Psychology's first prescribers

More than a decade has passed since a pilot program through the Department of Defense (DoD) placed 10 military psychologists in a new role--that of prescribing. These 10 graduates of the Psychopharmacology Demonstration Project (PDP) underwent intensive postdoctoral training in a congressionally authorized program that trained licensed DoD psychologists to prescribe psychotropic medications.

Their actions were monitored and scrutinized over the course of the project. Since the program ended in 1997, studies have made one thing clear: The psychologists did--and those who remain in the military continue to--prescribe psychotropic medications safely and effectively.

Today, they serve as a model for a possible future generation of prescribing psychologists. In March 2002, New Mexico became the first state in the country to enact a law allowing psychologists who receive postdoctoral training to prescribe psychotropic medications. That training includes, among other elements, 450 hours of coursework, a 400-hour, 100-patient practicum under the supervision of a physician and a requirement to pass a national certification exam.

As of December, 12 other states intend to introduce similar legislation in 2003. And that's welcome news to many of the PDP graduates, who agree that being able to prescribe offers numerous benefits, such as greater collaboration with medical colleagues and convenience for patients who no longer have to consult a third party for medication. But, they maintain, prescriptive authority should be reserved for psychologists who have undergone postdoctoral training in psychopharmacology.

Of those who originally received the training, seven are still prescribing as part of their regular practice in the military. The Monitor recently talked with them to see how they have used their prescriptive authority and how this new role has changed them:

Elaine Orabona Mantell

Prior to psychopharmacology training, Lt. Col. Elaine Orabona Mantell, PhD, did not receive many referrals for patients with severe psychotic or substance abuse conditions. She spent little time on psychiatric inpatient units working, for example, with bipolar patients in their active manic phases. But after graduating from PDP in 1996, Mantell says an "evolution" has taken place in her career.

"Prescribing has broadened the types of patients referred to me," she says. "These experiences have changed my approach to patients insofar as I can never go back to seeing them as purely a cognitive-behavioral challenge because prescribing requires vigilance in observing their physical as well as psychological symptoms."

After graduating from PDP, Mantell worked at Keesler Medical Center in Biloxi, Miss., serving as chief of the outpatient psychiatric unit and later chief of the inpatient psychiatric unit. Mantell is now the director of the Behavioral Health, Drug Demand Reduction and Child and Substance Abuse Clinics at Seymour Johnson Air Force Base in North Carolina.

As a prescribing psychologist, Mantell says the pharmacological element tends to take up more of the session when she works with complicated patients--such as those requiring frequent medication adjustments. So it "requires greater creativity/dedication managing the cognitive behavioral aspect of care," Mantell says.

Having prescriptive authority helps in treating patients with, for example, such neurovegetative symptoms as low energy or poor appetite. Mantell has found patients often benefit from receiving medication for initial relief of symptoms so then they are better apt to implement behavioral strategies to help in the long run.

"Prescribing is a good tool to have available, but I have found that it does not sustain if individuals do not modify their thoughts and behaviors," she explains. Mantell says she sees a bright future for psychologists with this authority. With greater psychopharmacology training, psychologists--with their research skills and preparation to look at psychosocial influences--are uniquely positioned to reinterpret some of the medical phenomena and recommendations that often remain unchallenged in psychiatry, she adds.

John Sexton

After graduating from the first PDP class in 1994, Cmdr. John Sexton, PhD, began working at the Naval Medical Center in Portsmouth, Va. Sexton became the nation's first independent prescribing psychologist when he wrote his first prescription on Feb. 10, 1995.

Since that time, he says the new role has changed him as a psychologist--for the better. "I think back to how it was before I was able to prescribe, and I can see that I was not as attuned to the biological aspects of some of the psychological disturbances I was seeing," Sexton says. Psychologists need to be more aware of this biological component, he adds, especially since one in seven mental health clinic patients has some form of physical abnormality, such as a thyroid malfunction, that is causing a psychiatric disturbance.

In 1997, Sexton became the head of the mental health department at the Naval Hospital in Camp Pendleton, Calif., where he managed psychiatrists and psychologists. He now runs the substance abuse rehabilitation department at Navy Medical Center in San Diego, overseeing 70 professionals and para-professionals and continues to serve as a prescribing psychologist. At Camp Pendleton, Sexton saw more than 1,000 new patients in three years and during that time wrote prescriptions to 13 percent of those patients. On the other hand, Sexton found that two of the psychiatrists prescribed to 61 percent and 68 percent of their patients, all of whom had been randomly assigned to the psychiatrists and Sexton.

"The majority of patients in mental health can be treated without psychotropic medications," Sexton says. "If the patient does not have a serious mental illness, I lead with talk therapy and then add medication if needed. That's different than what psychiatrists usually do--where patients most of the time walk out with a prescription....Very few have the luxury of doing psychotherapy."

Prescribing psychologists could offer a tremendous benefit to underserved populations, such as rural or inner-city areas where psychiatry isn't as accessible, he says. "We are a different breed," Sexton says. "We are trained differently, and I think we are going to practice differently if managed care gives us the opportunity to practice as we like and in a way that is best for patients."

James Meredith

Lt. Col. James Meredith, PhD, also says psychopharmacology training has made him become more aware of the biological component when treating patients. Since graduating from the DoD program in 1995, he says, "I definitely have learned more--and feel more effective--at treating physical problems that could compound or cause emotional problems."

Meredith is a life-skills flight commander at Hickam Air Force Base in Honolulu. In this role, he manages and directs the Life Skills Support Center, and family advocacy, substance abuse and drug demand reduction programs. Meredith believes that his psychopharmacology training has enhanced his ability as a psychologist to treat clients. "Most importantly, it has given me more control over the treatment," he explains. "When you divide up treatment and have to share it with another provider, you are not able to provide the same emphasis when you are doing it all yourself."

But the true benefit is to the patient, Meredith says. "I am able to work much more with [the patient] on compliance and adjust the medication to certain levels if needed," he says. Meredith also says he frequently sees patients who have been on medications for many years and is grateful that he can now take them off the medication or decrease their dosage if he sees fit. "And then I can see psychotherapy working," he says.

After graduating from PDP, Meredith served as deputy program director of the Outpatient Mental Health Clinic at Andrews Air Force Base in Maryland for three years. He then spent two years as a mental health flight commander at Kelly Air Force Base in San Antonio, where he doubled the productivity of outpatient psychotherapy and medication management for outpatient mental health patients.

Meredith says incorporating some form of knowledge on psychotropic medications should become a basic skill for psychologists. "They will then be able to more easily collaborate with a physician that is prescribing medication," he says.

Morgan Sammons

Cmdr. Morgan Sammons, PhD, says his role as a prescribing psychologist has not changed his approach when treating patients. "All patients still do require psychotherapy," he says.

Since 2000, Sammons has been the head of the multidisciplinary mental health department at the Navy Medical Center in Annapolis, Md. He has worked at a number of sites since he gained prescriptive authority in 1994. In 1998, he worked as the head of the mental health department at the U.S. Naval Hospital in Keflavik, Iceland, where he directed a department that included drug and alcohol programs, early childhood intervention and health promotion. He also served as the clinical director of Andrew Rader Community Mental Health Service in Ft. Myer, Va., where he developed mental health services for a rapidly growing clinic that included psychiatrists, psychologists, social workers and family advocacy professionals.

Sammons says he is encouraged that the PDP psychologists have proven themselves as capable prescribers. "There is no published evidence that any of these psychologists do this in any way less safe or effective," Sammons says. "A traditional medical education is not required to do many of these things."

With the proper training, Sammons says other psychologists should be able to follow suit. "Any psychologist who is interested and qualified should be able to receive prescriptive authority," he says.

However, Sammons says it's important to keep the effort in perspective and realize this is not just a fight for psychologists alone in attaining the right to prescribe. He notes that other professionals--such as nurse practitioners, physician assistants, physical therapists and optometrists--are also looking at ways to expand their practice. "It's part of a dramatic change in health care," Sammons says. "It's nonphysicians expanding the scope of their practice....We are part of this trend. It is not just psychology doing it alone."

Brian Pfeiffer

Maj. Brian Pfeiffer, PhD, is no longer alone in New Mexico as a psychologist with prescriptive authority. In New Mexican psychologists' pursuit of prescriptive authority, Pfeiffer proved to be an asset. He testified to the state legislature at several key points about the benefits of psychologists receiving this authority and taught a class on psychopharmacology for psychologists.

For those who were skeptical of prescribing psychologists, Pfeiffer became a model of the effectiveness and safety of a psychologist with this authority. "[The PDP graduates] were studied at numerous points during and after our training," Pfeiffer says. "Uniformly, we had positive patient outcomes. All the data showed that we worked well with other health-care professionals and that we provided safe and effective treatment to our patients."

After graduating from the PDP program in 1996, Pfeiffer was assigned to a hospital at Eglin Air Force Base in Fort Walton Beach, Fla., as a staff psychologist. After his first year there, he was promoted to chief of the outpatient clinic and was also granted admitting privileges to the psychiatric unit. Pfeiffer now is the specialty flight commander at Cannon Air Force Base in New Mexico, where he oversees the mental health department as well as the physical therapy unit.

He says the PDP program adequately prepared him for writing prescriptions. "But just like any other job, a lot of what you learn is learned by doing," he says. "It's obviously broadened my range of experiences. And I think it's only helped to make me more effective in dealing with patients. But it hasn't changed my approach to patients."

Pfeiffer continues to adhere to the same biopsychosocial spiritual model he used before going through the PDP program. "It's not just looking at the patient's biology and saying 'It's a chemical imbalance, and that's the problem. Now take a pill,'" Pfeiffer says. As always, he adds, it's important to question if distortions in the patient's thinking or other unhealthy behaviors are part of the problem.

Debra Dunivin

Lt. Col. Debra Dunivin, PhD, says she joined the PDP in 1997 to find out for herself if expanding psychologists' role to include clinical psychopharmacology would be a good idea for the field. And while she acknowledges that prescribing is not for every psychologist, she says because of the potential benefits a prescribing psychologist can offer, "It is important that some of us undertake the extensive training required to do this well.

"I had not expected when I entered the PDP that I would want a career in the military," she adds. "But the Army has offered me so many interesting opportunities for professional development that I decided to stay beyond the obligated service time."

Being able to prescribe has tremendously expanded the scope of services Dunivin says she can provide to patients. She considers herself more of a full-service holistic provider. "I've learned new intervention skills in pharmacotherapy that enable me to treat a wider range of conditions without splitting the treatment among different providers," she says.

After graduating from PDP, Dunivin became the chief of outpatient psychology service and a prescribing psychologist at Eisenhower Army Medical Center in Augusta, Ga. She now serves as chief of the department of psychology and the director of training for the Clinical Psychology Residency Program at Walter Reed Army Medical Center in Washington, D.C., where she oversees clinical services and training programs.

As a prescribing psychologist at Walter Reed, Dunivin has integrated psychopharmacology with traditional psychological interventions, such as when treating patients with severe panic disorder or obsessive compulsive disorder who might need medication. She is also developing innovative programs, for example, in psycho-oncology and women's health.

James Parker

Cmdr. James Parker, PhD, says he fills a void in rural Yuma, Ariz., where he is the only mental health provider at the Marine Corps Air Station's Naval Medical Clinic, which has a patient base of 10,000. Yuma, an underserved community of about 100,000 with no private psychiatrists, could greatly benefit if the state's psychologists were granted prescriptive authority, says Parker, who graduated in 1996 from PDP.

Parker's aim as a psychologist has always been to provide services to patients more efficiently. Being able to prescribe has helped him to do just that. "I'm not necessarily a quick results person, but with some of these conditions, medication will help attain benefits with people more quickly," he says. "Even if it is as simple as giving them a pill to help them sleep better."

He says being able to prescribe has changed him. "It strengthened my belief that biological treatments are very critical but that also an integrative approach is needed," he says. "Using only a biological approach or only a psychological approach misses significant parts of a problem." Parker spends a great deal of time working collaboratively with physicians developing Diagnostic and Statistical Manual axis I and axis III treatments best for patients.

Following graduation from PDP, Parker was assigned to Naval Hospital Bremerton in Washington state, where he served in various roles, including head of the psychology division within the multispecialty inpatient and outpatient mental health department, head of the mental health department, and head of the alcohol rehabilitation and substance abuse department. In April 1999, he began his current job as a clinical psychologist at the Marine Corps Air Station in Yuma.

Although he has not had any bad outcomes from prescribing, Parker, whose practice is 50 percent pharmacotherapy, says he is always aware of the possible reactions medications could have. "I think human beings are much more complex than a physical dimension. I appreciate that more than before," Parker says.

The other graduates

Here are updates on the other DoD graduates:

Anita Brown, PhD, left military service in 1999 and therefore can no longer prescribe. Brown, a 1996 PDP graduate, is president of APA's Div. 55 (American Society for the Advancement of Psychopharmacotherapy and is working to identify and develop a prescription movement in her home state of Virginia. She is chair and associate professor in the psychology department at Hampton University.

Gilbert Seda, PhD, a 1997 PDP graduate, is a third-year medical student at Eastern Virginia Medical School and an adjunct professor in psychopharmacology at Regents University.

Timothy Duke, PhD, also a 1997 PDP graduate, is attending medical school.

The opinions expressed in this article are not to be construed as representing those of the United States Air Force or DoD.