Depression CME Mandate Defeated in California

Legislation to require the more than 30,000 primary care physicians in California to qualify to treat depression was defeated shortly before the state legislature adjourned in August.

The California State Assembly rejected by a wide margin a bill (SB 524) that would have created a mandatory continuing medical education (CME) requirement for all family physicians who treat depression. The Assembly rejection followed the California Senate's approval of the measure on May 23.

The bill stated that “all primary care physicians who treat patients for depression and other related ailments, specifically through the prescribing of [selective serotonin] reuptake inhibitors (SSRIs) and other newer antidepressants, shall complete four units of mandatory continuing education on that subject every four years.”

The California Psychiatric Association (CPA) joined other physician groups to oppose the bill on the basis that it would discourage family physicians from treating depression because of the burden of additional mandated CME. That would result in reduced health care access for Californians with depression.

“Consultation and collaboration between psychiatrists and family physicians is the most important thing to get the highest quality of care, and this bill just wouldn't have achieved this goal,” said Randall Hagar, the CPA's director of government affairs.

The bill was sponsored by Sen. Tom Torlakson (D), whose interest in the issue developed after the suicide of his 21-year-old niece in March 2004. At the time she was taking Celexa prescribed by a general practitioner for depression.

Torlakson said in testimony that the use of antidepressant medications, specifically SSRIs, has increased significantly in recent years. Concern also has grown, he said, that in some cases the drugs may increase suicidal tendencies in those with depression, especially for adolescents and young adults.

The legislation, Torlakson said, arose from concerns that physicians are either unaware of the risks or are inadequately monitoring the danger such medications can pose to youths.

The legislation followed the Food and Drug Administration's October 2004 order that drug companies label all antidepressant medications distributed in the United States with strongly worded warnings regarding “clinical worsening, suicidality, or unusual changes in behavior” associated with initiation of antidepressant therapy.

The California legislation was supported by the California Psychological Association due to what it describes as a lack of standardized treatment protocols for physicians prescribing SSRIs—protocols that recommend the frequency of office visits when prescription medications are started, dosage is changed, or medication ended.

Opponents of the measure countered that the link between suicide and SSRIs remains unsettled and argued that uncertainty should not be enshrined in law until more is known. Untreated depression, Hagar said, is a much larger and more serious societal issue and entails many serious consequences, of which suicide is one.

“Legislative micromanagement of continuing education requirements can never be an effective substitute for medical judgment,” Hagar said.

California physicians are required to complete 100 hours of CME every four years. The only other specifically required CME courses are one-time courses covering pain management and treatment of the terminally ill. Physicians are exempt from those CME requirements if they do not directly care or provide consultations for patients in those categories, said state officials.

Opponents of the bill said the legislation would have created the first disease-specific education requirement for California physicians, which could open the door to requiring CME for many other high-profile conditions.

In addition to the CPA and CMA, the legislation was opposed by the American College of Obstetricians and Gynecologists, California Academy of Family Physicians, California Association of Physician Groups, California Society of Industrial Medicine and Surgery, California Society of Physical Medicine and Rehabilitation, Medical Board of California, and Osteopathic Physicians and Surgeons.

This was the first year the bill was considered by the legislature, and because the state Senate approved it, opponents said they may need to fight it again in the next legislative session.

SB 524 and related information are posted at<http://info.sen.ca.gov/cgibin/postquery?bill_number=sb_524&sess=CUR&house=B&site=sen>.▪