Prescribing Psychologists in Integrated Primary Care: Introduction to the Special Section

The authority to prescribe could differentiate psychologists from other non-physicians in primary care, achieving a significant step for the growth of our profession. Psychologists are currently prescribing in primary care settings in a number of public service venues, as well as medical school training facilities. In this Special Section of the Journal of Clinical Psychology in Medical Settings, results of a survey of physicians working with a prescribing psychologist indicate that the psychologist is highly valued and seen as a competent prescriber. A series of papers providing case examples demonstrate how psychologists are evolving in these new clinical roles, as well as participating in behavioral and psychopharmacology training of primary care physicians.     

Interprofessional Education: Preparing Psychologists for Success in Integrated Primary Care

Rapidly occurring changes in the healthcare arena mean time is of the essence for psychology to formalize a strategic plan for training in primary care settings. The current article articulates factors affecting models of integrated care in Academic Health Centers (AHCs) and describes ways to identify and utilize resources at AHCs to develop interprofessional educational and clinical integrated care opportunities. The paper asserts that interprofessional educational experiences between psychology and other healthcare providers are vital to insure professionals value one another’s disciplines in health care reform endeavors, most notably the patient-centered initiatives. The paper highlights ways to create shared values and common goals between primary care providers and psychologists, which are needed for trainee internalization of integrated care precepts. A developmental perspective to training from pre-doctoral, internship and postdoctoral levels for psychologists in integrated care is described. Lastly, a call to action is given for the field to develop more opportunities for psychology trainees to receive education and training within practica, internships and postdoctoral fellowships in primary care settings to address the reality that most patients seek their mental health treatment in primary care settings.     

Behavioral Health Integration in Health Care Settings: Lessons Learned from a Pediatric Hospital Primary Care System

Behavioral health integration within primary care has been evolving, but literature traditionally focuses on smaller scale efforts. We detail how behavioral health has been integrated across a large, urban pediatric hospital system’s six primary care clinics (serving over 35,000 children annually and insured predominately through Medicaid) and discuss strategies for success in sustaining and expanding efforts to achieve effective integration of behavioral health into primary care. In a time span of 3 years, the clinics have implemented routine, universal behavioral health screening at well child visits, participated in a 15-month behavioral health screening quality improvement learning collaborative, and integrated the work of psychologists and psychiatrists. Additional work remains to be done in improving family engagement, further expanding services, and ensuring sustainability.     

The Primary Care Prescribing Psychologist Model: Medical Provider Ratings of the Safety, Impact and Utility of Prescribing Psychology in a Primary Care Setting

Family medicine providers at a large family medicine clinic were surveyed regarding their impression of the impact, utility and safety of the Primary Care Prescribing Psychologist (PCPP) model in which a prescribing psychologist is embedded in a primary care clinic. This article describes the model and provides indications of its strengths and weaknesses as reported by medical providers who have utilized the model for the past 2 years. A brief history of prescribing psychology and the challenges surrounding granting psychologists the authority to prescribe psychotropic medication is summarized. Results indicate family medicine providers agree that having a prescribing psychologist embedded in the family medicine clinic is helpful to their practice, safe for patients, convenient for providers and for patients, and improves patient care. Potential benefits of integrating prescribing psychology into primary care are considered and directions for future research are discussed.     

Aging and mental health in the decade ahead: what psychologists need to know

Until relatively recently, most psychologists have had limited professional involvement with older adults. With the baby boomers starting to turn 65 years old in 2011, sheer numbers of older adults will continue to increase. About 1 in 5 older adults has a mental disorder, such as dementia. Their needs for mental and behavioral health services are not now adequately met, and the decade ahead will require an approximate doubling of the current level of psychologists' time with older adults. Public policy in the coming decade will face tensions between cost containment and facilitation of integrated models of care. Most older adults who access mental health services do so in primary care settings, where interdisciplinary, collaborative models of care have been found to be quite effective. To meet the needs of the aging population, psychologists need to increase awareness of competencies for geropsychology practice and knowledge regarding dementia diagnosis, screening, and services. Opportunities for psychological practice are anticipated to grow in primary care, dementia and family caregiving services, decision-making-capacity evaluation, and end-of-life care. Aging is an aspect of diversity that can be integrated into psychology education across levels of training. Policy advocacy for geropsychology clinical services, education, and research remains critical. Psychologists have much to offer an aging society.     

Primary Care Prescribing Psychologists in the Indian Health Service

Some of the largest health care disparities are those related to services for American Indians and Alaska Natives (AI/ANs), who show significantly greater prevalence for diabetes, coronary heart disease, smoking, obesity, heavy alcohol use, depression, and PTSD than the general population. Given the recognition of the behavioral components of all of these conditions, the Indian Health Service, the federal agency responsible for providing comprehensive health care services to AI/ANs, has been focusing on increasing the integration of behavior health and primary care. One innovation has been to hire prescribing psychologists on primary care teams. This paper describes the role of a prescribing psychologist on three treatment teams at an IHS facility in Montana. Prescribing psychologists in the Indian Health Service can serve as valuable members of comprehensive care teams, providing exceptional wrap-around care for some of our most vulnerable and underserved citizens. This model could be an example of how a prescribing psychologist could contribute to primary care clinics in a variety of other settings.     

Teaching psychological knowledge and skills to family physicians

Psychological problems (e.g., anxiety, depression, substance abuse) are prevalent in primary care medical settings. Family physicians (FPs) treat more patients than any other primary care medical specialists. Thus, FPs can play an extremely important role in providing psychological services to their patients. In contrast to other specialists (e.g., internists, obstetricians), FPs are required to complete behavioral science training in their residencies. In this paper, we describe standard undergraduate, graduate, and postgraduate training of FPs. We present our unique program for teaching psychological principles and skills to family practice residents at the University of Kansas Medical Center. And finally, we introduce an instrument, the Interview Rating Scale (IRS), for evaluating the interviewing skills of physicians and residents.     

Cultural Considerations for Psychologists in Primary Care

Many health concerns in the United States (e.g., diabetes) are routinely managed in primary care settings. Regardless of the medical condition, patients’ health is directly influenced by factors such as healthcare providers and cultural background. Training related to how behaviors influence health, coupled with training on how cultural diversity intersects with mental health, allows psychologists to have the relevant expertise to assist in the development of primary care behavioral health interventions. However, many psychologists in primary care struggle with how to integrate a culture-centered paradigm into their roles as behavioral health providers. This paper provides an introduction on how three culture-centered concepts (providers’ cultural sensitivity, patient–provider cultural congruency, and patients’ health literacy) can be applied in primary care using the Five A’s Organizational Construct and a model of cultural competence. In addition, the paper includes a section on integration of cultural considerations into consultation and training and concludes with a discussion of how the three culture-centered concepts have implications for health equity.     

Training Primary Care Psychologists

Primary care psychology is a new area that provides exciting opportunities for the field. This paper discusses the definition of primary care and the role of psychologists in primary health care. Educational programs developed by the author for pre- and postdoctoral training in primary care psychology are described.     

Primary Care Behavioral Health Provider Training: Systematic Development and Implementation in a Large Medical System

The expansion of integrated, collaborative, behavioral health services in primary care requires a trained behavioral health workforce with specific competencies to deliver effective, evidence-informed, team-based care. Most behavioral health providers do not have training or experience working as primary care behavioral health consultants (BHCs), and require structured training to function effectively in this role. This article discusses one such training program developed to meet the needs of a large healthcare system initiating widespread implementation of the primary care behavioral health model of service delivery. It details the Department of Defense’s experience in developing its extensive BHC training program, including challenges of addressing personnel selection and hiring issues, selecting a model for training, developing and implementing a phased training curriculum, and improving the training over time to address identified gaps. Future directions for training improvements and lessons learned in a large healthcare system are discussed.     

Counselling psychology in primary health care: A review

This paper reviews the development of counselling psychology within the field of primary health care. Issues discussed include liaison between counselling psychologists and other professionals, evaluation of treatment in primary care, family therapy in general practice and general practitioners’ skills in counselling. The need for training and evaluation of counselling are discussed and suggestions are made for further research.     

Ethical Care for Vulnerable Populations Receiving Psychotropic Treatment

The increasing use of pharmacotherapy raises specific ethical concerns for psychologists working with vulnerable populations. Due to a shortage of trained specialists, professionals without training in mental health, such as primary care providers, are increasingly prescribing and monitoring psychotropic medications. Vulnerable populations (e.g., older adults, people currently low in social status, immigrants, and racial/ethnic minorities) face additional barriers to mental health treatment and are at heightened risk when these factors intersect. Hence, these patients experience unique barriers to receiving optimal psychopharmacological care and are differentially vulnerable to deleterious outcomes associated with misdiagnosis and overmedication. Taken together, these factors fuel inequities in the access, quality, and utilization of mental health care. Psychologists working with these patients are ethically mandated to protect patients from harm and ensure equitable care across patient populations. Specifically, psychologists must respond to the dilemma of how to effectively treat patients within these vulnerable populations who have been misdiagnosed or poorly medicated while remaining within the bounds of their competence. This article recommends pathways to address these dilemmas through education, training, research, and advocacy.     

The Effect of Racial and Ethnic Diversity on the Delivery of Mental Health Services in Pediatric Primary Care

The effects of racial and ethnic diversity on the detection and management of behavioral and emotional problems in pediatric primary care are addressed. Service access and utilization as a function of race and culture are initially examined. Important barriers within pediatric training including minimal emphases on behavioral training and the limited supply of minority physicians are underscored. The impact of ethnicity on the development and maintenance of the clinical relationship that is critical to accurately and sensitively identifying and managing behavioral and developmental problems is briefly addressed. Recommendations for further integration of racial/ethnic issues into mental health service provision within the pediatric primary care arena are presented.     

Pediatric–Psychology Partnership for Abuse Prevention

Intimate partner violence (IPV) is a significant, albeit underreported and underidentified, public health problem that requires the informed and coordinated efforts of the health care system for appropriate recognition and intervention. In addition, health disparities are seen in the incidence, prevalence, and burden of IPV among specific population groups in the United States. Pediatric–Psychology Partnership for Abuse Prevention is a graduate psychology education training project focused on developing an integrated primary health-care based workforce that is culturally sensitive and competent in the identification and remediation of IPV. In addition, this project aimed to increase the number of health service psychologists from diverse backgrounds who are culturally competent and aware of health disparities. The training included clinical psychology trainees and pediatric residents working together in an ambulatory pediatric health care setting. Project methods, outcomes, and implications for predoctoral clinical psychology training programs are described.