This past June, Illinois became the 3rd state to allow psychologists to prescribe medications commonly used for psychiatric issues, after New Mexico and Louisiana have enacted similar laws. As indicated in a recent Chicago Tribune article, the debate around prescription privileges ended with some of the following stipulations. Psychologists currently will not be allowed to prescribe to minors, seniors, and any person with a “serious mental condition,” although the specific language of the bill indicates restrictions for those with a serious medical condition, developmental, or intellectual disability.
In order to obtain these privileges, psychologists will have to undergo 2.5 years of additional graduate training including relevant coursework. They will see a minimum of a 100 patients under physician supervision and sign a collaborative agreement, and will be limited to only prescribing certain classes of medications, such as anti-depressants, but not stimulants. Our own American Psychological Association (APA) applauded the decision while noting that “psychology advocates are hopeful that prescribing psychologists in Illinois will eventually earn a broader scope of prescriptive authority.” “This is a landmark moment for mental health care,” said Norman B. Anderson, PhD, APA’s executive vice president and chief executive officer. “Allowing properly trained clinical psychologists to prescribe is a logical step in helping to improve access to quality mental health care for consumers, especially the underserved.”
But are we really, really sure, it is a “landmark moment” or even a positive moment at all? Because when it comes to gambles for our profession, and frankly for the general public, it doesn’t really get much bigger than this. Proponents have cited a few primary (and inter-related) reasons for expanding prescription privileges to psychologists, of which APA provides more detail and resources on this link. These include providing more comprehensive care to patients, better access to psychiatric medications to patients in underserved areas (such as rural locations), expanding psychologists’ capacity to serve patients, and utilizing psychologists’ more specialized training in mental health issues in making decisions about appropriate medication use for psychological difficulties.
Despite these and other reasons, though, I feel the push to allow psychologists to prescribe is fraught with grave concerns. The following list provides a brief, yet certainly not comprehensive, overview of some of the most serious issues that face this discussion, both for psychologists and the general public.
Our Profession Will Follow the Path of Psychiatry, and Morph from the Practice of Psychology to the Practice of Pharmacology
There was a time when most, if not all, psychiatrists engaged in some psychotherapy. Many will argue if this was a good thing, but regardless, it was the reality. But with the increased advent of the pharmaceutical industry, psychiatrists in masses have moved from 50 minute appointments to 15 minute (or less) appointments. I can barely begin a conversation to really know what happened in a patient’s week in that time, let alone assess the myriad of factors that may be affecting his or her biopsychosocial well-being in order to prescribe medications.
But this is the pressure that most psychiatrists are feeling, whose employers are often not supportive of them having longer appointment times. Why? Well, they will see fewer patients, seemingly not meet the demand of their referring physicians as well, and ultimately make less money. Once psychologists start to obtain prescription privileges more widely, and the pharmaceutical and other financial/logistical influence creeps in, there is no reason that psychologists will not feel the same pressures, not just from their employers and their own bank accounts, but also from patients as well.
One of the best parts of my profession now is that families (most) coming to see me know that I cannot prescribe medications, and so they are much more willing to take on more long-term, systematic interventions. If I began to prescribe, there is no doubt that the pressure I would feel would change. My sense is that psychiatrists have felt this pressure, and it has transformed their profession in ways that many of them do not desire. “Those who do not know history are doomed to repeat.” Do we really want to repeat it?
Doing No Harm, or, in APA Terms; Nonmaleficence
“Principle A” for the American Psychological Association (APA) involves two ideas: beneficence and nonmaleficence. The former focuses on striving to benefit patients while the latter emphasizes doing no harm. Any professional endeavor must take both seriously, and not pursue a course of action unless the advantages clearly outweigh the costs. Every year, more than 770,000 people die or are seriously injured from adverse drug effects, some of which are associated with psychiatric medications. The costs total an average of 5.6 million per hospital in the United States.
The argument that psychologists are better equipped to recognize specific mental health issues, and thus theoretically allows them to prescribe more accurately, is belied by the fact that their limited training in all other related areas seems to put them at greater, not less risk for harm as noted in the article “Prescription Authority for Psychologists: A Looming Health Hazard?”
It also minimizes a seemingly more ideal circumstance in which the psychologist communicates more directly with a primary care physician or psychiatrist, who actually prescribes the medications. But my worry is that many psychologists are not taking this issue very seriously.
In fact, Patrick DeLeon, Ph.D., J.D., Past President of the APA, contended that ” . . . prescription privileges is no big deal. It’s like learning how to use a desk-top computer” (Roan, S., Tug-of-war over prescription powers; health: Pharmacists, nurses and other non-doctors want the authority to prescribe drugs. Others insist only physicians have the training to do so safely. Los Angeles Times, September 7, 1993, Part E, 1, 6.). I strongly disagree with this statement. It is a huge deal and a huge risk. Are we really sure that the undoubted costs of prescription privileges will be significantly outweighed by proposed benefits?
Are Psychiatric Medications Really Helping Us To Be Psychologically Healthier?
In 1987, Prozac was first introduced. Since 1996, the FDA has approved over 60 psychotropic drugs and counting for a wide variety of psychiatric conditions. Sales of prescription stimulants have more than quintupled since 2002 to over 8 billion dollars annually. Abilify was the number one selling drug in total sales in 2013. Meanwhile, in 1987 there were less than 20,000 severely mentally disabled children—now there are almost 600,000. The number of children under the age of six receiving SSI has tripled over the last ten years to more than 65,000. Mental and substance use disorders are now the leading cause of nonfatal illness worldwide. Depression is the number one cause of illness and disability in 10- to 19-year-olds internationally. Suicide ranks number three among causes of death. “The CDC, on May 3, 2013, reported that the suicide rate among Americans ages 35-64 years increased 28.4% between 1999 and 2010 (from 13.7 suicides per 100,000 population in 1999 to 17.6 per 100,000 in 2010).”
The statistics are endless, but the obvious question looms: Where exactly is the evidence that psychiatric drugs are the key to curing our mental health woes? Even if you do not accept the reasonable evidence to suggest possible iatrogenic effects of these medications on a large scale, it seems rather easy to acknowledge that psychiatric drugs aren’t exactly eliminating mental health concerns in the way that immunizations have (despite their controversy in some circles) for so many diseases over the past century. If they were, it seems a conversation around prescription privileges might be more reasonable, but the track record for their success on a population basis seems very unconvincing, especially when it comes to expanding their access. I fully recognize there is complexity of every possible persuasion here, but until the evidence is more convincing, it seems logical to not let more people start prescribing.
Logistical Problem of Combining Medical and Psychological Training (and doing both well)
Most programs to obtain a doctorate in clinical psychology or a related field require at least nine years of formal training to meet state requirements to become a licensed psychologist, and routinely students spend much more time than this. This includes four years of undergraduate training, usually (but not always) with a major in psychology or similar fields followed by at least four years in graduate training, which involves intensive coursework, research, and clinical experience. An additional year of internship ensues to further enhance training, before an individual can finally graduate with their Ph.D. or Psy.D. Even after this, many, such as me, will seek out a postdoctoral fellowship year (or two for neuropsychologists) to further refine and expand training, and also meet certain state licensing requirements. Meanwhile, psychiatrists typically spend at least twelve total years in formal training, often starting with an undergraduate degree in anatomy, biology, or a related area that forms the framework for later education. This is typically followed by four years of medical school, and four years of residency.
Although I cannot speak for my psychiatric colleagues, I can tell you that I never met a psychologist who said that their training overqualified him or her for the real life practice of psychology. It is a very challenging profession, one in which we are humbled daily at how much there still is (and will always be) to understand. I needed all of the training I received even to feel that I could begin to practice. So, as groups such as APA begin to push the idea of making pharmacological training as part of graduate education, it begs a simple question. Are we going to significantly increase the number of years it takes to become a psychologist? Otherwise, how exactly are we going to fit in all the knowledge needed to truly be able to provide expert services, both psychologically and pharmacologically, especially given that most psychology students don’t have a medical background? The obvious likelihood is simple: something will give, and chances are it will be areas (such as training in empirically-based therapeutic techniques and psychological testing) that currently make us unique.
Inadequate Training Despite Additional Provisions
This reason ties closely into the last, but speaks more directly to those actually providing the training, and how this occurs, both during or after graduate school. The first issue is just who will be providing the training, and just how scrutinized and closely supervised will this be? If psychologists are going to be provided with additional training in medical areas, will physicians be providing this, or will this fall upon psychological colleagues? Or will psychology programs begin expanding their staff to a number of other professionals, and just how will this work?
Even if this somehow occurs, adjunct professors (to a particular program) rarely have the time to provide extensive supervision when it does not directly involve the students their employment is based on. Furthermore, it is likely that much of the training for current practitioners will occur online given current trends. Although a case may be made for the flexibility this mode provides, it limits the options for direct supervision, especially as so many professional programs are looking to expand enrollment in order to increase revenue.
In general, training proposed by legislation, such as that through Illinois, still seems to leave large gaps in knowledge and experiential base, given it only occurs over 2.5 years while in practice. I was in a class of eight students for graduate school, and like my classmates, I needed all the direct supervision I could get. It wasn’t always pleasant, certainly it wasn’t without its flaws, but it was always there, especially when we most required it (which was regularly). Ultimately, as more space and individuals become involved, especially those loosely affiliated with the trainee, my sense is that we as professionals, and the general public, will lose out.
In closing, I will return to APA’s own words in the section on their website labeled, “About Prescribing Psychologists.” It ends with, “The need is great and the evidence is clear: Allowing prescribing rights for psychologists is an essential step to providing thousands of patients with access to comprehensive mental health care.”
Yes, the need to improve the psychological health of our country is great, but I am curious to know how adopting prescribing rights for psychologists became a foregone “essential step” in addressing this need? I know I speak for many APA members in saying that I am not only very concerned it is not an “essential step,” but most conceivably the wrong step, one that may drop us into a chasm with dire consequences. Unless things change, we had better be sure this is where we want to go, not just for our profession, but for the people we serve. Because if we are not, the costs could be huge, and irreversible. Just ask our psychiatric colleagues.