Psychologists Widen Push For Prescribing Privileges

The Connecticut bill was submitted by Rep. Walter Pawelkiewicz (D), the deputy majority leader of the state House of Representatives. Pawelkiewicz holds a Ph.D. in child and educational psychology from the University of Connecticut. The bill is in preliminary form and states that its intent is“ [t]o improve the availability of mental health services by permitting licensed psychologists to prescribe certain pharmaceutical agents within the scope of their practice.”

The bill was referred to the Public Health Committee, which can either draft formal legislation first and then hold hearings, or hold a public hearing on the subject matter of the proposed bill and then draft legislative language, said Jacquelyn Coleman, executive director of the Connecticut Psychiatric Society.

A similar bill was introduced in 2001, but died in committee after public hearings were held. This year the Public Health Committee must vote by April to decide whether the bill proceeds.

Bills before the Hawaii legislature differ from those in other states. They seek to offer prescribing authority only to psychologists practicing at federally qualified health centers or clinics located in designated medically underserved areas. Although this might appear to limit privileges geographically, large areas of Hawaii fall within these federal designations, said Johnson.

Psychologists working out of the U.S. Army's Tripler Medical Center now collaborate with primary care physicians in some of these areas.

Although advocates for the psychologists have pointed to the now-defunct Department of Defense psychologist-prescribing program as a model, the situation is much different at federal clinics in Hawaii, said Lydia Hemmings, executive director of the Hawaii Psychiatric Association. The Department of Defense patients were relatively young and healthy compared with the general population.

However, at the federally qualified health clinics in underserved rural Hawaii, patients are often poor and not in good general health, and may have comorbid substance abuse diagnoses, said Hemmings: “Psychologists would be testing their lack of adequate training on a vulnerable population, with few backup resources in these remote areas.”

Psychiatrists in Hawaii will urge that more funds be allocated to getting psychiatrists to rural areas (some now fly in one day a week to see patients), increasing the use of telemedicine, and organizing community liaison psychiatrists to work with primary care physicians in the federally qualified clinics, she said.

The chief sponsor and advocate of the senate version of the bill is Sen. Rosalind Baker (D-Maui), the powerful chair of the Health Committee, who previously supported prescribing privileges for nurse practitioners and optometrists. The Hawaii Psychological Association named her Legislator of the Year in 2003 for “outstanding contributions to psychology and mental health in the State of Hawaii.” The committee held hearings on the bill on February 18, voting 3-0 with two absences that the bill be adopted (with amendments) and sent to the Commerce, Consumer Protection, and Housing Committee. Baker is vice-chair of that body, which oversees occupational licensing.

The Oregon bill calls for 350 hours of psychopharmacology training, plus“ a supervised clinical practicum treating at least 100 patients with mental disorder.” The bill does not limit the conditions for which drugs may be prescribed, but would create the Council on Psychologist Formulary to establish which medications could be prescribed, “including controlled substances listed in [federal] schedules II, III, IIIN, IV, and V.”

The formulary council would include one member of the State Board of Psychologist Examiners, one other psychologist appointed by the board, two pharmacists, one physician, and two members of the public.

“There is no probationary or supervised prescribing period mandated by the bill, and all rule-making authority rests with the Board of Psychologist Examiners,” said Johnson.

At a hearing in mid-February, psychologists argued that passage would improve access to mental health care, especially in rural areas, and reduce waiting times to see a mental health professional. Members of the Oregon Psychiatric Association (OPA) opposed the bill as a threat to patient safety and no cure for questions of access.

“We explained how dealing with adverse drug effects requires medical skills and judgment and how physicians' training prepares them for that, but psychologists' study of social sciences does not,” said J. Teresa Shelby, M.D.,the legislative representative for the OPA. “As for access, in Oregon the problem is not lack of psychiatrists but rather one of economics, poverty, the uninsured, and cuts in the state health plan leaving thousands without coverage.”

The committee took no vote on the bill, but the chair suggested that proponents consider changing the composition of the formulary council. Thus, the bill is still alive and could come back at any time during the current legislative session, which runs until July.

Legislation introduced in Tennessee follows a familiar pattern. The bill calls for 450 hours of classroom training and a one-year preceptorship covering at least 100 outpatients under the supervision of a physician. The psychology board would have sole control over who may become a prescribing psychologist.

Prescribing psychologists could not treat patients who do not have an established relationship with a primary care physician. For the first two years after being allowed to prescribe, psychologists could do so only under a formal, written, “collaborative practice agreement” with a physician.

Rules, regulations, and a formulary would be set out by a group composed of members of “current health-related boards of healing arts,” including psychology, pharmacy, nursing, optometry, and medicine. However, the law does not specify the presence of a physician on this group, said Johnson.

“These bills have come up several years in a row,” said Nashville's Gregory Kyser, M.D., chair of the Tennessee Psychiatric Association's legislative committee. “Last year it was defeated in committee when no one would second the chairman's motion to bring it to the floor.” The psychologists' strategy this year has been to give an early push to the legislation, said Kyser.

“They've done a much better job between legislative sessions, holding regional dinners and contacting members of the health committee,” agreed Anne Carr, a lobbyist for the Tennessee psychiatrists. “We've been playing catch-up.”

Kyser said there is a difference between the psychologists' push for prescribing privileges and rights previously granted nurse practitioners in the state.

“Many nurse practitioners have graduated and gone to serve in rural areas, and their work is reviewed frequently by physicians,” he said.“ But they have basic medical training, as opposed to just learning how to prescribe psychotropic medications in a vacuum.”

The psychologist-prescribing bill in Wyoming never had a hearing and so did not leave the Committee on Labor, Health, and Social Services in the state senate.

“According to the rules, that means that the bill is dead for this session,” said APA's Johnson.

The bill delineated prescribing authority by directing that the state“ board of pharmacy, in collaboration with the board of psychology, shall develop a formulary of commonly used drugs for the treatment of mental and emotional disorders for use by psychologists with prescriptive authority.”

The bill's education section also called for licensed psychologists with doctorates to take 380 hours of “intensive didactic instruction” and complete one year's “supervised and relevant clinical experience” to qualify for prescribing authority.

The Wyoming Psychiatric Society, backed by the state's medical society, approached legislators by talking about not just the prescribing question but other issues, too, like changes in the involuntary commitment law and suicide-prevention coordination. ▪