June 1st, 2017

Push for prescribing privileges fizzles in Vermont

With the stroke of Gov. C. L. “Butch” Otter’s (R) pen on April 4, Idaho became the fifth U.S. state to permit clinical psychologists with advanced specialized training to prescribe medications to treat mental health disorders. So, expect to see continuing momentum for what the American Psychological Association maintains will improve access to mental health services, particularly in poorly-served areas.

Just not this year in Vermont.

A bill introduced in February in Vermont’s House of Representatives seeking to grant prescribing privileges for psychologist-doctorates with advanced training in psychopharmacology went nowhere after being referred to the Committee on Health Care.

The bill had specified that training consisted of either a postdoctoral master’s degree in clinical psychopharmacology from a regionally accredited institution of higher education or equivalent training approved by the state Board of Psychological Examiners.

“New ideas like this take some time for folks to learn about,” said the bill’s sponsor, Rep. Anne Donahue (R-Northfield). “It will be up to the proponents to build a case for it.”

Rick Barnett, Psy.D., M.S., past president and current legislative chair for the Vermont Psychological Association, will be working on that case this summer and fall. Barnett has promised lots of grassroots efforts, including contacting and meeting with individual legislators and outreach to other mental health provider groups and state health officials to push hard for passage next session.

“We’re going full steam ahead,” Barnett said.

Building a case for giving specialized psychologists prescriptive authority, or RxP for shorthand, will mean educating legislators about what psychologists actually do, what additional levels of training beyond a doctorate they would need, and why relying only on psychiatrists can’t meet the need.

And psychologists must confront opposition from the American Medical Association and the American Psychiatric Association. Both physicians’ groups argue that RxP training for psychologists is insufficient and cannot substitute for what physicians receive through their medical education and clinical experience.

The American Psychiatric Association provided the following statement to New England Psychologist in response to a request for comment: “The psychotropic medications that psychologists wish to prescribe are among the most powerful available to modern medicine. They don’t just affect the brain, they affect the entire body. We believe a medical degree is required to properly diagnose psychiatric illness and to prescribe medications safely and effectively.”

“We hear that a lot,” said Deborah C. Barker, J.D. director of legal and regulatory policy in the Office of Legal and Regulatory Affairs of the APA’s Practice Directorate. “They’re assuming it’s all psychologists and they may not appreciate what the training is.”

“The reality is there aren’t enough psychiatrists,” Barker added. “Psychiatrists are booked and in some places, psychiatrists aren’t accepting insurance.”

Barker has worked on task forces established to review and revise APA RxP policies and designation of psychopharmacology master’s degree programs. Only four U.S. higher education institutions offer an American Psychological Association designated postdoctoral education and training program in psychopharmacology needed for RxP: Alliant International University in San Francisco; University of Hawaii, Hilo; Fairleigh Dickinson University in Teaneck, New Jersey; and Southwestern Institute for the Advancement of Psychotherapy/New Mexico State University in Las Cruces, New Mexico.

Barker said she anticipates more states will be actively considering RxP legislation in the coming years.

“It rarely happens on the first go round, because trying to get any legislation enacted is a real complicated effort,” Barker said.

Idaho Psychological Association Advocacy Committee Co-Chair, Susan Farber, Ph.D., said it took three years to get RxP passed in her state, where the wait for a first-time psychiatrist appointment is two to three months in the Boise area but up to a year in the northern part of the state.

Much of IPA’s advocacy involved convincing legislators that the education and training psychologists would undergo in pursuit of RxP would be rigorous enough. Idaho’s House of Representatives Health and Welfare Committee chairman happens to be a physician, which turned out to be a “blessing in disguise,” Farber said.

“He forced the psychiatrists to sit down and meet with us,” Farber explained.

That process led Idaho’s psychiatrists to bring in as a consultant a respected nurse practitioner who was an independent prescriber to review the syllabi of psychopharmacology courses offered in New Mexico State University’s program. The consulting nurse practitioner declared the training at least equally rigorous to what a nurse practitioner would undergo to acquire RxP, Farber said.

“Prescribing psychologists aren’t seeking to displace psychiatrists,” Barker explained. “They’re just looking to fill in where there’s need, just as psychiatric nurse practitioners often do the same in communities and certain systems where there aren’t enough psychiatrists.”

The history of psychologists seeking RxP goes back to at least the 1980s, with the strongest momentum building after the U.S. Department of Defense approved a pilot project in 1991 for psychologists to receive formal training. Two Navy psychologists were the first to complete the training and began practicing as RxP providers in 1994. Trained RxP psychologists followed in the U.S. Army, and Air Force as well as in the Indian Health Service and Public Health Service.

The territory of Guam approved prescriptive authority for psychologists in 1999. New Mexico became the first state to enact a law to do so in 2002 followed by Louisiana in 2004. Illinois did so in 2014 and Iowa in 2016.

Several other states have tried unsuccessfully to pass RxP, including Hawaii where the Legislature revisited a proposal this year that broke down in the House of Representatives. Oregon passed legislation in 2010 that was vetoed by then Gov. Ted Kulongoski. Other states where efforts have stalled include California, Georgia, Illinois, Mississippi, Missouri, Montana, New Jersey and Tennessee.

Among those who will be keeping an eye on what transpires in Vermont will be Stanley Berman, Ph.D., vice president for academic affairs and associate professor at William James College, formerly the Massachusetts School of Professional Psychology, in Newton, Massachusetts.

The college had a psychopharmacology master’s degree program enrolling students from 2001 through 2006, graduating a total of 59 students. But the lack of enrollment growth led the school’s board of trustees to decide to discontinue the program, Berman said.

“If prescription privileges passed in a New England state, that would lead us to explore reopening our program,” Berman said.

By Janine Weisman

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