In Favor of Mindful Prescribing

1. In Favor of Mindful Prescribing Robert E. McGrath Fairleigh Dickinson University

2. The Three Futures

3. Future 1: Steady as she goes • Declining opportunities • Declining say in health care • Therapy “becomes” a master’s level practice • Continued lack of access to medication evaluation • Continued over-use of medication and polypharmacy

4. Future 2: Death by RxP • Prescriptive authority expands; our economic viability is secured; potentially play a stronger role in health care design • Examples exist already • In the absence of a vibrant discussion about how best to prescribe, psychologists gradually surrender to economic pressures for 10-minute med checks • Therapy “becomes” a master’s level practice • Continued over-use of medication and polypharmacy

5. Future 3: Rebirth by RxP • Prescriptive authority expands; our economic viability is secured ; potentially play a stronger role in health care design • Examples exist already • Instead of making believe RxP will go away, focus instead on creating a psychological model of prescribing • Training for conservative drug use • Training for combined therapy • Practice guidelines • Research on moderators of efficacy • Medication as a transference object • Redefining the role of the prescriber in primary care settings

6. Insufficient Arguments Against • Personal discomfort • “I understand you don’t want to prescribe; do you mind if I do?” (Brian Bigelow) • Economically naïve • Increased training for PCPs • Collaborative decision-making with psychologists • Collaborative decision-making with psychiatrists • Continue as we are • Insulting: It’s just about money • Politically naïve • Failure to pass = bad law

7. Is the Training Sufficient? • National standard in Britain for non-physician prescribers is 208 didactic hours, 96 clinical hours (Br J Clin Pharmacology, 2012) • Our standard: 450 didactic hours, 400 clinical hours • The problem with pilot testing • The first RCT on APNs was published 35 years after training began • I have challenged people for years to identify a single topic essential to prescribing not covered in the training. I’m still waiting. • All bills require some level of collaboration • Psychologists have prescribed in the private sector for 10 years without any concerns raised, regardless of differences in training requirements

8. Medical Training as a Benchmark • Medical training is wasteful unless you can demonstrate better outcomes/greater safety • Physicians have objected to EVERY non-physician expansion of scope of practice on grounds of insufficient training. They have been wrong EVERY TIME.

9. Disciplinary Resistance • Those raised against clinical psychology in the 1940s • This is just about money • This will change the nature of psychology • “In many places there was indifference. And in most places active antagonism was the most characteristic response. … I have spoken of this attitude as the naïve division of the world into two categories: virgins and prostitutes. The experimentalists saw themselves safely within the first group” (Shakow, 1965, p. 356). • Those raised against APNs • Training isn’t rigorous enough • It’s not nursing • Their safety hasn’t been demonstrated

10. Celebrating our Colleagues • Prescribers in all 3 military branches with health services • Psychologists prescribed independently in both Afghanistan and Iraq • Shearer et al. (2012): Survey of primary care staff about prescribing psychologists: over 90% found them safe and effective • Prescribing psychologists have been decorated by both the Army and the Surgeon General • A prescribing psychologist was deployed to southeast Asia after the 2004 tsunami and to Newtown CT after the Sandy Hook shooting • At NMSU, family practice residents receive their psychopharm training from prescribing psychologists • Two of the leading authors in psychopharmacology (Julien and Stahl) have published books with prescribing psychologists • Prescribing psychologists have been exclusive providers of mental health services on several Indian reservations • Does this sound fatally flawed to you?

11. Conclusions • Psychology IS a prescribing profession, and has been for 20 years with no evidence of problems • The thesis of a fatal flaw is patently false • Deal with it • RxP offers the potential for greater economic stability, improved access to evaluation, and reduced overuse • We would be better served if critics worked to improve RxP practice rather than make believe it will go away, because it won’t!

12. Even if you are on the right track, you’ll get run over if you just sit there. -- Will Rogers