Prescription Privileges for Psychologists PSYC 4500: Introduction to Clinical Psychology Brett Deacon, Ph.D. December 2,

1. Prescription Privileges for PsychologistsPSYC 4500: Introduction to Clinical PsychologyBrett Deacon, Ph.D.December 2, 2010

2. Announcements • Final exam: Tuesday, December 8 at 10:15 • Please complete online teaching evaluation!

3. From Last Class… • Critique of EMDR

4. Today’s Topic • Prescription privileges for psychologists • A little background…. • Huge thanks to William Robiner, Ph.D., for allowing me to use his slides in this lecture!

5. Issues to Consider… • What kind of support exists for prescription privileges among psychologists? • Why do some psychologists want prescription privileges? • What kind of training is necessary? • How might this affect the profession? • Is this a good idea? • What developments have occurred already?

6. Questions for Fox et al. (2000) response paper, due today • 1. Do you think that organized medicine’s historical (and current) opposition to prescription privileges for non-physicians like nurse practitioners, optometrists, and psychologists reflects (a) concerns about a public health hazard, (b) concerns about other professions encroaching on their turf, or (c) both? • 2. The American Psychological Association (APA) requires practicing clinical psychologists to pay an extra $137 per year in membership fees, which it calls a “Practice Assessment.” According to APA’s website, “this fee supports APA’s companion organization, the APA Practice Organization which is exclusively devoted to advancing the goals of the practitioner community.” A major goal of the APA Practice Organization is to advocate prescription privileges for psychologists, and much of the revenue raised by the $137 Practice Assessment supports this effort. What do you think of APA’s policy of charging all practicing clinical psychologists this extra $137 fee? • 3. To what extent will the ability of clinical psychologists to prescribe medication, provided that they have completed an approved training course, result in “expanded patient access to expert mental health services” (p. 267)?

7. Prescription Privileges for Psychologists: Will Deficits in Education and Knowledge Lead to a New Health Hazard? William Robiner, Ph.D. University of Minnesota Medical School

8. Historical Highlights • APA (1992) established an ad hoc Task Force on Psychopharmacologyto explore the desirability and feasibility of psychopharmacology prescription privileges for psychologists • The Task Force concluded that greater understanding of psychopharmacology would enhance the care that psychologists provide (Smyer et al., 1993)

9. Proposed Levels of Training • The APA Task Force proposed three levels of preparation in psychopharmacology: • Level 1- Basic Psychopharmacology Education • Level 2- Collaborative Practice • Level 3- Prescription Privileges • Whereas the Task Force considered that all psychologists providing mental health services should be prepared at Level 1, it did not take that position for training at Level 3

10. Legal Status of Prescribing • Most states and provinces do not allow prescribing • Supervised prescribing by “qualified” psychologists has been passed in Guam, New Mexico, and Louisiana, but several details have yet to be worked out

11. Does New Mexico Lead the Way? • Can you name 2 things that are legal in New Mexico, but not most places? • Cock fighting • Psychologist prescribing

12. Why Do Psychologists Want Prescription Privileges? • Money • Autonomy in clinical practice • Job security • Another marketable skill • Parity with other professions • Giveaways and meals from drug company salepersons

13. Why do Professional Organizations Want Prescription Privileges for Psychologists? • Hopefully increase revenues for practitioners. • Increase advertising and conference revenues. • Expand job options. • Wish for increased status within healthcare system and society.

14. Why Do Pharmaceutical Companies Want Prescription Privileges for Psychologists? • Increase revenues via increased sales of medications through more prescribers

15. What Factors Oppose Prescription Privileges for Psychologists? • Concerns about psychologists’ competence and training. • Concerns about the quality of patient care prescribing psychologists would likely deliver. • Note the absence of any financial incentives within psychology for opposing prescription privileges.

16. Who Wants Psychologists to Prescribe? • The prescription movement is notdriven be consumers, physicians, or other mental health providers • It originated with practitioners rather than academicians or scientists • Psychology training directors are equivocal about it (Evans & Murphy, 1997) • Relatively few academic psychologists are interested in developing training programs for it (Hanson et al., 1999) • Raising questions about the feasibility of developing high quality psychopharmacology training programs in settings with limited experience in educating and training psychologists

17. Prescription Privileges are Controversial Among Psychologists • Estimates vary about the percentage of psychologists favoring it (Gutierrez & Silk, 1998,Bush, 2002) • Frederick/Schneiders, Inc. (1990), the largest survey of APA members, found: • 30% strongly supported it and 38% favored it •  The rest are opposed or unsure. • A meta-analysis of 17 surveys revealed a lack of consensus (Walters, 2001)

18. Professional Groups Oppose Prescription Privileges • Society for a Science of Clinical Psychology • American Association of Applied and Preventive Psychology (AAAPP) • Committee Against Medicalizing Psychology (CAMP)

19. Support Is Not Unanimous 43% of psychologists responding to an APA survey indicted that “full medical training would be required” for prescription privileges(APA, 1992) • Nevertheless, the APA training model is shorter, as well as substantively and procedurally inferior to medical school

20. It Isn’t Just Up To Psychologists • Whatever sentiments surveys of psychologists reveal, it is less appropriate to decide this issue on the basis of its popularity among psychologists than on the quality of pharmacologic care that psychologists would provide(Bieliauskas, 1992b) • It concerns a range of potential stakeholders: • consumers, educators and practitioners in other health disciplines experienced in prescribing, and regulatory and governmental authorities, such as the Food and Drug Administration

21. Educational Prerequisites • The Task Force stated “retraining of practicing psychologists for prescription privileges would need to carefully consider selection criteria, focusing on those psychologists with the necessary science background”(APA, 1992) • This included undergraduate coursework in biology, chemistry, and other areas typifying the pre-medical curriculum • Butno physical or biological science prerequisites exist. • Some advocates of prescribing question the necessity of scientific background for prescribing(Hanson et al., 1999)

22. Other Prescribers’ Training Is much closer to that of physicians than to psychologists’, and their clinical practice is more focused on physical functioning, including medication effects

23. Undergraduate Differences* Between Psychologists and Psychiatrists

24. Psychologists’ and Psychiatrists’Pre-Med Courses

25. How Hard Is It To Prescribe? Former APA President, Patrick DeLeon, contends that: "...prescription privileges is no big deal. It's like learning how to use a desk-top computer"(Roan, 1993)

26. But Is It…….Really? Meet Noah Robiner • Hobby: Plays with laptop computer • Age: Six years

27. Or Is Safe Prescribing More Involved? • Would you have confidence in a prescription from my kindergartener? • Do psychologists want to “play” at being medical doctors too?

28. Differences* Between Psychologists’ and Psychiatrists’ Scientific Coursework

29. Graduate Education in Psychology • Comprises “vastly differing models of study and practice” with “no effort to standardize the training of psychologists”(Klein, 1996). • Some psychology degrees (e.g., school psychology) have relatively limited exposure to psychopathology and psychological treatments, let alone the physical sciences (DeMers, 1994; Moyer, 1995)or medical environments.

30. Where’s the Biology in Psychology Graduate Education? • Psychology doctorates require merely 3 graduate semester hours in the biological bases of behavior • which can cover a range of topics, such as physiological psychology, comparative psychology, neuropsychology, sensation and perception, or psychopharmacology • These courses’ relevance to and preparation for prescribing can be negligible.

31. The Trend for Less Science in Psychologists’ Training • According to the Director of the APA Education Directorate, the training of psychologists is moving away from the “scientist-practitioner” model, to other models that de-emphasize scientific background and activities(Belar, 1998) • By 1997, nearly 2/3s of clinical psychology degrees were conferred by professional schools, rather than university-based academic programs (Reich, 1999) which typically require more rigorous scientific training than professional schools

32. What is Happening • In 1995 the APA Council of Representatives’ passed a resolution making the pursuit of prescription privilege an official objective for the organization • APA devotes greatest attention to the most controversial option, Level 3, promoting prescription privileges through a hybrid of continuing education and a modular executive training in psychopharmacology for doctoral-level psychologists

33. Training Is Limited • Several training programs have developed, including some that emphasize distance-learning • 300 hours • 100 supervised patients • The available training is notclose to medical or psychiatric training, and is less comprehensive than nurse practitioner training

34. APA Training Model Does Not Specify Minimal Criteria For: • the breadthof patients’ mental health conditions • the duration of treatment (i.e., to allow for adequate monitoring and feedback) or requirements for outpatient or inpatient experiences, or length of training • exposure to adverse medication effects • exposure to patients with comorbid medical conditions and complex drug regimens • qualifications for supervisors

35. Training Without Accreditation • Unlike training for other prescribers, no accreditation mechanisms to evaluate psychopharmacology programs or supervised clinical experiences exist. • The psychopharmacology training programs do not meet the APA's (1996c) own criteria for accreditation of postdoctoral programs or internships.

36. What Isn’t Happening • The Task Force’s Level-2Collaborative Practice, envisioned to enhance patient care via collaborations with prescribers by expanding their expertise about medication management has not been pursued • Even though more psychology graduate students believe that Level 2 (77%) training should be offered in their programs than Level 3 (57%) (Tatman, Peters, Greene, & Bongar, 1997), and • Even though there is a good literature about the benefits of collaborations between psychologists and prescribers, such as primary care physicians

37. Argument #1 About Prescription Privileges for Psychologists It’s not a big deal: Psychologists have done it for years without problems (VA, Reservations, military) • How well and how long has it been studied in demonstration projects? • The DoD studied only 10 psychologists. • What controls were in place which might have prevented problems in these projects? • They were in supervised, military hospitals with a long history of teaching health professionals • How would the care psychologists be different on broader scale, without supervision, outside of medical settings?

38. Department of Defense (DoD) Psychopharmacology Demonstration Project (PDP) • Initial psychologist participants undertook preparation in chemistry and biochemistry beforecompleting a majority of 1st year medical school courses • During their first full-time year at the Uniformed Services University of the Health Sciences, they worked with the Psychiatry-Liaison service and assumed night call with 2nd year psychiatry residents • In the second full-time year, they completed core basic science courses and continued psychopharmacology training and clinical work • After 2-day written and oral examinations, they had a third year of supervised clinical work at Walter Reed Army Medical Center or Malcolm Grow Medical Center

39. Then DoD Training Was Reduced • Over time, the PDP curriculum was abbreviated, streamlining training to one year of coursework and a year of supervised clinical practice • For example, the didactic hours decreased by 48% in the second iteration • Most PDP graduates functioned as prescribing psychologists in branches of the military • At least one graduate went on to medical school

40. A Few Words About the DoD The PDP was discontinued after the first few years. • Proponents want you to believe: • the successes of DoD participants justify extending prescriptive authority to psychologists who undergo training consistent with the APA (1996a) model… • Even though the APA training model and the likely resources available for the training are less substantial than the PDP.

41. What Else You Need to Know About the DoD • The Final Report of the American College of Neuropsychopharmacology (1998) on the PDP assessed graduates as weaker medically and psychiatrically than psychiatrists • Limitations are likely to be most evident in treating medically complex patients (Kennedy, 1998) • Graduates only saw a limited range of patients • aged 18-65, generally with limited medical problems • Some graduates had limited formularies • Some graduates continued to have dependent prescriptive practice (i.e., supervised by a physician)

42. What Else You Need to Know About the DoD • DoD graduates advise against "short-cut" programs and consider that a year of intensive full-time clinical experience, including inpatient care, was essential • This is more comprehensive than psychopharmacology training currently recommended by APA or available • Some of the DOD psychiatrists, physicians, and graduates doubt the safety and effectiveness of psychologists prescribing independently outside of the interdisciplinary team of the military context • This concern has been echoed in a survey of military psychiatrists, non-psychiatric physicians, and social workers (Klusman, 1998)

43. Questions About the DoD • Do the relatively limited base rates of problems and tiny sample obscure genuine problems and suffer from Type II statistical problems (i.e., have inadequate statistical power to detect differences or problems)? • Can we generalize from 10 trained in military hospitals to 1,000s of psychologists across the spectrum of clinical or counseling settings with diverse and less healthy populations? • If training is less rigorous, with less access to medical populations, would the DoD outcomes overestimate outcomes of how other psychologists would perform?

44. Argument #2 About Prescription Privileges for Psychologists Most psychoactive medications are prescribed by physicians or others with less training in assessment or therapy than psychologists. • All other prescribing health professionals have relevant training in basic sciences: biology, chemistry, biochemistry • Psychologists do not • One study estimated that only 7% of psychology graduate students have the relevant scientific backgrounds

45. Lack of Undergraduate and Graduate Preparation Only 27% of graduate students thought they had the undergraduate preparation to undertake preparation to prescribe (Tatman et al, 1997) • Completed recommended biology & 7% • chemistry units (Fox et al., 1992) • > 4 units of undergraduate biology 48% • > 4 units of undergraduate chemistry 20% • Graduate course in psychopharmacology 25%

46. Argument #2 (continued) • All other prescribing professionals have years of training and experience in dealing with a wide range of side effects, adverse or toxic effects, drug interactions, and impact on other systems • Psychologists do not • Psychologists’ clinical skills provide fruitful opportunities for collaboration with prescribing health professionals but their lack of an educational foundation contraindicates prescribing themselves

47. Argument #3 About Prescription Privileges for Psychologists There are misuses and abuses in medication prescriptions by physicians • Such medication problems would not be remedied by giving psychologists prescription privileges • Psychologists would probably make similar errors, plus others due to their more limited training and experience with medications and physiological phenomena

48. Knowledge Base and Clinical Proficiencies Required for Prescribing1 • Psychopathology and Psychological Issues.2 • Medical Status Prior to Prescribing. • Response to Treatments. 1From Robiner et al. (2002). 2 The education and training of psychologists typically addresses this area only.

49. What Psychologists Know Psychopathology and Psychological Issues • Primary psychiatric conditions • Comorbid psychiatric conditions • Prevalence and course of psychiatric conditions • Knowledge of non-pharmacologic treatment options

50. What Psychologists Don’t Know Medical Status Prior to Prescribing • Comorbid medical conditions • Contraindications • Long-term effects of medication • Medical effects of concurrent treatments • drug interactions • other treatments • (e.g., dialysis, plasmaphoresis) • History of medication use