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Title: Psychologists Get Prescription Pads and Furor Erupts
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- Date: Thu, 28 Mar 2002 19:07:19 +0100
March 26, 2002
Psychologists Get Prescription Pads and Furor Erupts
By ERICA GOODE
sychologists are adept at diagnosing and treating mental illness. But unlike psychiatrists, who are medically trained, they have never been able to prescribe drugs for their suffering patients.
As of July 1, however, psychologists in one state, New Mexico, will be authorized to pull out the prescription pad. A new law will grant prescribing privileges to licensed, doctoral-level psychologists who have completed an additional training and certification program.
And though the specifics of the plan remain to be worked out, the law is already the focus of a bitter national debate.
Proponents argue that the law will provide greater access to quality care at lower cost. Opponents contend that psychology should remain distinct from its medical cousin and they worry that the legislation may place vulnerable patients in danger.
Most vehement in their objections are the representatives of organized psychiatry.
"Most of the patients we see as psychiatrists have many other medical problems," said Dr. Richard K. Harding, president of the American Psychiatric Association. "They have hypertension, diabetes, migraine headaches. And the interactions of the medicines we give for these other conditions are often extremely difficult and scary."
The new law, Dr. Harding said, does not require sufficient training.
"It really scares me," he added, "I think there will be some tragic results from it."
On the other hand, Dr. Russ Newman, the executive director for professional practice at the American Psychological Association, said a variety of studies had demonstrated that psychologists could prescribe safely.
Those studies, he said, included a pilot program run by the Defense Department from 1991 to 1997 that trained 10 psychologists to write prescriptions. Evaluators of the program, Dr. Newman said, concluded that its graduates "filled critical needs and performed with excellence wherever they served." (Seven of the psychologists continue to write prescriptions in military settings).
Other backers of the New Mexico legislation have noted that patients there now have to wait five weeks to six months to see a psychiatrist and that few psychiatrists practice in rural areas of the state. And they point out that in all states patients who see psychologists for psychotherapy must also consult physicians to get the appropriate prescriptions.
"In some conditions," Dr. Newman said, "the treatment of choice is a combination of psychotherapy and medication." Having the same professional cover both aspects creates "a more efficient, cost-effective way of providing services," he added.
Underlying the arguments on each side are other issues of economics and professional turf.
For psychologists, squeezed in a managed-care world, the addition of prescription-writing skills has definite appeal.
"From our vantage point, one of the driving forces has been to have as many strategic treatment interventions in our treatment bag as possible," Dr. Newman said.
For psychiatrists, on the other hand, any ground yielded carries the risk of income lost. The American Psychological Association has been lobbying for prescribing rights for its members for more than a decade. The Hawaii Senate defeated the first prescription bill in 1989. And legislation proposing similar authority for psychologists has been introduced in more than a dozen states over the last decade.
Practitioners in several other fields, including podiatrists, dentists and in some states nurse practitioners, can prescribe medicine without supervision. Still, some critics of the New Mexico law are concerned that the legislation is too weak to ensure that psychologists will be able to prescribe safely.
Under the law, psychologists who wish to gain prescribing privileges must complete at least 450 hours of courses in neuroscience, pharmacology, psychopharmacology, physiology, laboratory assessment and clinical pharmacology.
They must also spend at least 400 hours treating at least 100 patients with mental disorders under the close supervision of a psychiatrist or other physician, and they must pass a national examination.
After the psychologists complete the training and pass the test, they will be eligible for two-year licenses to prescribe psychiatric medication with medical supervision. Then, practitioners can apply to prescribe independently.
But Dr. Joel Yager, a professor of psychiatry at the University of New Mexico, said he was concerned that the law as written was not rigorous enough.
The legislation, he said, calls for far fewer hours of course work than were required of the first graduates of the Defense Department pilot study. The law also has no requirement for completing basic science courses like organic chemistry or biology, he said.
And, the law neither requires in-hospital training nor stipulates that a supervising physician has to be a psychiatrist or psychopharmacologist, with specialized knowledge of psychiatric drugs, rather than a family physician or other doctor.
"People are going to learn psychopharmacology for dummies," Dr. Yager said. "They will learn how to pass tests but will not really have a decent immersion in this material because they won't have the background for it."
Dr. Oakley Ray, a professor of psychology and psychiatry at Vanderbilt University, who was the chairman of the task force that evaluated the pilot program, also views the training requirement as "too little and not rigorous enough."
In the Defense Department program, Dr. Ray said, the psychologists "were on call and worked from 7 in the morning to 7 or 8 at night." Stringent criteria were used to select candidates for the program. And the trainees were supervised by a psychiatric psychopharmacologist, he said.
But Dr. Morgan T. Sammons, one of the first psychologists to graduate from the Defense Department program, said it quickly became clear that the amount of training necessary had been overestimated.
"When we first started out in 1991, our curriculum consisted of the first two years of medical school and the first year of a psychiatric residency," said Dr. Sammons, the president of the Maryland Psychological Association and the director of mental health at the Naval Medical Clinic in Annapolis.
But "as the program evolved," he said, "more specific courses were folded into the curriculum and the total hours were essentially cut in half."
Dr. Elaine LeVine, a psychologist in private practice in Las Cruces, N.M., and the chairman of the state psychological association's task force on prescriptive authority said, "We're not purporting to be physicians."
The new law, Dr. LeVine said, mandates that psychologists maintain continuing and collaborative relationships with their patients' primary doctors even after being certified to prescribe on their own.
And she noted that a majority of prescriptions for psychiatric drugs nationwide were written by primary care physicians, not psychiatrists.
"We already have expertise in diagnosing and treating mental conditions," Dr. LeVine said, "and now, working with the physicians, we can bring that expertise in terms of what particular medication might be best for that particular disorder."
In fact, the specifics of how psychologists will be selected, trained and supervised remain to be worked out. An amendment added to the law before it was signed by Gov. Gary E. Johnson, a Republican, delegates such details to the New Mexico Board of Medical Examiners and the New Mexico Psychologist Examiner's Board, which could take months to agree on a plan.
For his part, Dr. Ray said he thought it was probably inevitable that at some point psychologists would be able to offer their patients medication in addition to psychotherapy and other services.
"I've been telling my friends the psychiatrists for 10 years that this is something that's going to happen," Dr. Ray said. "They can either fight it and lose, or they can join it and make sure it works in the best possible way to benefit patients in the field."
Still, some psychologists oppose this new twist, believing they should stick with what they do best. Adding drugs to their armamentarium, they maintain, is a prescription for trouble.
"There's nothing to prevent psychologists from earning a nursing degree or a medical degree" if they want to prescribe drugs, said Dr. Gerald Davison, the chairman of psychology at the University of Southern California.
But without medical training, Dr. Davison said, psychologists put themselves at greater risk of condemnation for any mistakes that are made — and mistakes, in any medical endeavor, are inevitable.
"I think it's just a dreadful mistake that psychology is making," he said, "and I think that New Mexico has made a dreadful mistake."
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