Prescriptive authority for psychologists movement

The Prescriptive authority for psychologists (RxP) movement is a movement among certain psychologists to give prescriptive authority to psychologists with 2 years of postdoctoral training, or Continuing Education training in clinical psychopharmacology and related sciences, followed by 1 – 2 years of supervised prescribing, or a Certificate from the Department of Defense program, or the Board Certified Diploma from the Prescribing Psychologists Register (FICPP or FICPPM) to enable them, according to state law, to prescribe psychotropic medications to treat mental and emotional disorders. This approach is a non-traditional medical training focused on the specialized training to prescribe for mental health disorders by a psychologist. It includes rigorous didactics and supervised practicuums. Legislation pertaining to prescriptive authority for psychologists has been introduced over 180 times in over half of the United States. It has passed in three states, due largely to substantial lobbying effort by the American Psychological Association. Prior to RxP legislation and in states where it has not been passed, this role is played by psychiatrists, who possess a medical degree and thus the authority to prescribe medication (whose numbers are at a critical shortage), and by primary care physicians who can prescribe psychotropics but lack extensive training in psychotropic drugs and in diagnosing and treating psychological disorders. According to the American Psychological Association, the professional organization of psychologists, the movement is a reaction to the growing public need for mental health services, particularly in under-resourced areas where patients have little or no access to psychiatrists.^[1]

Currently, in states where RxP legislation has been passed, psychologists who seek prescriptive authority must possess a doctoral level degree (PhD/PsyD) and a license to practice independently, with five years of clinical experience working with patients as a health care provider, and complete a post-doctoral Master of Science degree or any of the training programs from the Department of Defense, the Prescribing Psychologists' Register Diplomate Certification, or a post-doctoral Master of Science in Clinical Psychopharmacology degree. A Preceptorship of one year of supervised work experience working directly with a licensed prescribing health professional for 100 patient supervision, makes the training a total of approximately 4 years. The medications the psychologist may then prescribe are limited to those indicated for mental and emotional health problems.

Psychologists' involvement in pharmacotherapy exists on a continuum, with psychologists serving as prescribers, collaborators, and information providers in the medical decision-making process. Currently, psychologists may prescribe in four states, Iowa, Illinois, New Mexico and Louisiana, as well as in the Public Health Service, the U.S. military and Guam. When psychologists act as collaborators, they lack the authority to make the final decision to prescribe; however, they may assist in the process by recommending clinically desirable treatment effects, certain classes of medications, specific medications, dosages, or other aspects of the treatment regimen. Psychologists also provide information that may be relevant to the prescribing professional. Psychologists may express concerns about treatment, refer patients for medication consults, direct patients to referral or information sources, or discuss with patients how to address their concerns about medication with the prescriber.^[2]

History

The first bill seeking to authorize prescription privileges to psychologists was introduced in Hawaii in 1985 under Hawaii State Resolution 159. The bill allowed licensed psychologists in the state of Hawaii to administer and prescribe psychotropic medication for the treatment of nervous, mental, and organic brain disorders.^[3] A total of 88 prescriptive authority bills have been introduced in 21 jurisdictions since then.^[3]

In 1988, the U.S. Department of Defense approved a pilot project to train psychologists in issuing psychotropic medications "under certain circumstances". Guam became the first U.S. territory to approve RxP legislation in 1999. New Mexico became the first state to approve RxP legislation in 2002, and Louisiana followed in 2004. In 2014, Illinois became the third state to approve RxP legislation. In 2016 Iowa became the fourth state to grant prescriptive authority. Five other states have introduced RxP bills that are under discussion but have yet to be approved.^[4][5]

The State of New Mexico was the first to enact a Psychologists prescribing law, which is still in effect. Louisiana's legislature established medical psychology as a separate and distinct healthcare profession and transferred the regulation of their practice of medical psychology to the Louisiana State Board of Medical Examiners. At this time, the entire practice of psychology (for medical psychologist) including psychotherapy and psychological testing was also transferred to the Louisiana Board of Medical Examiners, effectively making Louisiana the only state in the U.S. where, for some psychologists, a medical board has authority over the regulation of the entire practice of psychology. Because of this, several national organizations, including the American Psychological Association and the Association of State and Provincial Psychology Boards have expressed concern over a practice of psychology being regulated by another profession (i.e., medicine). The Louisiana Psychological Association has strongly echoed such concerns. However, the Louisiana Academy of Medical Psychologists, a Political Action Committee representing medical psychologists in that state, strongly endorsed this change of regulation by another profession.

APA Guidelines

In December 2011, the American Psychological Association (APA) published a list of practice guidelines that apply to all prescribing activities, with some also applicable to collaborating and information providing activities. The list is categorized according to the area of psychologists' involvement in pharmacological issues (general, education, assessment, intervention and consultation). The following list summarizes the guidelines by section.^[6]

*General

• Guidelines 1 through 3 encourage psychologists to act within the scope of their practice with regards to prescribing psychotropic medications, which includes seeking consultation before recommending certain medications; emphasize that psychologists' evaluate their own views and opinions towards prescribing medications in light of how it may affect communication with patients; and expect that psychologists involved in medication prescription or collaboration be wary of developmental, age, educational, sex, gender, language, health status, and cultural factors involved in populations a psychologist may serve, with regards to pharmacotherapy.

*Education

• Guidelines 4 through 6 require that psychologists attain a level of education specific to pharmacotherapy in order to serve their clients; expect that psychologists be wary of potential adverse side effects of psychotropic medications; and ask that psychologists that prescribe or collaborate with regards to medication prescription be aware of helpful technological resources that are available.

*Assessment

• Guidelines 7 through 9 require that psychologists familiarize themselves with procedures for monitoring the physiological and psychological effects of medications; expect that psychologists who prescribe medications consider other physiological disorders or underlying diseases that the patient may have that could affect the effectiveness of medications; and encourage psychologists to consider issues about patient adherence and concerns about medications.

*Intervention and Consultation

• Guidelines 10 through 15 require that psychologists employ a biopsychosocial approach when prescribing medications and that they also use informed consent procedures, act in the best interest of the patient, and consider current research; emphasize that psychologists be wary of commercial influences regarding medications; and encourage psychologists to consider the patient's interpersonal behaviors.

*Relationships

• Guidelines 16 and 17 expect that psychologists maintain appropriate relationships with other providers of psychological services and biological interventions.

Supporting arguments

There are several core arguments put forth by RxP advocates, including the following:

• Other non-physicians have prescription privileges, such as pharmacists, optometrists, nurse practitioners, and physician assistants. Some advocates have asserted that the latter three professions receive less training in clinical pharmacology, therapeutics, and psychopharmacology than many clinical psychologists.^[7]
• The statistics point to multiple content areas in which the other professions, such as Psychiatric Nurse Practitioners, Physicians are relatively deficient in comparison to pharmacologically trained psychologists’ preparation.^[8]
• The training model is supported by a complete lack of legal complaint after eight years regarding the practice of the initial ten psychologists trained by the U.S. Department of Defense.^[7] Legal complaints differ from legal suits, as military personnel cannot sue for redress.^[9]
• Access to medication would be improved in jurisdictions with long waiting times to see a psychiatrist or other qualified physician.^[10]
• The prescriptive authority would be enhanced by the psychologist's doctoral training in the science of psychology, assessment, and psychotherapy. This training is more extensive than that received by the average physician. In addition, the training program for psychologists would provide twice as much pharmacology training than nurse practitioners and physician assistants receive .^[10]
• It would address the fact that many lack access to psychiatrists (especially in rural areas).^[11][12]
• It would create a clearer distinction between doctoral and masters-level practitioners,^[11] and between doctoral and post-doctoral level practitioners.^[13]
• In circumstances in which the psychologist decided not to collaborate with medical colleagues, it could allow the psychologist control of the entire treatment process. In some cases, this might reduce or eliminate complications arising from interprofessional collaboration and potentially save clients money.^[11]
• Psychologists with prescriptive authority would add competence to the overall mental health system by adding a resource for general practitioners who need professional consultation regarding psychological disorders and psychotropic medications when a psychiatrist is unavailable.^[14]
• Psychopharmaceutical training allows psychologists to provide better advocacy for their clients.^[14]

According to a survey assessing the views of psychology interns, residents, and psychologists published in the journal Professional Psychology: Research and Practice, significant support exists regarding the APA's prescriptive authority initiative.^[6] Proponents of the prescriptive authority initiative believe that it would improve the economic stability of the profession, provide better opportunities to underserved populations, and enhance psychologists' clinical skills through a better understanding of biopsychosocial interactions.^[15] Support for the prescriptive authority initiative also appears higher amongst those with PsyDs and early-career psychologists than those with PhDs and mid- and late-career psychologists. Demographically, females and Caucasians expressed more willingness to seek prescription privileges.^[6] Also, those who attended a clinical or counseling graduate program, received a PhD degree, and those employed in a university counseling center, medical school hospital, or independent practice tend to demonstrate higher levels of support for the initiative. In terms of training, an overwhelming majority of those surveyed believe training should begin at the graduate level, but prior to completion of a doctorate. Additionally, respondents preferred that training occur on a part-time basis, be completed within 6 months to two years, and cost under $10,000.^[6]

Today, evidence exists to indicate a continual and growing level of support for the American Psychological Association's prescriptive authority initiative. Such support reflects psychologists' willingness to open their minds to learning about psychotropic medications, incorporating pharmacological treatment with therapy, and adapting to the demands of a rapidly changing health care world.^[6]

Opposition

Prescriptive authority for psychologists has been controversial, even within the community of psychologists. Psychologists have created entire organizations dedicated to objecting to prescriptive authority for psychologists. Specifically, critics within the psychology profession have expressed concern that they have no medical training. The current RxP model explicitly states that the this movement includes no medical training, but an abbreviated master's degree in psychopharmacology, typically from a distance-education program at a professional school. Physicians assistants and nurse practitioners can elect to specialize in psychiatry, but they have medical training and background, unlike psychologists.

The strongest opposition to date has come from current psychiatrists who point out that psychologists (even after attending additional training) lack the proper general medical knowledge obtained in medical school and residency necessary to effectively and safely manage patients' care (while exposing any patient to undue risk).^[16]

Some psychologists opposing prescriptive authority fear caseload pressures that might press increasing numbers of psychologists to respond to patients' needs via only one treatment modality (pharmacology), as do many psychiatrists.^[17]

Psychologists who extensively had researched the effects of psychopharmacology