Scope of Practice: Concerns About Psychologists Prescribing

1. Scope of Practice:Concerns AboutPsychologists Prescribing [NAME], M.D. [TITLE AND AFFILIATION]

2. 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

3. [BILL NUMBER]

4. Overview of [BILL NUMBER] • Include a brief overview of the legislation

5. Partners Opposed to [BILL NUMBER] • List any partners who you are working with to oppose the legislation in your state.

6. Supporters of [BILL NUMBER] • List any groups that are publicly supporting the legislation in your state.

7. Context of Scope of Practice Legislation

8. 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

9. International Perspective *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.

10. Psychologists Prescribing is NOT the solution

11. 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.

12. 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

13. 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.

14. [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.

15. Source: Tanya L. Tompkins, Ph.D.

16. The Importance of Medical Training

17. Medical vs. Medication Training • MEDICAL training involves scientific coursework in biology, anatomy, and chemistry, as well as clinical experience in real life settings. • Competence is measured by multiple evaluation methods, including real world observation, to assure one can practice safely. • MEDICATION training involves learning to identify and distinguish between medication types and categories, NOT the biological basis of medical conditions. • 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.

18. Equivalent Years of Biomedical Education and Training for Prescribing Practitioners 2 years child psychiatry training 3 years general psychiatry training 1 year pre- med physical science courses, and 4 years medical school *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. Training Comparison Adapted from the American Psychiatric Association

19. Psychotropic Medication and Children

20. 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 drug-drug interactions. • The wrong treatment plan can cause serious setbacks to a child’s emotional and physical development, or even death.

21. 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

22. 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.

23. Real Solutions to Improve Access to Care

24. 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

25. Collaborative Models of Care* Has implemented a collaborative model No known collaborative model Mental Health and Pediatric Collaborative Care Models • Pediatricians are well-positioned to detect mental health problems. • 50% of the treatment for common mental health problems is provided within a primary care practice. • Collaborative models are cost-effective. • The model is used successfully in many other pediatric subspecialties (endocrinology, hematology, neurology). *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.

26. 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.

27. 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.

28. 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.

29. Contact Information [NAME] [TITLE, AFFILIATION] [PHONE] [EMAIL]