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NAPPP NATIONAL ALLIANCE of PROFESSIONALPSYCHOLOGICAL PROVIDERS

The Clinical Practitioner

© 2016 National Association of Professional Psychological Providers TCP Online ISSN 2373-4787This website also contains material copyrighted by 3rd parties

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June 2016Volume 11 No. 6

18 Units of Continuing EducationThe National Alliance of Professional Psychology Providers

WWW.NAPPP.ORGPresents a Three Day Continuing Education Conference

September 23rd, 24th, 25th, 2016

Theme - Psychological Interventions: Past, Present & Future

San Antonio, TexasDrury Plaza Hotel-RiverWalk

This 24-story skyscraper sits right on the banks of the RiverWalk and is the perfect ambiance for a meeting location.

Registration Information: http://nappp.org/registration.html

Hotel Information: http://nappp.org/hotel.html

Participants will earn 18 hours of CE credit hours for the full three day meeting. The registration fee covers the entire program, There are no additional fees. Continuing education units are available through NAPPP. The National Alliance of Professional Psychology Providers is an approved sponsor of continuing education by the American Psychological Association. The National Alliance of Professional Psychology Providers maintains full responsibility for this program. NAPPP is also an accredited provider of continuing education by the National Institute for Behavioral Health Quality

A Professional Association Representing the Interests of Psychology Doctors in the Health Care System 2

The Clinical PractitionerJune 2016 Vol. 11 No. 6

Contents:Conference Program Pg. 3Bill of Rights Pg. 8When a doctorate and license is not enoughby John Caccavale Pg. 9AAMP News Pg. 12Psychology Times book review Pg. 16Sleep treatment alternativesby David Reinhardt Pg. 18ADHD in young children Pg. 28Fewer mental health visits Pg. 30Online therapy effective Pg. 31Opioid analgesics Pg. 32FDA News Pg. 35Science Notes- Drugs Pg. 35Science Notes- Alternative Approaches Pg. 39 BehavioralNewsby Levon Margolin Pg. 44CE questionsBy Gary Traub Pg. 52Free CE Course List Pg. 54How to Write a Brilliant Submission(Submission Guidelines) Pg. 56

Editor-In-ChiefDavid Reinhardt Ph.D.

EditorsSharna Wood, Ph.D.Gary Traub, Ph.D.

Levon Margolin, Ph.D.Past Issues

http://nappp.org/backissues.html

SubmissionsEditor.TheClinicalPractitioner@gmail.

comNAPPP on the Web

www.NAPPP.orgNAPPP Executive Board

John Caccavale, Ph.D.Nick Cummings, Ph.D.

Jerry Morris, Psy.D.David Reinhardt, Ph.D.Howard Rubin, Ph.D.Levon Margolin, Ph.D.

Jack Wiggins, Ph.D. (Ret)

Drury Plaza Hotel San Antonio Riverwalk105 South St. Mary’s Street San Antonio, TX 78205

Telephone: (210) 270-7799

Thank you for allowing Drury Plaza Hotel San Antonio Riverwalk to be a part of your next great event! We are looking forward to seeing you soon and we are ready to uphold our reputation for great service & value. Rooms have been held for NAPPP and to make reservations, please click on the link below.

https://www.druryhotels.com/Reservations.aspx?groupno=2272105

As you might have heard, The Extras Aren’t Extra at Drury Hotels! In addition to the great rate, here are some of the amenities your group will enjoy:

FREE HOT QUIKSTART ® Breakfast – At Drury, “hot” means fresh pancakes, scrambled eggs, biscuits & gravy, sausage and more.

FREE 5:30 KICKBACK® – From 5:30-7:00 pm each evening, kick back, relax and enjoy a rotating menu of hot foods and cold beverages.

FREE Free Long Distance - One hour every room every night. FREE Wireless Internet Access – High speed Internet in all rooms and the lobby.

FREE Soda and Popcorn – From 3:00 pm to 10:00 pm every night in the lobby.

Plus much more!! Please make your reservations by Sunday, August 21, 2016 to receive your group rate. Reservations made after this date will be subject to prevailing rate and availability.

Reservations may also be made by calling 1-800-325-0720 and refer to your group number (2272105)

mailto:editor.theclinicalpractitioner%40gmail.com?subject=TCP%20Feedback

mailto:editor.theclinicalpractitioner%40gmail.com?subject=TCP%20Feedback



http://www.druryhotels.com/about_spserv.cfm


ProgramKeynote: Nicholas Cummings, Ph.D., Sc.D.- THE HISTORY OF PSYCHOTHERAPY IN AMERICA

1945 TO 2016: THE GOLDEN ERA,THE FALTERING AGE, AND THE STALLED PRESENT.

PresentationsSusan Barngrover, Ph.D., ABMP -TRANSFORMING WOMEN’S HEALTH: FROM SYMPTOM REDUCTION TO INTEGRATIVE CARE.

Joan L. Biever, Ph.D & Bernadette H. Solorzano, Ph.D. - Using Client Feedback to Improve Therapy Outcomes.

John Caccavale, Ph.D., ABMP - THE FUTURE OF PSYCHOTHERAPY

Susana A Galle, Ph.D., MSCP, ABMP - GUT MICROBES AND THE PSYCHE? A bridge needed for best practices

Kasi Howard, Ph.D. - THE USE OF CES (CRANIAL ELECTROTHERAPY STIMULATION) IN CONJUNCTION WITH OTHER THERAPIES TO TREAT ANXIETY AND DEPRESSION

Ward Lawson, Ph.D, ABMP - NEUROPLASTICITY, PSYCHOLOGICAL DISORDERS AND COMPREHENSIVE TREATMENT

Samantha Miller, Ph.D. - PARENT CHILD INTERACTION THERAPY & CHILD MALTREATMENT.

Nori Mora, Ed.D. - SOCIAL SKILLS AS PSYCHOLOGICAL INTERVENTION

Jerry Morris, Psy.D., ABMP - THE OPIATE EPIDEMIC: THE STATE OF THE DATA & NATIONALPLAN/REACTION, NEW GUIDELINES, ENHANCEMENT OF ADDICTION SERVICES

Keith Petrosky, Ph.D.- A PARADIGM CHANGE IN INTEGRATED HEALTH CARE DELIVERY: ELIMINATING THE CONCEPR OF PATIENT NON-COMPLIANCE.

David Reinhardt, Ph.D., ABMP & Jorge Carrillo, Ph.D. - FUNCTIONAL PSYCHOLOGY? WHAT IS THAT?

Cal Robinson, Ph.D. - MINDFULNESS BASED CHRONIC PAIN MANAGEMENT.

Shiv Shankar, Pharm.D. - BRIEF MINDFULNESS BASED COGNITIVE BEHAVIORAL THERAPY TO IMPROVE ADHERENCE IN BIPOLAR DISORDER TO PREVENT RELAPSE.

WorkShopsRobert North, MD, Ph.D. - PHARMAGENOMICS: APPLIED GENETICS, THE CYTOCHROME P450 METABOLIC SYSTEM, PERTINENT GENETIC CLINICAL RESEARCH AND CASE HISTORIES.

Marlin Moore, Ph.D. - SUCCESSFUL PTSD TREATMENT USING A PROLONGED EXPOSURE (PE) BATTLEFIELD VARIANT


PresentersJohn Caccavale, Ph.D., MSCP, ABMPDr. Caccavale is a California licensed clinical an neuropsychologist and is the executive director of NAPPP. He is a diplomate of the American Board of Medical Psychology. Dr. Caccavale is a long time advocate for the advancement of clinical and medical psychology and its inclusion into primary behavioral healthcare. Dr. Caccavale serves on a number of professional boards including the National Institute of Behavioral Health Quality, the American Board of Behavioral Health Practice, the Lifestyle Medicine Foundation. He has published numerous articles, book chapters and book reviews on a wide array of subjects. His book, “Medical Psychology Practice and Policy Perspectives,” was published in 2013. In recent years, he has confined his writings to the current issues facing the profession. Dr. Caccavale is the 2011 recipient of the Cummings Foundation PSYCHE Award.

Jorge Carrillo, Ph.D.Dr. Carrillo received his undergraduate degree from La Salle University in Philosophy and Theology (Bogota, Colombia). He is a licensed psychologist, director and co-founder of of Houston Autism Center where he applies the principles of functional medicine in his work with developmentally delayed children. He is an international presenter speaking on biomedical intervention with children in the autistic spectrum. He is board certified in Psychopharmacology, Serious Mental Illness, and Children and Adolescents by the International College of Prescribing Psychologists. He has post graduate trining in Functional Diagnostic Nutrition and is a licensed sex offender treatment Provider.

Nicholas A. Cummings, Ph.D., Sc.D.Dr. Cummings is a psychologist who has been predicting the course of psychology for the past 50 years, and has innovated steps to enhance the profession along the way. In the 1950s he wrote the first comprehensive prepaid psychotherapy insurance benefit and through his medical cost offset research convinced third party payors to include psychotherapy as a covered benefit. His pioneering “intermittent, focused psychotherapy throughout the life cycle” is the way most psychologists practice today. He was active with the Dirty Dozen for 30 years, founded the professional school movement through the four campuses of the California School of Professional Psychology, created the nation’s only psychology-driven national healthcare company which grew to 25 million covered lives and in which psychiatric/medical directors reported to psychologists, and a host of other innovations too numerous to mention. He served as President of the APA, has six honorary doctorates, and holds every honor the profession can bestow, including the Gold Medal. He is President of the Cummings Foundation for Behavioral Health, Distinguished Professor at the University of Nevada, Reno, and is Founding Chair of CareIntegra. Dr. Cummings is a founding member of NAPPP and serves on the executive board.

Susan Barngrover, Ph.D., ABMP Dr. Barngrover is a licensed psychologist and board certified medical psychologist with over 30 years of clinical experience treating a myriad of complex cases. She embraces an integrative care model for developing and restoring health to individuals and their families. Formerly the Executive and Clinical Director of a rural community mental health center, she currently is in solo practice outside Kansas City where she consults with physicians and hospitals. Advocating for psychologists scope of practice, she is a member of NAPPP and AMP and currently serves on the Board of Directors of the Academy of Medical Psychologists.

Susana A. Galle, Ph.D., M.S.C.P., A.B.M.P.Dr. Galle spans three and a half decades of practice. She is a clinical and neuro-psychologist, psychopharmacologist, and neuroscientist. An AMP Diplomate, she holds a prescription license in New Mexico. Dr. Galle is Board Certified in Traditional Naturopath (ND, CTN), Clinical Nutritionist (CCN), Classical Homeopath (CCH), and Phlebotomist (NHA). She is a Registered Yoga Teacher (RYT 500) and Therapist (PRYT). She holds advanced certifications in Clinical Hypnosis (ASCH), Biofeedback (BCIA/EEG), and Forensic Neuropsychology (DABFE). She is a Functional Medicine practitioner (IFM). Multi-cultural and multilingual, serving a global clientele. She emphasizes function and systems rather than diagnosis per se. An alumna of U.


C. Berkeley, Yale, and Alliant, Dr. Galle’s pre-doctoral internship at U. C. Medical Center, S. Fco. was in Medical Psychology. She obtained her postgrad Dipl. in Homeopathic Medicine (DHM) from the British Institute of Homeopathy (BIH), and was winner of the 2004 Hahnemann Award.

Kasi Howard, Ph.D.Dr. Howard is a Texas native and Baylor graduate who moved to San Antonio in 2009 for her Pre-Doctoral Internship. After many years of working with at-risk and adjudicated youth, she began her transition to specialize in eating disorders and substance abuse. Dr. Howard has been intensively trained in Dialectical Behavior Therapy (DBT) and Interpersonal Therapy. She has developed several group curricula, including a seminar designed to promote a healthy body image in young females and an educational support group for spouses and significant others of those who suffer from mental illness. Dr. Howard served as MAL-Early Career Representative and President of the Bexar County Psychological Association. She has also taught at Trinity University and is passionate about promoting the field of psychology.

Ward Lawson, Ph.D., ABMP, ABPPDr. Lawson has been licensed as a psychologist in Missouri for 25 years and a neuropsychologist, completed a fellowship in forensic psychology, and is APA certified in the treatment of substance use disorders. He is board certified in Medical Psychology, is President of the Academy of Medical Psychology, and the Journal Manager of the Academy of Medical Psychology’s peer-reviewed journal, The Archives of Medical Psychology. He has ABPP status in Family Psychology and has served on the American Board of Couples and Family Psychology. From 1996 to 1998, he served on the MoPA board as Treasurer and on the Insurance and Managed Care Committee and the RxP Taskforce. He has published in The Archives of Medical Psychology, The Clinical Practitioner, Alcoholism Quarterly, and Acta Psychological. Dr. Lawson owns Tri-County Psychological Services, Inc., consisting of psychologists and licensed clinical social workers and counselors. Dr. Lawson has owned a Rural Health Clinic and is the founder and Director of a not-for-profit Tri-County Adult Day Care.

Dr. Samantha Miller,Ph.D. Dr. Miller is a Clinical Psychologist licensed in the States of Texas and in New York. Dr. Miller has expertise in providing clinical services and comprehensive diagnostic evaluations to children and adolescents, as well as providing behavioral parent training and family therapy. Dr. Miller specializes in cognitive behavioral therapy (CBT), including: Parent Child Interaction Therapy (PCIT; Within- Program Trainer), Teacher Child Interaction Training (TCIT), Dialectical Behavior Therapy (DBT; Intensively Trained), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; NCTSN certification), Rational Emotive Therapy (REBT; AEI advanced certificate), Multi-Systemic & Trauma Systems Therapy (MST & TST), Motivational Interviewing (MI), and exposure plus response prevention (E/RP).Dr. Miller consults with outpatient mental health programs, day treatment hospitals, and therapeutic school settings on implementing evidence-based treatments and behavior management strategies.

Marlin Moore, Ph.D. Dr. Moore is a TX licensed Psychologist, currently employed by the West Texas VA Health Care System. He earned his doctorate in Clinical Psychology at Memphis State University in 1991. He is an experienced educator and trainer, with over a dozen publications and invited presentations. Lieutenant Colonel Moore retired from the Air Force in July 2014, after serving 25 years on Active Duty. He was lauded by a 30-year AAAHC Inspector for the “best managed and most comprehensive” Outpatient Mental Health program seen to date, primarily due to his success in implementing same-day access for intakes and for reducing barriers to care. In addition to completing a post-doc in Health Psychology (1993-4), he served nearly six years in overseas, operationally-oriented assignments (i.e., Turkey, South Korea and Afghanistan). Dr. Moore is a Certified DoD SERE (Survival, Evasion, Resistance and Escape) Psychologist, and specializes in the treatment of psychophysiological disorders. While deployed to Afghanistan in 2008, he developed an abbreviated protocol (i.e., a “Battlefield Variant”) for Prolonged Exposure treatment of PTSD and ACR. Now, at the VA, he continues to refine this protocol, which has demonstrated robust and sustained efficacy among outpatient and inpatient populations of civilian and military patients. Workshop participants will review case examples, receive access to all my treatment materials, observe a live demonstration, then practice using the protocol. PE experience is helpful, but not required.


Nori Cuellar Mora, Ed. D.Dr. Nori Cuellar Mora received her Ed.D. in Educational Leadership and has been in education over 25 years as she worked as a high school English teacher, special education director and a principal in rural South Texas, Premont ISD, and in an urban school in Dallas ISD. She obtained a second masters in psychology to receive her license to practice in schools as a Licensed Specialist in School Psychology (LSSP). Because of her 12-year educational background experience, she believed she could bring educational credibility to her psycho-educational assessments of children ages 3-21. Dr. Mora has presented at state and national conferences and is a professor for Walden University teaching and chairing doctoral students.

Jerry Morris, Psy.D., ABMP, ABBPDr. Morris is a clinical psychologist who is also board certified in Medical Psychology, Family Psychology, School Psychology, Case Management, and holds the APA National College of Psychology Certification in the Treatment of Alcohol and other Psychoactive Substance Abuse. He is the author of books and numerous scientific and professional papers in the area of psychology, management, and economics. Dr. Morris is the President and Clinical Director of CMHC, Inc. Nevada MO, a comprehensive community mental health center serving Western Missouri. He has developed and owned psychiatric hospitals and other healthcare facilities. He has served as graduate and undergraduate faculty in psychology, economics, and management. Dr. Morris is on the board of directors of the ABPP Couples and Family Board, the ABMP Medical Psychology Board, and he has served on APA Council, and Rural and Finance Committees, and was the Division 42 Hospital and Healthcare Facilities Committee Chair for 11 years. He is the past president of the Academy of medical Psychology. Dr. Morris was President of the Missouri Psychological Association and served on the board for 8 years. He owns and operates a healthcare management consulting business, Morris & Morris, Inc. and serves as a CMS facilities monitor and consultant to Government and private healthcare facilities.

David Reinhardt, Ph.D., MSCP, ABMPDr. Reinhardt is the managing editor of NAPPP’s newsletter, The Clinical Practitioner. He is Board certified in Medical Psychology and has degrees in business Administration as well as his Ph.D. in Clinical Psychology and a post-doctoral Masters of Psychopharmacology from Alliant/CSCP. Dr. Reinhardt is a research scientist, with extensive research on nutrients in mental health and mental health symptoms in physical disorders. In addition to his NAPPP affiliations, he holds memberships in the International Society of Orthomollecular Medicine, the Orthomollecular Health-Medicine Society, the American Society of Clinical Hypnosis, and the Institute of Functional Medicine. Dr. Reinhardt is founder and Director of the Mental Health and Wellness Center, a hospital and skilled nursing focused practice in Southern California, and the Center for Health Science, a behavioral healthcare center in Orange County, California.

Robert North, Ph.D., MDDr. Robert North completed his doctoral degree in Psychology and Human Development from George Peabody College of Vanderbilt University in 1980. He completed postdoctoral training in medical psychology from The Psychopharmacology Institute in 2000. In 2004, he completed a doctor of medicine degree(M.D.) from The International University of Health Sciences in St. Kitts, a British Commonwealth WHO-approved medical school. He is approved to sit for the U.S. medical boards. Dr. North has been involved with the psychology prescription privilege movement since helping introduce legislation in 1998 (and many times since) in Tennessee and has served on TPA, APA, and various National committees and organizations toward this endeavor, including presenting to legislative hearings to explain and promote passage of bills. Dr. North has been in private since 1985 and owns a large group geropsychology practice, Medical Psychology Consultants, LLC that presently provides services in 48 intermediate care facilities in Tennessee and Kentucky.

Keith Petrosky, Ph.D.Dr. Petrosky, is in full time private practice in the Main Line Philadelphia suburb of Exton, seeing adults, children, couples, and families. He does behavioral health interventions for patients with medical issues, pre-surgical evaluations, and some disability work. He has run a lifestyle change group for heart attack patients undergoing


cardiac rehab for many years. He developed a number of hospital based programs such as an “integrative health and healing” program offered at a regional cancer center as well as an anxiety management program for patients scheduled for surgical procedures. He has consulted to hospitals on pain management, burn injury adjustment, and stress management. He was a member of an inpatient physical medicine and rehab unit for many years, including work in the outpatient back pain center. He also treated several thousand headache patients when working with a neurologist and physical therapist in a very busy private practice group.

Cal Robinson, Psy.D., MSCP, ABMPDr. Robinson currently is a medical psychologist at Orthopaedic and Spine Center in Newport News, Virginia, working with assessment and treatment of chronic pain patients. He has worked in behavioral medicine and chronic pain services for thirty years and is now establishing in the United States the MBCPM (Mindfulness Based Chronic Pain Management) program for chronic pain patients, which integrates mindfulness training for chronic pain. This is a Canadian based program with OSC being the first American organization to provide the service, a 13 week group program.

Sharna Wood, Ph.D.Dr. Wood is the current program chair for NAPPP and the San Antonio meeting. She is a tireless psychologist and has worked in public hospital, clinic and private practice settings for over 10 years. She is on the executive board for a geriatric psychiatric hospital group in east Texas, operates two physical locations and conducts specialized evaluations all over Texas. She has worked closely with several test publishers in gathering data for new and improving older test instruments such as the WAIS-IV, WMS-IV and NEPSY2. She was also a finalist for the National Academy of Neuropsychology Outstanding Dissertation Award for her research in geriatric neuropsychology. Dr. Wood is an associate editor of The Clinical Practitioner and a member of the advisory board of NAPPP..


NAPPP’s Bill of Rights for Practitioners

Preamble

All psychologists, in any stage of professional development, have the right to advocacy and support from a national organization that is dedicated solely to the interests of psychological practitioners and the people who receive our services.

All Practicing Psychologists have the right:

1. To be respected and valued as professionals reflective of the highest accomplishments and responsibilities for which we have trained.

2. To practice only under standards that are consistent with those of the profession.

3. To receive the same level of federal and state investment in training as physicians.

4. To receive financial compensation consistent with our professional training and activities.

5. To be protected from discriminatory treatment with respect to financial compensation or career advancement;

6. To receive continuing education that is relevant and of value to our patients and practice.

This includes credit for continuing education in practice development and related business of running a practice.

All Practicing Psychologists have the right:

1. To be allowed to practice to the full extent of our training and education.

2. To practice under state laws under which only psychologists are permitted to provide psychological services.

3. To practice under state laws that clearly identify the scope of practice and responsibilities of psychologists in contrast to non-psychologists and other healthcare disciplines.

4. To be subject to licensure by a state board dedicated to psychology regulation whose members consist of psychologists in the majority and who practice and provide psychological services.

5. To be treated fairly in hearings and to be judged by our peers in matters of complaint brought to the state licensing board.

6. To receive reciprocity as licensees where the salient elements of licensure are similar across state lines.

7. To practice under state laws that define title protection for psychologists.

8. To protect the privacy and confidentiality of the relationship with our patients subject to specified ethical and legal exceptions.

A Professional Association Representing the Interests of Psychology Doctors in the Health Care System9

When A Doctorate and License Is Not EnoughBy John Caccavale. Ph.D.

It’s an old idiom as well as a verse from an early

Bob Dylan song yet it still accurately describes

where behavioral health is going. The integration of

behavioral health into primary care clearly is a done

deal.

The Affordable Care Act mandates the integration

of behavioral health into primary care settings. The

on-going goal is for healthcare to comprise behavioral

health and medical professionals under the same

roof. It will not be instantaneous and smooth but

it will happen. The question is: Will it happen with

psychologists or will mental health be provided by

others?

The Solo Practice Model Is Unsustainable

Clinical psychology, although many are loath to admit

it, is a product of early psychoanalysis that still directs

how we practice. The majority of psychologists not

employed in clinics or in the relatively few group

practices, are solo practitioners.

For example, many continue to defend the 50-minute

hour as if it were written in the 10 Commandments

or the Talmud. Some cannot accept that positive

change can occur in even a 15-minute burst of insight.

The notion of a behavioral healthcare consultant is

abhorrent to others. Group therapy becoming a major

part of practice? Forget about it. Yet, as healthcare

has been evolving, many psychologists lounge in our

past rejecting anything that we think threatens our

traditional way of practice.

Because of this, we have lost ground to other

professions. Now we either make an assessment of

where we are and address the new order or become

irrelevant. It seems that for a profession whose very

foundation lies in change through self-discovery,

some of us appear to be the least insightful and most

resistant to change. Now, however, change is being

dictated to us.

The Accountable Care Model

This model envisions having several professionals,

ideally in the same location, providing behavioral,

medical, educational, and social services to patients.

This concept has taken such hold that significant

monetary incentives have been written into the ACA.

How this affects psychologists is clear. With the

emphasis on group practice and integrated services,

solo practice is more difficult to sustain and remain

competitive. The industrial model of healthcare gives

rise to the Wal-Mart model -- everything under one

roof and the lowest price. Clearly, there are advantages

and disadvantages for psychologists.

The main advantage is that integrating our

services directly into primary care presents greater

opportunities than ever before. Psychologists

can become partners, both economically and

professionally, with other healthcare professionals.

The expansion of scope of practice issues will likely

receive less opposition when physicians and others see

the importance and relevance of what we do. Doctoral

level psychologists can regain the prominence that we

once had.

A major disadvantage is that we have to start thinking

and practicing differently. We must upgrade our skills

and become more integrated in our training. Group



A doctorate not enough

therapy will become the norm because of its efficiency

and demonstrated results. In fact, any therapy that is

not supported by someone’s idea of research is likely

to be looked upon with suspicion and not reimbursed.

Medical treatment will be held to the same standard.

The 50-minute hour is likely to be replaced by much

shorter contact times. Behavioral health consulting

is a means to that end. These changes, according

to the policymakers, can result in better treatment

outcomes, better efficiency, and an end to professional

fragmentation. An added bonus is that academic

and research psychologists will be forced to focus on

reliable treatment outcome research as funding for the

largely irrelevant research that now fills our journals

will dry up. Practitioners and academic psychologists

can become partners instead of where we are now. I

look forward to this type of change.

Once Again We Are Confronted with A Decision

I would like to put this as simply as I can: If

psychologists resist these changes, behavioral

healthcare will be provided within the ACOs by

master level counselors, nurse practitioners, and

other providers. Unlike with Medicare, we will not

have the time to catch up. Once other professionals

take the lead, the likelihood that psychologists will

be able to compete is, at best, problematic. Please

note: In an integrated setting, psychiatry is not our

competition. Their declining numbers and limited

skills make psychiatrists the dodo birds of healthcare.

We can demonstrate to primary care physicians that

psychologists have much greater and more relevant

skills than any other provider. Moreover, given the

choice, patients would much rather deal with a doctor

than a counselor. However, we must be the “first with

the most.” The decision that every psychologist must

make is how do we ensure physicians and the public

that we are the premier providers of behavioral health

care?

Specialty Skills Providers

Presently, psychologists have been placed in an

untenuous position. Third parties, desiring to increase

profits, have blurred the distinction between a doctoral

level provider and lesser trained professionals. For

them, all we do is talk so why not pay the talker with

the lowest rate based on the lowest educational level.

However, in my opinion, we share the blame for our

current situation. We have many opportunities to

demonstrate our superior skills and treatment success.

In a competitive environment, psychologists must

demonstrate skills as behavioral healthcare providers.

There is a continual need to show objective proof that

we are certified as behavioral healthcare practitioners.

Simply having a degree and license as a clinical

psychologist obviously is not enough as our present

situation shows.

NAPPP, along with other groups, has developed

specialty certifications in behavioral healthcare

practice for psychologists and further accreditation

for our practices. Only doctoral level psychologists

qualify for these certifications. These programs were

developed out of necessity and a response to the new

environment. These are not vanity certifications and

anyone who reads what is required will see this. The

standards and requirements for board certification in

Behavioral Health Practice can be reviewed at http://

www.abbhp.org/ Practice accreditation standards and

requirements can be reviewed at http://www.nibhq.

org./

On the other hand, psychologists can become board

certified in Medical Psychology. This specialty goes

way beyond any certification in health psychology and

http://www.abbhp.org/


http://www.nibhq.org./

http://www.nibhq.org./


A doctorate not enough

is designed for the professional psychologist whose

focus is more on applying specific psychological

techniques to the host of medical illnesses found in

primary care. This certification also has the added

benefit of psychopharmacological training. To view

the requirements and standards for board verification

in Medical Psychology, please go to http://www.

amphome.org/. NAPPP also offers professional

certificate programs in Primary Care Psychology and

Clinical Psychopharmacology, which can be reviewed

on the NAPPP website.

All of these programs are specifically designed

for clinical psychologists to demonstrate clinical

superiority over every other mental health

professional. They are obtainable and clearly will place

psychologists in a position that indicates to physicians

and the public that they do not have to settle on less

when considering treatment for their patients. But, as

another old idiom states: You can only lead a horse to

water but you cannot force them to drink.

NAPPP is having a CE training conference

in San Antonio, September 23rd through

September 25th. The program focuses on

providing psychologists with the information

and skills to succeed in the environment we are

addressing. To read or download the program

and presenter biographies go to http://nappp.

org/pdf/program.pdf. The program consists

of 14 presentations and two specialized

workshops. Our goal is to provide practitioners

with every opportunity to receive up-to-date

training. Please plan to join us.

http://www.amphome.org/

http://www.amphome.org/

http://nappp.org/pdf/program.pdf.

http://nappp.org/pdf/program.pdf.


What’s being said...by the American Academy of Medical PsychologyA Letter to the Substance Abuse and Mental Health Services Administration


Sleep Treatment AlternativesBy David Reinhardt, Ph.D.

I’ve reported on many of the physical causes of psychological distress in past issues of The Clinical Practitioner. In this and coming issues I will present specific solutions based on healthcare science from a variety of perspectives.

The International Classification of Sleep Disorders (ICSD)8 lists 88 sleep-related disorders. Although insomnia affects everyone occasionally, about one out of every three adults indicates it is a significant problem, and 50% of these persons consider it to be severe.1 Sleep is vital to maintaining healthy mood and cognitive function. Inadequate sleep has been linked to anxiety, lack of motivation, irritability, depression, lack of concentration, attention deficits, distractibility, ADHD, reduced vigilance, slowed reaction times, fatigue, restlessness, forgetfulness, high blood pressure, obesity, diabetes, fibromyalgia, chronic fatigue, reduced quality of life, occupational injury, automobile injury, and relationship disruption.2

Psychological treatments for sleep including sleep hygiene, CBT, hypnosis and other techniques for sleep issues are generally well accepted and effective although underutilized in the healthcare field, whereas physical contributors to insomnia are often overlooked.

Causes and Science of Sleep Issues

Insomnia can be caused by psychological and medical conditions, unhealthy sleep habits, specific substances, and/or certain biological factors. Medical conditions that can cause insomnia include arthritis, cancer, heart failure, lung disease, gastroesophageal reflux disease (GERD), overactive thyroid, stroke, Parkinson’s disease and Alzheimer’s disease.

Many prescription drugs can interfere with sleep, including many antidepressants, heart and blood pressure medications, allergy medications, pain medications, stimulants (such as Ritalin), and

corticosteroids. Many over-the-counter (OTC) medications — including some pain medication combinations, decongestants and weight-loss products — contain caffeine and other stimulants.

Sleep apnea is being increasingly recognized as causing sleep disturbance. With sleep apnea, a person’s airway becomes partially or completely obstructed during sleep, leading to pauses in breathing and a drop in oxygen levels. This causes a person to wake up briefly but repeatedly throughout the night.

Sleep disturbance can also be caused by stress, anxiety, depression, changes in the environment or work schedule, poor sleep habits, eating too late in the evening, and by caffeine, nicotine and alcohol (which prevents deeper stages of sleep and often causes awakening in the middle of the night.)

Endocrine issues have a pronounced effect on sleep. The hypothalamic–pituitary–thyroid axis (HPT axis) regulates sleep in multiple ways, and a growing body of research suggests reciprocal associations between sleep and the activity of the HPA axis. Dysfunctional HPA axis activity may play a role in some sleep disorders, but in other cases the HPA axis dysfunction is actually the result of a sleep disorder, as seen in obstructive sleep apnea. HPA axis hyperactivity can lead to fragmentation of sleep,

decreased slow-wave sleep, and shortened sleep time. Both insomnia and obstructive sleep apnea are specific sleep disorders that are associated with HPA dysfunction.” 3

Cortisol, produced in the adrenal glands, follows a natural cycle of rising in the AM and peaking about 8 AM. Cortisol levels decline over the day and into the night, reaching lows between midnight and 4 AM. Cortisol functions to increase blood sugar through gluconeogenesis, to suppress the immune system, to aid in the metabolism of fat, protein, and carbohydrates, and to decrease bone formation. 4

a growing body of research

suggests reciprocal associations

between sleep and the activity of the

HPA axis.


Sleep treatment alternatives

Cortisol is known as the stress hormone. It is released in response to stress (the fight or flight response) and low blood glucose. Prolonged stress promotes hypercortisolism, chronic elevation of cortisol which may lead to Cushing’s syndrome. Signs and symptoms may include: high blood pressure, abdominal obesity but with thin arms and legs, reddish stretch marks, a round red face, a fat lump between the shoulders, weak muscles, weak bones, acne, and fragile skin that heals poorly. Women may have more hair and irregular menstruation. Occasionally there may be changes in mood, headaches, and a chronic feeling of tiredness.

Long term cortisol elevation may tax the adrenal glands, leading to adrenal exhaustion or fatigue (terms most often used by naturopaths and functional medicine specialists.) When the adrenal glands become inactive or fail to produce sufficient amounts of cortisol, primary hypoadrenalism, or Addison’s disease may result. Undiagnosed Addison’s sufferers often seek out psychologists for treatment of insomnia, anxiety, depression and exhaustion.

The terms “adrenal fatigue” and “adrenal exhaustion” are not recognized by most allopathic physicians, although Addison’s disease, the end point of prolonged hypercortisolism, is. Treatment for Addison’s under the allopathic model include oral corticosteroids (Cortef), replacement aldosterone (fludrocortisone) or corticosteroid injections. Corticosteroids may have significant adverse effects, including: • Elevated pressure in the eyes

(glaucoma)• Fluid retention, causing swelling in your lower legs• High blood pressure• Problems with mood, memory, behavior and other

psychological effects• Weight gain, with fat deposits in your abdomen,

face and the back of your neck• Long term use may result in:• Clouding of the lens in one or both eyes (cataracts)• High blood sugar, which can trigger or worsen

diabetes

• Increased risk of infections• Thinning bones (osteoporosis) and fractures• Suppressed adrenal gland hormone production• Thin skin, bruising and slower wound healing.5

Allopathic Medicines

Sleep issues are typically treated by allopaths by symptom suppression, specifically with CNS depressants including benzodiazepines and their near relatives, such as zolpidem (Ambien®). These chemicals have been shown to decrease the number of wakenings and increase total sleep time when used over a one-week period.6 Benzodiazapines increase the latency of REM sleep and significantly decrease the percentage of REM sleep. They typically increase theta wave sleep percentage at the expense of deep, delta wave sleep.7

These chemicals are GABA-A agonists, binding to the GABA-A receptor, with the effect of slowing the activity of other neurotransmitters, significantly impacting cognitive performance and motor performance and respiratory depression and causing a variety of abnormal thinking and behavior changes. These chemicals are highly addictive, with serious withdrawal effects. Although “first line treatment” for sleep impairment, these chemicals are nearly always tried prior to sleep studies to for apnea; they can reduce oxygen saturation to below 80%,8 making them an odd choice for

insomnia prior to a thorough investigation of causes for chronic sleep deprivation.

Sleep Studies

Sleep studies (polysomnograms), done at specific centers, have come into the consciousness of allopathic medicine. Stanford University established the first sleep center in 1970. In 1993, a congressional study found “a startling lack of information about sleep disorders among general practitioners. This lack



of information has resulted in misdiagnoses and mistreatments of patients estimated in the millions, very often in cases where a little knowledge and the right treatment might have worked wonders.”9

A sleep study usually requires spending a night or two in a sleep facility. During a polysomnogram, a sleep technologist records multiple biological functions during sleep, such as brain wave activity, eye movement, muscle tone, heart rhythm and breathing via electrodes and monitors placed on the head, chest and legs. Depending on outcome, patients may be prescribed a medication, oxygen or a device called continuous positive airway pressure therapy, or CPAP.10

Functional Medicine

Functional medicine approaches to sleep issues are based on gaining understanding the root cause of sleep disturbance, with reliance on sleep science and specific nutritional supplements. After ruling out less complex causes, sleep studies are commonly prescribed. The possibility of adrenal dysfunction is taken seriously by functional medicine specialists, who seek to treat dysfunction before it becomes “disease.” A diurinal cortisol saliva panel may be ordered to look for abnormalities in the cortisol cycle. This reliable test is typically not reimbursed by insurances, although they will pay for the equivalent four lab blood draws over 24 hours.

Common to all holistic sleep approaches are sleep hygiene training and relaxation therapies such as meditation, self-hypnosis and progressive relaxation. Nutrient supplementation therapy may be utilized to address metabolic causes. One or more herbal supplements may be utilized for symptomatic treatment.

Sleep Hygiene

Sleep hygiene refers to a variety of practices used to maintain a regular wake and sleep pattern. The American Sleep Association recommends the following approaches:

• Maintain a regular sleep routine. Go to bed at the same time. Wake up at the same time. Ideally, your schedule will remain the same (+/- 20 minutes)

every night of the week.

• Avoid naps if possible. Naps decrease the ‘Sleep Debt’ that is so necessary for easy sleep onset. Each of us needs a certain amount of sleep per 24-hour period. We need that amount, and we don’t need more than that. When we take naps, it decreases the amount of sleep that we need the next night – which may cause sleep fragmentation and difficulty initiating sleep, and may lead to insomnia.

• Don’t stay in bed awake for more than 5-10 minutes. If you find your mind racing, or worrying about not being able to sleep during the middle of the night, get out of bed, and sit in a chair in the dark. Allow your mind to race in the chair until you are sleepy, then return to bed. No TV or internet during these periods! That will just stimulate you more than desired. If this happens several times during the night, that is OK. Just maintain your regular wake time, and try to avoid naps.

• Don’t watch TV or read in bed. When you watch TV or read in bed, you associate the bed with wakefulness. The bed is reserved for two things – sleep and hanky-panky.

• Do not drink caffeine inappropriately. The effects of caffeine may last for several hours after ingestion. Caffeine can fragment sleep, and cause difficulty initiating sleep. If you drink caffeine, use it only before noon. Remember that soda and tea contain caffeine as well.

• Avoid inappropriate substances that interfere with sleep. Cigarettes, alcohol, and over-the-counter medications may cause fragmented sleep.

• Exercise regularly. Exercise before 2 PM every day. Exercise promotes continuous sleep.

• Avoid rigorous exercise before bedtime. Rigorous exercise circulates endorphins into the body which may cause difficulty initiating sleep.

• Have a quiet, comfortable bedroom. Set your bedroom thermostat at a comfortable temperature. Generally, a little cooler is better than a little warmer.

• Turn off the TV and other extraneous noise that may disrupt sleep. Background ‘white noise’ like a fan is OK.



• If your pets awaken you, keep them outside the bedroom.

• Your bedroom should be dark. Turn off bright lights.

• Have a comfortable mattress.

• If you are a ‘clock watcher’ at night, hide the clock.

• Have a comfortable pre-bedtime routine such as a warm bath, shower, meditation, or quiet time.11

Recent research has found that use of smart phones, e-Readers, video games and computers before bed prolongs the time it takes to fall asleep, delays the circadian clock, suppresses levels of melatonin, reduces the amount and delays the timing of REM sleep, and reduces alertness the following morning.12 Evening use of light-emitting e-Readers negatively affects sleep, circadian timing, and next-morning alertness. This is thought to be caused at least partially by the light from these screens which is shifted toward the blue end of the visual spectrum.

TV watching seems to be especially disruptive to sleep. Nursing home residents in my practice always have a TV available for night time watching. TV requires visual as well as auditory processing to follow dialog (try listening with your eyes closed!) I’ve found replacing the TV with a radio to substantially decrease sleep problems, even if patients listen to “talk radio.”

A light snack before bed may help patients sleep through the night without wakening. Peaks and troughs in blood sugar are thought by many to cause nighttime wakening. The hormones ghrelin (a hunger stimulator) and leptin (a satiation signal), have been associated associated with sleep issues, particularly so in those with diabetes and prediabetes.13 A bedtime snack should be low in sugar, with a reasonable balance of protein and complex carbohydrates. Many nutritionists consider half of a meat or high protein source sandwich to be ideal.

Orthomolecular Medicine

Orthomolecular treatments for sleep focus on replenishing nutrients (vitamins, minerals and amino acids) which may have been depleted by stress, medications or illness. It may take up to 6 weeks for nutrients to be replenished at the cellular level.

Naturally occurring substances are used to assist in the short term. Patients are urged to consider lifestyle and diet choices, and to utilize psychological techniques such as CBT, sleep hygiene, hypnosis, and progressive relaxation.

Magnesium: Magnesium deficiency is well established as a factor in insomnia.14 According to the USDA, magnesium deficiency occurs in over 2/3 of the adult population. Risk of magnesium deficiency is increased for those with GI disorders, type 2 diabetes, alcohol dependence, those that take proton pump inhibitors and older adults. It is related to migraine headaches and osteoporosis. Absorption of magnesium from different kinds of magnesium supplements varies. Forms of magnesium that dissolve well in liquid are more completely absorbed in the gut than less soluble forms. Studies have found that magnesium in the aspartate, citrate, lactate, and chloride forms is absorbed more completely and is more bioavailable than magnesium oxide and magnesium sulfate.

One study found that very high doses of zinc from supplements (142 mg/day) can interfere with magnesium absorption and disrupt the magnesium balance in the body.15 Magnesium has nearly the same molecular weight and the same electrical valence as calcium, which is over consumed in the American diet. Excretion of excess calcium by the kidneys may cause magnesium to be removed, making those who take calcium supplements a high risk for magnesium deficiency.

Individual needs for magnesium vary depending on stress levels, diet, medication use and individual genetics, and magnesium levels in tissues are not easily testable. I recommend adults start at 400-600 mg of magnesium in the evening to maximize absorption.

L-Theanine: L-Theanine is an amino acid that is not common in the diet, and is contained almost exclusively in tea (Camellia sinensis). L-theanine, at realistic dietary levels, has a significant effect on the general state of mental alertness or arousal. It increases activity in the alpha frequency band on an EEG, which indicates that it relaxes the mind without inducing drowsiness.16 Theanine has a chemical structure very similar to glutamate, a naturally occurring amino acid in the body that helps transmit nerve impulses in the brain. Some of the effects of theanine appear to be similar to glutamate, and some effects seem to block glutamate. People use theanine



for treating anxiety and high blood pressure, for preventing Alzheimer’s disease, and for making cancer drugs more effective.17

5-hydroxytryptophan (5-HTP): 5-HTP is an intermediate between tryptophan and serotonin in the serotonin cycle. Supplementation with 5-HTP is thought to increase serotonin and in turn its metabolite melatonin. It is used for sleep disorders such as insomnia, depression, anxiety, migraine and tension-type headaches, fibromyalgia, obesity, premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), attention deficit-hyperactivity disorder (ADHD), seizure disorder, and Parkinson’s disease.18

Melatonin: Melatonin is a natural hormone made by the pineal gland. During the day the pineal is inactive. When the sun goes down and darkness occurs, the pineal is “turned on” by the SCN and begins to actively produce melatonin, which is released into the blood. Usually, this occurs around 9 pm. As a result, melatonin levels in the blood rise sharply, which reduces alertness. Melatonin levels in the blood stay elevated for about 12 hours - all through the night - falling at dawn and reaching low daytime levels by about 9 am. 19

Supplemental melatonin was quickly adopted by natural health practitioners, and in recent years is gaining wider acceptance by allopaths, who most commonly prescribe it for “sundowning” dementia patients.

People use melatonin to adjust the body’s internal clock. It is used for jet lag, for adjusting sleep-wake cycles in people whose daily work schedule changes (shift-work disorder), and for helping blind people establish a day and night cycle. Melatonin is also used for the inability to fall asleep (insomnia); delayed sleep phase syndrome (DSPS); rapid eye movement sleep behavior disorder (RBD); insomnia associated with attention deficit-hyperactivity disorder (ADHD); insomnia due to certain high blood pressure medications called beta-blockers; and sleep problems in children with developmental disorders including autism, cerebral palsy, and intellectual disabilities. It is also used as a sleep aid after discontinuing the use of benzodiazepine drugs and to reduce the side effects of stopping smoking. 20

Commonly, 2 mg to 5 mg of melatonin one hour

before bedtime for up to 29 weeks has been used to treat sleeplessness. Many users report immediate results, although it may take 5 days or more for full effectiveness.

Herbology

Western herbalists often recommend the supplements listed above. In addition, they may recommend:

Valerian: Clinical trials have demonstrated that valerian not only improves the quality of sleep but also reduces the time needed to achieve sleep. Valerian root is traditionally used as a sedative, antiseptic, anticonvulsant, migraine treatment, and pain reliever.21 A perennial flowering plant native to Europe and parts of Asia, valerian root extract has been used for sleep since ancient times. It was recommended by Hippocrates. Like chemical approaches, valerian is thought to work primarily as a GABA receptor agonist, although few adverse events attributable to valerian have been reported.22 Valerian has been used extensively in Europe. The European health authorities list no contraindications for use and valerian is not physiologically addictive. The U.S. Food and Drug Administration also identifies valerian on its list of foods “Generally Recognized as Safe,” or GRAS. research suggests that valerian does not relieve insomnia as fast as “sleeping pills.” Continuous use for several days, even up to four weeks, may be needed before an effect is noticeable. Valerian seems to improve the sleep quality of people who are withdrawing from the use of sleeping pills.

As a natural, unregulated product, the concentration, contents, and presence of contaminants in valerian preparations cannot be easily determined. Because of this uncertainty and the potential for cytotoxicity in the fetus and hepatotoxicity in the mother, the product should be avoided during pregnancy.

Lemon Balm: “Lemon balm (Melissa officinalis), a member of the mint family, is considered a calming herb. It was used as far back as the Middle Ages to reduce stress and anxiety, promote sleep, improve appetite, and ease pain and discomfort from indigestion (including gas and bloating, as well as colic). Even before the Middle Ages, lemon balm was steeped in wine to lift the spirits, help heal wounds, and treat venomous insect bites and stings. Today,



lemon balm is often combined with other calming, soothing herbs, such as valerian, chamomile and hops, to promote relaxation. It is also used in creams to treat cold sores (oral herpes).”23

High doses of purified lemon balm extracts were found to be effective in the amelioration of laboratory-induced stress in human subjects, producing “significantly increased self-ratings of calmness and reduced self-ratings of alertness.” The authors further report a “significant increase in the speed of mathematical processing, with no reduction in accuracy” following the administration of a 300-mg dose of extract.24

Lemon balm extract was identified as a potent in vitro inhibitor of GABA transaminase, which explains anxiolytic effects. The major compound responsible for GABA transaminase inhibition activity in lemon balm was then found to be rosmarinic acid.25

Lemon balm is known to inhibit TSH from attaching to TSH receptors and should not be used by those who have symptoms of hypothyroid. It is being studied as a much safer treatment for hyperthyroidism than Tapazole®.

Passion Flower: Passiflora incarnata is a vine native to South America. Extracts of its above ground parts are used extensively in Europe for reducing anxiety and sleeplessness. In initial study in 2001 for treatment of generalized anxiety disorder, passion flower extract performed as well as oxazepam but with fewer short-term side effects.26

Passion flower is used for sleep problems (insomnia), gastrointestinal (GI) upset related to anxiety or nervousness, generalized anxiety disorder (GAD), and relieving symptoms related to narcotic drug withdrawal. It is also used for seizures, hysteria, asthma, symptoms of menopause, attention deficit-hyperactivity disorder (ADHD), nervousness and excitability, palpitations, irregular heartbeat, high blood pressure, fibromyalgia, and pain relief. Some people apply passionflower to the skin for hemorrhoids, burns, and pain and swelling (inflammation). In foods and beverages, passionflower extract is used as a flavoring.

Chamomile: Chamomile is a member of the daisy family Asteraceae, used to treat hay fever, inflammation, muscle spasm, menstrual disorders,

insomnia, ulcers, upset stomach, gas, and diarrhea, and hemorrhoids. It is also used topically for skin conditions and for mouth ulcers resulting from cancer treatment. Matricaria recutita, German chamomile, is the most studied species. A study by University of Pennsylvania researchers found that chamomile significantly reduces the symptoms of generalized anxiety disorder.27 Many clinical studies have shown no effects of the herb for those suffering with chronic insomnia. Chamomile may indirectly promote sleep by increasing mental calmness.

Kava Kava: Kava (Piper methysticum), comes from indigenous cultures in the Western Pacific, who have used the roots of this shrub in intoxicating beverages for centuries. Pharmacodynamic effects of Kava include: potentiation of GABA-A receptor activity, inhibition of the reuptake of norepinephrine and possibly also of dopamine, agonism of the CB1 receptor, inhibition of voltage-gated sodium channels and voltage-gated calcium channels and monoamine oxidase B reversible inhibition. 28 Kava is known for having a sleep inducing effect and is good for common restlessness and more serious insomnia. researchers have speculated that kava extracts may be an effective alternative to tricyclic antidepressants and benzodiazepines for the treatment of anxiety disorders.29

In 2001, concerns were raised about the safety of kava, which led to restrictions and regulations in several countries. According to a recent comprehensive review of the relevant literature by Showman et al. (2014): “Despite the link to kava and liver toxicity demonstrated in vivo and in vitro, in the history of Western kava use, toxicity is still considered relatively rare. Only a fraction of the handful of cases reviewed for liver toxicity could be, with any certainty, linked to kava consumption and most of those involved the coingestion of other medications/supplements. That means that the incident rate of liver toxicity due to kava is one in 60-125 million patients.”30 Adverse interactions with drugs have been documented, both prescription and nonprescription – including, but not limited to, anticonvulsants, alcohol, anxiolytics (CNS depressants such as benzodiazepines), antipsychotics, levodopa, diuretics, and drugs metabolized by CYP450 in the liver. 31

Hops: The Hop (Humulus Lupulus) is a native British plant related to stinging nettles. Hops is used for



anxiety, inability to sleep (insomnia) and other sleep disorders, restlessness, tension, excitability, attention deficit-hyperactivity disorder (ADHD), nervousness, and irritability. It is also used to improve appetite, increase urine flow, start the flow of breast milk, as a bitter tonic, and for indigestion. Other uses include prostate cancer, breast cancer, ovarian cancer, high cholesterol, tuberculosis, bladder infections, intestinal cramps, an intestinal disorder called mucous colitis, nerve pain, and prolonged painful erection of the penis (priapism). Hops is sometimes applied to the skin for leg ulcers and as an antibacterial agent.32 A 2012 study found: “The concentration of 2 mg of hop extract effectively decreased nocturnal activity in the circadian activity rhythm. On the basis of this investigation, administration of non-alcoholic beer would be recommended due to its hop content and consequent sedative action, which would be an aid to nocturnal sleep.”33 This research shows a combination of hops extract (120 mg) and valerian extract (500 mg) may help to improve sleep, and decrease the time it takes to fall asleep.

Ayurveda

In Ayurveda, health is defined as the dynamic state of balance between mind, body, and environment. Three mind-body types, or doshas, Vata, Pitta and Kapha, describe unique blends of physical, emotional, and mental characteristics. A vibrant and joyful state of health relies on

a person identifying their dominant dosha and living a lifestyle and diet compatible with it. A normally functioning Kapha provides a healthy sleep, while different types of insomnia may cause increased Vata and reduced Kapha. Vata is increased and may cause insomnia in disorders such as hyperthyroidism, rheumatoid arthritis, restless leg syndrome (RLS), premenstrual syndrome (PMS) and menopause. Improper diet, malnutrition, chronic exhaustion and degenerative diseases reduce Kapha, again resulting in disturbed sleep.

Three qualities of mind are also involved in a healthy balance and restful sleep: Animal, Raja and Tama. Tama is essential for healthy sleep, while Raja is responsible for an interrupted sleep and early waking. In most patients, insomnia is a symptom of a systemic or psychological imbalance. In about one half of diagnosed cases of insomnia, anxiety, rage, envy, and stress increase Raja, which in turn leads to poor sleep.

Vata and Kapha and Raja are increased with indigestion, heartburn, frequent urination, pain, unhygienic place to sleep, loud noises, bright lighting, disturbances of the circadian rhythm by night work, late parties, jet lag, and other stressors, leading to insomnia. The treatment of insomnia consists of calming the Vata Dosha and Raja and restoring the normal balance of Kapha and Tama.34

Ayurvedic treatment of insomnia emphasizes adjustment of diet to balance the doshas. Each nutrient is claimed to have a specific influence. In the case of insomnia, it is important to eat foods that promote the Tama and Kapha (especially at night) and avoid food that promotes Vata and Raja.

Yoga and breath therapy may be used to calm a hyperactive mind. Alternate Nostril Breathing is said to control Vata and calm a hyperactive mind. Along with breathing, postures and sequences (vinyasas) are used to gently and rhythmically balance Vata. Yoga Nidra is a systematic form of guided relaxation that has been found to reduce tension and anxiety. 35

Ayurvedic practitioners may utilize many of the same herbs as Western naturopaths, including valerian (known as tagar in Hindi) and chamomile. Specific Ayurvedic herbs for balance and sleep may include:

Ashwagandha: An “adaptogen” used to help the body cope with daily stress, and as a general tonic. Limited studies have found that ashwagandha contains chemicals that might help calm the brain, reduce swelling (inflammation), lower blood pressure, and alter the immune system. It may be helpful with blood sugar control, elevated cholesterol and arthritis.

Brahmi: (Bacopa monniera) This herb is used to treat Alzheimer’s disease, improve memory, reduce anxiety, and treat attention deficit-hyperactivity disorder (ADHD), allergic conditions, irritable bowel syndrome, and as a general tonic to fight stress.

Jatamansi: (Nardostachys jatamansi ) An herb used to combat the effects of day-to-day stress. Jatamansi is said to enhance the body’s innate ability to sleep well. It is considered a divine plant in Ayurveda and has traditionally been used as an air purifier. The Charaka Samhita recommends it highly for insomnia, mental instability and to enhance memory. It is said to promote growth and maintain the color of hair. It is said to be especially useful in calming the aggressive



conduct of hyperactive and otherwise disturbed children.

Traditional Chinese Medicine (TCM)

From the TCM viewpoint, insomnia is a manifestation of a Shen (spirit) disorder; various internal disharmonies making the spirit restless and create sleeping problems. According to TCM experience, difficulty in falling asleep means the body has accumulated heat or fire pathogens; restless sleep means the body has both pathogen accumulation and certain aspects of deficiency; easily arousal from sleep and difficulty falling back to sleep are simply deficiency usually seen in a weakened spleen and heart. When associated with signs like abdominal distension, gastric discomfort, belching and lack of appetite, the insomnia is usually due to spleen and stomach disorders. Heart disorders may also appear with symptoms such as dream-disturbed sleep, dizziness, headache and forgetfulness; frequent fearful awakening, timidity, irritability and sighing are associated with disorders in the liver and gallbladder.36

Many methods have been used historically in Traditional Chinese Medicine to treat insomnia including herbal remedies, acupuncture, Chinese massage, and qi gong. Acupuncture has been shown to be quite effective in treating insomnia as well as stress related sleeping issues such as difficulty falling asleep, unable to stay asleep for prolonged periods of time and having an overactive mind during the night. Through a complex series of signals to the brain, acupuncture increases the amount of certain substances in the brain, such as serotonin, which promote relaxation and sleep. 37

TCM practitioners treat sleep issues with herbal formulas specific to the individual’s symptoms, with emphasis on restoring balance. For example, sleeplessness related to overactivity of the thyroid is treated with a formula specifically designed to correct the thyroid imbalance. Insomnia related to depression is addressed in TCM as symptoms of stagnation of phlegm, qi, blood and food. Insomnia due to restlessness, stress and anxiety is seen as Shen (spirit) disturbance with Liver fire. Insomnia due to fatigue with stress and an overactive mind with difficulty falling or staying asleep is seen as Liver qi stagnation and qi deficiency.

Chinese herbs that promote sleep include Fu Ling

(Poria), Suan Zao Ren (Semen Zizyphi Spinosae), Long Yan Rou (Arillus Longan), and Yuan Zhi (Radix Polygalae). Wu Wei Zi (Fructus Schisandrae Chinensis has such uses as a general tonic, a nervous system regulator, gastrointestinal therapy, an adaptogen and others. Xie Cao (Radix et Rhizoma Valerianae) also has a wide range of functions, including but not limited to antispasmodic and sedative/hypnotic properties. Chai Hu (Radix Bupleuri) and Xiang Fu (Rhizoma Cyperi) are used to regulate qi circulation and relieve Liver qi stagnation. Gou Teng (Ramulus Uncariae cum Uncis) calms Liver yang, Deng Xin Cao (Medulla Junci) sedates Heart fire, and Zhi Mu (Radix Anemarrhenae) clears deficiency fire. These three herbs treat the excess aspects of Shen disturbance and relieve irritability.

TCM treatment is based on correcting imbalances, rather than on using substances to suppress symptoms. They are very effective but typically take a few days to nourish the underlying deficiency and restore normal sleep. Evergreen Herb Co. offers four traditional formulas that have been updated to reflect recent research:

Calm (ES)® is used to treat insomnia caused by restlessness, stress, anxiety. This formula is said to calm Shen (spirit) disturbance with Liver fire. It is used with insomnia with disturbed sleep and night awakenings.

Schisandra ZZZ® is used with excessive worries and dreams, fatigue, pensiveness, and poor appetite. This formula is designed to calm Shen disturbance due to Spleen and Heart deficiencies.

Thyrodex® is used for sleep disturbance due to hyperthyroidism. It calms Shen disturbance with qi and phlegm stagnation.

Shine® is used for depression caused insomnia. It addresses stagnation of phlegm, qi, blood and food.

Calm ZZZ® is used for fatigue with stress and an overactive mind, with difficulty falling or staying asleep. It is used for Liver qi stagnation and qi deficiency. Calm ZZZ is especially helpful for those with a sense of urgency without the body strength and constitution to cope with their stress.

A note about natural treatments

Herbal treatments do not isolate a single chemical compound from an herb proven to be effective



or a particular issue, but rather treat using the whole substance. Herbology is a step between pharmaceuticals and nutritional treatment. Herbal treatments are much less concentrated and take much higher doses. Adverse effects are quite rare.

Counterfeiting of pharmaceuticals is quite common, and counterfeiting of herbal supplements has been reported to be even more common. Basic nutrients such as minerals and synthetically produced vitamins and amino acids are generally reliable, even from on-line suppliers. I am wary of herbal supplements from health food stores, vitamin shops and e-tailers.

Life Extension Foundation (LEF) does extensive ingredient testing and I trust their products as being pure and well researched. Some LEF products may be found in large health food stores.

TCM practitioners have a long history of using bulk herbs in their practice and are familiar with the look, taste and smell of specific herbs, making counterfeiting very unlikely. Encapsulated, dried decoctions of herbs and herbal formulas are a recent improvement in dosing.

I use and recommend Evergreen Herbs for Chinese herbs and formulas. Evergreen is a professional-only line of both traditional and modern Chinese formulas that incorporate current research. Evergreen tests all of their products for authenticity and purity. I have arranged with Evergreen to supply their products to our professionals through my office and website CenterforhealthScience.com (CHS), and will consult with our readers at no charge to help pick the right formula for your patients. Healthcare professionals will receive 10% off retail by entering the code NAPPP10 during check out. Please call me at 714-886-9026 for help registering as a professional provider and for help selecting Evergreen products.

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regulation and function of mammalian melatonin receptors. Europe PMC Plus, EuropePMC.org

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21. http://www.livestrong.com/article/321310-the-use-of-valerian-root-to-relieve-stress

22. Questions and Answers About Valerian for Insomnia and Other Sleep Disorders. Office of Dietary Supplements. National Institutes of Health. 2006-04-13. Retrieved 2007-04-11

23. University of Maryland Medical Center Complementary and Alternative Medicine Guide

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25. Awad, Rosalie; Muhammad, Asim; Durst, Tony; Trudeau, Vance L.; Arnason, John T. (2009). “Bioassay-guided fractionation of lemon balm (Melissa officinalis L.) using an in vitro measure of GABA transaminase activity”. Phytotherapy Research 23 (8): 1075–81.

26. Passionflower in the treatment of generalized anxiety: a pilot double-blind randomized controlled trial with oxazepam. Journal of Clinical Pharmacy and Therapeutics 26 (5): 363–367. October 2001.

27. Amsterdam JD, Yimei L, Soeller I, et al. A randomized, double-blind, placebo-controlled trial of oral Matricaria recutita (chamomile) extract therapy for generalized anxiety disorder. Journal of Clinical Psychopharmacology. 2009 ; 29(4):378–382.

28. Singh YN, Singh NN (2002). “Therapeutic potential of kava in the treatment of anxiety disorders”. CNS Drugs 16 (11): 731–43.

29. Volz HP, Kieser M (1997). “Kava-kava extract WS 1490 versus placebo in anxiety disorders--a randomized placebo-controlled 25-week outpatient trial”. Pharmacopsychiatry 30: 1–5.

30. Showman; et al. (2014). “Contemporary Pacific and Western perspectives on `awa (Piper methysticum) toxicology.”. Filoterapia 100: 56–67.

31. University of Maryland Medical Center (2011).

“Kava Kava”.

32. Web MD retrieved 5/18/16

33. Acta Physiol Hung. 2012 Jun;99(2):133-9. doi: 10.1556/APhysiol.99.2012.2.6.

34. Insomnia: an Ayurvedic perspective. Het Ayurveda Instituut. http://www.ayurvedainstituut.com/en/insomnie-ayurvedisch-perspectief

35. Ayurvedic Treatment For Insomnia, www.ayurveda-foryou.com

36. http://www.shen-nong.com/eng/lifestyles/tcmrole_sleep_treatment.html

37. Acupuncture for Treatment of Insomnia: A Systematic Review of Randomized Controlled Trials. J Altern Complement Med. 2009 Nov; 15(11): 1171–1186.

Board certification for healthcare providers

American Board of Behavioral Healthcare Practice

Board certification by ABBHP is an indication to both

patients and providers that you are a specialist in

providing behavioral healthcare diagnoses and treat-

ments. Our board certification, the first of its kind,

tells the public and your referral sources that you are a

specialist and partner in the primary care of patients.

See our website to find out if you qualify

http://abbhp.org/

http://www.abbhp.org


What others are saying...From the CDC

ADHD in Young Children

Attention-deficit/hyperactivity disorder (ADHD)

is a biological disorder that causes hyperactivity,

impulsiveness, and attention problems. Parents do

not cause ADHD, but parents can play a key role in

treatment. Behavior therapy is an effective treatment

that improves ADHD symptoms without the side

effects of medicine. It is an important first step for

young children with ADHD and most effective when

delivered by parents. With the support of healthcare

providers and therapists, parents can learn specific

ways to improve their child’s behavior and keep their

relationships strong. Clinical guidelines for ADHD

treatment recommend that healthcare providers first

refer parents of young children for training in behavior

therapy before prescribing ADHD medicine. However,

more young children are taking medicine for ADHD

than receiving psychological services, which may

include behavior therapy. Most families will benefit

from behavior therapy and there are instances where

medicine may be appropriate. Healthcare providers and

families can work together to make sure children with

ADHD are receiving the most appropriate treatment.

The recommended first treatment for young

children with ADHD is underused.

The American Academy of Pediatrics recommends

healthcare providers first refer parents of young

children with ADHD for training in behavior therapy

before trying medicine.

With the support of healthcare providers and therapists,

parents can become trained in behavior therapy.

Behavior therapy can work as well as medicine. Both

behavior therapy and medicine work for about 70-

80% of young children with ADHD. However, only

about 40-50% of young children with ADHD received

psychological services.* This percentage has not

increased over time.

ADHD medicine can cause side effects, such as poor

appetite, stomach aches, irritability, sleep problems,

and slowed growth. The long-term effects of ADHD

medicine on young children are not known.

Behavior therapy can take more time, effort, and

resources than medicine and can be longer lasting.

Parents may need support in accessing behavior

therapy in their area

Healthcare providers and parents may not be aware

of the recommendations for and benefits of behavior

therapy for young children with ADHD.

It may be difficult to find therapists who train parents

in behavior therapy in some areas of the country. Visit

this page for more help: http://www.cdc.gov/ncbddd/

adhd/finding-therapy.html.

Healthcare providers and parents can work together to

make sure young children with ADHD are receiving the

most appropriate treatment. Topics they can discuss:

• Age of the child

• Side effects

• Urgency of need

• Duration of benefits

• Cost and other resources

• Availability and accessibility

• Family preferences



ADHD in Young Children

Refer parents of young children with ADHD for training

in behavior therapy before prescribing medicine.

Steps for healthcare providers

• Assess a young child with ADHD symptoms using

clinical practice guidelines.*

• Talk with parents about ADHD treatment and explain

the benefits of behavior therapy.

• Improved behavior, self-control, and self-esteem for

children.

• Better relationships and reduced stress for families.

• Benefits are lifelong for children and families.

Refer parents to a therapist before prescribing

medicine.** Find a therapist who:

• Teaches parents to better manage their child’s behavior

and strengthen parent-child relationship.

• Encourages parents to practice between sessions,

regularly monitors progress, and adjusts strategies as

needed.

Follow up with the family during and after treatment to

confirm progress.

What parents can expect in behavior therapy

With the support of healthcare providers and therapists,

parents can learn skills to help improve their child’s

behavior, leading to improved functioning at school,

home and in relationships. Parents typically attend 8

or more sessions with a therapist. Sessions may involve

groups or individual families. Learning and practicing

behavior therapy requires time and effort, but it has

lasting benefits for the child.

The therapist meets regularly with the family to monitor

progress and provide on-going support. Between

sessions, parents practice using the skills they’ve

learned from the therapist.

After therapy ends, families continue to experience

improved behavior and reduced stress.

For more information about behavior therapy, go to:

http://www.cdc.gov/ncbddd/adhd/behavior-therapy.

html.

What parents learn when trained in behavior therapy

Parents learn positive communication, positive

reinforcement, and structure and discipline.

*Clinical practice guidelines for primary care: http://

bit.ly/1nCUenn; Clinical practice guidelines for child

psychiatry: http://bit.ly/1UYugZ8

**In areas where behavioral treatments proven to work

are not available, the healthcare provider should weigh

the risks of starting medicine at an early age against

the harm of delaying diagnosis and treatment, as

recommended in the American Academy of Pediatrics

practice guidelines.

Vital Signs, CDC http://www.cdc.gov/vitalsigns/adhd/

index.html


What others are saying...From the CDCAccess to Care Among Adults Aged 18–64 With Serious

Psychological Distress: Early Release of Estimates from the National Health Interview Survey, 2012–September 2015

Medscape News Summary: A survey from the Centers

for Disease Control and Prevention (CDC) has turned

up a seeming paradox: More people with mental health

problems have gained insurance coverage, but the

percentage visiting mental health professionals has

dropped off.

The new data raise the question of whether more of

these patients are taking their troubles to primary

care physicians instead...Increased access to insurance

coverage did not translate into more crowded waiting

rooms for psychiatrists, psychologists, licensed

counselors, and other mental health professionals. The

percentage of adults with SPD who reported seeing

a mental health professional during the previous 12

months decreased from 41.8% to 34.2% during the

study period.

The findings appear in a report issued yesterday by the

CDC’s National Center for Health Statistics (NCHS).

From 2012 to September 2015, estimates of access to

and utilization of health care services have changed

among adults aged 18–64, including those with SPD.

One of these changes was a significant shift in coverage

(1). The percentage of adults with SPD who were

uninsured at the time of interview decreased from 2012

to the first 9 months of 2015, with a corresponding

increase in private coverage. For those with SPD, the

percentage with public coverage remained relatively

constant over this time period. Adults without SPD

also saw a decrease in the percentage uninsured, with

corresponding increases in percentages with private and

public coverage. This gain of health insurance may be

important, for it can facilitate the use of health services

by improving a patient’s ability to afford care (9).

Although adults with SPD had an increase in coverage,

there was no significant change in the percentage who

had a usual place to go for medical care at the time of

interview, or who had seen or talked to a health care

professional in the past 12 months. There was a decrease

in the percentage of adults with SPD who had seen or

talked to a mental health professional in the past 12

months. ..

Many measures associated with not receiving or

delaying services due to cost declined for those with

and without SPD between 2012 and the first 9 months

of 2015. In the first 9 months of 2015, adults with SPD

were significantly less likely to have needed mental

health care in the past 12 months but not receive it due

to cost compared with 2012. In addition, the ability to

afford necessary medical care significantly improved

over this time period, for both those with and without

SPD. Ability to afford prescription drugs also improved

over this time period for both groups.

Despite these improvements, disparities still remain.

In the first 9 months of 2015, 12.3% of adults without

SPD were uninsured compared with 19.5% of those

with SPD. At the same time, 6.1% of adults without SPD

reported being unable to pay for needed medical care in

the past 12 months, while the percentage was 4 times

higher (24.4%) among adults with SPD.

http://www.cdc.gov/nchs/data/nhis/earlyrelease/er_

spd_access_2015_f_auer.pdf



What others are saying...From University of Pittsburgh Schools of the Health SciencesOnline therapy effective at treating depression and anxiety

Doctors from the University of Pittsburgh showed that

providing an online computerized cognitive behavioral

therapy (CCBT) program both alone and in combination

with Internet Support Groups (ISG) is a more effective

treatment for anxiety and depression than doctors’ usual

primary care. The preliminary findings were highlighted

today at the annual meeting of the Society of General

Internal Medicine (SGIM) in Hollywood, Florida.

The National Institutes of Mental Health-funded

randomized trial, led by Bruce L. Rollman, M.D.,

M.P.H., professor of medicine and director of the

Center for Behavioral Health and Smart Technology at

the University of Pittsburgh, enrolled 704 depressed

and anxious patients from 26 UPMC-affiliated primary

care offices across western Pennsylvania.

Patients 18 to 75 years old were referred into the trial

by their UPMC primary care physician between August

2012 and September 2014. Eligible and consenting

patients were then randomized to one of three groups:

care manager-guided access to the eight-session Beating

the Blues CCBT program; care manager-guided access to

both the CCBT program and a password-protected ISG

patients could access 24/7 via smartphone or desktop

computer; or usual behavioral health care from their

primary care physician.

Over the six-month intervention, 83 percent of patients

randomized to CCBT started the program, and they

completed an average of 5.3 sessions. Seventy-seven

percent of patients assigned to the ISG logged into the

site at least once, and 46 percent provided one or more

posts or comments.

Six months later, those patients randomized to CCBT

reported significant improvements in their mood and

anxiety symptoms and the more CCBT sessions patients

completed, the greater the improvement in mood and

anxiety symptoms.

Although patients randomized to both CCBT and ISG

had similar overall improvements in mood and anxiety

symptoms compared to patients randomized to only

CCBT, secondary analysis revealed those who engaged

more with the ISG tended to experience greater

improvements in symptoms.

Several CCBT programs have proven as effective as face-

to-face cognitive behavioral therapy at treating mood

and anxiety disorders and are used by many patients

outside the U.S., but CCBT remains largely unknown

and underutilized within the U.S., Dr. Rollman said. ISG

that enable individuals with similar conditions to access

and exchange self-help information and emotional

support have proliferated in recent years, but benefits

have yet to be established in randomized trials.

“Our study findings have important implications for

transforming the way mental health care is delivered,”

Dr. Rollman said. “Providing depressed and anxious

patients with access to these emerging technologies

may be an ideal method to deliver effective mental

health treatment, especially to those who live in areas

with limited access to care resources or who have

transportation difficulties or work/home obligations

that make in-person counseling difficult to obtain. We

hope that these findings will focus further attention

on the emerging field of e-mental health by other U.S.

investigators.”

May 12, 2016

Ed: What is “usual primary care?”



What others are saying...From the FDAEXTENDED-RELEASE AND LONG-ACTING OPIOID ANALGESICS RISK EVALUATION AND MITIGATION

STRATEGY

Introduction for the FDA Blueprint for

Prescriber Education for Extended-Release and

Long-Acting Opioid Analgesics

In April 2011, FDA announced the elements of a

Risk Evaluation and Mitigation Strategy (REMS) to

ensure that the benefits of extended-release and long-

acting (ER/LA) opioid analgesics outweigh the risks.

The REMS supports national efforts to address the

prescription drug abuse epidemic.

As part of the REMS, all ER/LA opioid analgesic

companies must provide:

• Education for prescribers of these medications,

which will be provided through accredited continuing

education (CE) activities supported by independent

educational grants from ER/LA opioid analgesic

companies.

• Information that prescribers can use when counseling

patients about the risks and benefits of ER/LA opioid

analgesic use.

FDA developed core messages to be communicated to

prescribers in the Blueprint for Prescriber Education

(FDA Blueprint), published the draft FDA Blueprint for

public comment, and considered the public comments

when finalizing the FDA Blueprint. This final FDA

Blueprint contains the core educational messages. It is

approved as part of the ER/LA Opioid Analgesic REMS

and will remain posted on the FDA website for use by

CE providers to develop the actual CE activity. A list of

all REMS-compliant CE activities that are supported

by independent educational grants from the ER/LA

opioid analgesic companies to accredited CE providers

will be posted at www.ER-LA-opioidREMS.com as that

information becomes available.

The CE activities provided under the FDA Blueprint

will focus on the safe prescribing of ER/LA opioid

analgesics and consist of a core content of about three

hours. The content is directed to prescribers of ER/LA

opioid analgesics, but also may be relevant for other

healthcare professionals (e.g., pharmacists). The course

work is not intended to be exhaustive nor a substitute

for a more comprehensive pain management course.

Accrediting bodies and CE providers will ensure

that the CE activities developed under this REMS

will be in compliance with the standards for CE of

the Accreditation Council for Continuing Medical

Education (ACCME) 1,2 or another CE accrediting body

as appropriate to the prescribers’ medical specialty or

healthcare profession.

For additional information from FDA, including more

detailed Questions and Answers about the REMS for ER/

LA Opioid Analgesics, see http://www.fda.gov/Drugs/

DrugSafety/InformationbyDrugClass/ucm163647.htm.

Health care professionals who prescribe ER/LA opioid

analgesics have a responsibility to help ensure the

safe and effective use of these drug products. ER/LA

opioid analgesics should be prescribed only by health

care professionals who are knowledgeable in the use of

potent opioids for the management of pain.

The expected results of the prescriber education in this

REMS are that the prescribers will:



Opioid analgesics

a. Understand how to assess patients for treatment with

ER/LA opioid analgesics.

b. Be familiar with how to initiate therapy, modify dose,

and discontinue use of ER/LA opioid analgesics.

c. Be knowledgeable about how to manage ongoing

therapy with ER/LA opioid analgesics.

d. Know how to counsel patients and caregivers about

the safe use of ER/LA opioid analgesics, including

proper storage and disposal.

e. Be familiar with general and product-specific drug

information concerning ER/LA opioid analgesics.

FDA http://tinyurl.com/j8x5g58

Ed: To be effective, the FDA’s to-be mandated

training should be done by those who are qualified

and knowledgeable in assessing risk abuse, titration

strategies, supplemental pain management strategies,

recognizing, documenting, and addressing aberrant

drug-related behavior, and understanding the

pharmacokinetics and pharmacodynamics of opioids

and their interactions with other meds. The FDA

emphasizes the need for clear, understandable

communication with the patient.

Medical Psychologists are the ideal candidates to run

this type of training program. Unfortunately, the

FDA will only recognize the “CE accrediting body as

appropriate to the prescribers’ medical specialty,”

blocking the cross-pollination of knowledge between

allopathic practitioners and those who actually receive

formal training in addictions, psychologists.

National Alliance of Professional

Psychology Providers

FailureTo

Serve

A White Paper on The Use of Medications As A First-Line

Treatment And Misuse In Behavioral

Interventions

This report was prepared by:The National Alliance of Professional

Psychology Providershttp://www.nappp.org/

[email protected]

The Executive Summary can be read athttp://nappp.org/Exec_summary.pdf

Read the complete report athttp://nappp.org/White_paper.pdf

http://www.nappp.org/

mailto:admin%40nappp.org?subject=White%20Paper

http://nappp.org/Exec_summary.pdf

http://nappp.org/White_paper.pdf

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FDA Notices Science Notes- Drugs

FDA Drug Safety Communication: FDA warns about new impulse-control problems associ-ated with mental health drug aripiprazole (Abilify, Abilify Maintena, Aristada)

The U.S. Food and Drug Administration (FDA) is warning that compulsive or uncontrollable urges to gamble, binge eat, shop, and have sex have been reported with the use of the antipsychotic drug aripip-razole (Abilify, Abilify Maintena, Aristada, and gener-ics). These uncontrollable urges were reported to have stopped when the medicine was discontinued or the dose was reduced. These impulse-control problems are rare, but they may result in harm to the patient and others if not recognized.

Although pathological gambling is listed as a reported side effect in the current aripiprazole drug labels, this description does not entirely reflect the nature of the impulse-control risk that we identified. In addition, we have become aware of other compulsive behaviors as-sociated with aripiprazole, such as compulsive eating, shopping, and sexual actions. These compulsive behav-iors can affect anyone who is taking the medicine. As a result, we are adding new warnings about all of these compulsive behaviors to the drug labels and the pa-tient Medication Guides for all aripiprazole products.

Health care professionals should make patients and caregivers aware of the risk of these uncontrollable urges when prescribing aripiprazole, and specifi-cally ask patients about any new or increasing urges while they are being treated with aripiprazole. Closely monitor for new or worsening uncontrollable urges in patients at higher risk for impulse-control problems. These include those with a personal or family history of obsessive-compulsive disorder, impulse-control dis-order, bipolar disorder, impulsive personality, alcohol-ism, drug abuse, or other addictive behaviors. Consider reducing the dose or stopping the medicine if such urges develop.

FDA 5/3/16

Ed: This should make an interesting addition to the Abilify commercials!

Self-harm, Unintentional Injury, and Suicide in Bipolar Disorder During Maintenance Mood Stabilizer Treatment

Self-harm is a prominent cause of morbidity in pa-tients with bipolar disorder and is strongly associated with suicide. There is evolving evidence that lithium use may reduce suicidal behavior, in addition to concerns that the use of anticonvulsants may increase self-harm. Information is limited about the effects of antipsychotics when used as mood stabilizer treat-ment. Rates of unintentional injury are poorly defined in bipolar disorder, and understanding drug associa-tions with this outcome may shed light on mechanisms for lithium’s potential antisuicidal properties through reduction in impulsive aggression.

To compare rates of self-harm, unintentional injury, and suicide in patients with bipolar disorder who were prescribed lithium, valproate sodium, olanzapine, or quetiapine fumarate, a propensity score (PS)–ad-justed and PS-matched longitudinal cohort study was conducted in a nationally representative UK sample using electronic health records data collected between January 1, 1995, and December 31, 2013. Participants included all patients diagnosed as having bipolar dis-order who were prescribed lithium, valproate, olan-zapine, or quetiapine as maintenance mood stabilizer treatment. The primary outcome was any form of self-harm. Secondary outcomes were unintentional injury and suicide.

Of the 14,396 individuals with a diagnosis of BPD, 6671 were included in the cohort, with 2148 prescribed lithium, 1670 prescribed valproate, 1477 prescribed olanzapine, and 1376 prescribed quetiapine as main-tenance mood stabilizer treatment. Self-harm rates were lower in patients prescribed lithium (205; 95% CI, 175-241 per 10,000 person-years at risk [PYAR]) compared with those prescribed valproate (392; 95% CI, 334-460 per 10?000 PYAR), olanzapine (409; 95% CI, 345-483 per 10?000 PYAR), or quetiapine (582; 95% CI, 489-692 per 10?000 PYAR). This associa-tion was maintained after PS adjustment (hazard ratio [HR], 1.40; 95% CI, 1.12-1.74 for valproate, olanzapine, or quetiapine vs lithium) and PS matching (HR, 1.51; 95% CI, 1.21-1.88). After PS adjustment, unintentional injury rates were lower for lithium compared with valproate (HR, 1.32; 95% CI, 1.10-1.58) and quetiap-ine (HR, 1.34; 95% CI, 1.07-1.69) but not olanzapine. The suicide rate in the cohort was 14 (95% CI, 9-21)


Science Notes- Drugs

per 10,000 PYAR. Although this rate was lower in the lithium group than for other treatments, there were too few events to allow accurate estimates.

Conclusions: Patients taking lithium had reduced self-harm and unintentional injury rates. This finding augments limited trial and smaller observational study results. It supports the hypothesis that lithium use reduces impulsive aggression in addition to stabilizing mood.

JAMA Psychiatry May 11, 2016

Ed: Bipolar Disorder is not a psychological or psychi-atric condition, but rather a neurological one. The de-pression, suicidality and self-harm that may result are psychological, however. There is evidence that a con-tributing factor to Bipolar DO is a genetically driven, metabolic disruption in absorption and utilization of a basic element/nutrient, lithium. Studies have consis-tently shown that a small dose of lithium--.05 mg/kg even, is enough to affect behavior in humans (and in farm animals) and reduce aggression. This study found lithium worked, consistent with many previous stud-ies, to help those with Bipolar DO, even though they almost certainly administered a massive, nearly toxic dose. Valproate is not a “mood stabilizer” (a marketing term lacking scientific basis) but rather an anticonvul-sant which is believed to increase GABA levels. Studies have consistently shown minimal benefit in preventing state swings. Olanzapine and quetiapine are antipsy-chotics, not “mood stabilizers.” They have questionable use for psychosis during mania, acting primarily as a dopamine agonist, and have not been shown to influ-ence state swings.

Undetected ADHD May Explain Poor SSRI Re-sponse in Depression

Adults who fail to respond to antidepressant therapy may have underlying attention-deficit/hyperactivity disorder (ADHD) and not treatment-resistant depres-sion, as is often assumed, new research suggests.

“ADHD is relatively new as a diagnosis made in adult-hood, so when people present with symptoms of depression, physicians typically won’t ask any further questions about their history or assess for ADHD. Instead, they will prescribe them a selective serotonin reuptake inhibitor [SSRI],” Tia Sternat, START Clinic for Mood and Anxiety Disorders, in Canada, told Med-scape Medical News.

“But depressed patients with ADHD don’t typically respond to SSRIs because of the psychopathology involved — you have to activate the catecholaminergic system to treat ADHD — so they come in saying, ‘I feel better, but I’m not happy; I’m tired, I’m anxious, I’m having trouble with attention,’ and what you are see-ing are the adult signs of ADHD coming through,” she added.

“So physicians need to screen for premorbid condi-tions, including ADHD, before making the diagnosis of treatment-resistant depression.”

The research was presented here at the Anxiety and Depression Association of America (ADAA) Confer-ence 2016.

Ed: Why should those with ADHD respond to SSRIs? Those without ADHD don’t. Eight percent of recipi-ents, however, with or without ADHD, do get worse.

“You have to activate the catecholaminergic system to treat ADHD,” is even itself a marketing department promoted untruth.

Bidirectional Homeostatic Regulation of a Depression-Related Brain State by Gamma-Aminobutyric Acidergic Deficits and Ketamine Treatment

Major depressive disorder is increasingly recognized to involve functional deficits in both gamma-amino-butyric acid (GABA)ergic and glutamatergic synaptic transmission. To elucidate the relationship between these phenotypes, we used GABAA receptor ?2 subunit heterozygous (?2+/-) mice, which we previously char-acterized as a model animal with construct, face, and predictive validity for major depressive disorder.

To assess possible consequences of GABAergic deficits on glutamatergic transmission, we quantitated the cell surface expression of N-methyl-D-aspartate (NMDA)-type and alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA)-type glutamate receptors and the function of synapses in the hippocampus and me-dial prefrontal cortex of ?2+/- mice. We also analyzed the effects of an acute dose of the experimental anti-depressant ketamine on all these parameters in ?2+/- versus wild-type mice.

Modest defects in GABAergic synaptic transmis-



sion of ?2+/- mice resulted in a strikingly prominent homeostatic-like reduction in the cell surface expres-sion of NMDA-type and AMPA-type glutamate recep-tors, along with prominent functional impairment of glutamatergic synapses in the hippocampus and medial prefrontal cortex. A single subanesthetic dose of ketamine normalized glutamate receptor expression and synaptic function of ?2+/- mice to wild-type levels for a prolonged period, along with antidepressant-like behavioral consequences selectively in 2+/- mice. The GABAergic synapses of ?2+/- mice were potentiated by ketamine in parallel but only in the medial prefrontal cortex.

Conclusions: Depressive-like brain states that are caused by GABAergic deficits involve a homeostatic-like reduction of glutamatergic transmission that is reversible by an acute, subanesthetic dose of ketamine, along with regionally selective potentiation of GAB-Aergic synapses. The data merge the GABAergic and glutamatergic deficit hypotheses of major depressive disorder.

Biological Psychiatry, 2016; http://dx.doi.org/10.1016/j.biopsych.2016.02.009

Medical error—the third leading cause of death in the US

The annual list of the most common causes of death in the United States, compiled by the Centers for Dis-ease Control and Prevention (CDC), informs public awareness and national research priorities each year. The list is created using death certificates filled out by physicians, funeral directors, medical examiners, and coroners. However, a major limitation of the death certificate is that it relies on assigning an International Classification of Disease (ICD) code to the cause of death.1 As a result, causes of death not associated with an ICD code, such as human and system factors, are not captured. The science of safety has matured to describe how communication breakdowns, diagnostic errors, poor judgment, and inadequate skill can di-rectly result in patient harm and death. We analyzed the scientific literature on medical error to identify its contribution to US deaths in relation to causes listed by the CDC.

BMJ 2016; 353

Ed: Statistics and study design are not parts of the medical school curriculum. If physicians better under-stood the evidence for what they were being asked to promote this unnecessary loss of life and health might be reduced. See below.

Antidepressants Commonly and Increasingly Prescribed for Nondepressive Indications

Antidepressant use in the United States has increased over the last 2 decades. A suspected reason for this trend is that primary care physicians are increasingly prescribing antidepressants for nondepressive indica-tions, including unapproved (off-label) indications that have not been evaluated by regulatory agencies. For this study, the researchers used data from an electronic medical record and prescribing system that has been used by primary care physicians in community-based, fee-for-service practices around 2 major urban centers in Quebec, Canada. The study included prescriptions written for adults between January 2006 and Septem-ber 2015 for all antidepressants except monoamine oxidase inhibitors. Physicians participating in the study had to document at least 1 treatment indication per prescription using a drop-down menu containing a list of indications or by typing the indication(s).

During the study period, 101,759 antidepressant pre-scriptions (6 percent of all prescriptions) were written by 158 physicians for 19,734 patients. Only 55 percent of antidepressant prescriptions were indicated for depression. Physicians also prescribed antidepressants for anxiety disorders (18.5 percent), insomnia (10 per-cent), pain (6 percent) and panic disorders (4 percent). For 29 percent of all antidepressant prescriptions (66 percent of prescriptions not for depression), physicians prescribed a drug for an off-label indication, especially insomnia and pain. Physicians also prescribed anti-depressants for several indications that were off-label for all antidepressants, including migraine, vasomotor

symptoms of menopause, attention-deficit/hyperactiv-ity disorder, and digestive system disorders.

“The findings indicate that the mere presence of an antidepressant prescription is a poor proxy for depres-sion treatment, and they highlight the need to evaluate the evidence supporting off-label antidepressant use,” the authors write.

JAMA May 24, 2016



Off-Label Ketamine Prescribing: US Psychia-trists Troubled

With limited evidence the anesthetic ketamine is ef-fective for the short-term treatment of depression and almost no long-term safety and efficacy data, US psychiatrists are troubled by the rapidly growing trend of off-label prescribing.

“This is really an unusual situation in which a drug that was approved as an anesthetic is available to be prescribed by any physician,” Charles Nemeroff, MD, PhD, professor and chairman, Department of Psy-chiatry and Behavioral Sciences, University of Miami Miller School of Medicine, told Medscape Medical News.

“And while we are used to prescribing things off label all the time — obviously, medications find other uses — to take a drug like ketamine, which is an anesthetic and a well-known drug of abuse, especially when there are no data on its long-term effectiveness or its safety, is very worrisome.”

Dr. Nemeroff raised these and other concerns about the off-label use of ketamine here at Anxiety and De-pression Association of America (ADAA) Conference 2016 and was later interviewed by Medscape Medical News.

Re-evaluation of the traditional diet-heart hy-pothesis: analysis of recovered data from Min-nesota Coronary Experiment (1968-73).

To examine the traditional diet-heart hypothesis through recovery and analysis of previously unpub-lished data from the Minnesota Coronary Experiment (MCE) and to put findings in the context of existing diet-heart randomized controlled trials through a systematic review and meta-analysis, the MCE (1968-73) was a double blind randomized controlled trial designed to test whether replacement of saturated fat with vegetable oil rich in linoleic acid reduces coronary heart disease and death by lowering serum cholesterol. Unpublished documents with completed analyses for the randomized cohort of 9423 women and men aged 20-97; longitudinal data on serum cholesterol for the 2355 participants exposed to the study diets for a year or more; 149 completed autopsy files.

A serum cholesterol lowering diet that replaced satu-rated fat with linoleic acid (from corn oil and corn oil

polyunsaturated margarine) was compared to a control diet that was high in saturated fat from animal fats, common margarines, and shortenings.

Assessed were death from all causes; association between changes in serum cholesterol and death; and coronary atherosclerosis and myocardial infarcts de-tected at autopsy.

The intervention group had significant reduction in serum cholesterol compared with controls (mean change from baseline -13.8% v -1.0%; P<0.001). Ka-plan Meier graphs showed no mortality benefit for the intervention group in the full randomized cohort or for any prespecified subgroup. There was a 22% higher risk of death for each 30 mg/dL (0.78 mmol/L) reduc-tion in serum cholesterol in covariate adjusted Cox regression models (hazard ratio 1.22, 95% confidence interval 1.14 to 1.32; P<0.001).

There was no evidence of benefit in the intervention group for coronary atherosclerosis or myocardial infarcts. Systematic review identified five random-ized controlled trials for inclusion (n=10?808). In meta-analyses, these cholesterol lowering interven-tions showed no evidence of benefit on mortality from coronary heart disease (1.13, 0.83 to 1.54) or all-cause mortality (1.07, 0.90 to 1.27).

Conclusions: Available evidence from randomized con-trolled trials shows that replacement of saturated fat in the diet with linoleic acid effectively lowers serum cholesterol but does not support the hypothesis that this translates to a lower risk of death from coronary heart disease or all causes. Findings from the Min-nesota Coronary Experiment add to growing evidence that incomplete publication has contributed to overes-timation of the benefits of replacing saturated fat with vegetable oils rich in linoleic acid.

BMJ 2016;353:i1246

Ed: Reducing serum cholesterol did not reduce coro-nary atherosclerosis or myocardial infarcts. Statins are used to reduce cholesterol, and have been proposed to be available over the counter, and be given to children with low or no risk. Physician education should not be left to the marketing department!


Science Notes- Drugs Alternative Approaches

Maternal Use of Selective Serotonin Reuptake Inhibitors and Lengthening of the Umbilical Cord: Indirect Evidence of Increased Fetal Activity—A Retrospective Cohort Study

Antenatal depression affects up to 19% of pregnant women. Some of these women are also in need of antidepressant treatment. Nevertheless, the impact of maternal antidepressant treatment and prenatal de-pression on the course of pregnancy, fetal development and delivery outcomes is not fully understood.

We analyzed data from 24 818 women who gave birth at Kuopio University Hospital between 2002–2012. Logistic regression analysis was used to estimate associations between the use of selective serotonin reuptake inhibitors (SSRIs) during pregnancy and the progression of pregnancy, development of the fetus and delivery outcomes.

Altogether, 369 (1.5%) women used SSRIs. A regres-sion model adjusted for age, overweight, null parity, prior termination, miscarriages, smoking, maternal alcohol consumption, chronic illness and polyhydram-nion showed that pregnant women exposed to SSRI medication had significantly lower Apgar scores at 1 minute (p < 0.0001) and 5 minutes (p < 0.0001) and more admissions to the neonatal intensive care unit (p < 0.0001) than unexposed pregnant women. In addi-tion, exposed newborns had longer umbilical cords (p < 0.0001) than non-exposed newborns.

Conclusions: In addition to the previously known as-sociates with maternal SSRI exposure, such as lowered Apgar scores, SSRI exposure appeared to be associated with increased umbilical cord length. The observation related to increased umbilical cord length may be ex-plained by an SSRI-induced increase in the movements of the developing fetus.

PLOSone April 29, 2016

Ed: The APGAR score is a quick test performed on a baby at 1 and 5 minutes after birth. The 1-minute score determines how well the baby tolerated the birthing process. The health care provider examines the baby’s breathing effort, heart rate, muscle tone, reflexes and skin color. The effects of these mood chemicals contin-ues to unfold. “Some of these women are also in need of antidepressant treatment,” apparently to make up for their Paxil deficiency?

A Critical Approach to Evaluating Clinical Ef-ficacy, Adverse Events and Drug Interactions of Herbal Remedies

Systematic reviews and meta-analyses represent the uppermost ladders in the hierarchy of evidence. Sys-tematic reviews/meta-analyses suggest preliminary or satisfactory clinical evidence for agnus castus (Vitex agnus castus) for premenstrual complaints, flaxseed (Linum usitatissimum) for hypertension, feverfew (Tanacetum partenium) for migraine prevention, ginger (Zingiber officinalis) for pregnancy-induced nausea, ginseng (Panax ginseng) for improving fasting glucose levels as well as phytoestrogens and St John’s wort (Hypericum perforatum) for the relief of some symptoms in menopause. However, firm conclusions of efficacy cannot be generally drawn.

On the other hand, inconclusive evidence of efficacy or contradictory results have been reported for Aloe vera in the treatment of psoriasis, cranberry (Vaccinium macrocarpon) in cystitis prevention, ginkgo (Ginkgo biloba) for tinnitus and intermittent claudication, echinacea (Echinacea spp.) for the prevention of com-mon cold and pomegranate (Punica granatum) for the prevention/treatment of cardiovascular diseases.

A critical evaluation of the clinical data regarding the adverse effects has shown that herbal remedies are generally better tolerated than synthetic medications. Nevertheless, potentially serious adverse events, in-cluding herb–drug interactions, have been described. This suggests the need to be vigilant when using herbal remedies, particularly in specific conditions, such as during pregnancy and in the paediatric population.

Phytotherapy Research Volume 30, Issue 5, pages 691–700, May 2016

Ed: “Herbal remedies are generally better tolerated than synthetic medications.” Using their most strict standards, Vitex agnus castus for premenstrual com-plaints, flaxseed (Linum usitatissimum) for hyperten-sion, feverfew (Tanacetum partenium) for migraine prevention, ginger (Zingiber officinalis) for pregnancy-induced nausea, ginseng (Panax ginseng) for improv-ing fasting glucose levels as well as phytoestrogens and St John’s wort (Hypericum perforatum) for the relief of some symptoms in menopause all had “satisfactory evidence,” apparently with no conflicting studies. Hav-ing no conflicting studies in the pharmaceutical world is unheard of.


Alternative Approaches

Aloe vera in the treatment of psoriasis, cranberry (Vac-cinium macrocarpon) in cystitis prevention, ginkgo (Ginkgo biloba) for tinnitus and intermittent claudica-tion, echinacea (Echinacea spp.) for the prevention of common cold and pomegranate (Punica granatum) for the prevention/treatment of cardiovascular diseases all had conflicting evidence, putting them in the same class as ALL antidepressants, antipsychotics, anxiolyt-

ics, hypnotics, anticonvulsants and pretty much all other pharmaceuticals for effectiveness, just safer than the chemicals.

“Potentially serious adverse events, including herb–drug interactions, have been described. This suggests the need to be vigilant when using herbal remedies, particularly in specific conditions, such as during preg-nancy and in the paediatric population.” Since there are also many chemical/food adverse interactions, but not herb/food interactions, perhaps the chemical pre-scribers are the ones who should show more caution.

Adjunctive Nutraceuticals for Depression: A Systematic Review and Meta-Analyses

There is burgeoning interest in augmentation strate-gies for improving inadequate response to antidepres-sants. The adjunctive use of standardized pharmaceu-tical-grade nutrients, known as nutraceuticals, has the potential to modulate several neurochemical pathways implicated in depression. While many studies have been conducted in this area, to date no specialized sys-tematic review (or meta-analysis) has been conducted.

A systematic search of PubMed, CINAHL, Cochrane Library, and Web of Science was conducted up to De-cember 2015 for clinical trials using adjunctive nutri-ents for depression. Where sufficient data were avail-able, a random-effects model analyzed the standard mean difference between treatment and placebo in the change from baseline to endpoint, combining the effect size data. Funnel plot and heterogeneity analyses were also performed.

Primarily positive results were found for replicated studies testing S-adenosylmethionine (SAMe), meth-ylfolate, omega-3 (primarily EPA or ethyl-EPA), and vitamin D, with positive isolated studies for creatine, folinic acid, and an amino acid combination. Mixed results were found for zinc, folic acid, vitamin C, and tryptophan, with nonsignificant results for inositol. No

major adverse effects were noted in the studies (aside from minor digestive disturbance). A meta-analysis of adjunctive omega-3 versus placebo revealed a signifi-cant and moderate to strong effect in favor of omega-3. Conversely, a meta-analysis of folic acid revealed a nonsignificant difference from placebo. Marked study heterogeneity was found in a Higgins test for both omega-3 and folic acid studies; funnel plots also re-vealed asymmetry (reflecting potential study bias).

Conclusions: Current evidence supports adjunctive use of SAMe, methylfolate, omega-3, and vitamin D with antidepressants to reduce depressive symptoms.

A.J. of Psychiatry http://dx.doi.org/10.1176/appi.ajp.2016.15091228

Ed: Since depression pharmaceuticals are, essentially, placebos that have an 8% chance of worsening depres-sion, finding significant effectiveness for these 11 nutri-tional supplements is pretty persuasive!

Sam-e is naturally produced in the body. It has proven effectiveness for arthritis and depression, and positive early evidence for chronic liver disease.

Methylfolate is taken to overcome a genetically driven inability to properly absorb and utilize vitamin B9.

The body uses DHA, a major component of fish oil (omega 3’s) to build myelin (white matter). White mat-ter deficits are linked to depression, as well as other neuronal issues.

Vitamin D is required for the regulation of calcium and phosphorus and is a player in possibly all body sys-tems. Vitamin D deficiency is quite common, even in sunny locations.

Folinic acid is B9. Amino acids are building blocks of proteins, necessary for life. A deficiency in glycine, a “conditionally essential” amino acid has been linked to hyperactivity, and amino acid deficiencies may play a part in many “diseases.”

Zinc, in the form of “zinc fingers” acts as a catalyst for metabolization in every cell of the body. Zinc has a vital role in skin integrity and has many additional functions.

The writer seems a bit confused, finding methyfolate and folinic acid effectiveness well documented but finding mixed results for folic acid!

Vitamin C is an antioxidant, forms an important pro-



tein used to make skin, tendons, ligaments, and blood vessels, heal wounds and forms scar tissue, repairs and maintains cartilage, bones, and teeth, and aids in the absorption of iron.

L-tryptophan is considered an essential amino acid because our bodies can’t make it. It is important for the development and functioning of many organs in the body. After absorbing L-tryptophan from food, our bodies convert it to 5-HTP (5-hyrdoxytryptophan), and then to serotonin.

Inositol, vitamin B8, has been shown to be effective for treating panic disorder, OCD, PCOS and acute respira-tory distress syndrome in infants.

This article seems to prove: 1) their sample subjects had significant nutritional deficiencies, 2) their sub-jects had a significant level of genetic alleles which af-fected absorption and metabolization, 3) many cases of depression are primarily caused by these deficiencies, and 4) taking an “anti”depressant to overcome these deficiencies works about as well as one could expect, which is not benefit, significant harm. As many authors have noted, depression is not a Prozac deficiency.

Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline from the American College of Physicians

The American College of Physicians (ACP) developed this guideline to present the evidence and provide clin-ical recommendations on the management of chronic insomnia disorder in adults.

This guideline is based on a systematic review of ran-domized, controlled trials published in English from 2004 through September 2015. Evaluated outcomes included global outcomes assessed by questionnaires, patient-reported sleep outcomes, and harms. The target audience for this guideline includes all clini-cians, and the target patient population includes adults with chronic insomnia disorder. This guideline grades the evidence and recommendations by using the ACP grading system, which is based on the GRADE (Grad-ing of Recommendations Assessment, Development and Evaluation) approach.

Recommendation 1: ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder.

Recommendation 2: ACP recommends that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insom-nia disorder in whom cognitive behavioral therapy for insomnia (CBT-I) alone was unsuccessful

Annals of Internal Medicine http://annals.org/article.aspx?articleid=2518955

The Association of Lifestyle Factors and ADHD in Children

The objective of the study is to examine whether chil-dren aged 7 to 11 years with very well-characterized ADHD, recruited from the community, have a similar number of healthy lifestyle behaviors as compared with typically developing children from the same com-munity.

Parents of children with (n = 184) and without (n = 104) ADHD completed a lifestyle questionnaire asking about water intake, sweetened beverage consump-tion, multivitamin/supplement use, reading, screen time, physical activity, and sleep. A lifestyle index was formed from these seven domains (0-7), and multivari-able ordered logistic regression was used to examine the association of ADHD status and total healthy life-style behaviors.

Results: Children with ADHD were almost twice as likely to have fewer healthy behaviors, even after ad-justment for age, sex, intelligence quotient (IQ), ADHD medication use, household income, and four comorbid psychiatric disorders (odds ratio [OR] [95% confidence interval] = 1.95 [1.16, 3.30], p = .01).

Journal of Attention Disorders, 2016; DOI: 10.1177/1087054716646452

Less body fat for toddlers taking vitamin D

A healthy intake of vitamin D in the first year of life ap-pears to set children up to have more muscle mass and less body fat as toddlers, according to a new study. The findings emerged from research initially aimed at con-firming the importance of vitamin D for bone density.

For the first time, a connection was made between the benefits of achieving healthy vitamin D status during a baby’s first 12 to 36 months and how muscle mass



develops. The researchers achieved this by following up on a 2013 study in which 132 infants in Montréal, Québec, were given a vitamin D3 supplement at one of four different dosages between the ages of 1 month and 12 months.

The new study confirmed the importance for the de-velopment of strong bones of a vitamin D supplement of 400 IU/day during a baby’s first year. This amount is in line with current Canadian health guidelines. The researchers found that higher doses did not provide any additional benefit -- at least not in terms of bone development.

Pediatric Obesity, 2016; DOI: 10.1111/ijpo.12105

A Review of Natural Stimulant and Non-stimu-lant Thermogenic Agents

Obesity and overweight are major health issues. Exercise and calorie intake control are recognized as the primary mechanisms for addressing excess body weight. Naturally occurring thermogenic plant con-stituents offer adjunct means for assisting in weight management. The controlling mechanisms for ther-mogenesis offer many intervention points. Thermo-genic agents can act through stimulation of the central nervous system with associated adverse cardiovascular effects and through metabolic mechanisms that are non-stimulatory or a combination thereof. Examples of stimulatory thermogenic agents that will be discussed include ephedrine and caffeine. Examples of non-stimulatory thermogenic agents include p-synephrine (bitter orange extract), capsaicin, forskolin (Coleus root extract), and chlorogenic acid (green coffee bean extract). Green tea is an example of a thermogenic with the potential to produce mild but clinically insig-nificant undesirable stimulatory effects. The use of the aforementioned thermogenic agents in combination with other extracts such as those derived from Salacia reticulata, Sesamum indicum, Lagerstroemia speciosa, Cissus quadrangularis, and Moringa olifera, as well as the use of the carotenoids as lutein and fucoxanthin, and flavonoids as naringin and hesperidin can further facilitate energy metabolism and weight management as well as sports performance without adverse side ef-fects.

Phytotherapy Research Volume 30, Issue 5, pages 732–740, May 2016

Antidepressant Efficacy of Adjunctive Aerobic Activity and Associated Biomarkers in Major Depression: A 4-Week, Randomized, Single-Blind, Controlled Clinical Trial

Major depressive disorder (MDD) is a highly preva-lent, heterogeneous and systemic medical condition. Treatment options are limited, and recent studies have suggested that physical exercise can play an impor-tant role in the therapeutics of MDD. The aim of this study was to evaluate the antidepressant efficacy of adjunctive aerobic activity in association with phar-macotherapy (selective serotonin reuptake inhibitor) in symptomatic MDD as well as its association with physiological biomarkers.

In this randomized, single-blind, add-on, controlled clinical trial, 57 patients (18–55 years of age) were followed-up for 28 days. All patients were drug-free, had been diagnosed with symptomatic MDD and received flexible dose of sertraline during the trial. Patients were randomized to either a 4-week program (4x/week) of add-on aerobic exercise (exercise group, N = 29) or no activity (control group, N = 28). Depres-sion severity was assessed using the Hamilton Rating Scale for Depression (HAM-D) as the primary out-come. At baseline and endpoint, all patients underwent a comprehensive metabolic/cardiopulmonary exercise testing—including determination of maximal oxy-gen uptake (VO2max), VO2 at the second ventilatory threshold (VO2-VT2), and oxygen pulse (O2 pulse).

Depression scores significantly decreased in both groups after intervention. Importantly, patients in the aerobic exercise group required lower sertraline dose compared to the control group (sertraline monothera-py). The VO2max and O2 pulse parameters increased over time only in the exercise group and remained unchanged in the control group.

Conclusions

The present findings suggest that a 4-week training of aerobic exercise significantly improves functional capacity in patients with MDD and may be associated with antidepressant efficacy. This approach may also decrease the need for higher doses of antidepressants to achieve response. Further studies in unmedicated and treatment-resistant MDD patients are needed in order to confirm the utility of short-term aerobic exer-cise as an alternative therapeutic approach in MDD.

PLoS ONE 11(5): e0154195



Ed: This “study” compared an exercise program to those that did not, for effect on depression. Although the words “drug free” were used, all participants ap-parently received “anti”depressants. There was no control group that did not receive “anti”depressant chemicals, and the title is clearly a sham. The title is more properly “Aerobic exercise significantly reduces depression.”

Exercise as a treatment for depression: A meta-analy-sis adjusting for publication bias

The effects of exercise on depression have been a source of contentious debate. Meta-analyses have dem-onstrated a range of effect sizes. Both inclusion cri-teria and heterogeneity may influence the effect sizes reported. The extent and influence of publication bias is also unknown. Randomized controlled trials (RCTs) were identified from a recent Cochrane review and searches of major electronic databases from 01/2013 to 08/2015. We included RCTs of exercise interventions in people with depression (including those with a di-agnosis of major depressive disorder (MDD) or ratings on depressive symptoms), comparing exercise versus control conditions. A random effects meta-analysis calculating the standardized mean difference (SMD, 95% confidence interval; CI), meta-regressions, trim and fill and fail-safe n analyses were conducted. Twen-ty-five RCTs were included comparing exercise versus control comparison groups, including 9 examining participants with MDD. Overall, exercise had a large and significant effect on depression (SMD adjusted for publication bias = 1.11 (95% CI 0.79–1.43)) with a fail-safe number of 1057. Most adjusted analyses suggested publication bias led to an underestimated SMD. Larger effects were found for interventions in MDD, utilizing aerobic exercise, at moderate and vigorous intensities, in a supervised and unsupervised format. In MDD, larger effects were found for moderate intensity, aero-bic exercise, and interventions supervised by exercise professionals. Exercise has a large and significant anti-depressant effect in people with depression (including MDD). Previous meta-analyses may have underesti-mated the benefits of exercise due to publication bias. Our data strongly support the claim that exercise is an evidence-based treatment for depression.

Journal of Psychiatric research June 2016 Vol 77:42-51


June Continuing Education CreditBy Gary Traub, Ph.D.

Get one hour of CE credit by reading this edition of TCP and completing the following questions. E-mail your answers to Dr. John Caccavale, NAPPP, at [email protected]

1. According to the lead article, while initially very promising and almost a done deal, the integration of behavioral health into primary care is now very unlikely to occur. True/false

2. The author states that psychologists should assert their in-dependence and whenever possible, remain in a solo private practice. True/false

3. Under the accountable care model, it is envisioned that several professionals, ideally in the same location, would provide behavioral, medical, educational, and social services to patients. True/false

4. The author views the accountable care model as an opportu-nity for doctoral level psychologists to regain the prominence that they once had. True/false

5. The author predicts that under this model, individual therapy with the 45 to 50 min. hour will remain prominent, and group therapy will become utilized much less frequently than it is now. True/false

6. NAPPP is having a CE training conference in what lo-cation: __________________; and on what dates: _______________ through _______________ .

7. In a Medscape news summary, a seeming paradox was reported in which more people with mental health problems obtain insurance coverage, but the percentage visiting mental health professionals has dropped off. True/false

8. The international classification of sleep disorders lists how many sleep-related disorders?

9. Inadequate sleep has been linked to which of the following: a.. Anxiety b. Depression c. ADHD d. Hypertension e. Diabetes f. Relationship disruption g. a, b, e, and f h. all of the above

10. Causes of sleep issues include medical conditions; many medications including antidepressants, allergy medications, and pain medications; stress, anxiety, depression, caffeine,

nicotine, and alcohol. True/false

11. Which axis regulates sleep in various ways?

12. Cortisol, known as the _________ hormone, is produced in the __________ glands, rises in the morning and peaks about _____ am, reaching lows between _______ and 4 am. Cortisol functions to ___________ (increase/decrease) blood sugar which in turn ___________ (enhances/suppresses) the immune system.

13. Benzodiazepines, and their near relatives, such as Zolpidem (Ambien), have been shown to decrease the number of awak-enings and increase total sleep time when used over what period of time?

14. These chemicals are GABA-A agonists, binding to the GABA-A receptor, with the effect of __________ (enhancing/slowing) the activity of other neurotransmitters.

15. Holistic sleep approaches may include which of the following?

16. a. Sleep hygiene training

17. b. Relaxation therapies

18. c. Nutrient supplementation

19. d. Herbal supplements

20. e. All of the above

21. As part of sleep hygiene, patients are advised to limit naps to once or twice per day. True/false

22. Use of smart phones or computers be-fore bed may cause which of the following? a. Delayed sleep onset b. Delay of the circadian clock c. Increased melatonin production d. Increased REM e. a and b f. a, b, and c g. All of the above

23. A light snack before bedtime, low in sugar, with a reasonable balance of protein and complex carbohydrates, may help some patients sleep through the night without waking. True/false

24. Magnesium deficiency is well-established as a factor in in-somnia, occurs in over two thirds of the adult population, and the author recommends starting at 400 to 600 mg of magne-sium in the evening. True/false

mailto:doctorjc1%40ca.rr.com?subject=TCP%20CEs


CE Credit

25. Melatonin is a natural hormone made by the ________ gland. This gland is in active during the day, but when the sun goes down, the gland is turned on, usually at approximately _____ pm. Melatonin levels stay elevated for approximately ____ hours, falling at dawn and reaching low daytime levels by about ____ am.

26. Valerian is thought to work primarily as a _________ receptor agonist.

27. Kava can be effective for common restlessness, insomnia, and anxiety, but adverse interactions with certain drugs have been documented. True/false

28. In Ayurveda, it is thought that anxiety, rage, envy, and stress account for approximately half of diagnosed cases of insom-nia. True/false

29. In traditional Chinese medicine, the focus is on correcting imbalances rather than on suppressing symptoms. True/false

30. ADHD includes symptoms of hyperactivity, impulsiveness, and attention problems. True/false

31. These days, more children receive psychological services for ADHD, then those that take medication. True/false

32. The recommended first treatment for young children with ADHD is behavior therapy. True/false

33. What three things do parents learn when trained in behavior therapy?

34. It is recommended that extended release, long acting opiate analgesics be prescribed only by healthcare professionals who are knowledgeable in the use of them. True/false

35. In a recent FDA drug safety communication, Abilify has been recommended for impulse control problems. True/false. And please explain your answer:__________________

36. Bipolar disorder is a neurological condition, but the depres-sion, suicidality, and self harm that may result are psychologi-cal aspects of this condition. True/false

37. Fortunately, antidepressant use in the United States has decreased over the last two decades. True/false

38. The 1 minute APGAR score determines how well the baby tolerated the birthing process. True/false

39. Herbal remedies are generally better tolerated than synthetic medications. True/false

40. Sam-e is naturally produced in the body, and has been shown to be effective for arthritis, and depression. True/false

41. A new study confirmed the importance for the development of strong bones of a vitamin D supplement during a baby’s first

year. True/false

42. Meta-analysis showed that exercise had a large and signifi-cant effect on depression, and previous studies may have underestimated the benefits of exercise due to publication bias. True/false


Current Listing of Free CE Courses

Psy #1 - Pharmacotherapeutics: 10 CE credit hours

Integration of the principles of psychology in the application of pharmacological agents in the alleviation of mental health concerns.

Psy #2 - Neuropsychological Evaluations: 10 CE credit hours

The selection, administration and integration of neuropsychological data into a comprehensive report.

Psy #3 - Custody Evaluations: 10 CE credit hours

A complete course on the conducting and writing of custody evaluations for the practicing psychologist.

Psy #4 - Forensic Evaluations: 10 CE credit hours

This course will take you through the differing forms of forensic evaluations and discuss the formation of a comprehensive forensic report.

Psy #5 - Treating Childhood Sexual Abuse: 10 CE credit hours

This course discusses the thorough diagnosis and treatment of children who have been sexually abused.

Psy #6 - Domestic Violence - Treatment and Assessment: 10 CE credit hours

The assessment and treatment of domestic violence. Discussion of group and individual treatment is included.

Psy #7 - Ethics & Risk Management: 10 CE credit hours

This course qualifies for an additional 10% discount from NAPPP’s preferred malpractice insurer. This is a program that discusses the newest issues facing Psychologists ethically. A thorough discussion of prescription privileges and pharmacopsychology ethics is included.

Psy #8 - Mood Disorders: 10 CE credit hours

A review of the diagnosis of the spectrum of mood disorders along with a discussion of the psychological and pharmacological interventions for each disorder.

Psy #9 - Physiology For Psychologists: 10 CE credit hours

This course covers basic understanding of critical concepts in human physiology, including being aware of indications for referral to other health care providers for treatment and interrelationships between organs/systems, psychopharmacology, and psychopathology.

Psy #10 - Issues In Postpartum Disorders: 10 CE credit hours

A review of the evaluation and diagnosis of postpartum disorders. A review of the relevant literature is included.

Psy #11 - Doing Pre-Marital Counseling: 10 CE credit hours

Dr. Sandra Levy Ceren details how to do pre-marital counseling. This course is built upon Dr. Ceren’s many years of experience and is replete with case studies.

Psy #12 - Mastering Medical Terminology For Psychologists: 10 CE credit hours

This course is designed for Psychologists who want to learn and master medical terminology. This course will allow clinician’s to communicate effectively with medical practitioners. A must for clinicians who regularly work with medical practitioners.

Psy #13 - Caring For The Elderly: 10 CE credit hours

This course is a basic course designed for Psychologists who want to learn additional skills related to diagnosing and treating the elderly patient. Particular attention is devoted to dementias.

Psy #14 - Diagnosing and Treating Substance Abuse: 10 CE credit hours

A basic understanding of diagnosing and treating

The following courses are now available free with NAPPP membership. CE credit is provided by NAPPP and alliance partners who are approved sponsors of continuing education by the National Institute of Behavioral Health Quality and the American Psychological Association. Many states require specific courses for licensure and license renewal. NAPPP courses are designed to meet these requirements. However, members should check with their state statutes to determine specific CE requirements. Contact Dr. Caccavale for details at [email protected]

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Current CE courses

patients with substance abuse problems. The course focuses on alcohol abuse but does cover the abuse of other substances including prescription drugs.

Psy #15 - Ethics II: 4 CE Credit hours

This 4 unit course is for those Psychologists who do not require the more extensive 10 unit course.

Psy #16 - Introduction To Medical Psychology: 10 CE Credit hours

A basic course in medical psychology for Psychologists. Reading materials focus on the understanding and treatment of diseases and illnesses that Psychologists can treat.

Psy #17 - Primary Care Psychology: 15 CE Credit hours

An introduction to how clinical psychology is practiced in a primary care setting. Reasons for integrating psychology into primary care are discussed along with treatment models and the different aspects of practice in a primary care setting.

Psy #18 - Forensic Practice: 15 CE Credit hours

An introduction to the practice of forensic psychology for Psychologists who want to expand their services into this area of practice. Topics include psychological evaluations for the court (child custody; competency; insanity), psychological factors in eyewitness testimony, trial consultation, and criminal investigation.

Psy # 19 - Clinical Supervision: 6 CE Credit hours

Ethically and legally, supervisors are responsible for patient care as well as the training and development of their supervisees. Supervision becomes a balancing act between the needs of the patient population and the needs of the supervisee. This course will help you do your job better and give you skills to rely on in your supervision of interns.

Psy # 20 - Neurology For Psychologists: 15 CE Credit hours

An introduction to basic neurological practice for Psychologists. It provides participants with a thorough understanding of the structure of the nervous system. Topics include: performing a competent neurological work-up, basic description and components of typical neurological disorders, behavioral neurology, muscle disorders, sensory disorders, and ethical issues in practice.

Psy #21 - Understanding The Affordable Care Act: 15 CE Credit hours

This course presents a thorough presentation of the new healthcare reform laws and how both patients and practitioners will be affected as the new rules and regulations are implemented. This is a must course for those wanting to get the most out of these reforms.

Psy #22 - Entrepreneurship For Psychologists: 10 CE credit hours

An introductory course for Psychologists who want to expand their knowledge about the opportunities and benefits of becoming an entrepreneur in mental health. With the new Affordable Care Act now law, there are many opportunities for Psychologists if we can learn the concepts and success behind entrepreneurship. This is what has been missing from graduate psychology education.

Psy #23 - Crisis Management Intervention Consulting: 15 CE credit hours

This course is designed for clinical Psychologists who want to develop a significant and workable knowledge base to provide crisis management consulting services to municipalities and private organizations. It will also serve the function of providing practitioners with a good knowledge base to understanding crisis management interventions.

Basic Neuropsychology (10 Contact Hours)

This course is designed to introduce clinical psychologists to basic neuropsychological evaluation. It provides participants with a substantive understanding what constitutes a neuropsychological workup. Psychologists who complete this course will learn how to identify important neuropsychological disorders and how to evaluate dysfunction. This course is an introduction to what neuropsychology is but it is not intended to convey or imply certification as a neuropsychologist.

Interpreting Blood Panels For Psychologists (6 contact Hours)

Having an understanding about these tests and what they mean is essential to all healthcare providers. This course is designed to provide psychologists with general information to assist in their practices and professional development. The information provided in this course is based on research and consultation with medical and other authorities, and is, to the best of our knowledge,


HOW TO WRITE A BRILLIANT SUBMISSIONby David Reinhardt, Ph.D. and Elle Walker, Psy.D.

There is a famous proverb, “He who fails to plan, plans to fail.” It’s easy to notice when a submission (even with the best intentions) has not been planned well or organized. An organized and structured writing piece shows our readers (and editors!) that your arguments are clear, concise and coherent. Hopefully with careful planning and the application of the following tips, a great submission will not be far behind!

Please keep in mind that The Clinical Practitioner is the public face of NAPPP. Internal discussions, squabbles, rants and raves, politics and so on are best submitted to the members’ listserv. Although we entertain political discussions within our ranks only official policy positions will appear in TCP.

We Welcome Member Submissions! NAPPP is a practice organization. Please keep all submissions to practice issues.

All Submissions regardless of type should be proof read, spell checked, grammar and punctuation checked. Minor editing can be done to prepare a submission for print; However, if more than minor corrections are needed the submission will unfortunately have to be returned.

Technical Considerations1. Please attach submissions to your email as Word files (.doc), unless you have checked with us about other formats.

2. Use standard fonts. We have found Verdana and Georgia to be the most readable in electronic format.

3. If your submission must have special characters or fonts, please embed these in your document.

4. If your submission includes objects (pictures, graphs, drawings, etc.) these MUST be included as separate files.

5. Please include technical references and links as appropriate.

Letter Submissions We welcome short submissions which deal with issues such as insurance and billing, reports on published research, reports on conventions attended, the

business of practice, interesting solutions to patient problems, and other practice related topics.

1. Please make submissions @50-150 words.

2. The editors will select submissions based on relevance and space needs.

Submissions for feature articles We will consider feature articles of any length dealing with practice issues, “How To” articles, and any topic directly relating to practice. Please submit your article ideas to [email protected]

1. A brief statement of topic and short outline of your proposal will allow us to guide you on article development.

2. Articles can be any length. Please have your editor check that every sentence has a purpose and appropriate structure.

3. An Introductory Paragraph introducing your subject and main Idea of your article is a MUST.

4. Supporting Paragraphs that develop the main idea of your topic:

-Should list the points that develop the main idea of your article

-Please place each supporting point in its own paragraph

-Develop each supporting point with facts, details and examples.

5. End with a Summary Paragraph or Conclusion and do this by:

-Restating the strongest points that support the main idea

-Conclude by restating the main idea in different words

-Give a personal opinion or suggest a plan of action.

Keep in mind that readers will only continue as long as they are presented with new information. Do not rehash information or ideas, but do summarize in the final paragraph(s).

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A Board Certification for Clinical PsychologistsABBHP diplomate status in behavioral healthcare practice recognizes a set of specialty skills within general healthcare. The

diplomate recognizes experience and skills in working with behavioral health problems in ways that are coordinated with

allopathic medicine. The Specialty of Behavioral Healthcare Practice integrates behavioral health into medical care in diagnosing,

treating and providing the necessary monitoring of post-treatment behavioral follow up care.

Board certification by ABBHP is an indication to both patients and providers that you are a specialist in providing behavioral

healthcare diagnoses and treatments. Our board certification, the first of its kind, tells the public and your referral sources that you

are a specialist and partner in the primary care of patients.

Requirements

The ABBHP board certification is not a vanity board. It was designed by an experienced and influential board to be rigorous

and to ensure the public, healthcare providers and the healthcare industry that those who possess this diplomate have achieved

a high level of training and experience in providing behavioral healthcare services. Those possessing ABBHP certification are

making a statement that they are behavioral healthcare practitioners who work and belong in the healthcare industry. ABBHP

diplomates are doctoral level Psychologists who provide much more than psychotherapy services but can provide a wide range of

interventions that only a doctoral level Psychologists can. For information on qualifying for board certification, please go to


Summary of Requirements Current and valid license to practice psychology.

Successfully pass an examination.

Complete specific coursework.

Provide a product sample.

Provide letters of recommendation

Board of Directors Nicholas Cummings, Ph.D. Jerry Morris, Psy.D.

Elle C. Walker, Ph.D. Joseph Casciani, Ph.D.




The National Institute of Behavioral

Health Quality

The accreditation process for professionals and service providers engaged in behavioral healthcare is sorely lacking and mostly absent. Consequentially, consumers and professionals alike, have little idea or notion of what constitutes quality practice, services, and products. The mission of NIBHQ is to provide accreditation to licensed, doctoral level behavioral healthcare professionals and service providers. NIBHQ is a profession specific agency that awards accreditation based on standards developed by behavioral healthcare professionals. Our mission is to award accreditation only to those individuals and entities that can meet and maintain adherence to standards specifically developed to promote quality in the provision of behavioral healthcare services and products.

Do You Want To Distinguish And Promote Your Practice?Then NIBHQ accreditation is your best way to do this. We offer a unique accreditation that demonstrates your practice has met a high standard and is committed to quality care and services that patients, insurers, and other healthcare professionals can rely on. See our requirements at http://www.nibhq.org/

Continuing Education Providers- Are you a current continuing education provider or want to be one? Then NIBHQ accreditation of your organization will attract behavioral healthcare professionals to your courses.

Our requirements for CE providers can be obtained at

http://www.nibhq.org/

NIBHQ


Want to know what Medical Psychology is and how we practice? Want to support advocacy for psychological practice and get a book in return?If you purchase this book you can do both. All revenues from the sale of this book goes to our PsychAdvocacy Fund to help us deliver the message that doctoral level psychological services are valued and needed. We cannot do this without your support.

Book DescriptionIn 2009, over fifty-two million prescriptions for antipsychotic medications were written, totaling over $14.6 billion in sales. Such is just one small indication of how our current medical system treats its patients with medication as a first-line approach. This is not the answer. There is a growing need for integrated health care systems which include psychological care, particularly those services provided by medical psychologists. Medical psychologists are not physicians, but they do many of the same things that physicians do or should be doing. Medical psychologists are also doing things that clinical psychologists have never done. A medical system which profits from and relies primarily upon medication is not sustainable, especially when these medication-only treatments may be at the least ineffective and, at worst, harmful to patients. This reader seeks to define medical psychology's place in this complex and challenging environment.

To purchase the book, click here: http://www.nappp.org/book.html

http://www.nappp.org/book.html


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NAPP Members receive 20% off our Behavioral Health EHR

Just mention your NAPP membershipwhen you place your order to receive the discount

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the clinical practitioner - center for health scienceprescribing psychologists. he has post graduate...

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