High marks for psychologists who prescribe

Some trained to write prescriptions in now-defunct military program are still prescribing.

By Lisa Rabasca
Monitor staff

Psychologist John Sexton, PhD, had to wait seven months to write his first prescription, even though he had earned the authority to prescribe through a rigorous training program for military psychologists.

But since Feb. 10, 1995, when he wrote his first prescription for sertraline, Cmdr. Sexton has treated 976 patients and written hundreds of prescriptions, and not one patient has had a significant adverse event.

As the first of 10 psychologists who graduated from the Department of Defense Psycho-pharmacology Demonstration Project (PDP), today Sexton finds his prescription-writing services are welcomed by colleagues and patients. As head of the mental health department at Navy Hospital in Camp Pendleton, Calif., he is living proof that licensed clinical psychologists can be trained in medicine and psychopharmacology to safely and effectively prescribe.

A report by the General Accounting Office (GAO) released in June backs that conclusion, rating the quality of care provided by Sexton and his nine classmates as good to excellent.

"Without exception, [prescribing psychologists'] supervisors--all psychiatrists--stated that the graduates' quality of care was good," states the GAO report. In fact, several physicians told GAO that they came to rely on the graduates for information about psychotropic medications.

The report provides medical personnel, psychologists and state legislators with evidence that psychologists can be trained to prescribe safely and effectively, say APA officials.

The 26-page GAO report acknowledges that most PDP graduates serve in positions of authority, such as clinic directors or department chiefs, and prescribe independently without physician supervision. The report also finds that the graduates reduced the time that patients must wait for treatments by eliminating a patient's need to seek follow-up appointments with psychiatrists for medication and increasing the number of patients, including dependents, who can be treated for free.

"Up until now, most of the discussion has focused on whether or not psychologists could ever competently and safely prescribe psychotropic drugs," says Stephen Ragusea, PsyD, an APA council member who followed the issue of prescription privileges for psychologists for 25 years.

Now that we know they can, he says, that discussion needs to change. "We need to focus on how we're going to apply this knowledge."

Good quality, but cost-effective?

But the report is not all good news. It concludes the graduates will have a negligible effect on military readiness because there are only 10 of them, compared to the military's 400 psychiatrists and 400 psychologists. The graduates would likely have little effect on readiness during wartime, the report further concludes, because psychotropic drugs aren't generally used to treat combat stress.

The report also finds that the military spent more to train the 10 prescribing psychologists than it would have spent providing mental health services through a traditional mix of psychologists and psychiatrists.

A previous GAO report on the program came to a similar conclusion.

"Training psychologists to prescribe medication is not adequately justified," states the 1997 report, "because the Military Health Services System has no demonstrated need for them, the cost is substantial and the benefits are uncertain."

Sexton disagrees with these aspects of the report. Instead, he contents that prescribing psychologists can play a significant role in providing mental health services to military personnel and their families by decreasing the waiting time for psychiatric treatment and offering "one-stop shopping" through one provider who can perform psychiatric testing and psychotherapy, as well as prescribe medication.

"The reality is we are manned significantly below our peacetime needs for psychiatrists and I would venture to say the other services are in a similar situation," he explains, emphasizing that his comments were his own opinion, not that of the Department of Defense (DoD) or the Navy.

In fact, he says, GAO didn't see the value prescribing psychologists add to mental health efforts.

"To be a good warrior one needs to be taken care of well in peacetime and know that his or her family will have access to health care at a military hospital while he or she is off at war," Sexton says. "We often are unable to treat family members of military personal at military hospitals because we don't have enough psychiatrists."

Fellow graduate Tim Duke, PhD, agrees that prescribing psychologists can be helpful to the military in wartime and peacetime. During combat, psychologists could help psychiatrists treat more soldiers and units at the front, says Duke, clinical director of Cass County Psychological Services in Harrisonville, Mo. During peacetime, psychologists can help the military provide more cost-effective services to retirees and dependents, says Duke, who graduated in 1997.

Sexton also contends that the GAO's cost analysis is flawed.

"The start-up costs in creating 10 of us were tremendous," Sexton says. "Now that the program is shown to be effective, the start-up costs and much of the evaluation costs wouldn't need to happen."

Sexton's conclusion is backed by a 1996 report on the program, commissioned by the DoD, which concluded that the DoD program would be cost-effective even if the graduates only prescribed 59 percent of the time. Cost savings, said the report, would be realized largely by eliminating the need to switch patients from psychologists to psychiatrists when drug therapy is needed.

Despite this favorable report, the demonstration program was terminated in June 1997; however the psychologists continue to prescribe.

Putting knowledge to work

But, says Russ Newman, PhD, JD, APA's executive director for practice, the demonstration program is no longer necessary because it has answered the question of whether licensed psychologists could be taught to safely and competently prescribe medications. Now, he says, it should be up to each military branch to decide if it wants to train psychologists as part of its ongoing training program.

"The armed services should be free to use the knowledge that's been gained from the demonstration project," he says.

State psychological associations should also use that information, he says. They could provide copies of the GAO report to legislators when advocating for state laws to allow psychologists to prescribe. Four states introduced bills that would have granted prescription privileges to psychologists: Alaska, Georgia, Illinois and Louisiana. Georgia and Louisiana failed to enact their bills, and, at press time, proposals were still being debated in Alaska and Illinois.

In the meantime, many psychologists agree that professional psychology should move forward with educating psychologists about prescription drugs and preparing them for potential prescription-writing authority.

"Even if the psychologist never writes a prescription, he or she will be a better psychologist because a good percentage of that psychologist's patients are taking psychotropic medication," says Sexton. "And that psychologist would be able to speak about the medication's side effects, suggest alternatives, and know more about complicating medical illnesses."



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