Psychologists seek prescribing rights in 6 states

Psychologists in six states are seeking the authority to prescribe drugs, saying it would allow them to serve patients better in a mental health system stretched thin without enough physicians to meet growing demands.

Legislators in Arizona, Hawaii, Montana, New Jersey, Oregon and Tennessee are considering bills that would allow psychologists to prescribe psychotropic medications. But the measures are staunchly opposed by the American Medical Association, the American Psychiatric Assn., state physician organizations and others who maintain that the proposals would jeopardize patient safety.

"Psychologists are important to the health care team, but a psychologist's education and training does not equip them with the ability to prescribe potentially dangerous psychotropic drugs," said Denver psychiatrist Jeremy A. Lazarus, MD, speaker of the AMA House of Delegates.

Proposals in Hawaii, Montana, New Jersey, Oregon and Tennessee would require psychologists to have a master's degree in clinical psychopharmacology or its equivalent, pass a national examination and have a set amount of clinical experience. Psychologists in Hawaii would have to maintain a collaborative agreement with a physician.

In Hawaii and Oregon, psychologists first must get a conditional prescribing certificate and then qualify for a full certificate after two years. Prescribing rules in Arizona have yet to be set. Similar legislation in Utah failed to be approved in committee on March 2.

Psychologists already prescribe in the military and the Indian Health Service. At the state level, they gained prescribing rights in New Mexico in 2002 and in Louisiana in 2004.

Beyond mental health professionals, some nonphysicians have prescribing rights in certain states. For example, advanced practice nurses have limited prescribing authority in at least 40 states, many of which require a collaborative practice agreement between the nurse and a doctor.

Several health professions are seeking to expand prescribing rights this year. Advanced practice nurses in Illinois, Mississippi and New York want to eliminate the collaborative practice requirement. Naturopaths in more than 15 states are pushing for advanced prescriptive authority.

The number of states considering prescriptive authority for psychologists this year is not unusual, but the issue is alarming, said James H. Scully Jr., MD, medical director and CEO of the American Psychiatric Assn. "These bills essentially grant psychologists the authority to practice medicine," he said.

Proponents of the bills say patients in many areas can't access mental health services in a timely manner. Shortages of child psychiatrists mean that many families wait months to get needed medication for their children, and many pediatricians are reluctant to prescribe psychotropic drugs, said Katherine C. Nordal, PhD, executive director for professional practice at the American Psychological Assn.

"It's an access question, particularly in rural areas," she said. "We feel like it is more cost efficient [to allow psychologists to prescribe], and it is less hurdles the patient has to jump through."

Speaking before Utah's bill failed to be approved in committee, Nanci Klein, PhD, director of professional affairs for the Utah Psychological Assn., said long waits to see a psychiatrist can be devastating for patients. A survey by the association two years ago found that the average patient in Utah waits eight weeks for a psychiatric appointment.

For example, she said, a bipolar patient, who could not see a psychiatrist for eight weeks, was hospitalized after a suicide attempt. "If he had been able to be seen sooner, his deterioration and subsequent suicide attempt could have been averted."

The National Alliance of Professional Psychology Providers supports prescribing rights for psychologists, but only with strict training, said NAPPP Executive Director John L. Caccavale, PhD, a California clinical psychologist. The NAPPP has more than 10,000 practicing psychologists.

Shortages of psychiatrists mean that primary care physicians are seeing more mental health patients and prescribing drugs for many who would be better served through other treatment, Caccavale said. "NAPPP subscribes to psychotherapy as a first line of treatment, not medications," he said. "Our mission is to get mental health back to where it belongs -- with mental health professionals."

Questioning the need

The National Alliance on Mental Illness, however, opposes the prescribing bills. There is no evidence that allowing psychologists to prescribe would address shortages in mental health, NAMI said.

"We really see these medications as having very significant side effects, and we think that the people who prescribe that medication should have significant medical training," said Mike Fitzpatrick, NAMI's executive director. "We advocate for training of primary care physicians in prescribing for serious mental illness."

Numerous medical conditions can mimic mental health conditions, and only physicians are trained to recognize the differences, medical organizations said. Hypothyroidism, hyperthyroidism and adrenal insufficiency are a few that can mask themselves as depression, and lupus may be mistaken for a psychotic break.

Psychologists have limited pharmaceutical training and little, if any, exposure to diagnosing illnesses, said the AMA's Dr. Lazarus. "Physicians have more than 10,000 hours of specific training in diagnosing conditions and determining when pharmacological interventions are appropriate," he said. "During their medical residency, psychiatrists spend more than four years developing the skills and experience necessary to safely prescribe -- or not prescribe -- powerful psychotropic medications."

Editor's note: A version of this story appearing in the March 14 print edition included active legislation in Utah. The Utah bill failed to be approved in committee after the paper went to press.