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History of Prescriptive Authority for Psychologists in APA

This presentation provides a historical overview of the American Psychological Association's journey towards granting psychologists prescriptive authority. It covers key events, the role of primary care physicians, and the history of prescriptive authority in Iowa.

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History of Prescriptive Authority for Psychologists in APA

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  1. RXP FOR PSYCHOLOGISTS IPA PRESENTATION April 12, 2019 Des Moines, IA Elizabeth Lonning, PsyD, MSCP

  2. APA HISTORY • Year Event 1981 The APA Board of Professional Affairs defines the conditions under which the use of “physical interventions” is within the scope of practice of psychology. • 1984 Senator Daniel Inouye suggests to the Hawaii Psychological Association that psychologists should adopt prescriptive authority as a legislative agenda. • 1989 The Board of Professional Affairs endorses enhanced training in psychopharmacology for psychologists. Congress funds a pilot training program for the DoD. • 1990 The first APA task force on psychopharmacology is created. • 1991 The DoD Psychopharmacology Demonstration Project begins. • 1992 The APA task force report identifies three levels of preparation for involvement in pharmacotherapy. • 1993 The Prescribing Psychologists Register begins offering courses for civilian psychologists. Indiana permits prescriptive authority for psychologists in relevant federal programs.

  3. APA HISTORY CONTINUED • 1994 The Psychopharmacology Demonstration Project graduates its first two participants. • 1995 The APA Council of Representatives votes to make obtaining prescriptive authority APA policy. • 1996 APA Council adopts a model curriculum in psychopharmacology and model law for awarding psychologists prescriptive authority. • 1997 The Psychopharmacology Demonstration Project is discontinued. APA Council authorizes development of the Psychopharmacology Examination for Psychologists. • 1999 Guam approves prescriptive authority for appropriately trained psychologists. • 2001 APA recognizes psychopharmacology as a proficiency. • 2002 New Mexico approves prescriptive authority for appropriately trained psychologists. • 2004 Louisiana approves prescriptive authority for appropriately trained psychologists.

  4. APA HISTORY CONTINUED • 2005 The first prescription is written by a civilian psychologist. • 2008 APA Council adopts a revised model curriculum “in principle” pending development of a designation system and forms a task force for this purpose. • 2009 APA Council adopts the revised model curriculum, guidelines for a designation system for programs, and practice guidelines relevant to psychopharmacotherapy. • Note: In some cases, years differ slightly from those listed in other sources because there are multiple points that can be used to identify when a legislative action or set of guidelines was finalized. An attempt was made to use the dates that are most commonly cited. Abbreviations: DoD, Department of Defense; APA, American Psychological Association (McGrath, Bob. (2010). Prescriptive Authority for Psychologists. Annual Review of Clinical Psychology. 6. 21-47.)

  5. PRESSURES ON PRIMARY CARE PHYSICIANS • Increasingly, primary care physicians are having to help patients with emotional problems • Often they have neither the time nor the extensive training to deal with these issues in depth • Often they respond to this pressure with prescribing psychotropic medications

  6. PRESSURES CONTINUED • In fact, over 80% of psychotropic medications are prescribed by PCPs • Meta-analyses reveal often these emotional needs can be addressed as effectively or sometimes more effectively with psychotherapy • Psychotherapy plus medication is often more effective than medication alone (Levine and Foster, 2010, Integration of Psychotherapy and Pharmacology by Prescribing Psychologists: A psychobiosocial mode of care. In R. McGrath and B. Moore, Therapy for Psychologists: Prescribing Collaborative Roles. Washington, DC: American Psychological Association.)

  7. BRIEF HISTORY IOWA • In 2004 a task force was created to explore the concept of prescriptive authority for psychologists • This exploration included a survey of the member of the Iowa Psychological Association • Results of the survey indicated enough interest to have the task force evolve into a standing committee on Psychopharmacology Education

  8. HISTORY CONTINUED • The new committee submitted a 3 year strategic plan which included putting forth legislation as a final step • The first step of the 3 year plan was implemented annually by including psychopharmocology education at each conference offered by the association • The second step of the plan was implemented when IPA supported FDU’s MSCP program as the program of choice for Iowa

  9. HISTORY CONTINUED • We remained in this pattern of step 1 and 2 for many years. • Another survey of members was conducted around 2010-2011. The results indicated support for pursuing RxP legislation, however, older members stated they would support but not pursue the training or assist in securing legislation due to being late in their careers while younger members stated they would support legislation but due to current debt, would not begin training and since they were starting their practices and often families, would not assist with efforts to move forward.

  10. HISTORY CONCLUDED • After sharing the results of that survey it was recommended to the Executive Council that IPA move toward filing legislation or have the committee be dormant for a bit until there was more active support. • Legislation was filed for the first time in 2013.

  11. OVERVIEW OF LEGISLATION • Legislation was filed in 2013 and was assigned to sub-committees in both chambers. We had a Republican in the House and a Democrat in the Senate sponsoring the study bill. • In the Senate the bill moved out of sub-committee, in the House the sub-committee canceled the hearing and was unable to reschedule before the funnel date. • Bill was ‘dead’ for that session but remained alive for the second year of the 2 year session.

  12. OVERVIEW OF LEGISLATION • In 2014, a sub-committee hearing was held in the House and the bill passed out unanimously. • The bill was unable to move out of the full committee in either the House or the Senate. • The bill died and would need to be re-introduced in 2015.

  13. OVERVIEW OF LEGISLATION • In 2015, bill was again assigned to sub-committees in both chambers. • Senate sub-committee hearing scheduled first. No signatures given even though 2 of the 3 members were the same as in 2013. • Since sub-committee in Senate did not move the bill forward, the House did not schedule a sub-committee hearing. • The bill did not move that year but remained alive for the second year of the 2 year session.

  14. OVERVIEW OF LEGISLATION • In 2016, the legislation was heard and passed out of sub-committees in both chambers as well as out of both full committees in each chamber by the funnel date. • Bill came up for a vote on the floor of the Senate first and did not pass by a margin of 2 votes. Our bill sponsor changed his vote to ‘nay’ so he could file a motion to reconsider on this issue.

  15. OVERVIEW OF LEGISLATION • The House would not hold a floor vote until the Senate had finished its’ work on the bill. • The motion to reconsider and the new vote on the bill came to the floor shortly before the end of the session in April and passed. • When the bill went to the House for a vote, an additional amendment was added which stated that the administrative rules for this legislation would be determined jointly by the Board of Psychology and the Board of Medicine.

  16. OVERVIEW OF LEGISLATION • With this amendment the House passed the bill and sent it back over to the Senate which also passed the bill. • Governor Branstad signed the bill into law May 25, 2016.

  17. FEATURES OF THE IOWA LAW • Based on the New Mexico legislation • Requires a post-doctoral master’s degree in clinical psychopharmacology. The law does not have ‘APA designation’ written in it as this was not acceptable to those who opposed the law. • Requires practicum and 2 years of supervision. The second year of supervision was in response to those concerned about prescribing to special populations such as children, the elderly and pregnant women. The second year of the supervision is to focus on prescribing to those populations if the psychologist desires to have those populations as part of their practice. • Requires an ongoing collaborative practice agreement with a prescribing physician. • The supervising and collaborative physicians are not limited to psychiatrists.

  18. WEBSITE FOR LAW https://www.legis.iowa.gov/legislation/BillBook?ga=86&ba=HF%202334

  19. EDUCATION • Applicants will possess a post-doctoral master of science degree in clinical psychopharmacology from an APA designated program. • The degree shall be a minimum of 30 credit hours not including practicum • A minimum of 1/3 of the coursework must be completed in a live interactive format

  20. CLINICAL EXPERIENCE • At the beginning of the clinical experience the psychologist shall directly observe the training physician performing clinical assessments. • At the determination of training physician, psychologist will perform clinical assessments of patients under direct supervision of physician • At the determination of training physician psychologist will perform clinical assessments without direct supervision

  21. CLINICAL EXPERIENCE • The clinical experience shall consist of a minimum of 600 patient encounters to be completed by the end of practicum. • Competency in reaching milestones of health history, physical exam and neurological exam must be demonstrated

  22. PRACTICUM • This must be associated with the psychopharmacology training program and is to be completed in no less than 6 months and no more than 3 years • The process of observing physician, then physician observing psychologist then psychologist working without direct observation occurs here as well.

  23. PRACTICUM • Practicum shall consist of a minimum of 400 hours and 100 patients. • Only face to face evaluation and treatment of patients with mental health disorders and hours spent discussing treatment with training physician may be counted. • A patient may be counted toward this requirement is the patient has a mental health diagnosis and pharmacological intervention is considered even if no prescription is given

  24. PRACTICUM • Psychologist will observe, evaluate and treat patients encompassing a range of ages and a variety of diagnoses. • At least 100 hours of the 400 hours must be completed in a psychiatric setting. • At least 100 hours of the 400 hours must be completed in a primary care or community mental health setting

  25. PRACTICUM • Competency in these milestones must be reached: • Physical Exam • Review of Systems • Medical history review • Assessment indications and interpretations • Differential Diagnosis • Integrated treatment planning • Consultation and collaboration • Treatment management • Appropriate medical documentation

  26. SUPERVISED PRACTICE • Completion of a minimum of 2 years of supervised practice with a minimum of 300 patients diagnosed with a mental health disorder and pharmacological intervention is considered for treatment. A minimum of 100 patients will be treated with psychotropic medication during this time period.

  27. SUPERVISED PRACTICE • Special populations: • Children: Completion of one year of the required 2 years in either pediatric practice, a child and adolescent practice or a general practice treating a minimum of 50 patients who are less than 17 years of age • Elderly Patients: Completion of at least 1 year of the 2 years in either a geriatric practice or a general practice with patients across the lifespan including those over age 65

  28. SUPERVISED PRACTICE • Special Populations Continued: • Serious Medical Conditions: Serious medical conditions including but not limited to heart disease, cancer stroke, seizures, comorbid psychological conditions and patients with developmental and intellectual disabilities. Complete one year of prescribing psychotropic medications to these patients.

  29. CONSULTATION AND COLLABORATION • Prescribing psychologists will consult with the primary care physician of patients. Patients must have a designated primary care physician for a psychologist to be able to prescribe to them. • A prescribing psychologist will have a collaborative practice agreement with a physician at all times.

  30. WEB ADDRESS FOR ADMINISTRATIVE RULES • https://www.legis.iowa.gov/law/administrativeRules/rules?agency=645&chapter=244&pubDate=02-27-2019

  31. PRACTICE PATTERNS AND MEDICAL PROFESSIONAL EVALUATIONS OF CURRENT PRESCRIBING PSYCHOLOGISTS • Practice patterns: • Most reported increase in severity of diagnosis • Percentage of cases prescribers reported starting tx with medication alone versus psychotherapy alone was not significant • PP did report seeing twice as many patients for medication alone as for therapy alone, however, 57.8% of medication only patients were receiving therapy from another provider

  32. PERCEPTIONS OF MEDICAL COLLEAGUES • 95.5% agree or strongly agree the PP are adequately trained to prescribe medication • 100% agree or strongly agree the PP are safe prescribers • 100% agree or strongly agree they would refer to a PP • 95.5% agree or strongly agree that PP increased patient access to care • 95.5% disagree or strongly disagree that they are concerned PP will prescribe inappropriate medications and/or dosages. (Linda, W.P. & McGrath, R.E. (2017). The Current Status of Prescribing Psychologists: Practice Patterns and Medical Professional Evaluations. Professional Psychology: Research and Practice, 48(1), 38-45.)

  33. REFERENCES • Levine & Foster, 2010, Integration of Psychotherapy and Pharmacology by Prescribing Psychologists: A psychobiosocial mode of care. In R. McGrath and B. Moore, Therapy for Psychologists: Prescribing Collaborative Roles. Washington, DC: American Psychological Association. • Linda, W.P. & McGrath, R.E. (2017). The Current Status of Prescribing Psychologists: Practice Patterns and Medical Professional Evaluations. Professional Psychology: Research and Practice, 48 (1), 38-45. • McGrath, Bob (2010). Prescriptive Authority of Psychologists. Annual Review of Clinical Psychology. 6. 21-47. 10.1146/annurev-clinpsy-090209-151448.

  34. OTHER RESOURCES • Prescriptive Authority Sourcebook: A Guide for States (2005). Sammons, M.T., Cowardin-Bach, A., Harowski, K. J., Levine, E., Meit, S., McGraw, R. M., Rigdon, M., & Taylor, G.P. http://dx.doi.org/10.1037/e521302015-001 • American Psychological Association. (2011). Practice guidelines regarding psychologists’ involvement in pharmacological issues. American Psychologist, 66, 835-849.

  35. SPECIAL THANKS • Committee members : Dr. Brenda Payne and Dr. Greg Febbraro • Sub- Committee members : Dr. Brandon Davis, Dr. Matt Cooper, Dr. Jason Smith, Dr. Brenda Payne • Lobbyist Amy Campbell • Sharon Dozier, Board Executive Iowa Board of Psychology • Laura Steffensmeier, Office of the Attorney General • Dr. Elaine Levine, Dr. Bob McGrath, Dr. Casey McDougall, Dr. Dan Ullman, Dr. Judi Steinman, Dr. Anne Farrar-Anton • Deborah Baker, APAPO • Sydney Prochaska, Power Point consultant

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