Psychologists Win Prescribing Rights

Not surprisingly, closing one of the Oregon legislature’s most longstanding “scope-of-practice” issues still feels unresolved
The Lund Report
February 25, 2010 -- Beginning in July of next year, licensed psychologists may gain the right to prescribe certain mental health drugs under a bill (Senate Bill 1046) that passed the Oregon House and Senate this week. Everything hinges on whether Gov. Kulongoski decides to veto the measure.
 
The bill sets up training and certification requirements for prescribing psychologists. While the bill marks the culmination of a longstanding debate at the state capitol, this issue is by no means resolved.
 
The matter must still come before a new committee that reports to the Oregon Medical Board before issuing its first license. In addition, lawmakers created yet another task force to bring recommendations to the 2011 Oregon Legislature.
 
And it still faces controversy. One of the votes against the bill came from Sen. Alan Bates (D-Ashland), a medical doctor who made his opposition known early on. Bates started something of a legislative dust-up in a Feb. 2 public hearing when he said a workgroup charged with recommending curriculum requirements “went off the track and did some things that were very inappropriate.”
 
At issue was the appointment to the workgroup of Dr. Morgan Sammons, dean and professor at the San Francisco-based California School of Professional Psychology, which has trained 350 psychologists to prescribe psychotropic drugs in the United States. Bates claimed Sammons was brought up from California and temporarily licensed in Oregon to serve on the workgroup with the implication being that schools such as his would benefit from the legislation.
 
“We license people in our state to practice medicine,” Bates said. “We don’t license people to serve on a committee to present something new and dramatically different in our state. We don’t do that. It’s outrageous and completely inappropriate. To me that corrupts the entire process.”
 
Debra Orman McHugh, executive director of the Oregon Board of Psychological Examiners, which appointed Sammons to the committee, called Bates’ comments “unfortunate” and that Sammons was chosen for his unique expertise. 
 
McHugh delivered a written response to the committee and later told The Lund Report that Sammons, a native Oregonian, was granted a limited permit as any licensed psychologist in another state would receive. Legislation that created the workgroup, McHugh said, required Sammons to be licensed, but not necessarily practicing in the state.
 
“We allow them to get a temporary permit to practice until they take a state exam,” McHugh said. Sammons received this temporary license in June 2008 and passed the Oregon written exam in October 2008.
 
Sammons told the committee at that Feb. 2 hearing that he was chosen for the workgroup for his experience. He said he planned to move back to Ashland, though he had never practiced psychology in Oregon. He now holds an administrative job and did apply for the Oregon license after being approached to serve on the workgroup. 
 
“When this issue came up in the spring,” Sammons said, “people asked that I be a member of this workgroup since I’m a native of Oregon, and everyone knew of my deep affiliation with the state and the prescriptive authority movement for psychologists. (They) asked if I would serve on this (workgroup) since I have a great deal of experience designing curriculum and working on this issue, so I received a temporary license on (sic) that.”
 
McHugh scoffed at whether Sammons had a conflict of interest. “You wouldn’t put somebody on a workgroup who had no knowledge about the topic,” she said. “To me that’s kind of silly.”
 
Sen. Laurie Monnes-Anderson (D-Gresham) who chairs the Senate Health Care Committee, called the episode a political stunt. “I’m appalled I was not notified earlier,” she told Sen. Bates. “To me, this looks like gaming the system to prevent something from going forward.”

Divisions Run Deep

 
Those opposed to the idea of giving psychologists prescribing authority, represented most vocally by the Oregon Medical Association and the Oregon Psychiatric Association, still say the legislation provides inadequate training and supervision.
 
Patient safety could be at risk, said John McCulley, lobbyist for the Oregon Psychiatric Association. In just two other states that grant similar privileges, New Mexico and Louisiana, a medical doctor must directly supervise a prescribing psychologist for at least two years after receiving a license, McCulley said. The Oregon bill, in contrast, requires “collaboration” with a healthcare provider.
 
“What Oregon is establishing here is much looser oversight,” said McCulley who said  none of his proposed amendments reported in our earlier story, such as restricting prescriptive authority to adults, were included in the final version.
 
Supporters of the bill say it sets up equally rigorous clinical training requirements that meet or exceed those needed to prescribe drugs in other medical professions.
 
The bill also opened deep fissures within the medical community and between psychologists, including testimony from Tanya Tompkins, a professor in psychology at Linfield College, who opposed the measure.
 
“Psychologists are deeply divided over the policy of the American Psychological Association (which supports prescriptive authority),” according to Tompkins. “Typically, although about 60-65 percent of those polled agree to nominal support for prescription privileges, questions have not typically addressed the extent of training that would be required.”
 
A national group, Psychologists Opposed to Prescription Privileges for Psychologists, also opposed the bill because it “allowed psychologists to prescribe medication with less than half of the medical training required of all other prescribing professionals.”
 
The Oregon Psychiatric Psychological Association, which has lobbied for prescriptive authority for more than 10 years, said the issue always ranks high on member opinion surveys, particularly among those living in rural areas where there’s an acute shortage of mental health providers. They contend psychologists are more qualified to prescribe mental health drugs than primary care providers who have such authority. (See related article)
 
Opponents contend they have no problem giving prescribing authority as long as psychologists receive proper training. It’s not about turf, but patient safety, according to Dr. James Cho.  
 
“Several of the antidepressants such as the monoamine oxidase-inhibitors could be easily fatal if taken with the wrong foods,” according to Cho. “Lithium is known to be very toxic and can exacerbate several medical conditions, and several of the antipsychotics such as Clozapine require frequent blood test monitoring. All the antipsychotics by the standard of care require that lab tests be done to monitor possible metabolic side effects that could lead to metabolic syndrome, and worse, possibly diabetes, a heart attack, or stroke.”  

Editor’s Note

 
In our previous article on this topic, we referenced a 15-year precedent with the Department of Defense in training psychologists to safely prescribe medications. Several astute readers took issue with this comparison.
 
Dr. James Cho provided a link to a study about the DOD program and an independent review of the study by the National Association of Mental Illness. He said military psychologists had more limited prescribing authority compared to what the Oregon bill grants.
 
“The psychologists in the military study had more limitations in their ability to prescribe, and the study, while not even applicable to the public by the military's admission was considered cost-ineffective,” Cho wrote.

“The citizens of Oregon deserve that an actual study be done that emulates the parameters of the proposed bill before they allow it to become a reality,” Cho continued. “To do otherwise would be to put patients through an untested medical process that could yield negative outcomes including death.”

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Comments

Let's make clear some facts: Morgan Sammons is the San Francisco-based dean of a private school that sells prescription training programs to psychologists online for $13,000 a pop. He was appointed to the Oregon board to develop training recommendations for psychologists who want to prescribe. Does anyone dispute that this is a conflict of interest? His influence would directly and financially affect the school he's an executive for. Oregon has laws about conflicts of interest. I hope they are enforced. Furthermore, the psychology board that appointment him should be held accountable for helping to create this conflict of interest. Let's hope the law extends to those in position of public trust who make a conflict of interest possible. These bills are pushed by the American Psychological Association, which has spent millions over 15 years failing in almost every state. They brag that they can send "SWAT Teams" to the states to push them. They sent in people from around the country to testify. They give hundreds of thousands to the state organizations ... how much did OPA get from this national group? The APA also has an entire division devoted to just this national political campaign. And who is the president of that political division? Dr. Morgan Sammons of San Francisco. Oh ... and they love to say this is a "grass roots movement" They grow grass in funny places at APA. Perhaps the people of Oregon would like to decide their future themselves.

Wow, this law should really boost enrollment for that guy Sammons’ online prescribing school. So, private companies from out of state get to write laws now that the rest of us have to live with? Is this what we elected our state representatives to allow? That one senator (Monnes-Anderson) must have gotten a big campaign donation or something for allowing this special interest junk to reach all of us who live here. Emergency special session indeed......

Pychologist are currently prescribing in two separate STATES, the United States Army (to include in the combat zone), United States Air Force, United States Navy, and the United States Public Health Services (HRSA, IHS) for several years without any adverse outcomes. There are armed forces psychologists that have been successfully prescribing for many years (since the 1990s). Actually, Dr. Sammon was a Navy Psychologist who successfully prescribed for many years to include the battle zone. Individuals using the excuse that allowing psychologists to prescribe is unsafe are using their emotional reactions and not the reality that up to date psychologists that prescribe have done it in a safe manner without any adverse impact to their patients. Actually, psychologists that prescribed have used the combination of evidence-base psychologically approaches and medications to effectively treat their patients. On most cases, the combination of these two treatment approaches have resulted in a decrease in the reliance of psychotropics and better treatment outcomes.

The opposition to prescribing privileges for psychologists by psychiatrists and the AMA is not surprising. They are at the top of the power heap and are afraid of losing power and money. Psychiatrists are trained, largely, by psychologists. Take a look at the faculty list at any medical school and look at the psychiatry courses, in specific. Mental health clients are vastly underserved. Over 40% of psychiatric residency vacancies must be filled from foreign countries because there aren't enough med students interested in psychiatry. The MD's in Oregon are making the same argument as they do in every state. I practice with 3 prescribing psychologists in New Mexico. They are extremely competent and provide comprehensive treatment to include therapy and meds. So, they prescribe fewer meds to each client. The psychiatrists feel threatened because they have given up their therapeutic skills over the last several decades. They have chosen to increase their incomes by seeing there clients for 10 minute med checks. The psychologists spend 50 minutes with them. If a psychiatric patient also receives therapy, they have to see someone different. No wonder the psychiatrists feel threatened.

Why do we allow people with no medical background knowledge, such as anything remotely related to physiology, anatomy, pathology, biochemistry and pharmacology to prescribe medicine? These people went to school of psychology, instead of school of medicine in the first place because they cannot handle these tough courses to begin with, now they wan to take a short cut, at the expenses of the well beings of patients?

Please....well trained psychologists know more about science and research methods than any non-PhD physicians. Memorizing information isn't science and I'd put a well trained psychologist's knowledge of neuroanatomy and psychopharmacology up against any psychiatrist and non-psychiatric physician any day. I think the short cut is the ridiculous legal drug pushing that remains rampant in today's behavioral "medicine". Most psychotropic prescriptions come from non-psychiatric physicians who, on average have behavioral rotations of about 8-12 weeks. You can have all the pharmacology, anatomy, etc. you want but if you don't know what you're treating or have no experience in diagnosis you're doing nothing but "banging the TV set" hoping to clear up the picture. Enjoy your protected license for Maslow's hammer. Maybe a simple course in ethics might change your view..

As a Clinical Psychologist I find your posting typical of ignorance and total lack of understanding of our profession. Let us examine the actual facts, once an individual is admitted into medical school only 1% of medical students do not make it through the program, that's counting death, medical schools "drag" their students through their programs. Now compare that to University based Clinical Psychology Programs that are very, very, selective and ulike medical schools a very high percentage of students do not make it through our programs. In my particular program twenty five students were accepted and in the end only five of us graduated. Clinical Psychology programs generally are four years of study consisting of numerous statistics, research, various treatment modalities, psychopharmocology, biological, psychological, neuorlogical testing. 1700 hours of pre-doc internships, and a year post-doc internship/residencies. oh least I forget, prior to starting the wonderful world of writing a disertation followed by orals exams, we have to complete two day's of testing called comp's which is two day's of testing that covers eight differant areas..including "psychopharocology". If an student fails one portion of the comps they generally have to wait six months to take that portion of the exam again. Now on to licensure, we are requires to take and pass national examination called the eppp, which includes knowledge of treatment metodology, which included's psychopharocology, but the "fun" is not done yet as many u.s. state require that you take a state exam. I work in a rural area and have admission privlidges in two hospitals. I never wanted precription privlidges, "however" after comming to the realization of just how little trainning or knowledge most general medical doctors have in mental health psycotropic medications it is your type of arrogance that has changed my mind. It is YOUR type of arrogance that leads to poor patient care, try to be honest with yourself, and your patients....how much knowledge and trainning have you had in mental disorders? Thanks Doc.

Let's keep in mind that Nurse Practitioners and Physicians Assistants are both allowed to prescribe and have much less training than MDs. Both of these professions require only a masters degree (with a maximum of 7 years education), whereas psychopharmacologists must have a PhD, practice experience, and a MS specifically in prescribing meds (that's a minimum of 12 years education, not including time spent as a practicing psychologist). Prescribing psychologists also have a 2 year probation period where they are supervised by a MD. In comparison, internal medicine physicians have a total of 8 years in school and typically 3-5 years of residency. Even excluding the years of education psychologists commonly suggest medication for patients to their PCPs and should know exactly what psychotropic medications do and how they act on the brain.

This last post is so inaccurate that as a Psychologist I must respond. Psychologists have ALWAYS, traditionally, not fought for any piece of the health care pie or gone into the profession for monetary gain. To depict the division within APA dedicated to studying and/or advancing prescription privileges for Psychologists as "lobbyists" is absurd. To the contrary it is physicians and psychiatrists that have done the above. Physicians routinely deal with patients that have comorbid psychological issues/disorders that research repeatedly shows they are ill-equipped to handle. Not only are they ill-equipped their arrogance that they have competence in this area causes patient harm. Psychiatrists are too few. Current crops of med students lack the heart and soul that created the profession of psychiatry. They must receive specialized training, work with difficult populations, for generally less money and higher burn-out. So the number of psychiatrists is really a national crisis. Psychologists however have been working with patients taking psychotropic medications since the beginning and some are unquestionably capable of going beyond just monitoring the effects of psychotropics on patients to prescribing them in the first place. I often know more than the docs I work with what would be the best decision tree of meds to initiate with a patient. Get your facts straight and prostelytizing and spreading propaganda.

Why fault the psychologists here? Of course this is about power and financial gain for the vast majority of those who oppose and those who favor prescribing privileges for psychologists. Psychologists are trying to get a bigger piece of the pie, so what? How is this any different than the battles dentists, podiatrists, and optometrists have waged (and won) against the medical establishment? The only reason psychologist haven't won the battle in more states is because MD physicians have more money with which to sway legislators and governors. If some enormously wealthy person decided to champion the cause of prescriptive authority for psychologists, resistance would fade as quickly as the campaign contributions were banked. The only real issue here is whether psychologists can be trained to competently and safely prescribe medications. Based on the training models proposed, psychologists would be better trained for their part than nurse practitioners or physician assistants. So, psychologists should drop the "I care so much about underserved people" line, acknowledge that cash and control are the major motivators, and find that wealthy champion. And to the psychiatrists I say, your days are numbered. You are physicians who no longer practice medicine and psychologists who are not trained in psychology. You need to find a new way to be relevant in the current mental health marketplace (and it is a market place).

There is absolutely no intelligent arguement against Prescribing Psychologist. Its all AMA fear of lost power and $$$$. AMA you're on notice. The monoploy is OVER. Change is coming and it dam well should:)

How sad that individuals-many claiming to be professionals-say such insulting things about each other. Worse they hide with out even signing their real names. Many of the above -I suspect- would have trouble helping others,let alone themselves given their lack of common courtesy. Michael Kaplan,M.S. (Educational Psychology)

Oregon Health & Science University's Department of Psychiatry should design and offer a MS program in psychopharmacology to licensed PhD level psychologists. Everyone wins. This way we would have less para-professionals (Nurse Practitioners, PAs, Family Medicine docs who only had 6 week of psych rotation in med school, but who prescribe most psychothropic meds) dominate the field which they know only superficially.

“Several of the antidepressants such as the monoamine oxidase-inhibitors could be easily fatal if taken with the wrong foods,” according to Cho. “Lithium is known to be very toxic and can exacerbate several medical conditions, and several of the antipsychotics such as Clozapine require frequent blood test monitoring. All the antipsychotics by the standard of care require that lab tests be done to monitor possible metabolic side effects that could lead to metabolic syndrome, and worse, possibly diabetes, a heart attack, or stroke.” All excuses. I have seen a psychiatrist who was far from new in the field and completely useless. Not once did he ever test my blood, examine me, take down my medical history, or even monitor my blood pressure while prescribing anti-depressants for me. In fact, the meetings were at his house, not a physicians office or hospital. When I tried to explain that I was not depressed and the anti-depressants were not what I needed, he told me I don't know the meaning of depression! He spent most of my $200 an hour vists talking about himself. What a joke. I then saw a psychiatric nurse at a mental health clinic who tried to get me to go on anti-depressants the first time I met her. She drew me a picture of the receptors in the brain, which as a biochemistry student, was just insulting. When I asked her about the side effects of a drug she pulled out a giant "drug dictionary" to look it up in front of me. Needless to say, I never went back. Now, I see an amazing psychologist who has receieved post-doctoral training in psychopharmacology. She figured out that I have ADD and in conjunction with a primary care physician who she recommended (since she currently cannot prescribe in my state), I have been prescribed the proper ADD drugs and my problems are GONE. hmmm....

Responding to the first poster, I am Dr. James Cho. The fact that you saw two people that performed poor work is not indicative of an entire field. A broken clock is wrong twice a day. I've seen several bad psychiatrists out there, as there is in any field. I'm glad you found a psychologist that apparently correctly diagnosed you. Appropriate pescribing psychotropics is, however, about more than correct diagnosis, and it appears the first two clinicians you mentioned got the diagnosis wrong, and the psychologist got it right. It's also about prescribing the right medication. With each disorder there are several possible choices. After that, it's about monitoring for the benefits and side effects. Several of the side effects can be dangerous if not outright fatal and require adequate medical training to identify. I've never been against psychologists working in conjunction with M.D.s In fact I strongly condone it, and apparently that type of situation helped you. I think a better solution to the shortage of psychiatrists is for psychologists to work with primary care doctors and nurse practitioners. I am, however, against psychologists prescribing without adequate training. The Oregon bill that was vetoed IMHO didn't lead to enough training and to date, the proponents of the bill have never provided a study that showed it's enough. They have often referenced the DOD study that was very different than the current bill. I'll also add that I don't know the psychiatrist of whom you mention, but I'm getting the impression he was not a good one.

"The fact that you saw two people that performed poor work is not indicative of an entire field." Yes, I agree with this. The point I am trying to get across is that in this debate, there have been many people who have attempted to label psychologists as inadequate and incompetent. As if they are incapable of learning biological sciences when in reality, the field is becoming increasingly biologically based. Clearly from my previous example there are many current prescribers (both psychiatrists and nurse practitioners) who shouldn't have the privileges to prescribe. You may think it is unique that I have encountered two is such a short time span, but they aren't the only two in this country. I'm sure we could find more than one legitimate malpractice suit in the United States in the last decade. I absolutely agree that there needs to be a stronger relationship between general practitioners and psychologists. "Appropriate pescribing psychotropics is, however, about more than correct diagnosis, and it appears the first two clinicians you mentioned got the diagnosis wrong, and the psychologist got it right. It's also about prescribing the right medication. With each disorder there are several possible choices. After that, it's about monitoring for the benefits and side effects. Several of the side effects can be dangerous if not outright fatal and require adequate medical training to identify." How can you prescribe the right medication if you don't make the right diagnosis in the first place? Perhaps the psychopharmacology training program is not up to par with the necessary standard medical education as you mentioned, but this does not mean that it cannot be revised and that psychologists are too incompetent to be able to understand classes of drugs, dosages, physiology, anatomy, and side effects. Prescription privileges or not, psychologists need to know these things in order to work effectively with others in their patient's treatment team.

I think that the APA and psychologists need to be more active in protecting their "turf." That is, every pediatrician, family medicine physician, PA and NP is practicing "advice giving" and "counseling" on behavioral issues and none of them have required training. If we are stopping psychologist from getting additional training to prescribe medication, then let's stop those who never received even a single class of education in the area of psychotherapy - there should be a LAW that REQUIRES all physicians and other para-medical staff where they have to refer people to psychologist! Psychologists should advocate for what is rightfully their field and that is counseling, psychotherapy, therapeutic communication, etc... I do not want my child to be getting "counseling" in a form of an advice from a pediatrician or a nurse practitioners, who don't know what they are doing... We have people like "Dr. Drew" who is an internal medicine doctor with only one-year fellowship in addiction medicine, who talks like a psychologist, except he is NOT - he never obtained required education, and yet nobody seems to mind this...