Should Psychologists Have Prescriptive Authority?

Article Outline

• Support for Psychologist Prescribing
• Rationale Against Psychologist Prescribing

Cynthia A. Diefenbeck, PsyD, APRN, BC, is an assistant professor in the University of Delaware School of Nursing. She holds a PsyD in clinical psychology from Philadelphia College of Osteopathic Medicine, an MSN specializing in adult mental health from University of Pennsylvania, and a BSN from the University of Delaware. She is an advanced practice nurse with prescriptive authority and a licensed clinical psychologist. She has over a decade of experience working with adults in a wide variety of psychiatric settings. She currently serves on the review panel of the Journal of Psychosocial Nursing and maintains a modest outpatient caseload at Mid-Atlantic Behavioral Health in Newark, DE.

Maren S. Mayhew, MS, ANP, GNP, is an author and editor of Pharmacology for Primary Care Providers, a textbook for nurse practitioners published by Mosby, and writes the “Prescription Pad” column for JNP. She also practices in an integrative cardiac prevention program at Walter Reed Army Medical Center in Washington, D.C. As the faculty member responsible for teaching advanced pharmacology in an NP program she was also part of a three-year trial program that taught psychologists to prescribe medications.

At entry level, licensed clinical psychologists are experts in the diagnosis and nonpharmacologic treatment of human behavior problems but not in pharmacologic treatment. A shortage of psychotropic prescribers has caused the development of educational programs to teach certain psychologists the knowledge required to prescribe such agents. Advanced practice nurses have demonstrated for years that they are capable of diagnosing and safely managing a variety of health problems, including many psychiatric disorders. Like nurse practitioners (NPs), psychologists who prescribe medicine can improve access to desperately needed care. Also similar to NPs, there are no data indicative of poor outcomes associated with prescribing by psychologists.

Psychologist prescribing is not widespread, nor is there consensus among psychologists that prescribing should be part of their role. NPs are strongly educated to look at the whole patient and may question whether other disciplines are prepared to do the same. Do prescribing psychologists understand the potential impact of psychotropic agents on electrolytes, blood pressure, the gastrointestinal system? Do they understand how comorbidities such as diabetes, cardiac disease, stroke, or glaucoma may impact or be impacted by pharmacologic intervention?

The potential for drug interactions is also a concern. Are psychologists aware of what they don't know? Physicians have asked similar questions about nurse prescribers. Perhaps the larger question is how boundaries between disciplines should be defined.

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Support for Psychologist Prescribing 

Cynthia A. Diefenbeck

Given the nationwide shortage of psychiatric prescribers, it makes sense to increase the pool of providers. Waiting times for initial medication evaluations vary by location, but patients often wait 2 to 3 months. In some severely underserved rural areas, the wait can be as long as 8 months, and many patients must travel long distances. The shortage is even worse for children and adolescents. Many providers no longer accept Medicaid, Medicare, or any insurance at all, or they do not have sliding scale fee structures. All of this makes access to and affordability of specialist treatment even more challenging.

Psychologists are prepared to diagnose and treat the spectrum of mental illness. Psychologists with prescriptive authority are in a unique position to provide their patients optimal treatment—the combination of therapy with psychopharmacology.

Not every psychologist is interested in obtaining prescriptive authority. Those who do are required to complete a rigorous and organized course of study that includes coursework in “basic life sciences, neurosciences, clinical, and research pharmacology and psychopharmacology, clinical medicine and pathophysiology, physical assessment and laboratory exams, clinical pharmacotherapeutics, research, professional, ethical and legal issues,” according to the American Psychological Association (APA). In addition, several hundred hours of physician-supervised practicum with direct patient contact are required. Finally, prescribing psychologists must pass a national certifying examination.

The APA also says “Psychologists in the U.S. Department of Defense have been prescribing for more than 10 years without incident, while qualified psychologists in Louisiana and New Mexico have been doing so for nearly 3 years.”²

If we keep the patient at the center of the dialogue and the requirements for obtaining and maintaining prescriptive authority remain rigorous, it makes sense to increase the supply of mental health professionals who can provide psychopharmacologic treatment options to their patients.

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Rationale Against Psychologist Prescribing 

Maren S. Mayhew

It is true there is a shortage of prescribers. However, in order to increase access to care, we should focus on developing an adequate number of primary care providers who can prescribe psychotropic medications.

Prescribing medications requires in-depth knowledge of anatomy and physiology, pathophysiology, physical assessment, and primary care. These can be taught in a series of college level classes over a period of years; this information cannot be learned in a semester or two.

Prescribing a medication requires that a proper assessment is made. This involves a physical examination, placing a stethoscope on a chest, palpating an abdomen. Psychologists are trained to never touch their patients. Are they willing to violate this norm?

The focus of the debate is on the prescribing of medication as if choosing the right medication and writing the prescription is all there is to it. It is looked at as following a recipe. Current guidelines do not dictate which drug should be used for a particular set of patient characteristics; instead, considerable clinical judgment goes into selecting a drug.

This focus on choosing the right medication ignores the necessity of monitoring the patient afterward for therapeutic and adverse effects. Patients are complicated. They can develop symptoms that could be from medication or something unrelated. All medications have the potential to cause significant adverse effects. For example, serum serotonin reuptake inhibitors (SSRIs), the safest of psychotropic medications, can cause many adverse reactions, such as GI side effect or a rash, which can be innocuous or serious. SSRIs can also cause renal and hepatic dysfunction, the signs and symptoms of which can be subtle and require an astute clinician to ascertain.

I do not usually consider it to be my place to criticize another profession. However, in this case, I believe that psychologists should not prescribe medications.