Legislation allowing psychologists in Illinois to prescribe psychotropic medications has been approved by the state’s Senate committee amid strong opposition from psychiatrists and other physicians. But judging from the fate of many similar bills around the country — including 14 previous efforts in Illinois alone — it’s going to be an uphill battle.
Since 1995, there have been no fewer than 170 proposed bills in the United States that would have granted prescribing privileges to psychologists. Only 3 — in New Mexico, Louisiana and Guam – have passed.
The bills, like the one in Illinois, generally have the same stated purpose — to allow psychologists to address the increasing gap in mental health needs left by dwindling numbers of psychiatrists.
In Illinois’ case, there are as many as 50 counties with no inpatient psychiatric services and 24 counties with no hospitals at all, advocates of the bill say.
“Illinois faces a critical shortage in mental health professionals who are trained to prescribe medicine, resulting in inadequate treatment for mental illness across the state,” the bill’s sponsor, Sen. Don Harmon, D-Oak Park, told the Chicago Tribune.
Meanwhile, there are 4 times as many licensed clinical psychologists as psychiatrists in the state — about 4900 to 1200 — putting psychologists in a good position to fill the gap, Beth Rom-Rymer, PhD, president-elect of the Illinois Psychological Association, told Medscape Medical News.
“In most counties with no psychiatrists, there are either psychologists in that county or in adjacent counties,” she said.
Opponents of the bill argue that even in the absence of a psychiatrist, a range of physicians, including general practitioners, family physicians, and pediatricians, can all also prescribe pyschotropic medications to patients in need, but Dr. Rom-Rymer asserts that psychologists are more specialized than physicians in those fields when it comes to mental health patients’ needs.
“Psychologists in fact have 4 times as much training in clinical psychopharmacology as practitioners such as family practice or family care physicians, so they are more suited to address mental health needs,” she said.
Under the Illinois measure, psychologists could earn prescribing privileges after they have completed two and a half years of additional, postdoctoral training, with course work requirements including a graduate-level course in each of the following areas: neuroscience, pharmacology, psychopharmacology, physiology, pathophysiology, physical and laboratory assessment, and clinical pharmacotherapeutics.
In addition, clinical training requirements would include “management of the pharmacological treatment of a minimum of 100 patients under the full supervision and control of a designated qualified practitioner,” according to the Illinois Psychological Association.
These supervisors have so far almost all been board-certified psychiatrists, the group adds.
“When you combine that with the hours spent earning the doctorate in clinical psychology, the amount of advanced specialized training is more than 10,000 hours, so our amount of training is very much commensurate with what psychiatrists receive,” Dr. Rom-Rymer said.
Even with all of the hours, however, the training that psychologists receive does not include the type of anatomic, biomedical clinical training physicians and psychiatrists must receive, said Nicholas M. Meyers, director of government relations for the American Psychiatric Association.
“Mental health training does not equate to the biomedical training that physicians get at all. It denigrates the complexity of the brain medicine that psychiatrists and others prescribe by saying, ‘it’s really no big deal,’ ” he told Medscape Medical News.”
That complexity becomes particularly challenging in the common scenario of a patient who receives multiple medications or who has multiple conditions.
“You need to monitor and be prepared to adjust medication at all times and to be aware not just of the medication you’re prescribing and its effect not just on the brain but on the body, as well as all of the other medications the patient is taking and the interaction between those medications,” he said.
“So if you’re talking about a diabetic, for instance, who is also taking blood pressure medication and antidepressants, you need to be monitoring all of these things at all times, and a psychologist simply isn’t trained to do it.”
“Nadir of Prescribing Bills”
The fact that the Illinois bill allows some of the training to be received through online courses and its rules for out-of-state psychologists make it a more worrisome bill than most, Meyers said.
“I would characterize the Illinois bill as the nadir of prescribing bills — it is by far the worst of the state prescriptive authority bills that we’ve seen,” he said.
“What makes it particularly dangerous is it waves into the state psychologists who hold licenses to prescribe either in other states or from the old and long-since-defunct Department of Defense Psychopharmacology Demonstration Project.”
“So you feasibly have clinical psychologists who have earned a master’s degree in clinical psychopharmacology from an online school have their prescribing supervised by psychologists licensed from other states, and this whole mess would be supervised and run by a board which, in theory, could consist of psychologists with no prescribing authority whatsoever.”
“This is a recipe for lousy and dangerous care, and the entire premise upon which it is based is certainly open to challenge,” Meyers said.
Chicago psychiatrist Kenneth G. Busch, MD, agreed.
“Psychiatrists have more than 10,000 hours of training in physiology, biochemistry, pharmacology, anatomy, and clinical experience, and to say that this privilege can be granted with part of the training earned in online courses is, in my view, ridiculous,” Dr. Busch told Medscape Medical News.
“This is simply a very bad bill,” said Dr. Busch, a distinguished life fellow with the American Psychiatric Association.
AMA Weighs In
Dr. Busch disputed the contention that there is more access to psychologists in areas such as rural regions, where psychiatrists are lacking.
“This isn’t a matter of psychologists being in rural areas where there are no psychiatrists — geographically, they are in the very same areas. Just like psychiatrists, most of the psychologists are located in the city as well, and there is an access issue to both in any rural community,” he said.
He added that a more effective way of addressing the issue of access in rural areas is through the increasing use of telepsychiatry.
“There’s no question that access is indeed an issue in psychiatry, but one of the most important and effective ways we are reaching out to rural communities is with telepsychiatry,” Dr. Busch added.
Dr. Rom-Rymer countered that with the psychiatry shortage, many psychiatrists already have a 2- to 3-month waiting period for appointments.
“I fail to see how they can have time for enough telepsychiatry to make a difference if they are already that overbooked,” she said.
She added that telepsychiatry is costly to implement and that “it could cost millions of dollars to establish telepsychiatry to meet current mental health needs, and the ability to meet the state’s mental health needs through telepsychiatry is many years off.”
Katherine C. Nordal, PhD, executive director for professional practice with the American Psychological Association (APA), notes that psychologists are not alone in the class of healthcare providers who have sought prescribing rights that have been met with opposition from the physician community.
“Many other nonphysician providers, including those with prescribing rights such as optometrists, nurse practitioners, nurse anesthetists, nurse midwives, and others, have also struggled to advance necessary changes to their scope of practice due to the efforts of the medical community to oppose change.”
Dr. Nordal said that the APA has become a member, along with the other professions, of the Coalition of Patients’ Rights, as they “struggle to advance necessary changes to their scope of practice due to the efforts of the medical community to oppose change.”
The American Medical Association has issued a statement opposing psychologist prescription authority, calling on all state medical societies to “work closely with local psychiatric societies to oppose legislative or ballot initiatives authorizing the prescribing of medications by psychologists.”
But the medical community and psychiatrists are not the only ones opposed to psychologist prescribing privileges. Surprisingly, some of the strongest opponents are psychologists themselves.
Psychologists Among Key Opponents
A group of psychologists calling themselves Psychologists Opposed to Prescription Privileges for Psychologists (POPPP) asserts that they “do not believe that psychologists have sufficient training in basic and biological sciences to be able to prescribe drugs,” according to the organization’s Web site.
The group’s board of advisors includes accomplished psychologists from around the country. Among them is Richard Stuart, PhD, who said he strongly stands by the mission statement.
“I believe very strongly in the ethical necessity of practicing within a person’s scope of competence,” said Dr. Stuart, a licensed psychologist and professor emeritus at the University of Washington’s Department of Psychiatry in Seattle.
The ability to address the many potential biomedical effects of drugs is simply outside of that scope, he said.
“One of the realities of drugs is that they are really powerful — what we call side effects are not really side effects — they are direct effects, but they’re just not the effects you want,” Dr. Stuart toldMedscape Medical News.
“If you give someone a common SSRI, it affects the gut and many areas of the brain, and one needs to be able to competently monitor the effects.”
“Psychologists can’t order lab tests, and we are not qualified to do the kinds of systemic evaluations that responsible prescribing requires,” he said.
Dr. Stuart said that opposition to prescribing rights is widespread among psychologists. “Most of us consider it to be an unsafe practice.”
The sentiment is likely evidenced in the fact that in the 2 states where psychologist prescribing laws have passed, New Mexico and Louisiana, only a small percentage — 8% to 12% — of psychologists have become licensed to prescribe, and in the territory of Guam, none have become licensed, according to POPPP.
Money a Motive?
If the psychologists are not rallying en masse to push for prescribing rights, then who is behind the seemingly nonstop efforts to propose legislation?
“Generally speaking, it’s all about money, and all of these other arguments that are being put forward are a smokescreen,” Meyers said.
“It’s about money in terms of the ability to bill more and, likely in some cases, in terms of psychologists with financial interests in the clinical psychopharmacology training programs.”
“In Illinois, the danger of the latter scenario is you have the potential for clinical psychopharmacology training programs to spring up overnight and result in poorly trained psychologists.”
Meyers stopped short of implicating the pharmaceutical industry in the equation, however, suggesting that the idea of psychologists prescribing was likely too risky an idea even for them to latch onto.
“I think they might see it as a major liability because if there are untoward events, they could be the deep pockets to go after.”
Another expert who wished to remain anonymous on the subject, however, was not so quick to rule out the influence.
“Some of the funding for the psychologist prescription movement has been contributed by professional associations, and some has probably been donated by the for-profit psychologist-prescribing training programs, [but] it is also quite reasonable to assume that big pharma has pitched in, because it stands to profit substantially from tens of thousands of additional prescribers,” the expert said.
In the vast majority of states where prescribing authority remains limited to physicians, psychologists continue to hold critically important roles in the mental health community in the capacity they are trained for, and they can easily collaborate with physicians when medication is required.
“As psychologists, we are very competent at arriving at a diagnosis to determine what skills are lacking or what attitudes are lacking with a behavioral problem, or identifying when the behavior is the result of some kind of neurochemical abnormality, and when it is, we collaborate with the people who prescribe,” Dr. Stuart said.
The collaboration is ideal in utilizing the best skills of professionals in their own specialties in addressing patients’ mental health needs, he added.
“They don’t do what I’m good at, and I don’t do what they’re good at, and the collaboration works wonderfully,” Dr. Stuart said.
None of the sources have disclosed any relevant financial relationships.