For those of you with your nerves still frayed and hearts broken over the horrific act of violence in Newtown, the holiday season was a very difficult one this year, and particularly so for those of us here in the neighboring communities of Connecticut. However, while we may all want to forget about it and move on, this incident had better not be forgotten so easily like those that have happened prior. It had better be a call to action on a multitude of fronts or these precious children and adult educators will be added to the long list of those who have recently died in vain. There are a multitude of cultural issues facing us as a society that we simply can no longer delay facing and effectively dealing with head-on.

The immediate reaction to tragedies like this latest one is to concentrate on gun access and availability. No matter what side of the issue you are on politically on the Constitutional right to bear arms, it is becoming impossible to rationally support the need for public access to semi-automatic assault rifles, high capacity magazines, and military-style ammunition. Their only real purpose, by design, is to kill lots of people very quickly. There is a big difference between defending rational rights to gun ownership, and even concealed weapon permits, versus private access to military-style weapons. However, regardless of these issues, the guns remain the low-hanging fruit in this conversation. Other issues are equally, if not more, important and responsible for creating an environment for this kind of situation to occur.

The constant exposure to violent video games, movies, TV shows, and music of our children during their developmental years creates desensitization to violence and, in a small number of subjects, a tolerance for actually committing these kinds of acts as a way of living out for real what they do on the television or computer screen on a daily basis. Would anyone really be surprised if next year you can buy a video game where the theme is a person with an assault rifle entering a school to shoot up the place?

The breakdown of the family unit which has occurred in the past several decades is yet another issue that must be honestly evaluated. This is complex and due to many issues such as the steep rise in divorce, escalating numbers of births by single mothers, and fatherless homes being the norm in large segments of our population, and all are clearly taking a toll on our children. Declining spirituality and faith, and the aggressive, and many believe excessive, level of politically-correct secular pressure to defer from categorizing anything as unacceptable behavior with negative societal influence also has not helped.

Our population is also literally eating “junk” and goes through their daily life consuming calorie-rich, nutrient-insufficient, foods of convenience routinely just like they are encouraged to do on all of the television commercials. The cold hard truth is that even in a country of abundance like the U.S. people are malnourished. Yes, I said it, malnourished! Of course, I am referring to the inadequate consumption of real or whole foods and the critical micronutrients they contain, not the amount of calories. This has significantly contributed to the epidemic of chronic illness, including mental illness, and skyrocketing healthcare expenditures. We are frankly, as a society, becoming fatter, stupider, and more culturally regressed by the day. Yes, all of this matters!
Finally, one of the most important factors, in my opinion (and credible data backs this up) creating the soil for this reality we now confront is the literal breakdown of the mental health system. Since an almost total federal defunding of comprehensive mental health services in the 60s, 70s and 80s we have seen serious negative effects on our society. Almost total privatization of the system has led to non-livable wages for counselors and many front-line mental health professionals and no funding for their continued education. In fact, many have pointed out correctly that the U.S. effectively has no mental health “system” at all. However, in an outstanding Medscape article published as a response to the Newtown tragedy, psychiatrist James Knoll, IV, MD stated “It is my contention that there exists no legitimate ‘system’ in the United States when it comes to mental health treatment. From a literal perspective, one might define a system as an organized, regularly interacting set of principles forming a network — especially for distributing something or serving a common purpose.” The reality is that we really have no “system” at all by the classic definition to even blame. After one tragedy in Massachusetts, the state’s former mental health director responded, “Will this case be the canary in the coal mine? Will it signal that we’ve gone too far in reducing client-staff ratios, in closing hospitals, in pushing independence for people who may still be too sick?”

The reality is that the standard of care has been reduced to the cheapest solution, if you want to call it that, which is basically a “drug them and shove them” (out the door) approach. People with serious mental illness, and clearly violent tendencies, are no longer institutionalized and given the long-term comprehensive care they need. It is cheaper and easier to just prescribe an antidepressant, an antipsychotic medication, or both, and send them off unsupervised to live among us. It has been reported that Adam Lanza, the Newtown shooter, was taking the atypical antipsychotic drug Fanapt (formerly known as Zomaril), a medication with a very problematic history of its own. We know from medical studies that while antidepressant drugs may be marginally effective and necessary for some, other large meta-studies show they may be no better than placebo. We now have over 30,000,000 Americans taking SSRIs and the majority of those prescriptions are written by GPs, NPs, and PAs, most of who have no advanced psychiatric training. We also know that teenagers and young adults can react differently to these medications than adults do, and a small but significant percentage of them can be made worse by these drugs. Many teenage girls have committed suicide after starting antidepressant medications for what was only mild depression prior. Some boys and young men have virtually disassociated from reality and have committed horrendous acts of violence, sometimes in a manner completely out of character for them previously.

I have, since this latest incident, heard some discussion about the lack of funding for mental health, but will more funding really just mean more of these medications being handed out to our already drugged-silly children without serious thought to who they may be inappropriate for, or will it finally result in the addition of more comprehensive services and approaches? The handing out of medications to our children like it is candy is out of control and the link between their use and these incidents is becoming compelling. Could this be one of the main elements in the rise of such incidents? After all, guns have been widely available for a very long time, while the mass and almost reflexive use of these medications, like these incidents, is relatively new.

Fellow health care providers, citizens, and especially parents, we have a toxic soup of issues facing us, and particularly for our children, which may very well be leading to the acts of horror we have witnessed now on a multitude of occasions since Columbine. However, having an honest and non-political discussion as a nation about them will be difficult, but imperative. This will ultimately involve taking on powerful interests including the NRA, Big Pharma, Big Food, and the entertainment industry. These days our politicians are financially beholden to these very same powerful interests, they are barely capable of speaking civilly across the aisle to one another, and have become virtually worthless in affecting any kind of meaningful change. Do the politicians really have the backbone? I seriously doubt they do unless their feet are held to the fire by an outraged populous, and a united health care workforce, that will no longer stand by and see our children slaughtered in their schools.

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Dr. Brady is a licensed naturopathic medical physician and certified clinical nutritionist. He is currently the Vice Provost of the Division of Health Sciences, Director of the Human Nutrition Institute, and associate professor of clinical sciences at the University of Bridgeport. He is also the Chief Medical Officer of Designs for Health, Inc., and maintains a private practice, Whole Body Medicine, in Trumbull, CT. Dr. Brady has been a featured presenter at many of the most prestigious conferences in integrative and functional medicine, including the Institute for Functional Medicine, American College for Advancement in Medicine, American Academy of Anti-Aging Medicine, International and American Associations of Clinical Nutritionists, and more. He is a contributing author for Integrative Gastroenterology, the first integrative medical textbook on gastroenterology by Johns Hopkins physician Gerard Mullin, MD, and is a contributing author for Laboratory Evaluations for Integrative and Functional Medicine by Lord and Bralley and the second edition of Advancing Medicine with Food and Nutrients, Second Edition, by Ingrid Kohlstadt, MD.

and Bret A. Moore Editors

Wiley, 2012

The Handbook of Clinical Psychopharmacology for Psychologists provides the foundations of knowledge that readers will want for comprehensive understanding in clinical psychopharmacology, located in the broader context of biology, psychology, and social environment. For the prescribing psychologist the book will prove a user-friendly, efficient training tool, and for consulting healthcare psychologists, an essential desk reference.

Handbook successfully combines information from neuroanatomy, nervous system structure and functions, biochemistry, and physiology, with current information on pharmacology, research, and practice. The authors place the issues firmly in a meaningful context for those who treat patients into today’s mental health and health industry.

Co-editor Dr. Mark Muse, American Board of Professional Psychology (ABPP) diplomat, and licensed Louisiana prescribing medical psychologist, along with co-editor Dr. Bret Moore, ABPP and licensed New Mexico conditional prescribing psychologist, highlight the concept of the integrative view throughout the text.

They use the term psychobiosocial to stress the need to combine psychological, biological, and social systems. They point out that research and theory, and especially treatment, must be viewed in this broad and inclusive perspective. They present a view that takes into account the multiple influences and feedback loops on and by a “living, surviving, and adapting person.”

“I worked in primary care in Maurepas at a family clinic,” Dr. Muse told the Times, “and found the experience taxing and eye-opening. I would never have found myself in primary care if it were not for the medical psychology piece. I worked with underprivileged children who had never seen a psychologist, nor had their psychotropics ever been reviewed by a prescribing mental health specialist. The family practitioner was doing the best he could, as there were no psychiatrists in sight. He was progressive and forward-looking and wanted desperately to get a mental health professional on board.”

This awareness for a comprehensive model is highlighted throughout the Handbook, and most clearly in the beginning chapters, where Muse and Moore set out the philosophical framework, defining psychopharmacology as a subset of medical psychology and medical psychology as including “… health psychology, rehabilitation psychology, pediatric psychology, neuropsychology, and clinical psychopharmacology, as well as subspecialties in pain management, primary care psychology, and hospital-based (or medical school-based) psychology.”

As an educational resource the Handbook has real muscle. Chapters are logically structured with consistent statements of theme, effective expansion into relevant subtopics, and concise summaries. The writing style is clear, fast and straightforward. An excellent use of tables and charts graphically consolidates information. Sections for “Key Terms” make it easy to scan and process information. Post-tests engage the reader and contribute to interactive learning.

The Handbook also includes a CD-ROM with practice questions based on the American Psychological Association’s Psychopharmacology Examination for Psychologists (PEP). The reader can prepare for the actual experience of the exam, with 150 questions from ten content areas, presented in a timed, 3-hour format if desired. This ingenious approach no doubt comes from Muse’s bent toward education methods, a theme mirrored in his website, MensanaPublications.

“Those preparing for the PEP never seem to get enough rehearsal questions to satisfy their hunger,” Mark explained. “There are an additional 250 questions as a Mensana CE quiz with the same title,” he said, allowing additional practice.

The Handbook easily fulfills its promise of reviewing foundations for psychologists who want to be conversant with psychopharmacology, and should also be especially useful to those who simply want to be able to help their clients ask the right questions about medications.

In a spirited Forward, “Integrating Care: A Forward on Changing Times,” Drs. Pat LeLeon and Jack Wiggins, both past APA presidents, applaud the

text and the direction. “… an excellent treatise written by psychologists for psychologists,” they write. And, “Lamentably, it has become commonplace in physicians’ offices to dispense psychotropic medications without an appropriate diagnosis and to do so by providers with little or not training in alternative psychological interventions for behavioral disorders.” LeLeon and Wiggins also point to Louisiana’s Drs. Glenn Ally and James Quillin as prominent in the prescriptive authority movement in psychology.

In Chapter 1, “Medical Psychology: Definitions, Controversies, and New Directions,” Drs. Muse and Moore explain the philosophical issues and controversies in the field, a theme repeated in many of the chapters: that the living, adapting human requires a biopsychosocial paradigm, and not the medical model.

The term Medical Psychology is an umbrella term they say, “… it encompasses the multiple specialties and make up health-care psychology, embracing the biopsychosocial paradigm of mental/physical health and extending that paradigm to clinical practice through research and the application of evidenced-based diagnostic and treatment procedures.” They explain the limitations in the Cartesian idea that mind and body are separate, the limitations of the medical model, or the idea that an individual’s social environment is irrelevant.

They object to Louisiana’s Act 251 because, they say, it “… builds upon the definition issues by the U.S. Drug Enforcement Agency (DEA) which recognizes that the term medical psychologist refers to a mid-level provider/practitioner who has prescriptive authority.”

In Chapter 2 Muse and Moore outline more of their rationale, “Integrating Clinical Psychopharmacology within the Practice of Medical Psychology.” Authors point to interesting research demonstrating the complexity and interactions in this psychobiosocial perspective, with examples such as: research on OCD that indicates behavioral therapy is more effective than medication and behavior therapy together; that phobias are better treated with CBT and provides longer- lasting effects; and that 70 percent of the response to antidepressants medications is considered to be placebo. Authors summarize the major large-scale studies such as the STAR*D, TADS, and CATIE studies.

Chapter 3, “Neuroscience,” by Drs. Ken Fogel and George Kaplka (Pediatricians and Pharmacologically Trained Psychologists: A Practitioner’s guide to Collaborative Treatment) write, “Homeostatic balance is the ‘holy grail’ of living things, …” They include sections on neurons,

neurotransmitters, central nervous system, structure and function of the brain, and peripheral nervous system.

In Chapter 4 “Nervous System Pathology” authors provide a comprehensive list of disorders including “Nuerodegenerative/cognitive disorders,” “Mental Retardation,” “Neurodevelopmental Disorders,” “Vascular Disorders.” Readers will appreciate a section on “Behavioral/Psychological disorders with a Neuropathological Basis.”

Chapter 5 reviews “Physiology and Pathophysiology,” including the functional systems of the body, including endrocrine, hormonal, cardiac, digestive systems, and others.

Dr. Robert Younger, ABPP and Navy psychologist with prescriptive authority authors Chapter 6, “Biopsychosocial and Pharmacological Assessment and Monitoring.” He writes that safe and effective use of medications requires psychologists to know “… how to assess the biomedical status of patients, including ongoing assessment of iatrogenic effects of medications in general.” He explains history taking, psychological assessment, as well as physical and neurological examinations and laboratory testing. A list of drug-drug interactions, drug overdose, and a section for adverse drug reactions, are included.

Chapter 7, “Differential Diagnosis in Medical Psychology,” includes important sections on “Medical Disorders that Present as Psychological Disorders,” and “Psychological Disorders that Present as Medical Disorders,” along with other topics that are critical for today’s psychologists.

In “Pharmacology,” Chapter 8, the author addresses how drugs interact with the body to produce effects as well as how they are metabolized and distributed.

Chapter 9, “The Practice of Clinical Psychopharmacology,” by Drs. William Burns, Lenore Walker, and Jose Rey, is one of the longer chapters and explains the “integration of psychotherapeutic and pharmacotherapeutic modalities of treatment.” An extensive table on “Drug Indications, Dosage Ranges, Side Effects, Routes of Administration, FDA Approval for Children, and Pregnancy Risk” is worth the cost of the book. Also described is drug metabolism and CYP450 (Cytochrome P-450), the enzymes involved in detoxification.

“Research in Clinical Psychopharmacology” Chapter 10, and “Professional, Legal, Ethical, and Interprofessional Issues in Clinical Psychopharmacology” Chapter 11, complete the text.

“My hope,” Dr. Muse explained to the Times, “… is that it is a true reflection of the breadth of training a medical psychologist undergoes. I would like the detractors to read it before asserting that prescribing psychologists’ training is insufficient. It is, in fact, more rigorous than psychiatry or practical nursing’s preparations for integrating psychotropics into overall mental health diagnosis and treatment …”

Handbook of Clinical Psychopharmacology for Psychologists is a valuable addition to any psychologist’s library resources, a practical guide for key knowledge bases regarding biological, pharmacological, differential diagnosis, ethical issues, and the important contributions and perspectives that psychologists can bring to the challenges of modern healthcare.

Dr. Mark Muse and Dr. Bret Moore will be presenting aspects of Handbook at the American Psychological Association Convention, on Thursday, August 2, in a presentation titled, “New Resources for Preparing for the Psychopharmacology Exam for Psychologists (PEP).”

The book is widely available from the publisher (Wiley) and distributors. Also, Mensana Publications offers a 20 percent discount on the Handbook and all other books bought through the website link to the publisher.

Dr. Muse completed his doctorate in clinical research and counseling psychology at Northern Arizona U. in 1980 and next was awarded the Licentiate degree in clinical psychology by the Universitat de Barcelone in 1984. He later completed a postdoctorate M.S. in clinical psychopharmacology. He served as full professor at the Universitat de Ramon Llull, Barclona, lecturing in Catalan and Spanish. He returned to the U.S. in 1998. He is the author of six books in the area of psychology as well as numerous articles appearing in psychology and medical professional journals.