Psychologist Prescribing Law Stirs Controversy in N.M.

The minority opinion concluded that rather than basing the committee’s recommendations on a sound evidence base—including the DoD-PDP experience, the ACNP’s independent review of that program, and the experience of practicing psychopharmacologists, as well as existing nonphysician health care providers with prescriptive authority—the majority recommendations give “far too much weight to the guidelines promoted by the American Psychological Association.”

The majority recommendations call for psychopharmacology training programs that are based on a continuing education (CE) model—but only CE programs accredited by the American Psychological Association.

The minority opinion, however, points out that “psychologist training does not include sufficient education in medical subjects such as physiology, pathology, pharmacology, physical examination, or clinical and laboratory assessment; in other words, education for psychologist prescribing cannot be continuing education because there is nothing to continue from.”

The minority opinion also notes that by allowing CE-modeled programs, the majority recommendations make “no explicit requirement for face-to-face assessment during didactic programs.”

The minority recommendations favor a much more stringent model program, based upon the DoD-PDP, based in regionally accredited university settings where students study full time, in residence. The minority-favored program is nearly twice as long (712 hours in 12 core areas, compared with 450 hours in eight core areas), and involves much more intense clinical practicums.

Besides relying on the psychological association’s guidelines for curriculum development and content, the majority recommendations favor the Psychopharmacology Examination for Psychologists, developed by the psychological association, as the national certifying exam required by the law. In addition, the recommendations would allow the psychological association to designate the passing score for the exam and potentially change that score in the future without consultation with state regulators.

The minority calls for a nationally standardized exam developed by an independent, interdisciplinary team to include, in time, prescribing psychologists as the pool of certified practitioners grows.

The minority opinion would limit prescribing psychologists to treating only adult patients aged 18 to 65. The majority recommendations would allow candidates to prescribe to patients aged 14 to 65, and they could qualify to prescribe to patients under the age of 14 or over the age of 65 by prescribing to an additional 100 child and adolescent or geriatric patients during their practicum. This, the minority opinion concluded, “is unconscionable.”

In addition, the minority recommendations would significantly limit the formulary of medications available for prescribing by psychologists. Of particular note, no anticonvulsant mood stabilizers would be allowed to be prescribed. The minority noted that the law expressly prohibits psychologists from treating patients for nonpsychiatric medical disorders.

How, the minority ask, could a psychologist “prescribe valproate to a patient with bipolar disorder and partial complex seizures without violating [that clause of the law] or (intended or not) becoming involved in the treatment of primary somatic conditions?”

Lastly, but perhaps most importantly, the majority recommendations would seemingly allow a psychologist to prescribe a psychotropic medication to a patient against the advice of his or her medical doctor. The recommendations state “the primary health care practitioner and the prescribing psychologist do not need to agree about a particular treatment strategy.” If this occurs, the psychologist would be required only to document why he or she adopted a treatment strategy not agreed to by the primary care provider.

Noting that this would be “contrary to established medical practice, and dangerous,” the minority would give the medical provider’s judgment precedence over that of the prescribing psychologist.

The joint committee’s report has been forwarded to each of the full boards for consideration. The psychology board is designated to issue its full response first—it could adopt the majority recommendations or modify them with any of the minority opinions.

Following the psychology board’s action, the medical board will decide what it will do with the report. At some point the two boards must reconcile discrepancies and forward the recommendations to the governor and the legislature.

After a required public comment period, a rules hearing must be held.

At press time, both boards were expected to consider final approval of the recommendations sometime this month, with a rules hearing to occur in time to target formal implementation of the regulations soon after the first of the year.