription tion. from Taos. In Mescalero, the previous process very seamless. I was able to psychologist was a master‘s level practi- I have tried very hard throughout the order lab work, and then look it up tioner who had formed a strong alliance training and education process of RxP to from my desk. I could also look up with the Center for Rural and Commu- maintain rapport with psychiatrists. It other test results for my patients nity Behavioral Health which is affiliated was very difficult to find physicians will- (including those from outside clinics). with the University Of New Mexico ing to take me on as a practicum stu- Lab results such as blood sugar, lipids Health Sciences Center. Psychiatrists dent, and I often had to look for very and liver function tests (LFTs) were from UNM were providing extensive independent and forward-thinking clini- particularly important. Often, patients amounts of tele-psychiatry for the Rui- cians. I have been very fortunate in this could not remember their medical his- doso and Mescalero school-based clin- process to learn from outstanding tory, and that was available to me as ics, as well as the Mescalero Behavioral healthcare providers. I believe that in well. Whenever I had a question about a Health program. All of the aforemen- some respects the unpopularity of RxP patient‘s medical history that was not tioned facilities had tele-health equip- among physicians gives those of us seek- readily evident, I could usually speak ment which they purchased through ing supervision the opportunity to look with the provider immediately. Phar- grants. Apparently, both the psychia- for cutting edge thinkers willing to sacri- macy was good about reminding me to trists (who were based at UNM offices fice collegial popularity in order to im- keep costs down; I did, at times, have to in Albuquerque) and the recipient facili- prove patient care. rationalize moving away from the IHS ties were able to bill for this service. While my current professional place- formulary (which is quite dated for psy- Adult, pediatric and substance abuse ment remains ambiguous, I continue to chotropics), but in the end we found an specialists were made available. be dedicated to and supportive of the amicable middle ground. I met the director of this rural behav- training of psychologists to obtain pre- I can‘t say enough positive things about ioral health program when he visited scription privileges. I believe the process my brief, 18-month experience at Taos. Taos several months earlier, and was of licensure preparation is professionally Unfortunately, the tribe decided to take told by him that the psychiatrists at invaluable, regardless of whether the ownership of the behavioral health pro- UNM are strongly opposed to RxP. provider ultimately obtains full prescrib- gram, and I very much wanted to remain Upon my arrival at Mescalero, I was ing authority. within IHS. I was asked to transfer down informed that this director would be my Dr. Mimi Sa currently holds a conditional pre- to the Mescalero Apache service unit in clinical supervisor, but that he was not scribing license in New Mexico. She has served southern New Mexico because the willing to sign off on supervision hours exclusively in health shortage areas, and primar- community was suffering from a suicide ily with Native American patients, for the past for my prescribing license. Unlike my 10 years. She has been a National Health Ser- cluster, and their psychologist was predecessor, I saw less of a need for vice Corps provider, and recently received recog- retiring. I accepted this difficult assign- tele-psychiatry since I could prescribe nition by the Indian Health Service for her par- ticipation in the suicide emergency at Mescalero. on my own. In spite of being the Behav-

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Breaking Barriers to Treat Addiction the Passamaquoddy Tribe Jack Martinez, Psy.D., MSCP, CCS

The study and ping, blueberry raking and construction was severe. Although the Sipayik reser- practice of psy- are physically strenuous, and can result vation appears isolated in many ways chopharmacology in injury after years of punishing the from the communities that surround it, takes place in a body. Physical and psychological pain poverty and addiction easily cross variety of contexts often accompanies years of poverty and boundaries. far from research oppressive living conditions. Efforts to I had worked in a health care system laboratories. Most alleviate pain and suffering have lead to that not only divided providers of physi- people I talk to who live outside of the discovery of medicinal plants and cal health from mental health, but also Maine have never heard of the Passama- the manufacturing of modern pharma- practitioners of mental health from sub- quoddy Tribe. Some are even surprised ceuticals. stance abuse counselors. Barriers be- to find out that there are American In- In the late 1990s Purdu Pharma began to tween ―specialists‖ were not serving our dian reservations in the state of Maine. aggressively market the opioid analgesic patients well. As a clinical psychologist serving in the OxyContin, a ―break through‖ (―safe At PPHC, an opportunity to tear down US Public Health Service (USPHS) Com- and effective‖) drug for the treatment of some walls presented itself in the unex- missioned Corps, and assigned to the pain. OxyContin was heavily promoted pected form of OxyContin and pre- Indian Health Service (IHS), I traveled to and welcomed in Washington County, scription drug dependence. For Oxy- Washington County, Maine to work for Maine, and primary care providers at Contin did not come alone, but brought the Passamaquoddy Tribe on the Sipayik Pleasant Point Health Center (PPHC) family (Dilaudid, Vicodin, Percocet and (Pleasant Point) reservation. The Sipayik also embraced it. Well-meaning physi- Percodan) and friends (Xanax, Ativan, Passamaquoddy (People of the Dawn) cians with good intentions began pre- Klonopin and Ambien). Soon after, live on a peninsula at the eastern tip of scribing OxyContin and other opioid methadone and buprenorphine joined the United States. Canada is a short, but analgesics, in an effort to treat chronic the party to help clean up. Pain- difficult, canoe trip across Passama- pain that many of their patients pre- generated anxiety and anxiety- quoddy Bay. The Pleasant Point Tribal sented with. There appeared to be little exacerbated pain and depression soon Health Center (PPHC) serves the medi- awareness or concern for potential risk settled in. cal and behavioral health needs of the of drug dependence, diversion, and 2,000 or so community members who As in many poor, rural areas throughout abuse. live on or near the reservation. the U.S., Washington County has diffi- When I arrived at the PPHC, stories of culty attracting and maintaining physi- Washington County, Maine is one of the Oxycontin abuse were making headline cians, psychiatrists in particular. Mid- poorest counties per capita in the news on television, and in newspapers level health care providers, family nurse United States, and unemployment and periodicals throughout the U.S. practitioners and Physician Assistants, among the Passamaquoddy is estimated Washington County, Maine was one of a provide much of primary care medicine, at 68%. Many tribal members rely on few rural areas (rural Appalachia being including the prescribing of psychotropic seasonal labor to eke out a living. Clam- another) identified where this problem medications. Patients in rural areas have ming and fishing, logging and brush tip-

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Martinez, Medical Psychologist..., continued relied on their primary care providers afforded an opportunity to apply for a medication, I can influence the decisions to prescribe prescription medication for scholarship to Alliant International Uni- that other prescribes make regarding the treatment of physical and psycho- versity‘s Postdoctoral clinical psy- which medications to give or to take logical pain. But many of these prescrib- chopharmacology Program. I feel very away. My knowledge enables me to ers were discovering that their treat- fortunate to have been selected for the contribute to the safe and effective ments were generating new and, often, scholarship, as one of the first psycholo- practice of clinical psychopharmacology more difficult problems. Questions gists to express an interest in the pro- at our health center, where many pa- about drug-induced anxiety and depres- gram. In the August of 2006, I began the tients present with co-morbid illnesses. sion, along with questions about drug rigorous 28 month course of study that Tribal members participate in Passama- seeking behavior, began to arise more culminated in receiving the master‘s of quoddy culture and spirituality in a vari- frequently, as did questions about with- Science degree in December, 2008. A ety of ways, and to different degrees. drawal symptoms, detoxification and year later I passed the APA Psychophar- Passamaquoddy people have great re- residential rehabilitation. Discussions macology Examination for Psychologists spect for their traditional cultural and and consultations increased between (PEP). spiritual practices. Tribal members who providers of what was once considered suffer addiction show respect by not as three separate health care services. “… given my current participating in most spiritual practices, At Pleasant Point, a behavioral health understanding of clinical but by doing so they are cut off from team was established in a collaborative psychopharmacology , I am the healing benefits of those spiritual effort to address these problems and in a much better position practices. By bringing a team of health meet the needs of community members, to help bridge the gap care professionals together and treating by providing a holistic approach to between primary care addiction holistically, the possibility health care. It was out of these collabo- medicine, addiction and arises for some tribal members to re- rations, and through establishing work- behavioral health.” connect with their traditional spiritual/ ing relationships with other health care healing practices that will help them providers, that I discovered the need to Currently, I am considering options for maintain healthy physical and spiritual expand my understanding of psy- and barriers to acquiring prescriptive lives. chopharmacology. As questions regard- authority with the possibility of pre- Jack F. Martinez, PsyD, MSCP, CCS has ing medication side effects, drug interac- scribing on the Passamaquoddy reserva- served in the US Public Health Service tions and mechanisms of action arose, it tion in Maine. Commissioned Corps, on assignment to the became clearer that I would be of much Indian Health Service. As a Commissioned In the meantime, given my current un- Corps officer, Dr. Martinez has deployed to greater service to my colleagues and derstanding of clinical psychopharmacol- Florida, Mississippi, and Minnesota on dis- our patients if I had a broader knowl- ogy, I am in a much better position to aster response mental health teams. He edge of psychopharmacology. help bridge the gap between primary completed a postdoctoral master’s in clini- cal psychopharmacology from Alliant Inter- In 2005, as a member of APA Division care medicine, addiction and behavioral national University in 2008. 18, Psychologists in Public Service, I was health. Although I cannot prescribe

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Journey to RxP at Fort Thompson Johna Hartnell, Ph.D.

In April of 2010, I put many firework displays to shame. I live in government housing, right on arrived in Fort the property where the Indian Health The closest ―town‖ is Chamberlain, of Thompson, South Services (IHS) building is located. At approximately 2500 people and but one Dakota, my first shortly before 8:00 a.m., the fourteen grocery store. The next closest ―city‖ is time in the state, to family home doors open, spilling out the the capital, Pierre, with just over 11,000 begin a position workers, including myself, who live here. people. It takes a little less than an hour with Indian Health Service (IHS) where I Most weeks, my car never leaves the to drive to Pierre, without gas stations would work on my two preceptorships garage until the weekend, when I typi- or anything else, for that matter, but toward my licensure as an RxP psy- cally drive to Pierre to get groceries and ranch land. chologist. run any other errands needed for the Organizing is very different here for this week. There is no home mail service, so Fort Thompson is a ―town‖ of under former city slicker. There are no dry lunch is spent walking my little Westie 1500 people per the 2000 census, most cleaners but after some effort I discov- to the Post Office to pick up the mail. of whom are Native Americans of the ered pick up points, one of which is at Crow Creek Sioux. The county where it The people are incredibly friendly and ―Mac‘s Corner,‖ a tiny general store resides, Buffalo County, is the poorest helpful. I have been welcomed by many with the cheapest gas around! Mac‘s county in the US. Although the county of the Native people, who have eagerly Corner is also by the high and middle may be poor financially, it is rich in its shared their ways with me. I have par- schools, where I work two days a week. land. Much of it is located along the ticipated in a small sweat and attended a However, it can take one to two weeks beautiful Missouri River where the roll- pow-wow, where I tasted Indian bread to get your cleaning back, depending on ing hills are verdant with wild grasses, for the first time. The dog, to her sur- what day of the week you drop off – so scattered trees and miles and miles of prise, often goes leashless, unlike in the much for same day service. Formerly, I ranch land where horse, cattle and buf- big city. There is no dog licensing here, could walk to Starbucks; here the clos- falo laze and graze. As you leave the either. And speaking of dogs, there are est one is one state away! river border, it stretches out with the packs of wild dogs roaming through Fort Thompson is home to a single, flatness of the true prairie vision. from time to time. small general store where I can get ne- South Dakota, I have found, is a state of The decision to work in IHS was not cessities like milk, some fruits and vege- many extremes. From the bluest of skies made easily. Approximately five years tables, and other basics. There is, of with circling hawks, squawking pheas- ago, I enrolled in the MS in clinical psy- course, a casino where I‘m told the food ants and a quiet peacefulness, to violent chopharmacology program at Fairleigh is pretty good. There is also an assisted storms that show up in less than an Dickenson University. My decision was living home, a small motel, some kind of hour. In my first two months here I ex- based merely on my desire to gain take out store that I haven‘t visited yet, perienced heavy hail, torrential rains, knowledge in this area, and not with an a community center, the usual fire and tornadoes setting down nearby, high intent to head off to parts unknown. I police departments, and a Boys and winds and lightening storms that would had always been in favor of psycholo- Girls Club.

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Hartnell, Journey to RxP Psychologist..., continued gists gaining prescriptive privileges; it months ago. I will soon complete my 80 ing for the PEP, as they were out of my made sense to me, given how much hour preceptorship, primarily under the discipline, are now locked in forever. I coordinating with primary care and guidance of a wise and experienced GP. shall never forget metformin as a dia- other physicians I typically was doing. The patients he sees are medically very betic medicine! I have listened to hearts Often physicians would rely on my rec- complex. Most have diabetes, hyperten- and lungs, taken blood pressures and ommendations, as we would coordinate sion, hyperlipidemia and other health interviewed patients while waiting for care for patients. conditions. Many have alcohol and/or the GP to join us. I have held some drug issues as well. Unemployment is hands some when painful procedures But as I was completing my psychophar- significant here and there are few op- were performed. I have gotten to know macology degree, the business climate in tions for many, which is incredibly sad. some of the patients who have returned Madison, WI, where I had worked in Families are generally multi-generational, for follow up while I have been there. private practice for years, changed. I with as many as 17 or 18 people living in incurred a large loss of business and There have been a couple of emergency a small trailer or pre-fab home. There is believed the decline was going to con- patients, one who was sent by ambu- a strong sense of pulling together as a tinue, and likely exacerbate, long into lance to the hospital in Chamberlain. family and ―stepping up‖ to help each the future. One day it came to me- Why The GP has been patient in explaining other out, mostly from love and some- not go and complete my training, and how he considers caring for a particular what out of necessity. work somewhere as an RxP psycholo- patient, and has welcomed my sugges- gist? Thinking of no reason as to why tions when there has been psychiatric not, other than my fear factor, I began overlap with a patient. There is a free- “There is a freedom here the application and negotiations for dom here to treat patients without the to treat patients without work in Indian country. HMOs and insurance companies breath- the HMOs and insurance ing down your necks. That doesn‘t mean IHS, like the Department of Defense, is companies breathing down there are no restrictions on care, but it a federal agency that allows for people your necks. That doesn‟t does appear more like the medicine of with psychpharmacology training to mean there are no former years, without the current tight- practice RxP, regardless of what state restrictions on care, but it ness that many physicians and psycholo- they may reside in. It was an opportu- does appear more like the gists feel pressured by. It‘s refreshing in nity to complete the 80 hour medical medicine of former years, that way! preceptorship and the 400 hour supervi- …” sion, while working as a psychologist. It Another step in the process toward was a new challenge, and an exciting licensure was application in either of the My first day, in fact my first patient, was one. And the icing on the cake for this two existing states for a general psy- a toenail removal. I almost needed re- former private practitioner was a bene- chologist license, either New Mexico or moval myself. But by the third, and last, fit package and paid vacations! Louisiana. I chose New Mexico which I such patient of my rotation, I was a later learned had an added benefit,… So that‘s how I came to arrive in Fort trouper about it. Many of the medica- Thompson that April day less than three (continued on pg. 51) tions that were such a struggle in study-

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Standing Rock and Other Motivations for Becoming a Medical Psychologist Anthony Tranchita, Ph.D.

Disclaimer: The process, but not necessarily a part in try, I assure you it is not. Nothing would comments, observa- tions and opinions which I wanted a direct role. So, when I make me happier than to collaborate presented below are those of the started hearing about medical psychol- with psychiatrists regularly. I can think author and do not ogy in my internship with the United back to experiences in my graduate represent those of the Indian Health States Air Force, I was interested but, school training and my internship, with Service, the United States Air Force, the truthfully, not for very long. I was wary psychiatrists who taught me a great deal United States Public that in going the medical psychology about working with people and about Health Service or the United States government. route, my life would become a hamster- mental health practice. The problem in I submit this article as a clinical psy- wheel of 15 minute appointments, with trying to care for my patients, is that chologist who has chosen to start walk- the main goal being a prescription at the those contacts seven years ago were ing the path toward Medical Psychology. end. This did not seem to match what among the last regular contacts I have I was skeptical at first, and honestly my goals were in becoming a psycholo- had with these highly trained and impor- needed some coaxing to come this way. gist. I am still wary of this possible out- tant medical professionals. come, and am hopeful that I will still be My experiences in the United States Air Soon after coming out of residency, I able to practice across the breadth of Force and United States Public Health started working at a small Air Force psychology, rather than becoming the Service led me to overcome that skepti- Base in Oklahoma. Being fresh out of ―depression meds guy.‖ cism, as I could clearly see some of the residency, I had all kinds of ideas, some barriers faced by patients seeking psy- However, in seeing the experience of of which were good and useful, others chological and psychiatric care. As I many of my patients, I started thinking maybe not so much. However, one write this article, I am about a year and that it is a better road for at least some thing I came out with was an under- a half into a master‘s degree in clinical of us to travel. My work assignments, standing that mental health professionals psychopharmacology, which will give me mostly by design, have always and will working as consultants in primary care the skills to provide what I see as a likely always be in the classification of seemed to provide positive results for needed service for my patients, and the ―rural.‖ I prefer to live in small towns, patients and reductions in costs. We ability to be licensed and credentialed to with close access to outdoor activities, were able to get such a practice started prescribe. as that is how I maintain my mental in the primary care clinic at my first

Much of my reticence to come down health. There are many advantages to ―real‖ job. This job provided me with this path had to do with the reasons I working and living in environments like many lessons, one of the first of which decided to become a psychologist in the this for myself and my family. However, probably led me on the medical psychol- first place. Professionally, I came into working in this type of setting always ogy path, on which I now find myself. I the field knowing that I wanted to work carries a bit of difficulty accessing psy- met with a patient, performed a prob- with people, and that I wanted to de- chiatric referrals for patients. lem-focused assessment, and made some recommendations to the patient. velop collaborative relationships with Lest there be concern that this may turn One of those recommendations was people, leading to long-term positive to a partisan discussion against psychia- changes. I saw medication as part of the antidepressant therapy. I then went

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Tranchita, Standing Rock and Other Motivations..., continued back to the provider who referred the half years I worked there, more than writing a letter explaining my clinical patient, repeated that recommendation, half (approximately 60%) of our patients perspective and my recommendations and was then asked, ―OK, what med do met criteria for a co-occurring mental to the pediatrician or psychiatrist. I you think would work best?‖ Starting a health diagnosis along with the sub- would send this letter with the staff new consultation service, I wanted to stance misuse disorder. It was also en- member responsible for transport that come off as competent, so I made some tirely too common for them to endorse day. This was not a style of communica- non-committal noises that I hope helped suicidal ideation, or to have a history of tion that is ideal, but we did what we me sound intelligent. I realized on that suicidal behavior. In previous practice, I could. day, that if I wanted to work in a col- had placed faith on one of the predic- When the adolescents we served would laborative medical environment, I had tors of suicide being a completed suicide return home, there were many barriers better broaden my education on medi- by a friend or family member. This sup- to continued psychiatric care. Many cations. posed predictor was almost meaningless families faced the same issue of a lack of with this group of adolescents as, sadly, The next job I took was at a residential a local psychiatric provider, and did not it was a rare occasion in an assessment treatment center for Native American have access to resources to transport when I would ask, ―Do you have a family adolescents diagnosed with substance them that 100 miles or more. Or if member or friend who has attempted misuse disorders. The center is located they did have access, the immediate or completed suicide,‖ that the answer on the Standing Rock reservation in emergency had passed after a month, was ―no.‖ South Dakota. We treated patients and they decided not to go, only to have from many locations, the majority of the emergent symptoms occur again at a which were from North and South Da- later point. “While working in this kota, Nebraska, Iowa, and to a lesser treatment facility, the This last winter, I transitioned jobs extent, Wyoming and Montana. Obvi- closest psychiatrist was again, back to an Air Force medical ously, we had a very large catchment more than 100 miles treatment facility in North Dakota. area. But a common theme across the away.” While I would classify where I am now adolescents was that most came from as being less rural than my previous rural and/or reservation settings. jobs, the patients I refer for psychiatry While working in this treatment facility, I went to Standing Rock relishing the often still face 4 to 6 week waiting lists. the closest psychiatrist was more than opportunity to make a difference in a As part of my experiences as a psy- 100 miles away. Access to any medical population that is often classified as chologist, both past and present, I have care, other than emergency medicine, medically underserved. I was also aware generally focused on doing psychotropic was 50 miles away. Because the facility I that suicide rates in the group of adoles- med management with consultation to worked in was a residential treatment cents with whom I would be working general practitioners, physician assis- center, we would provide transport for was very high. After arriving, I started tants, and nurse practitioners, those those patients while they were in our tracking diagnoses of the patients we providers from whom reports… care. Consultation with providers for worked with. Across the two and one- (continued on pg. 44) psychotropic meds usually consisted of

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My Tenure as a Psychologist for the Indian Health Services Vincent Barnes, Ph.D.

I was fortunate to for suicide death in the United States in once. The local Standing Rock medical have started my ten- 2004 was 10.9 per 100,000 people. The staff would then attempt to continue ure with the Indian suicide rate on the Standing Rock Reser- regimen. Many patients lacked the funds Health Service on the vation in 2004 was 176.47 per 100,000 to travel such a long distance for a psy- Turtle Mountain Res- people, 17 times the national average. chiatric appointment, and relied entirely

ervation as a staff Standing Rock was a vastly different upon the medical staff for all of their psychologist. The reservation is home experience from what I had first been psychotropic medication prescriptions. to a band of Chippewa Indians in the exposed to on the Turtle Mountain res- northern part of North Dakota. The ervation. The populations of the reser- mental health department was well vations were similar, but the Turtle “When I realized that staffed with a group of dedicated provid- Mountain reservation is one of the some parts of the country ers. The office had six licensed provid- smallest in the country, and everyone would never receive ers, two mental health technicians and a was compacted closely together. Stand- adequate mental health psychiatrist. This allowed the ability for ing Rock reservation has been com- care, I became a proponent the reservation to have on-call mental pared to the size of Connecticut. of the prescribing health service without over burdening Whereas the Turtle Mountain reserva- psychology movement.” the staff. The caseloads were always full tion has one major school system, and complex, but they were manage- Standing Rock has eight school systems able. I was always busy, but rarely over- to establish connections with. The I knew that something needed to change whelmed. Standing Rock mental health department in order to help better meet the needs As I was about to complete my third was also dramatically different. There of the people on the reservations. I had year at the Turtle Mountain reservation, were only four staff members, and just heard the debates about the possibility I deployed for two weeks as a Public two of them were licensed. There was of psychologists prescribing psychotro- Health Officer to the Standing Rock no clerical staff to assist with scheduling, pic medications. When I realized that reservation to assist with a suicide epi- and no psychiatrist to manage medica- some parts of the country would never demic. Standing Rock reservation is oc- tion issues. receive adequate mental health care, I cupied by a Lakota band of Sioux Indi- I had come to rely heavily on the psy- became a proponent of the prescribing ans. The reservation straddles the chiatrist on the Turtle Mountain reser- psychologist movement. When given the North Dakota and South Dakota state vation. On Standing Rock, patients had opportunity to pursue a post-doctorate line. The reservation unfortunately ranks master‘s degree in psychopharmacology, to drive seventy miles or more for an high in suicide prevalence, compared to to start the journey to becoming a pre- appointment with a psychiatrist. Due to other tribes in the United States. Be- scribing psychologist, I quickly agreed. the lack of a psychiatrist being easily tween the years of 2004 & 2005, Standing accessible, patients on Standing Rock The suicide numbers did reduce after Rock Tribe suffered 26 suicides from a generally only visited the psychiatrist my deployment. But a pessimistic Stand- population base of 8,500. The overall rate

The Tablet, November 2010 Volume 11, Issue 3 Page 43

Barnes, My Tenure as a Psychologist..., continued ing Rock elder related her belief that all ing summary of my work for submission Specific examples of these success- of the suicidal people had merely died, to the Public Health Service after hear- ful partnerships include the one- and she dreaded the cycle returning. ing of my resignations: year tribal funding agreement of a clinical psychologist to work within During my deployment, the Indian Throughout the years, the mem- Health Service‘s Standing Rock mental bers of the Standing Rock nation HIS, with the intentions of LCDR health director resigned, placing in mo- have become cynical of mental Barnes finding third party reim- tion my application and acceptance of health directors on our reserva- bursement funds to allow that the director position. It was a difficult tion. The mental health providers psychologist to become a federal decision to leave the Turtle Mountains, were believed to be uncaring, un- employee, as well as the creation but this was my first opportunity to responsive and under qualified. and funding for both the Standing accept supervisory duties. I was sold by LCDR Barnes‘ first goal as director Rock Pre-Doctoral Psychology a regional administrator‘s vision of my was to increase access to mental Internship and Post-Doctoral Psy- ability to impact a region, instead of a health care, so that our people chology Residency program. These three acts of trust from our caseload, with the new assignment. The would not feel forgotten. He also nation to LCDR Barnes resulted in job description of a mental health direc- developed a plan to increase the the expansion of outreach from tor is what I thought I was accepting. I number of qualified providers, so two mental health clinics available also became a salesman, and at times a that they would get the quality to our people, to six clinics. The pitchman, for the ideas and funding I treatment they deserve. When IHS number of doctorate level psy- needed in order to develop a mental funding options were exhausted, chologists has increased from one health department to support the needs LCDR Barnes, in his humble ap- to five psychologists. The number of the reservation. My native friends proach, presented ideas to Stand- of master‘s level therapists from laughed with me as I departed three ing Rock Sioux Tribe and Standing zero to three. A total of seven years later, of the audacity I had when I Rock Public Schools that would qualified mental health profession- started. I was a white man, employed by accomplish these expansion goals. als added to the reservation with- the federal government, dressed in the LCDR Barnes‘ diplomatic and en- out an increase in his federal uniform of a Public Health Service offi- thusiastic presentations made his budget. The impact of his work has cer, asking for funds in return for ser- ideas sound conceivable. For the increased access and availability for vices from tribal leaders and school ad- first time a tribe and a grant mental health appointments for ministrators. school assisted a federal program financially. We believed in LCDR our people, and expanded our The three years at the Standing Rock Barnes, and he delivered his prom- nation‘s ability to disperse suicide reservation were very productive. I re- ises of action every time. Our prevention information. (Ron His lied upon the relationships I had estab- investments in his programmatic Horse Is Thunder, Standing Rock lished between the Indian Health Service ideas have produced many returns Tribal Chairman, personal commu- and Tribal government. Ron His Horse for our people. nication, June, 2010) Is Thunder, Council Chairman of the (continued on pg. 44) Standing Rock tribe, created the follow-

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Tranchita, Standing Rock and Other Motivations..., continued

(continued from pg. 41) many people in ―rural‖ settings, are a through addressing barriers to appropri- long drive away and there are often long ate psychiatric care. ... have shown that 80% of the country wait-lists. From an ethical perspective, gets their psychotropic medication Anthony Tranchita, Ph.D. is currently a staff the patients I have who are most in (Beardsley, Gardocki, Larson, & Hidalgo, psychologist and chief of the Alcohol and need of services are often the ones who Drug Abuse Prevention and Treatment 1988). The only time I really even try to wait the longest. (ADAPT) program manager at Grand Forks access a psychiatrist now is when the Air Force Base, ND. He is taking Psy- referral questions are more complex These are the reasons I chose to get a chopharmacology coursework from Alliant than GPs are comfortable with, such as master‘s in clinical psychopharmacology. International University, San Francisco. Pre- cases of polypharmacy, history of multi- I am hoping that I can make my contri- vious positions included staff psychologist at a residential treatment center for Native ple attempted medications without suc- bution by getting the rigorous training American youth with substance abuse is- cess, or increased suicidal risk. This required to become a medical psycholo- sues, and a previous Air Force assignment would typically be the case of a high-risk gist, as I believe it is the best and most in Oklahoma. patient, often with suicidal ideation or ethical way to serve may patients. I have References acting out behavior, who needs acute come to believe over time that psy- Beardsley, R., Gardocki, G., Larson, D., & care but does not meet criteria for hos- chologists being able to offer this addi- Hidalgo, J. (1988). Prescribing of psy- chotropic medication by primary care pitalization. This type of high risk patient tional service can have far reaching pub- physicians and psychiatrists. Archives of General Psychiatry, 45, 1117-1119. often will not receive services for an- lic health ramifications, as this can and other month because psychiatrists, for will have a direct and identifiable impact

Barnes, My Tenure as a Psychologist..., continued

(continued from pg. 43) mentation of the pre-doctoral intern- provider to the most complex mental ship. health cases imaginable, have the oppor- Overall, it was my experience that hard tunity to demonstrate leadership in the working professionals were recognized I would like to believe I left the Standing health care field, and feel a level of admi- for their dedication. In 2007, I received Rock reservation better than what I ―The Most Improved Mental Health found it, but there was so much more ration, respect, and love that you have Department Award‖ by the IHS Aber- work needed to be done. I wish I could not experienced from any other com- deen Area Office. In 2007, I also re- have stayed longer. I would like to relate munity. The experience has changed me ceived the PHS Commendation Medal my admiration to the dedicated mental as a person and as a clinician forever. for leadership of a mental health clinic in health workers of the Indian Health Vincent Barnes, Ph.D. currently serves as a an isolated service area, and the devel- Service. For psychologists wishing for licensed clinical psychologist with the Public Health Service, and is currently assigned as opment of a strategic suicide interven- the opportunity to care for the under- the Residential Drug Abuse Coordinator at tion plan. In 2008, I was awarded the served populations of the world, you the Federal Prison Camp in Yankton, South IHS Aberdeen Area‘s Supervisor of the need to go no farther than the nearest Dakota with the Bureau of Prisons. year Award and Indian Health Service‘s state that holds an Indian Reservation. National Director‘s Award for imple- There you will most likely become a

The Tablet, November 2010 Volume 11, Issue 3 Page 45

Interview with Robert M. Julien, M.D., Ph.D. Judith Julien, Ph.D.

In anticipation of pleting your doctorate in clinical psy- psychologists now have another unique his participation in Division 55’s 2011 chology and your residency in neuropsy- opportunity: To assist, as pharmacologi- Midwinter Confer- chology, I came to realize the almost cally-trained mental health providers, in ence in Washing- ton DC (see pg. complete absence of drug education in developing and monitoring an entire 81), Mark Muse, the graduate psychology curriculum. I collaborative treatment plan for a pa- MP, ABMP, gra- ciously facilitated wondered how one could possibly tient, including, in addition to robust an interview with counsel patients with mental health dis- diagnosis and psychotherapeutic inter- Dr. Robert Julien, author of A Primer of Drug Action and a strong supporter of orders without knowing how their ventions, understanding a client‘s medi- RxP. Dr. Judith Julien, a recently-retired medications affected their cognitive cations and monitoring for efficacy, ap- neuropsychologist and Robert’s wife of 47 years, graciously agreed to lead the dia- functioning, their behaviors, or their propriateness, and possibly debilitating logue. mental capacity? side effects.

Judi: Bob, tell us a little about your Judi: You will be presenting a work- background and how you became “My passion today is that shop for the Division 55 Mid- interested in mental health and the ALL psychologists, in order Winter Conference on the role of RxP movement. to function fully, need to pharmacologic agents in the treat- ment of children and adolescents. Robert: As a young PhD research psy- have psychopharmacology Could you give us a glimpse of chopharmacologist teaching a drug- knowledge,…” what that might entail? education course in the early 1970s, I observed that there were no materials Robert: Multiple research papers pub- This led to my role as a provider of con- to teach from; no introductory psy- lished in the early 2000s documented tinuing education for Oregon psycholo- chopharmacology textbooks were avail- the disastrous long-term outcomes of gists, both those with little knowledge of able. In 1975, I published the first edi- youth with untreated mental health dis- psychoactive medications as well as tion of my Primer of Drug Action. As the orders during childhood and adoles- those preparing to become RxP provid- literature changes so rapidly, the pub- cence. Indeed, we now know that men- ers. My passion today is that ALL psy- lisher agreed to an every three year tal health disorders are THE MAJOR chologists, in order to function fully, revision schedule, resulting in the re- chronic disease of young persons, and need to have psychopharmacology cently published 12th edition. Following that these disorders persist into adult- knowledge, albeit to varying degrees. completion of my Medical Degree in hood and become less responsive to 1977, I then spent 25 years teaching and As I travel and lecture, I ask clinical psy- treatment interventions. To reduce the performing clinical anesthesiology in chologists how they differ from mental rates of mental health disease in adults, Portland, Oregon. Yet, I never aban- health counselors. What do psycholo- we must address these disorders as they doned my love and passion for psy- gists bring to the therapeutic table? In first present in childhood. This applies chopharmacology. my view, your strength lies in the unique not only to school-aged children but to ability to provide excellence in testing, preschoolers, and even to… In the early and mid-1990s, while you, assessment, and diagnosis. Nonetheless, my wife, were in graduate school com- (continued on pg. 46)

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Julien, Interview..., continued

(continued from pg. 45) chronic pain and its associated disorders chologists at all levels of training and has to be a part of the practice of virtu- practice. ... neonates who are prone to develop ally every psychologist. Also to be ad- the untreated disorders present in their Judi: Your passion is convincing dressed are genetic (CYP450 polymor- pregnant mother. The literature in this mental health clinicians, especially phism) problems that result in ineffec- psychologists, of the need to de- area advances daily, and has developed tiveness, drug interactions, or dangerous velop a working knowledge in the over my last 2 editions into a major area of pharmacotherapy in order th accumulation of specific opioids. Careful component of the 12 edition. to provide a truly balanced ap- delineation of opioid responsiveness proach to treating emotional and Judi: You also have a special inter- and/or toxicity may help unravel genetic behavioral conditions. Do you have est, being an anesthesiologist by problems in CYP enzyme availability or a vision as to how this might be training, in pain management. Is done? there any particular role for RxP function. Amazingly, this may comprise psychologists working in the field up to 20% of patients with chronic pain. Robert: While some psychologists strive of pain management? to be prescribers, the vast majority will Judi: The new edition of your clas- Robert: Most certainly, and this does sic work, Primer in Drug Action, has not so chose, yet they need at least the not apply to the prescription of opioid just been released. Tell us a little basics of psychopharmacology in order analgesics. Such reliance has resulted in about the development of this to be better clinicians: To monitor for seminal work, and also explain why enormous prescription abuse and the medication side effects; to be able to you have entrusted future editions production of millions of opioid- advocate for their patients; to help guide of the book to a husband/wife team dependent persons in our country. of psychologists, one of whom is a overall therapy; to know their own prescribing medical psychologist. treatment limitations and those of medi- The founders of chronic pain manage- cations; and to bring much more of ment, such as Dr. John Bonica in his Robert: For all of its eleven editions, my their hard-earned talents to optimal classic textbook, The Management of text was intended to be the most up-to- clinical effectiveness. Pain, advocated a multidisciplinary ap- date, readable, and most well- proach, utilizing psychologists in a major referenced text available. After 36 years This is not a new idea; it is a reiteration collaborative effort. Dr. Bonica NEVER of continuous publication, however, the of a largely ignored 1993 call to imple- advocated reliance on opioids. Proper need for more clinical application has ment such knowledge by APA, a call use of psychotherapeutic strategies led to the addition of Drs. Joe Comaty issued nearly twenty years ago to (such as hypnosis), specific antidepres- and Claire Advokat to join me as au- change the way graduate education in sants, anticonvulsant mood stabilizers, thors. Joe is a prescribing psychologist psychology is taught and practiced NSAIDs, omega-3 fatty acids, and even in Louisiana, and Claire is a researcher [Smyer et al. (1993). Summary of the cannabinoids all reduce opioid use and professor of psychopharmacology at Report of the Ad Hoc Task Force on (termed opioid-sparing actions). Louisiana State University. Their input Psychopharmacology of the American has been tremendous, taking the text Psychological Association. Professional A huge percentage of our patients suffer beyond what I could have continued Psychology: Research and Practice, 24: 394- from chronic pain, as well as anxiety, th alone. I hope that this 12 edition will 403.] depression, and anger. Addressing be even more applicable to clinical psy-

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Julien, Interview..., continued

I am passionate that all patients, espe-  For your patients with anxiety dis- tients are taking. You can explain cogni- cially those presenting in primary care orders, do any of their medications tive problems in terms of brain process- underlie or intensify anxiety (e.g., settings, receive optimal mental health ing/medications. Bupropion and related dopaminer- care, and this necessitates collaborative gic agonists)? Part of your role as Medical Psycholo- care! To do this, all psychologists should gists is to bring your colleagues along, be able to keep a running list of their although to do so may not be remu- patients‘ psychoactive medications and, “My passion today is that nerative in every case. You are called to from this, they must be able to pose and ALL psychologists, in order serve a role as psychopharmacology determine answers to the following to function fully, need to educators because, as you know, there questions: have psychopharmacology is currently no ready pool of psycho-  Do any of these medications inter- knowledge,…” pharmacologically-trained clinician edu- fere with sexual functioning and cators (most psychopharmacologists are therefore with the marital relation- PhDs, and trained as researchers in ship? (obviously, SSRIs among oth- Judi: How do you view the current medical schools). There are few profes- ers) role of RxP doctoral level psycholo- sionals available to teach psychopharma-  Do any of these medications inter- gists with their master‟s in clinical cology in psychology graduate programs. fere with cognition, memory forma- psychopharmacology? tion, or intellectual functioning? You are needed in graduate psychology Robert: First and foremost, pharmaco- (benzodiazepines, lithium, topi- programs to round out the curriculum ramate, among others) How do logically-trained psychologists are qualified and to teach young psychologists how these medications interfere with to consult on medication and provide opin- to be integrated providers and, as such, their daily functioning? ions concerning pharmacotherapy to physi- better practitioners.  Do any of these medications result cians and mental health colleagues. Medi- All psychologists should know the ef- in undesired weight gain? (a major cal Psychologists, whether or not you reason for noncompliance) fects of drugs on learning, memory, cog- are in the political struggle with a legisla- nition, IQ, cognitive processing, and so  What do these medications cost? tive body to formally grant you prescrip- on. Such knowledge may have to come Do we have a choice between an tion privileges (which I wholeheartedly expensive drug and a similar drug from your teachings. I envision your role support), are fully qualified. Regardless that costs much less? not only as prescribers, but as educa- of politics, you are Medical Psychologists  How do these medications affect tors and leaders of this movement to and, as such, will be increasingly called depression and issues of depres- teach psychopharmacology to all of your upon to consult and to teach psy- sion? What are the drug expecta- colleagues. tions in contrast to drug limitations? chopharmacology as it applies to psy- How can we become involved in chological and medical interventions. (continued on pg. 48) consultation, treatment planning, You can raise the awareness of col- outcome measurements, and dis- continuation planning? leagues, referral sources, and patients. You can teach your colleagues about the

potential side effects of drugs their pa-

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Julien, Interview..., continued

(continued from pg. 47) giving back by generating new learning in Dr. Robert Julien received his Ph.D. in Pharma- cology from the University of Washington and current and future practitioners, inspir- Judi: Finally, how do you view RxP his Medical Degree from the University of Cali- psychologists still struggling for ing persons to strive for the same excel- fornia at Irvine. Previously an Associate Professor licensure to prescribe? lence in clinical knowledge and practice of Pharmacology and Anesthesiology at the Ore- gon Health Sciences University, Dr. Julien prac- that has, I am assuming, become your Robert: I would begin by asking each of ticed anesthesiology in Portland, Oregon until you to define what your passion is. Is it to passion. And in this vein, it is my per- 2006. An acclaimed teacher and author, Dr. be recognized by the State in which you sonal desire to inspire you special peo- Julien recently published the 12th edition of his psychopharmacology textbook, A Primer of ple, who have given much of yourselves practice? Is it to be a step ahead of your Drug Action (Worth Publishers, 2011). Now colleagues, or to strive for the cutting to bring medical psychology this far, and with 30 years of continuous publication, A edge within your chosen field? Do you to empower you to change the world Primer of Drug Action is regarded as the definitive textbook of psychopharmacology, cov- …. one person at a time. believe in what you are doing well ering both psychotherapeutic agents as well as enough to describe it as your passion? The issue of legislative approval for RxP substances of abuse.

I propose that with what you have affects a few (and you will eventually Don’t miss Dr. Julien’s pre-conference succeed); but the deficit in pharma- workshop and presentation at the Mid- achieved, your daily role is to push the winter Conference (see pg. 81). We look frontier ever forward and to begin to cologic knowledge affects all, especially forward to meeting him! think about bringing others along with our patients. you on this venture, to contemplate

Members of Division 55 Are Invited! One of the benefits of being a member is the APA Division 55 listserv. Join other members to share resources and ideas, keep informed of current RxP developments, and more! To join, send an email request to Gordon Herz, Ph.D. at [email protected] or go to http://lists.apa.org/cgi-bin/wa.exe?A0=ASAP and click the “Join ASAP” link under “Options.”

The Tablet, November 2010 Volume 11, Issue 3 Page 49

Threats Within the Ranks: Violence Across the Deployment Cycle Robert Younger, Ph.D., MP, ABPP

My interest in the as from shooting survivor, Colonel 2008. And lastly, I deployed on a Navy topic of threats Kathi Platoni, an Army Reserve psy- carrier strike group off the coast of within the ranks for chologist. Major Eduardo Caraveo, a Pakistan. the prescribing psy- prescribing psychologist killed in that Cases chologist grew, in attack, was honored at the 2010 Ameri- Case 1: Hallucinating in the Desert, part, related to per- can Psychological Association (APA) with the Marines in Operation Iraqi sonal experiences of Convention with the inauguration of a Freedom I persons being hurt or killed as a result Division 55 award named for him (Public A young Marine was diagnosed with of assault within the military forces, Health Service Captain Kevin McGuin- depression in the States, prescribed an while deployed to a combat theater or ness was the first recipient). At that antidepressant, and deployed to Kuwait, associated with deployment. Assault intimate ceremony, his family touchingly and later Iraq, for the invasion. He had and death ―within the ranks,‖ or vio- spoke of his dedication and desire to been in the desert for two to three lence within the military family, some- help others. I also knew Army Major months. Unfortunately, when he went times termed ―fratricide,‖ constitutes a Alan Hopewell, another Army prescrib- forward the antidepressant was left in a violation of some of the most basic ten- ing psychologist stationed at Ft Hood, secondary ―sea bag.‖ The initial fighting ets of military life (e.g., to preserve and who worked almost around the clock ended quickly, and for three days he protect comrades, and use force only following the shootings there. This last stood guard for 12 hours per day, with when authorized and directed toward assault touched me in several ways, no shade in the heat of about 100 de- the enemy). from having seen the alleged perpetra- grees. During the last few weeks, his tor, to knowing one of the dead, and Some of my personal friends and ac- affect worsened and he became severely reflecting upon those affected by the quaintances have been affected by such depressed. He repeatedly asked to be shootings. transgression of ethos and duty. Specifi- taken out of the fight, and eventually cally, in 2009, my friend and Navy Com- The purpose of this article is to use case was brought to the medical company in mander, Keith Springle, a social worker, studies involving potential violence, from northern Kuwait, after he voiced was killed in Camp Liberty, Iraq, where I three deployments since 2003, to illus- ―dreams‖ of sticking the Marine lying once worked, along with four Army trate the issues facing the prescribing next to him with a ―ka-bar‖ or fighting personnel, allegedly by Sergeant John M. psychologist in the military. As back- knife. Prescribing psychologist‘s solution: Russell, a 39 year-old soldier. In late ground, I first deployed with the Ma- Given the potential for violence, need 2009, 53 soldiers were injured with 10 rines in April, 2003, closely following the for semi-emergent treatment and lack of killed, allegedly by psychiatrist and Army initial invasion of Iraq in March, 2003. resources in the war zone, this Marine Major, Nadal Malik Hassan, at Ft Hood, Next, I was assigned to an Army Com- was evacuated to the rear and eventu- TX., shortly before three Army combat bat Stress Control Company at a re- ally to the states. stress control units were to deploy to mote Army Forward Operating Base in (continued on pg. 50) Iraq. I knew of Major Hasan from Wal- Baqouba, Diyala Province, Iraq, in the ter Reed Army Medical Center, as well ―surge‖ from July 2007 until February

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Younger, Threat Within the Ranks..., continued

(continued from pg. 49) He was hustled out of the war zone to Conclusions

Case 2: “I Want to Kill Them All,” the nearest in theater hospital. How- Possible Factors with the Army in Operation Iraqi ever, he returned to the forward oper- Although some might wonder how to Freedom VI – VIII ating base about 10 days later. The psy- make sense of the assessment of dan- A young Army corporal‘s service con- chologist completed his tour of duty, gerousness and possibility of harm con- tract was extended due to ―stop loss‖ transferred, and administrative and clini- nected to military deployment, my pur- for several months, and he deployed to cal outcome of the case was unknown. pose in selecting these cases is to show Forward Operating Base Warhorse. He Case 3: “More of the Same” or Per- that the potential for violence in the became increasing despondent and an- sonality Disorders and Interpersonal military, especially surrounding deploy- Conflicts on an Aircraft Carrier, Pre- gry, blaming the Army for being in Iraq. ment, easily crosses settings. Especially paring for Deployment to the Ara- But at the same time, he said he wanted when deployed in a war zone, everyone bian Gulf in Operation Enduring to stay in the war zone, to collect war Freedom carries weapons and has been trained to zone pays and go to college when he left A young sailor left his assigned ―watch,‖ use them. Nevertheless, like the prob- the Army and Iraq, in about 6 to 8 or place of duty, and assaulted another lem of suicide, the bottom line is that months. He said he wanted to fire sailor who had been in trouble many there is no easy fix or easy solution to the .50 caliber machine gun at random times earlier. The ―beater‖ left the threats within the ranks. Violence or Iraqis and ―kill them all,‖ so he was ―beaten‖ with many knots and bruises. threats can come from many factors. taken off the crew-served weapon. He Subsequent investigation has shown that Although there is no one reason for the began driving the large vehicle, probably the beaten sailor had been taunting the threat, targeting the following possibili- intentionally damaging civilian vehicles assaulter because both were dating a ties may have promise, in part because while going through the cities. The pre- female sailor on the same ship. Appar- they can be identified and (at least the scribing psychologist diagnosed depres- ently, conflict between the original cou- first two) possibly addressed: sion and some personality disorder fac- ple lead to a new, originally covert, rela-  Interpersonal and/or administrative tors, and strongly suggested that medi- conflicts- Based upon news reports, tionship with the second male, who in a cation be considered in the treatment the sergeant at Camp Liberty would poor display of judgment teased the well plan, but the patient refused. The psy- seem to fall into that group. Under- -muscled and poorly-controlled assail- lying personality disorders may chologist also strongly suggested that ant. Ultimately, both males were dis- complicate the situation. the patient was not suitable for the charged. The female sailor did not come  ―Mental Health‖ reasons separate Army and presented a risk to others, to the attention of the psychologist from personality disorder- An ex- including fellow soldiers and, therefore, again. In the case of assault, administra- ample could include a suicidal pa- recommended that he be removed from tient who is also homicidal. tive action and subsequent punishment the war zone. However, manning needs  Ideological cause or, as termed in occur due to violation of the Uniform overrode that recommendation. Ulti- media, ―terrorist threat‖- This is Code of Military Justice (UCMC), out- mately, in a dispute, the patient pulled the most difficult to assess and, side the realm of clinical responsibility within the traditional role of clinical his M-4 rifle on another soldier and then for the psychologist. psychology, I am not aware of any cut him, which he stated was accidental. treatment.

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Younger, Threat Within the Ranks..., continued

Suggesting a Framework assessment or national security func- military has, what is the ability to effect tions, for which the goal may not be change in administrative and personnel I offer the following suggestions in de- treatment or efforts to improve an indi- decisions? veloping a framework for dealing with vidual‘s condition at all. potential violence in deployed situations: And finally, assessing threats within the First, one must address the basic ques- ranks should not be attempted without tion of, ―Who is the client or patient?‖ “How well can we actually recognizing the supremacy of basic re- Another way of conceptualizing this assess dangerousness or spect for human rights and dignity, while assessment of threat and ―treatment‖ is, threat within this context? protecting the persons for which one is ―What is the purpose, or what are we Our superiors and the responsible. This is not just a throw- doing here?‖ This basic question is often American people assume away line but, as others have indicated, involved in, just to name a few, national that mental health respect for human rights is a part of the security issues, detainee issues, the con- professionals can perform soul, if you will, of the profession of cept of ―do no harm‖ in the Hippocratic this task.” psychology. Giving away Psychology‘s oath versus protection of the public, as values means, for practitioners, giving well as in more prosaic tasks such as Second, there is the question of the away a part of yourself. I recognize the fitness for duty or continued military feasability of psychologists accurately difficulty in operationalizing respect for service, and being evacuated from a war assessing threat. How well can we actu- human rights and dignity, but the diffi- zone. Such balancing of interests illumi- ally assess dangerousness or threat culty heightens the importance, rather nates differences between the history within this context? Our superiors and than diminishing it. This question will of, and focus for, the professions of Psy- the American people assume that men- continue to be explored and debated chology and Psychiatry (I‘m not sure tal health professionals can perform this for many years to come. how these differences influence actual task. Dr. Younger gained prescriptive authority while serving as a Reserve officer with the U.S. Navy in practice of either). To elaborate, psy- Thirdly, and at least as importantly, in a 1999. He returned to active duty after Septem- chologists historically perform many large organization with as many regula- ber 2001. He has prescribed in seven states, on additional functions in addition to actual tions and administrative layers as the two aircraft carriers, and in two foreign coun- clinical or patient care, such as forensic tries.

Hartnell, Journey to RxP..., continued

(continued from pg. 39) RxP license from New Mexico. have a long way to go to feel compe- tency in treating the myriad of patients ... for me anyway, of a 9 CEU require- I now see how important the medical served by the Indian Health Services ment to be completed after licensing, preceptorship is towards the training more independently, thus the 400 hour covering Native American health and and development of an RxP psycholo- history, and to a lesser extent, other gist. As mine draws to a close, I will supervision preceptorship is a highly minorities. Once my preceptorship truly miss my time in the medical clinic, regarded requirement! hours are completed, the next step is although I am looking forward to the Johna Hartnell, Ph.D. earned her MS in clinical psychopharmacology from Fairleigh Dickenson application for a two year provisional next step in my journey toward RxP. I University in 2009.

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Antipsychotics in Geriatric Patients: The Risk of Early Death G. Channing Harris

As a society, we portionately in older adults, and for certain types of ion channels (Glassman are moving into an over one quarter of Medicare benefici- & Bigger, 2001; Welch & Chue, 2000). era in which peo- aries in long-term care facilities in the The primary mechanisms through which ple are living United States (Wang et al., 2005). Al- antipsychotics lead to sudden death are longer. Research- though not approved, antipsychotics related to conduction delays, repre- ers anticipate the continue to be used as "off-label" treat- sented clinically as QT prolongation, number of people with dementia will ment for BPSD (Chen et al., 2010; Stahl, which may lead to fatal arrhythmias increase to 7.7 million by 2030 (Hebert, 2008;). (Kongsamut, Kang, Roehr, & Rampe,

Beckett, Scherr, & Evans, 2001). As the Both conventional and atypical antipsy- 2002; Leon et al., 2010; Li, Esterly, Pohl, incidence of dementia increases, so does chotics have associated risks, specifically Scott, & McBride, 2010; Schneeweis et the incidence of behavioral and psycho- increased risks of cardiovascular effects al., 2007). Research has implicated these logical symptoms of dementia (BPSD) and of sudden death (FDA, 2005, 2008; ion channels in the hypothesis that three (Lanctot, Herrman, & Mazzotta, 2001). Schneeweis, Setoguchi, Brookhart, Dor- electrophysiologic factors converge to Regardless of the level of cognitive im- develop drug-induced arrhythmogenesis: muth, & Wang, 2007; Schneider et al., pairment, BPSD may arise anytime dur- a decrease in repolarization reserve (i.e., 2005; Wang et al., 2005). After an initial ing the course of dementia (Lanctot et QT-prolongation), an increase in trans- FDA release of a black box warning for al.). A common feature of the various mural dispersion of repolarization, and atypical antipsychotics in older adults, forms of dementias, BPSD affects an the induction of premature heartbeats many patients were given conventional estimated 90% of people with dementia caused by early after depolarizations (Li antipsychotics (FDA, 2005; Wang et al., (Lanctot et al., 2001). Thus, the treat- et al., 2010). 2005). Comparatively, conventional an- ment of BPSD is an important aspect of tipsychotics are associated with a higher The interval between depolarization (Q dementia care. mortality rate than atypical antipsychot- wave) and repolarization (T wave) is BPSD can manifest as three main syn- ics (Kales et al., 2007; Wang et al., represented by the electrocardiogram dromes that often coexist: agitation, 2005). This article offers an exploration (ECG) measure known as the QT inter- psychosis, and mood disorders (Ballard of the mechanisms underlying these val (Glassman & Bigger, 2001). As the et al., , 2009). As dementia progresses, risks, treatment implications, and alter- heart rate increases, the length of the agitation and aggression become more native treatments. QT interval shortens; therefore, the QT evident, and most often require pharma- Electrophysiologic Factors Related interval is typically corrected for heart cotherapy (Ballard et al., 2009). With To Sudden Cardiac Death rate (QTc), which is most often used in many geriatric dementia patients experi- Although the mechanisms involved in research (Glassman & Bigger; Imran, encing BPSD, antipsychotic medications the influence of cardiac arrhythmogene- Rampes, & Rosen, 2003). Regardless of are commonly used to treat these sis by conventional and atypical antipsy- whether the absolute or corrected in- symptoms (Schneider, Dagerman, & chotics are complex and partially under- terval is used, antipsychotics lengthen Insel, 2005; Stahl, 2008). As such, antip- stood, research has yielded increasing the QT interval (Imran et al., 2003). sychotics are prescribed both dispro- evidence to suggest the involvement of Although only modestly associated with

The Tablet, November 2010 Volume 11, Issue 3 Page 53

Harris, Antipsychotics in Geriatric Patients..., continued arrhythmia, even slight lengthening of sodium, and potassium (Ca+, Na+, K+) discrete kinetic properties (Witchel et the QT interval has been associated channels are involved in repolarization al., 2003). The IK composite develops with an increase in mortality in older (Glassman & Bigger, 2001). The effect of progressively through the course of the adults (Roden & Vaswanathan, 2005). a given antipsychotic on repolarization is plateau phase, opposing the ionic influx Therefore, the QT interval is the best dependent upon the symmetry between central to the plateau depolarization; available predictor of cardiac related the inhibition of ionic efflux versus the repolarization occurs when the total mortality in older adults treated with inhibition of the influx (Witchel et al., balance of efflux exceeds the influx antipsychotics (Glassman & Bigger, 2003). Since multiple ion channels are (Witchel et al., 2003). Antipsychotics 2001). involved in cardiomyocyte repolariza- block the rapid component of the de-

Prolongation of the QT interval may tion, a defect in any one ion channel layed rectifier current (IKR), which ex- signal a problem related to sudden may decrease repolarization reserve poses defects in other ion channels, death in older adults taking antipsy- (Roden & Viswanathan, 2005). thereby further reducing repolarization chotic medications (Glassman & Bigger, Although there are multiple ion chan- reserve (Li et al., 2010; Roden & Viswanathan, 2005). Repolarization re- 2001; Welch & Chue, 2000; Witchel, nels involved in cardiac action poten- serve may also be influenced by drug- Hancox, & Nutt, 2003). Although tials, research supports the association drug interactions, thus creating a further lengthening of the QT interval is not a between arrhythmia and compounds reduction thereof (Li et al., 2010; Roden problem itself, it signifies a delay in re- that lengthen repolarization by blocking & Viswanathan, 2005). polarization of the ventricular myocar- specific ion channels (Barnes & Hollands, dium and the potential of the fatal par- 2010; Glassman & Bigger, 2001; Li, In the cardiac ventricles, the monopha- oxysmal ventricular arrhythmia torsades Esterly, Pohl, Scott, & McBride, 2010). sic action potential, represented by five de pointes (TdP) (Crumb et al., 2006; Of particular interest are the K+ chan- sections (phases 0 – 4) on ECG, results Glassman & Bigger, 2001; Welch & nels, as they are almost always involved from the synchronous action of the re- Chue, 2000). The effects of antipsychot- in drug-induced (acquired) QT lengthen- lated ion channels (Li et al., 2010). Myo- ics on the cardiomyocyte action poten- ing (Roden & Viswanathan, 2005). The cardial depolarization and repolarization tial are one of the most salient accom- initiation and completion of AP repolari- constitute electrical wavefronts, which panying effects (Imran et al., 2003). zation involves several specific K+ chan- may be visualized as two successive

Molecular Biological and Electro- nels that play prominent roles (Witchel waves crashing upon a shore (Li et al., physiological Perspectives et al., 2003). Specifically, the effect of 2010). The depolarization wavefront + The effects of antipsychotics on ion delayed K rectifier current (IK) on re- moves through the ventricle, on to the channels involved in the generation of polarization is one of the mechanisms bundle of His, downward through the ventricular action potentials are often through which drug-induced QT length- Purkinje fibers toward the ventricular reflected in QT prolongation (Barnes & ening occurs (Crumb et al., 2006; Glass- apex, and away from the endocardium, Hollands, 2010; Witchel et al., 2003). man & Bigger, 2001; Witchel et al., through both the midmyocardium and Ventricular cell depolarization results 2003). Both rapid (IKR) and slow (IKS) epicardium (Li et al., 2010). Immediately from a sodium ion (Na+) influx via selec- elements comprise the IK current, and following depolarization, the... both are specific channel subtypes with tive sodium channels, while calcium, (continued on pg. 54)

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Harris, Antipsychotics in Geriatric Patients..., continued

(continued from pg. 53) IKR or enhancing IKS, this increases the bined with reduced repolarization re- likelihood of development of antipsy- serve and increased transmural disper- ... repolarization wavefront, clinically chotic-induced TdP (Li et al., 2010; Ro- sion, leads to TdP (Welch & Chue, represented as the QT interval, follows den & Viswanathan, 2005; Witchel et al., 2000; Roden & Viswanathan, 2005; the same path (Li et al., 2010). The ef- fects of antipsychotics on the repolariza- 2003; Welch & Chue, 2000). Witchel et al., 2003; Li et al., 2010). tion wavefront are increased duration Inhomogeneity of ventricular action Aging may lead to a higher risk of ad- and reduced amplitude (T-wave flatten- potentials increases the likelihood of verse cardiac events associated with ing) (Li et al., 2010). As depolarization early after depolarizations (EADs) (Li et antipsychotics (Leon et al., 2010). An- and repolarization wavefronts move al., 2010; Roden & Viswanathan, 2005). tipsychotics, as well as other drugs, that through the pathways, the action poten- Because QT intervals are surface level block the IK rectifier current can poten- tial exhibits some heterogeneity, which recordings of action potentials, re- tially cause TdP and lead to sudden car- is referred to as dispersion (Li et al., searchers suggest one of the mecha- diac death in adults who are healthy 2010). Variability in repolarization af- nisms underlying the induction of TdP is (Glassman & Bigger, 2001; Li et al., fects dispersion (Li et al., 2010). An in- the occurrence of early after depolariza- 2010). Since antipsychotics can increase crease in transmural dispersion induced tions (EADs) (Welch & Chue, 2000). arrhythmias in healthy people, individu- by antipsychotics is the second of the EADs are spontaneous depolarizations, als who have cardiac disease are even arrhythmogenic characteristics associ- which cause the conduction of an asyn- more likely to experience these events ated with TdP development (Li et al., chronous, premature beat in segments (Glassman & Bigger, 2001). Considering 2010). of the ventricular myocardium (Barnes older adults are more likely to have & Hollands, 2010; Li et al., 2010; cardiac disease, they are also more likely Drugs used clinically to prolong the QT- Witchel et al., 2003). EADs, when dis- to experience arrhythmogenesis in re- interval increase transmural dispersion of repolarization typically via a preferen- tributed throughout the heart, lead to sponse to antipsychotic medications premature beats via triggered action (Mittelmark et al., 1993). Gender tial suppression of IKR (Li et al., 2010). potentials (Welch & Chue, 2000). If re- (higher risk for females), age, ion chan- Antipsychotic drugs that block the IKR channel can lead to action potential pro- polarization is inhibited (reduced repo- nel polymorphisms, electrolyte imbal- longation in the midmyocardial layer, as larization reserve) either through a de- ance, and cardiac disease in particular + compared to epicardial and endocardial crease in potassium (K ) and/or an in- are also associated with increases in the + layers (Li et al., 2010; Roden & Viswana- crease in the influx of sodium (Na ) or rates of sudden cardiac death (Glassman 2+ than, 2005). This occurs because cells of calcium (Ca ), then prolongation of the & Bigger, 2001; Li et al., 2010). QT interval via I blockade may occur, the midmyocardial layer, called M cells, KR Molecular Genetics allowing the activation of arrhyth- have a reduction in the density IKS and Each of the ion channels involved in the mogenic, inward currents underlying are more sensitive to antipsychotics cardiomyocyte action potential are en- EADs and triggered action potentials (Li blocking IKR (Li et al., 2010; Roden & coded by genes. Mutations of the fol- et al., 2010; Roden & Viswanathan, Viswanathan, 2005). Therefore, when lowing genes have been linked to pro- 2005; Welch & Chue, 2000; Witchel et antipsychotics increase transmural dis- longation of the QT interval: SCN5a al., 2003). The initiation of EADs, com- persion of repolarization by suppressing

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Harris, Antipsychotics in Geriatric Patients..., continued gene (Na+ channel), HERG (K+ channel), risperidone, sertindole, thioridazine, sychotics with other medications that KvLQT1 (K+ channel), and KCNE1 (K+ ziprasidone, and metabolites of some of have an affinity for the same enzymes channel) and KCNE2 (K+ channel) these drugs block the HERG current in (Llerena et al., 2002). Since polyphar- (Welch & Chue, 2000; Witchel et al., a manner that is concentration- macy is common in older adults receiv- 2003). Research has consistently impli- dependent having nanomolar range af- ing antipsychotics, there is an increase in cated the IKR current expressed by the finities. Therefore, the HERG current the risk of both drug interactions and human ether a go-go related gene blockade created by antipsychotics sudden death (Llerena et al., 2002).

(HERG) to be involved in drug-induced seems to be the most likely mechanism One method to counter for risk of sud- TdP (Roden & Viswanathan, 2005; Yap that causes prolongation of the QT in- den death is to measure the parent-drug & Camm, 2000). terval and antipsychotic-induced ar- to metabolite ratio in the blood (Llerena As previously mentioned, antipsychotics rhythmias (Crumb et al., 2006). et al., 2002). This offers a means of esti- linked to drug-induced QT prolongation Because the effects of antipsychotics on mating the capacity of the CYP2D6 target the rapid component of the de- cardiomyocyte and myocardium are isoenzyme, since the ratio of parent-

+ layed K rectifier current (IKR) (Crumb dose-dependent, increases in plasma drug to metabolite is correlated with et al., 2006; Roden & Viswanathan, concentration for the drug or its me- the activity of CYP2D6 (Llerena et al.,

2005; Welch & Chue, 2000). ―IKR is a co- tabolites increase the risk of TdP, as 2002). Therefore, this estimate may assembly of human ether-a-go-go gene certain metabolites also bind to HERG prove to be a useful method for the (HERG) A-subunits encoded by the (Crumb et al., 2006). Certain enzymes clinical management of a potentially fatal KCNH2 gene and MiRP1 B-subunits have been implicated in the increase of TdP side effect (Llerena et al., 2002). encoded by the KCNE gene‖ (Crumb et antipsychotic (and metabolite) plasma Treatment Implications al., 2006, p. 1133). Although some de- concentration (Llerena, Berecz, de la Given that antipsychotics are linked with bate exists, HERG seems to encode a Rubia, & Dorado, 2002; Llerena, Berecz, cardiac effects, a three-fold risk of cere- protein underlying the current I , thus Dorado, & de la Rubia, 2004). One such KR brovascular accidents (CVAs), and an HERG influences ventricular repolariza- enzyme implicated in the metabolism of increase in sudden death, it seems clear tion (Crumb et al., 2006). both thioridazine and risperidone is the that antipsychotics should be used as a cytochrome P450 isoenzyme CYP2D6 Mutations of HERG are associated with last resort in older adults with end-stage (Crumb et al., 2006; Llerena et al., long QT syndrome 2 (LQTS-2), an in- dementia, and only after all other at- 2002; Llerena et al., 2004). Plasma con- herited disorder, which suggests HERG tempts have failed (Ballard et al., 2009; centration can increase through several is a likely mechanism of TdP (Roden & Passmore, Gardner, Polack, & Rabheru, means. First, genetic defects in enzymes Viswanathan, 2005; Seussbrich et al., 2008). The first line of treatment for can increase the plasma concentration in 1997). Thus, HERG offers a mechanistic BPSD should be non-drug. therapies those affected by such defects, referred link between LQTS-2 and drug-induced (Alexopoulos, Streim, & Carpenter, to as poor metabolizers (Llerena et al., QT prolongation (LQTS-1) (Seussbrich 2005; Ballard et al., 2009; Grasel, Wilt- 2002; Llerena et al., 2004). Additionally, et al.). Additionally, Crumb et al. (2006) fang, & Kornhuber, 2003;… plasma concentration can increase found that the antipsychotics clozapine, (continued on pg. 56) through the co-administration of antip- haloperidol, olanzapine, pimozide,

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Harris, Antipsychotics in Geriatric Patients..., continued

(continued from pg. 55) mantine, an NMDA receptor agonist, sessing the capacity of CYP2D6 via par- has also shown promise in treating ag- ent-drug/metabolite ratio (Li et al., ... Passmore et al., 2008; Sutor, Nykamp, gression and agitation in dementia 2010; Llerena et al., 2002). These meth- & Smith, 2006). Clinicians should identify (Ballard et al., 2009; Passmore et al., ods of assessment offer a means of de- and address antecedents of BPSD, which may include comorbid medical and/or 2008; Wat, 2008). Antiepileptics creasing the risk of cardiovascular ef- psychiatric problems, pain, frustration, (sodium valproate and carbemazepine) fects, thereby decreasing mortality in β- and polypharmacy (Passmore et al., and adrenoceptor antagonists, such as older patients treated with antipsychot- 2008; Sutor et al., 2006). propanolol, may be effective in treating ics. If QT lengthening does occur, it may BPSD (Passmore et al., 2008). be treated with empiric magnesium, regardless of serum levels, as well as When all previous attempts at managing hypokalemia correction and withdrawal “Clinicians should identify BPSD have failed, antipsychotics may be of antipsychotic agents (Imran et al., and address antecedents of considered for short-term treatment 2003; Roden & Viswanathan, 2005). BPSD, which may include (Ballard et al, 2009; Passmore et al., However, since the risks of antipsy- comorbid medical and/or 2008; Sutor et al., 2006). When antipsy- chotic use in people with BPSD often psychiatric problems, pain, chotics are prescribed to older adults, outweigh the benefits, clinicians should frustration, and olanzapine may be considered since it reserve antipsychotics for short-term polypharmacy…” has the least blockade effect on the treatment and as a last resort. HERG channel (Crumb et al., 2006). Patients with severe symptoms may be Channing Harris, a doctoral student at Fielding If non-drug therapies are ineffective, Graduate University, lives in Nashville, TN. treated with short-term olanzapine then clinicians should proceed with along with the initiation of a long-term References pharmacological interventions treatment such as a cholinesterase in- Alexopoulos, G. S., Streim, J. E., & (Passmore et al., 2008). Although we Carpenter, D. (2005). Expert consensus hibitor, antidepressant, memantine or guidelines for using antipsychotic agents need further research to identify effec- in older patients. Journal of clinical another less established alternative Psychiatry, 65(Suppl. 2), 100-102. tive medications, the antidepressants (Passmore et al., 2008). When using Retrieved January 3, 2010, from http:// citalopram, sertraline, and trazadone www.psychiatrist.com/privatepdf/2004/ olanzapine, clinicians should consider v65s02/v65s0204.pdf have been shown to improve BPSD Ballard, C. G., Gauthier, S., Cummings, J. L., starting at the smallest dose possible (5 Brodaty, H., Grossberg, G., T., Robert, (Ballard et al., 2009; Lanctot et al., 2001; to 7.5 mg/day) and increase the dosage P., & Lyketsos, C. G. (2009). Manage- Passmore et al., 2008). Cholinesterase ment of agitation & aggression associ- slowly (Alexopoulos et al., 2004). ated with Alzheimer‘s disease. Nature inhibitors have also been shown to be Reviews Neurology, 39(5), 245-255. DOI: To avoid fatal side effects such as TdP, 10.1038/nmeurol.2009.39 an effective treatment for BPSD, such as Barnes, B. J., & Holl&s, J. M. (2010). Drug- clinicians should consider testing when donepezil for Alzheimer's dementia induced arrhythmias. Critical Care Medi- treating older adults with short-term cine, 38(Suppl. 6), S188-S197. (AD), rivastigmine for Lewy bodies de- DOI:10.1097/CCM.0b013e3181de112a antipsychotics. Assessments may include mentia, and galantamine in vascular de- Chen, J., Briesacher, B. A., Field, T. S., Tjia, J., 24-hour ECG monitoring, checking for Lau, D. T., & Gurwitz, J. H. (2010). Un- mentia and AD (Ballard et al., 2009; explained variation across US nursing the possibility drug-drug/disease-drug homes in antipsychotic prescribing Wat, 2008; Passmore et al., 2008). Me- rates. Archives of Internal Medicine, 170 interactions before prescribing, and as-

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( 1 ) , 89-95. DOI: 10.1001/ Kales, K. C., Valenstein, M., Kim, H. M., Drugs & Aging, 25(5), 381-398. archinternmed.2009.469 McCarthy, J. F., Ganoczy, D., Cunning- DOI:10.2165/00002512-200825050- Crumb, W. J., Ekins, S., Sarazan, R. D., ham, F., & Blow, F. C. (2007). Mortality 00003 Wikel, J. H., Wrighton, S. A., Carlson, risk in patients with dementia treated Roden, D. M. & Viswanathan, P. C. (2005). C., et al. (2006). Effects of antipsychotic with antipsychotics versus other psychi- Genetics of acquired long QT syn- drugs on Ito, INa, Isus, IK1, & hERG: atric medications. American Journal of drome. Journal of clinical Investigation, QT prolongation, structure activity Psychiatry, 164(10),1568-1576. doi: 1 1 5 ( 8 ) , 2025-2032. DOI: relationship, & network analysis. Phar- 10.1176/appi.ajp.2007.06101710 10.1172/JCI25539 maceutical Research, 23(6), 1133-1143. Kongsamut, S., Kang, J., Roehr, J., & Rampe, Schneeweis, S., Setoguchi, S., Brookhart, A., DOI: 10.1007/s11095-006-0070-7 D. (2002). A comparison of the recep- Dormuth, C., & Wang, P. S. (2007). Risk Food & Drug Administration. (2005). Public tor binding & HERG channel affinities of death associated with the use of Health Advisory: Deaths with Antipsychotics for a series of antipsychotic drugs. Euro- conventional versus atypical antipsy- in Elderly Patients with Behavioral Distur- pean Journal of Pharmacology, 450(1), 37- chotic drugs among elderly patients. bances. Retrieved May 10, 2010, from 41. DOI: 0014-2999/02/37 Canadian Medical Association Journal, FDA website: http://www.fda.gov/ Lanctot, K. L., Herrman, N., & Mazzotta, P. 1 7 6 ( 5 ) , 627-632. DOI: Drugs/DrugSafety/ (2001a). Role of serotonin in the behav- 10.1503/cmaj.061250 PublicHealthAdvisories/ucm053171.htm ioral & psychological symptoms of de- Schneider, L. S., Dagerman, K. S., & Insel, P. Food & Drug Administration. (2008). Infor- mentia. Journal of Neuropsychiatry & (2005). Risk of death with atypical antip- mation for Healthcare Professionals: Con- clinical Neuroscience, 13(1), 5-21. sychotic drug treatment for dementia: ventional Antipsychotics. Retrieved May DOI:10.1176/appi.neuropsych.13.1.5 Meta-analysis of r&omized placebo- 10, 2010, from FDA Web site: http:// Leon, C., Gerretsen, P., Uchida, H., Suzuki, controlled trials. Journal of the American www.fda.gov/Drugs/DrugSafety/ T., Rajji, T., & Mamo, D. C. (2010). Medical Association, 294(15), 1934-1943. PostmarketDrugSafetyInformationforPa- Sensitivity to antipsychotic drugs in DOI: 10.1001/jama.294.15.1934 tients&Providers/ucm124830.htm older adults. Current Psychiatry Reports, Stahl, S. M. (2008). Stahl's Essential Psy- George, A. L. (2005). Inherited disorders of 12(1), 28-33. DOI 10.1007/s11920-009- chopharmacology: Neuroscientific Basis voltage-gated sodium channels. Journal 0080-3 & Practical Applications, 3rd ed. Cam- of clinical Investigation, 15(8),1990– Li, E. C., Esterly, J. S., Pohl, S., Scott, S.D., & bridge University Press. New York, NY. 1999. DOI:10.1172/JCI25505. McBride, B. F. (2010). Drug-induced Suessbrich, H., Schonherr, R., Heinemann, S. Glassman, A. H., & Bigger, J. T. (2001). An- QT-interval prolongation: Considera- H., Attali, B., Lang, F., & Busch, A. E. tipsychotic drugs: Prolonged QT inter- tions for clinicians. Pharmacotherapy, (1997). The inhibitory effect of the an- val, torsades de pointes, & sudden 3 0 ( 7 ) , 684-701. DOI: tipsychotic drug haloperidol on HERG death. American Journal of Psychiatry, 158 10.1592/phco.30.7.684 potassium channels expressed in (11), 1774-1782. DOI: 10.1176/ Llerena, A., Berecz, R., de la Rubia, A., & Xenopus oocytes. British Journal of Phar- appi.ajp.158.11.1774 Dorado, P. (2002). QTc interval macology, 120(5), 968-974. DOI: Grasel, E., Wiltfang, J., & Kornhuber, J. lengthening is related to CYP2D6 10.1038/sj.bjp.0700989 (2003). Non-drug therapies for demen- hydroxylation capacity & plasma Sutor, B., Nykamp, L. J., & Smith, G. E. tia: An overview of the current situa- concentration of thioridazine in (2006). Get creative to manage demen- tion with regard to proof of effective- patients. Journal of Psychopharmacology, tia-related behaviors. Current Psychiatry, ness. Dementia & Geriatric Cognitive Dis- 1 6 ( 4 ) , 361-364. DOI: 5(5), 81-96. Retrieved May 10, 2010, orders, 15(3), 115-125. DOI: 10.1177/026988110201600411 f r o m 10.1159/000058477 Llerena, A., Berecz, R., Dorado, P., & de la http://www.currentpsychiatry.com/articl Hebert, L. E., Beckett, L. A., Scherr, P. A., & Rubia, A. (2004). QTc interval, CYP2D6 e_pages.asp?AID=4067 Evans, D. A. (2001). Annual incidence of & CYP2C9 genotypes & risperidone Wang, P. S., Schneeweiss, S., Avorn, J., Alzheimer disease in the United States plasma concentrations. Journal of Fischer, M. A., Mogun, H., Solomon, D. projected to the years 2000 through Psychopharmacology, 18(2), 189-193. H., et al. (2005). Risk of death in elderly 2050. Alzheimer Disease & Associated DOI: 10.1177/0269881104042618 users of conventional vs. antipsychotic Disorders, 15(4), 169-173. Retrieved Mittelmark, M., Psaty, B. M., Rautaharju, P. medications. The New Engl& Journal of July 10, 2009, from:http:// M., Fried, L. P., Borhani, N. O., Tracy, Medicine, 353(22), 2335-2341. DOI: journals.lww.com/alzheimerjournal/ R. P., et al. (1993). Prevalence of cardio- 10.1056/NEJMoa052827 Abstract/2001/10000 vascular diseases among older adults. Wat, K. H. Y. (2008). clinical management of Anual_Incidence_of_Alzheimer_Diseas American Journal of Epidemiology, 137(3), behavioural & psychological symptoms e_in_the.2.aspx 311-317. Retrieved May 23, 2010, from of dementia. The Hong Kong Medical Imran, N., Rampes, H., & Rosen, S. (2003). http://aje.oxfordjournals.org/cgi/content Diary, 13(9), 17-22. Retrieved May 28, Antipsychotic induced prolongation of /abstract/137/3/311 2 0 1 0 , f r o m QTc interval treated with magnesium. Passmore, M. J., Gardner, D. M., Polack, Y., http://www.fmshk.org/database/articles/ Journal of Psychopharmacology, 17(3), & Rabheru, K. (2008). Alternatives to 1722.pdf 346-349. DOI: 0269.8811/200309 atypical antipsychotics for the manage- ment of dementia-related agitation. (continued on pg. 58)

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(continued from pg. 57) Witchel, H. J., Hancox, J. C., & Nutt, D. J. Yap, Y. G. & Camm, J. (2000). Risk of tor- (2003). Psychotropic drugs, cardiac sades de pointes with non-cardiac Welch, R., & Chue, P. (2000). Antipsychotic arrhythmia, & sudden death. Journal of drugs. The British Medical Journal, 320, agents & QT changes. Journal of Psychia- clinical psychopharmacology, 23(1), 58-77. 1158-1159. try & Neuroscience, 25(2), 154-160. Re- DOI:10.1097/01.jcp.0000057188.35767. DOI:10.1136/bmj.320.7243.1158 trieved January 4, 2010, from 1d http://www.ncbi.nlm.nih.gov/pmc/article s/PMC1408064/

Appendix

Figure 1:

Mortality Of Older Adults Within 180 days of Being Prescribed Antipsychotics

Conventional Antipsychotics Atypical Antipsychotics Number of Patients

17.9% 14.6% 22,890

25.2% 22.6% 10,615

Adapted from: Wang et al., 2005; Kales et al., 2007

Figure 2:

Electrophysiological basis for LQTS.

(Reproduced with permission from the American Society for clinical Investigation: George, 2005)

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Figure 3:

Mechanisms of sudden death.

(Reproduced with permission from the American Society for clinical Investigation: Roden & Viswanathan, 2005)

Figure 4:

Antipsychotic drug blocking potencies for HERG

Drug HERG IC50 µM Metabolite HERG IC50 µM

Clozapine 0.320 Clozapine-N-oxide 133

Mesoridazine 0.320 N-Desmethylclozapine 4.5

Sertindole 0.0147

Haloperidol 0.0268

Olanzapine 0.231 Desethylolanzapine 14.2

Ziprasidone 0.125 2-Hydroxyolanzapine 11.6

Thioridazine 0.033

Risperidone 0.148 9-Hydroxyrisperidone 1.3

Quetiapine Not available

Pimozide 0.0546

Adapted from: Crumb et al., 2006.

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Psychiatric Taxonomy, Psychopharmacology and Big Pharma Lisa Cosgrove, Ph.D.

Introduction our role as healers, we work with funding, and the majority of the individu- Clinicians practic- our patients to provide the exten- als who serve as diagnostic panel mem- ing today need to sive informed consent that allows bers also have drug industry ties. My be aware of the them to make knowledgeable deci- colleagues and I discovered that 100% of ways in which the sions about using medications, the individuals on two DSM panels, current industry- given a thorough understanding of Schizophrenia and Psychotic Disorders, dominated climate the cost/benefit ratio. (p. 3) and Mood Disorders, had financial ties may undermine the integrity of the sci- (e.g., served on speakers‘ bureaus, cor- In order to be fully educated about the entific process and, thus, may compro- porate boards, received honoraria) with risk/benefit ratio of psychotropic medi- mise patient care. In the mental health the pharmaceutical industry (Cosgrove, cations, we must critically evaluate the field, corporate sponsorship bias can Krimsky, Vijayaraghavan, & Schneider, diagnostic and treatment information affect psychiatric taxonomy and clinical 2006). The fact that all of the members that is being produced and disseminated. Practice Guidelines (CPG). Financial of these panels had industry ties is prob- Psychiatric Taxonomy and the Phar- conflicts of interest (FCOI) can occur lematic because psychopharmacology is maceutical Industry when there are financial associations the standard treatment in these two In 1952, the first official Diagnostic and between researchers, authors, or panel categories of disorders. Statistical Manual of Mental Disorders members developing psychiatric diag- To its credit, the American Psychiatric (DSM) was published by the American nostic and treatment guidelines, and the Association has required all DSM-V Psychiatric Association. Few outside the pharmaceutical industry, or when ran- panel members to post financial disclo- field had ever heard of what is now of- domized clinical trials (RCTs) are indus- sure statements (http://www.dsm5.org). ten referred to as the ―bible‖ of psychi- try funded. Therefore, clinicians need to Indeed, the American Psychiatric Asso- atric disorders. Fewer still would have be especially vigilant about the informed ciation has made a commitment to bet- predicted that 58 years later there consent process when patients are pre- ter manage potential FCOI, and cer- would be a firestorm of controversy scribed psychotropic medications. As tainly this new disclosure requirement over the proposed revisions to the Past President, Elaine LeVine, Ph.D. appears to be a step in the right direc- DSM. noted in the December, 2007 issue of tion. One would, therefore, expect to The Tablet, the issue of informed con- In light of the DSM‘s clinical importance, see a decrease in the number of indi- sent is a particularly salient one for Divi- the appearance of industry bias, let viduals serving on the DSM-V panels sion 55 members: alone the reality, can undermine its in- who have corporate ties. However, as tegrity and weaken public trust. The Psychologists adopting a scientist- we reported in the New England Journal concern about undue industry influence practitioner model are in an excel- of Medicine last year, despite increased was heightened when it was discovered lent position to carefully analyze transparency, industry relationships with that the organization that produces the the research regarding the efficacy DSM panel members persist; approxi- DSM, the American Psychiatric Associa- and safety of various drugs. Be- mately 68% of the DSM-V task-force tion, receives substantial drug industry cause we view education as part of members report having ties to the phar-

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Cosgrove, Psychiatric Taxonomy..., continued maceutical industry (Cosgrove, to industry influence. Specifically, the toms Syndrome" (http://www.dsm5.org). Bursztajn, & Krimsky, 2009). This repre- lack of biological markers opens the This syndrome, proposed for inclusion sents a relative increase of 20% over the door for what some have referred to as in the DSM-V, describes symptoms of proportion of DSM-IV task-force mem- ―disease mongering‖ or ―widening the psychosis that are theorized to appear bers with such ties. But it is not only boundaries of treatable ill- in individuals at risk for developing task force members who have financial ness‖ (Moynihan, Heath, & Henry, schizophrenia, before they are actually relationships with Big Pharma; of the 2002). In turn, this may allow pharma- diagnosed with the disease. The idea is 137 DSM-V panel members who have ceutical companies to apply for FDA that if prodromal psychotic symptoms posted disclosure statements, 77 (56%) approval of new medications that are are diagnosed and treated early enough, reported industry ties, such as holding actually ―me too‖ drugs, drugs that are it will be possible to prevent at-risk indi- stock in pharmaceutical companies, neither more efficacious nor safer than viduals from developing schizophrenia serving as consultants to the drug indus- those already on the market. (See Egli (Gobal, Cosgrove, & Bursztajn, in press). try, or serving on drug company boards, and Egli‘s excellent essay in the July, However, the data do not support this which is no improvement over the 56% 2007 Tablet on the FDA approval of reasoning. Various studies have demon- of DSM-IV members who were found to Invega, then a new atypical antipsychotic strated that only 16-30% of people with have such industry relationships. Some that is essentially a patent extender). In symptoms of psychosis end up develop- DSM-V panels still have a majority of fact, sometimes the iatrogenic harms of ing schizophrenia later in life (McGorry members with industry ties. If financial these medications may outweigh their et al., 2009; Yung et al., 2008). More- conflicts of interest are not reduced, benefits. over, it is not even clear that treatment private-sponsor bias in research will be with antipsychotic medications reduces exacerbated. their risk for developing schizophrenia “… the lack of biological any more than treatment with placebo With concerns mounting about the markers opens the door for (McGlashan et al., 2006). Based on these American Psychiatric Association‘s fi- what some have referred to findings, and in light of the adverse side nancial ties with the pharmaceutical in- as „disease mongering‟ or effects of antipsychotic medications, dustry, questions have been raised by „widening the boundaries of including movement disorders, weight patient advocacy groups, investigative treatable illness‟” gain, and diabetes, some researchers journalists, clinicians and researchers as have concluded that the risk/benefit to whether the proposed changes for ratio does not justify treating those at the DSM-V are evidence-based. Because My colleagues and I have been following risk for psychosis with these medica- a DSM diagnosis influences treatment the proposed revisions to the DSM. An tions (De Koning et al., 2009; McGorry decisions, especially decisions about example of a new disorder that expands et al., 2009). We believe, therefore, that psychotropic medications, adding new diagnostic boundaries and would likely before the DSM-V adopts "Attenuated disorders can have a significant impact result in an increase in the number of Psychotic Symptoms Syndrome," panel on prescribing practices. Indeed, the individuals prescribed psychotropic members need to provide further… lack of biological markers for psychiatric medication, especially children and ado- conditions renders the field vulnerable lescents, is "Attenuated Psychotic Symp- (continued on pg. 62)

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(continued from pg. 61) Because meaningful informed consent sults of RCTs. Researchers studying requires a full representation of adverse financial conflict of interest in clinical ... evidence regarding the validity and effects and accurate information on the trials of psychiatric medications found reliability of this newly proposed cate- efficacy of the recommended medica- that, ―among the 162 randomized, dou- gory (Gobal et al., in press). tions, clinicians rely upon results of ble-blind, placebo-controlled studies Are clinical Practices Guidelines RCTs as the ―gold standard‖ for evi- examined, those that reported conflict (CPG) and Randomized clinical Trials dence-based medicine. Thus, it goes of interest were 4.9 times more likely to (RCTs) industry influenced? without saying that RCTs should be free report positive results‖ (Perlis et al., As noted above, there are increasing of sponsor bias. However, in today‘s 2005). ―[T]he randomized trials agenda concerns that the pharmaceutical indus- climate, should clinicians be wary about may need to reprogram its whole mis- try may be able to influence the defini- sion, including its reporting, toward bet- tion of a mental health problem. There ter understanding of harms‖ (Ioannidis, also is the concern that drug industry “Results of these and other 2009, p. 1739). involvement (e.g., funding of clinical tri- studies have led some to Results of these and other studies have als, guideline authors serving on speak- question whether financial led some to question whether FCOI and ers‘ bureaus of pharmaceutical compa- conflicts of interest and marketing have triumphed over science. nies) could affect CPG development. In marketing have triumphed The under-reporting of negative results 2009, my colleagues and I published the over science.” results of a study that examined financial and publication bias, leading to unsub- associations between the pharmaceuti- stantiated efficacy and safety data, may the ―evidence‖ being disseminated? cal industry and authors of three major prevent clinicians from being able to CPG for Bipolar Disorder, Major De- Let‘s look at the recent research that fully inform their patients about the as- pressive Disorder and Schizophrenia. addresses this question. Pitrou, sociated risks and benefits to taking a We found that 90% of the authors had Boutron, Ahmad, and Ravaud (2009) recommended medication. examined reporting and presentation of financial ties to the pharmaceutical com- This is not to suggest that pharmaceuti- harm-related results in RCTs published panies that manufactured the drugs that cally-funded researchers intentionally in general medical journals with high- were identified in the guidelines as rec- misrepresent their findings in a pro- impact factors. They concluded that ommended therapies for the respective industry way. Researchers are not al- reporting of harms continues to be in- mental illnesses; None of these financial ways aware of the subtle ways in which adequate. They found that information associations were disclosed in the CPG their industry connections may influence related to the severity of adverse events (Cosgrove, Bursztajn, Krimsky, Anaya, & their choice of language or influence was not reported in 27.1% of RCTs, and Walker, 2009). The results of this and their choice of which findings to high- withdrawal of patients because of ad- other studies highlight the need for light. It would also not be fair to say that verse events was not reported in 47.4% greater transparency and management we can never trust industry-sponsored of RCTs. Another study also raises of FCOI in the development of CPG. research. In fact, some studies have questions as to whether clinicians found that, ―the research methods of should unquestioningly accept the re-

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Cosgrove, Psychiatric Taxonomy..., continued trials sponsored by drug companies is at astutely pointed out, psychologists‘ something when his salary depends least as good as that of non-industry training in the scientist-practitioner upon his not understanding funded research, and in many cases bet- model is essential in being able to care- it" (1935/1994, p. 109). Prescribing psy- ter‖ (Lexchin, Bero, Djulbegovic, & fully and thoroughly assess the scientific chologists take heed. Clark, 2003, p. 1168). However, as this evidence regarding the efficacy and Lisa Cosgrove, Ph.D. is a clinical psychologist and brief review of the literature shows, safety of psychotropic medications. associate professor in the Counseling Psychology current disclosure requirements and the However, this training needs to be aug- Department at the University of Massachusetts- Boston. She is a Residential Research Fellow at peer-review process cannot ensure that mented by incorporating a critical and the Safra Center for Ethics, Harvard University treatment recommendations published reflective approach to psychiatric taxon- (AY 2010-2011). She is co-editor of Bias in in high-impact medical journals or pro- omy, and to the treatment recommen- Psychiatric Diagnosis, and a contributing editor of Psychiatric Ethics and the Rights of Per- duced by professional organizations will dations disseminated in clinical Practice sons with Mental Disabilities in Institutions be accurate, balanced, and free of cor- Guidelines. Consideration of the role and the Community. Her work addresses the porate sponsorship bias. that the funding source may have played ethical dilemmas that arise in the biomedical field when there are financial ties between the in the research design, data analysis, or Conclusion pharmaceutical industry and academic institu- reporting of results, is essential. For tions or professional organizations. The field of psychiatry has been plagued example, we must ask questions such as: References by allegations that the pharmaceutical Were adequate outcome measures used Cosgrove, L., Bursztajn H. J., Krimsky, S. industry may be exerting an undue influ- in this RCT? Was the effect size clinically (2009, May 7). Developing unbiased diagnostic and treatment guidelines in ence on the profession. For example, in meaningful as well as statistically signifi- psychiatry [Letter to the editor]. New 2008 Senator Charles Grassley widened England Journal of Medicine, 360, 2035- cant? Was equipoise violated by com- 2036. his series of hearings and investigations paring the new medication to a placebo Cosgrove, L., Bursztajn, H. J., Krimsky, S., into financial associations between Anaya, M., & Walker, J. (2009). Con- rather than to a comparable drug al- flicts of interest and disclosure in the medicine and the pharmaceutical indus- American Psychiatric Association‘s ready on the market? In terms of diag- clinical Practice Guidelines. Psychother- try by requiring the American Psychiat- nosis, we must carefully examine the apy and Psychosomatics, 78, 228-232. ric Association to provide, ―an account- Cosgrove, L., Krimsky, S., Vijayaraghavan, M., evidence when new DSM diagnoses are & Schneider, L. (2006). Financial ties ing of industry funding that pharmaceuti- proposed or when changes in sympto- between DSM-IV panel members and the pharmaceutical industry. Psychother- cal companies and/or the foundations matology are suggested, especially when apy and Psychosomatics, 75, 154-160. established by these companies have, De Koning, M. B., Bloemen, O. J. N., Van these changes will have a direct and Amelsvoort, T. A. M. J., Becker, H. E., including but not limited to grants, do- significant impact on prescribing prac- Nieman, D. H., Van Der Gaag, M., & nations, and sponsorship for meetings Linszen, D. H. (2009). Early interven- tices. tion in patients at ultra high risk of or programs‖ (Moran, 2008). psychosis: Benefits and risks. Acta Psy- Some psychiatrists have found it difficult chiatrica Scandinavica, 119, 426-442. The concerns about industry influence Gobal, A., Cosgrove, L., & Bursztajn, H. (in to understand how financial conflicts of press). The public health consequences in organized psychiatry make Division interest in the field may increase bias in of an industry-influenced psychiatric 55‘s goal of granting prescriptive author- taxonomy: ―Attenuated Psychotic the diagnosis and treatment of mental Symptoms Syndrome‖ as a case exam- ity to all properly trained psychologists ple. Journal of Accountability in Research. illness. As Upton Sinclair stated, "It is especially timely. As Dr. LeVine (2007) difficult to get a man to understand (continued on pg. 67)

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A Glimpse at an Evolving Practice Environment Pat DeLeon, Ph.D., JD, ABPP

The Institute of evidence. The three stated goals were: cycle of interventions  Focus on frontline providers Medicine (IOM) (1) To consider stakeholder capacity for  Foster a trusted intermediary for Roundtable on stronger progress toward a ―learning evidence Evidence-Based healthcare system;‖ (2) To explore  Build the capacity to meet the de- mand Medicine recently transformational opportunities; and, (3)  Create incentives for change conducted a work- To identify possibilities for collective  Accelerate advances in health infor- shop, ―Leadership initiatives that might be considered by mation technology (HIT) Commitments to Improve Value in Roundtable sectors. The participants The envisioned ―learning healthcare Health Care: Finding Common included high level officers from the system‖ is one that maintains a constant Ground.‖ The IOM established the Mayo Clinic, Blue Shield of California, focus on the health and economic value Roundtable in 2006, ―as a unique and National Business Group on Health, returned by care delivered, and continu- neutral venue where the key stake- Consumers Union, AMA, SEIU, CMS, ously improves in its performance. The holders could work cooperatively to VA, and a number of other impressive workshop participants felt that broad help transform the way in which evi- organizations. culture change is especially needed to dence on clinical effectiveness is gener- Common Concerns and Themes enable the evolution of the learning en- ated and used, to improve health and Concerns vironment as a common partnership of health care and to drive improvements  Rising costs and limited resources patients, providers, and researchers in the effectiveness and efficacy of medi-  System inefficiencies alike. Currently, health care has various cal care in the United States.‖ Central  Increasing complexity customs and practices which often are to the IOM vision is the notion that,  Expanding evidence gap not conducive to reform. Caregiving and  Limited system capacity and flexibil- collectively, the healthcare sectors pos- ity caregivers are often ―siloed,‖ with in- sess the knowledge, expertise, and lead-  Entrenched cultures adequate communications among the ership necessary to transform the Themes various functional areas of the health- healthcare system, and that what is  Build trust and collaboration care system. Information is not shared most acutely needed is a shared com-  Foster agreement on ―value‖ in as widely as it should be within specific health care mitment to improving the development healthcare systems, let alone between  Improve public understanding of and use of information about the effi- evidence systems, contributing to inefficiency and cacy, safety, effectiveness, value, and  Characterize the impact of short- distrust in the system. In general, pro- falls in the evidence appropriateness of the health care deliv- viders, patients, and other sectors do  Identify the priorities for evidence ered. The underlying objective is to de- development not yet believe that the development of velop a ―learning healthcare system‖ in  Improve the level, quality, and effi- evidence is an activity relevant to their ciency of the research which, by the year 2020, 90% of clinical experience in the routine delivery of  Clarify and promote transparency decisions will be supported by accurate, care. Accordingly, the point of care  Establish principles for the interpre- timely, and up-to-date clinical informa- tation and use of evidence must be the central focus for this con- tion, and will reflect the best available  Improve engagement in the full life tinuous learning process, a major point

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DeLeon, A Glimpse at..., continued which Steve Ragusea has been making to of infrastructures to improve the Yet, during the recent Congressional psychology‘s leadership for over a dec- focus, accessibility, use, and gen- deliberations on President Obama‘s ade. eration of the best evidence by healthcare reform legislation, in their providers, would also help make December 1, 2009 letter to the Senate Intriguing Notions evidence-based, team-driven care Majority Leader, the American Medical Accelerating the potential for better the norm. Similarly, practices could Association (AMA) shared its view: ―In development and application of evidence be designed and implemented to lieu of the proposed nurse- requires improved communication be- ensure that existing data from pa- managed health clinics, the AMA tween patients and clinicians about the tient care loops back to inform the supports fully integrated multidis- nature of the evidence base, and the generation of new evidence. Other ciplinary health care teams that need for partnership in its development levers noted to promote broader are comprised of nurses and other and use. Leadership is required from uptake of the use of evidence in health care professionals, which every quarter – strong, visible, and mul- clinical practice include education, are led by physicians to ensure that tifaceted leadership from all involved payments, measurement and as- patients get the best possible sectors to marshal the vision, nurture sessment, enhanced patient en- care” [highlighted in the actual letter]. the strategy, and motivate the actions gagement, and reporting require- The nurse-managed clinic provision was necessary to create the ―learning health- ments. retained in the final version of the Pa- care system‖ desired. The IOM indi- tient Protection and Affordable Care cated: This overarching vision is proposed Act (PPACA) (P.L., 111-148), notwith- within the context that 89% of physi- Workshop discussions were standing the AMA‘s expressed concern. cians work in solo practices or small- largely predicated on a central be- Today, pharmacists make up the third group practices (less than 10 physicians, lief that evidence-based care largest group of healthcare profession- with 50% working with four colleagues should be delivered by interdisci- als. Having matured to requiring the or fewer); a similar situation probably plinary teams, an approach that Doctor of Pharmacy or clinical phar- exists for psychologists. Because infor- requires a significant shift in the macy degree as their educational stan- mation in the healthcare system is pres- culture of health care, including dard, their members are providing an ently partitioned into ―silos‖ without embracing the patient as part of increasingly wide range of health ser- connectivity, a clinical data and analytic the team. To make team-driven vices (including behavioral health) to infrastructure must be created to enable care the norm, attention is needed their patients. evidence-based medicine, especially to retooling practices in the areas since physicians spend 60% of their time Change Is Coming of clinical education, ongoing train- seeking data. The importance of devel- It has consistently been reported that ing, testing, and credentialing for oping trust among the various stake- not only does care vary significantly, for front-line healthcare providers. holders, as well as encouraging interdis- reasons unrelated to appropriateness, The development of decision tools ciplinary collaboration, are major reoc- but that even when the available… and prompts, for use in the prac- curring themes. tice setting, and the establishment (continued on pg. 66)

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(continued from pg. 65) ers, although the tipping point may be based treatments but there it is. near.‖ A major challenge -- ―(T)he This is likely an expression of the ... evidence strongly supports a regimen United States devotes less than one- ‗Wampold factor‘ – all active credi- of care (i.e., identified best practices tenth of a percent of its total healthcare ble treatments are about as good exist), such care is received, on average, expenditures to understanding how well as any other active credible treat- only half of the time. It should not be health care works and how to improve ment. So rather than focusing on a surprising, therefore, that, in general, it, an amount that is small compared narrow subset of EBTs, we should the public is not aware of the concept of with the amounts invested to under- look at those components of active evidence-based medicine, nor does the stand other major segments of the credible treatments that make current terminology used to describe economy.‖ them in general somewhat, al- the concept resonate with consumers though not terribly, effective. Per- when presented to them. We have a Russell Lemle, Chief Psychologist at the haps it would be more efficacious long way to go in developing the neces- San Francisco VA Medical Center, and ecologically valid to focus on sary level of ―health literacy‖ among the points out that, ―The VA has been in the disease management strategies, general population. The IOM estimates, forefront of promoting the use of evi- rather than overly focusing upon a for example, that more than 47% of dence based psychotherapies (EBPs) for specific intervention that may not adults have difficulty locating, matching, mental health problems. However, they be applicable to many patients out- and integrating information in texts. In have instituted a narrow subset of EBPs side the confines of randomized fact, studies indicate that a majority of (without transparent selection criteria), trials. We live in a world of non- Americans get their health information in a manner that limits VA clinicians‘ use specificity of effect – and it doesn‘t from the media. Today‘s consumers are of the broader array of best available make a lot of sense to devise highly largely unaware of the variability in evidence-based interventions.‖ Reflect- elaborate, specific treatments for a healthcare quality, and do not have ade- ing the concerns of many clinicians, range of conditions that don‘t re- quate information with which to make Morgan Sammons (Past-President of spond to highly elaborate, specific informed healthcare decisions that are Division 55) cautions: treatments any better than they do based on evidence, and that reflect their What is eminently clear is that the nonspecific ones. This isn‘t antisci- values and preferences. effect size of EBTs often does not entific – indeed, it‘s quite a scien- Currently, the results of 10,000 ran- differ substantially from the effect tific opportunity – but it defies the domized control trials (RCTs) are pub- size of treatment as usual. There is probability based analyses that the lished each year. ―The complexity of often an .05 or better statistical real ‗scientific‘ psychology has be- modern medicine exceeds the inherent difference between EBTs and a come endeared of. limitations of the unaided human mind.‖ wait list or sham condition, but the The Commonwealth Fund ―(T)he critical importance of evidence- difference becomes much smaller A report from the Commonwealth Fund based decision making does not yet when you compare two active indicated: seem to be on the radar screen of the treatments. It‘s quite disconcerting majority of physician and hospital lead- to the developers of evidence Using Pharmacists, Social Workers,

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and Nurses to Improve the Reach primary care practices. With them ments…. and Quality of Primary Care. As comes a new set of skills that can Dramatic Change Is Coming the landmark health reform law improve care and lower costs for Over the next five years, we will wit- goes into effect, bringing millions of patients with depression, physical ness the systematic implementation of uninsured Americans onto insur- disabilities, and other conditions what is perhaps the most significant so- ance rolls over the next five years, that have proven difficult to treat cial legislation enacted by the Congress demand for primary care services in primary care settings…. since the Great Society programs of will increase; So, too, will demand The Commonwealth Care Alliance President Lyndon Johnson. Change is for more accessible, effective, and invested heavily in the model – definitely coming. This could well be an efficient models of primary care. spending approximately $4 million extremely exciting era for our profes- Rather than hiring more primary on 25 practices, many of which are sion‘s prescribing psychologists. Those care physicians, many medical prac- located in low-income, safety net with vision and perseverance will thrive tices, health centers, and other clinics. The investment, which and flourish. primary care settings have been covers the cost of hiring the nurse experimenting with innovative Pat DeLeon, Ph.D., ABPP is affectionately known practitioners by the primary care as the Father of RxP. He was President of the models of care that both extend practices and investing in infra- American Psychological Association (APA) in the reach of primary care physi- structure such as electronic medi- 2000. He won the Division 55 award for Na- cians and increase the quality of tional Contributions to Psychpharmacology in cal records, is more than offset in 2001 and the Division 55 Meritorious Service ambulatory services... [bringing] reductions in hospitalizations for Award in 2008. pharmacists, social workers, preventable conditions as well as nurses, and nurse practitioners to delays in nursing home place-

Cosgrove, Psychiatric Taxonomy..., continued

(continued from pg. 63) McGorry, P. D., Nelson, B., Amminger, G. P., clinical trials in psychiatry. American Bechdolf, A., Francey, S. M., Berger, G. Journal of Psychiatry, 162, 1957-1960. Ioannidis, J. P. (2009). Adverse events in & Yung, A. R. (2009). Intervention in Pitrou, I., Boutron, I., Ahmad, N., & Ravaud, randomized trials: Neglected, re- individuals at ultra-high risk for psycho- P. (2009). Reporting of safety results in stricted, distorted, silenced. Archives of sis: A review and future directions. published reports of randomized con- Internal Medicine, 169, 1737-1739. Journal of clinical Psychiatry, 70, 1206- trolled trials. Archives of Internal Medi- Lexchin, J., Bero, L. A., Djulbegovic, B., & 1212. cine, 169, 1756-1761. Clark, O. (2003). Pharmaceutical in- Moran, M. (2008, August 15). Senator wants Sinclair, U. (1994). I, candidate for governor: dustry sponsorship and quality: Sys- APA records of drug-industry interac- And how I got licked (p. 109). Berkeley, tematic review. British Medical Journal, tions. Psychiatric News. Retrieved from CA: University of California Press. 326, 1167-1170. http://pn.psychiatryonline.org/ (Original work published 1935) LeVine, E. (2007, December). President‘s content/43/16/1.1.full Yung, A. R., Nelson, B., Stanford, C., Sim- primer. ASAP Tablet, 8(4), 3. Moynihan, R., Heath, I., & Henry, D. (2002). mons, M. B., Cosgrave, E. M., Killackey, McGlashan, T. H., Zipursky, R. B., Perkins, Selling sickness: The pharmaceutical E., & McGorry P. D. (2008). Validation D., Addington, J., Miller, T., Woods, S. industry and disease mongering. British of ―prodromal‖ criteria to detect indi- W., & Breier, A. (2006). Randomized, Medical Journal, 324, 886-891. viduals at ultra high risk of psychosis: 2 double-blind trial of olanzapine versus Perlis, R. H., Perlis, C. S., Wu, Y., Hwang, C., year follow-up. Schizophrenia Re- placebo in patients prodromally symp- Joseph, M., & Nierenberg, A. A. (2005). search, 105, 10-17. tomatic for psychosis. American Journal Industry sponsorship and financial con- of Psychiatry, 163, 790-799. flict of interest in the reporting of

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Molecular Nutrition: A Missing Link in Pediatric Pharmacotherapy? Susana Galle, Ph.D., MSCP

“Let food be thy of MTHFR (methylene tetrahydrofolate ties) medicine, and medi- reductase) impairs folic acid conversion  Moderate animal products (unless cine be thy food” to its active metabolite, 5- vegetarian) Hippocrates‘ tenet is methyltetrahydrofolate (5-MTHF)  No Genetically Modified Organ- isms (GMO) universal and time- (Bender, 2002). Depressed individuals  No artificial preservatives, chemi- less. Once Western with that polymorphism benefit from cal pesticides or fungicides researchers isolated the biochemical methylated folate (l-methyl folate or 5-  Adequate hydration from clean units inside food and concentrated them MTHF) as an antidepressant-augmenting water for supplements, contemporary nutri- agent.  Proper ratio of alkalinizing and acid tion was born as a child of molecular Developmentally, nutrition and nurtur- -forming foods for pH balance science. Nowadays, so many things ance are pillars of health operating Combined with outdoor activities, sup- come as pills! Let us explore possible through complex gut-brain-mind con- plemental nutrients and elimination diets matches that may awaken the alchemy nections. Food, used in prevention and help correct imbalances. But wholesome of mental healing while still including cure, also activates children‘s genes. eating and lifestyle do not suffice to op- food in that mix… Currently, food can no longer stand timize health. In assessing child and ado- By focusing on metabolic pathways, mo- alone in the pursuit of health. The re- lescent mental conditions, today‘s envi- lecular nutrition has untapped potential duced nutritional value of foods has ronmental challenges require that we as an ally and complement of pediatric been cited among the causes of illness – factor in neurotoxins (heavy metals, psychopharmacotherapy. The fate of psychopathology included. A diet based pesticides, air pollutants), and inflamma- everything that enters the body depends on processed, sprayed foods, refined tion from varied sources (infection, in- on digestion, absorption, and circulation. sweets, sodas, and trans-fats, a.k.a ―junk jury, diet) (Crinnion, 2009; Kroger et al., Those processes entail a dialogue be- food,‖ has been labeled 2005). Being pro-inflammatory, negative tween two ―brains‖ (in the gut and the ―SAD‖ (Standard American Diet). This stress or emotions also affect gastroin- head), from which nutritional status unhealthy diet has matching effects on testinal (GI) physiology. emerges. Metabolism (Pharmacokinetics, mood, cognition, and behavior, let alone Enter nurturance into the epigenetic PK) responds to nutrition and its defi- the increase in overweight children. equation. As psychologists, we look at ciencies, which also affect drug utiliza- Although food compatibilities are an nutrition psychosocially. Food is tied to tion (Pharmacodynamics, PD). Genetic individual matter, a healthy diet template various rituals across the globe, often polymorphisms, in turn, influence how contains organic, unprocessed foods as understood as a symbol of love. The drugs and nutrients are processed. follows: quality of the eating experience matters: Nutrigenomics, the ―rubicon‖ of mo- Do families take meals together? What lecular nutrition, aims to modify gene  Plants (fruits, vegetables, nuts, and is the ―tone‖ at the dinner table? Family expression, impacting mental disorders seeds)  Moderate dairy and whole grains interactions affect the child‘s vagal tone, and recovery (Gillies, 2003; Kaput, (check casein and gluten sensitivi- and future behaviors (Gregory et al., 2004). For example, the 677C-T variant

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2010; Sen, 2010). School peer pressure chondria include antidepressants, antip- (Remeron) in Major Depressive Disor- has also been linked to stomachaches sychotics, and mood stabilizers. For der (MDD) (Ille et al., 2007). and headaches. Further, socioeconomic instance, valproic acid (VPA) depletes In pediatric nutrition, the first double and cultural factors can unfavorably im- carnitine and decreases beta-oxidation blind, placebo, controlled clinical trial pact nutrition. When chronic stressors in the liver, contributing to intracellular took place over fifty years ago, with 120 beset the child‘s daily life, GI distress lipid retention. Antipsychotic drugs that severely disturbed children (primarily may lead to mal-absorption and malnu- inhibit functioning of the electron trans- schizophrenic spectrum and bipolar). trition. Then, a two-way vicious cycle port chain (ETC) are: some old antipsy- That research shed light on the positive emerges. chotics (chlorpromazine, fluphenazine, role of vitamin B3 (niacin and niacina- haloperidol), and several atypical antip- Nutrient Deficiencies ß à Mind- mide) megadoses, also critical for the sychotics (risperidone, quetiapine, Brain-Behavior Dysfunction energy cycle as NAD+/NADH and clozapine, and olanzapine). Further, The gut, our ―second brain‖ (Gershon, NADP+/NADPH (Hoffer, 1999). Since among the benzodiazepines (BZD), di- 1999) contains leads to a child‘s suffer- then, nutrition studies have focused on azepam inhibits brain mitochondrial ing through GI symptoms (GERD, IBS, Attention Deficit/Hyperactivity Disorder function, while alprazolam does so in IBD, UC, ―leaky gut‖) (Gerson et al., (ADHD) and Autism Spectrum Disor- the liver (Neustadt & Pieczenik, 2008). 2006). The mind-brain-gut connection ders (ASD) (Kapalka, 2010). There is operates through feedback loops among Nutritional strategies can counteract also pediatric research on B vitamins the central nervous system (CNS), the deleterious drug effects. As we learn (B6, B2, and B3) in seizure disorders and enteric nervous system (ENS), and the more from controlled clinical trials, we their behavioral implications. Two re- enteric endocrine system (EES), with will be able to refine those interven- cent studies respectively focused on immune modulation playing an impor- tions. Some work exists on drug effect botanicals for ADHD (Katz & Kav, tant role. Thoughts and feelings set the enhancement through nutrient co- 2010), and vitamin D3 in autism (Meguid tone for those systemic interchanges. administration with antidepressants in et al., 2010). While pediatric research is

Psychotropic drugs were designed to adults. Examples are chromium and sketchy, evidence abounds linking nutri- improve mind-brain-behavior relation- inositol with regard to Selective Sero- tional deficiencies to all mental, emo- ships by restoring neurotransmitter bal- tonin Reuptake Inhibitiors (SSRIs) and tional, and behavioral disorders ance. The brain (along with the heart) is Selective Norepinephrine Reuptake In- (Werbach, 1991). Applying that knowl- the organ requiring the most energy to hibitors (SNRIs). Magnesium (Mg) was edge is likely to support growth and work properly. Nutrients work syner- found to benefit children on stimulants long-term health, as well as alleviating gistically to create that energy and main- (Stargrove et al., 2009). There is sup- children‘s symptoms. port for methylated folate (5-MTHF) tain health. Conversely, certain drugs Several nutrients may be supportive of and s-adenosyl-methionine (SAMe) as damage mitochondrial function. The neurotransmitters: vitamin A, D3, antidepressant augmentation strategies mitochondria fuel, ATP (adenosine Omega 3 essential fatty acids (EFA), free (Papakostas, 2010; Stahl, 2007). One triphosphate), mediates cell energy gen- -form amino acids, all B vitamins, eration and inter-neuronal communica- study successfully used free form amino (continued on pg. 70) tion. The medications that impair mito- acids as ―add-on therapy‖ to mirtazapine

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(continued from pg. 69)  Adaptogens (―stress busters‖): The development of biomarkers may Ashwagandha [Indian Winter eventually identify patients for whom ... and minerals (Fe, Cu, Zn, Mg, Li). cherry], Garum armoricum, Glycyr- antidepressants are appropriate, both in With regard to EFA‘s, a large cross- rhiza glabra [licorice], Hypericum the short and the long term (Pigott et sectional study of Japanese teenagers perforatum [St. John‘s Wort] al., 2010). Nutrition and pharmacology showed a higher intake of fish, EPA, and Rhodiola rosea, etc. (Head & Kelly, 2009) could coalesce in that endeavor through DHA, to be inversely correlated with  Nootropics (cognition enhancers): individualized metabolic analysis. Labora- depression in teenage boys (not signifi- pycnogenol, DMAE tory testing that only assesses serum cantly for girls) (Murakami et al., 2010). (dimethylethanolamine), PEA (from levels may not reflect nutrient function- Other nutrients for brain energy in- Aphanizomenon Flos-Aquae or AFA), ality. In contrast, metabolic pathway clude: alpha-lipoic acid, vitamin C and E, Alpha GPC (l-alpha glycerylphos- analysis reveals whether vitamins, amino n-acetylcarnitine, n-acetylcysteine, glu- phorylcholine), etc. acids, EFA‘s, minerals, etc., are ―doing tathione, and phytochemicals. CoQ10,  Detoxifiers (promote biotransfor- mation for toxin elimination their job.‖ For example Organic Acids, a intimately tied to ATP production, is a through the liver and kidneys): urinary test, yields a broad-spectrum nutrient of interest in relation to bipolar Sylibum marianum [milk thistle], profile. This includes the monoamine disorder (NIMH ongoing study, 2010). Taraxacum officinale [dandelion], neurotransmitter metabolites Homova- PEA (Phenyl Ethyl Amine), from Blue Berberis vulgaris [European bar- nillate (HVA), Vanilmandelate (VMA) Green Algae, is a natural stimulant used berry], etc. and 5-Hydroxy-Indole Acetic Acid in ADHD and depression. It acts to re- The field is ripe to explore molecular (5HIAA), as well as metabolites of vari- lease catecholamines. Antioxidants in nutrition and botanicals as potential ous B vitamins, Krebs cycle compo- those algae produce MAO-B inhibiting treatment adjuncts in pediatric mental nents, oxidative stress, liver detox indi- effects comparable to the drug se- health. The long-term impact of drugs cators, and measures of GI immune legiline. This protects PEA from rapid remains largely unknown. Drug side function (Lord & Bralley, 2008). metabolization, allowing its entry in the effects may be coupled with subtle, cu- brain (Sabelli, 2002). Lithium orotate is mulative nutritional deficiencies, and the It has been suggested that the neurobio- sometimes used in nutritional therapies risk of developing metabolic disorders logical correlates of childhood depres- of bipolar depression. Because it more (e.g., atypical anti-psychotics, lithium). sion may differ from adult ones. Many readily crosses the blood brain barrier While nutrient efficacy studies are few, children and adolescents do not experi- than prescription lithium and stays controversy now surrounds antidepres- ence hyper-cortisolemia. They also longer in the brain, lower doses are sants (Greenberg, 2010). A review of show a weaker response to antidepres- effective (Barker, 2008; Kling et al., four meta-analyses of efficacy trials sub- sants than adults. An animal study mod- 1978; Nieper, 1973) with minimal toxic- mitted to the FDA noted that antide- eling childhood depression found low ity (Sahelian, 2009). Research is needed pressants are only marginally efficacious levels of dehydroepiandrosterone sul- in this area. compared with placebo, and that their fate (DHEA-S) and BDNF (Brain- apparent efficacy has been profoundly Derived Neurotrophic Factor) Among botanicals, three classes are inflated by publication bias. (Malkesman et al., 2009). Certain nutri- relevant for medical psychologists: ents (omega 3 DHA, curcumin, and l-

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Galle, Molecular Nutrition..., continued glutamine with co-factors) could be used behavior. This was a result of individual- ing is beginning to show that psycho- to upregulate BDNF transcription. With ized programs consisting of diet, gentle therapy improves neuro-plasticity and regard to Autism Spectrum Disorders detox, nutrients, probiotics, herbs, and vagal tone through the mind connection, (ASD), a recent review article identified homeopathy, alone or in combination with no side effects. Pharmacology can the following biomarkers: oxidative with pharmacotherapy (Galle, 2006, give us an edge in the healing process, stress, deficiencies in methylation, glu- 2010). The therapeutic use of foods and particularly in the initial phases of treat- tathione, and mitochondrial function, diet with children and adolescents opens ment. However, we risk side effects. intestinal dysfunction, and neuroimmune the door to health-building habits for Drugs utilize and may deplete nutrients, dysregulation. Biomarker-guided inter- entire families. while nutrients replenish the metabolic ventions involving nutrition and medica- pool. For example, neurotransmitter Homeopathy also deserves mention. tion, as needed, have helped children production depends on amino acids, Dilutions may work through electro- with ASD (Bradstreet et al., 2010). vitamins, mineral cofactors, and en- magnetic (EM) signals (Davenas et al., Blaylock & Struneka (2009) emphasized zymes. 1988; Montagnier et al., 2009; Tournier, immune glutamatergic dysfunction in 2008, 2010). Homeopathy‘s profound Molecular nutrition addresses biological ASD, proposing corrective nutrition. energetic impact seems to ―move‖ roots as it tackles individual metabolism, Another reason to observe children and molecules, helping the whole person supplying substrates for growth, func- adolescents from novel angles is two- heal. An encouraging study involves chil- tion, and illness prevention, with rare fold. First, they are constantly changing. dren with ADHD (Frei et al., 2005). side effects. Key advantages of optimal Secondly, they do not quite fit into One article makes a case for its use by diet and nutrients in relation to pharma- medical nosology. One possible angle is medical psychologists (White, 2009). cotherapy are: mitochondrial dysfunction. Mental prob- The counterpoint is a meta-analysis  Drug effect enhancement lems express themselves in the body‘s casting a negative vote (Altung et al.,  Drug dose reduction energy system through disruptions in 2007). Homeopathy is gaining popularity  Fewer side effects any of its organs, muscles, nerve termi- among parents as a non-invasive  Detoxification support nals, etc. Test findings of abnormalities method. While publications and clinical  Ease in the tapering process in energy cycle intermediates (e.g. Or- trials are sprouting, the jury is still out. Considering these advantages, nutrition ganic Acids) can help address their Rather than making blanket generaliza- becomes a compelling link to the pediat- metabolic causes, allowing for nutrition- tions about a treatment mode, it be- ric primary care team. As scientifically ally improving neurophysiological activa- hooves us to observe what patient char- trained professionals, and at this state of tion and obtaining psychological benefits. acteristics make them likely to benefit the art, it is timely to update informed Such functional awareness is the starting from certain interventions (Gerber, consent forms by adding Complemen- point of holistic treatment. 1988). tary and Alternative Medicine (CAM) This writer‘s work, within a psycho- The stage is set for medical/prescribing options that include nutrition. therapeutic matrix, illustrates dramatic psychologists to practice integrative improvement in cognition, mood, and mental and behavioral care. Brain imag- (continued on pg. 72)

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(continued from pg. 71) ―in teams.‖ A drug, in contrast, is usually She is on the clinical faculty in Departments of Pediatrics at George Washington University tested in isolation. In addition to single The responsible practice of nutrition Medical School (Children’s National Medical vitamin research, there is much to learn calls for caution. Firstly, nutraceuticals Center, Adolescent & Young Adult Medicine) and from case studies using supplement pro- Georgetown University. She is on the adjunct do not go through Food and Drug Ad- faculty at Alliant International University, and grams based on psychological and bio- ministration (FDA) approval, while psy- teaches the “Introduction to Nutritional Science chemical individuality. Collaboration chotropic drugs do. Although OTC sup- and Its Role in Psychopharmacology,” course in with the primary care physician is the Postdoctoral master’s in clinical psychophar- plements are helpful for health mainte- macology program. She is also on the faculty strongly recommended, as well as con- nance, multiple products on the market and advisory board of the British Institute of sultation with a clinical nutritionist have varying levels of purity. ―Medical Homeopathy. (CCN). Armed with that objective grade‖ nutraceuticals tested for bioavail- References health information, one may safely and ability are suitable for therapeutic pur- Altung, U., Pittler, M. H., Ernst, E. (2007). effectively apply somatic methods as Homeopathy for childhood and adoles- poses. Companies following that proce- cent ailments: Systematic review of adjuncts at different stages of pediatric dure (Good Manufacturing Practices) randomized clinical trials. Mayo Clinic Proceedings, 82, 69-72. mental and behavioral care. Properly voluntarily adhere to stringent produc- Barker, J. E. (2009). Lithium orotate: The used drugs, nutrients, herbs, and home- mood-enhancing mineral. Complemen- tion and quality control. Secondly, little tary Prescriptions, 2, 9-10. opathy are catalysts enabling our young is known about nutraceuticals and herbs Bender, D. A. (2002). Introduction to nutrition patients to engage in the learning proc- and metabolism (4th edition). Miami, FL: PK & PD. Work on drug-herb-nutrient CRC Press. ess of psychotherapy. interactions has been emerging the last Blaylock, R. L. & Strunecka, A. (2009). Im- mune-glutamatergic dysfunction as a decade (Pelton et al., 2001). Certain Psychologists are invited to learn mo- central mechanism of the autism spec- trum disorders. Current Medicinal nutritional and herbal therapies may lecular nutrition in their postdoctoral Chemistry, 16, 157-170. impair drug effects by stimulating psychopharmacology training. Alliant Bradstreet, J. J., Smith, S., Baral, M., & Ros- signol, D. A. (2010). Biomarker-guided healthy physiological responses, which International University has paved the interventions of clinically relevant con- increases toxin and drug metabolism. In way with its ―Introduction to Nutri- ditions associated with autism spec- trum disorders and attention deficit those cases, it is best to separate drug tional Science and Its Role in Psy- hyperactivity disorder. Alternative Medicine Review: A Journal of clinical intake from the nutrient/herb by a few chopharmacology,‖ offered after the Therapeutics, 15, 15-31. hours (Stargrove et al., 2009). We must science and clinical medicine courses. Crinnion, W. J. (2009). Maternal levels of xenobiotics that affect fetal develop- consult reliable guides to ensure that Further progress in that direction entails ment and childhood health. Alternative Medicine Review: A Journal of clinical our selected supplements support me- a specialized training module. This will Therapeutics, 14, 212-223. tabolism and drug effects, without an- enable the inclusion of Nutritional Phar- Davenas, E., & Benveniste, J. (1988). Human basophil degranulation triggered by tagonizing the organism. macology within the scope of practice of very dilute antiserum against IgE. Na- medical/prescribing psychologists. ture, 333, 816-818. Nutritional medicine is gaining gravitus Frei, H., Everts, R., von Ammon, K., Kauf- by the weight of evidence from consum- Dr. Galle specializes in clinical psychology, foren- man, F., Walther, D., Hsu-Schmitz, Shu -Fang, Collengerg, M., Fuhrer, K., sic neuropsychology, psychopharmacology, clini- ers, health practitioners, and research. Hassink, R., Steinlin, M., & Thurneysen, A. cal hypnosis, and biofeedback. She is a tradi- (2005). Homeopathic treatment of An evidence base for pediatric nutrition tional naturopath, Board Certified clinical Nutri- children with attention deficit hyperac- needs to consider that nutrients work tionist and Classical Homepath, Functional Medi- tivity disorder: A randomized, double cine Practitioner, and Certified Yoga Instructor. blind, placebo controlled crossover

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trial. Euroepan Journal of Pediatrics, 164, handbook for mental health clinicians. tions of lithium orotate: A two years 758-767. San Diego, CA: Elsevier Science. study. Agressologie, 14, 407-11. Galle, S. A. (2006). The work of Susana Kaput, J. (2004). Diet-Disease Gene Interac- Papakostas, G. I., Mischoulon, D., Shyu, I., Galle with two cases: Article based on tions. Nutrition, 20, 26-31. Alpert, J. E., & Fava, M. (2010). S- an interview with Neil Tessler, N. D. Katz, M., Adar Levine, A., Kol-Degani, H., & adenosyl methionine (SAMe) augmen- (Ed.), Simillimum: Journal of the Homeo- Kav-Venaki, L. (2010). A compound tation of serotonin reuptake inhibitors pathic Academy of Naturopathic Physi- herbal preparation (CHP) in the treat- for antidepressant nonresponders with cians, 19, 30-51. ment of children with ADHD: A ran- major depressive disorder. American Gerber, R. (1988). Vibrational medicine: New domized controlled trial. Journal of Journal of Psychiatry, 167, 942-948. choices for healing ourselves. Santa Fe, Attention Disorders, 20, 1-20. Pelton, R., La Valle, J. B., Hawkins, E. B., & NM: Bear & Company. Kling, M. A., Manowitz, J. P., & Pollack, I. W. Krinsky, D. L. (2001). Drug-induced nd Gershon, M. D. (1999). The second brain: A (1978). Rat brain and serum lithium nutrient depletion handbook (2 edition). groundbreaking new understanding of concentrations after acute injections of Hudson, OH: Lexi-Comp. nervous disorders of the stomach and lithium carbonate and orotate. Journal Pigott, H. E., Leventhal, A. M., Alter, G. S., & intestine. New York, NY: Harper of Pharmacy and Pharmacology, 30, 368- Boren, J. J. (2010). Efficacy and effec- Collins. 370. tiveness of antidepressants: Current Gerson, M. J., Gerson, C. D., Awad, R. A., Kroger, S. M., Schestler, T., Weiss, B. (2005). status of research. Psychotherapy and Dancey, C., Poitras, P., Porcelli, P., & Environmental toxicants and develop- Psychosomatics, 79, 267-279. Sperber, A. D. (2006). An interna- mental disabilities: A challenge for Sabelli, H. (2002). Phenylethylamine deficit tional study of irritable bowel syn- psychologists. American Psychologist, 60, and replacement in depressive illness. drome: Family relationships and mind- 243-255. In D. Mishooulon & J. F. Rosenbaum body attributions. Social Science and Lord, R. S., & Bralley, J. A. (Eds.) (2008). (Eds.), Natural medications for psychiatric Medicine, 62, 2838-2847. Laboratory evaluations for integrative and disorders (pp.83-110). Baltimore, MD: Gillies, P. J. (2003). Nutrigenomics: The functional medicine (2nd edition). Du- Lippencott Williams & Wilkins. rubicon of molecular nutrition. Journal luth, GA: Metametrix Institute. Sahelian, J. (2009). Review of Lithium oro- of the American Dietetic Association, 103, Malkesman, O., Asaf, T., Shbiro, L., Gold- tate, carbonate and chloride: Pharma- 50-55. stein, A., Maayan, R., Weizman, A., cokinetics and polyuria in rats. In British Greenberg, R. P. (2010). Prescriptive au- Kinor, N., Okun, E., Sredni, B., Yadid, Journal of Pharmacology, 56, 399-402. thority in the face of research revela- G., & Weller, A. (2009). Monoamines, Sen, B. (2010). The relationship between tions. American Psychologist, 65, 136- BDNF, dehydroepiandrosterone, frequency of family dinner and adoles- 137. DHEA-Sulfate, and childhood depres- cent problem behaviors after adjusting Gregory, J. E., Paxton, S. J. & Brozovic, A. M. sion: An animal model study. Advances for other family characteristics. Journal (2010). Maternal feeding practices, in Pharmacological Sciences, 20, 1-11. of Adolescence, 33, 187-196. child eating behaviour and body mass Meguid, N. A., Hashish, A. F., Amar M., Sid- Stahl, S. M. (2007). Novel therapeutics for index in preschool-aged children: A hom G. (2010). Reduced serum levels depression: L-methylfolate as a tri- prospective analysis. The International of 25-hydroxy and 1alpha, 25 dihy- monoamine modulator and antidepres- Journal of Behavioral Nutrition and Physi- droxy vitamin D in Egyptian children sant-augmenting agent. CNS Spectrum, cal Activity, 28, 55-65. with autism. Journal of Alternative and 12, 739-744. Head, K. & Kelly, G. (2009). Nutrients and Complementary Medicine, 16, 641-645. Stargrove, M. B., Treasure, J., & McKee, D. L. botanicals for treatment of stress, Montagnier, L., & Aaissa, J. (2009). Electro- (2009). Herb, nutrient, and drug interac- adrenal fatigue, neurotransmitter im- magnetic signals are produced by aque- tions: clinical implications and therapeutic balance, anxiety, and restless sleep. ous nanostructures derived from bac- strategies. San Diego, CA: Mosby- Alternative Medicine Review: A Journal of terial DNA sequences. Interdisciplinary Elsevier. clinical Therapeutics, 14, 114-140. Science and Computer Life Science. Tournier, A. (2008). The structure of water. Hoffer, A. (1999). Dr. Hoffer’s ABC of natural Murakami, K., Davidson, P., & Bhatia (2010). Homeopathic Research Institute Newslet- nutrition for children. Kingston, Ontario: Higher intake of fish, EPA, and DHA ter, 5, 1-2. Quarry Press. linked to less depression in teenage Tournier, A. (2010). A new quantum theory Ille, R., Spona, J., Zickl, M., Hofmann, P., La- boys. Pediatrics, 126, 623-630. to explain homeopathy. Homeopathic housen, T., Dittrich, N., Gotz, B., Ha- National Institutes of Mental Health (NIMH) Research Institute Newsletter, 7, 1. siba, K, Mahnert, F. A., & Kapfhammer, (2010). Mitochondrial dysfunction in Werbach, M. R. (1991). Nutritional influences H. P. (2007). Add-on therapy with an the pathophysiology and treatment of on mental illness: A sourcebook of clinical individualized preparation consisting of bipolar disorder. clinical Trials. Gov (8- research. Tarzana, CA: Third Line free amino acids for patients with a 26-10). Press. major depression. European Archives of Neustadt, J. and Pieczenik, S. R. (2008). White, K. P. (2009). What psychologists Psychiatry and clinical Neuroscience, 257, Medication-induced mitochondrial should know about homeopathy, nutri- 222-229. damage and disease. Molecular Nutrition tion, and botanical medicine. Profes- Kapalka, G. M. (2010). Nutritional and herbal and Food Research, 52, 780-788. sional Psychology: Research and Practice, therapies for children and adolescents: A Nieper, H.A. (1973). The clinical applica- 40, 633-640.

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The Self-Medication Question in Response to Stimulant Medication for ADHD: Who is at Risk for Addiction? Brian J. Bigelow, Ph.D., C. Psych., ABPP, FSICPP, FPPR, FICPP

Attention deficit ADHD has also been identified as a neu- and adults. Intriguingly, prescribed hyperactivity dis- rological disorder related to an underac- stimulants increase DA activity but order (ADHD) is tive amygdala (Jones et al.) and smaller chronic drug abuse down-regulates it the most com- left putamen (Wellington et al., 2006). (Sonuga-Barke, 2003). Cannabis in par- mon disorder in Under-arousal of cortical extra- ticular reduces DA (Raiteri, 2006). Thus, pediatric practice pyramidal bodies and poor executive prescribed stimulants work in up- (American Psychiat- controls is a commonly held neurologi- regulating DA and non-prescribed drugs ric Association, 2000), and affects about cal model of ADHD, particularly in terms do not. Prescribed stimulants are moni- 8% of children and adolescents and of co-morbid conduct disorders (CDs), tored daily, while non-prescribed drugs about 4% of adults. ADHD is character- involving aggression, defiance, disobedi- are sporadic, of inconsistent composi- ized by a persistent pattern of inatten- ence and failure to comply across two tion, and introduce a variety of neuro- tion and/or hyperactivity-impulsivity that or more contexts (Jones et al., 2008). transmitters other than DA. is more severe and frequent than is In a thorough review of juvenile detain- The use of psycho-stimulants is gener- usual for persons at a comparable level ees covering 13, 778 boys and 2,972 ally effective in reducing the symptoms of development. ADHD is observed girls, Fazel, Doll and Langstram (2008) of ADHD (Brown, Amler & Freeman et across two or more contexts, such as found that for boys, 11.7% were diag- al., 2005). But there is the potential for home and school. nosed with ADHD and 52.8% with CD. neurotoxicity (e.g., psychotic/mania ad- For girls, 18.5% were diagnosed with There is a familial and possibly genetic verse events), particularly over the ADHD and 52.8% with CD. ADHD is connection to ADHD (Keyes, Legrand, longer term (Berman, Kuczenski, also a major risk factor in adult criminal Iacono, & McGue, 2008). The dopamine McCracken, & London, 2009). And pa- debut (e.g., Babinski, Hartsough, & Lam- hypothesis is compelling as a biological tients often worry about the possibility bert, 1999), particularly for males with understanding of ADHD. There is good of provoking addiction, concern which both CDs and hyperactivity-impulsivity, evidence that those with ADHD have tends to interfere with proper treat- where 71% had some criminal involve- impaired DA/monoamine oxidase (MAO) ment. The key question for treatment ment and 23% had an official arrest re- activity (Volkow et al., 2007; Zimmer- of ADHD with psycho-stimulants is one cord. Those with hyperactivity- man, 1990; Zimmerman, Buchsbaum, & of the prudent practice of balancing impulsivity symptoms and severe CD had Murphy, 1980). MAOs metabolize cate- benefits against such adverse effects. a 57% arrest record, and 54% of males cholamines such as serotonin (5-HT), Quantifying these potential risks is an with ADHD had self-reported criminal norepinephrine (NE) and DA. The MAO ongoing concern (e.g., Mosholder, hypothesis has also been associated with involvement. Gelperin, Hammad & Phelan, 2009; Ve- sensation-seeking behavior (Zuckerman, Psycho-stimulants, such as dextro- dantam, 2009). 1971. Dysregulation of MAO results in amphetamine, Adderall, Cylert, and Rita- In general, ADHD treated with stimu- less serum DA and NE. lin (Methylphenidate), are currently the lants reduces rather than increases risk gold standard pharmacological treat- of substance abuse (Biederman, 2003; ment of ADHD in children, adolescents

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Bigelow, The Self-Medication Question.., continued

Faraone, Biederman, Wilens and of dopaminergic (DA) neurotransmitters dependence. CDs were also associated Adamson, 2007; Wilens, 2003, 2004). in the nucleus accumbens. Thus, psycho with marijuana use. Molina and Pelham Thus, there is no compelling evidence -stimulants are highly reinforcing and are (2003) found that children with ADHD that stimulant medications are a gateway also prone to dependence. Moreover, administered psycho-stimulants devel- for substance abuse for most patients. when these medications are first intro- oped substance abuse as adolescents Untreated ADHD has a relatively more duced in adolescence, there is increased when they were co-morbidly diagnosed probable level of serious risk than treat- sensitivity to their reinforcing effects as oppositional/defiant (ODD) and con- ment with stimulants. (Biederman et al.; Mannuza et al., 2008; duct disordered (CD), and were engaged

Biederman (2003) found that substance Volkow & Insel, 2003), and the potential in illicit drug use in the last six months. abuse was three or four times greater for seeking them corresponding to the A social-developmental perspective to among untreated people with ADHD. maturity of the catelcholamine system. substance abusing has not been applied Untreated adolescents with ADHD often Once started, patients with ADHD to the understanding of stimulant pre- seem to self-medicate with a variety of should continue stimulant medication. scribing. Dodge et al.‘s (2009) dynamic illicit, dopaminergic drugs (Lambert, The introduction of stimulant medica- cascade model of substance abuse onset 2005), including stimulants, alcohol, to- tions for ADHD for children, and then invites a spectrum approach to identify- bacco, cocaine and amphetamines. El- discontinued before adolescence, does ing those most at risk for prescriptive- kins, McGue and Laconno (2007) exam- seem to increase the risk for substance induced drug problems. Dodge et al. ined 1512, 11 year-old twins with abuse in adulthood. A potential expla- noted that ADHD treatment may be ADHD, following them from 14 (age of nation for these findings is that pre- associated with later drug abuse perhaps onset) to 18 years of age and found that scribed stimulant medications may per- because conduct disorders are them- hyperactivity/impulsivity predicted all manently up-regulate the DA threshold. selves co-morbid with substance abuse types of substance use even when con- The most common drug of choice is (e.g., Mannuza, Klein, Bessler, Malloy, & trolling for CD. Conversely, Biedermen tobacco, which is a very dopaminergic LaPadula, 1998). Sampling 304 males and at al. (2008) found no such connection and adrenergic substance. Adolescents 281 females longitudinally from kinder- when controlling for CD. with ADHD are less likely to smoke, or garten to grade 12, Dodge, et al. tracked

However, the issue of psycho-stimulants may smoke less, if they are treated with the developmental occurrence of risk and addiction is not entirely benign. stimulant medication (Lambert, 2005; factors at each of six stages of develop- The potential risk for abuse of psycho- Whalen, Jamner, Henker, Gehricke & ment (i.e.: Child & Context, Early Par- stimulants is high. In their extensive re- King, 2003). This protective effect of enting, Early Behavior, Early Peer Rela- stimulant medication stopped shortly tions, Adolescent Parenting, & Adoles- view, Wilens, et al. (2008) found that after it was discontinued; those with cent Peer Relations Domains). These non-prescriptive, illicit use of stimulant ADHD who had been treated with risk factors increased the probability of medications is fairly common in both stimulants were significantly more likely lifetime substance abuse from .69 to .91. ADHD and non-ADHD populations. to be daily smokers in adulthood. For the Child and Context developmen- Stimulant medications share a common Stimulant treatment was also associated tal stage, child risks included... element with many common substances with future amphetamine and cocaine of abuse: the increased concentration (continued on pg. 76)

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Bigelow, The Self-Medication Question.., continued

(continued from pg. 75) (2005) sample, had a larger than normal were significantly more likely in adoles- incidence of subjects with co-morbid cence to use higher levels of alcohol, ... temperament, medical complications CDs. CDs are associated with substance tobacco and illicit drugs. The more se- and maternal alcohol abuse. Early child- abuse problems, apart from stimulant vere the symptoms, the more drugs hood context risks included social status, adult-child ratio, teen pregnancy, medications. These findings complement were used. ODD and CD symptoms, and unplanned pregnancy, family stress, and those of Mannuzza et al. (2008) who persistence of CD into adolescence, pre- social isolation. Early Parenting stage found that late initiation of stimulant dicted elevated drug use. Wilens (2004) risks included factors such as paternal medications was associated with greater also found this for adults. Again, the non-involvement, aggression, violence, substance abuse as well as mediated by more severe the symptoms, the more abuse etc. Early Behavior stage prob- antisocial personality disorder (APD). drugs were used. ODD and the persis- lems included externalizing problems. That is, those children treated with tence of ADHD were also associated Early Peer Relations stage problems stimulants who were also conduct dis- with high rates of substance abuse. In- reflected peer rejection. Adolescent ordered were more, rather than less, triguingly, smoking also increased more likely to become substance abusers (e.g., over the school year for the non- Parenting stage risks included lack of cocaine, nicotine, etc.). Accordingly, medicated group, suggesting that dopa- parental supervision. Adolescent Peer these data support the view that early minergic substances upregulate the Relations and context factors included use of stimulants increases subsequent baseline DA level. The effect size was neighborhood safety, mother and peer cigarette smoking and is a potential largest for tobacco and marijuana use drug abuse, peer and friend deviance, gateway for other forms of substance suggesting that there is a more complex and substance abuse by grade 12. Thus, abuse, when CDs are part of the clinical neurotransmitter system involved in the prodromal features of CDs overlap ADHD picture. Barkley (2002) also ob- substance abuse. significantly with the progression to- served the connection between cocaine wards lifetime substance abuse. Re- Accounting for the connection between abuse during adolescence and young search designs which tease apart these ODD/CD and the risk of increased drug adulthood for those with CD (2.35 developmental patterns from the effects abuse associated with stimulant medica- times) and for those treated with stimu- of stimulant medications would substan- tions has serious implications for manag- lants (4.11 times). tially help to address the key issue of ing young offenders, and children and whether or not to prescribe these drugs Again, the implication is that when adolescents with ADHD and at risk for for children and adolescents with behav- stimulants are prescribed for children elevated ODD/CDs. Moreover, using ior problems, and at what juncture in with ADHD, it is important not to dis- stimulants and then discontinuing them development. continue them in adolescence, especially during adolescence raises additional risk when CDs are involved. Not medicating factors within the non-ODD/CD ADHD As reported by Wilens, Faraone, Bied- increases the risk for substance abuse population. The overlap in ADHD/CD/ erman and Gunawardene (2003), who and is not a useful alternative in the pre- ODD and the development of APD also conducted a large meta-analysis of the vention of substance abuse. Molina and needs to be considered. A history of stimulant-substance abuse question, Pelham (2003) found that children (n = violent antisocial behavior has a signifi- Lambert and Hartsough (1998)‘s sample, 142) diagnosed with ADHD in childhood cant actuarial component (e.g., Quinsey, which presumably included the Lambert

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Harris, Rice & Cormier, 1998) which risk taking. The clearance of dopamine related to criminogenic behavior. Re- includes a large contribution of severe (oxidation) depends in part on the rate search needs to be done connecting the elementary school maladjustment, his- of its degradation by MAO-A and MAO-B risk taking personality, CDs and risk of tory of criminal violent or nonviolent (Weyler, Hsu & Breakfield, 1990). The substance abuse as the origins of antiso- offenses and a high Psychopathy Checklist higher the serum levels of MAO, the cial personality disorder (APD) may well score (Hare, 1996). CD originates in lower the levels of 5-HT, NE and DA. be linked to the neurological roots of either childhood (before age 10) or ado- Thus, it was hypothesized that there is a failure to learn from experience, a cardi- lescence and ODD originates in child- negative relationship between serum nal feature of CDs. Alternatives to hood (before age 10) and both are com- MAO and risk-taking. Indeed, Zucker- stimulant medications, such as selective mon co-morbidities of ADHD (Webster man (1990) and Zuckerman, Buchsbaum serotonin reuptake inhibitors (SSRIs) for & Hucker, 2007). Consequently, the and Murphy (1980) identified a deficit in conduct disordered children and adoles- risks of drug abuse associated with MAOs in those high in risk-taking. In- cents with ADHD should be considered, stimulant medications may require that deed, MAO-inhibitors serve to decrease as there is no drug-induced ―high.‖ clinicians first screen those children and depression and risk-taking by increases However, preliminary results are mixed. adolescents with CDs/ODDs, and take serum DA. Zuckerman reasoned that a For example, Olvera, Pliszka, Luh and special care to use medications without lack of regulation of DA by MAOs may Tatum (1996) found a 50% SSRI effec- a pronounced subjective ―high,‖ and to produce the augmenting response of tiveness in a sample of 16 children and continue the regimen throughout child- sensation seekers. Also, Zuckerman adolescents, using the Connors Parent hood and adolescence. The implications and Kuhlman (2000) found a significant Rating Scale. It is not clear whether al- are particularly germane to correctional relationship between (high) MAO levels ternatives to dextroamphetamines such populations, where such disorders are and sensation-seeking in terms of smok- as Adderall or Strattera, formulated to more commonplace. ing, drinking, drugs, sex, driving and reduce the ―high‖ normally associated gambling behaviors. MOAs oxidize 5-HT with stimulant use, are actually less Zuckerman (1971)‘s Sensation Seeking into NE and DA which are released by prone to being abused by children and Scale (SSS) is an attractive construct stimulants such as amphetamines, co- adolescents with ADHD and CDs. bridging the psychopharmacological per- caine and nicotine. Similarly, Akker- Clearly, more research on the drug spective in helping to account for the mann, Harro and Kabines (2003) and abuse profiles Young Offender popula- dynamics of stimulant discontinuation, Paaver, Diva, Pulver and Harro (2006) tions with ADHD and CDs and psy- conduct problems, and the risk for fu- found an inverse connection between chopharmacological treatments is war- ture substance abuse. Zuckerman de- scribed those scoring high on the SSS as MAO platelet activity and impulsivity and ranted. risk driving behavior. Dr. Brian J. Bigelow is a Registered Psychologist having the need to seek varied, novel, in the Province of Ontario with an ABPP in Child complex experiences, and the willing- While Zuckerman et al. (1980) did not and Adolescent clinical Psychology. He is a Full Professor and the Anglophone Director of the ness to undertake a variety of risks to link the sensation seeking construct M.A. /M. Sc. in Human Development at Lauren- tian University. He also has a part-time inde- achieve arousal. It was hypothesized directly to criminality, it is related to pendent practice, treating children and adoles- that serum monoamine oxidase inhibi- risk taking and being young and male, cents and performing related forensic… tors (MAOs) are inversely connected to precisely those components that are (continued on pg. 78)

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(continued from pg. 77) Faraone, S. V. (2008). Stimulant ther- metaregression analysis of 25 surveys. apy and risk for subsequent substance Journal of the American Academy of Child ... assessments. Dr. Bigelow has completed the use disorders in male adults with & Adolescent Psychiatry, 47(9), 1010- FICPP designation with the Prescribing Psycholo- ADHD: A naturalistic controlled 10- 1019. gists Register. He is currently on the RxP Task year follow-up study. American Journal Faraone, S. V., Biederman, J., Wilens, T. E., Force of the Ontario Psychological Association of Psychiatry, 165, 597-603. Epub & Adamson, J. (2207). A naturalistic and is Secretary-Treasurer of the Psychopharma- March 3, 2008. Available at: http:// study of the effects of pharmacother- cology section of the Canadian Psychological www.ncbi.nlm.nih.gov/ apy on substance use disorders among Association. pubmed/18316421? ADHD adults. Psychological Medicine, References o r d i n a l - 37(12), 1743-1742. Akkerman, K., Harro, J., & Kabins, M. pos=8&itool=EntrezSystem2.PEntrez.P Hare, R. D. (1996). Psychopathy: A clinical (2003). Platelet monoamine oxidase ubmed.pubmed_ResultsPanel.Pubmed_ construct whose time has come. activity and other markers of mono- RVDocSum. Criminal Justice and Behavior, 23, 25-54. aminergic systems in predicting impulsivity Brown, R. T., Amler, R. W., Freeman, W. Jones, A. P., Laurens, K. R., Herba, C. M., and risk-taking behavior. Estonian S., Perrin, J. M., Stein, M. T., Feldman, Barker, G. J., & Viding, E. (2008). Science Foundation Research Grant. H. M., Pierce, K., & Wolraich, M. L. Amygdala hypoactivity to fearful faces http://www.1st-world.org/Project De- (2005). American Academy of Pediat- in boys with conduct problems and tails.aspx? rics Committee on Quality Improve- callus-unemotional traits. American P r o j e c - ment: American Academy of Pediatrics Journal of Psychiatry, October 15. Re- tId=b349fb3781cc47dd93d7a3ff101bcc Subcommittee on Attention-Deficit/ trieved from h t t p : / / dc. Retrieved May 18, 2009. Hyperactivity Disorder. Pediatrics, ajp.psychiatryonline.org/cgi/content/ American Psychiatric Association (2000). 115(6), 749-757. abstract.appi.ajp.2008.070. Diagnostic and statistical manual of Carver, S., Johnson, S. L., & Joorman, J. Keyes, M., Legrand, L. N., Iacono, W. G., & th mental disorders (4 ed., text rev.) (2008). Serotonergic function, two- McGue, M. (2008). Parental smoking Washington, DC. mode models of self-regulation, and and adolescent problem behavior: an Babinski, L. M., Hartsough, C. S., & vulnerability to depression: What de- adoption study of general and specific Lambert, N. M. (1999). Childhood pression has in common with impulsive effects. American Journal of Psychiatry, conduct problems, hyperactivity- aggression. Psychological Bulletin, 134 165(10), 1338-1344. (6), 912-943. impulsivity, and inattention as predic- Kutcher, S., Murphy, A., & Gardner, D. tors of adult criminal activity. Journal Daley, K. C. (2005). Update on attention- (2008). Psychopharmacological treat- of Child Psychology and Psychiatry, 40, deficit/hyperactivity disorder. Current ment options for global child and ado- 347-355. Opinion in Psychiatry, 16(2), 217-226. lescent mental health: The WHO Essen- Barkley, R. A. (2002). Does the treatment Dembo, R., Turner, C. W., & Jainchill, N. tial Medicines Lists. Journal of the Ameri- of ADHD with stimulants contribute (2007). An assessment of criminal can Academy of Child and Adolescent to drug use/ abuse: A 13-year prospec- thinking among incarcerated youths in Psychiatry, 47(10), 1105-13. OUT. tive study. Pediatrics, 111, 1-1. three states. Criminal Justice and Behav- Lambert, N. (2005). The contribution of Barkley, R. A. (2003). Does the treatment ior, 34(9), 1157-1167. childhood ADHD, conduct problems, of ADHD with stimulant medication Dodge, K. A., Malone, P. S., Lansford, J. E., and stimulant treatment to adolescent contribute to illicit drug use and abuse Miller, S., Pettit, G. S., & Bates, J. E. and adult tobacco and psychoactive in adulthood? Results from a fifteen- (2009). A dynamic cascade model of substance abuse. Ethical Human Sci- year prospective study. Program and the development of substance-use ences and Services, 7(3), 197-221. abstracts of the American Psychiatric onset. Monographs of the Society for th Lambert, N. M., & & Hartsough, C. S. Association 156 Annual Meeting, May Research in Child Development, Serial (1998). Prospective study of tobacco 17-22; San Francisco, California. No. 294, 74(3), 2009. smoking and substance dependences Berman, S. M., Kuczenska, R., McCracken, J. Elias, M. (2008). Study: Most depressed among samples of ADHD and non- T., & London, E. D. (2009). Potential kids get antidepressants but no ther- ADHD participants. Journal of Learning adverse effects of amphetamine treat- apy. USA Today. OUT. Disabilities, 31, 533-544. ment on brain and behavior: a review. Elkins, I., McGue, M., & Lacono, W. G., Lambert, N. (2005). The contribution of Molecular Psychiatry, 14, 123-142. (2007). Prospective effects of atten- childhood ADHD, conduct problems, Biederman, J. (2003). Pharmacotherapy for tion-deficit/hyperactivity disorder, and stimulant treatment to adolescent attention-deficit/hyperactivity disorder conduct disorder, and sex on adoles- and adult tobacco and psychoactive (ADHD) decreases the risk for sub- cent substance use and abuse. Archives substance abuse. Ethical Human Sci- stance abuse: Findings from a longitudi- of General Psychiatry, 64(10), 1145- ences and Services, 7(3), 197-221. nal follow-up of youths with and with- 1152. Mannuza, S., Klein, R. G., Bessler, A., out ADHD. Journal of clinical Psychiatry, Fazel, S., Doll, S., & Layngstram, N. (2008). Malloy, P., & LaPadula, M. (1998). 64, 3-8. Mental disorders among adolescents in Adult pychiatric status of hyperactive Biederman, J., Monteaux, M. C., Spencer, T., juvenile detention and correctional boys grown up. American Journal of Wilens, T. E., MacPherson, H. A., & facilities: A systematic review and Psychiatry, 155, 493-498.

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McKetin, R., McLaren, J., Lubman, D., & tention and hyperactivity/impulsivity Wilens, T. E. (2004). Impact of ADHD and Leanne, H. (2008). Hostility among symptoms on development of nicotine its treatment on substance abuse in methamphetamine users experiencing dependence from mid adolescence to adults. Journal of clinical Psychiatry, 65, psychotic symptoms. The American young adulthood. Journal of Pediatric 38-45. Journal of Addictions, 17(3), 235-240. Psychology, 33(6), 563-575. Wilens, T. E. (2007). The nature of the Mannuzza, S., Klein, R. G., Truong, N. L., et Whalen, C. K., Jamner, L. D., Henker, B., relationship between attention- al., (2008). Age of methylphenidate Gehricke, J-G, & King, P. S. (2003). Is deficit/hyperactivity disorder and sub- treatment initiation in children with there a link between adolescent ciga- stance abuse. The Journal of clinical ADHD and later substance abuse: rette smoking and pharmacotherapy Psychiatry, 68(11), 4-8. prospective follow-up into adulthood. for ADHD? Psychology of Addictive Be- Wilens, T. E., Adler, L. A., Adams, J., Sgam- American Journal of Psychiatry, haviors, 17(4), 332-335. bati, S., Rotrosen, J., Sawtelle, R., 165(5)< 604-609. Epub, April, 2008. Raiteri, M. (2006). Functional pharmacology Utsinger, L., & Fusillo, S. (2008). Mis- Available at: in human brain. Pharmacological Re- use and diversion of stimulants pre- http://www.ncbi.nlm.nih.gov/pubmed/1 views, 58(2), 162-193. scribed for ADHD: A systematic re- 8381904?dopt=Abstract. Sonuga-Barke, E. J. (2003). The dual path- view of the literature. Journal of the Mannuzza, S., Klein, R. G., Truong, N. L., way model of AD/HD: an elaboration American Academy of Child and Adoles- Moulton, J. L. III, Roizen, E. R., Howell, of neuro-developmental characteris- cent Psychiatry, 47(1), 21-23. K. H., & Castellanos, F. X. (2008). Age tics. Neuroscience Biobehavior Review, Wilens, T. E., Faraone, S. V., Biederman, J., of methylphenidate treatment initiation 27, 593-604. & Gunawardene, S. (2003). Does in children with ADHD and later sub- Vedantam, S. (2009). Debate over drugs stimulant therapy of attention- stance abuse: prospective follow-up for ADHD reignites. The Washington deficit/hyperactivity disorder beget into adulthood. American Journal of Post, Friday, March 27; A01. later substance abuse? A meta-analytic Psychiatry, 165, 604-609. Volkow, N. D., & Insel, T. R. (2003). review of the literature. Pediatrics, Marcus, S. C., Wan, G. J., Zhang, H. F., What are the long-term effects of 111, 179-185. & Olfson, M. (2008). Injury among methylphenidate treatment? Biological Wilens, T. E., Martelon, M., Kruesi, M., J. P., stimulant-treated youth with ADHD. Psychiatry, 54, 1307-1309. Parcell, T., Westerberg, D., Schillinger, Journal of Attention Disorders, 12(1), 64- M., Gignac, M., & Biederman, J. (2009). 69. Volkow, N. D., Wang, G. J., Newcorn, J., Telang, F., Solanto, M. V., Fowler, J. S., Does conduct disorder mediate the Molina, B. S. G., & Pelham, W. E. Jr. (2003). Logan, J., Ma Y, Schultz, K., Pradhan, development of substance use disor- Childhood predictors of adolescent K., Wong, C., & Swanson, J. M. (2007). ders in adolescence with bipolar disor- substance abuse in a longitudinal study Depressed dopamine activity in cau- der? A case-control family study. The of children with ADHD. Journal of Ab- date and preliminary evidence of limbic Journal of clinical Psychiatry, 70(2), 259- normal Psychology, 112(3), 497-507. involvement in adults with attention- 265. Mosholder, A. D., Gelperin, K., Hammad, deficit/hyperactivity disorder. Archives Weyler, W., Hsu, Y. P., & Brakefield, X. O. T. A., & Phelan, K. (2009). Hallucina- of General Psychiatry, 64, 932-940. (1990). Biochemistry and genetics of tions and other psychotic symptoms Webster, W. D., & Hucker, S. J. (2007). monoamine oxidase. Pharmacology & associated with the use of attention- Violent risk: Assessment and manage- Therapeutics, 47, 391-417. deficit/hyperactivity disorder drugs in ment. Chichester; John Wiley & Sons. Wysong, P., & Adler, L. (2003). Long-term children. Pediatrics, 123(2), 611-616. treatment of ADHD. American Psy- Wellington, T. M., Semrud-Clikeman, M., th National Institute on Drug Abuse (2008). Gregory, A. M., Murphy, J. M., & Lan- chiatric Association, 156 Annual NIDA Infofacts: Stimulant ADHD caster, J. L. (2006). Magnetic reso- Meeting; San Francisco, California. medications – Methylphenidate and nance imaging volumetric analysis of Zuckerman, M. (1971). Dimensions of sen- amphetamines. the putamen in children with ADHD: sation seeking. Journal of Consulting and http://www.nida.nih.gov/infofacts/ADH combined type versus control. Journal clinical Psychology, 36, 45-52. D.html. Retrieved 2/12/2009. of Attention Disorders, 10(2), 171-180. Zuckerman, M. (1990). The psychophysiol- Paaver, M., Eensoo, D., Pulver, A., & Harro, Whalen, C., Jamner, L. D., Henker, B., Ge- ogy of sensation seeking. Journal of J. (2006). Adaptive and maladaptive hricke, J-G, & King, P. S. (2003). Is Personality, 58(1), 213-345. impulsivity, platelet monoamine oxi- there a link between adolescent smok- Zuckerman, M., & Kuhlman, M. (2000). dase (MAO) activity and risk-admitting ing and psychopharmacology for Personality and risk-taking: Common in different types of risky drivers. ADHD? Psychology of Addictive Behav- biosocial factors. Journal of Personality, Psychopharmacology, 186(1), 32-40. iors, 17(4), 332-335. 88(6), 999-1029. Quinsey, V. L., Harris, G. T., Rice, M. E., & Wilens, T. E. (2003). Does the medicating Zuckerman, M., Buchsbaum, M .S. & Mur- Cormier, C. A. (1998). Violent offend- of ADHD increase or decrease the phy, D. L. (1980). Sensation seeking ers: Appraising and managing risk. risk for later substance abuse? Revista and its biological correlates. 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Remembering Scott Borrelli Beth Rom-Rymer, Ph.D.

Scott Borrelli was a Dickinson University in 2007. Scott was del Sol in southern Spain. colleague whom we an international affiliate member of Divi- Scott was enthusiastic about his work in lost much too soon. sion 55 and the APA. Scott was a li- radio and television and consulted with An American who censed psychologist in Florida, Massa- the BBC. He was published in the Journal left for a year‘s stint chusetts, California, and Guam, as well of Elder Abuse and Neglect, (Division in Europe in 1989, as a chartered clinical psychologist, a 42‘s) The Independent Practitioner, the he fell in love with chartered counseling psychologist, and a Junge-Kinder Journal of the Association the European countryside, the lifestyle, chartered scientist in The British Psy- for Young Children (Europe), and The the people, and rarely returned to the chological Society. Stars and Stripes. He wrote on topics U.S. after that. Meeting his life partner, In the last two decades, Scott was a such as the British reaction to terrorist Gerco Verduijn, in 1990 in Munich, collegiate professor, practicum/ bombings in London, family violence, whom he married on November 18, internship coordinator of The University elder abuse, child advocacy, stress man- 2005, sealed his commitment to living of Maryland, European Division; on the agement and clinical psychopharmacol- abroad. faculty in psychology and Buddhism at ogy (with Dan Egli). Scott led an admirably active and pro- the International Institute of Tibetan and Scott was always a warm, energetic ductive life as a psychologist, both in the Asian Studies (his preferred practice presence in the lives of all of the people U.S. and in Europe. Having grown up in was with the Japanese Nichiren whom he touched. Perhaps it was be- Boston, he graduated from Boston Uni- Daishonin‘s Buddhism); the Director of cause of his many creative outlets, in- versity, cum laude in 1972; received his the University Counseling Services at cluding his music; he had been a guitar- Ed.M. in Counseling Psychology from The American InterContinental Univer- ist, lead vocalist and pianist in two differ- Salem State College in 1975, having sity of London, Coordinator of Special ent bands in earlier years. Even while written his thesis on ―A New Scoring Needs and Disability Services; a re- fighting his illness, having been diagnosed System for the Thematic Apperception search associate in psychology from with Non-Hodgkins Mantle Cell Lym- Test‖; and earned his Ed.D. in Counsel- Boston University; faculty instructor and phoma in October 2003, Scott remained ing Psychology from Boston University mentor in psychology at Walden Uni- optimistic, steadfast, and generous in all in 1979. Scott went on to achieve the versity, Minneapolis, Minnesota; a con- of his relationships and loved his life of ABPP in both clinical Psychology and sultant clinical psychologist with the domestic tranquility on the sunny coast Counseling Psychology, as well as the Psychiatric and Psychological Consulting of Spain. Scott succumbed to his illness FICPP from the International College of Services, Ltd., in London; the Chief Edi- on July 28, 2010. Prescribing Psychologists (2002) and tor and Column Contributor of The Scott leaves behind many good friends Board Certification as a Medical Psy- EMDR Practitioner in Europe; a precep- and colleagues and is survived by his chologist from the Academy of Medical tor/supervisor in the Substance Abuse partner, Gerco, and his daughter Darcie. Psychologists. He had completed all of Rehabilitation Programs in the U.S. Navy We will all miss him. his coursework for his MSc in clinical Medical Clinics, in London; and had a psychopharmacology from Fairleigh small clinical practice along the Costa

The Tablet, November 2010 Volume 11, Issue 3 Page 81

2011 Division 55 Midwinter Conference Washington, DC Saturday, March 12 - Monday, March 14

Go to www.div55conf.com for registration and hotel discount info!

 Preconference Workshop (Friday, March 11) by Robert Julien, M.D., Ph.D., Au- thor of A Primer of Drug Action– “Child and Adolescent Psychopharmacology, Prena- tal Through High School”

 Conference held concurrently with the State Leadership Conference, with sev- eral joint meetings

 Featured Speaker– Daniel J. Carlat, M.D., Editor-in-Chief of The Carlat Psychiatry Report, and strong advocate for integrated health care and prescribing by psycholo- gists

 Presentation by Robert Julien, M.D., Ph.D.– “To Intend or Not to Intend, That is the Question: Sedatives, Behavior, Amnesia, & Intent”

 Presentation by John Preston Psy.D., ABPP, author of Handbook of Psychopharma- cology for Therapists– “Stress-Induced Brain Damage and Neuroprotection”

 Presentation by Huib Van Dis, MD., Ph.D., Chairman of the Division of Psychology in Health Care of the Nederlands Instituut van Psychologen- “Diagnosis and Treat- ment of Delirium From An RxP Perspective”

 Town Hall Meeting– “RxP and Integrated Health Care”

 Panels- “RxP in the Public Sector,” and “How Psychopharmacology Training Can De- crease Meds and Increase CBT Referrals”

 Program- “Setting the Direction for RxP in the Future”

 Roundtable Discussions– Starting or Keeping RxP Going in Your State, and Inter- national RxP

 Participation in program presentations by 2 APA Past-Presidents, Robert Resnick, Ph.D. (1995) and James Bray, Ph.D. (2009)

 Opportunities for brainstorming with RxP leaders, as well as leaders from your state, to facilitate the prescriptive authority movement

The Tablet, November 2010 Page 82 THE TABLET: Newsletter of Division 55

Congratulations to Those Who Reported Being Psychopharmacology Exam for Psychologists (PEP) Passers in 2010

Lia Billington, Ph.D., MSCP David F. O’Connell, Ph.D., MSCP

Stacey R. Gedeon, Psy.D., MSCP Robert C. Rinaldi, Ph.D., MSCP

Hunter Hanson, Ph.D., MSCP Stephen Seaman, Ph.D., MSCP

Mike Kim, Psy.D. MSCP Faune T. Smith, Ph.D., MSCP

Heather Kirkpatrick, Ph.D., MSCP Earl Sutherland, Ph.D., MSCP

Tony J. Kreuch, Psy.D., MSCP, CEAP Michael R. Tilus, PsyD, MSCP

Bret Moore, Psy.D., MSCP, ABPP Renee Wilkins, Psy.D., MSCP

DIVISION 55 PEP PREP COURSE on CD With 16 Hours CE Credit Presented by Marlin Hoover, Ph.D. Now Available for Purchase

http://www.division55.org/PEPReviewCourse.htm

The Tablet, November 2010 j Volume 11, Issue 3 Page 83

Congratulations To Election Winners and Appointees: President-elect for 2011 Kevin M. McGuinness, Ph.D. Treasurer (2011-2012) Mary-Kathryn Black, Ph.D. Member-at-large (2011-2013) Kathleen M. McNamara, Ph.D . APA Council Rep (2011-2013) Robert McGrath, Ph.D. APAGS representative (2011) Katherine Bartek Fellows Committee Chair Ray Folen, Ph.D. To Division 55 Award Winners at the 2010 APA Convention: Kevin McGuinness, Ph.D., MP, ABPP– The 1st recipient of the Major L. Eduardo Caraveo National Service Award, established to honor the memory of prescribing psychologist Major Eduardo Caraveo, who was killed in the shootings at Ft. Hood Steven Tulkin, Ph.D., MSCP– Winner of the Award for Outstanding Advocacy at the National Level for a long history of involvement in training psychologists to prescribe, and a history of effective advocacy Don Fineberg, M.D.– Winner of the Award for Outstanding Advocacy at the State Level, for his continued work in the state of New Mexico in support of prescriptive authority for psychologists Susan Patchin, Psy.D., MSCP– Winner of the Special Advocacy Award in recognition of her work in the state of Oregon on behalf of prescriptive authority Senators Laurie Monnes-Anderson, RN and Bill Kennemer, Ph.D.– Winners of the Outstanding Legislative Advocacy award for their legislative support of prescriptive authority in the state of Oregon Amir Sepehry, M.Sc.– Winner of the Student Advocacy Award in recognition for his efforts as a graduate student to advance prescriptive authority in Canada Jessica Funk, M.A.– Winner of the 2010 Patrick H. DeLeon Prize for her dissertation entitled, ―Psychology‘s Expanding Scope of Practice: An Historical Analysis of Relations with Psychiatry, Prescriptive Authority, and Legislation‖ Laura Holcomb, Ph.D., MSCP– Award for service as Division 55 Tablet Editor for 2009 and 2010 (Editor‘s Note– Thank you!)

The Tablet, November 2010 The American Psychological Association Non-profit Org. US Postage Division Services Office/Div 55 PAID 750 First Street NE Permit No.6348 Washington DC Washington DC 20002-4242

2010 ASAP Committee Chairs

ABPP Awards Committee Canadian Psychology Committee Beth Rom-Rymer, Ph.D. Morgan Sammons, Ph.D. Brian Bigelow, Ph.D.

CAPP Liaison Chapter Chairs Continuing Education Director Neal Morris, Ph.D. Nancy Alford, Psy.D. Warren Rice, Ph.D.

APA Convention Program of 2010 Early Career Psychologist Education and Training Committee Massi Wyatt, Psy.D. E. Alessandra Strada, Ph.D. Lenore Walker, Ph.D.

Evidence-Based Research Committee Federal Advocacy Coordinator Fellows Committee Beth Rom-Rymer, Ph.D. Gilbert Sanders, Ph.D. Ray Folen, Ph.D.

Gerontology Psychopharmacology International Psychology Liaison to the Director of Committee Committee Professional Affairs Merla Arnold, Ph.D. Elizabeth Carll, Ph.D. Michael Schwarzchild, Ph.D. Beth Rom-Rymer, Ph.D. Brian Bigelow, Ph.D.

Media Membership Committee Pediatric Population Committee Nina Tocci, Ph.D. Massi Wyatt, Psy.D. George Kapalka, Ph.D.

Special Populations Committee Victor De La Cancela, Ph.D. (ethnic) Practice Guidelines Committee RxP National Task Force Beth Rom-Rymer, PhD. (geriatric) Bob McGrath, Ph.D. Michael Tilus, Psy.D. George Kapalka, Ph.D. (pediatric) Susan Patchin, Psy.D. (rural) Elaine Foster, Ph.D. (women)

S.W.A.A.T. Committee Tablet Webmaster & Listserv Monitor Owen Nichols, Psy.D. Laura Holcomb, Ph.D. Gordon Herz, Ph.D.

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