Medication and the Changing Role of the Mental Health Clinician

Behavioral health practice has changed rapidly over the last several decades. Now 57 percent of patients receive medication only, i.e. without psychotherapy, for their mental health problems, while only 10.5 percent of patients with mental health problems receive psychotherapy only. The new normal in psychotherapy practice is the patient who is receiving psychotherapy in conjunction with medication.

Our data show that non-medical psychotherapists have adapted to these changes by becoming increasingly sensitive to the psychiatric medications their patients take. Today the overwhelming majority of psychotherapists take a medication history at intake. Indeed, you could make the case that gathering medication history is a de facto standard for non-prescribing mental health clinicians. The chart below shows a big jump (>20%) in the rate that clinicians gather medication information at intake between 2005-08 and 2013:

by_year_table

We analyzed the rate at which different disciplines collect medication history at intake. The chart below shows that in 2013 psychologists were much less likely to get a medication history than social workers (89% v 73%). Counselors fall in the middle.

by_prof_table
It is impossible to know with certainty why these stark differences exist between psychologists and social workers, however, one might infer that social workers are trained more to be team players, while psychologists see themselves more as independent consultants. In fact, APA practice guidelines are scrupulously agnostic about the extent to which psychologists need to concern themselves with medications. Here are two quotations from APA publications:

“This guideline is not intended to imply any recommendation concerning the frequency of inquiry into patients’ reactions to or use of their medications, particularly in the case of psychologists who serve only in an information-providing role.”

“…they (the guidelines) are not intended to apply to those psychologists who choose not to become directly or indirectly involved in medication management…”

I would argue that clinicians of all stripes—psychologists, social workers, counselors—should expand their role in medication management for several compelling reasons:

1. Most medications are prescribed by PCPs (>80%). PCPs do not have the time to monitor medication issues including adherence. Psychotherapists, however, precisely because they see the patient more frequently and have a more intimate knowledge of the patient’s symptoms, feelings, behaviors, etc. are ideally suited to be the eyes and ears of the prescriber. Thus, they are in a position to provide valuable feedback to the prescriber about medication adherence and progress.

2. Over-and under-prescribing of psychoactive medications is the norm in the US. Americans, for instance, are prescribed three times as many antidepressants as are patients in many European countries. Some experts have opined (see Hollan) that as many as 50% of patients on antidepressants are receiving no clinical benefit whatsoever. On the other hand, almost three quarters of patients prescribed antidepressants stop taking them within three months. Other problems, e.g. ill-advised polypharmacy, are also common.

3. Medication monitoring is a behavioral integration best practice.

4. Providing medication monitoring is a great practice building tool. Sending a PCP or psychiatrist actionable information on a patient he or she has prescribed for is a great way to get their attention. Actionable information includes problems with adherence and response to medication or lack thereof. Thus, clinicians might want to employ a brief patient self-report adherence questionnaire as well as a condition-specific outcomes questionnaire (e.g. PHQ-9 for depression.)

To sum up, by becoming adept at monitoring medication adherence, behavioral clinicians can expand their practices, provide a valuable clinical service for prescribers and become more fully integrated in the healthcare team.

What’s not to like?