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Expanded Academic ASAP:Prescription privileges for psychologists: a comprehensive review and critical
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Lavoie, K L, & Barone, S. (Jan 2006). Prescription privileges for psychologists: a comprehensive

review and critical analysis of current issues and controversies.   CNS
Drugs.  , 20, 1. p.51(16). Retrieved January 09, 2011, from Expanded Academic ASAP via Gale:
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Abstract:
The debate over whether clinical psychologists should be granted the right to prescribe
psychoactive medications has received considerable attention over the past 2 decades in North
America and, more recently, in the UK. Proponents of granting prescription privileges to clinical
psychologists argue that mental healthcare services are in crisis and that the mental health needs
of society are not being met. They attribute this crisis primarily to the inappropriate prescribing
practices of general practitioners and a persistent shortage of psychiatrists. It is believed that, as
they would increase the scope of the practice of psychology, prescription privileges for
psychologists would enhance mental health services by increasing public access to qualified
professionals who are able to prescribe. The profession of psychology remains divided on the
issue, and opponents have been equally outspoken in their arguments.
The purpose of the present article is to place the pursuit of prescription privileges for
psychologists in context by discussing the historical antecedents and major forces driving the
debate. The major arguments put forth for and against prescription privileges for psychologists
are presented, followed by a critical analysis of the validity and coherence of those arguments.
Through this analysis, the following question is addressed. Is there currently sufficient empirical
support for the desirability, feasibility, safety and cost effectiveness of granting prescription
privileges to psychologists?
Although proponents of granting prescription privileges to psychologists present several
compelling arguments in favour of this practice, there remains a consistent lack of empirical
evidence for the desirability, feasibility, safety and cost effectiveness of this proposal. More
research is needed before we can conclude that prescription privileges for psychologists are a
safe and logical solution to the problems facing the mental healthcare system.

Full Text:COPYRIGHT 2006 Wolters Kluwer Health 

Contents

Abstract
1. Background
2. Historical Antecedents and Forces Driving the Prescription
Privileges for Psychologists Debate
2.1 The Origins of Clinical Psychology
 2.2 The Origins of Modern Psychopharmacology
2.3 Forces Driving the Prescription Privilege Movement
3. Who Can Legally Prescribe? International Prescribing
Practices
4. Major Milestones Achieved by the Prescription Privileges
for Psychologists Movement
4.1 Recommended Curriculum for Psychopharmacology Training
4.2 The Current Status of the Debate
5. Major Arguments For and Against Prescription Privileges for
Psychologists: A Critical Analysis
5.1 Major Arguments for Granting Prescription Privileges
5.2 Major Arguments Against Prescription Privileges
5.3 Critical Analysis
6. Desirability
7. Feasibility
8. Safety
9. Cost Effectiveness
10. Conclusions and Future Directions
1. Background
Over the last 2 decades, an important debate has emerged within professional psychology about
whether clinical psychologists should be granted the legal right to prescribe psychotropic
medications. The major argument from individuals in favour of prescription privileges for
psychologists is that mental healthcare services are in crisis, and as a result, the mental health
needs of society are not being met. [1-4] The major proponents of granting prescription
privileges to psychologists, who include the American Psychological Association (APA) [4] and
the American Society for the Advancement of Pharmacotherapy (ASAP, Division 55 of the
APA), attribute this crisis to the often inappropriate prescribing practices of general practitioners
and a persistent shortage in the number of available psychiatrists. [1,3] It is believed that by
increasing psychology's scope of practice, prescription privileges would enhance mental health
services by increasing public access to qualified professionals who can prescribe. Despite
important advancements in the pursuit of prescription privileges, those in the profession of
psychology remain divided on this issue, and opponents have been equally outspoken in their
arguments against the proposal. [5-12]
Throughout the course of this review, we attempt to put the debate into context by presenting the
historical antecedents and current forces driving it. We present the major arguments for and
against granting prescription privileges to psychologists, followed by a critical analysis of the
validity and coherence of those arguments. Through this analysis, we hope to answer the
following question. Is there currently sufficient empirical support for the desirability, feasibility,
safety, and cost effectiveness of granting prescription privileges to psychologists?
We conducted a literature search of relevant articles published from 1980 to 2005 appearing in
the PsychInfo, MEDLINE, EMBASE and Cochrane databases, using 'prescription privileges' and
'psycholog *' as search terms. We also searched relevant popular and professional media
publications using Google.
2. Historical Antecedents and Forces Driving the Prescription Privileges for Psychologists
Debate
2.1 The Origins of Clinical Psychology
The profession of 'clinical psychology' was originally founded in the late 19th century by
Lightner Witmer, who established the first American psychology clinic. [13] At that time, the
practice of clinical psychology was conceptualised as the application of psychological techniques
to the study of the individual. [14] Although clinical psychology has evolved to become a largely
(though not exclusively) practice-based profession, the PhD in clinical psychology was originally
developed as a research or academic degree. In fact, the APA's Committee on Training in
Clinical Psychology (CTCP) did not consider psychotherapy a central activity of clinical
psychologists [15] until after World War II, when the demand for mental health services
increased sharply, due to the need to treat the victims of war. A shortage in the number of
psychiatrists led the Veteran's Administration (VA) in the US to expand the role of clinical
psychologists to include many practice-based activities including psychometrics, diagnostic
interviewing and ultimately, psychotherapy. [16,17] Although psychiatrists were initially
opposed to psychologists providing psychotherapy, claiming that they lacked proper training,
psychotherapy had emerged as a major activity of clinical psychologists by the end of the 1950s,
[18] and has continued to be one of their central activities to this day.
2.2 The Origins of Modern Psychopharmacology
Interestingly, at about the time clinical psychologists were becoming important psychotherapy
service providers alongside psychiatrists, psychopharmacology emerged as a major force in the
mental healthcare arena. Many of the psychotropic medications in use today, such as
benzodiazepines, chlorpromazine and TCAs were introduced between 1950 and 1960, when
Freudian psychotherapy was dominant. This introduction led to a major shift in the
conceptualisation of mental illness as a psychological disorder to an emphasis on the medical
model. [19,20] Since then, the field of psychopharmacology has made considerable progress as
both a basic science and clinical treatment modality for several mental disorders. [21] In the
early 1980s, the SSRIs were introduced and they revolutionised modern psychopharmacology.
Although they were of comparable effectiveness to the older classes of antidepressants (e.g.
TCAs and MAOIs), SSRIs had a more favourable adverse effect profile, making them easier to
tolerate and a relatively safer pharmacological alternative for the treatment of many mood and
anxiety disorders. [22-26] Their relative safety and perceived ease of administration has also
made them more likely to be prescribed by general practitioners, [23,27-29] who are currently
responsible for prescribing over 80% of all psychoactive medications. [3,30,31]
2.3 Forces Driving the Prescription Privilege Movement
Since the inception of this debate approximately 20 years ago, many have asked: why
prescription privileges for psychologists, and why now? Understanding the nature and timing of
the prescription privileges debate involves the recognition that it is occurring within a larger
context of change within and around the practice of clinical psychology. Perhaps the most
obvious force driving the current debate is economics, or more specifically, an oversupply of
doctoral-level (PhD and PsyD) psychotherapists, who charge more than their master'slevel
counterparts, and a concurrent increase in the demand for less costly psychotherapeutic services.
[10,17] Research shows that, in most circumstances, psychotherapy may be effectively delivered
by non-doctoral-level psychologists, including master's-level psychologists, social workers,
counsellors, nurses, and sex therapists. [17,32,33] The concurrent rise of managed care and
health maintenance organisations (HMOs) in the US and a need to reduce healthcare costs in
Canada's public health system are increasingly leading to the replacement of doctoral-level
psychologists with less costly psychotherapists, whenever possible. [34,35] The result: many
clinical psychologists are facing the possibility that they are no longer needed to fulfill their
psychotherapeutic role, an activity in which they have dominated since the 1950s.
An additional force driving the movement for prescription privileges for psychologists involves
the rising pharmaceutical company interest in expanding the number of professionals who can
prescribe. [10] Drug companies are increasingly sponsoring psychological symposia and
providing research and education grants to clinical psychologists "with a strong
psychopharmacology emphasis". [36] Psychotropic medications now occupy a significant
proportion of the drug portfolios of the major pharmaceutical giants. In fact, in 2001, the largest
increases in drug sales were seen for psychotropic medications. [37] According to IMS Health, a
major global healthcare information company, drugs affecting the CNS underwent a sales growth
of 16%, to $US45.3 billion in the 12 months prior to May 2002.[37] Moreover, sales of
antidepressants experienced 18% growth, to total $US13.4 billion, which accounted for 4.2% of
all global pharmaceutical sales. Fluoxetine was the most successful product amongst the drugs
affecting the CNS, demonstrating a market share of 21.5%. North America was the highest user
of psychoactive drugs, accounting for 74.6% of sales, amounting to a 19% growth rate. It is
noteworthy that in Europe, sales fell by 1%, while Africa/ Asia/Australia and Latin America
reported only 4.5% and 2.4% increases in sales, respectively. Given the growth and sales records
of psychoactive medications in the US, it is perhaps not surprising that the prescription privilege
movement is so strong there, relative to other countries (e.g. Canada, the UK). [37]
3. Who Can Legally Prescribe? International Prescribing Practices
In order to appreciate the complexities of obtaining prescriptive authority, it is helpful to
understand how prescription privileges are legislated in different countries. In the US, the Food,
Drug and Cosmetic Act is responsible for defining whether a drug may be sold over the counter
or by prescription only. [2] However, through their respective pharmacy and medical practice
acts, individual states determine which professions are authorised to prescribe. [38] In Canada,
the Federal Bureau of Human Prescription Drugs decides how drugs are sold, and provincial and
territorial governments are responsible for regulating the practice of medicine and pharmacy,
often through their colleges or registrars of physicians and/or pharmacists. [39] In the UK,
prescribing is regulated by the Medicines and Healthcare products Regulatory Agency (MHRA),
an executive agency of the Department of Health. [40]
A two-factor classification scheme for prescription privileges was established to specify the
degree of prescriptive authority held by a particular profession. The first dimension (independent
vs dependent) involves whether physician supervision is required for the individual to be able to
prescribe. The second dimension (limited vs unlimited) concerns which categories of drugs may
be prescribed. [41] Only physicians have independent and unlimited prescription privileges in
the US, but in Canada and the UK, both physicians and dentists have independent and unlimited
privileges (table I).
Over the years, various non-physician professions, such as dentists, optometrists, and podiatrists,
have been granted limited prescription privileges in the US. Prescriptive authority for these
professions is limited typically to medications that affect the body systems in their area of
practice. [2] The APA is currently advocating for independent privileges, which would be
limited to prescribing psychoactive medications. For a summary of professions with various
levels of prescriptive authority in the US, Canada, and the UK, see table I.
4. Major Milestones Achieved by the Prescription Privileges for Psychologists Movement
When we wrote our first review on the prescription privileges for psychologists debate, [42] we
received a letter stating that advancing prescription privileges for psychologists was
"untenable ... [and that it] appears somewhat ludicrous that an article of this nature would grace
the pages of the Canadian Psychiatric Association's journal." [43] Since its inception, the
movement to gain prescription privileges for psychologists, at least in the US, has shown
considerable progress, despite the opinions of those who thought it impossible. For a summary of
the major milestones achieved by the movement, see table II.
4.1 Recommended Curriculum for Psychopharmacology Training
Both New Mexico and Louisiana have granted limited, independent prescriptive authority to
properly trained psychologists, based on training guidelines developed and approved by the
APA's Committee for the Advancement of Professional Practice (CAPP) and the APA College of
Professional Psychology (a subsidiary of CAPP). In order to undergo training to prescribe,
psychologists must have a doctoral degree in psychology, hold a current, valid state license as a
psychologist, and have at least 5 years experience as a 'health service provider' psychologist as
defined by state law or by the APA. [44] The actual psychopharmacology training programme
includes a minimum of 450 hours of didactic training in five core content areas: (i) neuroscience;
(ii) clinical and research pharmacology and psychopharmacology; (iii) physiology and
pathophysiology; (iv) physical and laboratory assessment; and (v) clinical pharmacotherapeutics.
Psychologist trainees must also complete a joint board-approved 80-hour supervised practicum
in clinical assessment and pathophysiology and an additional 400-hour practicum treating at least
100 patients with mental disorders. The 400-hour practicum also requires receiving 2 hours of
weekly individual supervision, which is reportedly more than physicians receive. [44] To receive
certification, trainees must pass a national certification exam, which will grant them a 2-year
license to prescribe under the supervision of a physician. At the end of the 2 years, subject to
supervisory approval, the psychologist can apply to prescribe independently. [44]
4.2 The Current Status of the Debate
As of April 2005, prescription privilege legislation has been introduced to study the prescription
privilege issue and/or enact laws enabling psychologists to prescribe in at least 20 US states.
[4,44,45,54,55] Nearly half of all the State Psychological Associations have developed a Task
Force to address prescription privilege issues in their respective states, and specific training
programmes based on the Department of Defense (DoD) training model have been introduced or
are being offered in 12 states. [44]
Although efforts to obtain prescription privileges for psychologists appear to be moving forward,
whether or not psychologists should gain prescription privileges remains hotly debated both
within and around professional psychology. The following sections summarise the major
arguments presented for and against the movement, followed by a critical analysis of those
arguments based on the extent to which they demonstrate the desirability, feasibility, safety, and
cost effectiveness of granting prescription privileges for psychologists.
5. Major Arguments For and Against Prescription Privileges for Psychologists: A Critical
Analysis
5.1 Major Arguments for Granting Prescription Privileges
First, the most popular argument put forth by advocates of prescription privileges for
psychologists is that there are important public mental health needs that are not being met under
the current healthcare system, and that increasing the number of mental health professionals who
can prescribe will improve public access to the needed quality mental healthcare. [1-3] Secondly,
proponents argue that properly trained clinical psychologists will offer the public a superior
quality of mental healthcare services than that currently being delivered by the majority non-
psychiatrist physicians (i.e. general practitioners [GPs]) who can prescribe). [1-3] Thirdly,
proponents argue that clinical psychologists are highly trained mental health professionals, and
that granting them prescription privileges is both a logical extension of their current practice and
that it would help circumvent their impending marginalisation in the face of the oversupply in
the number of professionals who conduct psychotherapy. [2,56] Finally, proponents argue that
granting psychologists prescriptive authority would provide greater continuity of care and would
be less disruptive and more cost effective than having to consult two professionals (a
psychologist and a physician) with potentially contrasting views on how to direct patient care.
[57-59]
5.2 Major Arguments Against Prescription Privileges
Firstly, the most common argument put forth by opponents of granting prescription privileges to
psychologists is that psychologists are simply not qualified to prescribe medication. [60,61]
Secondly, opponents claim that there is no societal need to grant psychologists prescriptive
authority, nor would psychologists be geographically better situated to serve rural populations
than other medical professionals. [60] Thirdly, it has been argued that psychologists have not
adequately demonstrated their competence to prescribe psychoactive medication, which may
pose an important threat to patient safety. [42,59,62] Fourthly, opponents have pointed to a lack
of consensus within professional psychology as to whether prescription privileges should even be
pursued, which they claim calls into question the desirability of redefining the practice of
psychology to include prescription privileges. [42,60,63,64] Finally, opponents raise concerns
about how granting prescription privileges to psychologists would drastically alter the
psychological content of graduate and post-graduate training programmes, and how that would
negatively impact the future direction of professional psychology. [10,12,38,41]
5.3 Critical Analysis
The questions we seek to answer through this critical analysis are the extent to which the current
literature has amply demonstrated the desirability, feasibility, safety and cost effectiveness of
granting prescription privileges to psychologists. Our goal is to present an updated and balanced
critical analysis of both sides of the argument from the perspective of a scientist-clinical
psychology practitioner, in order to assist readers in drawing informed conclusions about this
controversial issue.
6. Desirability
The most popular argument in favour of granting prescription privileges to psychologists is that
there is a societal need for greater access to mental health professionals who can prescribe, and
that granting psychologists prescriptive authority would serve the public interest by helping to
reduce society's mental health burden; this is a highly desirable goal. Advocates appear to be
correct on two counts: (i) that the mental health burden of industrialised nations is extensive; and
(ii) that there may be increasingly limited public access to mental health professionals (i.e.
psychiatrists) who can prescribe.
According to the National Institute of Mental Health (NIMH), 44.3 million Americans suffer
from a diagnosable mental disorder. [65] Left untreated, mental disorders can cause significant
psychological and functional impairment leading to absenteeism and lost productivity, which
total nearly $US312 billion annually in the US alone. [63] The acute shortage in the number of
available psychiatrists has been documented by both the Surgeon General's Report on Mental
Health [66] and the President's New Freedom Commission on Mental Health. [67] Advocates
point out that fewer and fewer psychiatrists are being trained, [1] and there was a 7.4% drop in
the number of graduates entering new psychiatry residencies between 1997 and 1998. [68] This
shortage is expected to increase, with demographic projections predicting that there will be a
shortage of over 22 000 adult and 28 000 child and adolescent psychiatrists by 2007. [69] This is
particularly true in rural areas, where access to quality mental healthcare is particularly limited.
For example, the APA reported that there are only 18 psychiatrists serving the 72% of New
Mexicans who live outside the major city centres of Santa Fe and Albuquerque, and that up to
75% of those with a treatable mental disorder are not receiving treatment and must endure
waiting times of as long as 6 months. [46]
However, what proponents have not adequately demonstrated is that there is actual societal
demand for psychologists to be the ones to meet their mental health needs, rather than increasing
access to properly trained physicians who can prescribe. The fact remains that it is the APA and
a group of psychologists who are advocating granting prescription privileges to psychologists,
not the general public. With the exception of one small study, which showed that consumer
demand for psychologists obtaining prescription privileges was quite low, [70] we are unaware
of any representative surveys of the general population's views on this matter.
It has also been argued that maintaining a class of mental health professionals who can offer an
alternative to medication can better serve the public interest than adding psychologists to the list
of professions who can prescribe. [12] There is also no evidence to suggest that psychologists
would be better geographically situated to serve rural populations, as they are generally located
in the same areas as physicians, psychiatrists, and other health professionals who have some
degree of prescriptive authority (e.g. nurse practitioners). We have not seen any published study
presenting data on: (i) the ratio of psychologists to 'other prescribing health professionals' in rural
areas; (ii) the number of psychologists currently situated in these areas who would be willing (or
able) to undergo the extensive training required to prescribe; or (iii) the number of psychologists
in urban areas who would be willing to relocate to serve these populations. Interestingly, the
profession of 'physician assistant' was created to help meet the healthcare needs of underserved
(e.g. rural) populations, but only 3% of all physician assistants actually do. [71] As of 1997,
there were over 160 000 advanced nurse practitioners who were either prescribing or
administering psychotropic medication in all 50 states. [44] This number rivals the 152 500
members of the APA (2000), a fraction of whom would likely undergo training to prescribe. [63]
Proponents have argued for the desirability of granting prescription privileges to psychologists
by stating that psychologists would provide superior mental health (and pharmacotherapy)
services than those that are currently being delivered by the majority of non-psychiatrist
physicians (i.e. GPs) who can prescribe. Advocates are correct to be concerned about the
prescribing practices of many GPs. With the advent of the newer and relatively safer classes of
antidepressants (SSRIs and serotoninnorepinephrine [noradrenaline] reuptake inhibitors), GPs
have become the largest prescribers of psychoactive medication. Between 60% and 83% of all
prescriptions written for psychotropic medications are now written by GPs, who often have <4-8
weeks of training in psychiatry and mental health. [3,31,72] US medical schools typically devote
only about 115 hours of classroom teaching to pharmacology (without a particular emphasis on
psychopharmacology). [73] In addition, there is evidence to suggest that many patients seen by
GPs are misdiagnosed, prescribed inappropriate medication or prescribed medication
unnecessarily. [3,74,75] Research shows that, in women alone, depression is misdiagnosed on
30-50% of occasions, and that when antidepressants are prescribed patients are often improperly
monitored. [74] Finally, a recent study by De Las Cuevas and Sanz [76] demonstrated an
important disparity between the knowledge of GPs and psychiatrists with regards to how to
appropriately prescribe benzodiazepines. Less than 43% of GPs (vs 82% of psychiatrists) knew
that abrupt cessation of benzodiazepines could cause serious harm. [77] Given these data,
proponents of granting prescription privileges to psychologists argue that appropriately trained
psychologists would be more qualified to properly diagnose, treat, and monitor the behavioural
effects of psychoactive medication than would other non-psychiatrist practitioners. [4]
While no one would argue against the necessity and desirability of providing a higher standard of
care to patients with mental disorders, proponents have yet to demonstrate how prescription
privileges for psychologists are the logical solution to what appears to be a training issue for
GPs. Given that GPs are, and will remain, the front-line service providers under most
international healthcare systems, it is unclear how prescription privileges for psychologists
would significantly alter the healthcare-seeking behaviour of patients or the number of
prescriptions written by GPs (unless, of course, GPs decided to systematically refer their patients
to psychologists for pharmacological treatment). Moreover, it is important not to dismiss the
extensive basic science, medical and pharmacological training these physicians undergo in
preparation to prescribe, which is a minimum of 9-12 years. [78,79] Rather than adding
psychologists to the list of professionals who can prescribe, a more logical solution may be to
provide greater mental health training to GPs and help promote greater collaboration between
GPs and psychologists. [42] Interestingly, the MHRA in the UK recently issued a list of
treatment guidelines for GPs on the proper administration of antidepressant therapy, including
specific recommendations about dosages, patient communication, and when to use
psychotherapy as a first-line therapy. [80] Although this is not necessarily a substitute for
additional training, it is an encouraging start.
Proponents have argued for the desirability of granting prescription privileges to psychologists
by stating that clinical psychologists are highly trained mental health professionals, and granting
them prescription privileges would be a logical extension of their current practice. In fact,
clinical psychologists do undergo extensive training in multiple areas of mental health and
illness, including psychometrics, psycho-diagnostics, neuroscience, psychological and
behavioural interventions, basic and clinical research on the aetiology and epidemiology of
mental disorders, and even psychopharmacology. [2,44,58,81] Typical graduate programmes last
approximately 7 years and many go on to complete more specialised post-doctoral training,
which in most states is a requirement for licensure. [2,44,58] However, this debate is not about
whether clinical psychologists should be allowed to acquire the credentials to prescribe
psychoactive medication. In fact, as it has been previously argued, clinical psychologists who
want to obtain prescription privileges can already do so through existing channels. Under
existing laws in both North America and the UK, any psychologist who wants to prescribe
medications can do so by earning an appropriate qualifying degree in medicine or a related
health profession (e.g. nurse practitioner, physician assistant). [6] It remains unclear why the
practice of psychology needs to be overhauled for psychologists to obtain prescription privileges.
One possible explanation is that the majority of psychologists simply do not have the basic
science background that is required for admission into many of these professional training
programmes. [10] Nonetheless, proponents of prescription privileges have not adequately
justified why psychology should be exempt from the prerequisite training that has been
necessary for all other prescribing professions. Although several proposals have been made with
regards to providing psychologists with comparable basic science training, this has raised several
issues related to feasibility, which are discussed in section 7.
Finally, proponents argue that there is a general consensus within professional psychology in
favour of pursuing prescription privileges for psychologists, indicating that the majority view it
as a worthwhile and desirable goal. [2,3,82] Although it has been repeatedly argued that support
for granting prescription privileges to psychologists is widespread and increasing, relatively few
studies have actually been published on the issue. [63] A recent meta-analysis of opinion data
from practicing psychologists, trainees, and training directors in the US shows that the results of
only 17 surveys have been published in over 20 years of debate. [83] Moreover, an examination
of this report by Walters actually reveals an important division within professional psychology,
as his analysis concluded that the absolute level of in-principal support for obtaining prescription
privileges is only around 50%. Since this report, only two additional surveys on this issue have
been published. [84,85] One reported that more than two-thirds of graduate students were in
favour of gaining prescription privileges, although less than half would personally undergo
training. [84] A more recent survey of psychologists and trainees in Canada also suggests general
support for obtaining prescription privileges, although less than half of those surveyed had plans
to personally seek training. [85] We are unaware of any survey data from British psychologists,
but individual opinions about gaining prescription privileges in the UK appear less favourable
compared with the opinions in the US and Canada. [86-88]
7. Feasibility
The major argument of individuals in favour of the feasibility of the prescription privileges for
psychologists proposal is that training programmes (e.g. the DoD programme) have already
successfully graduated several (n = 10) prescribing psychologists. [47,89] However, whether or
not a few military psychologists can be trained to prescribe is not the issue, but rather, the extent
to which prescription privilege training can be offered and undertaken by psychologists on a
national level without seriously compromising the integrity of psychological training. Opponents
have consistently argued that the training required to adequately prepare psychologists to
prescribe would have a significant impact on the academic structure and teaching of psychology,
and therefore would not be feasible without sacrificing both the substance and quality of current
clinical psychology programmes. [6,10,12] To prevent this, current training programmes are
proposed to be postgraduate programmes, and would only be offered to licensed psychologists
with at least 5 years of experience. [44] Although this proposal appears to protect the
psychological basis of graduate or pre-doctoral training, these proposals fail to specify who will
incur the financial burden of this additional training, which may include costs to students,
training sites, internship settings, tax payers, individual clinicians, and consumers. [90]
The Louisiana Psychological Association's model curriculum (which includes over 450 hours of
didactic coursework and nearly 500 hours of supervised practicum training) amounts to
approximately nine courses offered over least three semesters. To put the costs into perspective,
Wagner [90] published a report illustrating how 2 years of extra training in psychopharmacology
for approximately ten students per programme, per school in Louisiana (n = 2002 students),
would end up costing over $US232 million for the university and professional school
programmes combined. When a 2-year delay in earning potential for those undergoing training is
factored in, this would amount to an additional income (and tax) loss of over $US180 million.
Unfortunately, proponents have failed to demonstrate exactly who would bear this financial
burden and if there is government support for such an investment. Until these issues are resolved
and there is a firm financial commitment on the part of government and/or training facilities, the
feasibility of the granting prescription privileges to psychologists remains questionable.
Also related to feasibility is the extent to which proponents have successfully enlisted the support
of the medical community, who would remain important providers of patient care and, in most
cases, be the ones to refer patients to prescribing psychologists. The American Psychiatric
Association has repeatedly stated its firm opposition to granting prescription privileges to
psychologists, [60,91] and proponents have failed to produce data demonstrating support or
willingness to collaborate from non-psychiatrist physicians (e.g. GPs). In fact, one national
survey of family physicians in the US revealed that the majority did not favour granting
prescription privileges to psychologists and would not refer patients to these practitioners for
psychopharmacological treatment if such privileges were obtained. [77] Until proponents of
granting prescription privileges to psychologists can demonstrate that the medical community
will be active and willing collaborators, their efforts are unlikely to succeed.
8. Safety
Proponents assert that with the proper training, psychologists could prescribe both safely and
effectively. This is generally accepted. [6,10,86] Evidence emanating from both the DoD and
Indian Health Service (HIS) pilot training projects suggests that psychologists have already been
trained to prescribe safely. [47,89,92] At least two independent reviews of the DoD programme
have suggested that the ten graduates "performed with excellence" [93] and demonstrated "good
quality of care". [94] Additional evidence demonstrating the safety of non-physician prescribers
comes from at least one study showing comparable prescribing outcomes in both physician and
non-physician prescribers. [95] Advocates of granting prescription privileges to psychologists
claim that because there is no evidence that non-physician prescribers are less safe than
physician prescribers, there is no reason to believe prescribing psychologists would be any
different. [92]
However, when evaluating the success of the psychopharmacology training programmes, it is
important to note that the ten psychologists trained under the DoD programme prescribed under
the close supervision of psychiatrists in a military facility. [94] Moreover, a review of the
programme by the American College of Neuropharmacology (ACNP) pointed out that
psychologists trained under the programme were limited to treating active military personnel
between the ages of 18-65 years with 'uncomplicated' cases, and only after the patients had
received full medical evaluations. [93] This suggests that the conditions under which the
programme was judged to be 'successful' may not be representative of the prescribing conditions
under which most psychologists would be legislated to prescribe. It is also noteworthy that when
the US Government Accounting Office audited the programme in April 1997, they
recommended it be discontinued unless psychologists practiced under psychiatrist supervision.
[94] They were also highly critical of the programme, claiming the military health system had
"no demonstrated need" for prescribing psychologists, and that the benefits of training
psychologists to prescribe had still not been established.
Though there is some evidence documenting psychologists' ability to prescribe safely, it is
extremely difficult to draw any firm conclusions from so little data. To date, the results of only
one American study (the DoD Project) [47] has been published, and we are unaware of any
planned trials based in Canada or the UK. Moreover, the sample size (n = 10) upon which
conclusions concerning safety have been drawn is extremely small. Clearly, more research is
needed before concluding that psychologists are capable of prescribing psychoactive medication
safely and effectively, particularly considering the potential risks involved. Some of the major
safety concerns put forth by opponents of granting prescription privileges for psychologists
include whether psychologists would know enough to be aware of the gaps in their knowledge
and the need to refer the patient to an appropriate physician. [62] This may be especially true
when dealing with complex drug interactions, where recognising the limits of one's expertise
would be crucial to ensure patient health and safety.
Of particular concern is the extent to which psychologists can be relied upon to provide
evidence-based treatment, when a significant number continue to use unproven or non-
empirically validated methods of psychotherapy. [6,64] If psychologists were granted
prescription privileges, they would be obliged to follow the strict prescription guidelines
mandatory for all prescribing professions. The fact that so many psychologists continue to
dismiss empirically based psychological methods as superficial, inflexible, simplistic and
irrelevant [96] is indeed troubling. Resolving this issue seems to be a more pressing matter for
clinical psychology than the pursuit of prescription privileges.
9. Cost Effectiveness
Proponents of prescription privileges for psychologists have argued that granting psychologists
prescriptive authority would provide greater continuity of care, which would be less disruptive
and more cost effective than having to consult multiple professionals. Advocates argue that
under the current system, patients may be forced into 'divided loyalties' when treatment providers
do not agree about how to direct patient care. [57,58,66] The result is inefficient treatment
dissemination and, ultimately, diminished treatment efficacy. Proponents add that granting
prescriptive authority to psychologists would also result in decreased healthcare costs because
psychologists charge an average of 14% less than do psychiatrists for the same service, and
because patients would be able to meet all their mental health needs in a single visit (to a
psychologist). [95] As such, proponents believe granting prescription privileges for psychologists
would facilitate both treatment and recovery at a lower cost.
The vast majority of psychologists conducting psychotherapy do not practice in the same office,
or in close proximity to, the physicians who provide medications.[97] Effective communication
and collaboration between providers can be a major challenge with this type of arrangement, but
this does not preclude it from being the appropriate mode of mental healthcare delivery. Even if
psychologists were granted prescription privileges, their limited prescriptive authority would
require them to refer patients back to their primary physician for treatment of any co-morbid
medical conditions (which affect approximately 50% of patients with mental illness). [5] The
same would be true for the treatment of many of the adverse effects of psychoactive medication
(e.g. nausea, constipation, sexual dysfunction, abnormal heart rhythms, orthostatic hypotension
and hypertension). [98] For example, a male patient taking paroxetine may request a prescription
for sildenafil for the treatment of sexual dysfunction, which would fall outside the prescriptive
authority of the psychologist and require referral to a physician. Finally, a closer look at the
current prescription privilege legislation in Louisiana reveals a major weakness in the continuity
of care argument. According to the Louisiana House Bill 1426, psychologists with prescription
privileges are mandated to collaborate with physicians on all matters related to prescribing. [99]
Specifically, the law states that medical psychologists are "required to work collaboratively with
the patient's physician when prescribing medication". This condition appears to fly in the face of
the continuity of care argument, as even prescribing psychologists are required to do what they
have effectively been doing for years: collaborating with the patient's physician on matters
related to medication.
The assertion that granting prescription privileges to psychologists would be more cost effective
than current prescribing practices appears unsupported by the current literature. First, proponents
have not provided evidence that psychologists would do a better or more cost-effective job of
prescribing psychoactive medication than their physician-counterparts (although without
psychologists being granted some degree of prescription privileges, it would be impossible to
conduct such trials). Secondly, the costs of training psychologists to prescribe are likely to be
great. For example, the actual cost of training the ten psychologists to prescribe under the DoD
programme totaled $US6 million. [5,94] As previously mentioned, the costs of training in
psychopharmacology alone were estimated to reach over $US232 million for just 2 years of extra
training. [90] These estimates do not include the costs of delayed earnings, licensure, and
professional liability insurance. For example, it was estimated that a licensure increase of only
$US50 would cost the 40 000 American licensed psychologists $US2 million. Similarly, if
prescribing psychologists paid the same for liability insurance as psychiatrists, psychologists in
California would experience a premium increase of over $US10 000 per year. [90] These added
costs for training, licensure, insurance, and delayed earnings would likely encourage
psychologists to increase their fees, which would ultimately result in greater costs to consumers
and/or third-party payers.
Another consideration regarding the cost-effectiveness argument is the myth that drug treatment
is more effective and less expensive than psychotherapy. A recent cost analysis of the relative
costs of cognitive behavioral therapy versus medication for the treatment of depression
determined that the costs of cognitive behavioural therapy alone were significantly lower than
for medication alone or combination therapy ($US6809 vs $US12 737 and $US14 572,
respectively).[100] This analysis considered all costs related to third-party payments, provider
charges and medication costs. More importantly, there is evidence to suggest that many
psychological interventions, particularly cognitive behavioural therapy, are at least as effective
as medication for the treatment of both mood [101-103] and anxiety disorders, [104] and that the
effects of cognitive behavioural therapy are more likely to be maintained over the long-term.
[105,106] This suggests that for certain disorders, not only are psychological interventions less
expensive, but that they may also be more effective (and longer lasting) than medications. This
begs the question: why the push for prescription privileges for psychologists?
10. Conclusions and Future Directions
The debate about whether psychologists should be granted prescription privileges is still in its
infancy, particularly outside North America. However, there does not appear to be compelling
evidence of the desirability of granting prescription privileges for psychologists. Pilot projects
relating to the feasibility, safety, and cost effectiveness of prescription privileges for
psychologists are either sparse or unavailable. Although proponents present several compelling
arguments in favour of granting prescription privileges for psychologists, more research is
needed before we can conclude that prescription privileges for psychologists are a safe and
logical solution to the problems affecting the mental healthcare system.
In the meantime, psychologists should concentrate their efforts on improving both the
professional and public dissemination of the services they already provide. In particular, they
could work on improving collaboration with GPs and psychiatrists to ensure that medicated
patients are properly monitored and advised of available psychotherapy options. Psychologists
need not go beyond the boundaries of psychological practice to expand into new treatment areas.
There have already been important advances in the areas of health psychology and behavioural
medicine, where psychologists have demonstrated success in improving treatment adherence,
health behaviours and disease outcome in cancer patients, [107-109] obese patients, [110]
coronary artery disease patients [111,112] and patients with HIV. [113] Expanding the quality
and scope of these interventions may represent a more desirable, feasible, safe and cost-effective
goal than the pursuit of prescription privileges at this time.
Acknowledgements
The authors acknowledge the support of their work by the Canadian Institutes of Health
Research (CIHR) and the Auger Research Foundation at Hopital du Sacre-Coeur de Montreal.
The authors have no conflicts of interest that are directly relevant to the content of this review.
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Hopital du Sacre-Coeur de Montreal, 5400 Gouin W, Montreal, Quebec H4J 1C5, Canada. E-
mail: kiml_lavoie@yahoo.ca
Kim L. Lavoie (1,2,3) and Silvana Barone (1,3)
(1) Division of Chest Medicine, Research Center, Hopital du Sacre-Coeur de Montreal,
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(2) Department of Psychology, University of Quebec at Montreal (UQAM), Montreal, Quebec,
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(3) Department of Psychology, McGill University, Montreal, Quebec, Canada
Table I. Summary of professions with various degrees of prescriptive
authority in the US, Canada and the UK

Health professional US
independent unlimited limited

Physician Yes Yes No

Dentist Yes No Yes

Physician assistant No No Yes (a)

Pharmacist No No Yes (c)

Nurse/nurse practitioner Yes (d) No Yes

Health visitor NA NA NA

Nurse midwife No No No

Optometrist No No Yes
Podiatrist/chiropodist No No Yes

Physiotherapist No No No

Radiographer No No No

Psychologist No No Yes (f)

==================================

Health professional Canada

independent unlimited limited

Physician Yes Yes No

Dentist Yes Yes No

Physician assistant No No Yes

Pharmacist No No No

Nurse/nurse practitioner No No No

Health visitor NA NA NA

Nurse midwife No No No

Optometrist No No No

Podiatrist/chiropodist No No Yes (e)

Physiotherapist No No No

Radiographer No No No

Psychologist No No No

Health professional UK
independent unlimited limited

Physician Yes Yes Yes

Dentist Yes Yes Yes

Physician assistant NA (b) NA (b) NA (b)

Pharmacist No No Yes

Nurse/nurse practitioner No No Yes

Health visitor No No Yes

Nurse midwife No No Yes

Optometrist No No Yes

Podiatrist/chiropodist No No Yes

Physiotherapist No No Yes

Radiographer No No Yes

Psychologist No No No

(a) In 40 US states.

(b) Physician assistants do not exist in the UK.

(c) In eight US states.

(d) In 26 US states.

(e) In Alberta, Canada only."

(f) In the US military, New Mexico and Louisiana only."

NA = not applicable.

Table II. Summary of major milestones achieved by advocates of

prescription privileges for psychologists in the US [44-53]

Date Event
Nov-84 US Senator Daniel K Inouye (Hawaii) calls for psychologists to
seek prescriptive authority to help improve
availability of quality mental healthcare

1985 Hawaii State Legislature considers legislation to study the

issue of prescription privileges for psychologists

1989 Congress orders DoD to develop pilot training programme in

psychopharmacology (training began in 1991)

1990 APA approves the establishment of ad hoc Task Force on

Psychopharmacology to study the desirability and
feasibility of granting prescription privileges to
psychologists

1992 Task Force issues report concluding psychologists could be

properly trained to prescribe

1994 DoD training programme graduates its first two prescribing

psychologists

1995 APA formally announces endorsement of pursuing prescription

privileges for psychologists
1996 APA Council of Representatives formally adopts model
prescription bill and training curriculum

1997 APAGS formally announces endorsement of pursuing prescription

privileges for psychologists; authorises
College of Professional Psychology to develop suitable
psychopharmacology exam to be used by state licensing boards

1998 Legislation regarding prescription privileges for

psychologists about to be introduced or pending in seven
states (California, Florida, Georgia, Hawaii, Louisiana,
Missouri, Tennessee)

1999 US Territory of Guam approves legislation allowing

psychologists to prescribe in collaboration with physicians

Mar-02 New Mexico becomes the first state authorising properly

trained psychologists to prescribe

May-04 Louisiana becomes the second state authorising properly

trained psychologists to prescribe

APA = American Psychological Association; APAGS = American

Psychological Association of Graduate Students; DoD = Department of
Defense.
Gale Document Number:A199865934

© 2011 Gale, Cengage Learning.