Cover Story

Two years ago, a 40-year-old woman with bipolar disorder and fibromyalgia came to Elaine LeVine, PhD, in Las Cruces, N.M., for treatment. "Jane" had just been released from a psychiatric hospital, after trying to kill herself with an overdose of tranquilizers. She was on 11 medications: three psychotropics for her bipolar disorder and eight others for back pain, gastric distress and high blood pressure. She had gained 60 pounds within the year, wasn't working, couldn't do housework and was so emotionally distraught she couldn't drive. She also had marital problems and difficulty communicating with her teenage son.

"She was homebound, in bed a majority of the time," says LeVine, one of New Mexico's first civilian prescribing psychologists. Some of Jane's problems, says LeVine, stemmed from "polypharmacy." She had visited several physicians and obtained numerous prescriptions, making it difficult to tell where the effects of her medical conditions ended and the medications' side effects began.

In her work with Jane, LeVine used a combination of cognitive behavioral therapy, hypnotherapy and education to help her deal with intimacy issues, boost her self-esteem and teach her techniques to work through her physical pain. LeVine tapered the patient off an antidepressant, which had been exacerbating both her blood pressure and hypomanic behavior, and switched her bipolar medication to one less likely to cause weight gain. Because of the medication changes and subsequent weight loss, Jane's blood pressure returned to normal, and she no longer needed blood pressure medication. Working with a physician, LeVine also got Jane into physical therapy and convinced her to exercise regularly.

Eventually, 11 medications dropped to three, and other life improvements followed.

"She became functional, she started driving and became gainfully employed again," LeVine says.

Cases like Jane's are why many psychologists seek prescription privileges, says LeVine. They want to improve patient care by offering treatments that blend assessment, psychotherapy and medication, and to streamline the number of medications a patient is taking.

So far, prescribing for appropriately trained psychologists is limited to two states, New Mexico and Louisiana. In New Mexico, 13 of the state's 681 psychologists are certified by the state to prescribe, and in Louisiana, 42 of the state's 630 psychologists are certified by the state as "medical psychologists" and prescribe. So far, those with prescribing privileges report that they are getting good cooperation from physicians when a patient needs a psychotropic medication. As a side benefit, they also report that knowing more about medications in general helps them talk to their clients about side effects and drug interactions.

Advancing care

Baton Rouge, La., psychologist Thomas C. Fain, PhD, says prescriptive authority is improving patient care because patients don't have to wait so long to see a prescriber, and those who need medication receive it in the context of a therapeutic relationship.

"It's one-stop shopping," Fain says. "They can get both a trained psychotherapist/clinician/diagnostician, as well as someone who can prescribe, if necessary."

Curtis Vincent, PhD, another Baton Rouge practitioner, says that being knowledgeable about psychotropic medication makes him more credible to clients, "and to a large degree, that's the basis...of talk therapy and psychotherapy."

One of his specialties is evaluating children for attention-deficit hyperactivity disorder. In most cases, Vincent helps parents change their parenting styles and provide more structure and consistent discipline instead of medication. "If someone can be on minimal medication, or, preferably, no medication, then that's the way I want to go," Vincent says.

Like a few other psychologists interviewed, Vincent says that now that he can prescribe, he receives more referrals for patients who have complex medication issues, who might be seeing more than one physician for pain issues and heart problems with a mix of symptoms.

"Discerning which are physical and which are psychological is quite difficult at times, so I've had to become better at that," he says.

Psychologists with prescriptive authority are also finding that primary-care physicians increasingly refer patients with mental health concerns to them. Robert Mayfield, PhD, and Marlin Hoover, PhD, work with physicians at the Southern New Mexico Family Practice Center in Las Cruces, where they train family practice residents in behavioral health. Residents can directly refer patients to them, but often seek consultation on more complicated cases, either by bringing information to them, or by asking them to join in on an examination.

"We end up getting very complicated, complex cases to puzzle through with the other health-care providers," Hoover says.

The physicians rely on them to help sort out patients who might benefit from psychotherapy, or a combination of psychotherapy and medication, Mayfield says.

"One of our greatest strengths is our ability to accurately diagnose and assess what's going on with the patients," he says.

For Bert Garrett, MD, the residency's program director, being able to directly refer a patient to a prescribing psychologist improves patient care by eliminating the back-and-forth that can take place when a physician sends a patient to a psychologist who can give a diagnosis but can't prescribe a medication.

"These guys not only help you make the diagnosis, but they can prescribe the medications that they think are the most appropriate for the patient, in view of what medications they're already taking for medical problems," Garrett says.

He also likes the fact that the psychologists are parsimonious about prescribing.

"They're very stingy with the medications, and I have great respect for that, because I've seen the other side of it, where patients are just snowed with a huge bunch of stuff and have a huge number of side effects, and it's almost impossible to figure out what's causing the problem," Garrett says.

Practice implications

In Louisiana, Fain says since he gained prescriptive privileges in July 2005, the number of medical psychology related cases he handles has steadily increased: In 2006, about 3 percent of his cases related to medical psychology; now it's close to 30 percent.

"Medical psychology has grown as a percentage of my practice load, but 70 percent of my practice is still clinical/forensic. It's just added another tool to my practice," Fain says.

Looking at the 87 cases he's handled involving medications, Fain says that 66 percent of those patients were treated with a combination of medications and psychotherapy, while many of the remaining third of patients who got "medical consultation" appointments were referred to him by other psychologists.

Thinking about how being able to prescribe has improved patient care, he mentions a patient, a man in his 50s diagnosed with bipolar disorder. Fain put him on a combination of medications no one had tried with him before. The medications brought relief from his manic symptoms for the first time, Fain says.

"He tells me every time, he pats me on the shoulder and says, 'You saved me.'"