Pharmacology and the Debate over Prescription Privileges

Abstract

Patient care and well-being should be the top priority of every healthcare worker. Within the realm of psychology, a growing area of concern is the number of potentially unmet mental health needs within the population of the United States, including, but not limited to, access to medication to address those needs. In response, an area of discussion has arisen within current healthcare literature; that of prescription privileges for clinical psychologists.

Prescription Privileges for Clinical Psychologists

With the ever-changing healthcare industry, government changes to healthcare coverage, and challenges with billing to insurance companies, one thing remains, the needs and welfare of the patient.

Those within the mental health field desire to give the best care possible to their patients despite rising healthcare costs and obstacles to care. A topic that falls within this discussion is the opportunity for prescription privileges (RxP) for clinical psychologists. This paper looks to examine the arguments for and against this idea by reviewing current and past literature.

Laying the Foundation

In 1990, the American Psychological Association Board of directors assembled an ad hoc task force on psychopharmacology. Their goal was to assess the need and or desire of the possibility for clinical psychologists to obtain prescription privileges for providing medication to patients. Assuming the existence of unmet healthcare needs as an underlying factor, the Task Force held to two main objectives; the first was to determine the criteria needed for a clinical psychologist in order to offer best practice care to their patients.

The second objective was to design and evaluate various models of training in order to achieve the goal of the first objective. The Task Force determined, after examination of the various fields of psychopharmacology, psychology, and medicine, a recommendation for the implementation of three levels of training in psychopharmacology, including access to prescription privilege for psychologists (Smyer, Balster, Egli, Johnson, Kilbey, Leith, & Puente, 1993).

A Need for More Training

One of the concerns regarding granting prescription privileges to a clinical psychologists is the lack of quality training in psychopharmacology provided at all levels of their educational training (Heiby, 2010; Lavoie & Barone, 2006). Within their examination, the 1990 Task Force on Psychopharmacology discovered an underlying need for not only more training for psychologists but better training in relation to this field. Recognizing that the current pathways to clinical psychology included little and varied levels of training in pharmacology, they cited the science-practitioner-based foundation of current psychology as a reason to increase the number of training programs (Smyther et al., 1993).

Currently, practitioners in Guam, New Mexico, and Louisiana hold prescription privileges (Thomkins & Johnson, 2016). In order to acquire those privileges, a psychologist residing in one of these areas must hold current licensure with the state as a clinical psychologist before beginning an extensive level of post-doctoral training.

Training includes a minimum of 450 hours in five primary areas: neuroscience, research, and clinical pharmacology, as well as psychopharmacology, physiology and pathophysiology, lab and physical assessment, and finally, clinical pharmacotherapeutics. Also to be completed is an 80-hour, board-approved, supervised practicum in pathophysiology and clinical assessment, as well as a 400-hour practicum that is to include the treatment of at least 100 patients with diagnosed mental disorders. Upon completion of said requirements, certification is contingent upon the passing of a national certification exam granting, thereby granting them two years of licensure to prescribe medications under the supervision of a physician. At the end of 2 years, they may apply to prescribe prescriptions independently (Williams-Nickerson, as cited in Lavoie & Barone, 2006).

While training is addressed in the aforementioned context, the argument has been made to make it available at all levels of study in alignment with the recommendations from the 1990 Task Force. Julien (2011), a physician/psychopharmacologist, argues for the need for more training in the realm of psychopharmacology for clinical psychologists, regardless of the desire for prescription privileges.
Citing the limited knowledge many psychologists possess in regard to the effects of psychoactive medication on patients, he describes the negative implications related to this missing information. Namely, the effect these medications have on the cognitive and daily functioning of patients, which could potentially interrupt and hinder their progress in psychotherapy.

Contending for a team approach, Julien recommends that an increase in training for psychologists would allow them to not only practice at a higher capacity in patient care but it would also allow for greater involvement in case management. By collaborating with the prescribing doctor, a well-trained psychologist in psychopharmacology could easily monitor the side effects of medications and more effectively manage the treatment and care of their patient. Consideration of the fact that a large majority of prescriptions for psychoactive medications are written by non-psychiatric doctors, training clinical psychologists in this field would allow for a more collaborative effort covering all areas of care rather than managing one aspect, the biological (Julien, 2011).

Regardless of whether the argument is in support of or opposition to the obtainment of prescription privileges for clinical psychologists, a key factor supported by current literature is the need for more training.

Arguments for Prescription Privileges

Arguments in favor of granting prescription privileges cite unmet mental healthcare needs as one of the main reasons in support of permitting privileges (Ax, Bigelow, Harowski, Meredith, Nussbaum, & Taylor, 2008; Julien, 2011; Lavoie & Barone, 2006; Smyther et al., 1993). Approaching healthcare in a more holistic manner is argued for within the literature as a reason for the granting of prescriptive licensure.

Allowing for the full treatment of the mind and body by incorporating psychotherapy with medication by a licensed clinical psychologist in order to meet the needs of the patients potentially removes wait time to see a specialist and or psychiatrist (Heiby, DeLeon, & Anderson, 2004).

Other research in favor of this argument suggests that by allowing concessions to clinical psychologists, care costs for patients may actually be less than if they were to see a psychiatrist, though there is some deliberation to the full accuracy of this assessment (Heiby, 2002).
Research, as previously mentioned, cites the increase in non-psychiatric physicians and nurses prescribing psychotropic medications; the argument in support of prescription privileges asserts an increase in the level of care if clinical psychologists were allowed this function.

While physicians have the ability to prescribe these medications, the capacity to counsel and treat a patient psychologically is not available through them, particularly when the average doctor spends 20 minutes or less with a patient (Ball, Kratochwill, Johnston, & Fruehling, 2009); this, in turn, leads to adding additional care providers for the patient (Gutierrez & Silk, 1998; Heiby, 2002).

Also noted is the understanding that while medications have their role, a psychologist with these privileges would provide these services to a smaller number of patients (McGrath, Wiggins, Sammons, Levant, Brown, & Stock, 2004), opting first to treat with psychotherapy as research continues to show its efficacy in treatment for particular disorders, for example, generalized anxiety disorder (Tonks, 2003 as cited in McGrath et al., 2004). Although the current literature provides significant arguments in favor of providing privileges to clinical psychologists, namely, care of the patient as a top priority, urgings against it exist.

Arguments Against Prescription Privileges

While numerous support an argument exists for prescription privileges, there is as much existing in opposition. Lack of appropriate training is cited most frequently in resistance toward moving forward in prescriptive care by clinical psychologists.
Heiby et al. (2004) argue that currently, those who do hold licensure for prescriptions have received less than half the amount of training of typical medical prescribers. Others point out the lack of training within the undergraduate process in biology, physiology, and chemistry as a hindrance for clinical psychologists, as the required training to receive licensure hinges on this type of coursework. Also noted is the idea that, too, is fully prepared for this field; a full medical training background is necessary (Ball et al., 2009).

Refuting the argument against a physician’s ability to manage care for patients receiving psychotropic drugs, opponents of prescription privilege report greater collaboration with healthcare teams, particularly psychologists, in regard to case management. Coinciding with this argument are concerns about the lack of training to recognize serious physiological symptoms in patients under the sole care of a clinical psychologist, as certain side effects of the medication may mimic mental disorders (Ball et al., 2009).

Finally, while proponents of prescription privileges cite the unmet mental health needs of individuals, a counterargument has been presented. Those resistant to offering licensure point out that often those whose needs are unmet are individuals who are frequently not able to afford care. Those raising this argument also point to the fact of limited funding made available to public mental healthcare centers. This limited availability of funding could, in turn, affect the ability of clinical psychologists desiring privileges to attend and receive the necessary training needed to obtain licensure (Ball et al., 2009). Current literature raises seemingly valid concerns about prescription privileges for clinical psychologists, leaving the discussion to continue until a resolution can be found.

Conclusion

The debate over prescription privileges is not new; it has been occurring for well over two decades (Smyther, 1993). Both sides present compelling cases defending their position, ironically using many of the same foundational objectives with different reasoning to support their position.

It appears that training is a crucial factor in this debate. Concerns due to lack of foundational training are persuasive. Perhaps a resolution could be found in the collaborative efforts of the American Psychological Association and the America Medical Association in the designing of a training program that, in turn, could adequately prepare an individual for prescription services in regard to psychotropic medications.
While arguments can be made in either direction over those best suited to prescribe medication for individuals with mental illnesses requiring more than psychotherapy, it is essential to recognize that medical doctors, psychiatrists, and clinical psychologists share a common goal; the health and well-being of their patients.

Recognizing the rising cost of healthcare and the limited funding available is a reality that may not be remedied quickly. With this in mind, the goal of both parties should be that of best practice for patient care. If best practice means granting prescription privileges to clinical psychologists to meet these needs, reduce wait times and better serve the patients, perhaps this is worth consideration.

References

1. Ax, R. K., Bigelow, B. J., Harowski, K., Meredith, J. M., Nussbaum, D., & Taylor, R. R. (2008). Prescriptive authority for psychologists and the public sector: Serving underserved health care consumers. Psychological Services, 5(2), 184–197. https://doi.org.ezproxy.sagu.edu/10.1037/1541-1559.5.2.184
2. Ball, C.R., Kratochwill, T.R., Johnston, H.F., & Fruehling, J.J. (2009). Limited prescription privileges for psychologists: Review and implications for the practice of psychology in the schools. Psychology in the Schools, 46(9), 836-845. doi:10.1002/pits.20424
3. Gutierrez, P. M., & Silk, K. R. (1998). Prescription privileges for psychologists: A review of the psychological literature. Professional Psychology: Research and Practice, 29(3), 213–222. https://doi.org.ezproxy.sagu.edu/10.1037/0735-7028.29.3.213
4. Heiby, E. M. (2002). Prescription privileges for psychologists: Can differing views be reconciled? Journal of Clinical Psychology, 58(6), 589–597. Retrieved from http://ezproxy.sagu.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=6976986&site=ehost-live&scope=site
5. Heiby, E. M. (2010). Concerns about substandard training for prescription privileges for psychologists. Journal of Clinical Psychology, 66(1), 104–111. https://doi.org.ezproxy.sagu.edu/10.1002/jclp.20650
6. Heiby, E. M., DeLeon, P. H., & Anderson, T. (2004). A debate on prescription privileges for psychologists. Professional Psychology: Research and Practice, 35(4), 336–344. https://doi.org.ezproxy.sagu.edu/10.1037/0735-7028.35.4.336
7. Julien, R. M. (2011). Psychopharmacology training in clinical psychology: A renewed call for action. Journal of Clinical Psychology, 67(4), 446–449. https://doi.org.ezproxy.sagu.edu/10.1002/jclp.20773
8. Lavoie, K.L., & Barone, S. (2006). Prescription privileges for psychologists: A comprehensive review and critical analysis of current issues and controversies. CNS Drugs, 20(1), 51-66.
9. McGrath, R. E., Wiggins, J. G., Sammons, M. T., Levant, R. F., Brown, A., & Stock, W. (2004). Professional issues in pharmacotherapy for psychologists. Professional Psychology: Research and Practice, 35(2), 158–163. https://doi.org.ezproxy.sagu.edu/10.1037/0735-7028.35.2.158
10. Smyer, M. A., Balster, R. L., Egli, D., Johnson, D. L., Kilbey, M. M., Leith, N. J., & Puente, A. E. (1993). Summary of the report of the Ad Hoc Task Force on Psychopharmacology of the American Psychological Association. Professional Psychology: Research and Practice, 24(4), 394–403. https://doi.org.ezproxy.sagu.edu/10.1037/0735-7028.24.4.394
11. Tompkins, T. L., & Johnson, J. D. (2016). What Oregon psychologists think and know about prescriptive authority: Divided views and data-driven change. Journal of Applied Biobehavioral Research, 21(3), 126–161. https://doi.org.ezproxy.sagu.edu/10.1111/jabr.12044

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