FIG1Recently, I had the
opportunity to testify before the Missouri State Senate in strong opposition
to proposed legislation that would allow psychologists to prescribe
psychotropic medications (and related medications to treat side effects),
including controlled substances, without necessary medical education (see
article APA, DBs Prepared to Battle Psychology Prescribing Bills). I was
astounded to learn that through this proposed legislation, the board approving
and licensing such psychologists would be composed of other nonmedically
trained psychologists! How can you oversee what you do not know?
©Sylvia Johnson Photography 2007
Such a proposal puts patients at risk. Psychologists wishing to be deemed"
prescribers" often state that psychiatric medications comprise
only a small portion of the Physicians Desk Reference; this is
disingenuous. Psychotropic medications, as all medications—even
aspirin—affect the whole body and have the potential for dangerous side
effects. Their impact is not limited to the brain or the specific"
behavioral" symptoms for which they are being prescribed. Half of
the patients who require psychotropic medication have other medical conditions
that also require medication. Interactions of these medications can influence
both physical function and behavior. Further, medical students have long been
taught that patients do not arrive at a clinician's office knowing the
etiology of their symptoms or even what systems are involved, and just as
psychiatric disorders present with physical symptoms, psychiatric symptoms may
be indicators of nonpsychiatric medical disorders. One needs to know that a
condition exists to consider diagnosing it.
Basically, the professions come from an entirely different background,
educational focus, and understanding of illness. Psychiatry is a medical
specialty, using a biopsychosocial paradigm, addressing the interplay of
genetic and constitutional factors with the environment and experience.
Psychology is based on a psychosocial model rather than a medical model. The
focus of psychologists' training is not on normal/cellular/physiological
function or pathophysiology of diseases as it is for physicians. Moreover,
psychology trainees are not trained to diagnose and treat patients with
medical disorders other than mental disorders. Additionally, there are strong
differences in education time and type of experience: the proposed 400 hours
(10 weeks) of didactics for psychologists to be licensed to prescribe in
Missouri is way less than four years of medical school (at least two of which
are spent in many hours of hands-on supervised interaction with patients with
a broad range of psychiatric and other medical conditions) in addition to the
24/7 rigors of a medical internship that includes at least two months of
neurology followed by a psychiatry residency involving hospitalized severely
ill patients as well as ambulatory care.
Often the "success" of the Department of Defense (DoD) pilot
program to train psychologists to prescribe is cited as a rationale for
further efforts. Such citations ignore the 1997 report of the General
Accounting (now Accountability) Office that criticized the program, as well as
the recognition of the program's major limits. The DoD program, which was
promoted by a U.S. senator and a staff member (who during his tenure on the
senator's staff also was president of the American Psychological Association),
was designed to have the best possible outcome. Participants were handpicked
senior psychologists with extensive clinical experience. The program included
a year's intensive didactic and clinical experience with close medical
supervision. Patients were young, healthy adults; children, the elderly, and
patients with preexisting (nonpsychiatric) medical conditions were excluded.
Training the 10 psychologists who completed the program cost taxpayers
$610,000 for each, for a total cost of over $6 million in 1996—the
equivalent of tuition for a class of 200 students at a private medical school!
Ironically, two of the psychologists in the program eventually went to medical
Those wishing to expand psychologists' scope of practice without
appropriate training often cite the need for services in rural areas. Yet,
psychologists' demographics resemble those of other professionals (for
example, psychiatrists, attorneys) in that they are congregated in urban and
suburban settings. Family physicians (who are already trained in medicine and
have residency and certification-based experience in the treatment of mental
illness) are much more likely to practice in the less-populated areas, as are
physician assistants and nurse practitioners. In New Mexico, where some
psychologists became licensed to prescribe after completing "crash
courses," there are no data showing an influx of those licensed
psychologists to underserved areas.
Our voices must take action to protect our patients, many of whom by virtue
of their illness, stigmatization, or lack of resources are underserved, by
educating policymakers and the public about the need for access to safe and
appropriate care. ▪