Proposed Prescribing Bills Put Patients at Risk

Recently, 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 Original 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?

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 school.

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. ▪