by Neil Warres, M.D.
[February 1996; Vol. 23 No. 1]
Last winter, Montana psychologists read ads urging them to enroll in courses to learn prescribing skills. The Prescribing Psychologists’ Register touted this training program: “One (1) home study self test course and six (6) week-end, seminar-workshop direct contact courses. The home study offers 16 hours of study and the six seminar-workshop courses offer a total of 108 direct contact hours. The total amount of hours are 124 study hours.” The cost of each of the 7 courses was $125 ($150 with C.E. Credits). The psychologists completing this didactic work would receive the “Diplomate, Certified Fellow ‘FPPR’ designation....This award will allow for the designation of FPPR after the recipient’s name and degree.” At the time that prescribing privileges became legal for psychologists, an additional “Preceptor-Supervision Program,” lasting a year, would be offered. (The Prescriber, Prescribing Psychologist's Register, Inc. Winter 1994 Vol. 1, No. 2). Then, ostensibly, the psychologist would be ready to prescribe. In 1991 a major proponent for psychologists Prescribing, Patrick DeLeon, Ph.D., stated, “An appropriate [prescribing] training program for psychology would involve approximately three months of didactic training and significant ‘hands on’ supervision.” (The Scientist Practitioner, the American Association of Applied and Preventive Psychology Vol. 1, No. 2, March, 1991.)
Attempts to legalize psychologist prescribing privileges have occurred in Hawaii, Oregon and within the past year in Wisconsin, Montana and California. Additionally, the Department of Defense ran a pilot program to train psychologists to prescribe. This program, begun in 1991, was discontinued this past December.
There is significant division among psychologists about whether it would be responsible or advisable to seek legal ability to prescribe. However, there is no similar controversy in the psychiatric community. Psychiatrists strongly and virtually unanimously oppose psychologist prescribing privileges. Maurice Rappaport, M.D., Ph.D., of California, who is both a psychiatrist and a psychologist, has been particularly outspoken: “What the psychologists are asking for is the right to practice medicine without going to medical school -- that's as dangerous as it is ludicrous.... Psychologists are trying to achieve through legislation what they don't achieve through education.” Cynics claim that psychologists only support obtaining prescribing privileges because of selfish economic considerations - that if managed care companies discourage their performing psychotherapy, they must prescribe to survive. However, many psychologists seem to truly believe that acquiring prescription privileges would be safe, would serve the public good and decrease health care costs. This article represents an attempt to present a psychiatric perspective regarding this.
Psychiatrists do not agree that it is safe for non-physicians to prescribe psychiatric medications. These medications are potent, have profound effects on not only the brain but on other organ systems, have serious side effects, have dangerous effects when unwisely mixed with other prescribed medications, and can cause death and serious disability. These medications are not easy or straightforward to use. Many complex pharmacokinetic and pharmacodynamic factors must be weighed: examples include competitive inhibition at receptor sites, refractoriness of receptors, serum protein binding and displacement, multiple mitochondrial enzyme pathways and their activation or inhibition by other drugs, and biological variability - to name just a few. The safe use of psychotropic agents requires significant clinical training, experience and knowledge; sophisticated understanding of other medical conditions the patient may have; and the ability to make medical differential diagnoses. Non-physicians do not possess these skills or this expertise. It is naive to think that even two years of full-time didactic coursework coupled with supervised clinical supervision would be sufficient. The scientific knowledge and clinical proficiency which psychiatrists develop begins with pre-med undergraduate science courses, and continues with two years of didactic medical school basic science training, two years of clinical medical school clerkships, an internship and at least three years of psychiatric specialty training. Of note; psychologists who graduated from the 3-year Department of Defense prescribing training program did not earn independent prescribing privileges. These “pharmacopsychologists” were not allowed to either start or stop a medication without direct supervision from a physician. They were not allowed to even independently monitor any individual with “concomitant unstable medical conditions,” or those younger than 18 or over 65.
Medical training involves more than the acquisition of facts or didactic knowledge. It involves an indoctrination into a way of thinking: an acceptance of the medical model. This is an orientation that is not necessarily shared by psychology colleagues. (Smith D, Kraft, WA; Attitudes of psychiatrists toward diagnostic options and issues. Psychiatry 1989:52:66-73.) The importance of this and other differences in orientation and experience cannot be overemphasized. Psychology is at heart an academic discipline involving research, dissertations, the study of social science. It does not emphasize the understanding or treatment of disease. Psychologists do not receive training in obtaining medical histories, performing physical exams, or utilizing lab tests. During their training they do not routinely take life and death responsibility for critically ill patients. As Pies points out, the etymology of psychology is logos, “study,” while the root of psychiatry is iarreta or iarros, “healing or healer.” (Pies, RW, The “Deep Structure” of Clinical Medicine and Prescribing Privileges for Psychologists. J Clin Psychiatry 52:1, January, 1991 p. 4-8.)
Some psychologists have argued that because general practice physicians don’t have much interest or training in treating the mentally ill, psychologists who prescribe would provide better care for these patients. A far better solution than training psychologists in medicine would be to train general physicians more extensively in psychiatry. Furthermore, this argument supposes that if psychologists could prescribe, general physicians would refer to them for that purpose. This simply is not the case. General physicians, themselves, do the bulk of psychotropic prescribing and this is not likely to change. Often the patients whom they refer to psychiatrists are patients who were treatment failures who require more sophisticated pharmacologic regimens. It would not be desirable for these patients to be referred to less-extensively trained non-M.D. prescribers.
Psychologists have alluded to prescribing a “limited formulary.” It is unclear what this would constitute. Modern psychiatry uses a variety of somatic medications for psychiatric effects, including anticonvulsants, beta-blockers, antihypertensives and calcium-channel blockers. It would be unfair to have patients see practitioners who could not prescribe the full gamut of potentially effective medications. (And, as mentioned, even “standard” psychotropics are potent and potentially dangerous.)
There are other unanswered questions. If a patient is self-referred to a psychologist, who does the medical evaluation? Does the psychologist refer the patient to a general physician? If so, then why shouldn't that physician do the prescribing? If the patient is not referred to a physician, then does this constitute quality care? Who orders the medical drug levels? Who orders lab tests? Who interprets these? Also, if a psychologist prescribes medication and the patient develops symptoms such as a rash or urinary retention, who does the medical evaluation, and what are the implications of prescribing medication without being able to handle adverse effects?
Proponents of psychologists prescribing have strenuously argued that this would allow greater access to care because there would be greater availability of psychologists in underserved areas. However, a study by Lewin in 1989 showed that psychologists tend to practice in the same geographic areas as psychiatrists - that there is no significant difference. (Geographic Access to Psychiatrists’ Services: A County-Level Analysis. Lewin, ICE prepared for the American Psychiatric Association, January 1989.)
Another assertion is that costs would be reduced if psychologists prescribed. This seems particularly unlikely. The current differential between fees of psychiatrists and psychologists is not that great. If psychologists had to receive extra training in order to prescribe, clearly they would wish to raise their fees commensurately. Furthermore, their malpractice expenses would rise considerably, and their fees would have to reflect this. It seems probable that there would be an increase in hospitalization expenses due to adverse events related to an increased number of prescribing errors. If psychologists had a “limited formulary,” it would probably exclude older drugs such as tricyclic antidepressants which are complicated to use, and only include newer, more expensive medicines such as SSRIs. Thus, aggregate medication expenses would rise. Additionally, if there were more people prescribing medications, presumably a greater volume of medication would tend to be prescribed - again increasing costs.
If psychologists were allowed to prescribe medications, what would prevent social workers from prescribing, or nurses, or marriage and family therapists, or substance abuse counselors, or mental health technicians? Where would one draw the line? If it is simply a matter of taking didactic courses, why couldn’t virtually anyone with an interest ultimately demand the right to prescribe?
It does not appear safe, or in the public interest, to have non-physicians prescribe psychiatric medications. However, discussion of these issues does help identify problems and lead to solutions. For example, of psychologists are correct that general physicians do not have sophisticated knowledge of mental illness assessment or treatment, clearly this can be remedied by improving the education of those physicians. If psychologists are correct in implying that general physicians should refer more patients to mental health specialists, clearly psychologists and psychiatrists should focus together on developing more effective and appropriate patient referral patterns from primary care physicians. If psychologists feel they cannot provide comprehensive care for their patients because of an inability to prescribe, perhaps our two disciplines can work harder at creating better clinical collaboration.