Feature

Even though a bill approving prescriptive authority (RxP) for psychologists in Hawaii did not make it out of a key committee in the state legislature this year, supporters say the legislation made the most progress it's ever made, setting the stage for what they hope is eventual passage.

This year, the Hawaii House of Representatives and the Senate's Health Committee approved the bill. However, following a contentious three-hour hearing April 7 before the Senate Commerce, Consumer Protection and Housing Committee, the chairman deferred the bill, halting its progress this year.

But that same committee approved a resolution calling for the Legislative Reference Bureau, the legislature's nonpartisan research agency, to write a report on the issue of prescription authority for psychologists in time for next year's legislative session, which starts Jan. 17 and ends in early May.

"Tremendous progress was made," says Robin E.S. Miyamoto, PsyD. "This is the first time we got it out of one of the two houses." A psychologist at the Waimanalo Health Center on Oahu, Miyamoto co-chaired the Hawaii Psychological Association's RxP Task Force with Jill Oliveira-Berry, PhD, director of behavioral health at the Na Pu'uwai Native Hawaiian Health Care System clinic on Molokai.

Report is next step

The resolution calls for the Hawaii Legislative Reference Bureau to study the curriculum and safety issues associated with granting psychologists the authority to prescribe psychotropic medication. The resolution also calls for examining the experience of states such as New Mexico and Louisiana, where specially trained psychologists have the authority to prescribe.

It also calls for reviewing any evaluations of, or statistics on, the psychologists trained though the Department of Defense's Psychopharmacology Demonstration Project, a congressionally authorized program that trained 10 Department of Defense psychologists from 1994 to 1997 to prescribe psychotropic medications. The resolution received final approval April 25.

Miyamoto says the report should help advance the legislation next year by providing information that addresses doubts created in legislators' minds by the arguments made by psychiatrists in opposing the legislation.

"We'll have some better data, which will give the legislators some cover next year when they vote on what always ends up being a very controversial issue," she says.

State Sen. Rosalyn H. Baker (D-Maui), who serves as chair of the Senate Health Committee, agrees that the Legislative Reference Bureau study should help move the legislation forward next year. She supports the legislation because of the need to extend mental health services to more people, particularly in rural areas such as her district of Maui County, which meets the federal definition of a mental health professional shortage area.

"It will help some people sitting on the fenceā€¦see the issue more clearly," Baker says.

The task force Miyamoto co-chairs was formed prior to last year's legislative session, during which the prescriptive authority bill failed on its third floor vote in the Senate, and was held by the House Health Committee. This year, Miyamoto says the task force tried to argue more effectively for the bill by having psychologists lobby their senators and representatives with personal visits.

In Hawaii, the issue has been debated off and on since 1985, when the first bill allowing psychologists to prescribe was introduced.

Besides progress though the legislature, the bill received media attention this year in the form of newspaper articles, editorials, letters to the editor and discussions on talk radio, supporters say.

During hearings, primary-care physicians and medical directors working in community health clinics testified in support, helping educate lawmakers about the lack of adequate access to mental health care, and the Hawaii Primary Care Association ran a newspaper op-ed in favor of the legislation.

APA's executive director for professional practice, Russ Newman, PhD, JD, congratulates the Hawaii psychologists for the progress made this year.

"Educating legislators about the safe and effective use of psychologists to prescribe psychoactive medication is an ongoing process," he says, adding that "psychologists in Hawaii deserve high praise for their continued success in moving the prescriptive authority debate forward and for taking significant next steps in their effort to pass prescriptive authority for psychologists in Hawaii."

Mental health services

Psychologists tried to keep the legislature's debate and discussion focused on the public need for more access to mental health care and the way prescription privileges for qualified psychologists can help meet that need, says L. Martin Johnson, PsyD, MBA, chair of the state association's Public Relations Committee.

"I think wherever people are looking at the data, we get support," Johnson says.

During the debate, psychologists highlighted the public need by developing an estimate that 55,000 people visiting federally funded health clinics annually could benefit from mental health services.

Using a 1991 state survey that found that 70 percent of all patients showing up for primary care in Hawaii also had a mental health issue, the 55,000 figure was extrapolated from the 78,000 patients treated in federally funded clinics in 2004, Miyamoto says.

Even those who have health insurance in more-populated Oahu face three- to six-week waiting times to see a psychiatrist, Miyamoto says.

As written, the legislation would have authorized psychologists with more than five years of practice to apply for prescriptive authority after completing a lengthy education and training process. The authority would be limited to psychologists practicing in the network of 13 federally funded health clinics offering primary care to the poor and uninsured.

During the debate, psychologists, Miyamoto says, were willing to compromise to meet concerns expressed by lawmakers about the bill. They supported amendments that lengthened the practicum period and limited approved medication in an effort to keep the legislation moving through the different House and Senate committees.

"We felt that we wanted to get something out this year, and that it would be possible to change it once psychologists had demonstrated safe practice," she says.

Those amendments included:

  • Removing antipsychotics and stimulants from the formulary of approved drugs psychologists could prescribe.

  • Requiring the education in psychopharmacology to be part of a postdoctoral master's program with 500 hours of instruction.

  • Increasing the supervised practicum to two years, with a minimum of 500 contact hours and 150 patients, an increase from 400 contact hours and 100 patients.

  • Requiring collaboration with a physician on treatment.

The requirements to achieve prescriptive authority are different in New Mexico and Louisiana. In New Mexico, after completing 450 hours of instruction, a psychologist needs to complete a supervised 400-hour practicum with a minimum of 100 patients and pass a national certification exam in order to apply for a conditional prescribing certification. During a two-year conditional period and after, psychologists are required to maintain a collaborative relationship with the patient's primary-care physician on the patient's care.

In Louisiana, a psychologist must complete a postdoctoral master's degree in clinical psychopharmacology and pass a national certification exam to be eligible for prescriptive authority. Once certified, the medical psychologist is required to "consult, collaborate and concur" with the patient's primary-care physician on prescribing psychotropic medication, adjusting dosages or discontinuing medication.

Unlike the Hawaii bill, which would have excluded specific drugs, New Mexico's formulary includes all drugs approved by the federal Food and Drug Administration for the treatment of mental disorders. Louisiana's formulary includes non-narcotic drugs related to the diagnosis and treatment of mental and emotional disorders.

Opposition to the bill came from the Hawaii Psychiatric Medical Association and the Hawaii Medical Association, says Miyamoto. She described the opposition as "extremely intense," with psychiatrists lining up at long hearings to testify against the bill and barraging newspapers with letters opposing the move.

Overall, psychiatrists arguedthat the training program was too short; that patient safety would be put at risk because many people with mental health problems also have physical ailments; that psychotropics present a unique risk to patient safety because they cross the blood-brain barrier; and that access to mental health care in Hawaii isn't a problem, Miyamoto says.

Miyamoto says the amendments won the support of some legislators, but couldn't sway others to move toward the psychologists' position.

"For others, it was just the issue in general, and that it was being lobbied against by such a strong group," she says.

If the bill had gone forward, Hawaii could have been the third state granting prescription privileges to psychologists. New Mexico approved prescriptive authority for psychologists in 2002, followed by Louisiana in 2004. The territory of Guam came first in 1999.

According to APA's Practice Directorate, psychologists certified to prescribe have written more than 10,000 prescriptions without incident in New Mexico and Louisiana since February 2005. Statistics are not available on how many prescriptions have been written by certified military psychologists trained through the Psychopharmacology Demonstration Project.

Prescription legislation was also introduced this year in Georgia, Connecticut, Missouri and Tennessee, and Miyamoto hopes Hawaii follows this year's progress with full success in 2007.

"We should be in good shape for next year," she says.