Prescription Privileges for Psychologists

Introduction

“Prescription privileges” is one of the most controversial topics facing modern psychology. With the help of prescription privileges, psychologists will have another chance to take a leadership role in the practice of health care delivery. The mental health care system has undergone huge changes over the past decades. Power has increasingly shifted away from doctors and towards health insurance and drug companies. Conventional health insurance plans have all but died out, substituted by more efficient managed care models. Drug company breakthroughs have also occurred so that it is now possible to care for most mental disorders with medicine rather than with psychotherapy alone. As a result, when mental health care is offered these days, it is generally first offered in the form of medicine.

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The necessity of prescription privileges for psychologists

There is a growing consensus that several mental illnesses involve brain processes that can be corrected by medications. At the same time managed care is mandating medications in some instances and is reducing the number of therapy sessions allowed. Psychologists are seeing patients who need medications as a part of their treatment and they are not trained to prescribe medications (Glod & Manchester, 2000; Pincus, et.al, 1998; Olfson, Marcus, & Pincus, 1999).

Their patients must obtain these medications from a psychiatrist or from their family doctor. Hence in this atmosphere psychologists in the United States are increasingly calling for legislation permitting them to prescribe certain psychotropic medications, following extra training in physiology and pharmacology. Psychiatrists powerfully oppose this move by psychologists. The real issue centers on the nature of training needed for prescribing medications. Psychologists are not arguing that they should simply be allowed to prescribe. They are arguing that prescribing privileges should be granted only after a psychologist has taken widespread post-graduate training and supervision (Cypres, Landsberg, &

Spellmann, 1997; Pincus, et.al., 1998). Psychiatrists argue that medical school or at least nurse practitioner training is required for someone to be knowledgeable enough to prescribe medications. Not only medical school should be the only approach to get prescription privileges. There are too many additional professionals who have some skill to prescribe without having attended medical school. The Surgeon General’s report of 1999 revealed that less than one-third of all people with a diagnosable mental disorder in the U.S. receive treatment in a given year. The 1998 Schizophrenia PORT study revealed that fewer than 50% of all people with schizophrenia receive even simply adequate treatment in a given year.

History of prescription privileges for psychologists

In only a matter of a few years, the suggestion that the discipline and profession be changed to a new medical subspecialty has roared onto the central stage of organized American psychology. It gained considerable momentum in 1990 when the U.S. Senates Appropriations Committee recommended that the Department of Defense set up a demonstration prescription training program for psychologists (Sovner & Bailey,

1991; Troy & Schueman, 1996). At about the same time, the American Psychological Association’s (APA) Council of Representatives established a Task Force to inspect the feasibility of prescription privileges and to discover curriculum models for training. APA formally went on record supporting the idea in 1995 and has vigorously pursued prescription privileges at federal and state legislative bodies.

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Over the last several years, AAAPP has accepted the seriousness of the prescription privileges proposal and has begun an efficient attempt to estimate its impact upon the field. In 1993 a survey of the AAAPP membership indicated that a strong majority opposed prescription privileges. The AAAPP Committee Concerned about the Medicalization of Psychology was established in 1994 to evaluate the proposal and issue a report. Based in part on that report, the AAAPP Board in January 1995 endorsed a Resolution Opposing Prescription Privileges for Psychologists, becoming the first national scientific psychological society to take a formal position on this issue.

While some pro-prescription advocates thought that change in psychology would come very quickly, the movement has had many recent setbacks, in part due to the rise of an organized opposition within psychology itself. There are good arguments on both sides of the issue, but many leaders in applied scientific psychology felt that such a chief change deserved much more critical analysis. AAAPP’s Board felt that opposition would, at the very least, slow the pace and allow many of the more controversial issues to be examined. These issues are complex. Prescription privileges are not arising as an issue in a vacuum.

In the era of managed care, the practice of psychology is having a difficult time competing for resources (Le Monde, 2006). Many psychologists in the practice community hope to resolve this problem by expanding the practice of psychology to include psychoactive medications.

Arguments in favor of prescription privileges for psychologists

Psychologists already deal with psychiatric medicines on a regular basis (many of their patients are on them and they must become aware of what medications are used for what in order to do good work). In many cases, Psychologists are actually in a superior position than Psychiatrists to know when medication adjustments should be made; They see their patients several times per month (in the course of psychotherapy) while Psychiatrists see a given patient six times a year.

Other things to remain in mind are that making psychiatric prescriptions is not really rocket science (although it clearly does need an exact course of study, supervised practice, licensure, and continuing education in order to be done properly and accountably) and that Psychologists are normally very bright people who can learn how to do it right (Alcom & Nicholas, 1983). Psychologists are ready to work for less money than Psychiatrists.

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The huge majority of psychotropic drugs in this country are currently prescribed by nonpsychiatric physicians, with negligible training in the detection and management of mental illness. Such a pattern of practice perpetuates a system in which psychotropic drugs are overprescribed, at the expense of behavioral interventions which are often both more effective and have fewer side effects. The ability to prescribe would increase the capability of psychologists to work with the seriously mentally ill. Currently, patients of psychologists needing psychotropics must also see a physician solely for the purpose of obtaining medication.

This involves unnecessary inconvenience and expense to the patient and increases the chance of miscommunication or adverse outcomes. The seriously mentally ill would be better served by psychologists who could prescribe psychotropics as an adjunct to well-designed psychotherapeutic regimens and who could manage the patient throughout the episode of care (Whitely, 1984; Watkins, Schneider, Cox & Reinberg, 1987).

The shortage of psychiatrists

One factor contributing to low rates of treatment and services for people with mental illnesses is the lack of qualified psychiatrists and other mental health providers in many parts of the country. The nation’s supply of psychiatrists is shrinking, and that access to treatment with psychiatrists is particularly limited for lower-income individuals who rely on public mental health systems for treatment and services. Affording prescription privileges to psychologists will increase access to timely treatment for individuals with mental illnesses who reside in rural communities.

Arguments against the prescription privileges for psychologists

Graduate education for psychologists de-emphasizes the medical model in favor of a social and behavioral approach that trains psychologists to conduct psychological assessments and provide psychotherapy, not to provide medical treatment. Psychotropic medications used to treat mental illnesses are very powerful, can cause potentially disabling and life-threatening side effects, and require particular expertise among those who prescribe and monitor them.

Many Psychologists oppose prescription privileges for Psychologists (Ben Lesczynski, 2006). Generally, the argument within Psychology against prescription privileges goes something like, “Right now, Psychologists are experts at psychotherapy. We will lose this expertise and become nothing more than junior physicians if we go down the path of prescription privilege”. (Troy & Shueman, 1996; Wiggins & Cummings, 1998) Most existing psychology programs don’t have the faculty or other resources to provide the type of training needed to prepare psychologists to prescribe medications. Those who want prescription privileges for psychologists want the training to be postdoctoral, which would require programs to hire more faculty,

Legislations related to prescription privileges for psychologists

In 2002, Governor Gary Johnson of New Mexico signed into law a bill that grants licensed, doctoral-level psychologists who have completed a training and certification program the right to prescribe psychiatric medications. This is the first law of its kind. Opponents of the legislation argue that psychologists are not adequately trained to prescribe medications. The issue of prescribing privileges has appeared at several levels; notably through state legislation, but also through initiatives by the federal government, as well as in the daily prescribing practices of general practitioners. Since 1990, 12 states have rejected legislation to grant psychologists prescription privileges.

These states (some of which have rejected prescribing legislation on multiple occasions) include Alaska, California, Connecticut, Florida, Georgia, Hawaii, Illinois, Louisiana, Missouri, Montana, Tennessee, and Texas.

Department of Defense Demonstration Project

In 1989, Congress directed the Department of Defense (DoD) to create a Psychopharmacology Demonstration Project (PDP) to train military clinical psychologists to issue appropriate psychotropic medications to beneficiaries of the Military Health Services System. This program was operationalized in 1991. Between 1991 and 1997, ten military psychologists completed the training program and were granted the right to prescribe medications.

Way to provide prescription privileges for psychologists

Safety concerns can be addressed through specialized training of psychologists who wish to obtain certification to prescribe medications. They argue that the current level of basic science training in graduate education in psychology is sufficient to allow psychologists, with some additional specialized training, to safely and effectively prescribe psychiatric medications. It does make sense for Psychologists to be able to prescribe psychiatric medicines if they are properly trained and licensed to do so (Sammons, Sexton, & Meredith, 1996).

Psychologists have typically completed five or more years of doctoral clinical training in mental health diagnosis and treatment, have completed a year-long hospital residency, and have practiced under supervision for 2000 hours (a full year) before being allowed to practice independently.

The final bill requires that doctorate-level psychologists who want to prescribe privileges must attend 450 hours of classroom training in pharmacology, neuroscience, physiology, pathophysiology, and clinical pharmacotherapeutics. Once they complete this classroom training, psychologists will have to spend 400 hours treating people with mental disorders under the supervision of a psychiatrist or other physician. Each psychologist-prescribing candidate must treat at least 100 people. Once these requirements are fulfilled, psychologists can then apply for a “conditional prescription certificate.”

Efforts to obtain prescription privileges

1984

U.S. Senator Daniel K. Inouye urges psychologists at the annual meeting of the Hawaii Psychological Association to seek prescriptive authority in order to improve the availability of comprehensive, quality mental health care.

1985

President of APA Div. 42 (Independent Practice) Richard Samuels also calls for psychologists to seek prescription privileges. The first psychology prescription bill is introduced in the Hawaii State Legislature in 1985. After extensive hearings, the House of Representatives enacted a resolution in 1990 calling for a series of roundtable discussions conducted by the State’s Center for Alternative Dispute Resolution followed by a formal report and recommendations. By 1995, prescribing bills had been introduced in five different states.

1989

APA’s Board of Professional Affairs strongly endorses studying the feasibility and the appropriate curricula in psychopharmacology so that psychologists might provide broader service to the public and more effectively meet the psychological and mental health needs of society. The board also recommends that APA make its highest priority the responsibility of preparing the profession to address current and future needs of the public for psychologically managed psychopharmacological interventions. The U.S. Department of Defense is directed to institute a pilot training program to train military psychologists to prescribe. This project, which became the center of a legislative battle in the U.S. Congress, eventually graduated 10 fellows, each of whom received at least one year of didactic training and one year of clinical experience.

1990

APA Council of Representatives approves the establishment of an ad hoc Task Force on Psychopharmacology, which is charged with exploring the desirability and feasibility of psychopharmacology prescription privileges for psychologists and determining what training would be required.

1992

The ad hoc Task Force on Psychopharmacology’s report to the council concludes that practitioners, with combined training in psychopharmacology and psychosocial treatments, could be viewed as a new form of healthcare professional that could bring to healthcare delivery the best of psychological and pharmacological knowledge. Further, the proposed new providers had the potential to dramatically improve patient care and make important advances in treatment. The Task Force recommended training at three distinct levels: Basic Psychopharmacology Education for all graduate students in health-care provider programs; Collaborative Practice to enable psychologists to work more closely with medical prescribers; and Level III-Education for Independent Prescription Privileges.

1995

During APA’s Annual Convention, the Council of Representatives formally endorses prescriptive privileges for appropriately trained psychologists and called for the development of model legislation and a model training curriculum.

1996

At the Annual Convention in Toronto, the council formally adopts a model prescription bill and a training curriculum.

1997

At the Annual Convention in Chicago, the council authorizes its College of Professional Psychology to develop an examination in psychopharmacology suitable for use by state and provincial licensing boards once their legislatures have granted prescriptive authority to psychologists.

1998

Prescription privileges legislation is either pending or about to be introduced in seven states: California, Florida, Georgia, Hawaii, Louisiana, Missouri, and Tennessee; with five others actively planning for the near future.

Conclusion

By and large, prescription-making is not an innovative art, but rather a topic of learning standard dosages, drug interactions, side effect profiles, and how to handle emergencies. Psychologists will only gain prescription privileges for a limited subset of medications applicable to their work; they will not become licensed to offer surgery or anything really complicated like that. It just makes sense that prescribing and psychotherapy functions could be rolled up into one profession to attain significant cost and communications savings. Many Psychiatrists don’t like this new law. For Psychiatrists, any prescription ground gained by Psychologists will be perceived as a loss.

But it is ultimately money that rules the day in America, and not guild prestige. If Psychiatrists are going to be successful in holding on to their turf, they’ll have to convince those with power that they are fighting prescription privileges for Psychologists on grounds more substantial than that they don’t want to earn less money.

References

  1. “Application for Certificate of Prescriptive Authority”. Web.
  2. “Response to Clinical Psychologists Prescribing Psychotropic Medications”. Web.
  3. “Recommended Postdoctoral Training in Sychopharmacology for Prescription Privileges”. Web.
  4. “Response to Clinical Psychologists Prescribing Psychotropic Medications”. Web.
  5. “Letters to the Editor”. Web.
  6. David L. Downing, “A: Professional Ethics and Conduct Fall Trimester”. Web.
  7. Steven C. Hayes, Elaine M. Heiby, “Prescription Privileges for Psychologists: A Critical Appraisal”. Web.
  8. Patrick H. DeLeon, ”Prescriptive Authority –Welcome to the 21st Century”. Web.
  9. “Psychology and Psychopharmacology”. Web.
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