Prescriptive authority for psychologists movement
The Prescriptive authority for psychologists (RxP) movement is a public health initiative to give prescriptive authority to psychologists with 2 years of postdoctoral Masters degreed training, or Continuing Education training in clinical psychopharmacology and related sciences, followed by 1 – 2 years of supervised prescribing, or a Certificate from the Department of Defense program, or the Board Certified Diplomate from the Prescribing Psychologists Register (FICPP or FICPPM), www.pprpsych.com to enable them, according to state law, to prescribe psychotropic medications to treat mental and emotional disorders. Prior to RxP legislation and in states where it has not been passed, this role is played by psychiatrists, who possess a medical degree and thus the authority to prescribe medication (whose numbers, advocates assert, are at a critical shortage), and by primary care physicians who can prescribe psychotropics but (advocates argue) lack extensive training in psychotropic drugs and in diagnosing and treating psychological disorders. According to the American Psychological Association, the professional organization representing the interests of psychologists, the movement is a reaction to the growing public need for mental health services, particularly in less urbanized and therefore under-resourced areas where patients have little or no access to psychiatrists. Prescribing Psychologists' Register (PPR, or pprpsych.com) with Samuel Feldman, Ph.D., President, was the pioneer in first presenting such training for psychologists to prescribe,
Currently, in states where RxP legislation has been passed, psychologists who seek prescriptive authority must possess a doctoral level degree (PhD/PsyD/EdD) and a license to practice independently, with five years of clinical experience working with patients as a health care provider, and complete a post-doctoral Master of Science degree or any of the training programs from the Department of Defense, the Prescribing Psychologists' Register Diplomate Certification, or a post-doctoral Master of Science in Clinical Psychopharmacology degree. A Preceptorship of one year of supervised work experience working directly with a licensed prescribing health professional for 100 patient supervision, makes the training a total of approximately 4 years. The medications the psychologist may then prescribe are limited to those indicated for mental and emotional health problems.
Psychologists' involvement in pharmacotherapy exists on a continuum, with psychologists serving as prescribers, collaborators, and information providers in the medical decision-making process. Currently, psychologists may prescribe in three states, Illinois, New Mexico and Louisiana, as well as in the Public Health Service, the U.S. military and Guam. When psychologists act as collaborators, they lack the authority to make the final decision to prescribe; however, they may assist in the process by recommending clinically desirable treatment effects, certain classes of medications, specific medications, dosages, or other aspects of the treatment regimen. Psychologists also provide information that may be relevant to the prescribing professional. Psychologists may express concerns about treatment, refer patients for medication consults, direct patients to referral or information sources, or discuss with patients how to address their concerns about medication with the prescriber.
The first bill seeking to authorize prescription privileges to psychologists was introduced in Hawaii in 1985 under Hawaii State Resolution 159. The bill allowed licensed psychologists in the state of Hawaii to administer and prescribe psychotropic medication for the treatment of nervous, mental, and organic brain disorders. A total of 88 prescriptive authority bills have been introduced in 21 jurisdictions since then.
In 1988, the U.S. Department of Defense approved a pilot project to train psychologists in issuing psychotropic medications "under certain circumstances". Guam became the first U.S. territory to approve RxP legislation in 1999. New Mexico became the first state to approve RxP legislation in 2002, and Louisiana followed in 2004. In 2014, Illinois became the third state to approve RxP legislation. Five other states have introduced RxP bills that are under discussion but have yet to be approved.
The State of New Mexico was the first to enact a Psychologists prescribing law, which is still in effect. Louisiana's legislature established medical psychology as a separate and distinct healthcare profession and transferred the regulation of their practice of medical psychology to the Louisiana State Board of Medical Examiners. At this time, the entire practice of psychology (for medical psychologist) including psychotherapy and psychological testing was also transferred to the Louisiana Board of Medical Examiners, effectively making Louisiana the only state in the U.S. where, for some psychologists, a medical board has authority over the regulation of the entire practice of psychology. Because of this, several national organizations, including the American Psychological Association and the Association of State and Provincial Psychology Boards have expressed concern over a practice of psychology being regulated by another profession (i.e., medicine). The Louisiana Psychological Association has strongly echoed such concerns. However, the Louisiana Academy of Medical Psychologists, a Political Action Committee representing medical psychologists in that state, strongly endorsed this change of regulation by another profession.
In December 2011, the American Psychological Association (APA) published a list of practice guidelines that apply to all prescribing activities, with some also applicable to collaborating and information providing activities. The list is categorized according to the area of psychologists' involvement in pharmacological issues (general, education, assessment, intervention and consultation). The following list summarizes the guidelines by section.
- Guidelines 1 through 3 encourage psychologists to act within the scope of their practice with regards to prescribing psychotropic medications, which includes seeking consultation before recommending certain medications; emphasize that psychologists' evaluate their own views and opinions towards prescribing medications in light of how it may affect communication with patients; and expect that psychologists involved in medication prescription or collaboration be wary of developmental, age, educational, sex, gender, language, health status, and cultural factors involved in populations a psychologist may serve, with regards to pharmacotherapy.
- Guidelines 4 through 6 require that psychologists attain a level of education specific to pharmacotherapy in order to serve their clients; expect that psychologists be wary of potential adverse side effects of psychotropic medications; and ask that psychologists that prescribe or collaborate with regards to medication prescription be aware of helpful technological resources that are available.
- Guidelines 7 through 9 require that psychologists familiarize themselves with procedures for monitoring the physiological and psychological effects of medications; expect that psychologists who prescribe medications consider other physiological disorders or underlying diseases that the patient may have that could affect the effectiveness of medications; and encourage psychologists to consider issues about patient adherence and concerns about medications.
*Intervention and Consultation
- Guidelines 10 through 15 require that psychologists employ a biopsychosocial approach when prescribing medications and that they also use informed consent procedures, act in the best interest of the patient, and consider current research; emphasize that psychologists be wary of commercial influences regarding medications; and encourage psychologists to consider the patient's interpersonal behaviors.
- Guidelines 16 and 17 expect that psychologists maintain appropriate relationships with other providers of psychological services and biological interventions.
There are several core arguments put forth by RxP advocates, including the following:
- Other non-physicians have prescription privileges, such as pharmacists, optometrists, nurse practitioners, and physician's assistants. Some advocates have asserted that the latter three professions receive less training in clinical pharmacology, therapeutics, and psychopharmacology than many clinical psychologists.
- The training model is supported by a complete lack of legal complaint after eight years regarding the practice of the initial ten psychologists trained by the U.S. Department of Defense. Legal complaints differ from legal suits, as military personnel cannot sue for redress.
- Access to medication would be improved in jurisdictions with long waiting times to see a psychiatrist or other qualified physician.
- The prescriptive authority would be enhanced by the psychologist's doctoral training in the science of psychology, assessment, and psychotherapy. This training is more extensive than that received by the average physician. In addition, the training program for psychologists would provide twice as much pharmacology training than nurse practitioners and physician assistants (who cannot diagnose psychiatric disorders) receive .
- It would address the fact that many lack access to psychiatrists (especially in rural areas).
- It would create a clearer distinction between doctoral and masters-level practitioners, and between doctoral and post-doctoral level practitioners.
- In circumstances in which the psychologist decided not to collaborate with medical colleagues, it could allow the psychologist control of the entire treatment process. In some cases, this might reduce or eliminate complications arising from interprofessional collaboration and potentially save clients money.
- Psychologists with prescriptive authority would add competence to the overall mental health system by adding a resource for general practitioners who need professional consultation regarding psychological disorders and psychotropic medications when a psychiatrist is unavailable.
- Psychopharmaceutical training allows psychologists to provide better advocacy for their clients.
According to a survey assessing the views of psychology interns, residents, and psychologists published in the journal Professional Psychology: Research and Practice, significant support exists regarding the APA's prescriptive authority initiative. Proponents of the prescriptive authority initiative believe that it would improve the economic stability of the profession, provide better opportunities to underserved populations, and enhance psychologists' clinical skills through a better understanding of biopsychosocial interactions. Support for the prescriptive authority initiative also appears higher amongst those with PsyDs and early-career psychologists than those with PhDs and mid- and late-career psychologists. Demographically, females and Caucasians expressed more willingness to seek prescription privileges. Also, those who attended a clinical or counseling graduate program, received a PhD degree, and those employed in a university counseling center, medical school hospital, or independent practice tend to demonstrate higher levels of support for the initiative. In terms of training, an overwhelming majority of those surveyed believe training should begin at the graduate level, but prior to completion of a doctorate. Additionally, respondents preferred that training occur on a part-time basis, be completed within 6 months to two years, and cost under $10,000.
Today, evidence exists to indicate a continual and growing level of support for the American Psychological Association's prescriptive authority initiative. Such support reflects psychologists' willingness to open their minds to learning about psychotropic medications, incorporating pharmacological treatment with therapy, and adapting to the demands of a rapidly changing health care world.
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Prescriptive authority for other medical professionals who are not physicians (e.g., nurse-practitioners and pharmacists) has been controversial, even within the community of physicians. In the same way, there are psychologists who have raised objections to prescriptive authority for psychologists. Specifically, critics within the psychological profession have expressed concern that, if RxP became the norm, the biomedical approach could begin to encroach on the traditional psychology curriculum and that clinicians in training might eventually receive less grounding in psychotherapeutic interventions and research. At the present time, only psychiatrists who practice psychotherapy and psychologists with prescriptive authority are uniquely qualified to fit the treatment modality (pharmacology and/or psychotherapy) to patients' mental health needs. Some psychologists opposing prescriptive authority fear caseload pressures that might press increasing numbers of psychologists to respond to patients' needs via only one treatment modality (pharmacology), as do many psychiatrists.
Apprehensiveness towards the RxP movement may also be traced back to a series of events that occurred in the 1980s and 1990s. First, the introduction of the class of antidepressants known as serotonin selective reuptake inhibitors (SSRIs), also known as fluoxetine marketed under the name Prozac, between 1985 and 1999 let to a momentous increase in psychotropic drug prescription. In the 1990s, the New York Times declared the millions of Americans taking Prozac created a "legal drug culture", as antidepressants accounted for a 13.5% increase in the number of drugs prescribed during medical visits. There was also a significant rise in the amount of unwanted and serious side effects that accompanied the increased prescription of such drugs, especially in children and adolescents. As a result, concern then grew regarding the over-prescription of antidepressants and their safety.
Second, around the same time, the efficacy of both medication-based and psychotherapy-based treatments for depression were subjected to close scientific study. In 1989, the National Institute of Mental Health (NIMH) conducted a study called the Treatment of Depression Collaborative Research Program (TDCRP), which found various forms of depression treatments—interpersonal psychotherapy, cognitive behavioral therapy, antidepressant medication plus clinical management, or placebo plus clinical management—to be almost equally effective. Since then, proponents of pharmacological and nonpharmacological therapy have tirelessly attempted to prove one to be more effective than the other, with no definitive result.
Finally, the third event is the discovery of a substantial placebo response rate associated with antidepressant treatment, which has been shown to average 30-35%. Despite general rejection amongst clinicians that such a placebo effect denotes antidepressants as less effective, the placebo effect continues to serve as a strong basis for opposition over the use of antidepressants in therapy.
As Fox et al. (2009) found, most current opposition stems from the above stated events in the 1980s and '90s, and revolves around concerns about the overuse of psychotropic medications, the replacement of psychotropics for verbal or behavioral therapies, and the effectiveness of psychotropic medications in general. According to the APA, some also express concern that the RxP movement may exert pressure on psychologists that could lend itself to disparities in adherence to ethical and legal standards. Today, the dichotomy between those that support and those that oppose the RxP movement serves to hinder its progress in gaining legislative and authoritative support.
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