Psychologists in Louisiana and New Mexico are certified to prescribe

Elaine LeVine, PhD, is one of four psychologists able to prescribe medication in the United States, a privilege she received this February when New Mexico and Louisiana became the first states to issue psychologists prescribing certificates.

So far only two psychologists in New Mexico and two in Louisiana have completed the certification process. Another 40 psychologists are in various stages of training in New Mexico and are expected to qualify over the next two years. In Louisiana, 50 psychologists are expected to receive prescribing certificates by year's end.

Organized medicine was united in its opposition when New Mexico passed legislation in 2002 and Louisiana adopted a law in 2004. A number of physicians still believe it's unsafe to have psychologists prescribe medication. But as the program gets under way, a physician supervising Dr. LeVine said the new law is good for patients, particularly those in underserved areas.

"I've been in southern New Mexico for 16 years, and we spend hours every week trying to find help from psychiatrists and psychologists," said Tim Herndon, MD, who supervises Dr. LeVine and also is an instructor at the Southwestern Institute for the Advancement of Psychotherapy and in private practice. Roughly 40% of Dr. Herndon's practice is behavior pediatrics, not because he specializes in it but because there is a need.

He sees Dr. LeVine and her colleagues as a boon to the area's underserved population, and he's confident in their training and abilities.

"The psychologists I have worked with are very compulsive about going though the whole process, making sure the medication won't interact with others," he said.

New Mexico requires applicants to hold a doctorate and complete 450 hours in an approved psychopharmacology program, an 80-hour practicum and 400 hours of physician-supervised treatment of 100 patients. A psychologist must consult a patient's attending physician before prescribing.

However, George Greer, MD, the legislative representative for the Psychiatric Medical Assn. of New Mexico, said this won't keep patients safe.

"The regulations and the law are far short of what is safe for people to prescribe these medications," Dr. Greer said. "The supervision is not by a psychiatrist but by any physician. ... It's just not enough protection. That physician is not there seeing the patient with them and has to defer to their psychological diagnosis."

Now that the law has been passed, Dr. Greer said his organization was supporting a program to match psychiatrists with rural medical clinics in the state in an effort to boost access to mental health care.

Louisiana's psychiatrists are seeking to increase rural access via telemedicine. But some are still worried that Louisiana psychologists can prescribe anything a psychiatrist can, except narcotics.

"We have real concerns about that," said Dudley Stewart Jr., MD, with the Louisiana Psychiatric Medical Assn. "There are so many medications that are used off-label for psychiatry, like antiepileptics."

Moving forward

Dr. LeVine has been relieved that the deep tensions between New Mexico's psychologists and physicians hasn't kept her from writing prescriptions.

"I was wondering how open the physicians would be," she said. "In the past I could call physicians, and if they weren't familiar with a particular medication, they weren't comfortable prescribing it. Now I can defer to their judgment on the medical issues, but they let me take the lead on the psychotropic intervention."

Dr. LeVine says she's seeing the difference already in patient care, which is an important claim, since access to care was a winning argument for passage in both these rural states.

"I've only been practicing in this format a little over a month, but I've already had a couple of very gratifying situations," she said.

One case was a 12-year-old boy, who she had originally referred to a psychiatrist. The child waited three and a half months to see the psychiatrist, but there wasn't any follow-up with the family after the initial meeting, and no prescription was given.

"He's so busy," Dr. LeVine said of the psychiatrist. "It slipped through the cracks."

By this time, Dr. LeVine had her prescribing certificate. She consulted with the child's pediatrician and put the child on medication.

"He was cutting on himself, and it really allowed us to move forward to help him," Dr. LeVine said.

Dr. Herndon was the child's pediatrician in this case and had had only moderate success with medication for the boy, he said. It was Dr. LeVine who found the drug that worked.

"She was the one who figured it out," Dr. Herndon said. "He's doing better now -- that's the bottom line."

The ongoing battle

To date, only New Mexico and Louisiana have passed such legislation, but nine other states saw psychologist prescribing bills introduced in their legislatures this year, according to the American Psychiatric Assn.

Bills have died or are expected to go nowhere in seven states. At press time, legislation was still pending in Georgia and Tennessee.

The APA actively opposes prescribing bills and expects to continue seeing legislation introduced across the country.

The American Medical Association opposes groups using legislatures to expand their scopes of practice, saying that it is not safe for patients.

Members of the Association's newly formed scope-of-practice advisory committee are considering ways to bolster physician resources and block these measures.