4/29/2014. The Practice of Prescribing/Medical Psychology: Ethical Implications and Nightmare Sleep Management for PTSD. Disclaimer.

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1 The Practice of Prescribing/Medical Psychology: Ethical Implications and Nightmare Sleep Management for PTSD CDR ANTHONY TRANCHITA DIRECTOR OF PSYCHOLOGICAL HEALTH GRAND FORKS AIR FORCE BASE, NORTH DAKOTA Disclaimer The following represents the experience and recommendations of CDR Anthony Tranchita, and does not represent an official position of the United States Public Health Service or Department of Health and Human Services Bias My only funding is that of being a Public Health Service Officer. I do not have any financial bias towards any product or intervention upon which I am about to present to report. However, I did spend a great deal and time and effort to become a prescribing psychologist, and therefore will admit a personal bias towards it. I will do my best to present both sides of any argument for or against. 1

2 Thanks for Inviting Me! Why I chose this path I worked on a Native American Reservation in the Upper Midwest The closest psychiatrist was 80 miles away, and had a 45 day wait list Along with this, many people had limited transportation Regardless of how well I sold the idea at the time of referral, many people did not keep the appointment In 2009 I started course work through Alliant International University, completed my Postdoctoral Masters in 2011, and achieved Conditional Licensure Status in New Mexico in The Data to Support Lack of Access to Psychiatry, particularly at issue in rural areas Like this group needs me to tell you that PCMs are the de facto mental health system with minimal mental health training More than half of psychotropics are written by PCPs More than half of Family Medicine residences offer no training in psychopharmacology Psychologists have engaged in prescribing in a safe and effective manner 2

3 The Counter-Argument(s) Post-doctoral Master s Degrees ain t medical degrees The argument has been made that prescribing psychotropics without a medical degree is a threat to public safety If you want to practice medicine, go to medical school Identity diffusion of psychologists Education There are currently 4 Universities offering Post- Doctoral Masters in Psychopharmacology Alliant International University, San Francisco, CA This is where I did mine- Distance Learning Fairleigh-Dickinson, Madison, NJ New Mexico State University, Las Cruces, New Mexico Nova Southeastern University, Fort Lauderdale, FL The PEP Psychopharmacology Examination for Psychologists 150 multiple choice questions 3 hours Computer based at Prometric, Inc. Passing score set by State Boards 3

4 The PEP (cont) Knowledge Domains Integrating clinical psychopharmacology with the practice of psychology Neuroscience Nervous System Pathology Physiology and Pathophysiology Biopsychosocial and pharmacologic assessment and monitoring Differential Diagnosis Pharmacology Clinical Psychopharmacology Research Professional, legal, ethical, and interprofessional issues Diversity Factors Licensure/Credentialing Currently two states will license a psychologist to prescribe medication: New Mexico Louisiana Federal facilities have the ability to credential providers with outside state licenses, and in the case of the DoD, licensure may not be required However, not all do (e.g. VA and BOP do not) Multiple states have bills in varying degrees of the legal process Illinois, New Jersey, Missouri, Montana APA Division 55 American Society for the Advancement of Pharmacotherapy 4

5 Military Roots DoD Psychopharmacology Demonstration Project 10 psychologists trained to prescribe Mixed conclusions Lack of ABPP Certification There is currently no ABPP recognition of Medical/Prescribing Psychology There is Diplomate status that can be earned through the American Board of Medical Psychology Ethical Implications General Principles Beneficence and Nonmaleficence Justice Standards Boundary of competence Formulary Management of Pain, Off-label prescribing, etc Informed Consent Most people have never heard of a prescribing psychologist Cooperation with other professionals (under Human Relations) 5

6 Way Forward Those of us practicing as Prescribing/Medical Psychologists are still fringe Perhaps within states where there is licensure there are mentors programs, but many of us are making it up as we go with minimal support Military PTSD prevalence The best research we have indicates a prevalence rate of 17% of Veteran s from the military operations since 9/11 Estimates of lifetime prevalence for U.S. Population are around 8% Estimates for Vietnam-era vets is higher (some studies as high as 30%) In Calendar Years 2012 and 2013, PTSD accounted for approximately 20% of the clinical case load of the clinic where I work PTSD Treatment In our clinic, primarily we are utilizing the following psychological treatments: Prolonged Exposure Cognitive Processing Therapy Eye-Movement Desensitization and Reprocessing 6

7 PTSD Medication Treatment Standard medication treatment for PTSD is with antidepressants: Who can tell me the only medications FDA approved for PTSD treatment? This makes all other treatment choices off-label usage The impact of SSRIs and SNRIs on sleep structure can be unpredictable Side effects of both include both somnolence and insomnia Nightmare activity, and the subsequent sleep disturbance create multiple issues for those diagnosed with this condition, and our first-line agents sometimes (or often) don t help 70-80% of those diagnosed with PTSD list sleep disturbance as a symptom Use of short-acting benzodiazepines makes a member non-deployable Prazosin α 1 adrenergic antagonist Reduction in adrenergic response In general, stimulation of adrenergic receptors stimulates fight or flight responses, and shutting down higher cognitive processes (a gross overgeneralization for sure) Reduction in REM sleep Stimulation of α 1 receptors also has a role in CRH release, therefore decreasing system cortison (i.e. the stress hormone ) Original design and marketing for hypertension, and is still utilized today for that purpose Prazosin Discovery of use for nightmare prevention due to docs in VA system noticing that those treated for HTN with this medication, also had reduced PTSD symptoms, particularly nightmares Proposed action is through reduction of the adrenergic response in the locus ceruleus, hippocampus, amygdala and cerebral cortex Lipophilicity allows for crossing the Blood-Brain Barrier 7

8 Prazosin Common Side Effects Orthostatic hypotension, particularly at higher doses Fogginess or drowsiness Headache Dry Mouth Less commonly: blurred vision, nausea, vomiting, diarrhea or constipation, frequent urination, nocturnal incontinence, swelling of feet or ankles, allergic reaction Prazosin Research Review of research conducted in 2012 found 11 Studies Total of 252 patients for all studies, average duration 8 weeks Most of these studies from one research group in the Northwest 4 Open-label, 4 retrospective chart reviews, 3 placebo controlled trials Statistically and clinically significant reduction in both reported nightmare activity and non-nightmare distressed awakenings (>50% reduction reduction in individuals, effects sizes across studies greater than.8, in one study was 1.96) Hudson, S.M., Whiteside, T.E., Lorenz, R.A., Wargo, K.A. (2012) Prazosin for the Treatment of Nightmares Related to Posttraumatic Stress Disorder: A Review of the Literature, Primary Care Companion for CNS Disorders, 14 (2) Prazosin Research Average dosing 2.3 mg for elderly patients, 13.3 mg in Combat veterans Comparison to quetiapine showed better long-term effectiveness as quetiapine has a higher drop-out rate due to side effects Generally low drop out rates from tx w/prazosin In those studies that looked at BP, there were reductions in BP as expected, which for some can cause side effects, for some it meant possible improved long-term health 8

9 Local practice 19 patients 12 Deployment-related diagnosis 16 reported positive response Reduction in nightmare activity reported by all but those who discontinued for s.e. (and 1 lost to follow-up) 7 a total lack of nightmares Others a reduction of 50-75% of self-reported nightmare activity Average dose 2.4 mg Range 1-5 Local Practice 2 discontinuation due to side effects Insomnia and fogginess Headache, dizziness, and mild fogginess reported by others short-term but went away and stayed on it as it helped symptoms Questions? 9