A history of prescription privileges

By Ronald E. Fox, PhD and Morgan T. Sammons, PhD

One of the most controversial issues facing professional psychology during the 1990s has been whether the profession should collectively seek prescriptive authority.

Supporters of prescription privileges view them as the next logical step in expanding the clinical scope of practice of psychologists. They note that psychologists fought successfully for the right to independently bill third-party insurers in the 1970s and further expanded their scope of practice to include hospital practice privileges in numerous states in the 1980s and 1990s.

At the same time that psychology was becoming more intimately and independently involved in the health care of the nation, other nonphysician health-care professions also were making extraordinary gains in expanding the scope of their practices. It is appropriate to view psychology?s efforts to achieve prescriptive authority in the context of advances made by other health-care professions.

Prescriptive authority among other professions

A critical policy decision that psychology made early on was to seek 'independent' prescriptive authority. Physicians possess broad prescriptive authority. Dentists, optometrists, and podiatrists are generally deemed 'limited practitioners' with 'independent' status (i.e., no requirement of physician involvement), but are restricted in practice to specific body parts or conditions affecting those body parts.

In contrast, physician assistants, nurse practitioners and pharmacists are usually classified as 'physician extenders,' although nursing is gradually transitioning into 'independent' status. Optometry first obtained prescriptive authority in the State of Indiana in 1935. Forty years later (in 1975), nurses obtained similar authority in North Carolina.

Today dentists, optometrists, and podiatrists have the authority to prescribe, from varying forms of limited formularies, in all 50 states. By 1997, nurses holding several different advanced practice degrees, had obtained the authority to prescribe from limited formularies in all but one state, and without physician oversight in 26 states. Physician assistants possess the authority to prescribe under a physician?s supervision in 40 states. Doctors of pharmacy have begun a similar legislative quest for independent prescribing authority.

The increased autonomy of nonphysician health-care professionals to prescribe is seen by many observers as an index of their maturation. Psychologists seeking prescription rights assert that the rapid inroads made by these groups towards controlling the prescription pad are harbingers of fundamental changes in the way health care is delivered in the United States and abroad, where nonphysicians prescribing is already a relatively commonplace practice. They hold that prescriptive authority is a fundamental skill for psychologists who wish to remain competitive as health-care providers of the future.

A number of arguments have been promulgated in support of these assumptions. Those in favor point out that psychologists have more education and training in the assessment and psychosocial treatment of mental and emotional distress than any other profession.

Thus, psychologists are seen as the logical providers of psychotropics as they are well-equipped to effectively combine pharmacological and non-pharmacological interventions. Supporters note that the vast majority of psychotropic drugs in this country are currently prescribed by nonpsychiatric physicians, with minimal training in the detection and management of mental illness. Such a pattern of practice perpetuates a system in which psychotropic drugs are overprescribed, at the expense of behavioral interventions which are often both more effective and have fewer side effects.

Proponents also note that the ability to prescribe would increase the capability of psychologists to work with the seriously mentally ill. Currently, patients of psychologists needing psychotropics must also see a physician solely for the purpose of obtaining medication. This involves unnecessary inconvenience and expense to the patient, and increases the chance of miscommunication or adverse outcome. In sum, proponents believe that the seriously mentally ill would be better served by psychologists who could prescribe psychotropics as adjunct to well-designed psychotherapeutic regimens and who could manage the patient throughout the episode of care.

Opposition to prescriptive authority comes from within and outside of psychology. Within the profession, those opposed fear that psychologists? core identity as behavioral scientists would be lost and this would profoundly affect the importance attributed to basic science in graduate education.

They also believe that the clinical practice of psychology has prospered, in part because it has focused on nonphysical interventions. Adding this component would cause the practice of psychology to lose its unique expertise in psychotherapy and behavioral assessment. Prescribing psychologists risk becoming medication dispensers, or 'junior psychiatrists' who lack a medical education.

Opposition also stems from the fact that most existing psychology programs don?t have the faculty or other resources to provide the type of training needed to prepare psychologists to prescribe medications. Those who want prescription privileges for psychologists want the training to be postdoctoral, which would require programs to hire more faculty, a move that some fear could change the nature of psychology departments.

Opponents also predict a profound negative impact upon psychology?s relationship with organized psychiatry, destroying collaborative relationships built over several decades. They fear that even psychologists who are not interested in prescribing medication will have to do so in order to compete with their peers and that malpractice premiums for all practicing psychologists, not just those prescribing, will rise sharply.

From outside the profession, opposition to psychologists prescribing comes generally from the medical profession, and specifically from organized psychiatry. Psychiatrists opposed to the notion assert that to competently prescribe psychotropics, a medical education, including a psychiatric residency, is required. They predict that psychologists lacking such education will be public health hazards who will do harm to their patients.

Historical perspective

In November 1984, U.S. Senator Daniel K. Inouye urged psychologists at the annual meeting of the Hawaii Psychological Association (HPA) to seek prescriptive authority in order to improve the availability of comprehensive, quality mental health care. The following year, Richard Samuels, as President of APA Div. 42 (Independent Practice), issued a similar call for action.

Over the next several years, elected leaders of professional psychological associations began urging their colleagues to seek legislative authority to expand the boundaries of professional practice to include prescriptive authority.

In 1989, the APA Board of Professional Affairs (BPA) held a special meeting and strongly endorsed immediate research and study regarding the feasibility and the appropriate curricula in psychopharmacology so that psychologists might provide broader service to the public and more effectively meet the psychological and mental health needs of society.

Further, BPA strongly recommended that focused attention on the responsibility of preparing the profession to address current and future needs of the public for psychologically managed psychopharmacological interventions be made APA?s highest priority.

In the 1970s, the APA Board of Directors appointed a special committee to review this matter. The recommendation at that time was that psychology not pursue prescription privileges, primarily since the field was doing so well without that authority.

Over the years, policy documents adopted by the APA Council of Representatives laid the foundation for proactive action regarding prescription privileges. Although the council had never been asked to formally approve any particular clinical modality, many felt that the council should take specific action to endorse prescribing given the controversy within the profession.

Actions taken by APA?s governance

At the 1990 APA Council of Representatives meeting, a motion to establish an ad hoc Task Force on Psychopharmacology was approved by a vote of 118 to 2. The Task Force was charged with exploring the desirability and feasibility of psychopharmacology prescription privileges for psychologists and determining what training would be required.

Their 1992 report to the council concluded that practitioners, with combined training in psycho-pharmacology and psychosocial treatments, could be viewed as a new form of health-care professional, expected to bring to health-care delivery the best of both psychological and pharmacological knowledge.

Further, the proposed new providers had the potential to dramatically improve patient care and make important new advances in treatment. The Task Force recommended training at three distinct levels: Basic Psychopharmacology Education for all graduate students in health-care provider programs; Collaborative Practice to enable psychologists to work more closely with medical prescribers; and Level III?Education for Independent Prescription Privileges.

Meanwhile, psychologists in some states introduced enabling legislation granting prescriptive privileges to psychologists with appropriate training. The first psychology prescription bill was introduced in the Hawaii State Legislature in 1985.

After extensive hearings, the Hawaii House of Representatives enacted a Resolution, in 1990 calling for a series of roundtable discussions conducted by the State?s Center for Alternative Dispute Resolution, followed by a formal report and recommendations. By 1995, prescribing bills had been introduced in five different states.

Interestingly, in 1993 the Indiana legislature enacted into public law a provision expressly authorizing psychologists participating in a federal government sponsored training or treatment program to prescribe, although this provision has never been implemented.

The California Psychological Association (CPA), in collaboration with the California School of Professional Psychology, convened a special Blue Ribbon Panel of nationally renowned health professionals in May 1994, chaired by then-APA President Ronald Fox, to identify a model curriculum for prescribing psychologists. At its August 1995 meeting in New York, the APA Council of Representatives formally endorsed prescriptive privileges for appropriately trained psychologists and called for the development of model legislation and a model training curriculum.

By the 1996 Toronto meeting of the Council, the governance elements of APA had completed their work, and the Council formally adopted both a model prescription bill and a training curriculum. By this time the Committee for the Advancement of Professional Practice (CAPP) had assumed primary responsibility within the governance for legislative efforts to implement the new policy. The APA?s model bill proposed postlicensure certification by state psychology licensing boards, which would determine the conditions under which practitioners would be authorized to prescribe independently. The model training curriculum for licensed psychologists called for a minimum of 300 didactic contact hours in five core content areas, plus supervised, 'hands-on' medication treatment of at least 100 patients in both inpatient and outpatient settings.

At APA?s 1997 Annual Convention in Chicago, the council authorized its College of Professional Psychology to develop an examination in psychopharmacology suitable for use by state and provincial licensing boards once their legislatures have granted prescriptive authority to psychologists. Once again, when the council voted on the proposal, after extensive deliberation, only two hands were raised in opposition. The proactive stands taken by the council had a major beneficial effect on the prescription movement at the state association level.

By the beginning of 1998, prescription privileges legislation was either pending or about to be introduced in seven states: California, Florida, Georgia, Hawaii, Louisiana, Missouri and Tennessee; with five others actively planning for the near future. More than 25 other associations had established task forces to coordinate activities for their states. Perhaps most impressively, innovative training modules meeting the APA criteria had been developed by several schools of professional psychology, the Georgia and Louisiana Psychological Associations, and the Prescribing Psychologists? Register. These training modules were specifically planned to meet the needs and employment constraints of licensed practitioners already in the field. Collaborative efforts with nursing schools to train psychologists to prescribe as advanced practice nurses were also evolving.

Numerous surveys have been conducted on psychologists views about prescription privileges. Support for such privileges has increased the longer the issue has been debated and the more psychologists learn about it.

Surveys reported that nearly 75 percent of state associations? membership favored obtaining prescriptive authority, a very significant increase from the approximately one-third favorable ratings of surveys conducted only a decade before.

Federal government as a model

During the congressional deliberations on the Fiscal Year 1989 DoD Appropriations bill (P.L. 100?463), the department was directed to institute a pilot training program to train military psychologists to prescribe. This project, which became the center of a controversial legislative battle in the U.S. Congress, eventually graduated 10 fellows, each of whom received at least one year of didactic training and one year of clinical experience. These fellows were assigned to military facilities across the country where they have amassed substantial caseloads and have demonstrated a history of safe and effective use of psychotropics.

Summary

During the decade of the 1990s, organized psychology initiated a concerted effort to systematically obtain prescriptive authority at the state level. Colleagues within the federal system have demonstrated that they are able to utilize this clinical modality safely and competently and have improved the overall quality of care available to federal beneficiaries. Innovative training programs targeted towards those already in full?time practice have evolved. After extensive deliberations, APA?s Council of Representatives has formally endorsed obtaining independent prescription privileges as being within psychology?s appropriate scope of practice.

Ronald E. Fox, PhD, of Chapel Hill, N.C., is a former APA president. Morgan Sammons, PhD, is a graduate of the U.S. Department of Defense Psychopharmacology training program.

The opinions expressed in this article are personal views and do not reflect Department of Defense policy.

References

? Burns, S. M., DeLeon, P. H., Chemtob, C. M., Welch, B. L., & Samuels, R. M. (1988). 'Psychotropic medication: A new technique for psychology?' Psychotherapy: Theory, Research, Practice, and Training, 25, p. 508?515.

? DeLeon, P. H., Fox, R. E., & Graham, S. R. (1991). 'Prescription privileges: Psychology?s next frontier' American Psychologist, 46, p. 384?393.

? DeLeon, P. H., & Wiggins, J. G. (1996). 'Prescription privileges for psychologists' American Psychologist, 51(3), p. 225?229.

? Fox, R. E. (1988). 'Prescription privileges: Their implication for the practice of psychotherapy' Psychotherapy, 25, p. 501?507.

? Sammons, M. T. (1994). 'Prescription privileges and psychology: A reply to Adams and Bieliauskas' Journal of Clinical Psychology in Medical Settings, 1(3), p. 199?207.

A timeline of events in psychologists? efforts to obtain prescription privileges

1984

U.S. Senator Daniel K. Inouye urges psychologists at the annual meeting of the Hawaii Psychological Association to seek prescriptive authority in order to improve the availability of comprehensive, quality mental health care.

1985

? President of APA Div. 42 (Independent Practice) Richard Samuels also calls for psychologists to seek prescription privileges.

? The first psychology prescription bill is introduced in the Hawaii State Legislature in 1985. After extensive hearings, the House of Representatives enacted a resolution in 1990 calling for a series of roundtable discussions conducted by the State?s Center for Alternative Dispute Resolution followed by a formal report and recommendations. By 1995, prescribing bills had been introduced in five different states.

1989

APA?s Board of Professional Affairs strongly endorses studying of the feasibility and the appropriate curricula in psychopharmacology so that psychologists might provide broader service to the public and more effectively meet the psychological and mental health needs of society. The board also recommends that APA make its highest priority the responsibility of preparing the profession to address current and future needs of the public for psychologically managed psychopharmacological interventions.

The U.S. Department of Defense is directed to institute a pilot training program to train military psychologists to prescribe. This project, which became the center of a legislative battle in the U.S. Congress, eventually graduated 10 fellows, each of whom received at least one year of didactic training and one year of clinical experience.

1990

APA Council of Representatives approves the establishment of an ad hoc Task Force on Psychopharmacology, which is charged with exploring the desirability and feasibility of psychopharmacology prescription privileges for psycho-logists and determining what training would be required.

1992

The ad hoc Task Force on Psychopharmacology?s report to council concludes that practitioners, with combined training in psychopharmacology and psychosocial treatments, could be viewed as a new form of health-care professional that could bring to health-care delivery the best of psychological and pharmacological knowledge. Further, the proposed new providers had the potential to dramatically improve patient care and make important advances in treatment. The Task Force recommended training at three distinct levels: Basic Psychopharmacology Education for all graduate students in health-care provider programs; Collaborative Practice to enable psychologists to work more closely with medical prescribers; and Level III-Education for Independent Prescription Privileges.

1995

During APA?s Annual Convention, the Council of Representatives formally endorses prescriptive privileges for appropriately trained psychologists and called for the development of model legislation and a model training curriculum.

1996

At the Annual Convention in Toronto, council formally adopts a model prescription bill and a training curriculum.

1997

At the Annual Convention in Chicago, council authorizes its College of Professional Psychology to develop an examination in psychopharmacology suitable for use by state and provincial licensing boards once their legislatures have granted prescriptive authority to psychologists.

1998

Prescription privileges legislation is either pending or about to be introduced in seven states: California, Florida, Georgia, Hawaii, Louisiana, Missouri and Tennessee; with five others actively planning for the near future.