Transcript Why Psychologists Should Not Pursue Prescription Privileges

Concerns About Psychologist Prescribing
William Robiner, Ph.D., A.B.P.P.
Department of Medicine
?
UNIVERSITY OF MINNESOTA MEDICAL SCHOOL
??
Disclosure Information
Concerns About Psychologist Prescribing
William N. Robiner, Ph.D., A.B.P.P.
I have the following financial relationships to disclose:
Consultant for: HealthPartners
Stockholder in Medtronic but no pharmaceutical companies
Employee of: University of Minnesota
I have never received any funding from the American Medical
Association or American Psychiatric Association or any of their
affiliates.
I will not discuss of label use and/or investigational use in my
presentation.
Prescription Privileges for
Psychologists Are Controversial
“I don’t think we need to be
subliminable about the
differences between our
views on prescription
drugs”
George Bush, Orlando, FL
September 12, 2000
Prescription Privileges for
Psychologists Are Controversial
Many people, including psychologists, are not
fully informed of the issues in the ongoing
debate.
Many psychologists are reluctant to speak up
against the Prescription Privileges (RxP)
movement or are indifferent to the issue.
Objectives
Upon completion of the presentation, participants
should be able to:
1. Summarize diverse concerns about psychologist prescribing
2. Identify relative limits of the APA Clinical Psychopharmacology
Training model and the DoD PDP Program
3. Identify psychologists’ motives and rationales for pursuing
prescription privileges
4. Decide their position about the controversy about prescription
privileges for psychologists
What do Consumers Want of Their
Psychopharmacologist?
“Our Psychopharmacologist is a genius”
What Do Consumers Want Of Their
Psychopharmacologist?
• A knowledgeable, well-trained professional who is
as competent to manage their medications and
understand their overall health status as well as
all other prescribers
Why Do Psychologists Want Prescription Privileges?
$ Money
Also, Psychologists Want Prescription Privileges for
Autonomy in clinical practice
Job security
Another marketable skill
Parity with other professions
Giveaways and meals from drug company
salespersons
“Physician Wannabes”
“…if we talk like psychiatrists, if we practice like
psychiatrists, we will get our due”
“The principal reward for becoming a junior
psychiatrist must be financial- a chance to
break into what appears to be a profitable
market and grab a share of the action”
Hubble, M. A. & Miller, S. D. (2001). In pursuit of folly. Bulletin of the Academy of Clinical
Psychology, 7, 2-6.
Why Do Pharmaceutical Companies Want
Prescription Privileges for Psychologists?
$
Increase revenues via increased sales of
medications through more prescribers
$
More than $24 billion worth of antidepressants
and antipsychotic drugs were dispensed in 2008
Why Do Some Schools Want Prescription
Privileges for Psychologists?
$
Potential revenues from courses,
workshops, and continuing education
Hedge against potential future declines in
enrollment in traditional professional
psychology programs
Develop potentially new marketable skills
for graduates
Why Does the APA Want Prescription
Privileges for Psychologists?
$
Potential revenues from courses,
workshops, and continuing education
Develop potentially new marketable skills
for psychologists
Increased status and power of
psychologists in the market and health
care system
Why Does the APA Want Prescription
Privileges for Psychologists?
$
Potential revenues from advertising dollars
for its journals from pharmaceutical
companies
What Factors Engender Opposition to
Prescription Privileges for Psychologists?
Concerns about psychologists’ competence and
training (i.e., the training model for RxP)
Concern about adverse effects on the field – what
would be lost?
Concerns about the quality and safety of patient
care prescribing psychologists would likely deliver
What Factors Lead Psychologists to Oppose
Prescription Privileges for Psychologists?
A personal sense of responsibility to speak truth to power
Note the absence of any financial
incentives within psychology for
opposing prescription privileges on the
previous slides.
Who Wants Psychologists to Prescribe?
The prescription movement is not driven be consumers,
physicians, or other mental health providers
» NAMI does not support it
It originated with practitioners rather than academicians or
scientists
Psychology training directors are equivocal about it
» 62% are equivocal (Evans & Murphy, 1997)
Relatively few academic psychologists are interested in
developing training programs for it (Hanson et al., 1999)
» Raising questions about the feasibility of developing high quality
psychopharmacology training programs in settings with limited
experience in educating and training psychologists
Prescription Privileges are Controversial
Among Psychologists
Estimates vary about the percentage of
psychologists favoring it (Gutierrez & Silk, 1998, Bush, 2002)
Frederick/Schneiders, Inc. (1990), the largest
survey of APA members, found:
 30% strongly supported it and 38% favored it
 The rest are opposed or unsure
Prescription Privileges are Divisive
Among Psychologists
A meta-analysis of 17 surveys revealed a lack of
consensus (Walters, 2001)
• “Opinion… is divided and polarized”
• More psychologists than not believe that …organizations
•
•
like APA should not be spearheading efforts to gain
prescription privileges
Psychologists are more supportive of prescription
privileges in principle than they are of obtaining the
training to prescribe medication
Prescription privileges have the potential to confuse
issues of training and identity for future … psychologists
Professional Organizations of Psychologists
Oppose Prescription Privileges
Society for a Science of Clinical Psychology
(Section 3, Division 12)
American Association of Applied and
Preventive Psychology (AAAPP)
Committee Against Medicalizing
Psychology (CAMP)
Psychologists Opposed to Prescription
Privileges for Psychologists (POPPP)
Support Is Not Unanimous
• 43% of psychologists responding to an APA
•
survey indicted that “full medical training
would be required” for prescription privileges
(APA, 1992)
Nevertheless, the APA training model is
shorter, as well as substantively and
procedurally inferior to medical school,
nurse practitioner training, and other
prescribers’
It Is About Quality: Not Popularity
Whatever sentiments surveys of psychologists
reveal, it is less appropriate to decide this issue on
the basis of its popularity among psychologists than
on the quality of pharmacologic care that
psychologists would provide
Bieliauskas, L. A. (1992b). Rebuttal of Dr. Frank’s position. Physical Medicine and
Rehabilitation: State of the Art Reviews, 6, 584.
It Isn’t Just Up To Psychologists
It concerns a range of potential stakeholders
• Consumers
• Educators
• Practitioners in other health disciplines experienced in
•
prescribing
Regulatory and governmental authorities
» Food and Drug Administration
» Regulatory boards (e.g., Board of Psychology)
Historical Highlights
APA (1992) established an Ad Hoc Task Force on
Psychopharmacology to explore the desirability
and feasibility of psychopharmacology
prescription privileges for psychologists
The Task Force concluded that greater
understanding of psychopharmacology would
enhance the care that psychologists provide
(Smyer et al., 1993)
Proposed Levels of Training
The APA Task Force proposed three levels of
preparation in psychopharmacology:
» Level 1- Basic Psychopharmacology Education
» Level 2- Collaborative Practice
» Level 3- Prescription Privileges
Whereas the Task Force thought all psychologists
providing mental health services should be prepared at
Level 1, it did not take that position for training at
Level 3
Legal Status of Prescribing
Most states and provinces do not allow
psychologists to prescribe
Supervised prescribing by “qualified”
psychologists has been passed in Guam, New
Mexico, and Louisiana.
It took time for details to be worked out, so we
don’t know yet how this experiment is going.
Currently under review elsewhere
Does New Mexico Lead the Way?
Can you name 2 things that are legal in
New Mexico, but not most places?
Cock fighting
» Also legal in Louisiana
Psychologist prescribing
“Foundation”
Definitions
The lowest load-bearing part of a building,
typically below ground level
A body or ground on which other parts rest
or are overlaid
An underlying basis or principle for
something; specific learning skills as a
foundation for other subjects
Buildings Have Foundations
Foundation 
No Foundation 
Foundations are structurally important
Inadequate foundations can lead to instability of the
structure, creating safety risks to users
Foundation in Education: Prerequisites
The APA Task Force stated “retraining of
practicing psychologists for prescription privileges
would need to carefully consider selection
criteria, focusing on those psychologists with the
necessary science background” (APA, 1992)
This included undergraduate coursework in:
» Biology
» Chemistry, and
» Other areas typifying the pre-medical curriculum
Inadequate Foundation
• But no physical or biological
science prerequisites are
required!
• Instead, APA uses vague language
about trainees’ scientific background
Dumbing Down
“Demonstrated knowledge of human biology, anatomy and
physiology, biochemistry, neuroanatomy, and
psychopharmacology is a necessary prerequisite for
embarking on this postdoctoral training
Demonstrated knowledge involves evidence of
» (1) successful completion of a planned sequence of courses at a
regionally accredited institution of higher learning, OR
» (2) evidence of successful completion of a planned sequence of
continuing education courses offered by an accredited institution of
higher learning or an approved provider of continuing education and
passage of an examination covering the content of such a program
Are They The Same?
Rigorous
Coursework
?
=
Continuing
Education
Bait and Switch
By deleting the scientific prerequisites APA has
ignored the judgment of the importance of scientific
backgrounds of its own experts as well as nearly half
of the members it surveyed!
But nevertheless, APA says that members support
RxP, even if their favorable statements was based on
expectations of more stringent requirements
“PDP-Lite” (Stuart & Heiby, 2007)
“Ersatz training” (Anonymous Member of APA Task
Force)
Other Non-Physician Prescribers’
• Training is much closer to that of physicians
•
than to psychologists’
Clinical practice is more focused on
physical functioning, including medication
effects, than psychologists’
Is this good?
“Among all the disciplines whose members
include non-physician health care providers
who prescribe, psychology has the core
curriculum with probably the least overlap
with traditional medicine”
Fox, DeLeon, Newman, et al.., 2009
APA Knows Better
Accreditation criteria for all levels of
education specify:
Training for practice is sequential,
cumulative, graded in complexity
Inorganic
Chemistry
Organic
Chemistry
Biochemistry
Undergraduate Differences* Between
Psychologists and Psychiatrists
Major
Psychologists Psychiatrists
Physical
12%
Sciences
Social
79%
Sciences
Humanities 7%
Arts
* x 2 = 18.5;
2%
p < . 0 01.
67%
28%
6%
0%
Robiner et al., 20 0 3
Psychologists’ and Psychiatrists’
Pre-Med Courses
Psychiatrists
M = 12
Psychologists
M = 4.7
( t = 14.7; p < .0 0 7)
Robiner et al. (2003)
Robiner, W. N., Bearman, D. L., Berman, M., Grove, W. M., Colón, E., Armstrong, J., Mareck, S.,
Tanenbaum, R. (2003). Prescriptive authority for psychologists: Despite deficits in education and knowledge?
Journal of Clinical Psychology in Medical Settings, 10, 211-222.
Arrogance?
Some RxP advocates question the necessity
of scientific background for prescribing
(Hanson et al., 1999)
Does that denigrate the importance of other
scientific disciplines?
How Hard Is It To Prescribe?
Former APA President, Patrick DeLeon,
contends that:
"...prescription privileges is no big deal.
It's like learning how to use a desk-top
computer" (Roan, 1993)
But Is It…….Really?
Meet Noah Robiner1
Hobby: Plays with
laptop computer
Age: Six years
1
2002
Or Is Safe Prescribing More Involved?
Would you have
confidence in a
prescription from a
kindergartener?
Do psychologists
want to “play” at
being medical
doctors too?
Differences* Between Psychologists’ and
Psychiatrists’ Scientific Coursework
Coursework
Psychologists Psychiatrists
Anatomy or
Neuroanatomy
41.5%
100%
Chemistry/Biochemistry
58.5%/ 14.6%
100%/ 100%
Biology/Microbiology
65.9%/ 7.3%
100%/ 100%
Pharmacology
17.1%
100%
Physiology or
43.9%
Neurophysiology
*t = 14.7; p < .007.
Robiner et al., 2003
94.4%
Graduate Education in Psychology
Comprises “vastly differing models of study and
practice” with “no effort to standardize the training
of psychologists” (Klein, 1996)
Some psychology degrees (e.g., school
psychology) have relatively limited exposure to
psychopathology and psychological treatments,
let alone the physical sciences or medical
environments (DeMers, 1994; Moyer, 1995)
Where’s the Biology in Psychology
Graduate Education?
According to the APA Accreditation Commission:
Domain B. 3. …The program has…a…coherent curriculum plan
that provides the means whereby all students can acquire
and demonstrate substantial understanding of and
competence in the following areas:
a) The breadth of scientific psychology, its history of thought and
development, its research methods, and its applications. To
achieve this end, the students shall be exposed to the current
body of knowledge in at least the following areas: biological
aspects of behavior…..
http://www.apa.org/ed/accreditation/G&P0522.pdf
Where’s the Biology in Psychology
Graduate Education?
Note the absence of clear guidance from APA about
content or credits
Also note that “biological aspects of behavior” is
considerably narrower than the biological curriculum for
other prescribers (M.D., R.N., etc.)
It does not require any knowledge of human
physiology, pathophysiology, anatomy, etc.
Where’s the Biology in Psychology
Graduate Education?
According to the ASPPB/National Register
Designation Committee:
Psychology doctorates require merely 3 graduate
semester hours in the biological bases of behavior
» which can cover a range of topics, such as physiological
psychology, comparative psychology, neuropsychology,
sensation and perception, or psychopharmacology
These courses’ relevance to and preparation for
prescribing can be negligible
The Trend for Less Science in
Psychologists’ Training
According to the Director of the APA Education
Directorate, the training of psychologists is moving
away from the “scientist-practitioner” model, to other
models that de-emphasize scientific background
and activities
(Belar, 1998)
By 1997, nearly 2/3 of clinical psychology degrees were
conferred by professional schools, rather than
university-based academic programs (Reich, 1999)
which typically require more rigorous scientific training
than professional schools
Sometimes A Science Background
Isn’t So Important
Should cub scouts
or their dads have to
take physics to
design cars for the
pinewood derby?
Sometimes It Is
Would you want to get
on a plane if the
engineers who designed
it hadn’t taken physics?
If You’re Sick, Who You Gonna Call?
U of M Lung Transplant Team
ER Cast
Would you entrust your health to people who
lacked basic scientific backgrounds?
What is Happening
In 1995 the APA Council of Representatives passed a
resolution making the pursuit of prescription privilege an
official objective for the organization
APA devotes greatest attention to the most controversial
option, Level 3, promoting prescription privileges
through a hybrid of continuing education and a modular
executive training in psychopharmacology for doctorallevel psychologists
Training Is Limited
Several training programs exist, including
some that emphasize distance-learning
» 300 hours
» 100 supervised patients
The training is not close to medical or
psychiatric training, and is less
comprehensive than nurse practitioner
training
Where and When is it Occurring?
Wherever programs wish to offer it
Not at medical schools or top-ranked
nursing or physician assistant training
programs
Some is largely on-line
APA Training Model Does Not Specify
Minimal Criteria For:
 Breadth of patients’ mental health conditions
 Duration of treatment (i.e., to allow for adequate
monitoring and feedback) or requirements for
outpatient or inpatient experiences, or length of
training
 Exposure to adverse medication effects
 Exposure to patients with comorbid medical
conditions and complex drug regimens
 Qualifications for supervisors
Training Without Accreditation
 Unlike training for other prescribers, no
accreditation mechanisms to evaluate
psychopharmacology programs or supervised
clinical experiences exist.
 The psychopharmacology training programs
do not meet the APA's (1996c) own criteria for
accreditation of postdoctoral programs or
internships.
Designation: Minimal Standards
The 2008 APA Council meeting allocated funding for a
Task Force to create a “designation” system that was
charged with developing “the minimal standards for
programs of psychopharmacology education and training
programs.”
Note how this is inferior to the objective of the
accreditation process, as used in other psychology training,
which is intended to “promote consistent quality and
excellence in education and training in professional
psychology." (APA, 2008)
What Isn’t Happening
The Task Force’s Level-2 Collaborative Practice, envisioned
to enhance patient care via collaborations with prescribers by
expanding their expertise about medication management has
not been pursued
No Training for Collaborative Practice
Even though more psychology graduate students believe that
Level 2 (77%) training should be offered in their programs than
Level 3 (57%) and
(Tatman, Peters, Greene, & Bongar, 1997)
Even though there is a good literature about the benefits of
collaborations between psychologists and prescribers, such as
primary care physicians
RxP Advocacy Tactics
Pollitt, B. (2003). Fool's gold: Psychologists
using disingenuous reasoning to mislead
legislatures into granting psychologists
prescriptive authority. American Journal of
Law & Medicine, 29, 489-524.
Argument #1 About Prescription
Privileges for Psychologists
It’s not a big deal: Psychologists have done it for
years without problems (VA, Reservations, military)
How well and how long has it been studied in
demonstration projects?
» The DoD studied only 10 psychologists
What controls were in place which might have prevented
problems in these projects?
» They were in supervised, military hospitals with a long history
of teaching health professionals
How would the care psychologists be different on broader
scale, without supervision, outside of medical settings?
DoD/PDP Selection Bias
They were not typical psychologists
• 6 were Air Force Officers or Army Officers holding
•
•
the rank of Captain or higher
4 were Navy officers holding the rank of Lieutenant
Commander or Commander
8 were chiefs or assistant chiefs of an outpatient
psychology clinic or a mental health clinic
Department of Defense (DoD)
Psychopharmacology Demonstration Project (PDP)
Initial participants undertook preparation in
chemistry and biochemistry before
completing a majority of 1st year medical
school courses
During their first full-time year at the
Uniformed Services University of the Health
Sciences, they worked with the PsychiatryLiaison service and assumed night call with
2nd year psychiatry residents
Department of Defense (DoD)
Psychopharmacology Demonstration Project (PDP)
In the second full-time year, they completed
core basic science courses and continued
psychopharmacology training and clinical work
After 2-day written and oral examinations, they
had a third year of supervised clinical work at
Walter Reed Army Medical Center or Malcolm
Grow Medical Center
Then PDP Training Was Reduced
Over time, the PDP curriculum was
abbreviated, streamlining training to one year
of coursework and a year of supervised
clinical practice
 Didactic hours decreased by 48% in the 2nd iteration
Most PDP graduates functioned as prescribing
psychologists in branches of the military
At least one graduate went on to medical
school
A Few Words About the PDP
The PDP was discontinued after the first few
years
•
Proponents want you to believe:
» The successes of PDP participants justify extending
prescriptive authority to psychologists who undergo
training consistent with the APA model (1996a)
 Even
though the APA training model and the
likely resources available for the training are
less substantial than the PDP
What You Should Know Aboutthe PDP
 The Final Report of on the PDP the American
College of Neuropsychopharmacology (1998)
assessed graduates as weaker medically
and psychiatrically than psychiatrists.
 Limitations are likely to be most evident in
treating medically complex patients
Kennedy, J. (1998, April 3). Prescription privileges for psychologists: A view from the field. Psychiatric News, 33
(7), 26.
More to Know About the PDP
 “[The psychologists] medical knowledge was
•
•
variously judged as on a level between 3rd or
4th year medical students” (p. 6)
Note: Patients never get treated by medical
students without strict supervision
Should patients get healthcare from someone
approximating a medical student or a licensed
health professional who completed training?
Concern About the PDP Trainees
 “The most common concern cited by most of
the psychiatrist supervisors in one form or
another was that the fellows knew too little
medicine to prescribe psychotropic drugs
safely. They worried about the lack of medical
sophistication.” (p. 13)
Limits Within the DoD
 Graduates only saw a limited range of
patients
aged 18-65
generally with limited medical problems
 Some graduates had limited formularies
 Some graduates continued to have
dependent prescriptive practice (i.e.,
supervised by a physician)
Differences Between the PDP and APA Model
 PDP graduates advised against "short-cut"
programs and considered that a year of
intensive full-time clinical experience,
including inpatient care, was essential
 This is more comprehensive than
psychopharmacology training currently
recommended by APA or available
 There is no inpatient requirement for training
Doubts About Generalizing From the PDP
 Some of the DOD psychiatrists, physicians,
and graduates doubt the safety and
effectiveness of psychologists prescribing
independently outside of the interdisciplinary
team of the military context
 This concern has been echoed in a survey of
military psychiatrists, non-psychiatric
physicians, and social workers
Klusman, L. E. (1998). Military health care providers' views on prescribing privileges for psychologists,
Professional Psychology: Research and Practice, 29, 223-229
Questions About the DoD
Do the relatively limited base rates of problems and tiny
sample obscure genuine problems and suffer from Type
II statistical problems (i.e., have inadequate statistical
power to detect differences or problems)?
Can we generalize from 10 trained in military hospitals to
thousands of psychologists across the spectrum of
settings with diverse and less healthy populations?
If training is less rigorous, with less access to medical
populations, would the DoD outcomes overestimate
outcomes of how other psychologists would perform?
Argument #2 About Prescription
Privileges for Psychologists
Most psychoactive medications are prescribed by
physicians or others with less training in
assessment or therapy than psychologists

All other prescribing health professionals have
relevant training in basic sciences: biology,
chemistry, biochemistry, etc.
Psychologists do not!
» Only 7% of psychology graduate students have
the relevant scientific backgrounds (Tatman et al, 1997)
Lack of Undergraduate
and Graduate Preparation
Only 27% of graduate students thought they had
the undergraduate preparation to undertake
preparation to prescribe (Tatman et al, 1997)





Completed recommended biology &
7%
chemistry units (Fox et al., 1992)
> 4 units of undergraduate biology
48%
> 4 units of undergraduate chemistry
20%
Graduate course in psychopharmacology 25%
Argument #2 (continued)
All other prescribing professionals have years of
training and experience in dealing with a wide
range of side effects, adverse or toxic effects, drug
interactions, and impact on other systems
 Psychologists
do not!
Psychologists’ clinical skills provide fruitful
opportunities for collaboration with prescribing
health professionals but their lack of an
educational foundation contraindicates prescribing
themselves
Argument #3 About Prescription
Privileges for Psychologists
There are misuses and abuses in
medication prescriptions by physicians
Such medication problems would not be
remedied by giving psychologists prescription
privileges
Psychologists would probably make similar
errors, plus others due to their more limited
training and experience with medications and
physiological phenomena
Knowledge Base and Clinical
Proficiencies Required for Prescribing
Psychopathology and Psychological
Issues1
Medical Status Prior to Prescribing
Response to Treatments
1
The education and training of psychologists typically addresses this
area only
Robiner, W. N., Bearman, D. L., Berman, M., Grove, W. M., Colón, E., Armstrong, J., & Mareck, S. (2002).
Prescriptive authority for psychologists: A looming health hazard? Clinical Psychology: Science and Practice,
9, 231-248.
What Psychologists Know
Psychopathology and Psychological Issues
Primary psychiatric conditions
Comorbid psychiatric conditions
Prevalence and course of psychiatric conditions
Knowledge of non-pharmacologic treatment options
What Psychologists Don’t Know
Medical Status Prior to Prescribing
Comorbid medical conditions
Contraindications
Long-term effects of medication
Medical effects of concurrent treatments
 drug interactions
 other treatments (e.g., dialysis, plasmapheresis)
History of medication use
What Psychologists Don’t Know
Response to Treatments
Knowledge of adverse reactions
 side effects, toxic effects
Ability to recognize, diagnose, & treat adverse
reactions.
Ability to differentiate between physical and
psychiatric effects of psychoactive agents and
concurrent medications
Other issues related to monitoring, titrating or
discontinuing prescribed medications
For example ...
SSRIs can cause bleeding disorders, including GI and
retinal hemorrhage
Effexor overdoses have higher risk of mortality than
SSRI overdoses
Overdose with Celexa can cause life-threatening
cardiac crises; > 6 deaths so far
Abrupt clonazepam withdrawal can result in
hypoglycemic coma in diabetics
That is Just the Tip of the Iceberg
SSRIs inhibit CYP2D6 activity and when
combined with other drugs metabolized via the
P450 enzyme system result in toxic serum
concentrations of either or both drugs
For Complex Patients Medication
Management is Harder
Since 2005, the FDA requires black box warning
labels about the risk of antipsychotic use with the
elderly
Second-generation, antipsychotic medications have
black-box warnings noting that the drugs are
associated with increased risk of death and other
adverse effects in elderly patients
» (cardiac toxicity, stroke, infection, hyperglycemia)
1.6- to 1.7-fold increase in mortality in the elderly
Major Cytochrome P450 Isozymes and
Substrates Involved in Drug Metabolism
CYP1A2: Amitriptyline, Clozapine, Imipramine, Tamoxifen,
Theophylline
CYP2C9: Diclofenac, Ibuprofen, Losartan, Phentoin, Swarfarin, Tobutamide
CYP2C19: Citalopram, Clomipramine, Diazepam,
Imipramine, Omeprazole, Propranolol
CYP2D6:
Amitriptyline, Codeine, Clomipramine,
Debrisoquine, Haloperidol, Metoprolol, Paroxetine, Thoridazine
CYP3A4: Codeine, Cyclosporin, Diltiazem, Erythromycin,
Lignocaine, Nifedipine, Terfenadine, Verapamil
AdverseDrugReactionsMechanisms
There are numerous mechanisms
• Effects of disease, genes, smoking, diet,
receptor sensitivity alterations, etc.
• Drugs metabolized by the same P450
isozyme may competitively inhibit each
other’s oxidation in the liver
Argument #4 About Prescription
Privileges for Psychologists
People need medications in underserved areas
where there are few psychiatrists
The geographic distribution of psychologists and
psychiatrists are similar
Other health providers in those areas prescribe and are
open to collaboration with psychologists
» Rural family physicians have concerns about
psychologists prescribing (Bell et al., 1995)
Poor distribution may justify telehealth, or geographic
redistribution, but not psychologist prescription privileges,
which would lower standards of care for rural citizens
Dubious Plan for Serving the Underserved
APA Task Force’s expectation was that only “a
small...minority of psychologists” would seek Level 3
psychopharmacology training (APA, 1992)
There is no plan to redistribute prescribing
psychologists to meet needs of underserved
populations (May & Belsky, 1992)
It would be an indirect, needlessly risky, and
highly inefficient public policy response to rural
areas’ shortage of psychopharmacologic
prescribers (Robiner et al., 2002)
If This Were Really About
Serving the Underserved
The energy and resources psychologists are
currently investing into advancing the
prescriptive privileges could be refocused on:
Level 1 (basic knowledge) and 2
(collaboration) training and
On developing mechanisms to redistribute the
psychology workforce to address legitimate
societal needs (e.g., rural mental health)
Advocating for training more psychiatrists
Argument #5 About Prescription
Privileges for Psychologists
Some psychoactive medications are becoming
safer and more efficacious
This is why medications may be becoming more
helpful, but does not justify psychologists prescribing
Medications have side effects, toxic effects, addiction
potential, long-term adverse effects, drug interactions,
medical contraindications, and can result in death
Argument #5 (safer meds continued)
Can psychologists keep abreast of
burgeoning medication issues-both
psychoactive and non-psychoactive?
Where will their time to keep up come
from?
Argument #6 About Prescription
Privileges for Psychologists
Opposition to prescription privileges is
from the profession’s “conservative”
members
Denigrating legitimate concerns through
polarizing terms is not productive. It distracts
attention from real issues, reduces dialogue,
and focuses on emotional rather than rational
issues
Argument #7 About Prescription
Privileges for Psychologists
It’s just another fight with Psychiatry
It is a major controversy within psychology
and with other specialties within medicine.
Do psychologists really want to alienate the
other APA and the AMA at a time when
psychologists’ responses to other challenges
within health care warrant greater unity?
Psychiatric Nurses Oppose RxP
Position Statement of the International Society of
Psychiatric- Mental Health Nurses (ISPN)
“…nurses have an ethical responsibility to oppose the
extension of the psychologist’s role into the
prescription of medications. This is not a turf issue or an
attempt to limit a perceived competing profession. This belief is
rooted in the ethical guidelines of our own profession. The
professional standards for nursing require nurses who prescribe
pharmacologic agents to have their prescriptive actions based
on an awareness of pharmacological and physiological
principles and knowledge…We should expect the same from
other professionals.”
http://www.ispn-psych.org/docs/11-01prescriptive-authority.pdf
From a MN Psychologist/NP
“I oppose prescription…privileges for psychologists…In a previous
professional 'incarnation' I was a nurse and nurse practitioner. During the 4
years of my undergraduate nursing education I took courses in anatomy,
physiology, chemistry, biochemistry, embryology, microbiology,
pathophysiology and pharmacology. This was just a warm-up for the indepth physical assessment and illness-management skills I learned in the
nurse practitioner program. My education deepened in clinical settings during and after my formal training programs - where I was surrounded by
more experienced nurse and physician colleagues with whom I was able to
routinely consult. No two-year psychopharmacology course could
duplicate the breadth and depth of this education - which I feel
is the minimum necessary for safe medication management.”
Kate Pfaffinger, Ph.D. (former NP) 3/23/08
PsychologistsOppose RxP
PSYCHOLOGISTS OPPOSED TO PRESCRIPTION
PRIVILEGES FOR PSYCHOLOGISTS (POPPP)
You can join at: www.poppp.org
Logistical Challenges to Training
Psychologists to Prescribe


Unproven curricula and educational paradigms for
training
» Long-term outcomes remain unknown
Limited number of psychology supervisors to train
psychologists to prescribe safely and effectively
» Only 35% of medical school psychologists reported
having psychologist faculty who could teach or
supervise psychopharmacology
What Psychologists Don’t Know...
May Hurt Somebody
 Biology, Chemistry, Biochemistry, Pharmacology,
Physiology
 Clinical Medicine
 Physical Examination, Laboratory Tests
 How to Understand and Integrate All of the
Above in Decisions Involving Medications
 How to Assess Contraindicated Conditions and
Medication Side Effects
 What They Don’t Know
Psychologists’ Vs. Psychiatrists’
Knowledge Related to Prescribing
Domain
Psychologists Psychiatrists
Adverse Effects and
Contraindications
34.8
106.4
< .001
2.9
9.5
< .001
16.1
40.8
< .001
8.9
20.4
< .001
31%
87%
< .001
Drug-Related Clinical
Syndromes
Medications
Identification
Psychopharmacology
Examination
Total % Correct
From Robiner et al.
(2003)
P Value
As One Psychologist Turned
Psychiatrist Observed
The practice of psychology differs substantially from the
practice of psychiatry
“Studying the effects of medications on the kidney, the heart,
and so forth is important for the use of many medications.
Managing these effects is often crucial and has more to do with
biochemistry and physiology than with psychology. I was
surprised to discover how little about medication use
has to do with psychological principles and how
much of it is just medical.”
Kingsbury, S.J. (1992). Some effects of prescribing privileges. Professional
Psychology: Research and Practice, 23, 3-5.
»
He Also Observed
“In my first month of residency training in
psychiatry at a psychiatry emergency service I
believe I saw more patients individually than in my
entire graduate [Psychology] training.”
Kingsbury, S. J. (1987). Cognitive differences between clinical psychologists and
psychiatrists. American Psychologist, 42, 152-156.
Increasing Awareness of Adverse Effects
The Federal Drug Administration currently receives
400,000 reports per year about adverse drug events
http://www.fda.gov/cder/dsn/default.htm
Psychoactive medications have been described as
presenting more complex drug interactions and
adverse effects than any other class of drug
(Hayes, 1998)
Many people who take psychoactive medications also
take other medications that complicate their care
» Fewer than 30% who take an antidepressant take no other
medications (Preskorn, 1999)
Which of These Medication Effects or
Contraindications Can Psychologists Diagnose?
NONE









Agranulocytosis
Bundle Branch Block
Eosinophilia
Hyperpyrexia
Hyponatremia
Leukocytosis
Myoglobinuria
Opisthotonus
Thrombocytopenia
Additional Hazards Associated With
Prescription Privileges for Psychologists
Decreased quality of care for patients
 Increased professional liability rates for
psychologists
 Increased licensing fees for psychologists
 Increased risks of chemical dependency in
psychologists?
 Antagonism among psychologists
 Increased antagonism with physicians

» One article predicted a “Jihad” against psychology
by psychiatry and medicine
Why Don’t Majorities of Health
Psychologists Support Prescribing?
Only 27% hospital affiliated psychologists
approve (Boswell et al., 1988)
Only 23-30% of health psychologists approve
(Piotrowski & Lubin, 1989)
Only 43% of medical school psychologists
approve (Robiner, Wedding, & Koehler, 1998)
Does the limited support among psychologists in
health settings relative to psychologists in other
settings reflect better informed caution?
Argument #8 About Prescription
Privileges for Psychologists
It’s the “natural evolution” or “logical” step for the
profession
Even though it should more realistically be characterized as
“revolutionary” or “radical”
» It departs from psychology’s historic training paradigms and
conceptualizations of psychopathology and intervention
» It requires major shifts in focus, prerequisites, marked
expansions of training and continuing education in key areas,
reformulation of accreditation criteria, modification of
regulatory structure, domains, and processes, expanded
ethical guidelines, as well as uniform requirements that at
least part of psychologists’ training occur within health care
settings
Prescription Privileges May Conflict
With Darwin’s Notions of Evolution
• Survival depends on fitness for tasks
•
•
undertaken and challenges faced
Evolution does not favor inferior skills
Evolution does not forgive serious
miscalculations
The Evolution of Psychology
Demands that Psychologists:
 Do
what they do better
 Adapt appropriately to change
 Recognize their strengths and limitations
 Develop better understanding of
psychopharmacology
 Cultivate collaborations with prescribers
Questions to Consider- #1
If the job market for psychologists was more positive,
would psychologists and trainees still wish to pursue
prescription privileges?
If prescribing ends up not being lucrative, or
broadening marketability, would it still be being
pursued? Even with prescription privileges, Psychiatry
has been losing market share
Are nurse practitioners who prescribe compensated
more generously than psychologists?
Questions to Consider- #2
How would prescribing change the
therapeutic relationship?
How would psychologists deal with their
obligation to provide 24-hour emergency
coverage related to medications?
How would RxP training detract from
training in other dimensions of Psychology?
Questions to Consider- #3
Do changes in psychologists’ earlier opposition to
prescribing reflect desensitization to genuine
hazards as a result of the profession’s marketing
or “propaganda” campaign
» SSCP had to delete an anti-RxP statement from its website if
it wanted to continue affiliation with APA
Are there more appropriate ways for the
profession to respond to current challenges to
practitioners?
Are there safer and more appropriate ways to
assist patients who need medication get it?
Questions to Consider- #4
After decrying the “medical model” for decades, why
are psychologists now embracing prescription
privileges?
Can psychologists prescribe medications as safely
as providers with more extensive medical training?
Whenever mortalities or morbidities associated with
psychologists’ prescriptions result in lawsuits, will
juries agree it was a good idea?
Questions to Consider- #5
How does not going to medical school/nurse
practitioner training detract from understanding of
medications and physical functioning?
How does not going to medical school/nurse
practitioner training affect skill and experience in
prescribing?
If psychologists wish to prescribe medications well,
why don’t they pursue higher quality training?
» There generally are openings in good psychiatry residency
programs
Questions to Consider- #6
Would a psychologist be your first choice prescriber
for psychoactive medications for yourself or a loved
one?
Why or why not?
Who would be your first choice prescriber?
If Psychologists Are Granted Prescription
Privileges, Why Shouldn’t the...
189,000
Clinically Trained Social
Workers
50,000
Licensed Professional
Counselors
46,000
Marriage & Family Therapists
Current Focus on Medication Errors
Current Focus on Medication Errors
Psychologists’ lobbying for prescriptive authority is ironic in light
of growing national concern about errors in prescribing
medication
(Classen, Pestotnik, Evans, Lloyd, & Burke, 1997).
» Medication errors are estimated to lead to <7,000 deaths annually
(Phillips, Christenfeld, & Glynn, 1998).
» Among the many contributing factors to medication errors are
inadequate knowledge and use of knowledge regarding drug
therapy and inadequate recognition of important patient factors
(e.g., impaired renal function, drug allergies)
(Lesar et al., 1997).
Lesar TS, Briceland L, Stein DS: Factors related to errors in medication prescribing. JAMA 1997;277(4):312-317
Along With Other Strategies, Avoiding
Medication Errors Will Take
Improved prescriber education (Lesar et al. 1997)
Not creating a new category of prescribers
with relatively less training (as psychologist
prescribers would be)
» Short cuts in education seem likely to undermine
patient care and contribute to medication errors
along the patterns outlined by Lesar et al. (1997).
Collaborating? Yes!
Prescribing? No
Achieving the APA Task Force’s goals for
enhancing the care of patients needing
medications does not require prescriptive
authority for psychologists
Patients and other health professionals would
benefit from psychologists’ increased knowledge
related to psychopharmacology that would
enhance the services they provide and their
collaborations with prescribers
Effects of Controversies
“The diversity of our field often leads to
different, strongly held opinions about which
there appears to be little room for
compromise….The contribution that a unified
psychology can make to society and its own
health is eroded and weakened by scientists
and practitioners headed in different,
sometimes opposite directions”
Hargrove, S. (1997. March). We have only ourselves to fear. PsycCRITIQUES, 42(3).
RxP Effects1 on State Psychological Associations
State associations, that have already initiated an RxP initiative,
report having to allocate all of their legislative dollars to the effort
Tennessee reported not having legislative dollars for other bills due
to all efforts going towards RxP
APA has given $180K to 6 states due to lobbying costs of RxP
Due to the expense several states said they are near a point of
reconsidering whether to continue pursuing RxP
States with psychopharmacology training programs report a
shortage of psychologist enrollees and have opened the training to
nurses to meet their costs
1Personal
Communication from Willie Garrett, Ed.D. December 8, 2006 re: Directors of
Professional Affairs strategic planning meeting