Prescription Privileges

Prescription privileges refers to the right to prescribe medication. The psychologist prescription privilege (PPP) debate refers to legal and ethical arguments for and against a psychologist prescribing medication. Presently, there are legal avenues by which a psychologist may earn the right to prescribe medication. A psychologist could elect to earn a supplemental degree in such fields as medicine or advanced practice nursing and gain legal authority to pre-scribe. Extending prescription privilege to psychologists would provide a different and, presumably, less onerous means for a psychologist to gain the right to prescribe. In the United States, granting prescription privileges to psychologists was attempted by various pilot programs in New Mexico, California and, most notably, in the military. Recently, two states, Louisiana and New Mexico, have passed laws to permit additional avenues whereby a psychologist may prescribe medications. As of April 2005, legislatures in 20 states either began studying the impacts of extending PPP or have proposed prescription privilege legislation.

In the United States, only physicians have full prescription privileges. Other professions such as optometry, dentistry, and podiatry are granted limited prescription privileges to prescribe medications that affect the body systems in their area. By the year 2002, approximately 75,000 nonphysicians, including nurse practitioners, midwives, and other clinical specialists had prescription privileges across the United States. In 38 states, pharmacists had the power to prescribe medications.

Those psychologists in favor of granting prescription privileges to psychologists have been represented by the American Psychological Association (APA), an organization whose membership is largely composed of clinicians and independent practitioners. Those opposed to PPP represent two separate camps: those within the psychology profession and those outside of the psychology profession, many of whom are members of the medical establishment.

Psychologists standing in opposition to PPP have been represented by the American Association of Applied and Preventive Psychology (AAAPP), an organization created by psychologists opposing the proliferation of states authorizing PPP, and the Society for a Science of Clinical Psychology. Several physician groups, including the American Psychiatric Association and the American Medical Association (AMA), have also opposed allowing psychologists to have specific training permitting them to prescribe psychotropic medication.

The American Psychological Association’s Proposal

Currently, the APA proposes that psychologists earn the right to prescribe medication that directly affects individuals’ mental health needs. Both Louisiana and New Mexico have passed legislation that has closely mirrored the APA’s recommendations. The APA guidelines indicate that only those who hold a doctorate in psychology and have five years of experience in the healthcare industry should earn prescription privileges. Once the doctoral degree has been earned, a psychologist should take 450 hours of training in five areas: neuroscience, clinical psychotherapeutics, physical and laboratory assessment, physiology and pathophysiology, and clinical and research pharmacology and psycho-pharmacology. Following the didactic portion of the training, psychologists complete a 400-hour practicum, including 2 hours of weekly supervision, and treat at least 100 patients with mental disorders. The practicum would be followed by a certification examination that would allow for a 2-year probationary period during which the psychologist would be supervised by a physician. Following these 2 years of supervised practice, the psychologist would become eligible to earn a license to prescribe medication.

History of Psychologist Prescription Privilege

The Military

In 1989, the department of defense (DOD) launched a program to train psychologists in the military to prescribe medication. The program’s base included 1 year of didactic training followed by 1 year of clinical training. Ten individuals went through the training. As of 2003, 7 of the psychologists who had initially been trained were continuing to actively prescribe medication, while the other 3 were working on advocacy or attending medical school. The DOD program, which cost over $6 million, was stopped at the end of 1996. Proponents of the program claimed that psychologists had shown their ability to safely prescribe medications to patients and were able to provide both psychopharmacological and psychotherapeutic services together. Opponents felt that the program was expensive, that the psychologists were overly reliant on physicians, and that the psychologists were only able to prescribe to a restricted group of the active enlisted military.

New Mexico

In March of 2002, the state of New Mexico passed legislation allowing properly trained psychologists the right to prescribe medication on a limited basis. The regulations came into effect in January of 2005. The law closely followed the recommendations of the APA in terms of training and accreditation. The psychologists’ training includes an 80-hour practicum in clinical assessment and pathophysiology. After a psychologist earns prescription privilege, and following a 2-year probationary period during which a psychologist works with a physician, a psychologist can apply to prescribe medication independently. However, when prescribing, a psychologist must maintain a close collaborative relationship with a patient’s primary physician. This collaboration is designed to ensure that an individual is receiving regular medical physical exams, to ensure that there are no adverse reactions to the medication, and to provide a safeguard to prevent the prescription of medications that may have dangerous interactions with one another. To maintain a prescription license, a prescribing psychologist must receive 20 additional hours of training each year. A prescribing psychologist is allowed to prescribe medication and order requisite laboratory tests only for the treatment of mental disorders. The licensing board charged with allowing psychologists the right to prescribe psychotropic medications is run by physicians. Many psychologists argue that the physicians are too conservative and may be predisposed against allowing PPP. The PPP proponents claim that this regulation limits many qualified psychologists from earning the prescription privilege.

Louisiana’s Medical Psychologists

In May of 2004, Louisiana became the second state to allow psychologists to prescribe psychotropic medications. The Louisiana law stipulates that a psychologist must complete 2 years of postdoctoral training by earning a master’s degree in clinical psychopharmacology from a regionally accredited institution. He or she must then pass a national examination. The psychologist is then allowed to prescribe medication provided he or she works in conjunction with the patient’s primary physician. The law permits medical psychologists to prescribe medication only related to nervous and mental health disorders.

Louisiana’s law is slightly different in that the board that oversees prescribing psychologists is the Louisiana state board of examiners of psychologists, a nonphysician board. Also, the Louisiana law does not require a 2-year probationary period during which a psychologist must work closely with a physician’s oversight when prescribing medication.

The Psychologist Prescription Privilege Debate

The issue of extending prescription privileges to psychologists (PPP) has become possibly the most contentiously debated proposal advanced in the field’s recent history. Few topics have a more polarizing effect. This rancor is likely a direct result of the debate’s high stakes. The contest over prescription privileges has moved beyond the proposals and hypothetical ponderings first offered 18 years ago in the pages of professional and academic journals. In recent years, the issue has entered the realm of state legislative subcommittees, and in several states the issue has become a bill put up for a full state-level legislative vote.

The Debate among Psychologists

The competing views of professional psychologists regarding the extension of prescription privileges to psychologists were not adequately resolved before the question became a matter of public policy. The resulting high-stakes legislative debate has fueled a growing schism in the already fractionated field of professional psychology. Studies performed at the end of the 1990s found that nearly twice as many psychologists opposed PPP as favored it. However, as the movement has gained momentum, a greater percentage of psychologists have given at least tacit assent to the idea of advancing PPP. However, many argue that the interdisciplinary schisms within the field of psychology are sufficient to indicate that PPP should not be advanced. This public controversy has generated discussion rather than problem solving, and the opposing points of view have confused legislators and stalled or stopped several PPP bills from passage. Despite the confusion and controversy, the debate is more alive now than ever before. An increasing number of states are introducing bills that, if passed, would extend prescription privileges to psychologists. As these hotly contested bills are presented to states’ legislative bodies for debate, psychologists and the professional organizations formed to advance their views and positions are submitting position statements, legal briefs, and sworn testimony to promote their respective positions for and against PPP.

The Pros and Cons of PPP

A comprehensive review of the various positions articulated by psychologists for and against extending PPP reveals the following five central and recurrent themes around which the arguments are framed:

1. Would prescribing psychologists fill a real and pressing societal need?
2. Would prescribing psychologists provide a less expensive alternative to current prescribing healthcare professionals?
3. Would the training of professional psychologists be adversely affected by additional course work necessary to develop the knowledge base and skills to competently prescribe?
4. Would prescribing psychologists provide greater continuity of care and a more comprehensive service than conventional collaborative models?
5. Does an ample precedent for successful PPP exist?

Societal Need

Regarding the issue of societal need for PPP, the position advanced by the APA claims that an insufficient number of psychiatrists are available to adequately offer a complete array of mental health services, including the prescription of psychoactive medications. As a result, traditionally underserved populations (e.g., women, children, the elderly, inner city residents, and members of rural communities) are being deprived of quality mental health assessment and intervention.

The APA offers statistics suggesting that the majority of visits to primary care physicians are made by persons for whom no diagnosis of physical illness can be made and whose complaints result from psychological issues. The argument follows that psychologists are more familiar with mental disorders than are nonpsychiatrist physicians (general practitioners) who are currently prescribing approximately two thirds of all psychotropic medications in the United States.

General practice medical doctors typically receive less then 2 months of training in mental health and psychiatry. The APA argues that, with the appropriate supplemental training in physiology, chemistry, biology, and psychopharmacology, psychologists would be adequately equipped to serve the psychopharmacologic needs of people suffering from mental disorders. Psychologists would be able to offer the unique blend of psychological and psychopharmacological interventions that have previously fallen only into the realm of psychiatry.

The AAAPP position simply holds that the need to prescribe is filled by a sufficient number of physicians, nurse practitioners, and other members of the medical community. In fact, they argue that there is a surplus of physicians. Issues of poor distribution of psychopharmacological health care to reach traditionally underserved populations would best be addressed through subsidies and incentive programs. Many of the nonpsychologists who oppose the extension of PPP claim that psychologists who have specific training in psychopharmacology may harm their patients due to their narrow training. They also claim that physicians would be required to provide intensive oversight to psychologists.

Expense

The APA believes that psychologists with prescriptive privilege can provide medical mental health care more cost effectively than can psychiatrists, psychologists working in conjunction with physicians, or other combinations of mental health service provision. Frequently, a consumer of mental health care service will need to see a physician or psychiatrist for medication and a psychologist for psychotherapy and other behavioral health interventions, including case management and diagnosis. Psychologists with prescription privilege become valuable because they independently can serve the function of both general practice physicians and mental health treatment providers. These combined services result in fewer office visits for the consumer and, thus, less expense. Secondly, hourly rates for psychological services are typically significantly lower than costs for psychiatric or general practitioner services.

Proponents of PPP also dispute the claim that psychologists interested in prescription authority need only enter training programs for other professions who are able to prescribe, such as a those for nurse practitioners or physician assistants. A training program that is focused only on psychotropic medication will provide only the necessary expertise for a psychologist who chooses to prescribe psychotropic medication. The time and expense involved in becoming a nurse practitioner, a physician assistant, a dentist, or a physician is prohibitive and results in an extraneous skill set for a psychologist. This savings in training would result in lower costs for both psychologists and for the general public.

The AAAPP argues that any cost savings a psychologist may have offered would be eliminated by the costs involved in training, regulating, and supervising psychologists with prescription privilege. For example, the military’s attempt at training psychologists was exorbitantly expensive and cost prohibitive for civilian psychologists. These supplemental expenses would, as the AAAPP asserts, eventually be passed on to consumers.

Training

At the heart of the training debate is the question as to whether the APA’s recommended education for psychologists interested in obtaining PPP will sufficiently prepare psychologists and safeguard the community from unqualified personnel. The current recommendations advanced by the APA include 2 years of postdoctoral training, a 400-hour supervised practicum specifically addressing psychoactive medication management, and 2 years of subsequent clinical supervision by a physician. By contrast, nurse practitioners and physician assistants typically are required to complete 600 total hours of practicum experience, after which these professionals become license eligible. For physician assistants and nurse practitioners, these hours include nearly all training involved with patient care, not only medication management. Thus, the APA contends that the postdoctoral training of psychologists provides ample exposure to and practice with prescribing psychotropic medications. Moreover, because this training is postdoctoral and voluntary, it would not necessarily infringe upon the traditional training practices of professional psychology programs.

Many in the APA would argue that psychologists already represent the highest standard of nonmedical mental health care. These professionals offer expertise in the diagnosis and treatment of mental health disorders. This level of expertise far exceeds the experience of most general practice physicians and certainly that of physician assistants and nurse practitioners. A psychologist with supplemental training in prescribing psychoactive medication would offer a unique variety of interventions and a singularly proficient view of patient care.

Psychologist opponents to PPP articulate concerns that the fundamental focus of doctoral level psychological training programs would be altered substantially. These programs, as posited, would be required to focus much more intensely on the biological bases of behavior and on psychopharmacology. Additionally, undergraduate coursework in biology, chemistry, and other sciences may be additional requirements. If training programs focus more heavily on psychopharmacological interventions, nonmedical interventions and their subsequent benefits may be deemphasized in psychologists’ practice. These concerns also extend to the entire enterprise of training psychologists. Professional psychology is currently a highly fractionated and diverse field. To properly train a highly qualified professional psychologist, a broad regimen must be undertaken. These training protocols require a psychologist to demonstrate competence across a broad array of theoretical orientations, clinical perspectives, and subdisciplines, including development, cognitive science, behavioral science, and counseling.

Those concerned by the introduction of PPP fear an overemphasis on psychopharmacological interventions, reliance on reductionistic solutions involving only medication, and a departure from the traditional province of psychology, which may result in an underemphasis on areas where psychologists have traditionally excelled— in assessment, psychotherapy, and behavioral intervention. Further, PPP opponents are concerned that an increased emphasis on PPP would result in psychology following an increasingly medical model that is focused on extrinsic, individual pathology.

The American Medical Association (AMA) is also opposed to PPP on the basis of training. They assert that prescribing psychologists would require an unreasonably high level of ongoing supervision. This supervision would not only increase costs, but failure to provide this level of supervision would increase the risks to the general public. They argue that all medications affect the entire organism and that a training program focused only on psychotropic medications fails to appropriately address the complexity of the human system.

Continuity of Care

Those who support PPP argue that obligatory collaboration between various mental health care providers, by definition, interferes with continuity. When multiple care providers are involved in a patient’s treatment, it fractionates care. A patient who elects to see a psychologist for psychotherapeutic and assessment services is required to see an entirely different individual for prescription and monitoring the effectiveness of medication. This is currently true under existing laws governing psychological practice in 48 of the 50 states. Additionally, in many cases, healthcare providers who are prescribing will conduct their own, independent assessment. Assessment techniques practiced by nonpsychologist practitioners often fail to meet the psychometric rigor and best practice standards of psychologists. In this way, multiple care providers are more likely to duplicate assessment services. This duplication not only generates unnecessary expense but also occasionally contributes to disagreements in diagnosis and treatment recommendations.

Disagreements in diagnosis and treatment recommendations stem not only from differences in philosophy, professional orientation, and training experiences but also from simple communication breakdowns. Discontinuity of care increases the likelihood of communication breakdowns. For example, an individual consumer of mental health care may become confused about which mental healthcare provider received various pertinent details of case history. As a result, he or she may neglect to adequately supply a comprehensive account to one or both caregivers. This discontinuous approach often leads to incomplete assessment and treatment protocols, because necessary information is not fully gathered and not fully shared between care providers. Only in rare cases can caregivers sit down, compare notes, and discover omissions and inconsistencies. The risks involved in potential communication breakdowns between busy professionals put the client in danger of substandard care. These dangers may include conflicting diagnoses, incompatible treatment regimens, different methods of measuring outcomes, and divergent notions of treatment success.

Those opposed to PPP argue that collaboration is a standard aspect of both psychiatric and psychological practice. Representatives of these professions are accustomed to embracing other viewpoints and are trained in multidisciplinary treatment approaches. Patients benefit from the unique contribution supplied by practitioners versed in an array of specialties with varying areas of expertise. A multidisciplinary treatment approach is helpful, because specialists bring their own vantage to understanding psychopathology and subsequent treatment. Placing too many treatment options in one practitioner’s arsenal may result in a narrowing of treatment protocols, thus failing to incorporate multiple viewpoints and possibly neglecting viable treatment options. In sum, the opponents of PPP suggest that the dangers articulated with the requirements of collaboration are overstated and overshadow the risks associated with nonphysicians prescribing medication.

Precedent

The APA position points to past and current instances of psychologists safely and effectively providing psychotropic medications to their patients. Such instances include the military’s use of psychologists with prescribing authority and time-limited experimental programs executed in New Mexico and California. Further, the APA states that other non-physician service providers have safely been extended prescription privilege.

During the mid-1970s, the state of California launched a program to extend prescription privileges to many nonphysician mental health providers. These individuals received extensive training in prescribing medications, but they were never legally extended the privilege of prescribing medications. In the Indian Health Sciences Center in Santa Fe, New Mexico, a project that allowed one psychologist to prescribe a limited number of medications was also deemed to be effective during 1988-1989. There were further attempts to extend the prescription privileges to other nonpsychiatrist service providers that many argue were successful in both scope and safety. The APAalso argues that reviews of the performance of psychologists in the DOD have indicated that psychologists have been able to prescribe psychopharmacological interventions safely. Through this program, called the Psychopharmacology Demonstration Project (PDP), 10 psychologists were trained to prescribe medications. Two independent reviews of the military’s prescribing psychologists indicate that the psychologists demonstrated high levels of competence and offered excellent care when prescribing psychopharmacological medications. Further, proponents argue that these 10 psychologists have lessened the workload on physicians, have shortened wait times for mental health services and follow up, and have extended care to a broader constituency.

Those opposed to PPP state that previous pilot projects have been limited in scope and disproportionately expensive, and they have required psychologists to be closely monitored by physicians. For example, they state that the DOD project cost $6 million dollar while training only 10 psychologists. Moreover, they argue that the psychologists needed to be so highly supervised by physicians that their independence was put into question. Finally, opponents argue that the military’s psychologists were restricted to treating relatively uncomplicated cases. In the Santa Fe Indian Health Sciences Project, only one psychologist was extended prescription privilege, indicating a limited precedent. The AMA has argued that previous experiences with PPP have required physicians to undertake an undue financial and time burden in supervising relatively naive psychologists. Thus, the opponents have stated that the expense and training obstacles have proved too onerous and have not resulted in sufficient benefit for the general public.

Future Directions

The prescription privilege debate cuts across many intellectual and proprietary boundaries. Within the field of psychology, the debate focuses on the quality of service provided by psychologists and whether extending PPP would improve or diminish psychologists’ abilities to provide the highest quality mental health care. The discussion between members of the psychological community and those outside of the psychological community has focused on the effects of increasing the number of psychopharmacological prescribers and whether such expansion would provide better or worse service to the general public. As state psychological associations continue to propose legislation, and as physician and psychological groups oppose this legislation in various states, the debate will certainly continue for years to come.

References:

1. American Psychological Association. (2002). New Mexico governor signs landmark law on prescription privileges for psychologists. Retrieved February 6, 2016, from http://www.prnewswire.com/news-releases/new-mexico-governor-signs-landmark-law-on-prescription-privileges-for-psychologists-76321937.html
2. Caccavale, J. (2002). Opposition to prescriptive authority: Is this a case of the tail wagging the dog? Journal of Clinical Psychology, 58(6), 623-633.
3. Dittman, M. (2003). Psychology’s first prescribers [Electronic version]. Monitor on Psychology, 34(2). Retrieved February 6, 2016, from http://www.apa.org/monitor/feb03/prescribers.aspx
4. Heiby, E. M. (2002). Prescription privileges for psychologists: Can differing views be reconciled? Journal of Clinical Psychology, 58(6), 589-597.
5. Lavoie, K. L., & Barone, S. (2006). Prescription privileges for psychologists: A comprehensive review and critical analysis of current issues and controversies. CNS Drugs, 20(1), 51-66.
6. McFall, R. M. (2002). Training for prescriptions vs. prescriptions for training: Where are we now? Where should we be? How do we get there? Journal of Clinical Psychology, 58(6), 659-676.
7. New Mexico Prescriptive Authority Law. 1967 Laws 23 §2 (2002). Retrieved February 6, 2016, from https://cep.nmsu.edu/academic-programs/clinical-psychopharmacology/new-mexico-rxp-law/
8. Norfleet, M. A. (2002). Responding to society’s needs: Prescription privileges for psychologists. Journal of Clinical Psychology 58(6), 599-610.

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