Governor Wields Final Say on Psychologist Bill

No matter what he decides, this issue will come back to haunt the 2011 Oregon Legislature next February
March 4, 2010 -- The battle lines have been drawn, and now it’s up to Gov. Kulongoski to determine whether psychologists should be able to prescribe psychotropic drugs.
Unless the governor uses his veto pen before April 8, Oregon will become the third state in the country – along with New Mexico and Louisiana -- with such a privilege.
Despite passing by a comfortable margin during the February special session, (48-9 in the House and 18-11 in the Senate), the bill remains contentious, as we reported previously. The arguments revolve around patient safety, training, curriculum requirements and physician supervision.
With the governor on the hot seat, no matter what he decides, this issue is unlikely to fade into the sunset. A veto would undoubtedly lead to another heated debate in the 2011 legislative session.
If Kulongoski gives his consent, psychologists couldn’t be certified until the Oregon Medical Board sets up a special committee to review the curriculum and training.      
“They get a whole other whack at it,” said Donna Silverberg, the facilitator who led a work group of psychologists, psychiatrists and primary care physicians, which determined those requirements before Senate Bill 1046 reached the legislative chambers at the February session. “Our conversations were rich and robust.”
But everything didn’t run smoothly at the work group, according to John McCully, the lobbyist who represents the Oregon Psychiatric Association. In fact, one psychiatrist mentioned he felt “kind of coerced” into agreeing to the new training requirements.
“I’m surprised to hear that because that’s not the experience I had,” Silverberg said. “I don’t ever remember anyone saying they felt coerced. Rather it was an open place to have conversations.”
The work group agreed to keep the meetings confidential so people could talk freely and get into the “nuts and bolts,” she said. Representatives from the Oregon Psychiatric Association, the Oregon Psychological Association and legislators were allowed to attend, but couldn’t share the details. “These were highly educated and very articulate and high integrity individuals who were working to solve a problem.”
Appointed by their licensing boards, the work group members didn’t talk about whether giving prescribing privileges “was the right thing to do,” said Dr. L.G. Fagnan, a family physician at OHSU. “Our task was to define the curriculum, what it should look like and how this should be processed.”
In 2009, there were 1,227 licensed psychologists in Oregon and 481 psychiatrists, with the overwhelming majority practicing in urban communities, according to research by Fagnan who directs the Rural Health Network.
“This will have zero impact, and not change the distribution in rural Oregon because primary care physicians are the ones prescribing these medications,” Fagnan said. “My sense is that we’re going through this process for a handful of folks who want to prescribe.”
That’s exactly why psychologists need these privileges, according to Lara Smith, the lobbyist for the Oregon Psychological Association. Right now 80-90 percent of psychotropic medications are being prescribed by primary care physicians who don’t have special training in diagnosing mental health illness. “If you can’t diagnose correctly, how can you prescribe the right medication?” she said.
This fight has turned into a turf battle about scope of practice, according to Dr. Robert Julien, PhD, a retired anesthesiologist and psychopharmacologist. “Those in opposition are largely self-serving and more interested in turf protection than in better mental health delivery to Oregon residents,” said Julien, who believes giving such privileges to psychologists will help integrate practice standards in a more cost effective and efficient manner.
“To say this is just a turf battle is irresponsible,” said Jeff Heatherington, CEO of FamilyCare. Being able to prescribe drugs means that someone has reviewed the bodily system, done a physical history and a differential diagnosis. “Psychologists aren’t trained to do any of that.”
What happens when a physician disagrees with the psychologist about a certain psychotropic drug, said John McCulley. “There’s no opportunity for them to override their decision.”
When it comes to children, Dr. David Willis, president of the Oregon Pediatric Society, has serious concerns. “It makes me shutter to think about giving psychologists prescribing rights. I don’t want to compromise the safety of children. This is a bad way to solve a problem.”
None of these issues were raised during the February special session, said Smith. “Collaboration is one of the strongest pieces in this bill, and liability issues are clearly spelled out.”
Every time there’s a change in the physical or psychological status of a patient, a physician and psychologist must work together, she said. “I don’t think there’d be a problem where a provider was prescribing medications that didn’t work well. A psychologist has the ability to diagnose and treat mental illness where many of our physicians don’t have ability to diagnose a mental illness.”
The Oregon Medical Association, together with organizations representing pediatricians, psychiatrists, osteopaths, orthopaedists, anesthesiologists and ophthalmologists, is also urging Gov. Kulongoski to veto this measure. “We strongly believe patient care will suffer if this bill becomes law,” according to their letter.
For related stories click here.
To read the bill click here.

To listen to the most contentious public hearing on the bill click here.


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A quote from the article: “I don’t think there’d be a problem where a provider was prescribing medications that didn’t work well. A psychologist has the ability to diagnose and treat mental illness where many of our physicians don’t have ability to diagnose a mental illness.” This is NONSENSE! As an advocate for the welfare of foster children, who are medicated at a rate 4-5 times the general population, I can tell you that a large number of these children are prescribed medications that don't work well BY PSYCHIATRISTS and other medical professionals. Theese children are not carefully monitored, physical health issues that affect mental health are often missed, side effects are often not noticed or attributed to other causes (and frequently medicated with yet more drugs), and ineffective treatments can be continued for YEARS before anyone says a word to challenge them. And when we as advocates do bring it up, the resistance by professionals to re-examining treatment options is frequently extreme. Part of this is because, as many people do not know, there is no objective way for psychologists or anyone else to diagnose mental illness. They are diagnosed by checklists of symptoms which, as the DSM diagnostic manual readily admits, could be caused by any number of things, both physical and psychological in nature. Since there is no test for mental illness that can be relied on, diagnoses vary widely and criteria for successful treatment are extremely weak. Hence, it is primarily a matter of presonal or professional opinion whether a particular treatment "works" or "doesn't work," and the prescribers usually win out when opinions conflict. Psychologists have played a role historically in providing a broader context for "diagnoses" and helping us assess both causal factors and a range of psychosocial interventions that get beyond mere symptom reduction. It seems unfortunate, at best, that psychologists are advocating for abdicating this important role and embracing the reductionistic medical model that increasingly dominates the field. The basic tenet of that model seems to be: we don't care why you feel like you do, we just want your "bad feelings" to go away. This works well for pharmaceutical companies and perhaps for physicians that are only concerned with short appointments and maximizing their profits, but for those who care about what happens to people as a result of our "treatments", it is a totally unacceptable viewpoint. We should also all remember that medication of any type can be dangerous. An article several years ago in the prestigious Journal of the American Medical Association found that the third leading cause of death in the USA was from receiving medical care. The huge bulk of the deaths were not from medical errors, but from side effects of drugs appropriately prescribed and administered. We also know that chronically mentally ill people die an average of 20 years earlier than their non-labeled counterparts in society. We can attribute at least a significant portion of these early deaths to the cumulative or acute impact of the drugs they take for their condition. Psychologists will not ever be in a position to take all of the possible risks of medication use into account. Psychiatrists aren't doing a very good job of it even now. Drugs treat symptoms, they don't cure mental health problems. A wide range of options should be made available to everyone who is suffering from mental or emotional challenges, including those that help the person recover, not just cope with symptoms. Prescriptions are generally all to easy to get hold of as it is - it is the other kinds of treatment that are unavailable. And giving psychologists prescribing rights will do nothing to assist rural communities anyway, as the bulk of psychologists live in urban areas with the psychiatrists. What we really need is a way to create real options for mental health consumers in both rural and urban areas so that the current over-reliance on medical means to "treat" mental illness can be brought under control. In addition to being very dangerous, this bill takes us in the opposite direction. I hope it is vetoed.