Feature

Texas psychologist Elizabeth Richeson, PhD, who has just finished psychopharmacology training, is treating a young woman with cancer that has metastasized to her brain. A few weeks ago, Richeson felt that the patient's antidepressant was not having optimal effect.

Armed with psychopharmacology training, Richeson says she is "much more aggressive" about such matters. She mentioned the matter to the patient's physician; he increased the medication and the patient responded nicely. "Her last days can be a little easier, for her and her family," says Richeson.

That story illustrates a growing trend: On the road to prescription privileges, students and graduates of psychopharmacology training programs say the training has had a profound, even transforming, impact on their work even before any state has passed the right to prescribe. In many cases, psychologists say they are better able to diagnose certain of their patients' symptoms and more equipped to talk with physicians about medication regimens and have a deeper understanding of medications and their potential side effects and contraindications.

"It is one of the more worthwhile things that I have done--regardless of whether we get prescriptive authority," says Ana Rivas-Vazquez, PhD, a clinical psychologist in Florida for more than 30 years, who is taking the psychopharmacology training at Nova Southeastern University.

"Something happens almost daily where I feel that the knowledge I have gained helps me help my clients," says Elaine LeVine, PhD, a private practitioner in Las Cruces, N.M., who trained with the Prescribing Psychologists' Register.

Better patient care

Probably the advantage trainees mention most often is a new insight into the mind-body connection.

"I thought that it would be learning about the psychopharmacology alone," says Richeson. "And you cannot learn about that in isolation."

The rigorous lessons she got in physiology and anatomy have been "incredible" in helping her help patients. "I don't have to lay hands on the patient to be aware, after brief contact, of someone who may be presenting with some kind of a symptom that they are not even particularly aware of themselves."

In New Mexico, LeVine says the implications of training's focus on the latest research on pathophysiology and cellular metabolism "are almost immeasurable. I just have a much deeper understanding of how certain illnesses contribute to psychological problems. I have a more comprehensive understanding when a person might be physically ill and need a referral."

As one example, she notes that many ill people "do a lot of self-blaming." One of her patients had thalassemia, a genetic disorder that involves underproduction of hemoglobin. The patient's physician said her illness was not severe enough to require treatment. So the patient berated herself for missing work due to headaches and fatigue. But, because of her training, LeVine knew that illness, even at that relatively mild level, could be causing the symptoms. When psychologists understand what the illnesses are actually doing to patients, "we can intervene in that and start a more constructive way of looking at things," she says.

James Quillin, PhD, a practitioner in Louisiana, says, "I just have a broader appreciation of the patient. I am looking at them as a broader system: a psychological and a biological system."

And as Rivas-Vazquez puts it, "Thirty years ago when I graduated from the University of Miami, the science did not have the understanding about the neurobiological basis of behavior that we have now. So it really updates us tremendously in what is going on."

Communicating with physicians

Ironically enough, given some medical societies' opposition to the training, a number of psychologists say that a top benefit is the enhanced communication with physicians. They even say some physicians are among the leading enthusiasts for them getting the training and the prescribing privileges.

Richeson says many doctors say, "Please hurry up and get these privileges approved," because they feel burdened with all the facets of patient health for which they are responsible.

Similarly, Rivas-Vazquez notes that, "the primary-care physicians really appreciate the information that I can give them" in discussing symptoms, side effects and other concerns.

That appreciation can turn into increased referrals, says Matthew Nessetti, PhD, of Nebraska. He says that family physicians feel a kinship with his practice because he can better communicate with them, to help them manage their patients.

Michael Enright, PhD, RN, of Jackson Hole, Wyo., who will gain prescription authority when he becomes an advanced practical nurse, has already been approached by two physicians who want to refer to him exclusively when their patients have psychological and/or psychotropic medication needs.

He says that's because the training "has really facilitated our discussion, because I can, when needed, speak a language that is much more medical and [physicians] are more comfortable talking to me in that regard. But they also understand and have respect for my psychological training and expertise."

The medications

Although the new education is about much more than pharmaceuticals, the trainees emphasize that their new understanding of medications is a powerful part of their enlarged abilities.

"What I am learning is how medication can help children and how it can't help with their treatment," says Martha Brisky, PhD, a supervisory psychologist for schools on a Navajo reservation in western New Mexico. "And that some of the behaviors that you might see subsequent to a prescription are more a reaction to the medication than a part of the psychopathology, per se."

Enright sees the knowledge about medications as key in today's environment, where 60 to 70 percent of patients he sees are on psychotropic drugs. Further, he explains, "There is a large proportion of people who have been consulting with primary-care providers who are taking perhaps the right medicine, but at a subclinical dose."

For Rivas-Vazquez, the understanding of interactions--among psychotropics, other medication and physical and mental conditions--is crucial. For instance, she says she is much more aware of the need to avoid certain antidepressants with patients with cardiac conditions. "You really understand that there are medical problems that do have an impact or that the medication would have an impact on."

And, of course, she stresses, "You are also aware of drug interaction, not only for psychotropic medications, but also for other medications that the patient might be on. So you can discuss the cases with the referring physicians in a more intelligent way."

Along those lines, Robert Richardson, PsyD, of Georgia, says that he is much more aware of the risks that a "med-seeking" patient is taking when he goes from doctor to doctor looking for prescriptions.

On the other side of the same coin, Robert Younger, PhD, of Louisiana, says that the training is helpful in resisting society's idea that there is a medication for every human condition. Younger, who writes prescriptions through the Department of Defense, cites in particular the inclination in many managed-care organizations to give patients medications or give them nothing.

"I feel more comfortable now talking with people on the limitations and side effects and how psychological therapies can be given in lieu of medications or can enhance the use of medications," he says.

Similarly, Elizabeth Richeson notes that patients sometimes come in on a combination of antidepressants and benzodiazepines for anxiety. But she says as the antidepressants take effect, they should be addressing the anxiety and the benzodiazepines should be stopped, since there is an addiction risk. She makes such observations now, she indicates, and looks forward to the day licensed psychologists gain the statutory authority to make the adjustments themselves.

And beyond just influencing the prescription process, LeVine says her psychopharmacology classmates agree that the education on how psychotropics work and how they vary in effectiveness in different patients--along with the added biological perspective--is an advantage not only in discussing the medication issues with her clients but also in selecting the therapy technique.

A new approach

Several of the psychologist trainees stress that the training has had such an impact in so many ways that they believe it is creating a new approach, one that--far from being that of a mini-psychiatrist, as some have alleged--will use the psychological orientation to look at the person in a more holistic way.

Ronald Levant, EdD, the director of the psychopharmacology training program at Nova Southeastern University in Florida, says that the trainees, unlike many professionals with only medical training, "are fully aware of psychosocial methods and are not reductionistic.

"The bottom line is that psychologists approach medication differently than traditionally trained medical people do," says Younger of Louisiana, "and I think we should use our strengths in that area and not assume that the treatment of choice would be some biomedical one, or in this case, medications. If you just jump to that as an initial conclusion, you may be avoiding something that may be of benefit to people and that in the long run may be more empowering to them than attributing their improvement to a chemical."