WK 1 SOCW 6443 Discussion 2: Ethical Dilemas for Mental Health Professionals

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Ethics & Behavior

ISSN: 1050-8422 (Print) 1532-7019 (Online) Journal homepage: https://www.tandfonline.com/loi/hebh20

Ethical Care for Vulnerable Populations Receiving Psychotropic Treatment

Darren R. Bernal, Rachel Becker Herbst, Brian L. Lewis & Jennifer Feibelman

To cite this article: Darren R. Bernal, Rachel Becker Herbst, Brian L. Lewis & Jennifer Feibelman (2017) Ethical Care for Vulnerable Populations Receiving Psychotropic Treatment, Ethics & Behavior, 27:7, 582-598, DOI: 10.1080/10508422.2016.1224187

To link to this article: https://doi.org/10.1080/10508422.2016.1224187

Accepted author version posted online: 16 Aug 2016. Published online: 20 Sep 2016.

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Ethical Care for Vulnerable Populations Receiving Psychotropic Treatment

Darren R. Bernal, Rachel Becker Herbst, Brian L. Lewis, and Jennifer Feibelman

Department of Psychology University of West Florida

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

Keywords: socioeconomic status, elderly, immigrants, ethics, psychotherapy

PSYCHOPHARMACOLOGICAL TREATMENT OF VULNERABLE POPULATIONS

Mental health treatment in the United States has evolved to include professionals from multiple fields, both within and outside of psychology. Many patients receive psychopharmacological interventions in conjunction with psychotherapy. As a result, psychologists may face ethical dilemmas when patients in their care receive suboptimal treatment from other sources, such as when psychotropic medications are prescribed by nonpsychiatrists. Populations such as the working poor or racial/ethnic minorities have risk factors that leave them vulnerable to adverse

This article was accepted under the previous editor, Gerald P. Koocher. Rachel Becker Herbst is now a Pediatric Psychologist at the Department of Physical Medicine and Rehabilitation,

Children’s Hospital Colorado. Brian L. Lewis is now in independent practice in Roanoke, Virginia. Jennifer Feibelman is now with the Graduate Student Department of Psychology at University of West Florida.

Correspondence should be addressed to Darren R. Bernal, Department of Psychology, University of West Florida, 11000 University Parkway, Pensacola, FL 32514. E-mail: [email protected]

ETHICS & BEHAVIOR, 27(7), 582–598

Copyright © 2017 Taylor & Francis Group, LLC

ISSN: 1050-8422 print / 1532-7019 online

DOI: 10.1080/10508422.2016.1224187

side effects from psychotropic medications. This increased risk likely results from a confluence of factors such as marginalization, interpersonal bias (Levine & Ambady, 2013), inadequate treatment (Alegria et al., 2008), and provider–patient communication difficulties (Verlinde, De Laender, De Maesschalck, Deveugele, & Willems, 2012; Zolnierek & DiMatteo, 2009). In addition, the likelihood that psychologists will treat members of vulnerable populations is increased by growth among these populations and increasing prevalence of psychotropic treat- ment. Due to changes in health care professionals’ roles—especially concerning psychopharma- cological prescriptions—it is important for mental health professionals to build competence to respond to the needs of vulnerable populations. This article introduces ethical concerns for treating vulnerable populations and offers guidelines for mental health professions working with these populations.

Increasing Prescription Rate

Prescription of psychotropic medications such as antidepressants has undergone a dramatic change in the past 25 years (Pincus et al., 1998) with usage increasing in American adults from 6.1% to 11.1% between the years 1988–1994 and 1999–2002 (Paulose-Ram, Safran, Jonas, Gu, & Orwig, 2007). Although research indicates that the use of antidepressants may have peaked in the early 2000s (Harman, Edlund, & Fortney, 2009), the prescription of antidepressant medications has shown a continued increase in certain populations such as the elderly (Hanlon, Handler, & Castle, 2010), older nursing home residents (Maguire, O’Reilly, Hughes, & Cardwell, 2011), and some racial/ ethnic minority groups including African Americans and Latinos (Paulose-Ram et al., 2007). The role of psychopharmacology has become increasingly relevant in light of the declining use of psychotherapy. Between 1998 and 2007 the reported rate of psychotherapy use decreased from 53.6% to 43.1% per 100 persons receiving outpatient treatment for depression (Marcus & Olfson, 2010; National Alliance of Professional Psychology Providers, 2010). This approximately 10% drop in psychotherapy utilization was accompanied by an increase in prescription of psychotropic medication (Marcus & Olfson, 2010). Despite this prescription increase, research on the use of these medications with vulnerable populations is generally lacking in adequate drug trials. Thus, there is an increased demand for and an expansion of medications, but there is insufficient informa- tion about prescribing effectively in vulnerable populations. This is of particular concern, as the role of the primary care provider has evolved from gatekeeper to direct and sole provider of mental health care for many patients with depression.

Decreasing Referrals

Historically, primary care providers conducted assessments and referred patients to specialists when needed, such as when psychological problems were suspected. However, the primary care setting has emerged as the most common avenue to psychotropic treatment, thus disrupting the traditional referral pathway to psychologists. The use of psychotropic medications as “the first line of defense” (Gray, Brody, & Johnson, 2005; National Alliance of Professional Psychology Providers, 2010) is not inherently problematic, as they are valuable for treating mental health concerns; however, several factors complicate the treatment process. Due to greater demand for psychological skills in primary care settings, existing gaps in treatment and training have become more pronounced. Deficiency in psychological skills and increased medication prescription compound with risks particular to

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vulnerable populations and further increase risks. Because members of vulnerable populations are underrepresented in clinical trials and because primary care providers may not be well versed in multicultural mental health considerations, there is more risk for error in prescribing psychotropics to members of vulnerable populations.

Psychiatrists maintain that there has been a long-standing problem of insufficient mental health training for primary care providers and this is an area in need of improvement (Hodges, Inch, & Silver, 2001). As a result of increased time pressures and inadequate training, primary care providers often rely on brief screening methods, and residents have reported feeling underprepared to deal with the psychosocial problems of their patients (Duke, Griffith, Haist, & Wilson, 2001). In addition to feeling underprepared, primary care providers are not substitutes for psychologists, as they are not trained to provide therapy. This undesirable situation may present a larger disservice to the patient or provider.

Despite these concerns, primary care providers in the United States have been found to prescribe up to 70% of antidepressants (National Alliance of Professional Psychology Providers, 2010), which belong to the second most prescribed class of drugs in America, preceded only by antihypertensives (Lindsley, 2015). This increase of psychotropic medication prescription by primary care providers is disconcerting, given these providers’ documented difficulty in accurately identifying mental health problems (Furedi, Rozsa, Zambori, & Szadoczky, 2003; Jones, Badger, Ficken, & Leeper, 1987; Von Ammon Cavanaugh & Elliott, 1988; Watts et al., 2002) and their propensity to prescribe psychotropic medications without consistently making a formal diagnosis (Beardsley, Gardocki, Larson, & Hidalgo, 1988). Studies using the NIMH Diagnostic Interview Schedule found a low detection rate of mental health concerns by general practitioners in their patients (Jones et al., 1987), as well as a low level of agreement between the general practitioner’s diagnosis and standardized measures for diagnosis (Furedi et al., 2003), with increased diagnostic accuracy when patients presented a lack of somatic complaints. The purpose of highlighting these discrepancies is not to criticize primary care providers for making diagnostic errors in the area of mental health, but rather to raise awareness among psychologists of an ethical concern, as these errors have implications for our field and our patients. An additional concern is the need for continued monitoring for some psychotropic medications due to deleterious side effects. In a small number of cases, primary care providers may not able to provide consistent monitoring of mental health and psychotropics due to lack of patient follow-up.

Shifting Prescription Rights and Professional Roles

The number of health care professionals with prescription rights may compound the problem of pharmacotherapy without adequate monitoring capacity. In addition to primary care provi- ders, about one fourth of advanced practice psychiatric nurses have the ability to prescribe independently in 15 states as of 2003 (Feldman, Bachman, Cuffel, Friesen, & McCabe, 2003). In addition, nurses can collaborate with providers to prescribe in another 27 states (Feldman et al., 2003). These nurses are often in the position to see vulnerable populations due to their potentially lower billing rate and location in rural areas. This additional prescription authority represents another health professional with whom psychologists may collaborate in order to provide optimal services to their patients.

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Further complicating the treatment process, psychiatry, a discipline that is typically associated with psychology, has a personnel shortage (Lipzin, 1979; Thomas, Ellis, Konrad, Holzer, & Morrissey, 2009). The current data indicate a shortage of psychiatrists in 96% of American counties (Thomas et al., 2009), and this overall trend is expected to continue until at least 2020, according to the U.S. Department of Health and Human Services (2006). This shortage also increases the difficulty of finding psychiatrists who have expertise in areas underrepresented in research, such as treatment of specific immigrant cultures. Not having enough psychiatrists to meet the demand puts an additional burden on the primary care providers to address mental health needs.

With a shifting psychopharmacological atmosphere, it is important to define the roles of psychologists in treatment of medicated patients (McGrath & Rom-Rymer, 2010). A psycholo- gist may have prescription rights or may work more indirectly by advocating for patients and collaborating with other health care professionals. Psychologists must assess whether they have the competence required for collaborating on medication prescription decisions and must decide if their input regarding medication prescription is to the benefit of the patient. Factors that may influence these decisions include the number of clientele taking psychotropic medications, consideration of medications’ side effects, age of patients, race and ethnicity of patients, and severity of patients’ illness or symptoms. Currently, there is a gap within the health care delivery system, with a large proportion of psychotropic medication prescriptions being ordered by primary care providers who have not had extensive mental health care training. Similarly, most psychologists have not had extensive biological or medical training. Psychologists can close this gap by collaborating with providers, by advocating for their patients, and by serving as consultants for other health care professionals.

THE ROLE OF THE PSYCHOLOGIST

Vulnerable populations may receive substandard health care, which can result in increased, rather than decreased, suffering. Patients receiving substandard pharmacotherapy while engaged in psychotherapy may misattribute their side effects. For example, patients may attribute increased mood fluctuation or depressed mood to their participation in psychotherapy if they are not properly informed about their medications. The advent of integrated care, increased use of psychotropic medications, and the burgeoning size of vulnerable populations such as Latinos and the elderly in the United States (U.S. Census Bureau, 2012) have combined to create a new frontier in the treatment of mental health concerns. Psychologists are thus faced with a new role and new challenges, and this is particularly true when helping marginalized populations.

To address psychologists’ role of working with pharmacotherapy, the American Psychological Association’s (APA’s) ethics task force concluded that issues related to prescriptive authority were addressed under current sections of the Ethical Principles of Psychologists and Code of Conduct (APA, 2010) and did not require a special section (Resnick & Norcross, 2006). Therefore, the current Code of Conduct (APA, 2010) lacks specific guidance on potential ethical dilemmas associated with psychotropic medication; however, it does provide a framework from which to approach these ethical concerns. In this section, we discuss the broad application of this framework to the psychologist’s role in working with patients from vulnerable populations who are receiving

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pharmacotherapy. We build upon this foundation in subsequent sections, where we present considerations specific to different vulnerable populations.

The Code of Conduct (APA, 2010) has two principles and one standard that are particularly salient to ethical dilemmas posed by working directly with vulnerable populations who are being prescribed psychotropic medications. The first relevant principle is Principle E: Respect for People’s Rights and Dignity. This principle states, “Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices” (APA, 2010, p. 4). The vulnerable populations discussed in this may have been subjected to biases such as those based on age, language, race, and social status—biases that could affect the accuracy of their evaluations for psychotropic prescription. If the psychologist suspects that his or her patient may have been misdiagnosed and subsequently may have received suboptimal treatment, Principle E becomes pertinent. The implication is that the psychologist must take action to avoid condoning the less than optimal treatment that may stem from bias against these vulnerable populations.

When faced with a member of a vulnerable population who is receiving suboptimal psychotropic treatment based on membership in that group, a psychologist may choose to help the patient work more effectively with his or her primary care provider or obtain consent to cooperate directly with the primary care provider. It may be advantageous for potential prescriber collaboration to be covered in the initial informed consent for treatment. The second relevant APA guideline, Principle B: Fidelity and Responsibility, reads, “Psychologists consult with, refer to, or cooperate with other professionals and institutions to the extent needed to serve the best interests of those with whom they work” (APA, 2010, p. 3). Although psychologists typically do not have the training necessary to be competent in the prescription of psychotropic medication, it could be argued that some working knowledge of the usage and effects of these medications is necessary for competently treating patients where these medications are(or should be) used.Indeed,courseworkonpsychopharmacologyisarequired curricular component of some doctoral programs in counseling and clinical psychology and are available through continuing education. So when faced with a patient who is having adverse effects or potential misdiagnosis, is it within the scope of competence to take action?

The APA’s (2010) Code of Conduct 2.01: Boundaries of Competence states, “Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consulta- tion, study, or professional experience” (p. 4). Reassessing or working with psychotropic medication is beyond the scope of competence of most psychologists; however, diagnosing psychopathology in vulnerable populations is within the scope of competence. If the psychologist finds himself or herself frequently faced with the dilemma of patients who may not be receiving optimal treatment due to inappropriate medication, additional efforts to develop competence in this area are warranted. The section titled Boundaries of Competence further states that in the absence of standards, psychologists must “take reasonable steps to ensure the competence of their work and to protect patients … and others from harm” (APA, 2010, p. 5). Additional training in this case would not be to obtain prescription rights but merely to make the psychologist a better advocate for the patient and collaborator with prescription writers such as the primary care provider.

Social justice is also a component of a psychologist’s interaction with patients who receive poor mental health care based on classism, ageism, or racism. Social justice is integral to the APA principles (e.g., justice, beneficence, and nonmaleficence). By refraining from intervening, a psy- chologist may be causing harm. Psychologists are in a difficult position when addressing this

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injustice because they do not possess the training. However, they are in a position to help their patients receive and understand the psychopharmacological information patients deserve. When necessary to protect the welfare of the patient, psychologists can act as intermediaries, provided that informed consent is obtained beforehand. Acting as an intermediary may be useful if the patient is an inconsistent reporter of symptoms or situation. In the spirit of social justice, however, it is preferential to empower the patient to relay the information directly.

VULNERABLE GROUPS

Psychologists are ethically bound by their responsibility to act in their patient’s best interest and to ensure that their patients’ rights to optimal care are maintained. Factors placing patients at a heightened risk of receiving substandard care due to bias or underrepresentation compels psychologists to possess the knowledge, skills, and awareness to identify these potential dilemmas and intervene according to an ethical decision-making framework. Therefore, psychologists need foundational knowledge about populations vulnerable to these risks: older adults, people of low social status, immigrants, and racial/ethnic minorities. For increased understanding and readability, we present the literature for distinct categories of vulnerable populations. However, we acknowledge that intersectionality exists, such that members of one group (e.g., low social status) may also belong to another group (e.g., racial/ethnic minorities). In such cases, the intersection of factors, such as ethnicity and unemployment, may result in an accumulative risk for mental health issues (Mallett, Leff, Bhugra, Pang, & Zhao, 2002). Thus, reducing the complexity of an individual to one factor, such as social status, and then grouping that individual in a vulnerable population based on that factor is inherently problematic. Such a practice has great potential to miss the nuanced intersection of factors that compose an individual’s biological, psychological, and social contexts, as well as the person’s strengths and vulnerabilities. However, some research indicates that solitary factors can be associated with negative outcomes such as the overdiagnosis of schizophrenia in some ethnic groups (Snowden & Cheung, 1990; Strakowski et al., 2003). These factors represent a confluence of societal and psychological elements; therefore, we identify group memberships such as race or being of a low social status to highlight the “cause of the causes” and not to imply that belonging to the specific group is the problem. In other words, living below the poverty line does not directly translate into an increased risk for poor mental health; it is the social, biological, and psychological stresses of having low social status that are relevant to mental health risks. Other potentially vulnerable populations such as those distinguished by sexual orientation, gender, and disability were not reviewed directly but are also subject to bias in health care treatment and may be party to similar ethical considerations.

Social Status

Social status is the intersection of a person’s socioeconomic status, social class, and current social context and is a key social determinant of health and psychotropic prescription. The association between lower social status and increased prevalence of psychological problems has been consistently supported (Chazelle et al., 2011; Kristensen, Gravseth, & Bjerkedal, 2010; Stansfeld, Head, & Marmot, 1998). Social status has also been shown to influence physiological

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health status. The complex relationship between being lower on the social hierarchy and physical health outcomes (e.g., life expectancy and hypertension) has been well established across a variety of populations (Marmot, 2015; Satcher, 2001). Social status factors such as employment, financial wealth, and social rank may account for some of the increased pathology manifested in lower social classes and represent additional considerations for mental health diagnosis and treatment. Considering these social determinants of health pharmacotherapy on its own may not be the optimal response for the multiple factors that contribute to poor mental health in people of low social status.

Financial disadvantage and minority status can interact to intensify the effects of poor mental health outcomes or services. Limited financial resources and belonging to a minority population have been linked to increased likelihood of being uninsured, underinsured, or lacking access to health care (Newport & Mendes, 2009). Being uninsured has been consistently related to inadequate levels of mental health treatment in minority populations, beginning in childhood (Kataoka, Zhang, & Wells, 2002) and continuing into adulthood (Wang, Berglund, & Kessler, 2000). Employment status is also consistently associated with mental health. The longitudinal White Hall studies of social class found that work characteristics were responsible for much of the variation in depression and well-being (Stansfeld et al., 1998). Although unemployment is not a stable dimension of identity, it disproportionately afflicts minorities of all education levels and individuals with lower levels of education. Being unemployed or having a lower level of education has also been linked to increased anxiety and depression as diagnosed by providers (Ansseau et al., 2008). Similarly, patients who were unemployed or had lower levels of education were prescribed more anxiolytics/antianxiety medications by primary care providers when compared to employed and higher educated popula- tions (Kisely, Linden, Bellantuono, Simon, & Jones, 2000).

Low social status has been linked to increased prescription of antidepressant medications (Olfson & Marcus, 2009; Roer, Fonager, Bingley, & Mortensen, 2010; Von Soest, Bramness, Pederson, & Wichsrtom, 2012). Individuals of low social status are therefore more likely to be prescribed antidepressant medication despite being at increased risk for lack of adherence, poor doctor–patient communication, and potential misdiagnosis. Meta-analysis of doctor–patient com- munication identified differences in patient-centered behavior, nonverbal behavior, and affective behaviors, suggesting that lower social status may disadvantage individuals when interacting with the prescribers (Verlinde et al., 2012).

The status difference between a higher social status prescriber and a lower social status patient affects quality of care and prescription adherence. Low social status has been related to premature discontinuation of antidepressants use (Bocquier et al., 2014; Sundell, Waern, Petzold, & Gissler, 2013). A review of 60 years of research related prescriber–patient communication styles to differ- ences in prescription adherence levels (Zolnierek & DiMatteo, 2009). Social status is related to a more directive and less collaborative care style received by lower social status patients in prescriber communication style (Willems, De Maesschalck, Deveugele, Derese, & Maeseneer, 2005).

In addition, social status may serve as a psychological barrier to seeking help. Lower social status patients reported low confidence and low trust in primary care provider’s ability to address their mental health needs (Kravitz et al., 2011). The combination of help-seeking behaviors, systemic stressors, communication differences, and limited economic means can diminish the agency needed to play an effective role in fine-tuning pharmacotherapy.

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Racial and Ethnic Minorities

The APA (2002) describes race as more “socially constructed, rather than biologically determined” (p. 9), emphasizing that there is more in-group variation than between-group variation. Ethnicity is also a social construct. The distinguishing factor, though, is its roots in individuals’ cultures of origin. Ethnicity describes the cultural background of individuals and their related traditions. It is possible for individuals to identify with multiple ethnicities.

Disparities in mental health have been established between African American, Latino, and White American populations (Satcher, 2001). Moreover, African Americans not only are diagnosed at different rates than White Americans but also have worse prognoses when diagnosed with common conditions like major depressive disorder (Williams et al., 2007). African Americans are also more likely than Whites to be diagnosed with schizophrenia and are typically prescribed higher levels of medication (Snowden & Cheung, 1990; Strakowski et al., 2003). Ethnopsychopharmacology has demonstrated ethnic variation in drug metabolization; African Americans and Asian Americans often metabolize antipsychotic and antidepressant medications more slowly than Caucasians (Lin, 2001; Strickland, Stein, Lin, Risby, & Fong, 1997). With the growing evidence on genetic variation in drug response to common psychotropics such as selective serotonin reuptake inhibitors, the differences in medication response will continue to be an issue (Chaudhry, Neelam, Duddu, & Husain, 2008). Race affects psychotropic medication usage and response along physiological, psychological, and cultural dimensions, and this complex interaction must be accounted for in treatment.

Diagnosis may be influenced by differential expression of symptoms of mental health concerns. Disparities in the prevalence of mental health between racial/ethnic minority groups indicate that thorough diagnostic assessment must take ethnicity into account. For example, African Americans and Latinos have been shown to somaticize psychological complaints (Ayalon & Young, 2003) more frequently than Americans of the dominant culture. Health care providers must also balance the knowledge of different prevalence of some mental health conditions without generalizing, developing bias, or failing to consider individual differences.

Furthermore, help-seeking patterns may differ across racial/ethnic groups. African Americans often seek help through informal sources such as friends and neighbors before seeking help from medical professionals such as primary care providers (Ayalon & Young, 2005; Woodward et al., 2008). The use of informal networks may extend as far as sharing medications (Comas-Díaz, 2012). It is not known whether this help-seeking behavior in African Americans is detrimental to their treatment outcomes when they do seek treatment. This help-seeking behavior may be an indication of strong social support, but it also indicates that African Americans may interact differently with providers. If providers expect that racial/ethnic minorities seek help in a similar manner as the dominant culture, this may lead to misunderstandings and inappropriate treatment.

The nature of interactions between racial/ethnic minority populations and providers affects treatment-seeking behaviors, quality of medication adherence, communication, and treatment (Johnson, Roter, Powe, & Cooper, 2004; Manfredi, Kaiser, Matthews, & Johnson, 2010). Cultural factors may contribute to lower medication adherence rates in Latinos and African Americans (Diaz, Woods, & Rosenheck, 2005). Nonadherence may result from drug expense, unavailability, and miscomprehension of dose and schedule. The combination of both lack of monitoring and the potential for misdiagnosis with differences in metabolization of medication

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may lead to extrapyramidal side effects (Binder & Levy, 1981). Racial/ethnic minority populations therefore could be particularly vulnerable to health complications, which may become evident while under the care of a psychologist.

Older Adults

The World Health Organization (2014) defined the elderly as anyone who is age 60 or older. It is projected that the world’s elderly population will double between the years 2,000 and 2,050 to reach about 2 billion, or about 22%. This growing demographic is often overmedicated (Hanlon et al., 2010), especially in the nursing home setting (Maguire et al., 2011). Not only are primary care providers the main prescribers of psychotropic medication to the elderly, but pharmacotherapy is also the most commonly provided provider service to this group (Larson, Lyons, Hohmann, Beardsley, & Hidalgo, 1991). In a review of the small body of literature on psychotropic usage in older racial/ethnic minority groups, older African Americans were found to use psychotropic medications at lower rates than White Americans (Voyer, Cohen, Lauzon, & Collin, 2004). Elderly populations have been theorized to be at an increased risk for medication nonadherence, but this predictive relationship is not conclusively supported in the literature (Hughes, 2004). Overall medication adherence is higher for White Americans when compared to African Americans and Latinos. Thus, older African Americans and Latinos may be at risk for poor psychopharmacological treatment due to lower prescription adherence (Lanouette, Folsom, Sciolla, & Jeste, 2009).

A systematic review of the literature found that inappropriate prescription of psychotropic medication occurred approximately 9% to 24% of the time for the elderly (Mort & Aparasu, 2002). In some cases, the side effects of these medications have interfered with psychotherapy and have even led to fatal outcomes, prompting the government to issue warnings (U.S. Food and Drug Administration, 2005). Psychopharmacologic treatment of the elderly population is particularly problematic because specific dosages of psychotropic medications are tested less frequently on the elderly than on younger adult populations due to the difficulty of recruiting elderly participants who meet study criteria. This underrepresentation increases the need for monitoring side effects. As a result, the elderly may be considered especially vulnerable and require a greater level of psychological care than they are currently receiving.

Immigrants

Immigrants encounter many of the same challenges faced by other vulnerable populations; however, unique factors have the potential to impact immigrant health and treatment. For example, immigrants tend to earn significantly less than native-born individuals, and many are from nondominant racial/ethnic groups (Camarota, 2005; Kochhar, 2008). Immigrants from the Latino and Caribbean Black populations have demonstrated deteriorating mental health associated with increased length of stay in the United States (Alderete, Vega, Kolody, & Aguilar-Gaxiola, 2000; Jackson et al., 2007). Although the mechanism of this phenom- enon is unclear, the immigrant paradox requires health care providers to attend to the length of time an immigrant has resided in the United States and to be aware that a longer stay may intimate increased vulnerability. Acculturative factors related to a decrease in health, such as language barriers, may also be associated with potential difficulties with pharmacotherapy.

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For example, studies have found a relationship between limited English proficiency and difficulties obtaining health insurance coverage and accessing health care (DeNavas-Walt, Proctor, & Smith, 2008; Yu, Huang, Schwalberg, & Nyman, 2006).

Beyond the more salient characteristics of language and time spent in the United States, considerations related to help-seeking behaviors and symptom presentation must be examined. These elements of culture, which are more covert and dynamically intertwined with individuals’ health schemas, may significantly influence the type of health care received. The role of doctor differs by culture (Neighbors et al., 2007). Immigrants’ vestigial schemas of health care systems in their native countries may interfere with their ability to receive adequate care in the United States, especially when individuals need to be clear from whom to seek medication advice and how to understand potential pharmacological side effects. Psychosomatic manifestation of symptoms also differs by culture, and this may obfuscate accurate diagnoses (Patel, 2001), which places additional barriers on immigrants’ receipt of adequate health care.

Factors associated with immigration status, socioeconomic status, racial minority status, and acculturation place individuals in a vulnerable position within the health care system. Furthermore, the intersectionality effect of these factors (Cole, 2009) places these individuals at a higher risk than individuals from the dominant culture for deleterious experiences in the management of their mental health concerns. Therefore, it is important for providers and psychologists alike to be mindful of ethical dilemmas that may arise when employing pharma- cotherapy treatment with immigrant patients.

RECOMMENDATIONS

Psychologists must take proactive steps to address ethical concerns for psychopharmacological treatment of vulnerable populations. This requires the use of an ethical decision-making framework that integrates the aforementioned standards from the APA’s Code of Conduct with specific knowledge of risk factors within vulnerable groups. To facilitate this process, we provide strategies to help address these concerns through education, training, direct clinical care, consultation, advocacy, policy change, and research.

Education and Training

Psychologists have a role to play in decreasing the risk of negative outcomes for vulnerable populations in regard to psychotropic medications. Psychologists should seek further specia- lized training to meet the needs of the current landscape where psychotropic medications are an integral part of treatment. Incorporation of the knowledge of additional psychotropic medication risks associated with underrepresented populations is essential. Failing to do so could indicate negligence, as it would leave psychologists unable to understand the full gamut of their patients’ concerns. Providing input on psychotropic medication, without having had specific training, is outside the scope of competence and could be considered unethical. There is evidence that training psychologists to advise patients about psychotropics may be feasible, as Gutierrez and Silk (1998) found evidence in the literature that psychologists are capable of prescribing effectively. Alternatively, psychologists can also adopt and expand on the APA’s recommendations (Smyer et al., 1993), in particular those encouraging increased collaboration.

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Furthermore, consultation steps recommended by Haley et al. (1998) should be considered an integral part of the response in vulnerable cases.

Consultation and Advocacy

Consultation with prescribers is a concrete step that psychologists can take to improve quality of patient care and to respond to the additional risks faced by vulnerable populations. In the new mental health landscape, psychologists must be open and willing to collaborate in a consulting role to provide a high level of treatment service for those who choose medication only to address mental health concerns. The role of a good consultant includes components of advocacy and social justice. In integrated care settings, consultation and collaboration with prescribers is actively encouraged; however, in external or colocated systems, psychologists may need to initiate relationships with primary care providers and emphasize the benefit of the role of collaboration for patient well-being. This outreach is particularly salient because primary care providers often report difficulty finding mental health care for their patients (Cunningham, 2009). In an environment of increased liability, collaboration to correctly diagnose and treat patients is an attractive proposition. However, a psychologist’s mere presence in a collaborative relationship is not enough; optimal treatment obliges the psychologist to establish themselves as resource for both the patient and prescriber.

Diagnostic Clarification

Members of vulnerable populations may express and respond to mental health concerns differently. The somatization of psychological concerns can be addressed through psychoe- ducation with the patient and training provided to prescribers regarding differential cultural expression of symptoms. This psychoeducation may also increase medication adherence by addressing the potential disconnect between treating somatic symptoms with medicine perceived to be psychological prescription.

Misdiagnosis or overmedication may result from communication challenges, improper or damaged screening tools, or lack of feedback about side effects. Prescribers utilizing brief screening tools that rely on the self-report of psychological symptoms may be less effective in identifying mental health concerns in racial/ethnic minority groups than in the dominant White American population (Ayalon & Young, 2003). This dilemma may be mitigated by the psychologist commu- nicating directly with the prescriber or indirectly through the patient. Power differentials between the prescriber and patient are also a viable target of intervention for psychologists who can change the patient’s schema of the prescriber–patient relationship to a more collaborative one. For example, psychologists who work with overmedicated elderly patients may intervene by discussing with their patients the possibility that they are inappropriately medicated. A collaborative relationship between the psychologist and the prescriber may result in significant benefits for the patient.

Promoting Adherence

Psychologists’ training positions them to directly respond to potential disparities and ethical dilemmas in pharmacotherapy. For example, consistent adherence to medication is required

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for the desired effect; however, adherence issues and the underutilization of services in vulnerable populations may necessitate an additional emphasis on monitoring. Some aspects of medication nonadherence may directly relate to vulnerable groups’ risk factors, such as lack of insurance, transportation difficulties, lack of education/understanding of the impor- tance of adherence, and differential response to medication resulting in an ineffective dose response. Periodic checks on the patient’s adherence and communication with the prescriber may bridge the gap between prescriber visits. Psychologists can also facilitate the identifica- tion of potential barriers to adherence, engaging the patient in motivational interviewing and behavioral strategies to promote adherence.

Patient–Prescriber Communication

Communication between the patient and prescriber may be impeded by a mismatched communica- tion style, mistrust, and power differentials that can be ameliorated by a psychologist. For example, the less collaborative communication received by lower social status patients (Willems et al., 2005) may be counteracted by raising patient awareness of these differences. Patients receiving treatment from a prescriber who has a more directive style of communication may benefit from assertiveness training focused on advocating for their treatment preferences. Psychologists can also offer training to prescriber colleagues, presenting research regarding potential communication pitfalls and evidence- informed communication strategies (e.g., motivational interviewing, open-ended questioning). Mistrust of treatment providers may be addressed in therapy through the clarification of roles, expectations, and reflection on negative experiences. If perceived as beneficial and empowering, psychologists may also facilitate difficult dialogues between patients and prescribers regarding mistrust, engaging in strategies to strengthen the patient–prescriber relationship. Psychologists’ training regarding effective communication, relationship building, and power differentials uniquely positions them to identify these potential ethical concerns and guide them to empower, advocate for, and educate their patient.

Policy Change

The increased prevalence of mental health disorders has been identified as a result of social determinants of health (Marmot, 2015). Considering the contextual factors that contribute to the increased prevalence of psychological disorders, a complete solution must also include contextual factors. Treating a social problem with prescription may be a short-term solution. Psychologists must advocate for policies that address inequities in treatment such as lack of insurance, underrepresentation in research, and communication difficulties.

Psychologists can affect public and organizational policy, both individually and through organiza- tions such as the APA. The social justice mandate of the APA principles calls for psychologists to be aware of and active in policies that have ramifications for their patients, at an organizational and government level. Knowledge of policy changes, such as the establishment of Medicaid criteria for appropriate psychotropic medication use, is needed to effectively serve vulnerable populations. Opening a discussion about psychotropic public policies, such as prescription rights for psychologists, may raise awareness that could facilitate a subset of psychologists to provide consultation services. Creating organizational policies that mandate the availability of therapy or provide information about

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psychotherapy to individuals using psychotropic medications may ensure a consistent quality of care. These actions of advocacy have the potential to close the treatment-monitoring gap for patients.

Research Priorities

Further research on the manifestation of psychopathology in diverse populations may also help to reduce misdiagnosis and to improve both psychotropic and psychotherapeutic treat- ments. Specifically needed is research that facilitates documentation of the prevalence of psychological illness across populations, validation of screening measures in underrepre- sented groups, and increased understanding of societal and contextual factors that may contribute to differences in treatment outcomes. Many of the previously established associa- tions, such as the relationship between low social status and poor mental health, should continue to be examined with the aid of new multivariate statistical techniques in order to clarify the modifiable psychological factors. Further study is also necessary to understand collaboration trends between primary care providers and psychologists when dealing with vulnerable populations. It is equally important to expand the examination of this collabora- tion in residential facilities for disabled or older adults and in settings where a psychologist is unlikely to be consulted, such as private primary care practices. Research already indicates positive results in integrated care by specialists who collaborate with treatments (Pampallona, Bollini, Tibaldi, Kupelnick, & Munizza, 2004).

CONCLUSION

The intersection of the risks factors experienced by patients in vulnerable populations creates the potential for unequal and potentially substandard quality of psychotropic care. Inequity remediation in psychotropic care for vulnerable populations is a systemic problem and requires more interdisciplinary collaboration. Optimal treatment requires raising the level of specific training to increase expertise for working with these populations. For instance, psychological specialization (e.g., geropsychology) positions psychologists to collaborate more effectively with experts in psychopharmacology. Demographic characteristics such as low social status, race, age, or immigrant status and their inter- section appear to be associated with vulnerabilities in psychotropic treatment. Consideration of this vulnerability is the ethical responsibility of a psychologist. Trends in the prescription and use of psychotropic medication impel psychologists to proactively establish collaborative relationships with prescribers, contribute to organizational and public policy change, support research into pharmacother- apy and treatment considerations with vulnerable populations, seek specialized training in pharma- cotherapy, and engage in patient-level advocacy. Through engaging in an active role in the pharmacotherapy management of vulnerable populations, psychologists can prevent ethical dilemmas, improve the quality of patient care, and ameliorate health disparities.

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