Transcript medical - American Academy of Child and Adolescent Psychiatry

Scope of Practice:
Concerns About Psychologists Prescribing
[NAME], M.D.
[TITLE AND AFFILIATION]
Overview






[BILL NUMBER]
Context of scope of practice legislation
Psychologist prescribing is NOT the solution
The importance of medical training
Psychotropic medication and children
Real solutions to improve access to care
[BILL NUMBER]
Overview of [BILL NUMBER]

Include a brief overview of the legislation
Partners Opposed to [BILL NUMBER]

List any partners who you are working with to
oppose the legislation in your state.
Supporters of [BILL NUMBER]

List any groups that are publicly supporting
the legislation in your state.
Context of Scope of
Practice Legislation
History of Scope of Practice Legislation


47 states and the District
of Columbia prohibit
psychologists from
prescribing
Only New Mexico and
Louisiana have passed
laws giving prescriptive
authority to psychologists


No formal study of impact
Few psychologists are
prescribing
International Perspective
United States
Canada
United Kingdom
Unlimited
Limited
Unlimited
Limited
Unlimited
Limited
Physician
Yes
No
Yes
No
Yes
Yes
Psychologist
No
Yes*
No
No
No
No
*Only in New Mexico, Louisiana and US Military
Source: Lavoie KL, Barone S. Prescription Privileges for Psychologists: A Comprehensive
Review and Critical Analysis of Current Issues and Controversies. CNS Drugs, 2006;
20(1): 51-66.
Psychologists Prescribing
is NOT the solution
Department of Defense Pilot

In 1992, the Department of Defense implemented a program
to train psychologists to prescribe medication.





Trained 10 psychologists to prescribe
Cost more than $610,000 per psychologist = $6 million
Psychologists only allowed to treat active military personnel between
18-65 with uncomplicated cases, and only after patients received full
medical evaluation.
Not authorized to treat children or elderly.
Terminated in 1996


General Accounting Office (GAO) investigation found the program to
be too expensive and unneeded.
Recommended that program be discontinued unless psychologists
practiced under psychiatrist supervision.
Risks to Patient Safety


Psychotropic medications are the most powerful in modern
medicine – they impact all parts of the body, not just the
brain.
If improperly prescribed, psychotropic medication can have
dangerous side effects:








convulsions
epilepsy
heart arrhythmia
blood disease
seizures
coma
stroke
death
Risks to Patient Safety

Case example: a patient reports that they are lethargic
and gaining weight.



These are common symptoms for both depression AND
hypothyroidism.
A psychologist is not trained to distinguish between the
conditions, leading to possible misdiagnosis and the
unnecessary prescription of an antidepressant.
There is a consistent lack of evidence about the
safety of granting prescription privileges to
psychologists.
[BILL NUMBER] Will Not Improve
Access to Care

Psychologists are generally located in the
same geographic areas as physicians and
psychiatrists.


Will not alleviate the shortage of mental health
providers in rural and underserved areas.
Few psychologists have completed training
and become licensed to prescribe in NM and
LA.
Source: Tanya L. Tompkins, Ph.D.
The Importance of
Medical Training
Medical vs. Medication Training

MEDICAL training involves scientific coursework in biology, anatomy,
and chemistry, as well as clinical experience in real life settings.


MEDICATION training involves learning to identify and distinguish
between medication types and categories, NOT the biological basis of
medical conditions.


Competence is measured by multiple evaluation methods, including real world
observation, to assure one can practice safely.
Competence is measured by written exams and does not include real world
observation.
MEDICAL training would prepare one to distinguish between a mental
illness (schizophrenia) and conditions that may mimic a mental illness
(brain tumors and thyroid disease). MEDICATION training would not.
Training Comparison
Years
Equivalent Years of Biomedical Education and Training for Prescribing Practitioners
10
9
8
7
6
5
4
3
2
1
0
2 years child
psychiatry
training
3 years
general
psychiatry
training
1 year premed physical
science
courses, and
4 years
medical
school
Child and
Adolescent
Psychiatrist
Nurse
Practitioner*
Physician
Assistant**
Prescribing
Psychologist
(NM)
Prescribing
Psychologist
(LA)
*State laws vary regarding the restrictions on types and schedules of medications
that nurse practitioners are able to prescribe.
** Physician Assistants are solely licensed to prescribe under physician supervision.
Adapted from the American Psychiatric Association
Psychotropic Medication
and Children
Psychotropic Medication and Children



Children’s bodies metabolize medication
differently than adults.
Children with mental illness can be on more
than one medication, creating possible drugdrug interactions.
The wrong treatment plan can cause serious
setbacks to a child’s emotional and physical
development, or even death.
Prescribing Psychotropic Medication
to Children and Adolescents

Prescribing psychoactive medications for children and
adolescents requires the judgment of a physician with training
and qualifications in the use of these medications in this age
group.

Before prescribing medication, a physician does a
comprehensive medical evaluation, including:





symptoms
co-morbid psychiatric conditions
co-morbid physical condition
family history
laboratory tests, if necessary
Case Example: The Need for Medical
Training

Include an example of a real-life child patient
situation from your state in which you felt the
training of a child psychiatrist was essential to
positive outcomes.
Real Solutions to Improve
Access to Care
Recommendations


Provide consultative reimbursement between child
and adolescent psychiatrists and primary care
physicians
Increase the child and adolescent psychiatric
workforce:




Provide incentives for medical students to go into child
and adolescent psychiatry.
Provide funding to child psychiatry training programs to
fund additional residents
Provide funding for the creation of post-pediatric training
programs
Increase funding for the overall mental health system
Mental Health and Pediatric
Collaborative Care Models

Pediatricians are wellpositioned to detect mental
health problems.



Collaborative Models of Care*
50% of the treatment for
common mental health problems
is provided within a primary care
practice.
Collaborative models are costeffective.
The model is used successfully
in many other pediatric
subspecialties (endocrinology,
hematology, neurology).
Has implemented a
collaborative model
No known collaborative
model
*Please note that this list is not exhaustive and other models may exist.
Source: The American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry .
Massachusetts Child Psychiatry Access
Project



Provides PCPs with timely access to child
psychiatry consultation via telephone.
Designed to support PCPs in managing
children with less complex mental health
needs, freeing the limited child psychiatry
workforce for more complex cases.
Implemented through managed care
organization, which contracts with 6 regional
academic medical centers.
Massachusetts Child Psychiatry Access
Project


Grew out of discussions among Medicaid
personnel to find solution to the lack of access
to high quality mental health services.
Funded by Massachusetts Department of
Mental Health.


Included as a budget line item
Program has enrolled most PCP practices in
state, representing 95% of all youth.
State Initiatives to Increase the Child
and Adolescent Psychiatric Workforce

Louisiana and Virginia provided stipends to
training programs to fund additional child
psychiatry residents.


Programs have since been cut from state budgets.
Pennsylvania introduced legislation that
would have provided up to $50,000 in loan
forgiveness for each year of specialty training
in child psychiatry.
Contact Information
[NAME]
[TITLE, AFFILIATION]
[PHONE]
[EMAIL]