Letters

Prescription privileges
THE OCTOBER column, "Making the point of prescriptive authority," is a stark example of how far apart the two sides are in the struggle for psychologists to gain the authority to prescribe drug therapies for mental health disorders. There is overwhelming evidence that many clients and medical care providers would reap the benefits of allowing psychologists to prescribe. Currently, care must be orchestrated between medical and psychological services, creating delays in continuity of care, potentially an acute exacerbation of a mental health crisis.

In answer to Dr. Richard Harding, of the American Psychiatric Association, many PhD-level psychologists do take more than one biologically based course in behavior or pathology. The choice lies in the individual's focus of interest and career path to specialization. Not every PhD-level psychologist desires prescription privileges, but those who do take the proper sequence of educational classes to comply with requirements that would be determined before allowing prescriptive authority to be granted to psychologists. Lastly, I would remind Dr. Harding of the controversy surrounding the acceptance of the physician's assistant (PA) in the 1980s. AMA refused to see PAs as valuable and knowledgeable professionals whose expertise would compliment the care of the medical doctor. AMA's arguments were basically the same ones reported in the July 2001 Physician's Weekly to reject the psychologist's prescriptive authority: "that there is no societal need for more prescribing professionals and the programs proposed by organized psychology simply cannot train psychologists to prescribe psychotropic drugs appropriately. Also that the needs of the underserved patients can best be met by collaboration between psychiatrists and other medical professionals."

Medical doctors and physician's assistants are now colleagues, and it is high time that psychiatrists and psychologists stop being self-serving on both sides and consider the clients' needs.

KATHRYN YANICK
Lisle, Ill.

I FOUND THE REPRINT FROM Physician's Weekly in the October Monitor to represent a weak and self-serving rationale as to why psychologists should not have prescriptive authority. The author, Dr. Richard Harding, will first have to understand the differences between a doctoral-level psychologist, mental-health counselor and social worker before he can offer a credible opinion on related competencies. A psychologist is no more capable of dealing with everything psychological than a medical doctor can, or should, presume to deal with everything that is medical. And it is for this exact reason that far too many medical doctors find themselves overextended in their own practices and with regards to the use of medications.

It is very likely that the prescriptive authority currently granted to MDs is far to broadly based and over applied. For instance, pediatricians and psychiatrists, without additional and highly specific training have absolutely no basis to be prescribing antidepressants and antipsychotics to adolescent and younger children. Yet this is done routinely. Similarly, a psychologist certainly should not prescribe hypertensive medications even when they are providing services where therapeutic goals include reduced stress with its link to blood pressure. There is absolutely no professional reason that doctoral-level psychologists cannot prescribe relevant medications with additional training. One way to maximize this ability is to recognize that neither psychologists nor medical doctors should really have free reign on the use of medications for any kind of disorder across any specialty. [However] the one point where Dr. Harding and I agree is that there is "no societal need for more prescribing professionals." Access to medications is already far too readily available. The strength of the practice of psychology is that it cannot lean on medications and, therefore, must deal directly with the patient, the patient's family, and other directly relevant social and environmental issues. It is in the belief that prescriptive authority could actually degrade the practice of psychology that I do not support the practice.

LOU SANDLER, PHD
Eugene, Ore.

Eating disorders
I APPLAUD THE MONITOR FOR the October article "Eating disorders on the rise", about the Eating Disorder Coalition and the importance of combating eating disorders,e specially among women in the United States. I am impressed by the Eating Disorder Coalitions goals and efforts. However, the article, and the Eating Disorder Coalition's web page failed to address an important influence on eating disorders, namely the mass media.

We cannot ignore the impact that the mass media has on women's perceptions of their bodies and how the media's influence contributes to eating disorders. The media introduces a full range of issues including gender-role pressure, the glorification of unnaturally thin women, and excess exposure to such images. I realize that a number of the Coalition's stated policy priorities are quite broad and could apply to the relationship between the media and eating disorders. However, I feel that the role that the media plays in eating disorders should be addressed directly and explicitly outlined in the policies. In my opinion, the Eating Disorder Coalition needs to include one more extremely important policy priority: The need to addressthe role of the media in helping to create and perpetuate eating disorders.

JAYMEE HOLSTEIN
Auburn University

An idea worth emulating
READERS OF DEBORAH SMITH'S informative article on Arizona Psychology Training Consortium in the October issue may also be interested in its financial underpinnings. Medicaid regulations permit states to determine the qualifications of providers of professional services. The shortage of qualified mental health providers available created an opportunity for postdoctoral psychologists, working under supervision, to gain experience required for the licensing.

However, many agencies had no supervising psychologist and the state had no money to fund supervisory requirements. Dr. Hogg's intrepid efforts created the Arizona Psychology Training Consortium to provide the required supervision. Kudos to Dr. Hogg for an idea worth emulating.

JACK G. WIGGINS, PHD
Fountain Hills, Ariz.

Romanticizing a psychiatric disorder?
"SCHIZOPHRENIA MAY BE THE origin of jazz," according to an October Monitor article, describing a paper by Sean M. Spence, MD, on jazz pioneer Charles "Buddy" Bolden. The quoted sentence is catchy, but it, along with Dr. Spence's presentation to the Royal College of Psychiatrists, seemingly disregards important social factors--especially the dynamic African-American culture and the vital New Orleans community--that help account for the emergence of jazz in the late 19th century.

The article indicates that Bolden's schizophrenia imposed such severe limitations on his ability to perform musically that he had no choice but to improvise. Bolden's innovation is thus explained by schizophrenia rather than creativity. That might be true. But it's an interpretation that can both stigmatize and romanticize psychiatric disorder: The disorder was so disabling, it had a positive effect. Jazz historians report that Bolden was an accomplished cornetist and a powerful player, though his improvisation may have been rudimentary. Donald Marquis's "In search of Buddy Bolden: First Man Of Jazz" describes the man, his music and his surroundings. There is no question that part of Bolden's story is a sad one. He was admitted to a state mental hospital in 1907 when he was 29, and he remained there until his death at age 54. In the first half of his life, however, he overcame disadvantages and personal losses to become a charismatic person, a husband and father, an acclaimed musician, and the putative originator of jazz. To credit schizophrenia as the origin of jazz and as the primary reason for Buddy Bolden's originality is to overlook crucial social and cultural factors and to underestimate the role of nonpathological personal attributes.

ALFRED L. BROPHY, PHD
West Chester, Pa.

End-of-life issues
WE WERE PLEASED TO SEE THAT APA is taking the lead in addressing end-of-life issues (October issue), but we were disappointed by the inaccurate cliches that were apparently dispensed in the July 18 congressional briefing.

We are referring to Barry Rosenfeld's unsubstantiated claims that most depressed terminally ill patients are not being treated because physicians are reluctant to prescribe antidepressants. Rosenfeld's own research found that whereas only 17 percent of terminally ill patients were depressed, 40 percent of all patients in his sample were receiving an antidepressant. Our work finds that a third of breast cancer patients are receiving an antidepressant. That includes 75 percent of all patients with major depression, but many more patients who have never been depressed. Nonspecific prescription of antidepressants without adequate follow up or demonstrated benefit is part of the problem of end of life care, not the solution to unmet needs. Rates of prescription of antidepressants now exceeds the prevalence of depression, particularly among the elderly. Casual dispensing of antidepressants has become an expedient alternative to a sensitive eliciting and humane addressing of patients' needs, not only at the end of life, but throughout medical care. We hope that the next time APA seeks to inform Congress about end of life issues, it will come armed with accurate data.

JAMES C. COYNE PHD AND STEVEN PALMER, PHD
University of Pennsylvania
Comprehensive Cancer Center

Unmasking third-party payers
I WAS PLEASED TO READ THE article entitled, "Nailing them with statistics," in the September Monitor. The study conducted by the Ohio Psychological Association (OPA) has highlighted an important and present problem with the current managed-care status of the United States health-care system. In the vein of true scientist-practitioners, OPA provided a methodology for unmasking the reimbursement practices of these companies. Although the focus of public and political action has focused primarily on the relationship between consumers and insurers, little attention has been paid to examining or remedying the problematic relationship between health-care providers and insurers. Collecting, analyzing and presenting data regarding the reimbursement practices of insurance companies was used effectively by the OPA to begin this process.

With the emphasis on psychologists to provide evidence-based treatment, it seems only fitting that insurers provide evidence-based reimbursement. Due to the amount of financial and political clout that insurance companies presently hold, relentless lobbying on the part of health-care practitioners at the local, state and federal level will be needed to correct this imbalance of power. This imbalance all too often leads to financial ruin for health-care providers. Larger scale studies in other states and on the national level need to be conducted and presented to legislators to facilitate these changes.

Future directions should focus on assessing and disseminating information to health-care providers on other problematic practices of managed-care organizations that affect providers. Educating health-care providers' on insurance company practices such as the difficulties with gaining authorization for services, paperwork time and problems with receiving referrals would help providers decide which managed-care panels to join or avoid. In very much the same way that Consumer Reports educates the public on products and practices of providers, the dissemination of periodic reports for health-care practitioners on the practices of insurers would update providers on the changing practices of individual insurance companies.

JEFFREY W. BRAUNSTEIN, PHD
SUNY Downstate Medical Center

One for the girls
I WAS VERY PLEASED TO READ the article about APA's collaboration with Kartemquin Films on their documentary 5 GIRLS in the September Monitor. I am the director and producer of 5 GIRLS and on behalf of everyone who worked on this film, I want to express how much that collaboration has meant to us. I also want to acknowledge the generous help and support I received from other APA members who were not mentioned in the article.

From the very beginning, when my film was nothing more that words in a proposal, I contacted Dr. Lyn Mikel brown and asked her to be one of my experts. Her willingness to come on board even before the project was funded was instrumental in my being able to go forward. She donated her time and knowledge early on in my efforts by reading rough drafts of the proposal and by providing much needed feedback on how to make the proposal better. Her stature and reputation gave my project and me credibility, which was crucial to my getting funded.

She has remained involved in the project throughout these four years, advising on the development of the Web site and by creating a valuable diversity guide, "Thinking through differences," for the film.

Finally, Lyn, herself a member of APA's Task Force on Adolescent Girls, was the person who told me about the work of the task Force and wisely suggested that I contact them. Her help and the counsel of all Task Force members, including Dr. Jessica Henderson Daniel and Dr. Denise Dezolt, have been invaluable.

For all of us at Kartemquin Films the making of this film has been a wonderful experience made even richer by our collaboration with APA. We thank you for your counsel.

MARIA FINITZO
Kartemquin Films