Arguments in Favor of Granting Prescription Privileges to Psychologists
One of the primary arguments set forth for allowing qualified psychologists3 to prescribe psychotropic medications is that it would improve both the access to and quality of comprehensive mental and behavioral healthcare.4 Allowing psychologists to prescribe medications for persons suffering from mental and/or behavioral health disorders would help improve access to much-needed psychotropic medications, especially in underserved or rural areas, where psychiatrists are often few and far between or do not exist at all.5
In support of this argument, many arguing for prescription privileges assert that the current supply of qualified psychiatrists in the United States is insufficient to meet the needs of those who may require psychotropic medication. For example, in Idaho, the granting of prescription privileges for psychologists was partially credited to the shortage of psychiatrists, long waiting times, and high suicide rates.6 Prescription authority proponents argue that granting prescription privileges to qualified psychologists would address both the problems of a psychiatry workforce shortage and the lack of access to psychiatric care in underserved and rural regions.
Further, it is estimated that 75 percent of office visits that result in prescription of a psychotropic medication involved a non-psychiatric physician, mostly primary care physicians. Proponents of granting prescription privileges argue that psychologists’ education and clinical training better qualify them to diagnose and treat mental illness compared to primary care physicians.7 Their experience and training with mental illness and behavioral health disorders uniquely qualify them to better understand when medication is appropriate, and when it is not. Most primary care providers do not have that degree of specialized training in mental and behavioral health disorders.
Proponents also argue that prescribing psychologists may reduce healthcare costs, as patients would not need to seek treatment from multiple providers. Instead of receiving therapy from a psychologist and a prescription from a psychiatrist or primary care provider, patients would be able to receive both therapy and prescriptions from a single provider.8
Arguments Against Granting Prescription Privileges
Many opponents argue that psychologists do not have sufficient medical training to safely and properly prescribe psychotropic drugs. The issue of qualifications is often connected to the issue of safety for patients who are having psychotropic medications prescribed to them by psychologists.9 Many also question the efficacy of the APA Recommended Postdoctoral Training in Psychopharmacology for Prescription Privileges, which serves as the APA’s recommended model of postdoctoral education and training for psychologists to obtain prescriptive privileges, arguing that the model involves less than half the amount of medical training of any prescribing profession, including the 10 prescribing psychologists who were trained in the trial by the Department of Defense, which is discussed in more detail below.10
Another common argument against psychologists obtaining prescription privileges is that there is not an “underserved” need warranting such an expansion of a psychologist’s scope of practice in light of the number of psychiatrists and other professionals who are able to safely prescribe the necessary medications. Additionally, arguments supporting prescriptive privileges for psychologists that reference needs in rural areas are often rebutted by opponents stating that psychologists and psychiatrists tend to practice in similar, urban regions, and therefore granting prescriptive privileges to psychologists would not actually expand access to care in rural regions.11
Telehealth has often been viewed as a possible solution to healthcare access issues, and the advent of the COVID-19 crisis appeared to accelerate the adoption of the telehealth platform. However, the expansion of access to care has not been as drastic as predicted. Studies show that although the growth of telepsychiatry outpaced other forms of telemedicine, the growth has been modest. This stifled growth is thought to be due in part to the incongruity between reimbursement and insurance coverage for in-person care versus remote care; however, as parity in reimbursement for the types of care grows, utilization of telepsychiatry continues to be depressed, suggesting that other factors may be contributing to the lack of adoption.12 A series of TIME/Harris Poll national surveys conducted during early 2021 indicate that although telehealth use increased, only about five percent of respondents stated that they received mental healthcare for the first time during the COVID-19 crisis, suggesting that the mass adoption of telehealth did not expand access to mental healthcare to the extent many expected.13 Moreover, only a quarter of all Americans reported seeking mental health services during the pandemic, which is even lower than the 29 percent that indicated they had sought mental health care prior to the pandemic.14
Finally, the psychologists and organizations that oppose prescriptive authority for psychologists are concerned that the financial and logistical pressures that colleges and universities would face from this expansion will negatively impact psychology doctoral and post-doctoral programs, with the primary concern being a shift to a programmatic emphasis placed on using psychopharmacology as opposed to psychotherapy – essentially going the way of psychiatry, which has gone from a profession routed in psychotherapy and psychoanalysis to one that primarily prescribes medications.15
The Department of Defense Experiment
In 1991, the Department of Defense began a six-year trial program to train 10 psychologists to prescribe medication at assigned military bases to determine the feasibility of training military clinical psychologists to prescribe psychotropic drugs safely and effectively. The program was established in response to a conference report dated September 28, 1988, which directed the Department of Defense to establish a demonstration pilot training program in which military psychologists may be trained and authorized to issue psychotropic medications.16 The program was proven successful, demonstrating that psychologists can be taught to prescribe safely. During the time that the program was operational, it was independently evaluated by a third party four times for feasibility, financial costs, necessity, and outcome performance. In addition to establishing feasibility, this study also concluded that the cost of training psychologists to prescribe would be less than employing physicians to prescribe and that the “graduates’ quality of care was good.”17 However, the United States General Accounting Office (GAO) conducted an evaluation assessing the costs and need for the psychology prescribing program in 1997. Its findings indicated that the program costs for training psychologists to prescribe were excessively high. The GAO also concluded that at that time there was not a shortage of psychiatrists in the Military Health Services System that would require prescribing psychologists, thus rendering the substantial cost of the program unjustifiable.18 Although the number is small, some psychologists in the military continue to prescribe medications.19
States That Have Granted Prescription Privileges
In total, five states have enacted legislation authorizing psychologists to prescribe certain medications for the treatment of mental health disorders, provided specific requirements are met. In 2002 New Mexico led the way, becoming the first state to pass a law extending prescriptive authority to psychologists.20 Louisiana quickly followed suit and passed a similar bill granting prescriptive authority to psychologists.21 Illinois became the third state to grant such authority when it passed a more narrow law in 2014 granting prescriptive authority to psychologists, but with far more restrictions compared to the laws passed in New Mexico and Louisiana.22 Iowa and Idaho, in 2016 and 2017 respectively, each passed legislation granting prescriptive authority to psychologists, becoming the fourth and fifth states to do so.23
Although these five states have granted prescriptive authority to psychologists, such authority is only available if certain requirements are met. Many of the states appear to follow the APA policy on the Model Legislation for Prescriptive Authority and the Recommended Postdoctoral Training in Psychopharmacology for Prescription Privileges as the foundation for their legislation, but each state has imparted individual nuances and differences. In support of the efforts to obtain prescriptive authority for psychologists, the APA proposed the Model Legislation for Prescriptive Authority as an APA-approved template or model for states to use to assist in developing their own legislation. Some states, Illinois in particular, stray further from the APA Model Legislation for Prescriptive Authority and recommended postdoctoral training, and stand out as imposing far more restrictions on a psychologist’s ability to prescribe, a number of which are discussed in more detail below. Differences aside, one constant in the laws of each state is a requirement for some form of additional didactic training from an approved institution, with Idaho, Iowa, and Louisiana each requiring a post-doctoral master’s degree in some form of clinical pharmacology or psychopharmacology awarded by approved and accredited institutions.24 Notably, the didactic requirements in Illinois are more extensive, as Illinois requires at least 60 credit hours of advanced coursework, which is twice the amount required by Iowa.25
In terms of clinical experience requirements, the states diverge to a greater degree. For example, at one end of the spectrum, a licensed psychologist in Louisiana is eligible to prescribe, in collaboration with a licensed physician, following the completion of the didactic requirements and passing the Psychopharmacology Examination for Psychologists (PEP).26 New Mexico, positioned somewhere in the middle of the spectrum, requires an 80-hour practicum in clinical assessment and pathophysiology, as well as a 400 hour/100 patient practicum supervised by a physician.27 Illinois, situated at the opposite end of the spectrum, requires a full-time supervised 14-month clinical practicum, including a research project and clinical rotations in emergency medicine, family medicine, geriatrics, internal medicine, obstetrics and gynecology, pediatrics, psychiatrics, surgery, and one elective of the psychologist’s choice.28
Idaho, Iowa, and New Mexico each also require psychologists to first obtain a conditional or provisional prescription certificate and complete a period of supervised practice under a licensed physician before psychologists in their state are able to obtain a full prescription certificate and practice and prescribe independently.29 In lieu of the required supervised period, Louisiana offers a Certificate of Advanced Practice, which permits a psychologist to make changes to medication without consulting the primary care physician prior to such changes, provided the physician is regularly updated.30 Additionally, each of the states requires some form of collaboration with a physician, in most cases the patient’s primary care physician, with Illinois and Iowa requiring formal agreements setting forth the collaborative relationship.31
Even with the relevant certificates and licenses, the authority of a psychologist to prescribe in these states is not plenary. The states impose clearly defined boundaries and generally only permit psychologists to prescribe drugs recognized in or customarily used in the treatment and management of mental health diseases or illnesses, and in states like Illinois, Iowa, and Louisiana, psychologists are not permitted to prescribe certain types of medication narcotics at all.32 Some states also restrict a psychologist’s ability to prescribe medications to or impose additional requirements that need to be met in order to prescribe medications to special populations. In Idaho, for example, a psychologist who seeks to prescribe to pediatric or geriatric patients must also have completed at least one year of satisfactory prescribing to such patient population as attested to by a supervising physician with specialized training and experience in treating such populations.33 In Illinois, psychologists with prescriptive authority may not prescribe to patients who are less than 17 years of age or over 65 years of age, to patients during pregnancy, or to patients with serious medical conditions (which under the statute include inter alia heart disease, cancer, stroke or seizures), or developmental or intellectual disabilities.34
As the movement to grant prescriptive authority to psychologists continues, more states will consider legislation affording such rights. Indeed, bills granting prescriptive authority to psychologists have previously been introduced in many other states, including Florida, New Jersey, Oregon, and Texas. Although none of these bills were passed and enacted into law, the introduction of the legislation alone highlights the fact that prescriptive authority for psychologists is an ongoing discussion that merits attention and consideration. Other states can and likely will look to the original five states to learn from their experiences with this expanded scope of practice for psychologists as part of their deliberation as to whether such an expansion is appropriate for their state.
Psychology’s drive to obtain prescription privileges has persisted for nearly 50 years. Although psychologists do have prescription privileges in five states, and bills have been introduced in at least four others to allow psychologists to prescribe psychotropic medications, the debate rages on with fierce opposition from physician groups and even some psychologists. It remains to be seen how many more states may grant psychologists with prescribing authority. However, the recent focus on mental illness and access to adequate mental healthcare raised during the COVID-19 pandemic may result in more attention being given to this evolving area of the law.