American Journal of Law & Medicine

Fool's gold: psychologists using disingenuous reasoning to mislead legislatures into granting psychologists prescriptive authority.

I. INTRODUCTION

Mental illness is a serious problem in the United States. Based on "current epidemiological estimates, at least one in five people has a diagnosable mental disorder during the course of a year." (1) Fortunately, many of these disorders respond positively to psychotropic medications. While psychiatrists write some of the prescriptions for psychotropic medications, primary care physicians (2) write more of them. (3) State legislatures, seeking to expand patient access to pharmacological treatment, granted physician assistants and nurse practitioners prescriptive authority for psychotropic medications. (4) Over the past decade other groups have gained some form of prescriptive authority. (5) Currently, psychologists (6) comprise the primary group seeking prescriptive authority for psychotropic medications. (7)

The American Society for the Advancement of Pharmacotherapy ("ASAP"), (8) a division of the American Psychological Association ("APA"), (9) spearheads the drive for psychologists to gain prescriptive authority. The American Psychological Association offers five main reasons why legislatures should grant psychologists this privilege: 1) psychologists' education and clinical training better qualify them to diagnose and treat mental illness in comparison with primary care physicians; (10) 2) the Department of Defense Psychopharmacology Demonstration Project ("PDP") demonstrated non-physician psychologists can prescribe psychotropic medications safely; (11) 3) the recommended post-doctoral training requirements adequately prepare psychologists to prescribe safely psychotropic medications; (12) 4) this privilege will increase availability of mental healthcare services, especially in rural areas; (13) and 5) this privilege will result in an overall reduction in medical expenses, because patients will visit only one healthcare provider instead of two-one for psychotherapy and one for medication. (14) Conversely, some organizations challenge these contentions as unfounded and oppose granting psychologists prescriptive authority.

The American Psychiatric Association (the Association) (15) is the strongest opponent to granting psychologists prescriptive authority. The Association argues "safe and effective use of potent psychotropic medications requires extensive medical training and a thorough understanding of the brain and body." (16) Accordingly, psychologists lack the requisite education and training to safely prescribe such medication. (17) The Association contends "the needs of rural and other underserved patients can best be met through collaboration between psychiatrists and other medical professionals." (18) Along with the Association, the Committee Against Medicalizing Psychology opposes granting psychologists prescriptive authority because they believe this privilege would diminish the traditional benefits of talk-therapy. (19)

This Article challenges the psychologists' arguments, favoring legislative approval that grants them prescriptive authority. While the data show primary care physicians do lack expertise at treating mental illness, (20) psychologists are at an immensely greater deficit of assessing and treating non-mental health illnesses, even with additional post-doctorate training. (21) As for the PDP study, it did show successful training of non-physician psychologists, (22) however, it did so under controlled, military settings. (23) It is grossly inappropriate to argue this study "conclusively demonstrated psychologists' ability to prescribe safely and effectively," (24) especially in regard to non-military psychologists prescribing independently. (25)

The psychologists seeking prescriptive authority further contend their behavioral science education (26) ensures they can prescribe safely. (27) Yet, these psychologists complete fewer science courses and shorter clinical internships than nurses trained under the medical model, (28) and who possess no prescriptive authority. (29) The psychologists skew their arguments, avoiding discussion of the potentially catastrophic effects on patients suffering from missed or incorrect diagnoses, missed drug interactions, missed drug side-effects, incorrect test interpretations, or missed necessary test orders due to the psychologists' inferior medical background. (30)

The psychologists' contention that granting them prescriptive authority would significantly allay un-met mental health needs in rural areas is also highly questionable. (31) Less than one-seventh of very rural counties, and less than one-half of rural counties (32) have a practicing psychologist, compared to all of those counties having a family physician. (33) Moreover, the majority of mental health patients choose treatment from their family physician instead of from psychologists. (34) Due to the stigma attached to mental illness and the dynamics of close-knit rural societies, (35) there is no guarantee any significant number of rural inhabitants with a mental health disorder would even seek treatment from a psychologist.

In regard to the psychologists' argument that granting them prescriptive authority would reduce monetary costs associated with a patient seeing multiple providers, (36) the savings they boast do not take into consideration all of the economical expenses associated with granting this privilege. (37) They ignore the likely possibility that prescribing psychologists would significantly increase fees, though 75% of a sample of practicing psychologists "agreed or strongly agreed that RxP [prescription privilege] would lead to higher incomes for psychologists." (38) They assume malpractice premiums will not increase, yet 85% of a sample group of practicing psychologists believed that obtaining prescription privileges would increase malpractice rates. (39) Psychologists also overlook the additional fees associated with prescribing, such as the cost of out-of-office testing, (40) and they neglect the issue of how patients will deal with medications after treatment ends. (41) While there are savings in having a patient see only one mental healthcare provider, (42) there are many real and potential hidden costs not recognized or acknowledged by the psychologists seeking prescriptive authority. (43)

Granting psychologists prescriptive authority will also adversely affect the mental healthcare system by reducing the number of psychiatrists and non-prescribing psychologists in urban areas where they are most needed. (44) Prescription writing psychologists would be de facto psychiatrists. (45) Possessing only a fraction of the education and experience, these psychologists propose to offer the same services provided by psychiatrists, but for commensurately lower fees. (46) If existing geographic distributions for psychologists and psychiatrists remain stable, the data show the majority of prescription-writing psychologists will work in urban areas. (47) This places them in direct competition with psychiatrists, but offering cheaper pseudo-psychiatric treatment. With the current difficulty in retaining psychiatrists, this increased competition will further reduce the number of practicing psychiatrists. (48) The majority of prescription-writing psychologists will also compete directly with non-prescription-writing psychologists in urban areas. (49) Although charging higher fees than non-prescribing psychologists, managed care organizations certainly will fund prescribing psychologists over non-prescribing psychologists because they get de facto psychiatric services at cheaper rates. Thus, one very real consequence of granting psychologists prescriptive authority is a backlash reduction in much needed psychiatrists and non-prescription-writing psychologists. (50)

While the lack of available psychopharmaceutical treatment is a serious concern for all healthcare professionals, patient safety must remain paramount. Increased availability of harmful, substandard treatment is not the solution. The crux of the problem centers on what constitutes satisfactory education and training to grant prescriptive authority. The minimum standard for granting prescriptive authority needs to maximize the availability of psychotropic medication to rural and underserved populations while concurrently providing maximum protection to patients. The current minimum standard for psychopharmaceutical prescriptive authority, established by physician assistants and nurse practitioners, accomplishes this goal. (51) Lowering this standard to allow psychologists to prescribe poses too great a risk to patient safety. Several much more effective and practical alternatives exist for safely increasing access to psychopharmaceutical treatment for rural and under-served populations. (52) Ultimately, the potential harm to children, the elderly, and society in general, (53) by granting psychologists prescriptive authority under the current guidelines, (54) far outweighs the speculative benefits touted by psychologists seeking this privilege. (55) For the reasons and evidence stated in this Article, legislatures should not grant psychologists any prescription privileges without requiring a medical model-based education equivalent to physician assistants or nurse practitioners, including prerequisites and clinical internships. (56)

II. HEALTHCARE PROVIDERS WITH PSYCHOPHARMACEUTICAL PRIVILEGES

In the United States, physicians, including psychiatrists, possess virtual carte blanche prescriptive authority, (57) which includes authorization to write prescriptions for psychopharmaceuticals. (58) When addressing mental health issues, physician assistants and nurse practitioners also possess some prescriptive authority for psychopharmaceuticals. (59) All of these professions require strict licensing, with physicians facing the strictest licensing criteria with respect to required education and experience.

A. PHYSICIANS

Prior to applying for medical licensure in the United States, one must complete medical school. Medical schools throughout the United States share similar prerequisites and curricula for acceptance into medical school and for conferring a medical degree. (60) These schools desire a strong, broad science foundation in preparation for advanced medical science courses. (61) Typical prerequisite science courses include one year of college Biology, two years of college Chemistry, and one year of Physics, each with an accompanying lab. (62) Many schools also require one year of Calculus. (63) Because of the nature of the study of medicine, medical schools recommend that "students take their [prerequisite] course of study in the most demanding curricular environment possible." (64) Medical schools also require submission of Medical College Admission Test ("MCAT") scores. (65) Competition remains high on MCAT scores and grade-point-average for entering students. (66)

The first two years of the four-year medical school curriculum involve classroom study of basic medical science courses and physician-patient interaction. (67) The typical curriculum includes the study of pharmacology, neurology, and mental disorders. (68) Many medical programs now also require an additional course in behavioral and social science. (69) In the third and fourth years, students participate in clinical rotations, which include a required six unit rotation in psychiatry. (70) In addition to the unit and clinical requirements, medical students must pass a three-step national exam for graduation and medical licensure. (72)

Each state establishes its own regulations and licensing boards for physicians, (72) which serve a variety of medically related functions. (73) Establishing and verifying licensing requirements are primary functions. (74) These boards also enforce minimum requirements for medical education and clinical training, (75) and mandate specific topics of study for licensure. (76)

Psychiatrists are specialized medical doctors, and thus, must complete a four-year medical program of extensive clinical training (77) and a residency program. (78) At the completion of residency, a psychiatrist qualifies to take a board-certifying exam, (79) making psychiatrists the most extensively trained, mental health providers. (80)

B. PHYSICIAN ASSISTANTS (PA)

In the mid 1960s, the advent of the physician assistant ("PA") extended limited prescriptive authority to non-physicians. (81) Since that time, "forty-seven states have enacted laws or regulations that allow supervising physicians to delegate prescriptive authority to PAs." (82) As of 2001, "eighty-five percent of these states allow PAs to prescribe controlled medications." (83) Students applying to PA programs typically possess a college degree, have significant experience in the health field, (84) and have also completed the same foundational prerequisite science courses as those required for medical students. (85) Though the course length is shorter than a medical program, the curricula share similar features. (86) PA students typically receive more than 1,500 hours of education based on the medical model. (87) In addition to PA programs adhering to the same set of national accreditation standards, (88) PA licensure requires 100 hours of continuing education every two years and re-licensure every six years. (89) Advanced PA degrees in specialties are available, including psychiatry. (90) Despite completing almost 40% more education and training than that recommended by psychologists to write prescriptions, (91) no state allows PAs to prescribe independently of a physician.

C. NURSES WITH PRESCRIPTIVE AUTHORITY

Nurses complete approximately two-thirds of the prerequisite course load required for medical students. (92) Notwithstanding, the prerequisites serve the same preparatory function of building a foundation for future advanced nursing science courses. (93) The actual nursing program typically requires three years to complete and consists of courses similar to those taken in medical school. (94) Despite completing more education and training than that recommended for psychologists to write prescriptions, (95) no state permits nurses to prescribe medications without a minimum of a masters degree. (96) Currently there are 58,000 certified advanced practice nurses in the United States. (97) All of these nurses possess a masters degree and have completed a certification exam. (98) Nurse practitioners may choose an adult or family specialty in mental health. (99)

Over the past decade, legislatures across the country began granting these specially qualified nurses limited prescriptive authority. (100) All states require some form of collaboration or supervision with a physician and many place restrictions on the Schedules of medications these nurses may prescribe. (101) Some states only permit authority to prescribe non-controlled drugs, (102) while other states permit prescriptive authority for controlled drugs, but on limited basis. (103) The most restrictive state is Georgia, which does not permit independent prescriptive authority. (104) The least restrictive state is Arizona, permitting full prescriptive and dispensing privileges to nurses with advanced practice certification, but still requiring a consultative or referral relationship with a physician. (105) Only after completing three years of nursing school and obtaining a Master of Science in Nursing degree or Master of Nursing degree, (106) do states grant these specially trained nurses some level of prescriptive authority within the scope of their respective practice. (107)

The important theme among physicians, physician assistants, and nurse practitioners is their extensive education in foundational and advanced medical science courses, (108) and their daily practical experience working with patients prescribing myriad medications. (109) All three professions require years of experience in a medical environment, working with hundreds of patients, at a minimum, for licensure. (110) Such training exposes students daily to such important aspects of pharmaceutical treatment as: 1) diagnosis of mental and non-mental illnesses; 2) knowledge of necessary tests and ability to comprehend the results; 3) identification of appropriate medications to administer and dosages to prescribe; and 4) knowledge of possible drug interactions and side-effects of hundreds of medications, not limited to psychopharmaceuticals. (111) The education proposed for granting psychologists prescriptive authority lacks the medical instruction required to prescribe safely, especially independently, based on inferior prerequisites, inferior core requirements, and inferior practical experience. (112)

III. EDUCATIONAL REQUIREMENTS FOR PSYCHOLOGISTS

Most American universities offer a Bachelors of Arts ("BA") degree in Psychology that requires the equivalent of at least 120 semester hours for completion. (113) The awarding of this degree typically requires 12 semester hours of general education, non-behavioral, science courses. (114) Some universities, however, place few restrictions on which science courses will satisfy this unit requirement. (115) Students, for example, can complete the general education requirements by completing a single three unit, non-major biology course, (116) and completing the remaining nine required science units with non-medical science courses. (117) Additionally, BA Psychology degree programs typically require 36 to 40 psychology units for graduation, (118) but all units may consist of non-medical science courses. (119) There is no assured consistency in the non-behavioral science education acquired by students graduating with a BA degree in Psychology. (120)

Many American universities also offer a Bachelor of Science (BS) degree in Psychology that requires the equivalent of at least 120 semester hours for completion. (121) BS Psychology degree programs, when supplemented with a science minor, require approximately 27 science units for the BS degree and approximately 22 science units for the minor. (122) Universities often permit students, however, to "double count" these courses, thereby reducing the overall actual number of units completed. (123) Moreover, some of the science courses offered, just as with the BA degree in Psychology, have no connection with the medical field. (124) Students completing a BS degree in Psychology, with a science minor, may actually complete substantially fewer than the required 49 science units for graduation. Additionally, a student may complete the typical 36 psychology units required for graduation without taking any medical science courses. (125) As with the BA degree in Psychology, there is no assured consistency in the adequacy of the non-behavioral science education of students completing the BS degree in Psychology with a science minor; they can satisfy all requirements with non-medical courses. (126) Only under the most favorable circumstances do students graduating with a BS degree in Psychology begin to complete the prerequisite medical science education and training obtained by medical, physician assistant, and nursing students. (127)

Almost all graduate programs in psychology require General Graduate Records Exam scores with applications for admittance, (128) and almost all programs also require a Psychology Graduate Records Exam score. (129) Most psychology graduate programs offer a Master of Arts ("MA") degree that typically requires the equivalent of 30 semester hours for completion. (130) Many psychology graduate programs also offer a Master of Science ("MS") degree that typically requires the equivalent of 30 to 79 semester hours for completion. (131) MA and MS degrees in Psychology generally offer, but do not require, medical science courses for graduation. (132) These programs almost invariably require a master's thesis, project, or a comprehensive exam for completion of the degree. (133) Unlike the medical science-based professions, however, there is no uniformity among the required science courses for BA, MA, or MS degrees in Psychology. Additionally, some Doctor of Philosophy in Psychology ("PhD") degree programs do not require a masters degree for entrance. (134)

Clinical psychology doctorate programs also require relatively few medical science courses similar to those taken by physician, physician assistants, and nurse practitioners. (135) Clinical psychology PhD programs typically focus on research issues and developing counseling skills. (136) Many PhD in Psychology programs are now offered at professional schools, (137) and focus heavily on developing counseling skills that include diagnosis and treatment of mental disorders, which is not provided in traditional PhD degree programs. (138) Clinical psychology programs often provide courses on psychopharmacology, brain anatomy, and physiology, but clinical psychologists generally lack the foundational and advanced medical science education, and receive no practical training for treating non-mentally ill patients. (139) In contrast, all three of the other mental healthcare providers receive clinical training with both mentally ill and non-mentally ill patients. (140)

All states require licensure for psychologists. (141) State Psychology Boards determine what activities a licensed psychologist may perform. (142) These Boards often offer certificate programs for specialty areas, (143) and typically require continuing education for re-licensing, (144) but at this time, State Boards lack the power to grant prescriptive authority.

IV. AVAILABILITY AND ACCESS TO HEALTH AND MENTAL HEALTH SERVICES PROVIDERS IN THE UNITED STATES

There exists a shortage of health and mental health providers in rural America that is of serious concern for all health professionals. …

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