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
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
"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
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
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
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.