concerns about psychologist prescribing

Concerns About Psychologist Prescribing

William Robiner, Ph.D., A.B.P.P.Department of Medicine

UNIVERSITY OF MINNESOTA MEDICAL SCHOOL

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Disclosure InformationConcerns 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 MinnesotaI 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.

Prescription Privileges for Psychologists Are Controversial

“I don’t think we need to be subliminable about the differences between our views on prescription drugs”

George Bush, Orlando, FLSeptember 12, 2000

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.

ObjectivesUpon completion of the presentation, participants

should be able to:1. Summarize diverse concerns about psychologist prescribing2. Identify relative limits of the APA Clinical Psychopharmacology

Training model and the DoD PDP Program3. Identify psychologists’ motives and rationales for pursuing

prescription privileges4. Decide their position about the controversy about prescription

privileges for psychologists

What do Consumers Want of Their Psychopharmacologist?

“Our Psychopharmacologist is a genius”

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

Why Do Psychologists Want Prescription Privileges?

$ Money

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

“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.

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

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

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

Why Does the APA Want Prescription Privileges for Psychologists?

$ Potential revenues from advertising dollars for its journals from pharmaceutical companies

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

What Factors Lead Psychologists to Oppose Prescription Privileges for Psychologists?

A personal sense of responsibility to speak truth to power

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

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

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

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

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)

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’

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. Frank’s position. Physical Medicine and

Rehabilitation: State of the Art Reviews, 6, 584.

It Isn’t Just Up To PsychologistsIt 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)

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)

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

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 don’t know yet how this experiment is going.

Currently under review elsewhere

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

“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

Buildings Have Foundations

Foundation No Foundation Foundations are structurally important Inadequate foundations can lead to instability of the

structure, creating safety risks to users

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

Inadequate Foundation

•But no physical or biological science prerequisites are required!

• Instead, APA uses vague language about trainees’ scientific background

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

Are They The Same?

Rigorous Coursework

Continuing Education

?=

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)

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’

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

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

Undergraduate Differences* Between Psychologists and

PsychiatristsMajor Psychologists Psychiatrists Physical Sciences

12%

67%

Social Sciences

79% 28%

Humanities 7% 6%

Arts 2% 0%

*x2 = 18.5; p < . 001. Robiner et al., 2003

Psychologists’ and Psychiatrists’Pre-Med Courses

Psychiatrists

M = 12

Psychologists (t = 14.7; p < .007)

M = 4.7 Robiner et al. (2003)

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, 211-222.

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?

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)

But Is It…….Really?Meet Noah Robiner1

Hobby: Plays with laptop computer

Age: Six years

1 2002

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?

Differences* Between Psychologists’ and Psychiatrists’

Scientific CourseworkCoursework Psychologists Psychiatrists

Anatomy or

Neuroanatomy

41.5%

100%

Chemistry/Biochemistry 58.5%/ 14.6% 100%/ 100%

Biology/Microbiology 65.9%/ 7.3% 100%/ 100%

Pharmacology 17.1% 100%

Physiology or

Neurophysiology

*t = 14.7; p < .007.

Robiner et al., 2003

43.9% 94.4%

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)

Where’s 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…..

http://www.apa.org/ed/accreditation/G&P0522.pdf


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.


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

These courses’ relevance to and preparation for prescribing can be negligible

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

Sometimes A Science Background Isn’t So Important

Should cub scouts or their dads have to take physics to design cars for the pinewood derby?

Sometimes It Is

Would you want to get on a plane if the engineers who designed it hadn’t taken physics?

If You’re 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

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

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

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

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

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.

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)

What Isn’t Happening The Task Force’s Level-2 Collaborative Practice, envisioned

to enhance patient care via collaborations with prescribers by expanding their expertise about medication management has not been pursued

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

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, 489-524.

Argument #1 About Prescription Privileges for Psychologists

It’s 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?

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

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

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

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 2nd iteration

Most PDP graduates functioned as prescribing psychologists in branches of the military

At least one graduate went on to medical school

A Few Words About the PDPThe 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

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.

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?

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)

Limits Within the DoD Graduates only saw a limited range of

patients aged 18-65generally with limited medical problems

Some graduates had limited formularies Some graduates continued to have

dependent prescriptive practice (i.e., supervised by a physician)

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

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, 223-229

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?


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)

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%

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


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

Knowledge Base and Clinical Proficiencies Required for Prescribing

Psychopathology and Psychological Issues1

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, 231-248.

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

What Psychologists Don’t 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

What Psychologists Don’t 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

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

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

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

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

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 other’s oxidation in the liver


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

Dubious Plan for Serving the Underserved

APA Task Force’s 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)

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


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

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?


Opposition to prescription privileges is from the profession’s “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


It’s 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?

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 psychologist’s 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.”

http://www.ispn-psych.org/docs/11-01prescriptive-authority.pdf

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

Psychologists Oppose RxP

PSYCHOLOGISTS OPPOSED TO PRESCRIPTION PRIVILEGES FOR PSYCHOLOGISTS (POPPP)

You can join at: www.poppp.org

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

What Psychologists Don’t 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 Don’t Know

Psychologists’ Vs. Psychiatrists’ Knowledge Related to Prescribing

Domain Psychologists Psychiatrists P Value Adverse Effects and Contraindications

34.8

106.4

< .001

Drug-Related Clinical Syndromes

2.9 9.5 < .001

Medications Identification

16.1 40.8 < .001

Psychopharmacology Examination

8.9 20.4 < .001

Total % Cor rect From Robiner et al. (2003)

31% 87% < .001

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.

»

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, 152-156.

Increasing Awareness of Adverse Effects

The Federal Drug Administration currently receives 400,000 reports per year about adverse drug events http://www.fda.gov/cder/dsn/default.htm

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)

Which of These Medication Effects or Contraindications Can Psychologists

Diagnose?

NONE Agranulocytosis Bundle Branch Block Eosinophilia Hyperpyrexia Hyponatremia Leukocytosis Myoglobinuria Opisthotonus Thrombocytopenia

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

Why Don’t 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?


It’s the “natural evolution” or “logical” step for the profession

Even though it should more realistically be characterized as “revolutionary” or “radical”» It departs from psychology’s 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

Prescription Privileges May Conflict With Darwin’s 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

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

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?


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?

Questions to Consider- #3 Do changes in psychologists’ earlier opposition to

prescribing reflect desensitization to genuine hazards as a result of the profession’s 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?


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?


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 don’t they pursue higher quality training?» There generally are openings in good psychiatry residency

programs


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?

If Psychologists Are Granted Prescription Privileges, Why Shouldn’t

the...

189,000 Clinically Trained SocialWorkers

50,000 Licensed ProfessionalCounselors

46,000 Marriage & Family Therapists

Current Focus on Medication Errors

Current Focus on Medication Errors

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):312-317

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).

Collaborating? Yes! Prescribing? No

Achieving the APA Task Force’s 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

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).

RxP Effects1 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 costs1Personal Communication from Willie Garrett, Ed.D. December 8, 2006 re: Directors of Professional Affairs strategic planning meeting

concerns about psychologist prescribing

Documents

prescription drugsgeorge

potential revenues

american medical association

academy of clinical

controversial i dont

potential future declines

diverse concerns

welltrained professional