Missouri became the first state to see psychologist prescribing legislation this year when a bill was introduced January 8 in the state Senate. An identical companion measure was introduced in the House nine days later.

The two bills (SB 917 and HB 1739) would authorize the licensure of" prescribing psychologists," who could "prescribe certain Schedule II stimulants and Schedule IV tranquilizers or any other psychological treatment or laboratory test as it relates to the practice of psychology, excluding electro-convulsive therapy," according to the legislation.

APA and the state's three district branches are strongly opposing the legislation.

Jack Croughan, M.D., president of the Eastern Missouri Psychiatric Society, testified early last month against the Senate bill before the Senate Financial and Governmental Organizations and Elections Committee. He told legislators that all medications for mental illness have potentially serious side effects and that patients taking them require careful and knowledgeable monitoring.

Carolyn Robinowitz, M.D., president of APA, testified that the measures would allow psychologists to write prescriptions after completing training requirements set by the Missouri State Committee of Psychologists, not the State Board of Registration for the Healing Arts (see Proposed Prescribing Bills Put Patients at Risk).

"In fact, there is no medical involvement or oversight in this legislation," she said.

Drugs used to treat mental illnesses also affect other organ systems and interact with other medications, Robinowitz said. She noted that about half of all patients with mental illness are taking medications for other medical illnesses.

Psychiatrists were critical of the bills' training requirement for" weekly supervision by a physician" because the oversight could be provided by physicians with little background in psychotropics or other medications that psychologists would have authority to prescribe.

"These bills are bad medicine and not the way to address mental health care access issues," Rebecca DeFilippo, executive director of the Eastern Missouri Psychiatric Society, told Psychiatric News.

Opponents of the bills also pointed out that the requirement, as stated in the bills' summaries, for psychologists to complete 400 hours of" didactic educational training recommended by the American Psychological Association and a one-year fellowship" would focus on about only 5 percent of the medications in the Physicians Desk Reference, whereas psychiatrists must have a much broader medical understanding.FIG1

The bills also require psychologists to pass "a national examination testing competency to engage in the practice of prescriptive authority." However, no such examination exists, opponents said.

The bills state that prescribing psychologists must complete at least 20 hours of "psychopharmacology continuing education credit" in addition to 40 hours of continuing education within the two years before license renewa. This latter requirement was criticized because the content of the continuing medical education is not specified.

Similar to psychologist-prescribing advocates in other states, proponents of the bills have argued that granting prescriptive authority to psychologists would be cost-effective and increase access to care, especially for rural populations in Missouri.

The measures were introduced by state Rep. Danielle Moore (R) and state Sen. Jack Goodman (R), rural representatives, who have framed them as an important part of their efforts to reduce the cost of health care and reduce the number of uninsured residents below 700,000.

"There is nothing more important to the welfare of our citizens than having access to health care, whether it is for treatment of an injury or for treatment of an emotional or mental disorder," Moore said in a statement issued by an advocacy coalition called the Missouri Families for Access to Comprehensive Treatment. "When people run into obstacles finding affordable care, they become frustrated and too often will go untreated."

A coalition statement said that the legislation would reduce waiting periods that are now as long as eight months in rural and inner-city areas to see a psychiatrist and obtain needed prescriptions.

Psychiatrists acknowledge that there are access problems—especially to pediatric and geriatric psychiatrists—in some areas of the state, but family physicians are already trained to prescribe medications for mental illness and are better spread throughout the state than are psychologists.

In answer to psychologists' contention that general practice physicians have only about eight weeks of training in mental health—according to research by the Missouri Psychological Association—Robinowitz said the health care needs of underserved populations are best met by improving the mental health training of primary care providers, who already have far more pharmacological training than the bills require.

Supporters of the bills said that the enactment of psychologist prescribing laws in 2002 in New Mexico and in 2004 in Louisiana, along with Guam in 1998, have paved the way for other states to take similar action. However, the description of the discontinued Department of Defense Psychopharmacology Demonstration Project (PDP) as "proof" that psychologists can be trained to prescribe psychotropic drugs safely to patients drew a sharp rebuke.

"Not only were the participants carefully screened and selected, but the didactic and clinical psychopharmacology training they received far exceeds the curriculum of any psychopharmacology training course in existence today," Robinowitz said.

Psychologists in the PDP undertook a full year of didactic classroom lectures and spent a second year training full time under the direct supervision of military psychiatrists.

"To propose crash-course, shortcut training based on ever more vague standards and requirements is an insult to persons who need treatment for mental illness, including substance use disorders," Robinowitz said.

This year promises to be a busy one for psychologist-prescribing advocates and opponents, as Missouri has joined three other states—California, Hawaii, and Mississippi—in considering such bills.

In 2007 psychiatrists helped halt bills in 10 states that would have extended prescribing privileges to psychologists. One effort helped win a veto by Hawaii's governor, Linda Lingle (R) (Psychiatric News, August 17, 2007). Supporters of psychologist prescribing have reintroduced the measure in the Senate (SB 2531) and the House (HB 2411). The House held its first hearing on February 6.

In California, a wide-ranging bill (SB 993) to expand psychologists' scope of practice was temporarily stopped in 2007 by the Senate Committee on Business, Professions, and Economic Development, but the legislation is still active due to that state's two-year legislative session.

Last year, Mississippi legislators considered a bill that would have authorized prescribing privileges for "medical psychologists" who have "specialized training in clinical psychopharmacology and have passed a national proficiency examination in psychopharmacology" approved by the Mississippi Board of Psychology. Although supporters were unable to muster enough support in either chamber, they introduced new bills (HB 148 and SB 2863) on January 22 and February 5, respectively.

APA also is watching for bills in six states that are considered likely to introduce such measures: Alabama, Florida, Georgia, Minnesota, New Hampshire, New Jersey, Ohio, Oklahoma, Tennessee, and Washington.

The text of most of these bills can be accessed on the official Web sites of the respective state legislatures. ▪