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policy_research_institute

PRESCRIBING PRIVILEGES TASK FORCE REPORT AND RECOMMENDATIONS TO THE NAMI BOARD OF DIRECTORS

Submitted by Ron Honberg and Joel Miller

Executive Summary:

On December 11, 2002, the NAMI Policy Research Institute (NPRI) convened a meeting of experts and stakeholders to discuss the complex issues surrounding the debate on prescribing privileges for psychologists as well as serious human resource shortages in the mental health workforce.

A series of presentations were provided offering the perspectives of psychiatrists, psychologists, psychiatric nurses, and county behavioral health directors on these issues. Based on input received at this meeting and independent research conducted by staff, the following staff recommendations are set forth.

Prescribing Roles and Impacts on Safety and Quality

  • Based on the information and evidence obtained at the Task Force meeting and in preparing this report, staff believe that it would not be appropriate at this time for NAMI to adopt a position in support of state legislation allowing prescribing privileges for psychologists.
  • Implementation of the New Mexico law granting prescribing rights to psychologists should be carefully monitored, through the Policy Research Institute and other vehicles, to assess its impact on patient safety and outcomes as well as its impact on addressing serious human resource shortages in public sector mental health.
  • There appear to be a serious lack of clinical protocols guiding advance practice psychiatric nurses and other non-psychiatrists authorized to prescribe psychiatric medications regarding when to seek psychiatric supervision or transfer complex cases to psychiatrists. Staff recommend that clinical protocols and algorithms be developed to guide practitioners in these treatment considerations.

Addressing the Workforce Shortage Crisis

Staff recommend several measures for addressing general workforce shortages in the mental health field that have been included in recent testimony submitted by NAMI to New Freedom Commission on Mental Health:

  • Providing scholarships or stipends to psychiatrist trainees, psychologist trainees, and other mental health professional trainees who commit to providing services to people with mental illnesses in under-served regions or sectors;
  • Establish and expand loan forgiveness programs for psychiatrists, psychologists and other mental health professionals who serve for particular periods in under-served regions;
  • Reducing stigma within the medical profession towards mental illness and psychiatry in general and thereby attracting more young medical students to specialize in psychiatry and/or psychopharmacology:
  • Paying adequate wages to case managers, counselors, and other important but traditionally inadequately compensated mental health professionals to retain qualified and dedicated individuals in the field; and
  • Employing consumers and family members in a variety of professionals capacities in the mental health field whenever possible.
  • Additionally, if the American Psychological Association is correct that 70% of psychotropic medications are today prescribed by general practitioners, it will be important to carefully examine the training and knowledge of these physicians about mental illnesses, psychopharmacology and interactions between psychotropic and other types of medications.

The following recommendations for addressing workforce shortages in the mental health field provided by the National Association of County Behavioral Health Directors should also be considered.

  • SAMHSA should conduct a comprehensive study to define the nature and extent of mental health workforce shortages across the country. This study should be organized by regions of the country to account for the variability in the availability of mental health professionals across the country.
  • Expand the existing mental health professional shortage designation program to include service within any public sector agency providing services to Medicaid beneficiaries.
  • Increase the number of psychiatrists permitted under the Medicare Graduate Medical Education Program and extend the Board Eligibility period for residents and fellows from five to six years.
  • Review the Need for the Development of a Public Mental Health Leadership Development Program. This is particularly important because many of today’s leaders in the field are aging out. There is a need for a sustained process for developing new leaders within the public sector mental authorities over an extended period of time. The program should not only teach and support leadership development but must also incorporate sector values within new leaders. Such a leadership development program should provide senior mental health leaders with a learning laboratory to assist them in creating and mapping the future of public mental health services in the U.S.

____________________________________________________________________

Background

The NAMI Board of Directors has charged NPRI with examining the policy issues surrounding prescribing privileges for psychologists and to provide policy guidance to the Board. This report to the Board provides a comprehensive overview of the debate on prescribing privileges, describes a meeting of experts convened to explore issues pertaining to prescribing privileges and workforce shortages in the mental health field, and offers a set of recommendations to the Board on prescribing privileges and boundary-related issues affecting the availability of providers.

Introduction

In 2002, Governor Gary Johnson of New Mexico signed into law a bill that grants licensed, doctoral-level psychologists who have completed a training and certification program the right to prescribe psychiatric medications. With passage of this law, attention is increasingly being riveted to policy questions surrounding whether psychologists should ever have the right to prescribe psychiatric medications and, if so, under what circumstances.

The contentious debate about prescription privileges is occurring with concerns about limited access to care and severe workforce shortages in the mental health field as a backdrop. The 1999 Surgeon General’s report revealed that fewer than one-third of all people with a diagnosable mental disorder in the U.S. receive treatment in a given year. And, the 1998 Schizophrenia PORT study, revealed that fewer than 50% of all people with schizophrenia receive even minimally adequate treatment in a given year.

One factor contributing to low rates of treatment and services for people with mental illnesses are the lack of qualified psychiatrists and other mental health providers in many parts of the country. There is compelling evidence that the nation’s supply of psychiatrists is shrinking, and that access to treatment with psychiatrists is particularly limited for lower-income individuals who rely on public mental health systems for treatment and services.

These problems are particularly severe in rural parts of the country. In fact, in New Mexico, the lead proponent of the prescribing privileges legislation noted that only 18 psychiatrists of the state’s 90 licensed psychiatrists are located outside of Santa Fe or Albuquerque, whereas 175 of the 400 licensed psychologists in the state reside outside of these two population centers.

At the same time, since New Mexico’s law is the first of its kind, there is no clear evidence that affording prescription privileges to psychologists will increase access to timely treatment for individuals with mental illnesses who reside in rural communities. And, opponents of the legislation argue that psychologists are not adequately trained to prescribe medications and expanding prescription privileges to psychologists will therefore seriously compromise the quality of care, safety and well-being of vulnerable individuals with mental illnesses.

History

The issue of prescribing privileges has appeared at several levels; notably through state legislation but also through initiatives by the federal government, as well as in the daily prescribing practices of general practitioners.

State Legislation

Psychologists

Since 1990, 12 states have rejected legislation to grant psychologists prescription privileges. These states (some of which have rejected prescribing legislation on multiple occasions) include Alaska, California, Connecticut, Florida, Georgia, Hawaii, Illinois, Louisiana, Missouri, Montana, Tennessee, and Texas. Not surprisingly, the state and federal chapters of the American Psychiatric Association and American Psychological Association have worked strenuously and expended considerable resources in opposition or support respectively of these legislative initiatives.

Nurse Practitioners and Other Advance Practice Nursing Professionals

All 50 states and the District of Columbia authorize nurse practitioners or other advance practice nursing professionals to prescribe medications, including psychiatric medications, with certain conditions. Nursing professionals authorized to prescribe medications include psychiatric nurse practitioners, clinical nurse specialists (psychiatric), certified nurse anesthetists and certified nurse midwives.

Most laws authorizing advanced nursing professionals to prescribe medications contain limits in terms of practitioners authorized to prescribe, drug schedules under which they may prescribe, or supervisory/collaboration requirements.

For example, certain states (e.g. Arizona, California, Georgia, Guam, Maryland, Mississippi, New Hampshire, North Carolina, Oregon, South Dakota, Washington) limit prescribing authority to nurse practitioners, while others authorize a broader range of nursing professionals. And, some states impose restrictions on the types of drugs that these nursing professionals may prescribe. For example, Alabama, California, Florida, Hawaii, Kentucky, Mississippi, Nevada, and the Virgin Islands restrict prescribing privileges by authorized nursing professionals to "noncontrolled substances only", including antibiotics, analgesics, and anti-inflammatory medications, among others.

Prescribing by General Practitioners and Other Non-Psychiatric Physicians

According to the American Psychological Association, 70% of psychiatric medications are today prescribed by general practitioners. General practitioners have extensive medical and pharmacology training, but may have limited training in psychiatry and psychopharmacology.

Department of Defense Demonstration Project

In 1989, Congress directed the Department of Defense (DoD) to create a Psychopharmacology Demonstration Project (PDP) to train military clinical psychologists to issue appropriate psychotropic medications to beneficiaries of the Military Health Services System. This program was operationalized in 1991. Between 1991 and 1997, ten military psychologists completed the training program and were granted the right to prescribe medications.

Research and Outcomes

Since New Mexico is the first state to authorize psychologists to prescribe medications, little research has been done on the impact of prescribing privileges for psychologists, including patient outcomes and safety factors. The only published research to date is on the DoD Demonstration Project.

Four separate evaluations were conducted of the DoD demonstration project. These evaluations yielded the following information across several parameters.

  • High Selection Criteria: Ten psychologists completed the DOD program and nine remained in the military employed as psychopharmacologists as of 1998. Most served in high-level supervisory positions at military hospitals or clinics. The American College of Neuropsychopharmacology (ACNP) reported that most graduates demonstrated high levels of competence and achievement when they entered the program. This, according to the ACNP, suggests that "selection standards should be high for candidates for any future prescribing psychologist training, be it military or civilian."
  • Types of Patients Treated: The ACNP study revealed that the majority of psychologists trained by the DoD to prescribe medications treated patients in outpatient clinics rather than hospitals. The majority of patients treated in these settings were diagnosed with adjustment disorders, anxiety disorders or depressive disorders. Only one trainee treated patients with more serious or acute psychiatric conditions in an inpatient setting.
  • Training: Most graduates of the DoD program expressed strong support for a two year program like the one they completed, emphasizing the importance of at least one year of supervised clinical training.
  • Effectiveness and Safety: Although many of the supervising clinical psychiatrists had reservations about the appropriateness of affording psychologists prescribing privileges, they unanimously rated the quality of care provided by these psychologists as good to excellent. Some supervisors reported that graduates brought a unique combination of psychopharmacology and behavioral expertise to their programs that many of the psychiatrists in these programs lacked.

Clinical supervisors reported no adverse patient outcomes resulting from treatment provided by psychologists who completed the PDP program. However, clinical supervisors unanimously expressed the opinion that graduates of the PDP program were weaker in terms of their medical expertise than psychiatrists. They also noted that graduates were aware of their limitations and did not hesitate to ask for advice, seek consultation or refer patients to psychiatrists when necessary.

  • Costs: The GAO projected that the DoD will spend somewhat more (7% higher) on its 10 prescribing psychologists than it would have spent on providing services with a more traditional mix of psychiatrists and psychologists.
  • Staff Morale: While graduates of the DoD program initially experienced strained relationships with some of their psychiatrist colleagues, these problems generally abated over time and most reported harmonious relationships with their psychiatrist colleagues.
  • Overall Impact on Capacity: The GAO concluded that the PDP program did not substantially improve the medical readiness of the Department of Defense. The GAO particularly emphasized that the program would not enhance the wartime readiness of the military because "psychotropic drugs are not generally the treatment of choice in combat and thus prescribing authority would not be in great demand." The GAO acknowledged that the peacetime capacity of the Department of Defense to provide medical treatment might be "modestly enhanced" as a result of the program.

It should be noted however that the human resource limitations that are today so pervasive in public mental health systems may not be as prevalent in the Department of Defense, which employed approximately 400 psychiatrists and 400 psychologists at the time of the 1999 GAO report.

The New Mexico Law – Description and Analysis

As stated above, New Mexico earlier this year became the first state to enact legislation granting authority to psychologists to prescribe psychiatric medications.

The legislation creates a two step process for licensing psychologists to prescribe psychiatric medications. Psychologists who meet certain requirements specified in the law are eligible to be granted "conditional prescribing certificates." Following an additional period of clinical supervision, psychologists with conditional certificates are then eligible to be granted general "prescription certificates." Authority for reviewing applications and determining whether applicants meet criteria for conditional or general certificates is vested with the New Mexico state board of psychologist examiners.

Conditional prescribing certification: To obtain a conditional prescribing certificate, a psychologist must, among other things, within five years of applying complete at least 450 hours of didactic educational instruction in at least the following core areas:

  • Neuroscience;
  • Pharmacology;
  • Psychopharmacology;
  • Pathophysiology;
  • Appropriate and relevant physical and laboratory assessment; and
  • Clinical pharmacotherapeutics.

Additionally, an applicant psychologist must, within five years of applying, be certified by a supervising psychiatrist or physician as having completed a supervised clinical practicum involving, among other things, at least four hundred hours treating no fewer than one hundred patients with mental disorders.

Finally, the applicant must pass a national certification examination approved by the board of psychological examiners that test’s his/her knowledge of pharmacology in the diagnosis, care and treatment of mental disorders.

General certification: A psychologist with a conditional prescription certificate may apply for a general prescription certificate after successfully completing two years of experience prescribing psychotropic medications under the supervision of a licensed physician. The state board of psychologist examiners is granted authority to develop additional requirements for general certification.

Additional requirements are set forth in the New Mexico law for psychologists to maintain their general prescription certificates, including:

  • No fewer than 20 hours per year of continuing education; and
  • An ongoing collaborative relationship with the health care practitioner overseeing the patient’s general medical care.

Liability of supervising physicians: The New Mexico law specifies that physicians supervising psychologists with conditional prescribing certifications are individually responsible for the acts and omissions of the psychologist while under their supervision. It will be interesting to see if concerns about liability deter physicians from willingness to function as supervisors.

Comparison with DoD curriculum requirements: Even though the DoD curriculum was scaled back after year one, it still required significantly more academic training and clinical training and supervision than the New Mexico law requires. For example, the DoD curriculum required 660 hours of academic training versus 450 for the New Mexico curriculum. Additionally, the DoD curriculum required approximately 1,900 hours of clinical training versus a minimum of 400 hours to be granted conditional certification in New Mexico.

Meeting of the Prescribing Privileges Taskforce:

In the wake of last year’s New Mexico legislation, it is very likely that prescription privileges bills will be introduced in a number of additional states in FY 2003. Historically, NAMI-national has remained neutral on this issue as a matter of policy, and NAMI state organizations have adopted positions on state legislative proposals with little guidance from the national office. However, the accelerating pace of the prescription privileges debate made it timely to convene a group of experts and representatives from stakeholder organizations to examine the issues surrounding this debate.

Members of the taskforce include:

  • Suzanne Andriukaitis, MSW, NAMI – Greater Chicago
  • Robert Egnew, MSW, MPH, National Association of County Behavioral Health Directors (NACBHD)
  • Edward Foulks, M.D., Ph.D., Chair, NAMI Policy Committee, Tulane University School of Medicine
  • Patrice Harris, M.D., American Psychiatric Association
  • Linda Manglass, RN, MS, CS, American Psychiatric Nursing Association
  • E. Mario Marquez, Ph.D., New Mexico Psychological Association
  • Diane Marsh, Ph.D., University of Pittsburgh at Greensburg.
  • Nicholas Meyers, Deputy Director, Federal Relations, American Psychiatric Association
  • Lt. Col. Elaine Orabonna-Mantell, Ph.D., Prescribing Psychologist, U.S. Department of Defense.
  • Sylvia Stevens, R.N., MS, CS, Prescribing Nurse, American Psychiatric Nursing Association.
  • CW Tillman, NAMI Consumer Council, New Mexico.
  • Jane White, DNSc, RN, MSN, CS, Executive Director, American Psychiatric Nursing Association.

The Task Force met on December 11, 2002 and heard presentations from representatives of the American Psychiatric Association, American Psychological Association, American Psychiatric Nurses Association and the Department of Defense.

Two threshold questions were at the core of NAMI’s consideration of this issue.

  • First, what are the potential implications of psychologists prescribing medications on the safety and well-being of consumers?
  • Second, will providing prescription privileges to psychologists increase access to treatment and services for consumers?

Supporters of prescription privileges for psychologists contend that safety concerns can be addressed through specialized training of psychologists who wish to obtain certification to prescribe medications. They argue that the current level of basic science training in graduation education in psychology is adequate to enable psychologists, with some additional specialized training, to safely and effectively prescribe psychiatric medications.

Opponents of prescription privileges for psychologists argue that graduate education for psychologists de-emphasizes the medical model in favor of a social and behavioral approach that trains psychologists to conduct psychological assessments and provide psychotherapy, not to provide medical treatment. They point out that psychotropic medications used to treat mental illnesses are very powerful, can cause potentially disabling and life-threatening side effects, and require particular expertise among those who prescribe and monitor them.

Additionally, they also emphasize the importance of experience and expertise in monitoring complex medication interactions, pointing out that over 50% of individuals with mental illnesses prescribed psychotropic medications also have other serious medical conditions requiring medications.

Staff Recommendations on Prescribing Privileges and Workforce Shortages:

Prescribing Roles and Impacts on Safety and Quality

Historically, NAMI has adopted no formal policy on prescribing privileges for psychologists.

  • Based on the information and evidence obtained at the Task Force meeting and in preparing this report, staff believe that it would not be appropriate at this time for NAMI to adopt a position in support of state legislation allowing prescribing privileges for psychologists.

Research on the safety and efficacy of psychologists prescribing is currently very limited. The only research that has been conducted has been on the Department of Defense Psychopharmacology Demonstration Project (PDP). It appears that ten psychologists successfully completed this program, nine continue to prescribe, and there have apparent been few, if any adverse effects on patient outcomes or safety.

However, the PDP was conducted under circumstances very different from those experienced by mental health practitioners in the public sector. For one thing, DOD psychologists practice under controlled circumstances, with specific formularies and close collegial relationships with psychiatrists. Moreover, with some exceptions, they tend to treat patients with less serious mental illnesses.

By contrast, psychologists in the public sector would more likely treat patients with more serious mental illnesses and other medical conditions. They would also have less access to consultation and supervision by psychiatrist colleagues, due to severe workforce shortages in the public sector.

  • Implementation of the New Mexico law granting prescribing rights to psychologists should be carefully monitored, through the Policy Research Institute and other vehicles, to assess its impact on patient safety and outcomes as well as its impact on addressing serious human resource shortages in public sector mental health.
  • There appear to be a serious lack of clinical protocols guiding advance practice psychiatric nurses and other non-psychiatrists authorized to prescribe psychiatric medications regarding when to seek psychiatric supervision or transfer complex cases to psychiatrists. Staff recommend that clinical protocols and algorithms be developed to guide practitioners in these treatment considerations.

Addressing the Workforce Shortage Crisis

Although workforce shortages are clearly a problem in the mental health field, it is unclear what impact, if any, affording prescription privileges to psychologists will have on increasing timely access to medications for people with severe mental illnesses. The New Mexico experience may shed light in this regard, but data is unlikely to be available for a number of years.

Staff recommend several measures for addressing general workforce shortages in the mental health field that have been included in recent testimony submitted by NAMI to New Freedom Commission on Mental Health:

  • Providing scholarships or stipends to psychiatrist trainees, psychologist trainees, and other mental health professional trainees who commit to providing services to people with mental illnesses in under-served regions or sectors;
  • Establish and expand loan forgiveness programs for psychiatrists, psychologists and other mental health professionals who serve for particular periods in under-served regions;
  • Reducing stigma within the medical profession towards mental illness and psychiatry in general and thereby attracting more young medical students to specialize in psychiatry and/or psychopharmacology:
  • Paying adequate wages to case managers, counselors, and other important but traditionally inadequately compensated mental health professionals to retain qualified and dedicated individuals in the field; and
  • Employing consumers and family members in a variety of professionals capacities in the mental health field whenever possible.
  • Additionally, if the American Psychological Association is correct that 70% of psychotropic medications are today prescribed by general practitioners, it will be important to carefully examine the training and knowledge of these physicians about mental illnesses, psychopharmacology and interactions between psychotropic and other types of medications.

In addition, the following recommendations for addressing workforce shortages in the mental health field provided by the National Association of County Behavioral Health Directors should be considered.

  • SAMHSA should conduct a comprehensive study to define the nature and extent of mental health workforce shortages across the country. This study should be organized by regions of the country to account for the variability in the availability of mental health professionals across the country.
  • Expand the existing mental health professional shortage designation program to include service within any public sector agency providing services to Medicaid beneficiaries.
  • Increase the number of psychiatrists permitted under the Medicare Graduate Medical Education Program and extend the Board Eligibility period for residents and fellows from five to six years.
  • Review the Need for the Development of a Public Mental Health Leadership Development Program. This is particularly important because many of today’s leaders in the field are aging out. There is a need for a sustained process for developing new leaders within the public sector mental authorities over an extended period of time. The program should not only teach and support leadership development but must also incorporate sector values within new leaders. Such a leadership development program should provide senior mental health leaders with a learning laboratory to assist them in creating and mapping the future of public mental health services in the U.S.

Conclusion

The contentious debate on prescribing privileges for psychologists is obfuscating serious underlying problems with lack of qualified mental health professionals that are growing worse by the day. It is critically important that we carefully assess the experience of the New Mexico law and support a comprehensive effort to address the lack of qualified mental health professionals and its impact on accessibility to mental health treatment.

 

 

 

 

 

 


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