Practice Guidelines Regarding Psychologists' Involvement in Pharmacological Issues

Introduction

Several factors have converged that will inevitably increase psychologists' involvement in the medication management of the individuals they serve. One is the increasing use of psychotropic medications for the treatment of psychological disorders, a clinical practice which will be referred to as pharmacotherapy in this document. A national survey of physician records suggested the proportion of the population using antidepressants increased from 6.7% in 1990 to 15.1% in 1998, an increase of 125.4% even after adjusting for population growth (Skaer, Sclar, Robison, & Galin, 2000). According to VandenBos and Williams (2000), practicing psychologists on average estimated that 43% of their current patients were using psychotropic medications. Another factor is the movement for prescriptive authority within psychology. Appropriately trained psychologists are now eligible for prescriptive authority in two states (Louisiana and New Mexico) as well as in the military. With similar legislative agendas emerging in a number of other states, the number of states offering prescriptive authority to psychologists will inevitably increase further.

In response to a series of articles describing the professional challenges faced by psychologists as they become prescribers (e.g., Antonuccio, Danton, & McClanahan, 2003; Buelow & Chafetz, 1996; DeLeon, Robinson Kurpius, & Sexton, 2001; McGrath et al., 2004), it was recognized in discussions among members of the American Psychological Association (APA) Division 55, the American Society for the Advancement of Pharmacotherapy, that the implications of the APA (2002b) Ethical Principles of Psychologists and Code of Conduct (the Ethics Code) specifically for psychologists' involvement in pharmacotherapy merited clarification. Beth Rom-Rymer, president of the division at that time, convened a task force to explore the issue. Four of seven task force members were psychologists with prescriptive authority in the civilian or military sector, while three supervised postdoctoral programs in clinical psychopharmacology for psychologists. The task force also included representation from Division 18 (Psychologists in Public Service).

Members of the task force reviewed relevant literature and participated in formulating the content of the guidelines. The literature review began with a document titled Policies of Other Organizations and Background Materials: Pharmaceutical Marketing, Gifts, and Financial Support (APA, 2002c), which provided primary sources addressing the relationship between prescribing professionals and the pharmaceutical industry. This document was updated with more recent publications on the topic. Medicine, nursing, pharmacy, and the pharmaceutical industry have all generated guidelines relevant to the practice of pharmacology, and these were reviewed as well. Finally, the task force considered specific implications of the APA's (2002b) Ethics Code for psychologists' involvement in the practice of pharmacotherapy.

The guidelines presented in this document are intended to provide a resource to psychologists interested in the issue of what represents optimal practice in relation to pharmacotherapy. They are not intended to apply to those psychologists who choose not to become directly or indirectly involved in medication management regardless of their level of competency. As background to these guidelines, it may be noted that psychologists’ involvement in pharmacotherapy can be conceptualized as a continuum, though prior APA documents (e.g.,Smyer et al., 1993) have identified three particularly salient steps along that continuum. The first occurs when the psychologist serves as the prescriber. As indicated above, psychologists currently can only prescribe in the U.S. military and in two states, though the latter authority also allows psychologists to prescribe in the Public or Indian Health Services. The population of psychologists with prescriptive authority is therefore small but is one that is sure to increase in size in the coming years. It should be noted that some psychologists prescribe only through a second license, for example, as a nurse practitioner or physician. Such individuals determine for themselves the degree to which the guidelines presented here for prescribing are relevant to their activities.

The second level occurs when psychologists actively collaborate in medication decision making. The psychologist is not ultimately responsible for the decision that is made in these circumstances, but does play a substantive role in the decision-making process. VandenBos and Williams (2000) found that 87% of their sample of practicing psychologists reported they had been involved in the decision to prescribe medication for at least one of the patients on their caseloads. However, it is unclear what role they played in the decision, especially since over 80% also indicated this was not a frequent occurrence. On the other hand, 7% of respondents indicated they participated in the decision to prescribe for more than half their patients, suggesting that they were consistently and perhaps formally involved in decisions about the appropriateness of medications for their patients. This might for example include making recommendations concerning specific classes of medications to be used or even specific medications, dosing, or other aspects of the treatment regimen, though the prescribing professional maintains ultimate responsibility for the decision.

The third, and probably most common, level describes psychologists who provide information that may be relevant to pharmacotherapy decision-makers. The information-providing psychologist may offer opinions relevant to the pharmacotherapy, but does not play a formal role in the decision-making process. Examples of providing information include reporting concerns about the treatment to the prescribing professional, referring patients for a medication consult, pointing patients to vetted referral or information sources, or discussing with patients how to address their concerns about the medication with the prescriber. It is likely that many of those psychologists who indicated to VandenBos and Williams (2000) that they were infrequently involved in the decision to prescribe did so in an information-providing role.

Some of the guidelines presented in this document are targeted specifically at the population of psychologists with prescriptive authority. Others are considered relevant in any case where the psychologist is actively involved in decision-making, whether as a prescriber or collaborator.

Still others are considered applicable any time a psychologist is involved in the practice of pharmacotherapy whether as a prescriber, collaborator, or information provider. Given the unique elements of the population of psychologists who can prescribe on the one hand, and the frequency with which psychologists participate in collaborative and information-providing activities on the other, it was considered important to provide guidelines appropriate to each set of activities. However, it is also important to recognize that a principle of optimal practice may have different implications in the context of active participation versus providing information. In particular, the distinction between active participation and providing information can often be blurred in the practice setting, with a psychologist often playing different roles at different points in the treatment. Given the ambiguity that surrounds these activities, it is urged that these guidelines be read with the understanding that the clearest practice delineation occurs between those psychologists who possess prescriptive authority and those who do not, and that psychologists who do not possess prescriptive authority use critical judgment in determining which guidelines best inform their practice.

Technology-based alternatives to face-to-face contact with patients are proving particularly useful in the conduct of pharmacotherapy (Hyler, Gangure, & Batchelder, 2005). The telephone has dramatically affected the nature of interactions with patients; videoconferencing can expand these options even further, particularly in rural areas. E-prescribing and e-mail correspondence between patients and providers regarding medication will be used more and more as a mechanism for service delivery. For example, prescription renewal can often be safely and efficiently accomplished without face-to-face contact between the prescribing professional and the patient. These guidelines can be considered relevant regardless of the modality of contact.

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