SB 1046: Opposing Prescription Privileges for Psychologists

February 2, 2010

SB 1046: Opposing prescription privileges for psychologists

Honorable Senators Anderson, Bates, Kruse, Morse, and Morrisette:

My name is Tanya Tompkins. I am a professor in psychology at Linfield College. I hold a PhD in psychology with a minor in measurement and psychometrics from UCLA. I trained at the Resnick Neuropsychiatric Hospital at UCLA, one of the top facilities in the country for mental health care. I serve on the Yamhill County Commission on Children and Families, and am the Chair of the Yamhill County suicide prevention coalition.

I am pleased that so many professionals in the fields of psychology, psychiatry, and pediatric medicine have come together to discuss the issue of improving mental health care in rural communities, and I believe that all of us, regardless of professional role, share the same concern, which is to ensure safe and effective mental health treatment in Oregon’s rural communities.

I am here today to testify in opposition to this bill, which will allow psychologists to prescribe medication with additional post-doctoral training that is less than half of the medical training required of all other prescribing professionals.

I have 5 basic concerns about this bill, none of which have been adequately addressed in the six years since this bill was first introduced in the 2003 legislative session:

1. Psychologists are deeply divided over the policy of APA to change the profession from a bio-psychosocial one to a medical one by seeking prescription privileges. Legislators should not be asked to resolve disputes within any profession.

Given the American Psychological Association (APA) and the Oregon Psychological Association (OPA) officially supports prescription privileges, legislative support for SB 1046 may be incorrectly predicated on the assumption that such privileges are universally supported by the discipline of psychology and that there is an urgent need for society to train more prescribers.

In fact, you may have received testimony asserting nearly unanimous support for prescription privileges among psychologists. This is misleading at best. 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 (Walters, 2001; Baird, 2007). Thus, these data may include psychologists who envision post-doctoral training that varies from self-study and passing an exam to receiving training equivalent to a medical degree. What is also clear is that even though a slim majority support prescription privileges, significantly fewer express an interest in pursuing such training themselves. There is also evidence to suggest that few – even those drawn to the idea of attaining the training – are aware of and have given careful thought to the issue (Baird, 2007). APA adopted the policy to pursue prescription privileges by suspending parliamentary rules, so the issue was not debated by the rank-and-file of the APA (DeNelsky, 2001),

2. Granting prescription privileges to psychologists will affect the profession and the greater public in damaging ways

I believe that this legislation fundamentally changes the nature of clinical psychologists’ practice and training at the undergraduate, graduate, and post-doctoral levels. Graduate education in basic psychological science and psychosocial treatments would be severely diminished and distorted unless most or all biomedical coursework were at the post-doctoral level. Adding faculty to departments of psychology to only teach the RxP curriculum would cost an estimated $800,000 to $1,000,000 annually. Only schools wholly supported by tuition could hope to recover these costs (and most of these are for-profit institutions). Psychological treatments have been shown to improve the human condition, often more effectively than drugs. The science of psychology has contributed to the understanding and amelioration of human suffering by the development of dozens of evidence-based psychosocial interventions and prevention strategies. My fear is that the passage of this bill in Oregon will provide impetus for other western states to follow suit and that slowly the profession will be shaped to produce prescribing psychologists. In the long run, it will be at the expense of the broader areas in which psychologists contribute knowledge.

3. Safety concerns – there is a clear risk to the consumer because of inadequate medical training.

Safety should be first and foremost on everyone’s mind when considering whether to allow non-medically trained professionals to prescribe medication. However, the risk to consumers of licensing psychologists who prescribe is unknown. Those who support prescription privileges for psychologists often point to the fact that there are adequate training programs in place and that the training is adequate. However, most if not all programs purporting to offer this experimental APA curriculum offer only part of the recommended training. The APA model training includes a background that translates into about 480 classroom hours (30 semester credits) of undergraduate courses in biology, chemistry, and related natural and life sciences.

Most programs in the country that offer so-called APA model training do not require the undergraduate science semester hour pre-requisites or their equivalent. In addition, most of the programs are correspondence schools (distance learning) offered by for-profit organizations and require no examinations for admissions. It was my understanding that serious concerns were raised in this body about the adequacy of distance-learning as an option for high school students, yet I find it surprising that similar questions haven’t been raised about post-doctoral training in psychopharmacology that will directly affect Oregon consumers of prescription medication. Is training adequate? Proponents of this legislation have pointed to a Department of Defense (DoD) study that allowed 10 psychologists prescription privileges before the program was discontinued by the DoD because it was not cost-effective. The DoD graduates completed 2712 hours of medical training (712 classroom hours and 2000 hours of supervised practicum). All of the graduates of the DoD program argued against less training (ACNP Bulletin, 2000). Despite these findings, the APA model involves less than half the amount of training provided by the DoD program and, as I have mentioned, most training programs do not meet even that low bar. Given the lack of specifics in the current bill it is unclear how 18 months of training compares (e.g, is it full-time work, will past training, even if it occurred years ago, be counted).

Will current training models allow for safe practice? Proponents point to the total number of prescriptions written by psychologists and then correctly state that there have been no reported adverse events. They use this as an indication that consumer safety is known to not be a concern. It turns out that they are measuring adverse events in terms of whether any prescribing psychologist has willingly chosen to contact the federal government to admit to harming someone. No adverse events, per a self-policing policy, is tenuous evidence of safety at best.

4. Granting prescription privileges to psychologists will not likely improve access or outcomes of mental health services.

Proponents have argued that the passage of this legislation will improve access to MH care (especially to underserved populations like children, the elderly, the chronically mentally ill and rural Americans). Again, there are no data to support significantly improved access in states where psychologists enjoy prescription privileges (see Table 1). In fact, data from NM and LA suggest that 80% will move out the state (and be unable to practice) or will be treating patients in cities and major urban centers. Given estimates that non-psychiatrically trained physicians prescribe between 70-80% of psychotropic drugs, to truly improve access (and likely decrease vs. increase prescription rates) we should craft legislation to improve mental health training for nurses and physicians and look for ways to enhance collaboration between primary care and mental health.

Even if granting prescription privileges does not demonstrably expand access, some proponents might argue that it may improve patient outcomes. Many aspects of the current legislation parallel laws established in Louisiana in 2002 or New Mexico in 2004, there is as yet no evaluation of the impact of those laws, nor any data to suggest that patient care has improved as a result of allowing psychologists to prescribe medications (even though there has been more than sufficient time to generate data). Even in the Department of Defense project there was no systematic follow-up of consumer effects. Consumer risk is high given the complex and sometimes negative side effects of psychoactive drugs. There is no reason to assume that prescribing psychologists would actually prescribe medication significantly less often than psychiatrists - and yet this argument is often advanced by proponents without any supporting data. Some of the DoD psychologists assert that they prescribe medications less readily that medically trained doctors; however, given the military’s cultural pressures NOT to prescribe medications these assumptions are hardly generalizable to the broader social culture which includes: consumer desire for a quick fix; Direct-to-Consumer-Advertising that increases prescription seeking; reimbursements that encourage quicker solutions so more patients can be seen and more money made; pharmaceutical marketing to prescribers that powerfully shape prescribing practices.

5. If neither safety nor outcomes have been evaluated, and claims of improved access proven false, why are we considering initiating a controversial, dangerous, and likely expensive experiment with Oregon mental health consumers?

Many of my concerns revolve around the lack of data to suggest that this path is the safest, most cost-effective way to improve lives which leads to me to the question of why we would risk moving forward with this bill? That leads me to ask a second question – who stands to benefit? For-profit training programs stand to benefit from the promise of boosting enrollments as more states push for legislation granting prescription privileges to psychologists. With antidepressants surpassing antihypertensives in 2005 to become the most widely prescribed class of drugs in primary care and in hospital outpatient clinics (Olfson & Markus, 2006), the bloated pharmaceutical industry stands to benefit.

Practicing psychologists who feel they deserve a greater share of the treatment pie stand to benefit by using a treatment approach that promises a more substantial revenue stream; this probably explains why the American Psychological Association Practice Organization collected $4.8 million dollars in dues from licensed psychologist members in 2009 and $455,000 to state psychological associations across three categories: emergency grants, legislative grants, and organizational development grants. In my mind, Oregon will not benefit. If you disagree and find testimony opposing this bill unpersuasive, I hope that at the very least you will amend the current bill to include a comprehensive plan to monitor and evaluate this experiment on Oregon’s citizens and a include “sunset” clause to terminate these privileges if it proves to be dangerous. They deserve it.

Thank you for your kind consideration.

Respectfully,

Tanya L. Tompkins, Ph.D.

Table 1. Number of prescribing psychologists by state and population size

TOTAL 51 14 65***

* US Census Dept defines “rural” as unincorporated areas or towns of less than 2,500 residents

** “out of state” means that these psychologists can not prescribe in their place of residence.

***The total is actually 64 since one psychologist has obtained prescription privileges in both LA and NM. He resides in TX.