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By Ami Albernaz
The drive toward allowing psychologists the option of prescribing
medications has gained momentum since New Mexico became the first
and only state to pass a prescription privileges law for psychologists
last year.
Bills allowing psychologists the option to prescribe were on the
legislative agendas of six states this year, including New Hampshire,
where it was defeated. Debate on the issue is nothing new. Since
1990, well over a dozen states have put forth legislation to grant
prescription privileges, all of which were rejected until New Mexico's
successful bid.
Although the debate is multi-faceted, at its core is the belief
that granting psychologists prescription authority will make treatment
more expedient and seamless, versus the belief that such authority
would jeopardize clients' safety, since psychologists at present
do not have the pharmacological training that psychiatrists do.
Nationally, the American Psychological Association (APA) has been
vocal in its endorsement of prescription privileges; new president
Robert Sternberg, Ph.D., is in favor of prescribing privileges and
has assembled a task force to prepare teachers and training directors
for psychopharmacology programs. Psychiatric associations, as well
as some psychologists groups, have been opposed.
A compelling factor in New Mexico's passage of prescription authority
was the difficulty in accessing psychiatric care for large pockets
of the state's population. Only 18 psychiatrists served the 72 percent
of New Mexicans living outside Albuquerque and Santa Fe, compared
to about 175 psychologists. Waiting times to see a psychiatrist
in these rural areas were as long as five months.
Proponents of prescription privileges in other states say that
residents of their states face similarly difficult access. Michael
Schwarzchild, Ph.D., director of the Center for Child and Adolescent
Behavior in Brookfield, Conn. says that some regions of the state
are "woefully underserved" in terms of mental health care and prescription
access.
"In West Central Connecticut, to find a psychiatrist that is ready
and able to provide medication for children is difficult, if not
nearly impossible," he says. "With managed care, it's difficult
to find a child psychiatrist, then find one accepting patients,
then find one on the same plan as a given patient. Put those three
together, and you have what I would call a crisis in West Central
Connecticut, especially when it comes to children, and geriatric
populations." (According to Schwarzchild, Connecticut will present
a prescription bill before the legislature next year.)
Proponents also say that granting psychologists prescription privileges
allows for greater continuity of care, particularly in light of
the managed care trend toward consolidation.
"Our patients would benefit from having one provider who can competently
diagnose, use psychotherapy techniques, and then reserve medication
only when needed to complement basic psychological treatment," says
Sandy Rose, Ph.D, a Hover, N.H. psychologist who has been active
in the push for prescription privileges. "Without privileges, we
currently must work hard to build an alliance, teach coping skills,
only to then ask our patients to start anew with another provider.
This fragments care and often delays important treatment, including
detection and management of side effects or titrating dosages to
match patient status changes."
As a result, she adds, "often patients will get frustrated and
drop out of medication regimens, or become over- or under-medicated
or disillusioned with psychiatric care completely."
Among psychologists at large, statistics on the numbers in favor
of and opposed to prescription privileges vary. Russ Newman, Ph.D.,
JD, APA's executive director for professional practice, cites one
survey in which around 67 percent of psychologists said they favored
prescribing privileges, while 25 percent opposed. Groups opposed
to the privileges, meanwhile, cite surveys in which nearly 50 percent
of psychologists are against them.
State legislators, meanwhile, have by and large been unconvinced
to date. In Wyoming, where a prescription privileges bill was rejected
in February, the main sticking point was the belief that psychologists
would not be adequately prepared to prescribe, even after completing
the pharmacology training called for under the bill. Mary Jo Atherton,
executive director of the Wyoming Psychological Association, says
that this belief reflects a misunderstanding on the part of legislators.
"Psychologists generally have seven years of training after their
bachelors' degree, and the bill calls for two to three years beyond
that," she says. "But it seemed a difficult concept to grasp, that
this would be adequate."
Rose believes a similar misunderstanding was behind the bill's
failure in New Hampshire. "It was not even clear that after all
our efforts, the legislators knew the difference between psychiatrists
and psychologists, the difference between master's level and doctoral
level psychologists, and the extent of training we were proposing
in psychopharmacology," she says. A study bill, which Rose says
will allow for more in-depth analysis of the key issues, will be
presented next year.
While the amount of training that prescribing psychologists would
be required to undergo could vary from state to state, there would
be a considerable transition period between the time of a bill's
passing and when psychologists actually begin prescribing. In New
Mexico, prescribing psychologists must finish 450 hours of post-doctoral
academic work, and see 100 patients under supervision. This period
is followed by a licensing exam, and gradually less supervision
before independent practice is permitted. In addition, a committee
comprised of psychologists and medical examiners is collaborating
on how to implement specific points of the bill. According to Elaine
LeVine, Ph.D., who served on the New Mexico Psychological Association
task force, a report on the committee's progress is expected this
month, and psychologists could begin prescribing not long after.
"My hope is that we could have psychologists in their sites do
some prescribing under supervision by the end of 2003 or beginning
of 2004," she says. Supporters and opponents will doubtless be watching
the process in New Mexico as it continues. "It is more difficult
to get the first state law passed," Newman says. "It's always an
evolutionary process, an educational process of legislators and
the public. In each state, the circumstances are different."
In projecting the likely success of psychologists in prescribing
medication, Newman points to the findings of the U.S. Department
of Defense's Psychopharmacology Demonstration Project, in which
10 military psychologists were trained to prescribe medications
during a two-year program. "Licensed clinical psychologists prescribed
medications safely and effectively, and performed with excellence
wherever they served," he says. He adds that they were also less
apt to prescribe than their psychiatric counterparts.
Newman says that one thread running through the opposition to prescription
privileges is that pharmacology training might change the identity
of psychologists. "There's a fear that this will change the profession,
and that they would be more like physicians, and less like psychologists,"
he says.
Yet psychologists such as Schwarzchild insist that having the authority
to prescribe would give therapists an additional tool in which to
help their clients, and not change their fundamental purpose. "The
bottom line is to be of more help in easing patients' emotional
pain and helping them with behavioral problems," he says. "A one-hour
evaluation isn't enough compared to week-after-week sessions. To
learn to use medication as a tool effectively and well is something
we should be able to do to help us serve our patients."
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