Psychologists Prescribing Bill Introduced – Ohio Academy of Family Physicians

Below is the letter I drafted in regards to Ohio’s Bill 326–The Psychologist’s Prescribing Bill.

I plan on sending this to every member of the Ohio senate as well as the Governor.

I encourage everyone to write their own letters, however, I am currently sharing the letter with physician colleagues of all specialities via two physician facebook groups.

Dear Senator,

I am writing you as a physician who specializes in psychiatry, along with my colleagues, who represent various specialties —from psychiatry to surgery— and from multiple states, regarding Bill 326 which is being considered in Ohio to expand the scope of talk therapists (psychologists) to practice medicine via ‘prescribing’ psychotropic medications. While we are not all Ohio residents, we are all physicians. Our ethical duty is first and foremost to patients. Therefore, advocating to protect them from harm vis a vis the lowering of standards to practice medicine, makes all those potentially affected—be it Ohioans or Californians—simply Americans. Our profession requires of us an ethical commitment to protect patients as a group, not only those on our insurance panels.

Fundamentally, we believe that while this bill and others preceding it, are at their core well-intentioned, however, given the fundamental problems medically, ethically and legally, they must be based on misperceptions of what is involved in the treatment provided by a physician psychiatrist.

Perhaps the strongest evidence of this is in the language of the bills themselves which use the word “prescribing” as though its a separate privilege and licensure than the practice of medicine. Indeed it is not. It may be useful for the legislature and constituents to know that there is no carve out in medicine for the act of ‘prescribing’. Medical schools do not offer a separate ‘prescribing’ class that allows students to skip the other 3.5 years of rigorous schooling and 4 years of tireless residency. Prescribing medications is a complex, high-risk treatment modality that is embedded within the practice of medicine.

Also, given the similarity sounding titles of ‘psychologist’ and ‘psychiatrist’, and the more recent use of “Doctor” in healthcare settings for non-physicians with doctorate degrees, has helped set the stage for such bills—which further move patients away from truth and transparency about their providers. Bills such as 360 build on the ambiguity and confusion that many Americans have about who is who and who does what. The American Medical Association has dedicated an entire focus area to remedying this state by state.

Unfortunately, in cases such this, it is easy to see how misinformation can lead to serious consequences in the quality of care provided to Americans.

It may be helpful to know that to psychiatrists are physicians with a foundation in medicine. Psychologists are talk therapists with no medical background, and have either a PhD or PsyD in psychology. To become a physician psychiatrist, even the years before medical school have a science/biomedical basis. It takes four years of an undergraduate education which has multiple basic science requirements, a standardized admission test for medical school, the MCAT, after which one may be admitted to medical school—which is four years long. Following successful completion of those four years, two of which are purely clinical, one receives their Doctor of Medicine degree. At that point, they begin residency training, which starts with a one year internship—mostly in general medicine, pediatrics and neurology (thirty percent of the psychiatry board examination is pure neurology). Physicians can apply for medical licensure through their state medical boards after completing their internship year and successfully passing the required four standardized exams: USMLE 1-3 and USMLE CK. Years two through four are dedicated to various settings where psychiatry is practiced—mostly inpatient hospitals, ER’s, and finally the outpatient component toward the later stages of training. Physician psychiatrists can apply to the American Board of Psychiatry and Neurology to take the written examination for certification after passing a set of three oral exams and successful completion their four year residency.

For Child and Adolescent Psychiatry, a total of 5-6 years of a medical residency is required after medical school—just one year less than neurosurgery and an additional exam by the American Board of Psychiatry and Neurology.

To maintain our specialty board certification by the ABPN, we need to accumulate 30 hours of continuing medical education credits per year for ten years (300 hours total), then take the written test again for recertification. The cost of certification and maintenance of certification are in the thousands. Yet, we accept these requirements—the 8-10 years of post-graduate training, the 300 hours of CME’s, the costly retaking of our board certification exam every ten years—because we didn’t choose this profession to take shortcuts.

In fact, the United States and Canada have the longest training period for physicians in the world—our predecessors set the bar high. We should not unravel it through legislation that will make our country’s standards for practicing medicine one of the lowest in the world.

The diagnosis and pharmacologic treatment of psychiatric illness is based on an understanding of all the organ systems—from first ruling out a non-psychiatric etiology for the symptoms (i.e. endocrine or neoplasm), to understanding the risks versus the benefits of specific pharmacologic treatments (i.e. agranulocytosis vs. remission from chronic psychosis or diabetes insipidus vs stabilization of mania). Additionally, most psychotropic medications are associated with multiple effects on other organ systems—they do not exert their effects simply on the targeted psychiatric symptom. Rather, they can and often do affect renal, hepatic, hematologic, cardiac, neurologic, and musculoskeletal systems—with some effects resulting in death. Perhaps constituents would be interested in knowing that most of the medications prescribed in psychiatry have black box warnings by the FDA—this includes all antidepressants, most anticonvulsants (which we use as first line mood stabilizers for bipolar disorder I and II), all atypical antipsychotics, as well as other psychotropics that have life threatening side effects. If the FDA believes that these medications are dangerous enough for black box warnings, shouldn’t patients have them prescribed by physicians who have met the highest standard for treatment with them? Anectodetally, I began my career in family medicine, and as a primary care resident, I did not feel comfortable treating moderate to severe depression, any bipolar disorder or any psychosis. I deferred to my colleagues, psychiatrists who were the experts in the complex pharmacological interventions that stabilization of these disorders required. I knew that I could potentially cause more harm than good due to my lack of experience and knowledge with these classes of medications.

Further, an important point that this bill misses is that these patients rarely exist as simply psychiatric patients. In fact, the opposite is true. Patients with mental illness are more likely to have cardiovascular disease and overall, have a lower life expectancy (1). A recent review of all cause deaths in this population shows that those with mental illness have a mortality risk larger than or comparable to heavy smoking. Many have one or more of the diagnoses commonly seen in Americans: hypertension, DMII, obesity, and/or hyperlipidemia (1). An entire class of medications we prescribe to treat psychosis, bipolar disorder and treatment resistant depression, raise the risk of the aforementioned diseases and also have the potential to change a component of the heart rhythm (the QTc interval) which increases the risk of sudden cardiac death (2) . A psychiatrist has to monitor all of these parameters and collaborate with other physicians involved in the patient’s care to optimize treatment in the context of co-occurring diseases.

Numerous psychotropics increase the Qtc interval of the heart rhythm which increases their risk of sudden cardiac death via a fatal arrhythmia called Torsades de Point. (2,3,4,5,). We monitor and screen for this by reviewing electrocardiograms. How does a talk therapist do this? If they opt out of prescribing Qtc prolonging medications because they can’t monitor this important parameter, then that would mean they would not be able to prescribe the most common antidepressants and all antipsychotics, including second generation ones with FDA approval for treatment resistant depression.

Otherwise, who will this burden fall on? It can’t simply be shifted to other physicians as it is the responsibility of the prescribing physician to monitor and manage side effects. How will a psychologist—someone with a PhD or a PsyD who is trained in talk therapy, and has no medical foundation except for an online class on ‘prescribing’ know what lab values assessing hepatic function or white blood cell count mean? Both of these are affected by psychotropic medications—including antidepressants. How will they understand the worrisome interaction between an anti-neoplastic agent, Tamoxifen, and commonly prescribed SSRIs? Or which lab to order when an elderly patient on prozac becomes confused? How do they know what SIADH (syndrome of inappropriate anti-diuretic hormone secretion) is and that it’s likely causing hyponatremia (low serum sodium)? How will they know if the cause of behavioral changes in a young female patient is not actually new onset schizophrenia, rather due to an NMDA-receptor encephalitis—a paraneoplastic syndrome which is associated with a primary ovarian tumor? In essense, how will they know to rule out organic causes of psychiatric presentations, even for “simple” diagnoses such as unipolar depression which can often mimic other disorders such as hypothryoidism, anemia, and most often, bipolar disorder which is has devastating results when treated with common antidepressants.

Lastly, and perhaps most importantly, it is not only the understanding of human physiological system and its relationship with psychotropic medications, system by system, that is needed to practice medicine in the specialty of psychiatry, it is the ability to convey that understanding with clarity and integrity to the patient for true informed consent—a critical component of good care. If someone is prescribing medications with enough risk to summon a black box warning from the FDA, they should be able to address all the issues raised in the paragraph above with a patient to reach true informed consent. Without the medical education that a physician has, this simply doesn’t possible.

It’s further lowering of standards to deviate from recommendations of the American Medical Association and the American Psychiatric Association, many other specialty associations including the American Academy of Family Practitioners, and probably every academic medical institution in the nation—in the name of increasing access. Not only that, this is myopic in that it doesn’t look at the long term effects on psychiatrists and physicians in general in the state. Many physicians, in particular psychiatrists, are weary of practicing in a state where non-physicians can practice medicine not only because it blurs the lines medico-legally but also because it sends a message to us that we’re not valued. Thus, a decrease in physicians may actually result in the long term with passage of such bills. In the short term, if the statistics from Louisiana and New Mexico, the two first states with such laws, are reviewed, the utility of such a bill may be questionable as a review of those registered in both states with “prescribing” licenses total less than a100. In Louisiana, most are in urban areas—so much for increasing rural access.

Although lowering standards and compromising patient safety should never be part of a solution when access is the problem, it’s important to note that when the first two states (NM and LA) passed psychologists’ prescribing laws, telepsychiatry was not a functioning proxy. (I should add that cockfighting was also legal in NM and LA at the time–applying their jurisprudence systemically should be done with pause). Again, studying the impact of these laws on access should be considered—given the low number of psychologists in those states who have these licenses, these bills can’t be making much of a dent in addressing the need for psychiatric care. It would’ve been much more effective to invest in telepsychiatry, which allows thousands of patients to gain access at a net savings in cost (6, 7).

As a former Chief Psychiatrist at the California Department of Corrections, I can attest to the effective and efficient application of telepsychiatry across large systems of care. We were able to provide thousands upon thousands of inmates timely psychiatric evaluations even in the most difficult to staff regions of the state, by employing telepsychiatry along with our in house psychiatrists and care teams. We were able to serve over a 100,000 inmates daily under rigid court mandates for psychiatrist face to face evaluation times without expanding the scope of a single psychologist. A study of telepsychiatry application in correctional settings includes CDCR’s experience and also highlights the cost savings of employing this modality—up to $4 million dollars a year (7). Other studies I’ve referenced below highlight telepsychiatry’s efficacy and validity (8,9).

Given such precedents and the significant risks that such a bill would post to patients, we ask that you strongly consider opposing Bill 326 in Ohio. Addressing access to physicians shouldn’t be done by creating shortcuts. That’s not what made the US a leader in physician quality standards and patient safety. There are no shortcuts to becoming a physician. There are only shortcuts to acting like a physician. Americans, including Ohioans deserve real physicians, not those acting the part.

Torie Sepah, MD
Diplomate, ABPN–Psychiatry
Pasadena, CA

References:

1.Chesney E, Goodwin GM, Fazel S. Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry. 2014;13(2):153-160. doi:10.1002/wps.20128.

2. Goren JL, Dinh TA. Psychotropics and sudden cardiac death. R I Med J (2013) 2013;96:38–41

3. Maust DT, Kim HM, Seyfried LS, et al. Antipsychotics, Other Psychotropics, and the Risk of Death in Patients With Dementia: Number Needed to Harm. JAMA psychiatry. 2015;72(5):438-445. doi:10.1001/jamapsychiatry.2014.3018.

4. Rabkin SW. Impact of Age and Sex on QT Prolongation in Patients Receiving Psychotropics. Canadian Journal of Psychiatry Revue Canadienne de Psychiatrie. 2015;60(5):206-214.

5. Wiśniowska B, Tylutki Z, Wyszogrodzka G, Polak S. Drug-drug interactions and QT prolongation as a commonly assessed cardiac effect – comprehensive overview of clinical trials. BMC Pharmacology & Toxicology. 2016;17:12. doi:10.1186/s40360-016-0053-1.

6. Deslich SA, Thistlethwaite T, Coustasse A. Telepsychiatry in Correctional Facilities: Using Technology to Improve Access and Decrease Costs of Mental Health Care in Underserved Populations. The Permanente Journal. 2013;17(3):80-86. doi:10.7812/TPP/12-123.

7..Johnston B, Solomon NA. Telemedicine in California: progress, challenges, and opportunities [monograph on the Internet] Oakland, CA: California Healthcare Foundation; 2008. Jul.

8.Chakrabarti S. Usefulness of telepsychiatry: A critical evaluation of videoconferencing-based approaches. World Journal of Psychiatry. 2015;5(3):286-304. doi:10.5498/wjp.v5.i3.286.

9. Hubley S, Lynch SB, Schneck C, Thomas M, Shore J. Review of key telepsychiatry outcomes. World Journal of Psychiatry. 2016;6(2):269-282. doi:10.5498/wjp.v6.i2.269.

FDA: Drug development and drug interactions: Table of substrates, inhibitors and inducers. Available from http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/DrugInteractionsLabeling/ucm093664.htm. Accessed June 20, 2015.

1 thought on “Psychologists Prescribing Bill Introduced”

Torie Sepah, MD says:

April 23, 2018 at 11:06 pm

Below is the letter I drafted in regards to Ohio’s Bill 326–The Psychologist’s Prescribing Bill.

I plan on sending this to every member of the Ohio senate as well as the Governor.

I encourage everyone to write their own letters, however, I am currently sharing the letter with physician colleagues of all specialities via two physician facebook groups.

Dear Senator,

I am writing you as a physician who specializes in psychiatry, along with my colleagues, who represent various specialties —from psychiatry to surgery— and from multiple states, regarding Bill 326 which is being considered in Ohio to expand the scope of talk therapists (psychologists) to practice medicine via ‘prescribing’ psychotropic medications. While we are not all Ohio residents, we are all physicians. Our ethical duty is first and foremost to patients. Therefore, advocating to protect them from harm vis a vis the lowering of standards to practice medicine, makes all those potentially affected—be it Ohioans or Californians—simply Americans. Our profession requires of us an ethical commitment to protect patients as a group, not only those on our insurance panels.

Fundamentally, we believe that while this bill and others preceding it, are at their core well-intentioned, however, given the fundamental problems medically, ethically and legally, they must be based on misperceptions of what is involved in the treatment provided by a physician psychiatrist.

Perhaps the strongest evidence of this is in the language of the bills themselves which use the word “prescribing” as though its a separate privilege and licensure than the practice of medicine. Indeed it is not. It may be useful for the legislature and constituents to know that there is no carve out in medicine for the act of ‘prescribing’. Medical schools do not offer a separate ‘prescribing’ class that allows students to skip the other 3.5 years of rigorous schooling and 4 years of tireless residency. Prescribing medications is a complex, high-risk treatment modality that is embedded within the practice of medicine.

Also, given the similarity sounding titles of ‘psychologist’ and ‘psychiatrist’, and the more recent use of “Doctor” in healthcare settings for non-physicians with doctorate degrees, has helped set the stage for such bills—which further move patients away from truth and transparency about their providers. Bills such as 360 build on the ambiguity and confusion that many Americans have about who is who and who does what. The American Medical Association has dedicated an entire focus area to remedying this state by state.

Unfortunately, in cases such this, it is easy to see how misinformation can lead to serious consequences in the quality of care provided to Americans.

It may be helpful to know that to psychiatrists are physicians with a foundation in medicine. Psychologists are talk therapists with no medical background, and have either a PhD or PsyD in psychology. To become a physician psychiatrist, even the years before medical school have a science/biomedical basis. It takes four years of an undergraduate education which has multiple basic science requirements, a standardized admission test for medical school, the MCAT, after which one may be admitted to medical school—which is four years long. Following successful completion of those four years, two of which are purely clinical, one receives their Doctor of Medicine degree. At that point, they begin residency training, which starts with a one year internship—mostly in general medicine, pediatrics and neurology (thirty percent of the psychiatry board examination is pure neurology). Physicians can apply for medical licensure through their state medical boards after completing their internship year and successfully passing the required four standardized exams: USMLE 1-3 and USMLE CK. Years two through four are dedicated to various settings where psychiatry is practiced—mostly inpatient hospitals, ER’s, and finally the outpatient component toward the later stages of training. Physician psychiatrists can apply to the American Board of Psychiatry and Neurology to take the written examination for certification after passing a set of three oral exams and successful completion their four year residency.

For Child and Adolescent Psychiatry, a total of 5-6 years of a medical residency is required after medical school—just one year less than neurosurgery and an additional exam by the American Board of Psychiatry and Neurology.

To maintain our specialty board certification by the ABPN, we need to accumulate 30 hours of continuing medical education credits per year for ten years (300 hours total), then take the written test again for recertification. The cost of certification and maintenance of certification are in the thousands. Yet, we accept these requirements—the 8-10 years of post-graduate training, the 300 hours of CME’s, the costly retaking of our board certification exam every ten years—because we didn’t choose this profession to take shortcuts.

In fact, the United States and Canada have the longest training period for physicians in the world—our predecessors set the bar high. We should not unravel it through legislation that will make our country’s standards for practicing medicine one of the lowest in the world.

The diagnosis and pharmacologic treatment of psychiatric illness is based on an understanding of all the organ systems—from first ruling out a non-psychiatric etiology for the symptoms (i.e. endocrine or neoplasm), to understanding the risks versus the benefits of specific pharmacologic treatments (i.e. agranulocytosis vs. remission from chronic psychosis or diabetes insipidus vs stabilization of mania). Additionally, most psychotropic medications are associated with multiple effects on other organ systems—they do not exert their effects simply on the targeted psychiatric symptom. Rather, they can and often do affect renal, hepatic, hematologic, cardiac, neurologic, and musculoskeletal systems—with some effects resulting in death. Perhaps constituents would be interested in knowing that most of the medications prescribed in psychiatry have black box warnings by the FDA—this includes all antidepressants, most anticonvulsants (which we use as first line mood stabilizers for bipolar disorder I and II), all atypical antipsychotics, as well as other psychotropics that have life threatening side effects. If the FDA believes that these medications are dangerous enough for black box warnings, shouldn’t patients have them prescribed by physicians who have met the highest standard for treatment with them? Anectodetally, I began my career in family medicine, and as a primary care resident, I did not feel comfortable treating moderate to severe depression, any bipolar disorder or any psychosis. I deferred to my colleagues, psychiatrists who were the experts in the complex pharmacological interventions that stabilization of these disorders required. I knew that I could potentially cause more harm than good due to my lack of experience and knowledge with these classes of medications.

Further, an important point that this bill misses is that these patients rarely exist as simply psychiatric patients. In fact, the opposite is true. Patients with mental illness are more likely to have cardiovascular disease and overall, have a lower life expectancy (1). A recent review of all cause deaths in this population shows that those with mental illness have a mortality risk larger than or comparable to heavy smoking. Many have one or more of the diagnoses commonly seen in Americans: hypertension, DMII, obesity, and/or hyperlipidemia (1). An entire class of medications we prescribe to treat psychosis, bipolar disorder and treatment resistant depression, raise the risk of the aforementioned diseases and also have the potential to change a component of the heart rhythm (the QTc interval) which increases the risk of sudden cardiac death (2) . A psychiatrist has to monitor all of these parameters and collaborate with other physicians involved in the patient’s care to optimize treatment in the context of co-occurring diseases.

Numerous psychotropics increase the Qtc interval of the heart rhythm which increases their risk of sudden cardiac death via a fatal arrhythmia called Torsades de Point. (2,3,4,5,). We monitor and screen for this by reviewing electrocardiograms. How does a talk therapist do this? If they opt out of prescribing Qtc prolonging medications because they can’t monitor this important parameter, then that would mean they would not be able to prescribe the most common antidepressants and all antipsychotics, including second generation ones with FDA approval for treatment resistant depression.

Otherwise, who will this burden fall on? It can’t simply be shifted to other physicians as it is the responsibility of the prescribing physician to monitor and manage side effects. How will a psychologist—someone with a PhD or a PsyD who is trained in talk therapy, and has no medical foundation except for an online class on ‘prescribing’ know what lab values assessing hepatic function or white blood cell count mean? Both of these are affected by psychotropic medications—including antidepressants. How will they understand the worrisome interaction between an anti-neoplastic agent, Tamoxifen, and commonly prescribed SSRIs? Or which lab to order when an elderly patient on prozac becomes confused? How do they know what SIADH (syndrome of inappropriate anti-diuretic hormone secretion) is and that it’s likely causing hyponatremia (low serum sodium)? How will they know if the cause of behavioral changes in a young female patient is not actually new onset schizophrenia, rather due to an NMDA-receptor encephalitis—a paraneoplastic syndrome which is associated with a primary ovarian tumor? In essense, how will they know to rule out organic causes of psychiatric presentations, even for “simple” diagnoses such as unipolar depression which can often mimic other disorders such as hypothryoidism, anemia, and most often, bipolar disorder which is has devastating results when treated with common antidepressants.

Lastly, and perhaps most importantly, it is not only the understanding of human physiological system and its relationship with psychotropic medications, system by system, that is needed to practice medicine in the specialty of psychiatry, it is the ability to convey that understanding with clarity and integrity to the patient for true informed consent—a critical component of good care. If someone is prescribing medications with enough risk to summon a black box warning from the FDA, they should be able to address all the issues raised in the paragraph above with a patient to reach true informed consent. Without the medical education that a physician has, this simply doesn’t possible.

It’s further lowering of standards to deviate from recommendations of the American Medical Association and the American Psychiatric Association, many other specialty associations including the American Academy of Family Practitioners, and probably every academic medical institution in the nation—in the name of increasing access. Not only that, this is myopic in that it doesn’t look at the long term effects on psychiatrists and physicians in general in the state. Many physicians, in particular psychiatrists, are weary of practicing in a state where non-physicians can practice medicine not only because it blurs the lines medico-legally but also because it sends a message to us that we’re not valued. Thus, a decrease in physicians may actually result in the long term with passage of such bills. In the short term, if the statistics from Louisiana and New Mexico, the two first states with such laws, are reviewed, the utility of such a bill may be questionable as a review of those registered in both states with “prescribing” licenses total less than a100. In Louisiana, most are in urban areas—so much for increasing rural access.

Although lowering standards and compromising patient safety should never be part of a solution when access is the problem, it’s important to note that when the first two states (NM and LA) passed psychologists’ prescribing laws, telepsychiatry was not a functioning proxy. (I should add that cockfighting was also legal in NM and LA at the time–applying their jurisprudence systemically should be done with pause). Again, studying the impact of these laws on access should be considered—given the low number of psychologists in those states who have these licenses, these bills can’t be making much of a dent in addressing the need for psychiatric care. It would’ve been much more effective to invest in telepsychiatry, which allows thousands of patients to gain access at a net savings in cost (6, 7).

As a former Chief Psychiatrist at the California Department of Corrections, I can attest to the effective and efficient application of telepsychiatry across large systems of care. We were able to provide thousands upon thousands of inmates timely psychiatric evaluations even in the most difficult to staff regions of the state, by employing telepsychiatry along with our in house psychiatrists and care teams. We were able to serve over a 100,000 inmates daily under rigid court mandates for psychiatrist face to face evaluation times without expanding the scope of a single psychologist. A study of telepsychiatry application in correctional settings includes CDCR’s experience and also highlights the cost savings of employing this modality—up to $4 million dollars a year (7). Other studies I’ve referenced below highlight telepsychiatry’s efficacy and validity (8,9).

Given such precedents and the significant risks that such a bill would post to patients, we ask that you strongly consider opposing Bill 326 in Ohio. Addressing access to physicians shouldn’t be done by creating shortcuts. That’s not what made the US a leader in physician quality standards and patient safety. There are no shortcuts to becoming a physician. There are only shortcuts to acting like a physician. Americans, including Ohioans deserve real physicians, not those acting the part.

Torie Sepah, MD
Diplomate, ABPN–Psychiatry
Pasadena, CA

References:

1.Chesney E, Goodwin GM, Fazel S. Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry. 2014;13(2):153-160. doi:10.1002/wps.20128.

2. Goren JL, Dinh TA. Psychotropics and sudden cardiac death. R I Med J (2013) 2013;96:38–41

3. Maust DT, Kim HM, Seyfried LS, et al. Antipsychotics, Other Psychotropics, and the Risk of Death in Patients With Dementia: Number Needed to Harm. JAMA psychiatry. 2015;72(5):438-445. doi:10.1001/jamapsychiatry.2014.3018.

4. Rabkin SW. Impact of Age and Sex on QT Prolongation in Patients Receiving Psychotropics. Canadian Journal of Psychiatry Revue Canadienne de Psychiatrie. 2015;60(5):206-214.

5. Wiśniowska B, Tylutki Z, Wyszogrodzka G, Polak S. Drug-drug interactions and QT prolongation as a commonly assessed cardiac effect – comprehensive overview of clinical trials. BMC Pharmacology & Toxicology. 2016;17:12. doi:10.1186/s40360-016-0053-1.

6. Deslich SA, Thistlethwaite T, Coustasse A. Telepsychiatry in Correctional Facilities: Using Technology to Improve Access and Decrease Costs of Mental Health Care in Underserved Populations. The Permanente Journal. 2013;17(3):80-86. doi:10.7812/TPP/12-123.

7..Johnston B, Solomon NA. Telemedicine in California: progress, challenges, and opportunities [monograph on the Internet] Oakland, CA: California Healthcare Foundation; 2008. Jul.

8.Chakrabarti S. Usefulness of telepsychiatry: A critical evaluation of videoconferencing-based approaches. World Journal of Psychiatry. 2015;5(3):286-304. doi:10.5498/wjp.v5.i3.286.

9. Hubley S, Lynch SB, Schneck C, Thomas M, Shore J. Review of key telepsychiatry outcomes. World Journal of Psychiatry. 2016;6(2):269-282. doi:10.5498/wjp.v6.i2.269.

FDA: Drug development and drug interactions: Table of substrates, inhibitors and inducers. Available from http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/DrugInteractionsLabeling/ucm093664.htm. Accessed June 20, 2015.

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