Prescriptive Authority For Psychologists: Issues And Considerations - Executive Summary
Prescriptive authority for psychologists has been the subject of legislative efforts and extensive debate for more than two decades. From 1991 through 1997, the United States Department of Defense's Psychopharmacology Demonstration Project (PDP) trained military clinical psychologists to prescribe psychoactive drugs to treat patients between the ages of 18 and 65 for mental illness, generally not of the serious mental illness category. All patients were treated at military medical facilities. External evaluations of the PDP program report that patients were screened to eliminate complicated medical conditions. Thirteen individuals participated, ten graduated. PDP participants had a minimum of one year of full time classroom training at the Uniform Services University of Health Sciences (USUHS) and one year of full time clinical training, supervised by a psychiatrist, at Walter Reed Army Medical Center or Malcolm Grow Medical Center.
A number of external evaluations reviewed the PDP program, its participants, and graduates and concluded that the program had met its goal of training military psychologists to prescribe safely and effectively for their mental health patients in military medical facilities. Program graduates interviewed as part of the final evaluation in 1998 were found to hold positions of head or assistant head of departments or clinics, indicating to interviewers that program graduates were well respected by their peers and suggesting that candidates for future psychopharmacology training programs should be held to high selection standards when admission decisions are made.
To date, only two states, New Mexico and Louisiana, have authorized prescriptive authority for psychologists. Both programs were implemented in 2005. As of this writing, there are only four conditional prescribing psychologists, who require supervision for two years, in New Mexico; there are no independent prescribing psychologists. Louisiana reports thirty-four psychologists have been issued certificates of prescriptive authority. Although both states require prescribing psychologists to have a collaborative relationship with a patient's primary care physician, whose approval must be received before a prescription can be written, Louisiana does not require an initial two year period of supervision. Also, both states have classroom and clinical training requirements for prescribing psychologists that appear less stringent than the PDP training model, although there have been no known adverse affects on patient safety in either state. However, the training requirements for either state have not been externally evaluated and there have been no external evaluations relating to patient safety or whether access to mental health care services has changed as a result of allowing psychologists to prescribe.
Even though only two states have authorized prescriptive authority for clinical psychologists, there are at least ten independent programs that offer postdoctoral training in psychopharmacology for clinical psychologists. These programs are not uniform in their requirements or approaches, although they all claim to meet the recommended standards of the American Psychology Association (APA). Because the APA recommended standards are less rigorous than the training requirements of the PDP, none of the current training programs meet the classroom or clinical training requirements of the PDP program. Similarly, none offer one year of fulltime classroom or clinical training or classroom and clinical training facilities equal to the USUHS or Walter Reed or Malcolm Grow. Whether these independent programs can train clinical psychologists to prescribe safely has not been established by external evaluations.
Generally speaking, supporters of prescriptive authority for psychologists claim such authority would increase access to mental health services for the medically underserved. Opponents generally point to psychologists' lack of medical education and inability to distinguish between organic conditions that mimic mental illness and mental conditions. Opponents contend that psychologists' lack of scientific background would endanger patients. While psychologists point out that nonphysicians have safely prescribed drugs for some time, psychiatrists note that those prescribers include advance practice registered nurses, physician assistants, and others who have a medical based background that includes biological and neurosciences, anatomy, and other courses not taken by psychologists. Nonphysician prescribers, therefore, are better qualified to prescribe than psychologists, according to opponents of prescriptive authority for psychologists.
Federally qualified health centers, or community health centers, are required to provide medical services, including mental health care, to medically underserved areas or populations. There is no dispute that there is a shortage of mental health care services available to the medically underserved in Hawaii; however, there are differences in how to increase services. Community health centers are among the supporters of prescriptive authority for psychologists as a way to increase access to mental health care for their clients.
Whether clinical psychologists should be authorized to prescribe medication is a policy decision for the legislature. The ultimate decision should be guided by considerations of patient safety. Whatever the decision or solution on this issue, patient safety cannot be compromised.