Pharmacological Adjuncts

Abstract:

There is a broadly accepted list of basic competencies that are expected of a licensed clinical psychologist. In the case of a clinical psychologist with advanced training in Clinical Psychopharmacology (CPP), who is engaged in prescribing or consulting about medications, there is also a list of acceptable basic competencies. In order that psychologists may achieve basic competency in psychopharmacology, they need to begin with a solid core of academic learning and clinical practicum in psychopharmacology that will motivate them to continue to progress in competency as they engage in this specialized field of patient care. To progress from basic to expert competency, most clinicians trained in CPP will need years of experience. The route to expert competency is made more complex by the added burden of combining two disciplines effectively. Since there is no national board exam for diplomate status in CPP, the competencies of an expert need to be defined informally by colleagues in the field. There is no doubt that experts are appearing among the small group of men and women who were first to enter this career. The knowledge and experience that drive the transition from basic to expert competence reaches beyond an academic program. It must be nurtured by the experiences that these professionals encounter in their practice and especially by the input of other competent practioners who provide professional models for this new generation of prescribing and consulting psychopharmacologists.

Appendix

Seven Academic Content Areas of Specific Competency. The primary skills expected of a clinical psychologist who has basic competency in clinical psychopharmacology are the following:

• 1. Neurosciences. For the clinicians to understand the brain tissues in which psychopharmacological medications have their effects, they need to have a thorough knowledge of neuroanatomical structure; neurochemistry and neurophysiological function of neurons; central nervous system and peripheral nervous system neuronal pathways and their functions; vascular supply of the brain, and the blood-brain and placental barriers; cellular and molecular nervous system biology and regulatory processes and second messenger systems; endocrine system and the interface of various hormones and other neurotransmitters; major neurotransmitter and neuromodulator synthesis, storage, release, distribution throughout the brain and the rest of the body; action, reuptake, and degradation of neuropeptides; etiological factors and diagnosis of sleep disorders as related to the nervous system and psychopathology; neurodiagnostic markers of neurobehavioral disorders.

• 2. Neuropathology. For them to understand the interaction between neuropathology and psychopathology, clinicians need to have a thorough knowledge of neurological disorders such as dementia, delirium, pain, Parkinson’s, Huntington’s, and Tourette’s syndromes, mental retardation, fetal alcohol syndrome, pervasive developmental disorders, Fragile-X syndrome, CNS vascular disorders, seizure disorders, traumatic brain injury, multiple sclerosis, infectious diseases, neoplasms, schizophrenia, affective disorders, anxiety, ADHD, and the mechanism of extrapyramidal dysfunction.

• 3. Pharmacology. For them to understand the interaction between medications for other diseases and those for mental disorders, clinicians need to have a thorough knowledgeof general pharmacology principles. These would include, but not limited to, drug classifications and pharmacokinetic principles such as absorption, bioavailability, volume of distribution, protein and tissue binding, metabolism, elimination and clearance, and half-life. Pharmacodynamic principles such as dosing, potency, efficacy, toxicity, types of drugs and other agents interacting with receptors (e.g., agonists, antagonists, and inverse agonists), drug-induced cellular adaptation (e.g., cellular signaling of ion channels, second messenger systems, neurotransmitter release, sensitivity, and supersensitivity), drug effects on genetic expression, mechanisms of action of a range of pharmacotherapeutic agents, the theoretical relationships thought to exist between neurotransmitter systems and psychopathological conditions are also included. In addition, drug–drug, drug–disease and drug–food interactions, drug-induced disease and dysfunction, and adverse reactions, genetic polymorphisms, familial patterns of drug response and toxicity, and pharmacoepidemiology are also considered. Understanding the development of drug tolerance, dependence, and withdrawal syndromes is necessary. Also knowledge of the U. S. Food and Drug Administration (FDA) drug development process and the current status of research regarding specific medications is necessary.

• 4. Psychopharmacology. For them to be capable of properly selecting and prescribing appropriate medications for their patients, clinicians need to have a thorough knowledge of indications, contraindications, and off-label uses of various psychotropic and adjunctive medications, and the rational for psychotropic medication selection, taking into ac-count target symptoms, patient and family history, premorbid personality, demographics, comorbid medical conditions, existing medication regimen and potential for interactions, and differences among medications within classes of drugs. Knowledge of dosing, time course of therapeutic action, and adverse effects; patient factors that influence dose, therapeutic monitoring, augmentation strategies; dose adjustment, route of administration, management of adverse reactions, interactions, relapse prevention, drug effects in special populations; psychological and physiological manifestations of recreational substances and treatment of intoxication or addiction, including strategies for assisted withdrawal, maintenance, and relapse prevention, tolerance, cross tolerance, dependence and withdrawal; sensitization/cross-sensitization with respect to specific medications; and the management strategies used to treat them are necessary. Clinicians also need to be trained in the method of combining psychological treatment with psychopharmacotherapy, especially its adaptation to be used in children and the elderly. They need to learn how to use computer-based practice aids to search the literature for research findings regarding practice and updates on medications and their applications, as well as epidemiological findings about diseases.

• 5. Anatomy, Physiology, Pathophysiology. For clinicians to understand the anatomical basis for disease, and understand the relationship between disease and mental disorder, they need to have knowledge of normal anatomy and physiology and pathophysiology including cardiovascular, pulmonary, renal/genitourinary, hepatic, endocrine, hematological, muscular, skeletal, dermatologic, and immunologic/rheumatology, and reproductive systems, and how each of these systems is affected by psychopharmacological medications. An excellent example of these potential interactions is the issue of how many psychotropics have been associated with an increased risk for hyperglycemia, hyperlipidemia, and weight gain requiring special monitoring and careful consideration in psychotropic drug selection in patients with preexisting diabetes mellitus or hyperlipidemia and the possible changes in treatment selection when these drug–disease interactions or drug-induced adverse reactions occur (ADA, 2004; Rey 2002, 2006b).

• 6. Physical Assessment, Laboratory Exams and Differential Diagnosis. Clinicians also need to be trained in assessing pathophysiology through the use of a physical exam, interpreting the results of laboratory tests and arriving at a differential diagnosis of disease.

• 7. Special Issues in Pharmacotherapeutics. Finally, clinicians must know psychotherapy–pharmacotherpy interaction, computer-based practice aids, pharmacoepidemiology, and professional, ethical, legal, and interprofessional issues.