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AMERICAN PSYCHOLOGICAL ASSOCIATION

M E M O R A N D UM

TO:
APA Board of Directors
APA Council of Representatives
Board of Educational Affairs (BEA)
APA Division Presidents
State Psychological Associations
Council of Graduate Departments of Psychology (COGDOP)
National Council of Schools and Programs in Professional Psychology (NCSPP)
Association of Psychology Postdoctoral and Internship Centers (APPIC)
Chairs of Training Councils

THROUGH:
Kathleen M. McNamara, PhD, Chair, Board of Educational Affairs (BEA) Jill N. Reich, PhD, Executive Director, Education Directorate

FROM:
M. Marlyne Kilbey, PhD, Chair, BEA Working Group on Psychopharmacology

DATE: June 28, 1996

SUBJECT:
Request for Feedback on the DRAFT Curriculum for Psychopharmacological Training Programs for Collaborative Practice with Specific Populations

Introductory Curriculum for Training in Psychopharmacology

As you may recall, the APA ad hoc Task Force on Psychopharmacology issued its final report in July, 1992 which suggested three levels of training for psychologists in psychopharmacology. To follow on the recommendations contained in that report, the Board of Educational Affairs (BEA) appointed a Working Group in 1994 to develop a Level 1 curriculum for psychopharmacology education and training.

750 First Street, NE
Washington, DC 20002-4242
(202) 336-5500
(202) 336-6123 TDD
Web www. apa. org

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On behalf of the BEA Working Group on Psychopharmacology, I am pleased to inform you that the Introductory Curriculum for Training in Psychopharmacology” is now available. The curriculum covers 9 modules as follow:

Modules

1. Biological Bases of Psychopharmacological Treatment
2-3. Principles of Psychopharmacological Treatment
4. General Introduction to Clinical Psychopharmacology
5. Introduction to Psychopharmacological Treatment of Psychoactive Substance Use Disorders
6. Introduction to Psychopharmacological Treatment of Psychotic Disorders
7. Introduction to Psychopharmacological Treatment of Mood Disorders
8. Introduction to Psychopharmacological Treatment of Anxiety Disorders
9. Introduction to Psychopharmacological Treatment of Developmental Disorders

Each module consists of learning objectives, a detailed outline of suggested topics, and extensive teaching resources. Copies are available in a printed format or on diskette. Requests should be directed to Martha Braswell, Project Assistant, Education Directorate, at the APA address (202/336-6140 or by email to MBB.APA@EMAIL.APA.ORG). Please specify in which format (document or diskette) the curriculum should be sent.

Curriculum for Psychopharmacological Training for Collaborative Practice with Specific Populations

In a continuation of its work, the BEA Working Group modified its original plan for a life-span Level 2 curriculum as described by the 1992 APA Ad Hoc Task Force on Psychopharmacology. The Working Group decided to focus on developing formal curriculum modules to teach psychopharmacology to those persons who are interested in working collaboratively with physicians in the management of clients who receive psychoactive medication. The Working Group envisions each curriculum as containing three major sections: content, vignettes, and resources.Within the content section, there are five subsections: professional/legal issues, assessment, pharmacological issues for the specific population; treatment; and research. The sections comprising the curriculum will serve as a template for the content of training programs that could be offered in a number of different venues. An overview of the curriculum is enclosed for your information.

The Working Group selected four underserved patient populations to serve as the focus of the curriculum including:

-child/adolescent populations
-populations with mental retardation/developmental disabilities
-populations with serious mental illness
-aged populations (to be available by early fall 1996)

The curriculum materials at this time are in a draft form and the documents are in various stages of development.However, Working Group members wanted the benefit of your review and feedback as the curriculum is developed. Thus, we invite your review and comments on the enclosed draft curriculum. Please submit your comments to Martha Braswell by Thursday, August 1st.

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Plans for the 1996 APA Convention

You may also be interested to know that psychopharmacology training issues will be the focus of a number of sessions at the APA Convention in Toronto, Canada in August. To provide a forum for discussion on the draft Curriculum for Psychopharmacological Training Programs for Collaborative Practice with Specific Populations, the BEA Working Group has scheduled an open meeting on Sunday, August 11, 1996, from 10:00 am-10:50 am in Tudor Room #7 of the Royal York Hotel. Written feedback on the curriculum received by August 1st will be included in the open meeting agenda. Audience questions and comments will be invited as time allows.

The Board of Educational Affairs, along with Divisions 28 and 42, will sponsor an APA symposium Psychopharmacology Update: Addressing Issues of Special Populations through Education and Practice.” This session is also scheduled on August 11, 1996 from l:00-2:50 pm in room 202-A of the Metro Toronto Convention Centre. Participants include the following members:

Edward F. Bourg, PhD  Chair
M. Marlyne Kilbey, PhD  "Level 1 and 2 Training: Report of BEA Working Group”
Ronald T. Brown, PhD  "Addressing Needs of Special Populations in Education and Training for Collaborative Practice”
Dale L. Johnson, PhD "Understanding Integration of Pharmacotherapy with Psychosocial Treatments for the Seriously Mentally 111”
Martha E. Banks, PhD "Psychotropic Medications: Ethnic and Racial Concerns”
Dan Egli, PhD "Level 3 Training: Report of CAPP Task Force”
Rosalie J. Ackerman, PhD "Gender Concerns in Prescription Privileges”
Morgan T. Sanunons, PhD "Translating Psychopharmacology Education into Practice: New Roles for Psychologists”
Patrick H. DeLeon, PhD, JD  Discussant

Future Plans for the Curriculum Materials

Following the APA Convention, the revised draft curriculum will be circulated at the consolidated Committee and consolidated Board meetings in the fall of 1996. The Working Group will continue to incorporate feedback from the field in preparation for the Board of Educational Affairs meeting in November. It is anticipated that a final draft of the curriculum will be presented to the BEA for approval at its November l-3, 1996 meeting. The final report will be completed for the Center for Mental Health Services by February 1, 1997, and dissemination of the curriculum will begin in early 1997.

Enclosures

copies:
Raymond D. Fowler, PhD
William C. Howell, PhD, Executive Director, Science Directorate
Russell Newman, PhD, J.D., Executive Director, Professional Practice Directorate
Henry Tomes, PhD, Executive Director, Public Interest Directorate
Christine Cubby, Governance Officer, Education Directorate
Paul Wohlford, PhD, CMHS
Karen Beaty, Financial Services

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Plans for the Curriculum for Psvchonharmacological Training Programs for Collaborative Practice with Specific Populations

I. An Overview

A. Psychopharmacological Training for Collaborative Practice with Specific Populations reflects the knowledge base and skills necessary for psychologists to actively work with licensed prescribers to manage medications for mental, emotional, and behavioral disorders and integrating these medications into psychosocial treatments.

B. The Introductory Curriculum for Training in Psychopharmacology is a prerequisite for Psychopharmacological Training for Collaborative Practice with Specific Populations.

C. The Working Group is developing a Curriculum for Psychopharmacological Training for Collaborative Practice with Specific Populations for four specific populations that need to be considered in training psychologists:

1. child/adolescent populations
2. populations with mental retardation/developmental disabilities
3. populations with serious mental illness
4. aged populations

D. Within the curriculum modules for each of these specific populations, the following cross-cutting issues need special consideration because important content issues are involved and/or important constituencies need to be taken into account.Specific emphasis needs to be placed on pharmacotherapies, co-morbidity, treatment settings (e.g., research hospitals, inner-city hospitals, rural settings), treatment teams, substance abuse, gender, ethnicity, physical disability, sexual orientation, and environment.

E. Psychopharmacological Training for Collaborative Practice with Specific Populations builds on the Introductory Curriculum for Training in Psychopharmacology and differs from it in two specific ways:

1. incorporation of more in depth material on specific populations, and
2. extensive supervised professional experience working with specific populations on the management of psychopharmacological treatment.

F. Psychopharmacological Training for Collaborative Practice with Specific Populations utilizes an array of pedagogical methods:

1. self-study utilizing innovative technologies
2. didactic training
3. supervised professional experiences:
- assessment
- grand rounds
- co-therapy
- emergency treatment experiences
- other supervised clinical experiences

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G. Psychopharmacological Training for Collaborative Practice with Specific Populations will take a variety of forms depending upon:

1. the specific needs of the individual learner
2. the training setting
3. the training and skills of the members of the specific treatment team (physicians and other mental health practitioners with prescriptive authority)

H. The BEA Working Group envisions that a prototypical program for Psychopharmacological Training for Collaborative Practice with Specific Populations could occur at various levels of professional education and would include:

1. At the doctoral level, 2 didactic courses plus 1 day per week for a one year period of practicum experience in the specialty area, or;
2. At the internship and post-doctoral residency program level, the equivalent of one, four month rotation in the specialty area with increasing emphasis on supervised professional experience, or;
3. In continued professional education programs for licensed practitioners, the program would encompass 8 hours/month of didactic training and 4 hours/week of supervised professional experience in the specialty area for one year, or:
4. the same material could be acquired longitudinally throughout the sequence of doctoral, internship, and postdoctoral experiences.

I. A prototypical program for Psychopharmacological Training for Collaborative Practice with Specific Populations should include:

1. specific configurations of the pedagogical methods in I.F
2. supervised professional experience with sufficient number of clients to provide breadth of presenting conditions and stages of treatment
3. supervised professional experience which will ensure breadth in treatment settings (inpatient and/or outpatient) and breadth in working with an inter-disciplinary treatment team
4. an established program of evaluation to ensure that the stated goals and desired outcomes of the program are achieved

J. The four modules to be developed by the Working Group represent choices from a wide variety of programs that could be developed. The Working Group focused on these programs because of clearly identified needs of these specific populations. These modules will serve as templates for future development of psychopharmacology modules for collaborative practice with additional specific populations. Future modules may be developed to add a psychopharmacological dimension to existing training programs which focus on other populations and problems (e.g., neuropsychology, substance abuse, rural populations).

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DRAFT

Curriculum for Psychopharmacological Training for Collaborative Practice with Specific Populations

Child/Adolescent Module

Purpose and Learning: Objectives

I. Professional/Legal Issues

1. The participants will acquire advance knowledge and understanding of:

a. the nature of the collaborative relationship between psychologist and pediatrician/psychiatrist/family practitioner. A focus on the benefits obtained and difficulties involved in collaborative practice for the purpose of facilitating an integrative relationship in the care of children and adolescents;

b. the legal and ethical issues to consider with the introduction of pharmacological interventions with children and adolescents as part of a collaborative practice.

CONTENT AREAS

1. Interdisciplinary collaboration between psychologist and pediatrician/child psychiatrist/family practitioner

a. benefits
b. training, philosophical, assessment and treatment differences
c. responsibility issues
d. child/parent/family variables and their effect on the collaborative process
e. development of an integrated collaborative relationship

2. Legal and ethical issues

a. scope of practice limitations

    1. consultation and referral
    2. providing mental health services to those referred by others
    3. boundaries of competence and need to maintain current knowledge
    4. avoiding harm
    5. vicarious liability

b. confidentiality

c. informed consent

    1. providing information

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Child/Adolescent Module 2

    2. volunteering for consent
    3. individual's competencies to provide consent
    4. Special ethical considerations where consent may not be obtained
    5. Specific consent issues with pediatrics populations and individuals with developmental disabilities

        al. parental or caretaker authority
        b2. authority of children
        c3. developmental issues in obtaining competency
        d4. assent

6. procedures for obtaining consent
7. documenting consent
8. issues of consent and custody
9. refusing treatment

    a. child
    b. parent or caretaker
    c. Privilege
    d. Malpractice as a function of psychologists having greater knowledge of psychopharmacology

II. Assessment

LEARNING OBJECTIVES

The participants will acquire advanced knowledge and understanding of :

1. assessment and monitoring of physical effects, behavioral, emotional and cognitive effects of various pharmacotherapies for children and adolescents and individuals with specific developmental/medical disabilities.

A. Physical
1. Baseline physical assessment
2. Medical review of organ systems
3. Psychiatric review
4. Physical and neurological examination
5. Speech and language assessment
6. Monitoring untoward side effects
    a. side effect rating scales
    b. physical and neurological examinations
7. Laboratory measures

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Child/Adolescent Module 3

    a. Biochemical assessment of blood and urine
    b. Electrophysiological measurement (i.e., EKG)

B. Psychological

1. Rating scales
2. Direct observations of behavior
3. Laboratory measures
    a. IQ
    b. measures of executive functioning
    c. vigilance measures
    d. measures of learning and tests of achievement

C. Pharmacological

1. Efficacy and untoward effects
2. Evaluating response to medication

D. Environmental

1. Attributing behavior change to medication
    a. teacher
    b. parents
    c. child
    d. peers

2. Placebo effects
3. Informed consent
4. Interaction of environment with psychopharmacotherapy

III. Pharmacological Issues and Pediatric Variations

LEARNING OBJECTIVES

The participants will acquire advanced knowledge and understanding of

1. basic tenets in pharmacology including pharmacokinetics and mechanisms of drug actions (pharmacodynamics) as they specifically relate to: (1) normally developing pediatric populations; (2) pediatric populations with psychiatric disturbances; (3) pediatric populations with developmental and/or physical disabilities requiring medication; and (4) pediatric populations with developmental disabilities with comorbid psychiatric disturbances.

A. Routes of drug administration

B. Distribution

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Child/Adolescent Module 4

C. Elimination

1. biotransformation
    a. hepatic
    b. intestinal
    c. gastric
    d. renal

2. variability in biotransformation in pediatric populations
3. excretion
    a. urine
    b. feces
    c. lungs
    d. sweat

D. Pharmacokinetics
1. volume of distribution
2. elimination and clearance

E. Pharmacodynamics
1. receptor density
2. function

F. Drug concentrations
G. Time course of action
H. Dose dependent drug effects
I. Mechanisms of drug action
J. Tolerance and dependence
K. Pediatric pharmacokinetics

IV. Unique Issues for Youth with Developmental and Medical Conditions

The participants will acquire advanced knowledge and understanding of:

1. the interaction between psychopharmacological treatment and developmental/medical conditions that might affect both side effects and treatment outcome.

A. Physical sequelae

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Child/Adolescent Module 5

B.Pharmacological factors
C.Unique untoward side effects
D.Response factors

V. Treatment Issues

LEARNING OBJECTIVES

The participants will acquire advanced knowledge and understanding of:

1. Social and environmental factors that influence medication administration, efficacy, and untoward effects. Specifically, the role of institutions including schools, residential facilities, and psychiatric facilities as they influence pharmacotherapy with children and adolescents and those individuals with developmental/medical disabilities;

2. Various phases in psychopharmacotherapy including the decision whether or not to initiate pharmacotherapy, assessing long-term benefits as well as untoward effects, and considering whether discontinuation of pharmacotherapy is warranted;

3. Psychopharmacotherapy, particularly as it interacts with various non-somatic psychotherapies. This will include an essential understanding of efficacy of various psychopharmacologies in either combination with psychotherapy or alone; and

4. Assessment of and management of non-adherence with prescribed psychopharmacotherapy.

CONTENT AREA

A. Initiation of treatment of psychopharmacotherapy

1. Physical assessment and baseline physical assessment and laboratory tests
    a. pre-drug physical
    b. laboratory assessment

2. Patient and family education
3. Obtaining consent for treatment
4. Gender and ethnic considerations

B. Stabilization of psychopharmacotherapy

1. Monitoring efficacy of psychopharmacotherapy
    a. cross-situational evidence of efficacy

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Child/Adolescent Module 6

    la. parents
    1b. teachers/school personnel
    lc. child

b. rating scales
c. direct observations of behavior
d. laboratory measures of cognition

2. Assessment of untoward side effects
a. formal behavioral assessments
    la. rating scales
    1b. direct observations
    1c. physiological assessments
    1d. blood and urine measurements

b. parent assessments
    la. parent education and guidance
    lb. rating scales

3. Dose-response relationships

C. Maintenance of pharmacotherapy

1. Tolerance
la. behavioral and psychological tolerance
2b. physical tolerance

2. Dependence la. assessment of addiction potential
3. Ongoing monitoring and assessment of efficacy
4. Ongoing monitoring and assessment of untoward side effects
5. Short-term versus long-term gains
6. Normalization of behavior, cognition, and learning
7. Domain specificity and individual differences

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Child/Adolescent Module 7

D. Discontinuation/follow-up
1. Patient education
2. Systematic evaluation of behavior across informants

    la. rating scales
    lb direct observations of behavior

3. Titration of dose
4. Ongoing psychoeducation and psychotherapy

E. Multimodal therapies

1. Attributional effects of medication used alone
2. Benefits of both biologically mediated therapies and psychological therapies (Biopsychosocial model)
3. Systematic evaluation of comparative efficacy of psychopharmacotherapy and traditional psychotherapy and the combination of therapies

F. Compliance
1. Counseling and education
2. Relationship between client or patient and prescribing physician
3. Assessment of compliance

    1a. duration of psychopharmacotherapy
    lb. number of doses

4. Direct measures of compliance

    1a. laboratory measures
        a. blood levels

5. Indirect measures of compliance

    1 a. interviews
    1 b. pill counts

6. Risk factors for noncompliance

    la. cultural issues
    lb. social class
    lc. untoward (uncomfortable) side effects

G. Psychoeducation

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Child/Adolescent Module 8

1. Enhancing compliance
2. Patient and parent education
3. Teacher and school education

V. Research

LEARNING OBJECTIVES

The participants will acquire advanced knowledge and an understanding of:

(1) the importance of new developments in field of pediatric psychopharmacology through systematic reading of recent research;

(2) conducting systematic controlled clinical research including clinical trials, single subject designs;

(3) available sources for new research in the area of pediatric psychopharmacology including accessing of data bases, informational services, and other resources.

(4) theoretical models of central nervous system mechanisms

CONTENT AREA

1. Research Preparation

A. Literature retrieval strategies

B. Pharmacological retrieval strategies and data bases

C. Research strategies for single case and group studies

2. Preclinical/Clinical Research

A. Theoretical models of mechanism of disorder

B. Models of drug development

C. Measurement and design strategies

D. Safety/abuse liability

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Child/Adolescent Module 9

3. Conducting clinical research

A. Acute trials

B. Long-term follow-up trials

C. Developmental issues

D. Multi-modal trials

E. Consumer satisfaction

F. Cost effectiveness

G. Meta-analytic strategies

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Child/Adolescent Module 10

Learning Resources

A. Journals

Journal of Child and Adolescent Psychopharmacology
Journal of the American Academy of Child and Adolescent Psvchiatrv
Journal of Autism and Developmental Disabilities
Journal of Child Psychology and Psvchiatrv
Archives of General Psychiatry Pediatrics
Journal of Pediatrics Archives of Diseases of Children

B. Other References
1. Professional and ethical/legal issues

American Psychological Association (1992). Ethical Principles of Psychologists and Code of Conduct. Washington, DC, American Psychological Association.

American Psychological Association (1994). The Legal and Legislative Considerations of Prescription Privileges for Psychologists. Washington, DC: Practice Directorate, American Psychological Association.

Applebaum, P.S. & Gutheil, T.G. (1991). Handbook of Clinical Psvchiatrv and the Law (2nd Ed). Baltimore, MD: Williams and Wilkins

Beitman, B. & Klerman, G. (1991). Integrating Pharmacotherapv and Psychotherapy. Washington, DC: American Psychiatric Press.

Ellison, J.M. (1989). (Section I). Chicago: Year Book Medical Publishers.

Hinshaw, A.S. & DeLeon, P.H. (1995). Towards achieving multidiscipline professional collaboration. Professional Psychology: Research and Practice, 26, 115-l 16.

Kenkel, M.B. (Ed.) (1995). Special section: Psychology and Primary Care/Family Practice Medicine. In Professional Psychology: Research and Practice, 26, 117-146

Kingsbury, S.J. (1987). Cognitive differences between clinical psychologists and psychiatrists. American Psvcholonist, 42, 152-I 56.

Kisch, J. (1994). The need for psychopharmacological collaboration in managed mental health care. In C.S. Austad & W.H. Berman (Eds.), Psychotherapy in managed care. Washington, D.C.: American Psychological Association.

Littrell, J. & Ashford, J. (1995). Is it proper for psychologists to discuss medication with clients? Professional Psychology: Research and Practice, 26, 238-244.

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Child/Adolescent Module 11

Pilette, W.L. (1988). The rise of three-party treatment relationships. Psvchotherapv, 25. 420-423.

Reisner, & Slobogin (1994). Law and the Mental Health System. St. Paul, MN: West Publishing.

Schindler, F., Berren, M. & Beigel, A. (1981).A study of the causes of conflicts between psychiatrists and psychologists. Hospital and Communitv Psvchiatrv, 32, 263-266.

Simon, R. (1987). Clinical Psvchiatrv and the Law. Washington, DC: American Psychiatric Press.

Stanford University School of Medicine (1993). Special section: Psychotherapy and Pharmacotherapy, American Journal of Psychotherapy, 47 Palo Alto, CA.

Stromberg, C. et. al. (1988). The Psvcholoaists Legal Handbook. Washington, DC: The Council for the National Register of Health Service Providers in Psychology (including update of December, 1993) titled Malpractice and other Professional Liabilitv by Stromberg, C. & Dellinger, A.)

Swenson, L.C. (1993). Psvchologv and Law for Helping Professions. Pacific Grove, CA: Brooks/Cole.

Specific State Psychologists' Certification&censure Acts and Medical Practice Acts.

2. Assessment, psychopharmacotherapy, and treatment

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders 4th ed.). Washington, D.C.: American Psychiatric Association

Baldessarini, R.J. (1996). Chemotherapy in psychiatry: Principles and practice (3rd ed.). Cambridge, MA: Harvard University Press.

Dulcan, M.K. (1995). Treatment of children and adolescents. In R.E. Hales, C. Yudofsky, & J.A. Talbott (Eds.), American Psychiatric Press Textbook of Psychiatry (2nd ed.), Washington, DC.: American Psychiatric Association.

Hugo-Green, W. (1995). Child and adolescent clinical psvchopharmacologv (2nd ed.). Baltimore: Williams & Wilkins.

Medical Economics Company. Physicians Desk Reference (50th ed.), Author.

Meichenbaum, D. & Turk, D.C. (1987). Facilitating treatment adherence. New York: Plenum.

Poling, A. (1986). A primer of human behavior pharmacology. New York: Plenum.

Popper, C.W. (1988). Child and adolescent psychopharmacology. In J.O. Cavenar (Ed.), Psvchiatrv (vol. II). Philadelphia: J.R. Lippincott.

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Child/Adolescent Module 12

Popper, C.W., & Zimnitzky, B. (1996).Sudden death related to desipramine treatment in youth: A fifth case and a review of speculative mechanisms. Journal of Child and Adolescent Psvchopharmacologv, 5 283-300.

Rosenberg, D.R., Holttum, J., & Gershon, S. (1994). Textbook of pharmacotherapv for child and adolescent psychiatric disorders. New York: Brunner/Mazel.

Weiner, J.M. (1985). Diagnosis and psvchopharmacologv of childhood and adolescent disorders. New York: Wiley.

3. Research

Hayes, S. (1986). Conceptual foundations of behavioral assessment. New York: Guilford Press.

Barlow, D.H. (1984). The scientist practitioner: Research and accountabilitv in clinical and educational settings. New York: Pergamon.

Fleiss, J.L. (1986). The design and analysis of clinical experiments. New York: John Wiley and Sons.

Hayes, S. & Barlow, D.H. (1984). Single case experimental designs: Strategies for studying behavioral change. New York: Pergamon Press.

Johnston, J.M. & Pennypacker, H.S. (1993).Strategies and tactics of behavioral research (2nd ed.). Hillsdale, N.J.: Lawrence Erlbaum.

Rapaka, R.S. & Hawks, R.L. (1993). Medication development: Drug discovery, data bases, and computer aided drug design (Monograph 134). Washington: NIDA.

Sorer, H., & Rapaka, R.S. (1994). Imaging techniques in medication development: Preclinical and clinical aspects (Monograph 138). Washington: NIDA.

VIGNETTES

I. Professional and Legal/Ethical Issues

(1) Dr. A, a child clinical psychologist with 10 years of post-graduate experience has decided to move the practice to a rural area of the northwest. There are no psychiatric practitioners within 200 miies of the new town and Dr. A is interested in establishing collaborative practice arrangements with several local family practitioners.Discuss the issues that Dr. A will need to address to facilitate the development of an integrative collaborative effort.

(2) Dr. B, a pediatric psychologist with a practice in a Medical Arts” building has been referred a child by one of the pediatricians in the building. The referring pediatrician has only mentioned that the child is overactive and distractible and the physician has recommended family psychotherapy in conjunction with the stimulant treatment. Dr. B observes a child who is extremely lethargic, and his parents' report that he refuses to eat, and has difficulty falling to sleep at night.Discuss how you might approach this issue with both the parent and the physician.

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Child/Adolescent Module 13

II. Assessment, Psychopharmacotherapy, and Treatment

(1) A family practitioner refers a 14-year-old adolescent who has recently demonstrated a decrease in academic performance, as well as increased oppositionality both at home and at school coupled with increased appetite and hyposomnulence. The physician wishes to determine whether the youngster would be an appropriate candidate for pharmacotherapy.Address how you might handle this issue with reference to assessment and subsequent evaluation if medication is introduced.

(2) An obese lo-year-old adolescent with a long history of attention deficit hyperactivity disorder presents to a psychologist for the purpose of behavior management. The child is receiving 30 mg. of Ritalin on a twice daily dosing schedule, corresponding to 10 mg./kg. of body weight.Comment on issues that you would want to discuss with the physician regarding pharmacotherapy for this patient.

(3) A 4-year-old preschooler has been referred to you by a pediatrician who has found your name in the managed care directory. The child has been diagnosed with Trisomy-21 and also has a congenital heart defect. The child at times becomes highly aggressive and unmanageable at home and at preschool. The physician wishes to engage you in a collaborative plan involving both pharmacotherapy and psychotherapy. How might you consult in this situation?

III. Research

(1) You have been referred a l2-year-old with a history of a closed head injury who has emotional lability, impulsivity, and severe attentional problems. The child's history prior to the injury is unreliable.Due to the target symptoms, you suggest a trial of sympathomimetic drugs, although the collaborating physician insists that the child will not respond to this class of medication. What information retrieval strategies could you employ to research this issue?

(2) You have been hired by a large managed care corporation for the purpose of determining whether antidepressant medication is a behaviorally and cost effective intervention in the treatment of acting-out adolescents. How might you approach this opportunity?

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DRAFT

Curriculum for Psychopharmacological Training for Collaborative Practice with Specific Populations

Mental Retardation/Developmental Disabilities Module

Purpose and Learning Objectives

I. Professional/Legal Issues (not yet developed)

II. Assessment

Learning Objectives

The participants will acquire advanced knowledge and understanding of:

1. behavioral and psychological disorders among people with developmental disabilities and their common origins;

A. Common presenting behavior problems of people with mental retardation and related developmental disabilities which are treated pharmacologically
1. Prevalence of aggression, self injury, stereotypies
2. Prevalence of other destructive behavior

B. Psychiatric causes of behavior disorders among people with mental retardation and related disabilities

C. Behavior disorders unique to people with developmental disabilities
1. Self injury in Autism, de Lange syndrome, Rett's syndrome and Lesch-Nyhan syndrome
2. Eating disorder in Prader Willi syndrome

2. assessment and monitoring of physiological and biochemical effects, behavioral, emotional and cognitive effects of various pharmacotherapies for children, adolescents and adults with mental retardation and other developmental disabilities

3. assessment of the appropriateness of pharmacological, social, communicative and other environmental interventions which may be most relevant to the behavior problems exhibited by the client

A. Physiological and biochemical
1. Baseline physical examination
2. Medical review of organ systems
3. Neurological examination
4. Analysis of standard blood and urinary lab workup
5. Psychiatric interview
6. Speech and language assessment
7. Other health conditions that could contribute maladaptive behavior
    a. gastrointestinal problems (e.g. chronic constipation, gastric reflux, esophageal stricture and hiatal hernia)
    b. ear infections and toothache c. menstrual discomfort
7. Monitoring untoward effects of drugs
    a. side effect rating scales
    b. baseline measures of adaptive behavior
    c. physiological and neurological examination

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B. Behavioral and psychological measures
1. Direct behavioral observations in natural environments
2. Rating scales and checklists
    a. adaptive behavior scales
    b. maladaptive behavior scales
    c. psychiatric symptom checklists
3. Laboratory measures
    a. intellectual assessments
    b. measures of learning and achievement

C. Analysis of social circumstances surrounding client
1. Functional analysis of client behavior in natural environment
    a. degree of client skills and competence in meeting day to day needs
    b. opportunities to participate in age appropriate functional, meaningful and engaging activities
    b. degree of support by parents and caregivers for competent, independence-promoting skills
    c.. degree to which social environment inadvertently contributes to and maintains maladaptive behavior
2. Physical/social setting
    a. crowding, noisy, physically uncomfortable or barren environment
    b. appropriate opportunities in physical environment for access to age appropriate vocational and/or recreational materials and activities

D. Interpretation of Medication effects
1. Attributing behavior/psychological change to medications
    a. parent or other caregiver
    b. teacher
    c. client
2. Placebo effects
3. Multiple interactive drug effects
4. Informed consent
5. Interaction of environmental events with medications

III. Pharmacological Issues

Learning Objectives

The participants will acquire advanced knowledge and understanding of:

1. basic principles of pharmacology including drug classification, basic neuropharmacology, routes of administration, absorption, distribution, metabolism and excretion as they apply to people with developmental disabilities.

A. Drug classification
1. Neuroleptics
2. Antidepressants
3. Mood stabilizers
4. Anxiolytics
5. Adrenergic agents
6. Other unapproved agents

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B. Neurochemical mechanisms of drug action
1. Neuroreceptor theory
2. Neurochemical transmitters
3. Agonists
4. Antagonists
5. Neuromodulators
6. Reuptake inhibitors
C. Factors influencing blood level
1. route of administration (time course)
2. absorption (presence of food or other drugs in stomach)
3. distribution (physical activity level)
4. metabolism (liver function; enzyme induction)
5. excretion (renal disease; liquid intake)
D. Tolerance, withdrawal and drug seeking

IV. Unique Issues for People with Developmental Disabilities

The participants will acquire advanced knowledge and understanding of:

1. the frequent co-occurrence of seizure disorders and behavior disorders among people with developmental disabilities;

2. the unique occurrence of specific behavior and emotional problems among people with specific developmental disabilities (e.g. anxiety disorder in autism, obsessive compulsive disorder in Prader Willi syndrome)

3. the possibility that medications may produce iatragenic behavior and other physiological problems:

a. neuroleptic-induced akathisia is often interpreted by parents and staff as an indication that a higher neuroleptic dose is necessary;

b. care givers may wish to try to mask Parkinson-like tremors induced by neuroleptics by administering a second or third medication, rather than reducing dose or changing medications;

c. agitation during the early period of treatment with some SSRI's occurs before positive treatment effects becomes obvious;

d. some medications cause anticholinergic side effects, which themselves induce additional behavior problems (e.g. constipation caused by neuroleptics).

4. the time course for reaching therapeutic levels of some drugs may interact with caregiver expectations (e.g. SSRI's may require 3-4 weeks to achieve optimal receptor level changes, which caregivers may grow impatient within a week if the client has not improved).

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V. Treatment Issues

LEARNING OBJECTIVES

The participants will acquire advanced knowledge and understanding of:

1. social and environmental factors that influence medication administration, efficacy, and untoward effects. Specifically, the role of institutions including schools, residential facilities, and psychiatric facilities as they influence pharmacotherapy with children and adolescents and those individuals with developmental/medical disabilities;

2. various phases in psychophannacotherapy including the decision whether or not to initiate pharmacotherapy, assessing long-term benefits as well as untoward effects, and considering whether discontinuation of pharmacotherapy is warranted;

3. psychopharmacotherapy, particularly as it interacts with various non-somatic psychotherapies. This will include an essential understanding of efficacy of various psychopharmacologies in either combination with psychotherapy or alone; and

4.assessment of and management of non-adherence and specific with prescribed psychopharmacotherapy.

CONTENT AREA

A. Initiation of treatment of psychopharmacotherapy

1. History

    a. History of presenting problem over the past year
    b. History of previous treatments and outcomes
    c. Family history of mental illness and developmental disabilities

2. Baseline assessments
    a. Observational assessments in natural settings
    b. Caregiver interviews (multiple caregivers, teachers & family members)
    c. Physical examination, including review of physiological and laboratory (blood, urine test data)
3. Patient and family education
4. Obtaining consent for treatment
5. Disability-specific considerations
6. Gender and ethnic considerations

B. Stabilization of psychopharmacotherapy
1. Monitoring efficacy of psychophamracotherapy
    a. cross-situational evidence of efficacy
        la. parents and/or other care givers
        lb. teachers/school personnel

 [Page 23]

        lc. client
c. direct observations of adaptive and maladaptive behavior
b. rating scales of efficacy
d. laboratory measures of cognition

2. Assessment of untoward side effects
    a. formal behavioral assessments
        1a. direct observations
        2 b. rating scales and checklists
        1 c. physiological assessments
        1 d. blood and urine measurements
    b. parent assessments
        la. parent education and anticipatory guidance
        lb. rating scales

3. Dose-response and time course relationships

C. Maintenance of pharmacotherapy
1.Tolerance
1 a. behavioral and psychological tolerance
2b. physical tolerance
2. Dependence
1 a. assessment of addiction potential
3. Ongoing monitoring and assessment of efficacy 4. Ongoing monitoring and assessment of untoward side effects
5. Short-term versus long-term gains
6. Normalization of behavior, cognition, and learning
7. Domain specificity and individual differences

D. Discontinuation/follow-up
1. Systematic evaluation of behavior across informants
    la. rating scales
    lb. direct observations of behavior
2. Titration of dose
3. Ongoing psychoeducation and psychotherapy
E. Multimodal therapies

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1. Attributional effects of medication used alone
2. Benefits of both biologically mediated therapies and psychological therapies (Biopsychosocial model)
3. Systematic evaluation of comparative efficacy of psychopharmacotherapy and traditional psychotherapy and the combination of therapies

F. Compliance
1. Relationship between client or patient and prescribing physician
2. Compliance assessment
    1a.length of psychopharmacotherapy
    lb. number of doses
3. Direct measures of compliance
    1a. laboratory measures
    a. blood levels
4. Indirect measures of compliance
    la. interviews
    lb. pill counts
5. Risk factors for noncompliance
    lc. untoward (uncomfortable) side effects
    2b. caregiver resistance to use of medications
    3c. caregiver misunderstanding or cognitive problems

G. Psychoeducation
    1. Enhancing compliance
    2. Patient and parent education
    3. Teacher and school education

VI. Research

LEARNING OBJECTIVES

The participants will acquire advanced knowledge and an understanding of:

(1) the importance of new developments in field of psychopharmacology for people with mental retardation and developmental disabilities through systematic reading of recent research;

(2) conducting systematic controlled clinical research including clinical trials, single subject designs;

 [Page 25]

(3) available resources for new research in the area of psychopharmacology treatment for people with developmental disabilities including accessing of data bases, informational services, and other resources. Specific

(4) theoretical modes of central nervous system mechanisms

CONTENT AREA

1. Research preparation

A. Literature retrieval strategies
B. Pharmacological retrieval strategies and data bases
C. Research strategies for single case and groups studies

2. Preclinical/Clinical Research

A. Theoretical models of mechanisms of disorder B. Models of drug development
C. Measurement and design strategies
D. Safety/abuse liability

3. Conducting clinical research

A. Acute trials
B.Long-term follow-up trials
C. Developmental issues
D. Multi-modal trials
E. Consumer satisfaction
F. Cost effectiveness
G. Meta-analytic strategies

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References

Aman, M.G. (1984) Drugs and learning in mentally retarded persons. Advances in Human Psychopharmacology, 3, 121-163.

Aman, M.G., Sarphare, G. and Burrow, W.H. (1995) Psychotropic drugs in group homes: Prevalence and relation to demographic/psychiatric variables. American Journal on Mental Retardation, 99, 500-509.

Aman, M.G., and Singh, N.N. (1988) Psychopharmacology of the Developmental Disabilities. New York: Springer-Verlag.

Baumeister, A.A., Todd, M.E. and Sevin, J.A. (19931) Efficacy and specificity of pharmacological therapies for behavioral disorders in persons with mental retardation. Clinical Neuropharmacology, 16,27 l-294.

Boyd, R.D. (1993) Neuroleptic malignant syndrome and mental retardation: Review and analysis of 29 cases. American Association on Mental Retardation, 98, 143-155.

Chadsey-Rusch, J. & Sprague, R.L. (1989) Maladaptive behaviors associated with neuroleptic drug maintenance. American Journal on Mental Retardation, 93, 607-617.

Hill, B.K, Balow, E.A. and Bruininks, R.H. (1985) A national study of prescribed drugs in institutions and community residential facilities for mentally retarded persons. Psychopharmacology Bulletin, 21,279-284.

King, B.H. (1993) Self-injury by people with mental retardation: A compulsive behavior hypothesis.American Journal on Mental Retardation, 98,93- 111.

Lewis, M. H. , Bodfish, J.W., Powell, S.B. and Golden, R.N. (1995) Clomipramine treatment for stereotypy and related repetitive movement disorders associated with mental retardation. American Journal on Mental Retardation, 11, 299-3 12.

McDougle, C. et al. (1995) Risperidone in adults with autism or pervasive developmental disorder. J. Child & Adolescent Psychopharmacology, 5, 273-282.

Poling, A. and LeSage, M. (1995) Evaluating psychotropic drugs in people with mental retardation: Where are the social validity data. American Journal on Mental Retardation, 100, 193-200.

Ratey, J.J. (ed) (199 1) Mental retardation: Developing pharmacotherapies. Washington, DC: American Psychiatric Press, Inc.

Sandman, C. A., Hetrick, W.P., Taylor, D.V., et al. (1993) Naltrexone reduces self-injury and improves learning. Experimental & Clinical Psychopharmacology, 1, 242-258.

Schaal, D.W. and Hackenberg, T. (1994) Toward a functional analysis of drug treatment for behavior problems of people with developmental disabilities. American Journal on Mental Retardation, 99, 123- 140.

Schroeder, S.R. et al. (1995) Clinical trials of D1 and D2 dopamine modulating drugs and self-injury in mental retardation and developmental disability. Mental Retardation and Developmental Disabilities Research Reviews, 1, 120- 129..

 [Page 27]

Sovner, R., Fox, C.J., Lowry, M.J. et al, (1993) Fluoxetine treatment of depression and associated self-injury in two adults with mental retardation. J. Intellectual Disability Research, 37, 301-3 11.

Thompson, T., Hackenberg, T. , Cerutti, D., Baker, D. and Axtell, S. (1994) Opioid antagonist effects on self-injury in adults with mental retardation: Response form and location as determinants of medication effects. American Journal on Mental Retardation, 99, 85- 102.

Thompson, T., Schaal, D.W. and Hackenberg, T.D. (1991) Pharmacological treatments for behavior problems in developmental disabilities.In Treatment of Destructive Behaviors in Persons with Developmental Disabilities. NIH Publication No. 9 l-2410. Bethesda, MD: Department of Health and Human Services, pp. 343-440.

Thompson, T., Symons, F., Delaney, D. and England, C. (1995) Self-injurious behavior as endogenous neurochemical self-administration. Mental Retardation and Developmental Disabilities Research Reviews, 1, 137-148.

White, M.J. et al. (1995) Diagnostic overshadowing and mental retardation: A meta-analysis. American Journal on Mental Retardation, 100, 293-298.

 [Page 28]

DRAFT

Curriculum for Psychopharmacological Training for Collaborative Practice with Specific Populations

Populations with Serious Mental Illness Module

Purpose and Learning Objectives

A. Professional/Legal Issues (not yet developed)

B. Assessment Issues

Possible Vignettes

Accountability and cost saving have become the dominant. themes for the staff of the North Central Mental Health Centcr. NCMHC provides services to about 100 priority clients with severe and disabling mental illness. All clients have prescriptions for anti-psychotic or anti-depressive medications. In addition, the treatment team led by a half-time psychiatrist attempts to help clients with problems of daily living through case management activities, A prevocational training program is being developed. The clinical director wonders whether most effective treatments arc being applied for each client and has asked the psychologist to design a system for conducting on-going evaluations of client progress. This system should be particularly sensitive to medication-related changes, but should also be responsive to other activities of the NCMHC.

A team of pharmacists is planning research on a new anti-psychotic medication that will be carried out in a psychiatric hospital that is part of a state prison.They have been informed that it is essential that participants understand what the research entails. They ask a prison psychologist for advice on assessing competence to give informed consent.

Richard, a 27 year old Pueblo Indian who is deaf and has schizophrenia, had not responded well to haloperidol or to prolixin. He lives in the community in a board and care facility. His mother urged the clinic team to ask the parti-time psychiatrist to prescribe risperidone. This was done and Richard showed a marked improvement. He became active in the psychosocial club and made more visits home, especially at ceremonial times. After several months of this he told his mother hc was feeling so good he knew he did not need to take the medciation and despite her urging compliance he quit taking taking the medication and his symptoms rapidly became much worse. The community mental health center team has the psychologist for help in designing a medication compliance program with measures of the patient's progress.

Julia has not responded to anti-psychotic medications as well as expected. Her symptoms abate and then become much worse, and in a few weeks they diminish. This pattern is not related to dosage level and Julia insists that she takes the medication regularly. She denies illicit drug use. The general practitioner who is treating her has asked Dr. Lopez, a clinical psychologist, to look into the matter and advise him about what might be done to improve the situation.

 [Page 29]

Although her parents wanted to visit Erika and learn more about her involvement in the Assertive Community Training program they found being with her very difficult. She paced up and down and was extremely irritable. She had finally accepted that she needed to take anti-psychotic medication and was doing quite well on Navanc. Her major symptoms were minimal. The ACT staff agreed with her parents, but were puzzled about what to do. They asked Dr. Richardson, a clinical psychologist, for assistance.

Purpose

Psychologists have long been recognized as being experts in asscssmcnt of human behavior. This section extends assessment activities to include more that is traditionally medical. This requires an understanding of medical assessment and an ability to relate it to psychological assessment.

Learning Objectives
A. The psychologist will develop skills for communicating to other professionals the need for assessment in planning effective treatment
B.The psychologist will learn about medical asscssmcnt techniques in order to bc able to communicate clearly with physicians and other medical professionals about the interaction of medical assessment results and psychosocial assessment results.
C.The psychologist will develop skills in the assessment of comorbid conditions.
D. The psychology will understand how gender, ethnicity, age, and socioeconomic factors interact with medications used in the treatment of people with serious mental illnesses.

CONTENT AREAS

A, Physiological Assessment
--understand appropriate laboratory assessment procedures and when they can be used to supplement self-report and significant other report (Rosse and Morihisa, 1988).
--interpret findings from physical examinations and laboratory studies (Karon, et al., 1989).
--evaluate laboratory findings that demonstrate medication effectes on organ systems, levels of medication in the patient's system.
--assess use of substances that may interact with prescribed medications and interpret their probable effects on treatment outcomes.

B. Psychological Assessment
--conduct a basic neuropsychological assessment (Iioff, et al., 1992; Lezak, 1983)
--identify and diagnose psychology disorders including comorbid conditions (American Psychiatric Association, 1994a).
--assess the patient's ability to understand the treatment process (David, Buchanan, Reed & Almeida, 1992).
--make use of knowledgeable sources of information, including relatives (Platt, Weyman, Hirsch & Hewett. 1980; Schene, Tessler & Gamache, 1994).
--utilize standard measures of cognitive, emotional and social functioning.

C. Psychosocial Assessment

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-assess the patient's biopsychosocial context to recommend treatment that is most congruent with the patient's gender, ethnicity, age, cognitive ability, educational level, and functional competence (Paul, 1986; 1987).
--assess the impact of medications on the patient's qualtity of life, including sleep, sexual functioning, interpersonal relations, self-esteem, psychomotor functioning, and economic status (Lukoff, Liberman & Nuechterlein, 1987).
--assess factors that may enhance or inhibit patient compliance with treatment/rehabilitation (Blackwell, in press).
--assess factors that may be barriers to effective treatment such as patients cognitive, educational or economic limitations (Wallace, 1987).
--assess ethnicity-related response to medications (Strickland. Lawson Lin & Fu, (1993).
--identify sources of treatment support for the patient such as family, friends, coworkers, or affiliations with religious or social organizations (Platt, Weyman, Hirsch ct. Hewett, 1 9 8 0 ).

D. Psychopharmacological Assessment
--assess the effectiveness of treatment/rehabilitation on symptoms and the patient's general well-being.
--identify and evaluate side effects of medication, including short-and long-term effects (Raskin & Niederehe, 1988).
--recognize medication toxicities (Hyman, Arana & Roscnbaum, 1995).
--recognize potential interactions with other medications, diet or self-selected drugs.
--understand advantages and disadvantages of various treatment options (American Psychiatric Association, 1994b; Lehman, Thompson, Dixon & Scott, 1995).
--assess the patient's ability to understand prescribed treatment and ability to give informed consent to treatment , and how to include significant others in the consent process (Folstein, Folstein & McHugh, 1975 ; David, Buchanan, Reed & Nmeida, 1992)
--use standard measures to assess the effects of medications and changes in target symptoms (Lukoff, Liberman and Nucchtcrlcin, 1987).
--assess patient's prior responses to the same o r related medications (Bellack, 1989).

References

American Psychiatric Association (1994a). DSM-IV: Diagnostic and Statistical Manual. 4th ed. Washington, DC: American Psychiatric Press.

American Psychiatric Association (1994b). Practice guideline for the treatment of patients with bipolar disorder. American Journal of Psychiatry, 151 (Supplement).

Bellack, A. S. (1998). Treatment outcome evaluation methodology with schizophrenics. Advances in Behavioral Research and Therapy, 11, 191-200.

 [Page 31]

Blackwell, B . (Ed.)(in press), Compliance and the treatment alliance in serious mental illness. Newark, NJ: Gordon & Breach.

David, A., Buchanan, A., Reed, A., & Almeida, 0. (I 992). The assessment of insight in psychosis, &&&Journal of Psychiatry, 161, 599-602.

Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-Mental State: A practical method for grading the cognitive stale of patients for the clinician. Journal of Psychiatric Research 12, 189-l 98.

Hoff, A. L., Riordan, H., O'Donnell, D. W., Morris, L., & DeLisi, L. E. (1992). Neuropsychological functioning of first-episode schizophreniform patients. Journal of American Psychiatry, 149, 898-903.

Hyman, S.E., Amnn, G. W. & Rosenbaum. J. F. (1995) Handbook of psychiatric drugs, 3rd ed. Boston: Little, Brown.

Karon, L. M., Sox, H. C., Matton, K. I., S , Moltzen, S. Kraemer, H.C., Imai, K., Kelsey, T.G., Rose, T.G., Levin, L. C., & Chandra, S. (1989). Medical evaluation of psychiatric patients. Archives of Gencral Psychiatry, 46, 733-740.

Lehman, A. F., Thompson, J. W., Dixon, L.B., & Scott, J. E. (1995). Schizophrenia: Treatment outcomes research. Psychophrenia Bulletin. 21, (Special issue).

Lezak, M. (1983). Neuropsychological assessment. New York: Oxford.University Press.

Lukoff, D., Liberman, R. P., & Nuechterlein, K. H. (1987). Symptom monitoring in the rehabilitation of schizophrenic patients. Schizophrenia Bulletin. 12, 578-603,

Platt, S., Weyman, A. Mirsen, S., & Hewett, S. (1980). The Social Behavior Assessments Schedule (SBAS): rationale, contents, scoring and reliability of a new interview schedule. Social Psychiatry, 15, 43-55.

Paul, G.L. (Ed.) (1986) Assessment in residential settings: Principles and methods to support cost-effective quality operations. Champaign, IL: Research Press.

Paul, G.L. (Ed). (1887). The Time Sample Behavioral Checklist: Observational assessment instrumentation for service and research. Champaign, IL: Research Press.

Raskin, A., & Niedersehe, G. (Eds). Assessment in diagnosis and treatment of geropsychitric patients. Psychopharmacology Bulletin, 24 (Entire issue).

Rosse, R.B., & Morihisa, J.M. (1988). Laboratory and other diagnostic tests in psychiatry (pp. 247-276). In J.A. Talbott, & S.c. Yudofsky (eds). Textbook of psychiatry. Washington, D.C.: American Psychiatric Press.

Schene, A.H., Tessler, R.C. & Gamache, Cr. M. (1994). Instruments measuring family or caregiver burden in severe mental illlness. Social Psychiatry and Psychiatric Epidemiology, 29, 228-240.

Strickland, T.L., Lawson, W., Lin, K.M., & Fu. P. (1993). Interethnic variation in response to lithium therapy among African-American and Asian-American populations. Jn K.M. Lin, R.E., Poland & G. Nakasaki (Eds). Psychopharmacology and psychobiology of ethnicity (pp. 107-120). Washington, DC: American Psychiatric Press.

Wallace, C.J. (1987). Functional assessment in rehabilitation. Schizophrenia Bulletin 12, 604-630.

[Page 32]

LEVEL 2
CURRICULUM: ADULTMODULE
6/9/966 rev.

D. TREATMENT ISSUES

Possible vignettes.

Clinical Vignette #1.

A 45 year old male with schizophrenia lives at home with an intrusive critical mother who worries about what will happen when she dies if he does not get a job.He sleeps during the day, plays loud music at night and is verbally abusive to his mother and disturbs the neighbors.There is constant conflict over taking medication and getting a job. Neither are knowledgeable about serious mental illnesses or available services.Hc currently is seeing a CP physician who is prescribing Haldol. The GP has approached the psychologist for advice.

Clinical Vignette#2 .

Another example is a 35 year old unemployed single mother of 3 with rapid cycling bipolar disorder with drug abuse issues. She and her children are currently living in a shelter.The Department of Social Services is trying to place her children in foster care while the mother wishes to keep them.The shelter provider asks the psychologist for advice about treatment.

Clinical Vignette #3.

Alfred A., a 38 year old ranch hand with a long-standing diagnosis of schizophrenia, disorganized type, also has a history of a closed head injury suffered at age 25 when he was thrown from a horse.He has been stable for many years on a regimen of low dose haloperidol and low dose benztropine. In the past. you have provided social skills training to him, and regularly discuss his cast with the local general practitioner, who manages his medications. Recently, he visited his physician with complaints of recurrent, severe neck and shoulder pain and was given several pain compounds, including cyclobenzaprine. He presented acutely several days later with disorganized behavior and visual hallucinations. His physician suspects a psychotic break brought on by recent stressors. Discuss your assessment and management strategies.

Clinical Vignette #4

Rachel K. is a 20 year old Native American woman who suffered a psychotic episode during her junior year of college.She was hospitalized in a distant major medical center for several weeks, and a course of haloperidol, benztropine, and lorazepam was initiated. She was discharged after 14 days and returned to her parents' rural home. Her medications are managed by the nurse practitioner at the county health facility where you consult. Her parents, although extremely distressed by the new onset of their daughter's illness and the many positive symptoms she continues to display, have sought to educate themselves about the disorder and its treatment. They are

 [Page 33]

particularly concerned that she will develop tardive dyskincsia, and wish to stop treatment with haloperidol. Discuss both psychological and pharmacological management of this case.

PURPOSE

This section on treatment issues is aimed at providing the trainee with knowledge and skills nccdcd to identify and monitor medication needs of clients with schizophrenia, to facilitate a sophisticated integration of psychosocial and pharmacological services, including consultation with non-psychiatric mental health workers such as rehabilitation staff and with non-mental health service providers such as general practitioners in rural areas. In addition, it provides some sophistication about the many factors which shape the course of illness, including gender, ethnicity, and comorbid conditions.

LEARNING OBJECTIVES

A)The participants will acquire advanced knowledge and skill in handling the four stages in the delivery of psychopharmacological agents for people with SMI: (a) Initiation, (b) Stabilization, (c) Maintenance, and (d)discontinuation/ follow-up.

B)The participants will acquire advanced knowledge and practice in integrating psychosocial and pharmacological treatments.
C)The participants will acquire advanced knowledge and practice in the management of comorbid conditions.
D)The participants will learn how gender and ethnicity among people with serious mental illness shape the above objectives.

CONTENT AREAS

A)Stages of treatment and the knowledge/skills needed by the level II psychologist:

l) Initiation
* Ethical and legal considerations in initiating treatment.

* Development of a medication treatment plan based on comprehensive assessment (American Nurses Association, 199 ; Janicak et al., 1993).

*Treatment initiation

*Adjuvant agents (e.g., Siris, 1993)

* Strategies to insure patient safety.

 [Page 34]

2) Stabilization

* Monitor symptoms, side effects, and changes in functional status. (E.g., Side effects: Addonizio & Risch, 1995; Awad, 1995; Casey, 1995; Gaff & Shader, 199s; Stanilla & Simpson, 1995. Tardive dyskinesia: Kane, 1992. Task Force Report, 1992.)

* Therapeutic monitoring (Laboratory reports, patient reports, other objective measures).

*Altcrnativc medication (c.g.Simhandl & Mcszaros, 1992; Wolkowitz & Pickar, 1991), and medication strategies (e.g., see Schooler, 1991).

*Adjuvants.

* Treatment of neuroleptic nonresponders (Meltzer, 1992; Schulz & Buckley, 1995), and use of other somatic interventions (Christison, Kirch, & Wyatt, 1991; Krueger & Sackeim, 1995)

3)Maintenance (e.g., Kane, 1984; Davis 6r Andriukaitis, 19&j>

* Develop a. collaborative plan of patient management.

* Identify possible impediments to optimal psychopharmacological management.

* Develop effective strategies for relapse prevention (e.g., tisling, 1992).

* Psychoeducational interventions for maximizing treatment outcome.

4)Discontinuation/Follow-up

*Pharmacological issues (discontinuation, withdrahral, rebound, recurrence).

* Psychosocial interventions for relapse prevention.

* Depot medications (Feltner & Hertzman, 1993)

* Tardive dyskinesia & other tardive phenomena (Casey, 1987; Cavallaro et al., 1993)

B)The integration of psychosocial and pharmacological treatment

1) Knowledge of effective treatments

Learning objective 1: Psychologists should have both knowlcdgc and some skills in those treatments which have been shown to be effective for people with serious mental illnesses.

Content: In terms of knowledge, for schizophrenia, see the special section in Schizophrenia Bulletin  (1995, volume 21, No. 4, pp. 361-675; also Hegarty et al., 1994; Marder et al., 1995a, 1995b; and Bergin & Garfield, 1994). In terms of skill, this should be gained in internships, post-doctoral baining, continuing education, but probably not during Level 11 psychopharmacology training.

 [Page 35]

2) Treatment Programs

Learning Objectives 1: Psychologists should have at least a basic knowledge of major treatment programs (i.e., programs which attempt to remediate symptoms and / or psychosocial functioning).

Content:
Hospitalization. (e.g., Wright, Thase, Beck, Ludgate, 1993; Brabender, CL Fallon, 1993)
Hospital alternatives. (e.g., Warner, R., 1995)
Psychosocial rehabilitation. (e.g. Anthony, Cohen, & Farkas, 1990)
Social skills training. (e.g., Scott & Dixon, 1995-a)
Residential services. (e.g., Gerhart, 1990)
Vocational rehabilitation. (e.g., Lehman, 199s)
Case Managment. (e.g., Gerhart, 1990)
Self help. (e.g., Baer, 1991; Bourne, 1990; Burns, 1980; Mueser & Ginger&, 1994; Spaniol, Koehler, & Hutchinson, 1994; Spaniol & Koehler, 199s; Torrey, 1995.)
Psychoeducation.
Long-term outcomes. (e.g., Harding, Brooks, et al., 1987; Harding, Zubi!., et al., 1987; Torrey, 1995)

Learning Objective 2: Psychologists should have basic knowledge of adequate integrated systems of care. The student should also be informed of how managed care affects behavioral health care of people with SMT.
Content: Assertive community treatment (Scott & Dixon, 1995). Community Support System (Stroul, 1989); Managed care & public services (Budman, 1995; Patterson & Sharfstein, 1992; Sullivan, 1995)

Learning Obiective 3: Psychologists should have moderate to excellent I knowledge and skill levels in providing a variety of traditional psychological intcrvcntions with this population, e.g. asscssmcnt, neuropsychological assessment, functional assessment, individual and group psychotherapy.
Content: Depending on the training model used, an adequate knowledge and skills level should be achieved prior to entering the Level II curriculum.
Individual psychotherapy (Beck, Freeman, (Ir Associates, 1990; Coursey, 1989; Craske & Bklw, 1990; Jamiscm 6r Goodwin, 1983; Seeman & Greben, 1990; Beck, Rush, Shaw, & Emery, 1979; Gunderson, Frank, Katz, Vannicelli, Frosch, & Knapp, 1984; Hogarty, Kornblith, Greentirald, DiBarry, Cooley, Flesher, Reiss, Carter, 1995; Kingdon & Turkington, 1994; Klerman, Weissman, Kounsaville, & Chevron, 1984; Novalis, Rojcewicz, & Peele, 1993; Rockland, 1993).
Group psychotherapy. (Kanas 1986,199s; Scott & Dixon, 1995.) .
Family interventions. (Dixon & Lehman, 1995.)

 [Page 36]

Psychological assessment: relevant instruments with appropriate populations. (Bedell, 1994).
Neuropsychology & assessment. (Lezak, 1995. Goldberg, Gold, & Braff, 1991. Knable, Kleinman, & Weinbager, 19%).

3) Integration of psychopharmacology and psychosocial treatments.
Leaming Objective 1: Psychologists should have both knowledjie and skill in integrating psychosocial and pharmacological treatments.
Content: (Beitman & Klerman, 1991; Collins & Munroe-Blum, 1995; Hammersley, 1995; Novalis, Rojcewicz, & Peele, 1993; Jamison, & Goodwin, 1983; Seeman & Greben, 1990). Training should be provided through both didactic and supervised experiences,

C)Management of comorbid conditions

* Substance abuse and schizophrenia/affective disorders (e.g. Dixon & Rebori, 1995).
* Co-occurring affective and Psychotic disorders (DeLisi, i990; Plasky, 1991; Simhancll & Meszaros, 1992; Atre-Vaidva & Taylor, 1989; Goodwin & Jamison, 1990). .
* Interactions between antipsychotic and other-psychotropic drugs (Tan&k et al., 1993; Marder & Van Putten, 1995).

D)Gender, ethnicity, and SMI
Learning Obiective 1: Psychologists should be familiar with the differential I needs and problems, response patterns, and best Practices in psychosocial and psychopharmacolo,cal interventions by gender and ethnicity.

Content:
Gender: (Bachrach & Nadelson, 1988; Dutton-Douglas, & Walker, 1989; Lin & Poland, 1995; McGrath, Keita, Strickland, & Russo, 1990; Seeman, 1995; Yonkers & Hamilton, 1995).
Ethnicity: (Aponte, Rivers, & Wohl, 1995; Yamamoto & Lin, 1995).

Note: The BEA Working Group on Psychopharmacology has not yet developed  modules for other diagnostic categories
Major depressive and bipolar disorders (American Psychiatric Association, 1993; American Psychiatric Association, 1995; Goodwin & Jamison, 1990).
Organic mental disorders.
Axis II conditions such as borderline personality disorder.
Anxiety & panic disorders.
Obsessive-compulsive disorder.
Dissociative identity disorder, etc.

 [Page 37]

RESOURCES

Addonizio, G. & Susman, V. L. (1995). In Shriqui, C. L., & Nasrallah, H. A. (Eds.). Contemporary issues in the treatment of schizophrenia. pp. 551-574. Washington DC: American Psychiatric Press.

American Nurses Association (199_). Psychopharmacology guidelines for - psychiatric mental health nurses.

American Psychiatric Association (1993) . Practice guideline for major depressive disorder in adults. Washington DC: American Psychiatric Press.

American Psychiatric Association (1995). Practice guideline for treatment of patients with bipolar disorder. Washington DC: American Psychiatric Press.

Anthony, W., Cohen, M., & Farkas, M. (1990). Psychiatric rehabilitation. Boston: Center for Psychiatric Rehabilitation.

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Csernansky, J. G. Newcomer, J. G. (1995). Maintenance drug treatment for schizophrenia. In Bloom, F. E., & Kupfer, D. 1. (Eds). Psychopharmacology: The Fourth Generation of Progress. New York: Raven Press, pp. 1267-1276.

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Marder, S.R. & Meibach, R.C. (1995a). Risperidone in the treatment of schizophrenia. American Journal of Psychiatry, 151, 825-835.

Marder, S.R., & Van Putten, T. (1995b). Antipsychotic medications. In Schatzberg, A.F., & Nemeroff, C.B. (Eds.). The American Psychiatric Press Textbook of Psychopharmacology, pp. 247-262. Washington DC: American Psychiatric Press.

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Schooler, N. R. (1991). Maintenance medication for schizophrenia: Strategies for dose reduction. Shchizophrenia Bulletin. 17(7L 311-324.

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Psychosocial Interventions
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Dixon, L.B., & Lehman, A.F. (1995). Family interventions for schizophrenia. Schizophrenia Bulletin, 21-631-643.

Gerhart, U.C. (1990). Caring for the chronic mentally ill, Itasca, IL: Peacock.

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Jamison, K.R., & Goodwin,, F.K. (1983). Psychotherapeutic issues in bipolar illness. In L. Grinspoon, (ed). Psychiatry Update: The APA Annual Review. (vol. 2), American Psychiatric Assoc. Press, pp. 319-337.

Harding, C. M., Brooks, G. W., Ashikaga, T., Strauss, J. S., Breier, A. (1987). The Vermont longitudinal study of persons with severe mental illness, I: Methodology, study sample and overall status 32 years later. American Journal of Psychiatry, 144 (6), 718-727.

Harding, C. M., Zubin, J., & Strauss, J. 5. (1987). Chronicity in schizophrenia: Fact,
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Hogarty, G.E., Kornblith, S.J., Greenwald, D., DiBarry, A.L., Cooley, S., Flesher, S., Reiss, D., Carter, M., and Ulrich R. (1995). Personal therapy: A disorder-relevant psychotherapy for schizophrenia. Schizophrenia Bulletin, 21, 379-393.

Kanas, N. (1986). Group therapy with schizophrenics: A review of controlled studies. International Journal of Group Psychotherapy, 36-339-351.

Kanas, N. (1993). Group psychotherapy with schizophrenia. In H.I. Kaplan & B.J. Sadock (Eds). Comprehensive group psychotherapy. (3rd ed. pp. 407-417). Baltimore, MD: Williams & Wilkins.

Kanas, N. (1993). Group psychotherapy with schizophrenia. In H.I. Kaplan & B.J. Sadock (Eds.) Comprehensive group psychotherapy. (3rd ed., pp. 407-417) Baltimore, MD: Williams & Wilkins.

Kingdon, D.G. & Turkington, D. (1994). Cognitive-behavioral therapy of schizophrenia. NY: Guilford Press.

Klerman, G.L., Weissmam, M.M, Rounsaville, B.J., & Chevron, E.S. (1984). Interpersonal psychotherapy of depression. NY: Basic Books.

Lehman, A.F. (1995). Vocational rehabilitation in schizophrenia. Schizophrenia Bulletin, 21, 645-656.

Novalis, P.N., & Rojcesicz, S.J., & Peele, R. (1993). Clinical Manual of Supportive Psychotherapy. American Psychiatric Press.

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Scott, J. E. & Dixon, L. B. (1995-a). Psychological interventions for schizophrenia. Schizophrenia Bulletin, 621-630.

Scott, J. E. & Dixon, L. B. (1995-b). Assertive community treatment and case management for schizophrenia. Schizophrenia Bulletin, 21, 657-668.

Seeman, M. V. & Greben, S. E. (1990). Qffice treatment of schizophrenia. Washington DC: American Psychiatric Press, 1990. ISBN 0-88048-191-9

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Self-help Books/Groups, Psychoeducation, and Recovery
Baer, L. (1991). Getting control Overoming your obsessions and compulsions. Boston: Little, Brown, & Co.

Bourne, E. (l990). Anxiety and phobia handbook. Oakland CA: New Harbinger.

Burns, D. D.. (1980). Feeling good. NY.: Signet Book, 1980.

Mueser, K. T., & Gingerich, S. (1994). Coping with schizophrenia. Oakland CA: New Harbinger Publications.

Spaniol, L., Koehler, M, & Hutchinson, D. (1994). The recovery workbook: Practical coping and empowerment strategies for people with psychiatric disability. Boston: Center for Psychiatric Rehabilitation.

Spaniol, L., & Koehler, M. (1995). The experience of recovery. Boston: Center for Psychiatric Rehabilitation.

Torrey, E. F. (1995). Surviving schizophrenia: A family manual. (3rd ed.) NY: Harper & Row.

Women

Bachrach, L.L., & Nadelson, C.C. (eds.) (1988). Treating chronically mentally ill women. Washington DC: American Psychiatric Association Press.

Dutton-Douglas, M.A., & Walker, L.E.A. (Eds) (1989). Feminist psychotherapies: Interaction of therapeutic and feminist systems. Norwood, NJ: Ablex.

Lin, K.M., & Poland, R.E. (1995). Ethnicity, culture, and psychopharmacology, in Bloom, F.E. & Kupfer, D.J. (Eds). Psychopharmacology: The Fourth Generation of Progress. New York Raven Press, pp. 1097-1918.

McGrath, E., Keita, G.P., Strickland, B.R., & Ruse, N.F. (1990). Women and depression: Risk factors & treatment issues. Washington DC: American Psychological Association.

Seeman, M.V., (Ed). (1995). Gender and psychopathology. Washington DC: American Psychiatric Press.

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Cross-cultural
Aponte, J.F., Rivers, R.Y., Wohl, J. (1995). Psychological Interventions and Cultural Diversity. Boston: Allyn & Bacon.

Yamamoto, J., & Lin, Keh-Ming (1995). Psychopharmacology, ethnicity, and culture. In J.M. Oldham & M.B. Riba (Eds.) American Psychiatric Press Review of Psychiatry. (Vol. 14, pp. 529-542). Washington DC: American Psychiatric Press.

Managed Care and Serious Mental Illness

Budman, S.H. (1995) New clinical challenges: Managed behavioral healthcare and the chronic psychiatric patient. Behavioral healthcare Tomorrow, 4, 49-51.

Patterson, D.Y., & Sharfstein, S.S. (1992). The future of mental health care. In J. Feldman issues. (Pp. 3335-346). Washington DC: American Psychiatric Press.

Sullivan, M.J. (1995). Medicaid's quiet revolution: Merging the public and private sectors of care. Professional Psychology: Research and Practice 26, 229-234.
 
 

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