Prescription Privileges for Psychologists: The Foundation for an Expanded Vision
by Pat DeLeon, former APA President – Division 12
Federal Involvement: On November 30, 1984, at the Hawaii Psychological Association (HPA) annual convention, U.S. Senator Daniel K. Inouye urged the membership to amend their state practice act to allow them to independently utilize drugs where appropriate so that their “clients will be well-served.” After the Senator’s challenge, the HPA Executive Committee agreed to pursue legislation which would study the feasibility of obtaining this clinical responsibility. At that time there was little enthusiasm for the proposal within the psychological community and extreme opposition within the psychiatric community. During the 1989 legislative session, hearings were held on eight separate bills. A House Resolution was enacted “Requesting the Center for Alternative Dispute Resolution to convene a series of roundtable discussions.” Thus, Hawaii became the first state in the nation in which the issue of psychologists prescribing (RxP) was seriously debated. Interestingly, their RxP legislation was ultimately vetoed on July 10, 2007 – more than two decades after the Senator’s address. In the 2015 legislative session, renewed HPA and grassroots interest resulted in their RxP bill passing the House of Representatives on March 10, 2015, by a vote of 23 yes, 13 yes with reservations, and 15 no.
During Congressional deliberations on the Fiscal Year 1989 Appropriations bill for the Department of Defense (DoD) [P.L. 100-463], Senator Inouye included language which directed the Department to establish a “demonstration pilot training project under which military psychologists may be trained and authorized to issue appropriate psychotropic medications under certain circumstances.” Organized psychiatry raised considerable objections. The following year the conferees stated: “the Department cannot ignore direction from Congress and therefore should develop such a training program….” A DoD Blue Ribbon Panel was established, with Russ Newman representing APA, and recommended a two year fellowship, combing didactic and practicum activity. To begin on time, two psychologists were initially assigned to the Army Physician Assistant program at Ft. Sam Houston Texas.
The Walter Reed/Uniformed Services University of the Health Sciences training program (PDP) began in the summer of 1991, and was closely monitored by the American College of Neuropsychopharmacology (ACNP). ACNP concluded: “All 10 graduates of the PDP filled critical needs, and they performed with excellence wherever they were placed.” On June 17, 1994, Navy Commander John Sexton and Lt. Commander Morgan Sammons became the first graduates. RxP training has continued in various venues, particularly in the private sector. DoD and USPHS credentialing policies have been issued. The seminal contribution of the DoD initiative is to affirmatively demonstrate that psychologists could be trained to safely prescribe in a cost-effective manner. Interestingly, individual psychologists had been prescribing within the VA and Indian Health Service (Floyd Jennings) during this time period; however, without any formal organized training.
APA Governance: In 1989, under the leadership of Norma Simon, the APA Board of Professional Affairs (BPA) held a special meeting to explore this intriguing phenomenon. BPA recommended: “focused attention on the responsibility of preparing the profession to address… needs of the public for psychologically managed psychopharmacological interventions be made APA’s highest priority.” In August 1990, the Council of Representatives established an ad hoc Task Force on Psychopharmacology, chaired by Michael Smyer. Its report concluded that practitioners, with combined training in psychopharmacology and psychosocial treatments, “could be viewed as a new form of health care professional, expected to bring to health care delivery the best of both psychological and pharmacological knowledge. Further, the proposed new providers had the potential to dramatically improve patient care and make important new advances in treatment.” In August 1995, Council formally endorsed RxP for appropriately trained psychologists as APA policy and called for the development of model legislation and a model curriculum. Subsequent Councils adopted these (1996); called for a national examination (1997); and formal APA recognition of Designated Postdoctoral RxP Training programs (2009). APAGS adopted its Resolution of Support in 1997. Bob McGrath estimates today there are more than 1750 psychologists who have completed their post-doctoral psychopharmacology training.
State Legislation: In March 1993, Indiana and in December 1998, Guam passed psychology RxP authorization legislation, although neither has been implemented to date. In March 2002, New Mexico and in May 2004, Louisiana passed RxP legislation with John Bolter signing the first civilian script on January 20, 2005. Elaine LeVine was the first female civilian prescriber. More than a decade later, Illinois enacted its RxP legislation which was signed into law on June 25, 2014. What is unique to Illinois is the decision to legislatively address the specifics of the required training (including at the undergraduate level) and its openness to incorporating RxP training at the graduate level. Previous policy discussions had focused exclusively upon post-doctoral training.
Future Challenges: Although military and USPHS prescribing psychologists have provided quality psychopharmacotherapy services for more than two decades, there has been continued resistance within the VA and the federal Bureau of Prisons. Ron Fox, former APA President: “As of December 31, 2013 when I was chair of the APA Insurance Trust, I can attest to the fact that prescribing psychologists do NOT have to pay higher premiums for professional liability insurance as the Trust deemed an increase unnecessary; and, because the Trust policy provides insurance to cover expenses related to licensing board complaints, I know that there have been no complaints or actions taken by state licensing boards regarding prescribing abuses by appropriately trained psychologists.” Along with enacting additional state practice laws, future challenges will include expanding to Federally Qualified Community Health Centers, state and local mental health clinics, and the evolving Accountable Care Organizations and Patient-Centered Medical Homes envisioned under President Obama’s Patient Protection and Affordable Care Act. Aloha,
Pat DeLeon, former APA President – Division 12 – April, 2015