Integrated primary care is essential
We were surprised and disappointed by Dr. Nadine J. Kaslow's "President's Column" in the April APA Monitor ("Our Opportunity to Reduce Suicide"). The column and the related articles by other authors missed an important suicide prevention opportunity by failing to list integration of primary care and behavioral health as a suicide prevention strategy.
Integrating psychologists into primary care is one of the best suicide prevention opportunities we have. In contrast to the mental health system, the average American will enter a primary-care clinic twice in the course of a year, and around 45 percent of people who commit suicide had a visit with a primary-care provider (PCP) in the month prior (75 percent in the year prior). Such statistics suggest that better identification and intervention with primary-care patients who are suicidal could be invaluable, and integration provides the context for achieving that. In addition, PCPs prescribe the overwhelming majority of antidepressants in the country. Studies have shown that treatment solely by a PCP is often inadequate but that adding a mental health professional to the treatment team can significantly improve depression outcomes. Thus, integration may aid suicide prevention by detecting and treating more people who are suicidal, as well as by improving depression treatment in general.
Even with the new mental health parity law for insurers, primary care is and always will be where the majority of people with psychiatric problems, including suicidal tendencies, will present. The primary-care system is exponentially larger than the mental health system. It's time for all psychologists to recognize the tremendous opportunities that primary care represents not only for us as a profession, but also for promoting the health of the population.
Jeff Reiter, PhD, and the following members of APA Div. 38 (Health):
Melissa Baker, PhD
Daniel Baughn, PhD
David Bauman, MA
Bridget Beachy, MA
Andrea Bischoff,PsyD
Thekla Brumder, PsyD
Sandy Bushberg, PhD
Gerald Carpenter, PsyD
Andrea Cook, MA
Kent Corso, PsyD
Barbara Cubic, PhD
Jeffrey Goodie, PhD
David Guggenheim, PsyD
Moreen Halmo, PhD
Hunter Hansen, PsyD
Barbara Hare, PsyD
Christopher Hunter, PhD
Gene Kallenberg, MD
Anne-Marie Kimbell, PhD
Alexander Kraft, PsyD
Larry Lantinga, PhD
Elana Maurin, PhD
Bill McFeature, PhD
Neal Morris, EdD
Maureen O'Reilly-Landry, PhD
Daphne Papadopoulos, PhD
Rebeca Rios, PhD
Patricia Robinson, PhD
Chelsea Rothschild, PhD
Nancy Ruddy, PhD
Christine Runyan, PhD
Bruce Rybarczyk, PhD
Brian Sandoval, PsyD
Gordon Schneider, PhD
Carolyn Schroeder, PhD
Neftali Serrano, PsyD
Christy Sherman, PhD
Mark Skrade, PsyD
Tara Staehlin, MA
Heidi Stouffer
Gerald Strauss, PhD
Mary Talen, PhD
Steven Tulkin PhD
Shanda Wells, PsyD
Cynthia White, PsyD
Paul Wilson, PhD
Lori Zeman, PhD
Response from APA President Kaslow:
I sincerely appreciate your bringing this issue to my attention. I want to apologize for not addressing primary care in my brief column. With the limited length of the column, I was unfortunately not able to make all of the key points that I had hoped to make, with the issue of the critical role of psychologists in primary-care settings being one of those.
I agree with you it would have been better if I had included it. Fortunately, in the article in the same issue of the Monitor on suicide in rural communities, there was a section on primary care. Also, as you know, one of my presidential initiatives relates to the inclusion of psychologists in patient-centered medical homes, so this is a topic that will receive additional coverage from me and the Monitor.
Nadine J. Kaslow, PhD
APA President
Suicide-assessment training
As a psychologist specializing in suicide-risk management, I read the April Monitor article about the need for better suicide-assessment training with interest. In my experience as a trainer, including at numerous APA convention workshops, the most common problem, to quote Donald Rumsfeld, is that many practitioners don't know what they don't know. In the final analysis, the basic responsibility for filling the knowledge gap must rest squarely with training institutions and CE programs, but they can never hope to remedy the problem without retooling their approach. Today, teaching suicide assessment typically offers little more than an age-worn list of depression-related warning signs to check off during an interview. But training provides limited information about their relevance in decision-making or how to use them to develop a clinically sound and defensible plan of action. Clearly, training must be better, but training, although necessary, is insufficient to ensure change.
To be fair, an equal share of the blame must rest with practitioners themselves. Despite excessive concerns about potential liability in the wake of a completed suicide, the statistical rarity of suicide means most clinicians never feel the adverse consequences of using what might actually be legally indefensible techniques. As a result, many resist expending the time required to conduct more comprehensive assessments based on an incomplete cost/benefit analysis of perceived risk.
Thus, without both better training and better practice, it will be difficult to change the way this critical skill is delivered and practiced for both students and practitioners.
Thomas W. White, PhD
Overland Park, Kansas
Psychologists and smoking cessation
In addition to their roles in identifying nicotine as an addictive substance and developing treatments for smoking cessation, psychologists have played a major role in identifying and implementing public health approaches to tobacco control. Forty years ago one could not expect to dine in any restaurant without exposure to ambient tobacco smoke, which was largely viewed as harmless. In 1980, psychologist Michael B. Horwitz self-published "A Guide to Smoke-Free Dining," identifying a public looking for a healthier and more pleasant restaurant experience. Considered quirky at the time, Horwitz was at the forefront of a public health movement to restrict smoking in public places and to create healthier environments for all. Public health approaches such as the restriction of smoking in public places may have had as much or more to do with the decline in smoking as individually based treatment models.
Mary Ellen Olbrisch, PhD
Virginia Commonwealth University
Rating psychologists
It was a huge relief to look in my mailbox and find your April cover package "How do you rate?" This is a growing problem and one that tormented my world. I was a victim of a patient who was "cyber-harassing" me.
I was fortunate enough to have Yelp remove this patients' untrue and inappropriate commentary about my services, but many are not as fortunate. For me, although a nightmare, it turned out to be a blessing in disguise. I repaired the one negative posting by asking some respected colleagues to post positive comments on my clinical work, and ended up having those reviews stand out. Unintentionally, I get many very good, appropriate referrals from these sites now.
The more concerning factor is the inappropriateness of the more popular sites (Yelp), in placing unlicensed and "para" professionals under the listing of "counseling and mental health." So, the average consumer logs on to Yelp, types a request for "counseling," and there they are — "life coaches," "hypnotherapists" and other unlicensed people combined with licensed mental health people. The general public doesn't know the difference and is getting misled. When I was in graduate school, it was drilled into us not to advertise outside our scope of practice, but now we have the unlicensed "helpers" fully taking advantage of misleading the public. Please, can we begin addressing this huge issue?
Anonymous
Intellectual disability and the death penalty
The April "Judicial Notebook" on revisiting intellectual disability and the death penalty failed to address what is arguably the single most important limitation of using a "bright line score of 70" typically obtained on the WAIS to establish a deficit in intellectual functioning. Namely, another intelligence test with validity equal to that of the WAIS can yield a vastly different IQ.
For example, a 2010 study by Silverman et al. published in the journal Intelligence found that the Stanford-Binet yielded an IQ 16.7 points lower than that of the WAIS on a sample of adults who were diagnosed with an intellectual disability. Various editions of the WAIS and Stanford-Binet were represented in the study except for the most recent versions (WAIS-IV and Stanford-Binet 5). This study, which needs to be replicated on the current versions of these tests, has two profoundly important implications. First, any lawyers representing a client in a death penalty case should have their clients tested on the Stanford-Binet to assess for a deficit in intellectual functioning. Second, the Supreme Court needs to be fully educated on the serious limitation of IQ tests.
Sincerely,
Robert Eme, PhD
Illinois School of Professional Psychology at Argosy University,
Schaumburg Campus
