Despite strong support among leading legislators, a bill to allow
psychologists to prescribe medications in Hawaii was derailed through the
efforts of local physicians and APA. In its place, a nonbinding resolution was
approved by the Hawaii Senate to direct state officials to study the
The bill (HB 2589) would have authorized "trained and supervised
medical psychologists working in federally qualified health centers or other
licensed health clinics located in federally designated medically underserved
areas" to prescribe psychotropic medications.
The Hawaii House of Representatives approved the prescribing bill in March,
and it was moving quickly through the Senate until an extensive lobbying
effort by the Hawaii Psychiatric Medical Association (HPMA) to educate the
senators raised their concerns about the bill and resulted in the study
The resolution (SCR 113) asks the Legislative Reference Bureau (LRB) to
study prescriptive authority for psychologists who have "obtained the
appropriate education, training, and experience to prescribe a limited
formulary of psychotropic medications for the treatment of mental illness,
while practicing in federally qualified health centers or licensed health
clinics located in federally designated medically underserved areas or in
mental health professional shortage areas."
The Senate-passed resolution will move on to the House, which is expected
to approve it. The state Senate is not expected to address the prescribing
issue again this year.FIG1
APA financial and staff support were cited as critical in redirecting the
prescriptive legislation into the nonbinding resolution, according to
opponents of the bill. APA sent staff to Hawaii and provided extensive
financial support throughout the legislative fight and during the late-session
push against the prescribing bill.
"The defeat of the prescribing bill was the result of a concerted
lobbying and information campaign by HPMA with key support from APA,"
said Nick Meyers, director of APA's Department of Government Relations
APA has made a long-term effort to support Hawaii and other district
branches in the struggle over prescribing legislation. APA's direct staff
support and information included DGR testimony against the bill and creation
of a prescribing resource packet, and DGR staff called all HPMA members"
to alert them to the need for their personal intervention,"
"It really was a collaborative effort by APA and HPMA to defeat this
bill, with APA providing a needed boost at the end to make sure that
happened," said Lydia Hemmings, HPMA executive director.
The LRB has a limited amount of research it can conduct in any year, but
Hemmings said she expects legislative supporters of psychologist prescribing
to push prioritization of research into mental health medication access
The HPMA plans to address access problems before the start of the next
legislative session in January 2007 through work with state health agencies to
increase access to psychiatrists on more islands of the state.
The HPMA is also coordinating with the State of Hawaii Health Planning
Development Agency to establish a family-physician medical school and
residency program in part designed for master's-level graduates in psychology
or social work enrolled at the School of Psychology at the University of
Hawaii. Program supporters believe that these graduates would be better
trained to address the substance abuse and mental health problems that
predominate in rural, low-income settings where psychiatrists and mental
health professionals are in short supply.
"These would still not be the specialists in mental health, but they
would be better able to respond and triage and refer patients to a
psychiatrist when necessary." The graduates would be licensed physicians
with a background in psychology, Hemmings said.
A psychologist-prescribing bill is likely to return in future legislative
sessions. The 2006 version would have required psychopharmacological training
from an institution of higher learning approved by the state psychology board.
It also would have required a one-year supervised practicum involving 400
hours treating at least 100 patients with mental disorders. The practicum was
to be supervised by a "licensed health care provider who is experienced
in the provision of psychopharmacotherapy" (Psychiatric News,
April 7). The prescriptive authority would have sunset in 2013 unless
legislators extended it.
The bill's supporters, including the Hawaii Psychological Association and
the Hawaii Primary Care Association—composed of directors of the state's
community health centers—said it would benefit patients at rural
community health centers who can wait from six weeks to three months to see a
psychiatrist. They noted that in 2004 only six psychiatrists served in three
of Hawaii's 13 community health centers, compared with 10 psychologists who
served in nine of the centers.
Hawaii psychiatrists and other physicians said that the access problem
stems in part from the refusal of community health centers to hire
psychiatrists. The claims that psychologist prescribing would provide
cost-effective assistance ignores the likely need for an expensive
quality-assurance system for the new prescribing group, money that would be
better spent hiring a psychiatrist in every clinic, said opponents of the
Hawaii psychiatrist Jeffrey Akaka, M.D., who lobbied against the bill,
compared it to allowing "trained mechanics who never went to pilot
school [to fly] a gassed-up Boeing 767 full of passengers."
"It doesn't matter if the mechanic spent seven years studying how to
repair airplane-cabin cooling systems or reading pilot journals. Nothing short
of pilot school with thousands of hours of training under the supervision of
pilots gets you a commercial pilot's license to fly human beings," he
In a letter to Hawaii state senators, the American Osteopathic Association
wrote that "effective use of medications to treat brain disorders
requires medical training with a thorough understanding of physiology,
chemistry, drug interactions, and medical problems that may masquerade as or
cause brain malfunctions."
House members sought to limit potential dangers of psychologist prescribing
by amending the bill to limit allowed medications under an "exclusionary
formulary" to antidepressants, benzodiazepines, and possibly Ritalin and
The Senate's Committee on Health approved the bill, but the Committee on
Commerce, Consumer Protection, and Housing took no action, stalling its
The HPMA has opposed psychologist prescribing for more than 20 years. It
has fought 25 psychology prescribing bills in that time.