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Concerns About Psychologist Prescribing William Robiner, Ph.D., A.B.P.P. Department of Medicine U NIVERSITY OF M INNESOTA M EDICAL S CHOOL ??????

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Presentation on theme: "Concerns About Psychologist Prescribing William Robiner, Ph.D., A.B.P.P. Department of Medicine U NIVERSITY OF M INNESOTA M EDICAL S CHOOL ??????"— Presentation transcript:

1 Concerns About Psychologist Prescribing William Robiner, Ph.D., A.B.P.P. Department of Medicine U NIVERSITY OF M INNESOTA M EDICAL S CHOOL ??????

2 Disclosure Information Concerns About Psychologist Prescribing William N. Robiner, Ph.D., A.B.P.P. I have the following financial relationships to disclose: Consultant for: HealthPartners Stockholder in Medtronic but no pharmaceutical companies Employee of: University of Minnesota I have never received any funding from the American Medical Association or American Psychiatric Association or any of their affiliates. I will not discuss of label use and/or investigational use in my presentation.

3 Prescription Privileges for Psychologists Are Controversial I dont think we need to be subliminable about the differences between our views on prescription drugs George Bush, Orlando, FL September 12, 2000

4 Prescription Privileges for Psychologists Are Controversial Many people, including psychologists, are not fully informed of the issues in the ongoing debate. Many psychologists are reluctant to speak up against the Prescription Privileges (RxP) movement or are indifferent to the issue.

5 Objectives Upon completion of the presentation, participants should be able to: 1.Summarize diverse concerns about psychologist prescribing 2.Identify relative limits of the APA Clinical Psychopharmacology Training model and the DoD PDP Program 3.Identify psychologists motives and rationales for pursuing prescription privileges 4.Decide their position about the controversy about prescription privileges for psychologists

6 What do Consumers Want of Their Psychopharmacologist? Our Psychopharmacologist is a genius

7 What Do Consumers Want Of Their Psychopharmacologist? A knowledgeable, well-trained professional who is as competent to manage their medications and understand their overall health status as well as all other prescribers

8 Why Do Psychologists Want Prescription Privileges? Money

9 Also, Psychologists Want Prescription Privileges for Autonomy in clinical practice Job security Another marketable skill Parity with other professions Giveaways and meals from drug company salespersons

10 Physician Wannabes …if we talk like psychiatrists, if we practice like psychiatrists, we will get our due The principal reward for becoming a junior psychiatrist must be financial- a chance to break into what appears to be a profitable market and grab a share of the action Hubble, M. A. & Miller, S. D. (2001). In pursuit of folly. Bulletin of the Academy of Clinical Psychology, 7, 2-6.

11 Why Do Pharmaceutical Companies Want Prescription Privileges for Psychologists? Increase revenues via increased sales of medications through more prescribers More than $24 billion worth of antidepressants and antipsychotic drugs were dispensed in 2008

12 Why Do Some Schools Want Prescription Privileges for Psychologists? Potential revenues from courses, workshops, and continuing education Hedge against potential future declines in enrollment in traditional professional psychology programs Develop potentially new marketable skills for graduates

13 Why Does the APA Want Prescription Privileges for Psychologists? Potential revenues from courses, workshops, and continuing education Develop potentially new marketable skills for psychologists Increased status and power of psychologists in the market and health care system

14 Why Does the APA Want Prescription Privileges for Psychologists? Potential revenues from advertising dollars for its journals from pharmaceutical companies

15 What Factors Engender Opposition to Prescription Privileges for Psychologists? Concerns about psychologists competence and training (i.e., the training model for RxP) Concern about adverse effects on the field – what would be lost? Concerns about the quality and safety of patient care prescribing psychologists would likely deliver

16 What Factors Lead Psychologists to Oppose Prescription Privileges for Psychologists? A personal sense of responsibility to speak truth to power

17 Note the absence of any financial incentives within psychology for opposing prescription privileges on the previous slides.

18 Who Wants Psychologists to Prescribe? The prescription movement is not driven be consumers, physicians, or other mental health providers »NAMI does not support it It originated with practitioners rather than academicians or scientists Psychology training directors are equivocal about it »62% are equivocal (Evans & Murphy, 1997) Relatively few academic psychologists are interested in developing training programs for it (Hanson et al., 1999) »Raising questions about the feasibility of developing high quality psychopharmacology training programs in settings with limited experience in educating and training psychologists

19 Prescription Privileges are Controversial Among Psychologists Estimates vary about the percentage of psychologists favoring it (Gutierrez & Silk, 1998, Bush, 2002) Frederick/Schneiders, Inc. (1990), the largest survey of APA members, found: 30% strongly supported it and 38% favored it The rest are opposed or unsure

20 Prescription Privileges are Divisive Among Psychologists A meta-analysis of 17 surveys revealed a lack of consensus (Walters, 2001) Opinion… is divided and polarized More psychologists than not believe that …organizations like APA should not be spearheading efforts to gain prescription privileges Psychologists are more supportive of prescription privileges in principle than they are of obtaining the training to prescribe medication Prescription privileges have the potential to confuse issues of training and identity for future … psychologists

21 Professional Organizations of Psychologists Oppose Prescription Privileges Society for a Science of Clinical Psychology (Section 3, Division 12) American Association of Applied and Preventive Psychology (AAAPP) Committee Against Medicalizing Psychology (CAMP) Psychologists Opposed to Prescription Privileges for Psychologists (POPPP)

22 Support Is Not Unanimous 43% of psychologists responding to an APA survey indicted that full medical training would be required for prescription privileges (APA, 1992) Nevertheless, the APA training model is shorter, as well as substantively and procedurally inferior to medical school, nurse practitioner training, and other prescribers

23 It Is About Quality: Not Popularity Whatever sentiments surveys of psychologists reveal, it is less appropriate to decide this issue on the basis of its popularity among psychologists than on the quality of pharmacologic care that psychologists would provide Bieliauskas, L. A. (1992b). Rebuttal of Dr. Franks position. Physical Medicine and Rehabilitation: State of the Art Reviews, 6, 584.

24 It Isnt Just Up To Psychologists It concerns a range of potential stakeholders Consumers Educators Practitioners in other health disciplines experienced in prescribing Regulatory and governmental authorities » Food and Drug Administration » Regulatory boards (e.g., Board of Psychology)

25 Historical Highlights APA (1992) established an Ad Hoc Task Force on Psychopharmacology to explore the desirability and feasibility of psychopharmacology prescription privileges for psychologists The Task Force concluded that greater understanding of psychopharmacology would enhance the care that psychologists provide (Smyer et al., 1993)

26 Proposed Levels of Training The APA Task Force proposed three levels of preparation in psychopharmacology: »Level 1- Basic Psychopharmacology Education »Level 2- Collaborative Practice »Level 3- Prescription Privileges Whereas the Task Force thought all psychologists providing mental health services should be prepared at Level 1, it did not take that position for training at Level 3

27 Legal Status of Prescribing Most states and provinces do not allow psychologists to prescribe Supervised prescribing by qualified psychologists has been passed in Guam, New Mexico, and Louisiana. It took time for details to be worked out, so we dont know yet how this experiment is going.

28 Currently under review elsewhere

29 Does New Mexico Lead the Way? Can you name 2 things that are legal in New Mexico, but not most places? Cock fighting »Also legal in Louisiana Psychologist prescribing

30 Foundation Definitions The lowest load-bearing part of a building, typically below ground level A body or ground on which other parts rest or are overlaid An underlying basis or principle for something; specific learning skills as a foundation for other subjects

31 Buildings Have Foundations Foundation No Foundation Foundations are structurally important Inadequate foundations can lead to instability of the structure, creating safety risks to users

32 Foundation in Education: Prerequisites The APA Task Force stated retraining of practicing psychologists for prescription privileges would need to carefully consider selection criteria, focusing on those psychologists with the necessary science background (APA, 1992) This included undergraduate coursework in: »Biology »Chemistry, and »Other areas typifying the pre-medical curriculum

33 Inadequate Foundation But no physical or biological science prerequisites are required! Instead, APA uses vague language about trainees scientific background

34 Dumbing Down Demonstrated knowledge of human biology, anatomy and physiology, biochemistry, neuroanatomy, and psychopharmacology is a necessary prerequisite for embarking on this postdoctoral training Demonstrated knowledge involves evidence of » (1) successful completion of a planned sequence of courses at a regionally accredited institution of higher learning, OR » (2) evidence of successful completion of a planned sequence of continuing education courses offered by an accredited institution of higher learning or an approved provider of continuing education and passage of an examination covering the content of such a program

35 Are They The Same? Rigorous Coursework Continuing Education ?=?=

36 Bait and Switch By deleting the scientific prerequisites APA has ignored the judgment of the importance of scientific backgrounds of its own experts as well as nearly half of the members it surveyed! But nevertheless, APA says that members support RxP, even if their favorable statements was based on expectations of more stringent requirements PDP-Lite (Stuart & Heiby, 2007) Ersatz training (Anonymous Member of APA Task Force)


38 Other Non-Physician Prescribers Training is much closer to that of physicians than to psychologists Clinical practice is more focused on physical functioning, including medication effects, than psychologists

39 Is this good? Among all the disciplines whose members include non-physician health care providers who prescribe, psychology has the core curriculum with probably the least overlap with traditional medicine Fox, DeLeon, Newman, et al.., 2009

40 APA Knows Better Accreditation criteria for all levels of education specify: Training for practice is sequential, cumulative, graded in complexity Inorganic Chemistry Organic Chemistry Biochemistry

41 Undergraduate Differences* Between Psychologists and Psychiatrists

42 Psychologists and Psychiatrists Pre-Med Courses Robiner, W. N., Bearman, D. L., Berman, M., Grove, W. M., Colón, E., Armstrong, J., Mareck, S., Tanenbaum, R. (2003). Prescriptive authority for psychologists: Despite deficits in education and knowledge? Journal of Clinical Psychology in Medical Settings, 10,

43 Arrogance? Some RxP advocates question the necessity of scientific background for prescribing (Hanson et al., 1999) Does that denigrate the importance of other scientific disciplines?

44 How Hard Is It To Prescribe? Former APA President, Patrick DeLeon, contends that: "...prescription privileges is no big deal. It's like learning how to use a desk-top computer" (Roan, 1993)

45 But Is It…….Really? Meet Noah Robiner 1 Hobby: Plays with laptop computer Age: Six years

46 Or Is Safe Prescribing More Involved? Would you have confidence in a prescription from a kindergartener? Do psychologists want to play at being medical doctors too?

47 Differences* Between Psychologists and Psychiatrists Scientific Coursework

48 Graduate Education in Psychology Comprises vastly differing models of study and practice with no effort to standardize the training of psychologists (Klein, 1996) Some psychology degrees (e.g., school psychology) have relatively limited exposure to psychopathology and psychological treatments, let alone the physical sciences or medical environments (DeMers, 1994; Moyer, 1995)

49 Wheres the Biology in Psychology Graduate Education? According to the APA Accreditation Commission: Domain B. 3. …The program has…a…coherent curriculum plan that provides the means whereby all students can acquire and demonstrate substantial understanding of and competence in the following areas: a)The breadth of scientific psychology, its history of thought and development, its research methods, and its applications. To achieve this end, the students shall be exposed to the current body of knowledge in at least the following areas: biological aspects of behavior…..

50 Wheres the Biology in Psychology Graduate Education? Note the absence of clear guidance from APA about content or credits Also note that biological aspects of behavior is considerably narrower than the biological curriculum for other prescribers (M.D., R.N., etc.) It does not require any knowledge of human physiology, pathophysiology, anatomy, etc.

51 Wheres the Biology in Psychology Graduate Education? According to the ASPPB/National Register Designation Committee: Psychology doctorates require merely 3 graduate semester hours in the biological bases of behavior »which can cover a range of topics, such as physiological psychology, comparative psychology, neuropsychology, sensation and perception, or psychopharmacology negligible These courses relevance to and preparation for prescribing can be negligible

52 The Trend for Less Science in Psychologists Training According to the Director of the APA Education Directorate, the training of psychologists is moving away from the scientist-practitioner model, to other models that de-emphasize scientific background and activities (Belar, 1998) By 1997, nearly 2/3 of clinical psychology degrees were conferred by professional schools, rather than university-based academic programs (Reich, 1999) which typically require more rigorous scientific training than professional schools

53 Sometimes A Science Background Isnt So Important Should cub scouts or their dads have to take physics to design cars for the pinewood derby?

54 Sometimes It Is Would you want to get on a plane if the engineers who designed it hadnt taken physics?

55 If Youre Sick, Who You Gonna Call? Would you entrust your health to people who lacked basic scientific backgrounds? ER Cast U of M Lung Transplant Team

56 What is Happening In 1995 the APA Council of Representatives passed a resolution making the pursuit of prescription privilege an official objective for the organization APA devotes greatest attention to the most controversial option, Level 3, promoting prescription privileges through a hybrid of continuing education and a modular executive training in psychopharmacology for doctoral- level psychologists

57 Training Is Limited Several training programs exist, including some that emphasize distance-learning »300 hours »100 supervised patients The training is not close to medical or psychiatric training, and is less comprehensive than nurse practitioner training

58 Where and When is it Occurring? Wherever programs wish to offer it Not at medical schools or top-ranked nursing or physician assistant training programs Some is largely on-line

59 APA Training Model Does Not Specify Minimal Criteria For: Breadth of patients mental health conditions Duration of treatment (i.e., to allow for adequate monitoring and feedback) or requirements for outpatient or inpatient experiences, or length of training Exposure to adverse medication effects Exposure to patients with comorbid medical conditions and complex drug regimens Qualifications for supervisors

60 Training Without Accreditation Unlike training for other prescribers, no accreditation mechanisms to evaluate psychopharmacology programs or supervised clinical experiences exist. The psychopharmacology training programs do not meet the APA's (1996c) own criteria for accreditation of postdoctoral programs or internships.

61 Designation: Minimal Standards The 2008 APA Council meeting allocated funding for a Task Force to create a designation system that was charged with developing the minimal standards for programs of psychopharmacology education and training programs. Note how this is inferior to the objective of the accreditation process, as used in other psychology training, which is intended to promote consistent quality and excellence in education and training in professional psychology." (APA, 2008)

62 What Isnt Happening The Task Forces Level-2 Collaborative Practice, envisioned to enhance patient care via collaborations with prescribers by expanding their expertise about medication management has not been pursued

63 No Training for Collaborative Practice Even though more psychology graduate students believe that Level 2 (77%) training should be offered in their programs than Level 3 (57%) and (Tatman, Peters, Greene, & Bongar, 1997) Even though there is a good literature about the benefits of collaborations between psychologists and prescribers, such as primary care physicians

64 RxP Advocacy Tactics Pollitt, B. (2003). Fool's gold: Psychologists using disingenuous reasoning to mislead legislatures into granting psychologists prescriptive authority. American Journal of Law & Medicine, 29,

65 Argument #1 About Prescription Privileges for Psychologists Its not a big deal: Psychologists have done it for years without problems ( VA, Reservations, military ) How well and how long has it been studied in demonstration projects? »The DoD studied only 10 psychologists What controls were in place which might have prevented problems in these projects? »They were in supervised, military hospitals with a long history of teaching health professionals How would the care psychologists be different on broader scale, without supervision, outside of medical settings?

66 DoD/PDP Selection Bias They were not typical psychologists 6 were Air Force Officers or Army Officers holding the rank of Captain or higher 4 were Navy officers holding the rank of Lieutenant Commander or Commander 8 were chiefs or assistant chiefs of an outpatient psychology clinic or a mental health clinic

67 Department of Defense (DoD) Psychopharmacology Demonstration Project (PDP) Initial participants undertook preparation in chemistry and biochemistry before completing a majority of 1st year medical school courses During their first full-time year at the Uniformed Services University of the Health Sciences, they worked with the Psychiatry- Liaison service and assumed night call with 2nd year psychiatry residents

68 Department of Defense (DoD) Psychopharmacology Demonstration Project (PDP) In the second full-time year, they completed core basic science courses and continued psychopharmacology training and clinical work After 2-day written and oral examinations, they had a third year of supervised clinical work at Walter Reed Army Medical Center or Malcolm Grow Medical Center

69 Then PDP Training Was Reduced Over time, the PDP curriculum was abbreviated, streamlining training to one year of coursework and a year of supervised clinical practice Didactic hours decreased by 48% in the 2 nd iteration Most PDP graduates functioned as prescribing psychologists in branches of the military At least one graduate went on to medical school

70 A Few Words About the PDP The PDP was discontinued after the first few years Proponents want you to believe: »The successes of PDP participants justify extending prescriptive authority to psychologists who undergo training consistent with the APA model (1996a) Even though the APA training model and the likely resources available for the training are less substantial than the PDP

71 What You Should Know About the PDP The Final Report of on the PDP the American College of Neuropsychopharmacology (1998) assessed graduates as weaker medically and psychiatrically than psychiatrists. Limitations are likely to be most evident in treating medically complex patients Kennedy, J. (1998, April 3). Prescription privileges for psychologists: A view from the field. Psychiatric News, 33 (7), 26.

72 More to Know About the PDP [The psychologists] medical knowledge was variously judged as on a level between 3rd or 4th year medical students (p. 6) Note: Patients never get treated by medical students without strict supervision Should patients get healthcare from someone approximating a medical student or a licensed health professional who completed training?

73 Concern About the PDP Trainees The most common concern cited by most of the psychiatrist supervisors in one form or another was that the fellows knew too little medicine to prescribe psychotropic drugs safely. They worried about the lack of medical sophistication. (p. 13)

74 Limits Within the DoD Graduates only saw a limited range of patients aged generally with limited medical problems Some graduates had limited formularies Some graduates continued to have dependent prescriptive practice (i.e., supervised by a physician )

75 Differences Between the PDP and APA Model PDP graduates advised against "short-cut" programs and considered that a year of intensive full-time clinical experience, including inpatient care, was essential This is more comprehensive than psychopharmacology training currently recommended by APA or available There is no inpatient requirement for training

76 Doubts About Generalizing From the PDP Some of the DOD psychiatrists, physicians, and graduates doubt the safety and effectiveness of psychologists prescribing independently outside of the interdisciplinary team of the military context This concern has been echoed in a survey of military psychiatrists, non-psychiatric physicians, and social workers Klusman, L. E. (1998). Military health care providers' views on prescribing privileges for psychologists, Professional Psychology: Research and Practice, 29,

77 Questions About the DoD Do the relatively limited base rates of problems and tiny sample obscure genuine problems and suffer from Type II statistical problems (i.e., have inadequate statistical power to detect differences or problems)? Can we generalize from 10 trained in military hospitals to thousands of psychologists across the spectrum of settings with diverse and less healthy populations? If training is less rigorous, with less access to medical populations, would the DoD outcomes overestimate outcomes of how other psychologists would perform?

78 Argument #2 About Prescription Privileges for Psychologists Most psychoactive medications are prescribed by physicians or others with less training in assessment or therapy than psychologists All other prescribing health professionals have relevant training in basic sciences: biology, chemistry, biochemistry, etc. Psychologists do not! »Only 7% of psychology graduate students have the relevant scientific backgrounds (Tatman et al, 1997)

79 Lack of Undergraduate and Graduate Preparation Only 27% of graduate students thought they had the undergraduate preparation to undertake preparation to prescribe (Tatman et al, 1997) Completed recommended biology & 7% chemistry units (Fox et al., 1992) > 4 units of undergraduate biology 48% > 4 units of undergraduate chemistry 20% Graduate course in psychopharmacology 25%

80 Argument #2 (continued) All other prescribing professionals have years of training and experience in dealing with a wide range of side effects, adverse or toxic effects, drug interactions, and impact on other systems Psychologists do not! Psychologists clinical skills provide fruitful opportunities for collaboration with prescribing health professionals but their lack of an educational foundation contraindicates prescribing themselves

81 Argument #3 About Prescription Privileges for Psychologists There are misuses and abuses in medication prescriptions by physicians Such medication problems would not be remedied by giving psychologists prescription privileges Psychologists would probably make similar errors, plus others due to their more limited training and experience with medications and physiological phenomena

82 Knowledge Base and Clinical Proficiencies Required for Prescribing Psychopathology and Psychological Issues 1 Medical Status Prior to Prescribing Response to Treatments 1 The education and training of psychologists typically addresses this area only Robiner, W. N., Bearman, D. L., Berman, M., Grove, W. M., Colón, E., Armstrong, J., & Mareck, S. (2002). Prescriptive authority for psychologists: A looming health hazard? Clinical Psychology: Science and Practice, 9,

83 What Psychologists Know Psychopathology and Psychological Issues Primary psychiatric conditions Comorbid psychiatric conditions Prevalence and course of psychiatric conditions Knowledge of non-pharmacologic treatment options

84 What Psychologists Dont Know Medical Status Prior to Prescribing Comorbid medical conditions Contraindications Long-term effects of medication Medical effects of concurrent treatments drug interactions other treatments (e.g., dialysis, plasmapheresis) History of medication use

85 What Psychologists Dont Know Response to Treatments Knowledge of adverse reactions side effects, toxic effects Ability to recognize, diagnose, & treat adverse reactions. Ability to differentiate between physical and psychiatric effects of psychoactive agents and concurrent medications Other issues related to monitoring, titrating or discontinuing prescribed medications

86 For example... SSRIs can cause bleeding disorders, including GI and retinal hemorrhage Effexor overdoses have higher risk of mortality than SSRI overdoses Overdose with Celexa can cause life-threatening cardiac crises; > 6 deaths so far Abrupt clonazepam withdrawal can result in hypoglycemic coma in diabetics

87 That is Just the Tip of the Iceberg SSRIs inhibit CYP2D6 activity and when combined with other drugs metabolized via the P450 enzyme system result in toxic serum concentrations of either or both drugs

88 For Complex Patients Medication Management is Harder Since 2005, the FDA requires black box warning labels about the risk of antipsychotic use with the elderly Second-generation, antipsychotic medications have black-box warnings noting that the drugs are associated with increased risk of death and other adverse effects in elderly patients »(cardiac toxicity, stroke, infection, hyperglycemia) 1.6- to 1.7-fold increase in mortality in the elderly

89 Major Cytochrome P450 Isozymes and Substrates Involved in Drug Metabolism CYP1A2: Amitriptyline, Clozapine, Imipramine, Tamoxifen, Theophylline CYP2C9: Diclofenac, Ibuprofen, Losartan, Phentoin, S- warfarin, Tobutamide CYP2C19: Citalopram, Clomipramine, Diazepam, Imipramine, Omeprazole, Propranolol CYP2D6: Amitriptyline, Codeine, Clomipramine, Debrisoquine, Haloperidol, Metoprolol, Paroxetine, Thoridazine CYP3A4: Codeine, Cyclosporin, Diltiazem, Erythromycin, Lignocaine, Nifedipine, Terfenadine, Verapamil

90 Adverse Drug Reactions Mechanisms There are numerous mechanisms Effects of disease, genes, smoking, diet, receptor sensitivity alterations, etc. Drugs metabolized by the same P450 isozyme may competitively inhibit each others oxidation in the liver

91 Argument #4 About Prescription Privileges for Psychologists People need medications in underserved areas where there are few psychiatrists The geographic distribution of psychologists and psychiatrists are similar Other health providers in those areas prescribe and are open to collaboration with psychologists »Rural family physicians have concerns about psychologists prescribing (Bell et al., 1995) Poor distribution may justify telehealth, or geographic redistribution, but not psychologist prescription privileges, which would lower standards of care for rural citizens

92 Dubious Plan for Serving the Underserved APA Task Forces expectation was that only a small...minority of psychologists would seek Level 3 psychopharmacology training (APA, 1992) There is no plan to redistribute prescribing psychologists to meet needs of underserved populations (May & Belsky, 1992) It would be an indirect, needlessly risky, and highly inefficient public policy response to rural areas shortage of psychopharmacologic prescribers (Robiner et al., 2002)

93 If This Were Really About Serving the Underserved The energy and resources psychologists are currently investing into advancing the prescriptive privileges could be refocused on: Level 1 (basic knowledge) and 2 (collaboration) training and On developing mechanisms to redistribute the psychology workforce to address legitimate societal needs (e.g., rural mental health) Advocating for training more psychiatrists

94 Argument #5 About Prescription Privileges for Psychologists Some psychoactive medications are becoming safer and more efficacious This is why medications may be becoming more helpful, but does not justify psychologists prescribing Medications have side effects, toxic effects, addiction potential, long-term adverse effects, drug interactions, medical contraindications, and can result in death

95 Argument #5 (safer meds continued) Can psychologists keep abreast of burgeoning medication issues-both psychoactive and non-psychoactive? Where will their time to keep up come from?

96 Argument #6 About Prescription Privileges for Psychologists Opposition to prescription privileges is from the professions conservative members Denigrating legitimate concerns through polarizing terms is not productive. It distracts attention from real issues, reduces dialogue, and focuses on emotional rather than rational issues

97 Argument #7 About Prescription Privileges for Psychologists Its just another fight with Psychiatry It is a major controversy within psychology and with other specialties within medicine. Do psychologists really want to alienate the other APA and the AMA at a time when psychologists responses to other challenges within health care warrant greater unity?

98 Psychiatric Nurses Oppose RxP Position Statement of the International Society of Psychiatric- Mental Health Nurses (ISPN) … nurses have an ethical responsibility to oppose the extension of the psychologists role into the prescription of medications. This is not a turf issue or an attempt to limit a perceived competing profession. This belief is rooted in the ethical guidelines of our own profession. The professional standards for nursing require nurses who prescribe pharmacologic agents to have their prescriptive actions based on an awareness of pharmacological and physiological principles and knowledge…We should expect the same from other professionals.

99 From a MN Psychologist/NP I oppose prescription…privileges for psychologists…In a previous professional 'incarnation' I was a nurse and nurse practitioner. During the 4 years of my undergraduate nursing education I took courses in anatomy, physiology, chemistry, biochemistry, embryology, microbiology, pathophysiology and pharmacology. This was just a warm-up for the in- depth physical assessment and illness-management skills I learned in the nurse practitioner program. My education deepened in clinical settings - during and after my formal training programs - where I was surrounded by more experienced nurse and physician colleagues with whom I was able to routinely consult. No two-year psychopharmacology course could duplicate the breadth and depth of this education - which I feel is the minimum necessary for safe medication management. Kate Pfaffinger, Ph.D. (former NP) 3/23/08


101 Logistical Challenges to Training Psychologists to Prescribe Unproven curricula and educational paradigms for training »Long-term outcomes remain unknown Limited number of psychology supervisors to train psychologists to prescribe safely and effectively »Only 35% of medical school psychologists reported having psychologist faculty who could teach or supervise psychopharmacology

102 What Psychologists Dont Know... May Hurt Somebody Biology, Chemistry, Biochemistry, Pharmacology, Physiology Clinical Medicine Physical Examination, Laboratory Tests How to Understand and Integrate All of the Above in Decisions Involving Medications How to Assess Contraindicated Conditions and Medication Side Effects What They Dont Know

103 Psychologists Vs. Psychiatrists Knowledge Related to Prescribing

104 As One Psychologist Turned Psychiatrist Observed The practice of psychology differs substantially from the practice of psychiatry Studying the effects of medications on the kidney, the heart, and so forth is important for the use of many medications. Managing these effects is often crucial and has more to do with biochemistry and physiology than with psychology. I was surprised to discover how little about medication use has to do with psychological principles and how much of it is just medical. Kingsbury, S.J. (1992). Some effects of prescribing privileges. Professional Psychology: Research and Practice, 23, 3-5. »

105 He Also Observed In my first month of residency training in psychiatry at a psychiatry emergency service I believe I saw more patients individually than in my entire graduate [Psychology] training. Kingsbury, S. J. (1987). Cognitive differences between clinical psychologists and psychiatrists. American Psychologist, 42,

106 Increasing Awareness of Adverse Effects The Federal Drug Administration currently receives 400,000 reports per year about adverse drug events Psychoactive medications have been described as presenting more complex drug interactions and adverse effects than any other class of drug (Hayes, 1998) Many people who take psychoactive medications also take other medications that complicate their care »Fewer than 30% who take an antidepressant take no other medications (Preskorn, 1999)

107 Which of These Medication Effects or Contraindications Can Psychologists Diagnose? NONE Agranulocytosis Bundle Branch Block Eosinophilia Hyperpyrexia Hyponatremia Leukocytosis Myoglobinuria Opisthotonus Thrombocytopenia

108 Additional Hazards Associated With Prescription Privileges for Psychologists Decreased quality of care for patients Increased professional liability rates for psychologists Increased licensing fees for psychologists Increased risks of chemical dependency in psychologists? Antagonism among psychologists Increased antagonism with physicians »One article predicted a Jihad against psychology by psychiatry and medicine

109 Why Dont Majorities of Health Psychologists Support Prescribing? Only 27% hospital affiliated psychologists approve (Boswell et al., 1988) Only 23-30% of health psychologists approve (Piotrowski & Lubin, 1989) Only 43% of medical school psychologists approve (Robiner, Wedding, & Koehler, 1998) Does the limited support among psychologists in health settings relative to psychologists in other settings reflect better informed caution?

110 Argument #8 About Prescription Privileges for Psychologists Its the natural evolution or logical step for the profession Even though it should more realistically be characterized asrevolutionary or radical »It departs from psychologys historic training paradigms and conceptualizations of psychopathology and intervention »It requires major shifts in focus, prerequisites, marked expansions of training and continuing education in key areas, reformulation of accreditation criteria, modification of regulatory structure, domains, and processes, expanded ethical guidelines, as well as uniform requirements that at least part of psychologists training occur within health care settings

111 Prescription Privileges May Conflict With Darwins Notions of Evolution Survival depends on fitness for tasks undertaken and challenges faced Evolution does not favor inferior skills Evolution does not forgive serious miscalculations

112 The Evolution of Psychology Demands that Psychologists : Do what they do better Adapt appropriately to change Recognize their strengths and limitations Develop better understanding of psychopharmacology Cultivate collaborations with prescribers

113 Questions to Consider- #1 If the job market for psychologists was more positive, would psychologists and trainees still wish to pursue prescription privileges? If prescribing ends up not being lucrative, or broadening marketability, would it still be being pursued? Even with prescription privileges, Psychiatry has been losing market share Are nurse practitioners who prescribe compensated more generously than psychologists?

114 Questions to Consider- #2 How would prescribing change the therapeutic relationship? How would psychologists deal with their obligation to provide 24-hour emergency coverage related to medications? How would RxP training detract from training in other dimensions of Psychology?

115 Questions to Consider- #3 Do changes in psychologists earlier opposition to prescribing reflect desensitization to genuine hazards as a result of the professions marketing or propaganda campaign »SSCP had to delete an anti-RxP statement from its website if it wanted to continue affiliation with APA Are there more appropriate ways for the profession to respond to current challenges to practitioners? Are there safer and more appropriate ways to assist patients who need medication get it?

116 Questions to Consider- #4 After decrying the medical model for decades, why are psychologists now embracing prescription privileges? Can psychologists prescribe medications as safely as providers with more extensive medical training? Whenever mortalities or morbidities associated with psychologists prescriptions result in lawsuits, will juries agree it was a good idea?

117 Questions to Consider- #5 How does not going to medical school/nurse practitioner training detract from understanding of medications and physical functioning? How does not going to medical school/nurse practitioner training affect skill and experience in prescribing? If psychologists wish to prescribe medications well, why dont they pursue higher quality training? »There generally are openings in good psychiatry residency programs

118 Questions to Consider- #6 Would a psychologist be your first choice prescriber for psychoactive medications for yourself or a loved one? Why or why not? Who would be your first choice prescriber?

119 If Psychologists Are Granted Prescription Privileges, Why Shouldnt the...

120 Current Focus on Medication Errors

121 Psychologists lobbying for prescriptive authority is ironic in light of growing national concern about errors in prescribing medication (Classen, Pestotnik, Evans, Lloyd, & Burke, 1997). »Medication errors are estimated to lead to <7,000 deaths annually (Phillips, Christenfeld, & Glynn, 1998). »Among the many contributing factors to medication errors are inadequate knowledge and use of knowledge regarding drug therapy and inadequate recognition of important patient factors (e.g., impaired renal function, drug allergies) (Lesar et al., 1997). Lesar TS, Briceland L, Stein DS: Factors related to errors in medication prescribing. JAMA 1997;277(4):

122 Along With Other Strategies, Avoiding Medication Errors Will Take Improved prescriber education (Lesar et al. 1997) Not creating a new category of prescribers with relatively less training (as psychologist prescribers would be) »Short cuts in education seem likely to undermine patient care and contribute to medication errors along the patterns outlined by Lesar et al. (1997).

123 Collaborating? Yes! Prescribing? No Achieving the APA Task Forces goals for enhancing the care of patients needing medications does not require prescriptive authority for psychologists Patients and other health professionals would benefit from psychologists increased knowledge related to psychopharmacology that would enhance the services they provide and their collaborations with prescribers

124 Effects of Controversies The diversity of our field often leads to different, strongly held opinions about which there appears to be little room for compromise….The contribution that a unified psychology can make to society and its own health is eroded and weakened by scientists and practitioners headed in different, sometimes opposite directions Hargrove, S. (1997. March). We have only ourselves to fear. PsycCRITIQUES, 42(3).

125 RxP Effects 1 on State Psychological Associations State associations, that have already initiated an RxP initiative, report having to allocate all of their legislative dollars to the effort Tennessee reported not having legislative dollars for other bills due to all efforts going towards RxP APA has given $180K to 6 states due to lobbying costs of RxP Due to the expense several states said they are near a point of reconsidering whether to continue pursuing RxP States with psychopharmacology training programs report a shortage of psychologist enrollees and have opened the training to nurses to meet their costs 1 Personal Communication from Willie Garrett, Ed.D. December 8, 2006 re: Directors of Professional Affairs strategic planning meeting

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