Hawaii Psychiatrists Await Prescribing-Bill Veto Decision

APA urged Hawaii's governor to veto legislation narrowly approved on May 1 that would grant prescribing privileges to psychologists.

In a May 3 letter to Gov. Linda Lingle (R), APA President Pedro Ruiz, M.D., urged a veto of a bill (SB 1004) that cleared the state Senate by one vote and the House by seven votes.

“Psychotropic medicat ions used to treat mental illnesses are among the most powerful in modern medicine,” he wrote. “These medications have potentially disabling and deadly side effects if improperly prescribed and can cause convulsions, epilepsy, heart arrhythmia, blood disease, seizures, coma, stroke, and death.”

The AMA also wrote a letter to the governor asking her to veto the legislation.

The legislation calls for training for psychologists that would include a two-year postdoctoral program of at least 660 hours of classroom instruction. The bill also would require a one-year supervised practicum in which at least 100 patients would be treated under the supervision of a psychiatrist or other physician, who “accepts professional responsibility for the provision of psychopharmacotherapy and who is not in the employ of the person being directed or supervised.” Further, psychologists must maintain “an ongoing collaborative relationship” with a physician who oversees the patient's general medical care.

The governor has until July 10 to either sign or veto the bill, according to Russell Pang, the governor's chief of media relations, or it will take effect without her signature. The measure is undergoing “an extensive review process by all of the relevant departments,” and the governor continues to accept public comments regarding it, he said.

Physician groups, including the American Academy of Child and Adolescent Psychiatry, have urged their members to oppose the legislation because“ psychoactive medications for children and adolescents require the judgment of a physician, with training and qualifications in the use of these medications, and psychologists do not have the medical and clinical training to prescribe these medications safely.”

Although the governor has not issued public comments on the measure, objections raised by the Hawaii State Department of Health earlier this year suggest to psychiatrists that she is unlikely to sign it (Psychiatric News, April 6).

Similar legislation was approved by the Hawaii House, but a Senate committee chose instead to order a review of data concerning psychologist prescribing by the Hawaii Legislative Reference Bureau (LRB).

The LRB review concluded in January that if the legislature were to approve a psychologist-prescribing program, it should include a training model with classroom and clinical training requirements at least as rigorous as a Department of Defense (DoD) pilot psychologist prescriptive training program in the 1990s. The DoD program, the Psychopharmacology Demonstration Project, included at least one year of full-time classroom training at the Uniformed Services University of the Health Sciences and one year of full-time clinical training supervised by a psychiatrist. After privileges were granted, psychologists were supervised by a psychiatrist for two years.

Psychiatrist opponents of the Hawaii prescribing bill pointed out that in many areas the proposed training courses fall far short of the DoD program, which required a longer supervised practicum and supervision by psychiatrists only.

The Hawaii Psychiatric Medical Association (HPMA) strongly opposes the measure and argues that psychologists lack comprehensive medical training, accreditation standards, and clinical supervision. During the recent legislative session, APA again provided personnel, financial, and strategic support to Hawaii psychiatrists opposing the prescribing measures. District branch members also were active in lobbying against the proposal.

In his letter, Ruiz said that the training the bill requires for psychologists “in no way provides an adequate substitute for the extensive training required of licensed psychiatrists and other physicians.” He noted physician education entails more than 4,000 classroom hours of medical school and a one-year internship within a medical setting. Psychiatrists and other specialist physicians also must have at least four years of residency.

Ruiz emphasized the importance of medical training when prescribing medications such as antidepressants and stimulants. He cited the October 2004 Food and Drug Administration (FDA) decision to direct pharmaceutical companies to label all antidepressant medications distributed in the United States with a black-box warning that the medications “increase the risk of suicidal thinking and behavior (suicidality) in children and adolescents with major depressive disorder (MDD) or other psychiatric disorders.”

The FDA did not prohibit use of the medications in youth, but urged physicians and parents to monitor closely children and adolescent for a worsening in symptoms of depression or unusual changes in behavior (see“ Suicidality Warning to Be Extended to Young Adults”).

“Used properly, [psychotropic medications] can offer remarkable benefits to patients struggling with severe brain illnesses,” Ruiz wrote.

Ruiz's letter emphasized that serious mental illnesses involve abnormalities in brain chemistry—often with strong genetic components—that affect patients' capacity to think, to reason, to judge reality, and to control emotions and behavior. The psychologists' proposed training program would not leave them well-versed in this area.

Ruiz wrote that “efficient team-based care” depends on collaboration among physicians, nurses, and other limited-licensure providers, including psychologists. “However, problems arise when limited-licensure providers seek practice expansions, by legislation, that are not commensurate with their education and training.”

The prescribing bill is one of seven considered by states during their 2007 legislative sessions, although the other legislatures rejected their measures. In the last 10 years 22 states have considered and rejected similar proposals, according to APA.

Only two states—Louisiana and New Mexico—allow any psychologists to prescribe medications.

The legislative push for psychologist-prescribing privileges in Hawaii has been under way for more than 20 years, but this is the first measure to clear the legislature.