Executive Director's Report: December 2008

Prescribing rights for psychologists?

Professor Lyn Littlefield OAM FAPS
Executive Director  

The Federal Health Minister's announcement in June this year of the development of the National Primary Health Care Strategy foreshadowed the introduction of significant reforms of the primary care system, which are likely to result in a broadening of health professionals' roles and scopes of practice to address workforce shortages. One potential reform that has received significant press coverage is the extension of prescribing rights to nurses to enable improved health services in situations where doctors are in short supply. This context provides an opportunity for the psychologist prescribing rights issue to be examined more prominently.

Independent of the Minister's announcement, a process was already underway within the APS to investigate prescribing rights for psychologists. The APS Prescription Rights Working Group (PRWG) was first convened in June 2006 in response to an international trend which has seen an increasing number of countries training and accrediting psychologists to have limited prescribing authority for psychoactive medications.

International prescription privileges

The last decade has seen an increase in the number of peak psychology bodies internationally actively seeking ‘prescribing privileges' or ‘prescriptive authority' for psychologists. In 1999 the first legislation was passed allowing prescriptive authority for psychologists in Guam, an unincorporated territory of the United States. Prescriptive authority of varying kinds now also exists for specifically trained psychologists in South Africa, one province of Canada (Alberta) and two States of the US (Louisiana and New Mexico). The limits of prescriptive authority, and the education, training and supervision required to gain accreditation as a prescribing psychologist, vary across States and countries. Those countries that have achieved limited prescription rights for psychologists have often done so as a means of increasing access to prescribing mental health practitioners in areas where access to psychiatrists is severely limited.

Training in psychopharmacotherapy

Information on current programs that provide training in psychopharmacotherapy for psychologists comes from the US. While programs are likely to exist in other countries, no information on these has been located. Training programs are underway in approximately a dozen US States. To date over 1,000 psychologists in the US have completed training in psychopharmacotherapy and are qualified to prescribe according to American Psychological Association (APA) guidelines.

The APA College of Professional Psychology has identified the following prerequisites to participate in postdoctoral training in psychopharmacotherapy:

• A doctoral degree in psychology
• Current registration as a psychologist
• Five years of practice as a ‘health services provider' as defined by State law or by the APA.

Training in psychopharmacotherapy involves didactic and clinical components. A minimum of 300 hours of didactic instruction in the following core areas is recommended: neuroscience; clinical and research pharmacology and psychopharmacology; physiology and pathophysiology: physical and laboratory assessment; and clinical pharmacotherapeutics. The clinical program involves exposure to a range of patients and diagnoses in both inpatient and outpatient settings and should include a minimum of 100 patients to be seen by the trainee and a minimum of two hours of weekly individualised supervision. Following the training program, psychologists must pass an examination accepted by the State Board of Psychologists.

Arguments for and against prescriptive authority

Some of the more common arguments for and against granting appropriately trained psychologists prescriptive authority are outlined below.

Arguments favouring prescriptive privileges

• Many general practitioners do not feel they have adequate training to diagnose and treat mental disorders and are uncomfortable making psychiatric diagnoses, while psychologists have extensive training in biopsychosocial assessment and treatment of mental disorders and psychological aspects of disease (particularly some specialties).
• While general practitioners use medication as their customary and primary treatment, psychologists will be able to evaluate client mental health needs more effectively and only prescribe when necessary.
• Psychologists' prescriptive privileges will lead to superior treatment integrating psychotherapy and pharmacotherapy and provide greater continuity of care and convenience for the client.
• Psychologists often have more time for ongoing dialogue about client views and expectations about medication and the risks and benefits and can work consistently with clients on adherence to medications.
• Psychologist prescription privileges will mean increased access to the public of trained professionals able to prescribe psychoactive medications. This may be particularly important for under-serviced areas such as rural areas and prisons.
• Many other non-medically trained healthcare providers in Australia have the legal authority to prescribe. This includes dentists, podiatrists, optometrists and advanced nurse practitioners. These practitioners who are prescribing competently and safely have in fact enhanced health services.

Arguments against prescriptive privileges

• Psychologists do not have the medical training to prescribe and their training does not necessarily include biomedical science subjects.
• Psychology is identified as a non-prescribing profession and this allows consumer choice of treatment modalities.
• Prescription privileges will change the nature of psychology and important psychological models of treatment. Psychologists will quickly turn to writing prescriptions.
• The likelihood of mis-prescribing will be present. Liability insurance premiums will go up and those who do not prescribe will pay higher rates to cover those who do.
• Psychotropic medications are amongst the most potentially dangerous drugs for patients, requiring the utmost care and training to prescribe. Psychologist prescriptions will result in risk to mental health care consumers unless psychologists have adequate training in human biological systems and chemical interactions to adequately recognise and address possible
  side effects.
• There will need to be major changes in the core psychology curricula in graduate programs, which will also mean extending the duration of a psychology degree.

APS Prescription Rights Working Group

The APS PRWG, comprising APS Board members and academic experts in this area, has the Terms of Reference to: (1) investigate the views of APS members regarding the prescriptive rights issue; (2) make recommendations on the length, content and supervision requirements of the education and training of prescribing psychologists; and (3) make recommendations about the type of, and limitations to, prescriptive authority for psychologists.

Two preliminary surveys have been conducted by the APS requesting opinions related to prescribing rights for Australian psychologists. The first survey requested opinions from APS members about whether appropriately trained Australian psychologists should be able to receive limited prescriptive authority. The second survey was distributed to members of a number of committees and organisations currently involved in the education, training or accreditation of Australian psychologists. This survey asked for opinions on the educational, training and supervision requirements of Australian prescribing psychologists if legislation and policy change allowed limited prescriptive authority. Some of the main findings of the preliminary surveys are presented below.

Survey of APS members

The survey was advertised on the APS website inviting members to participate and 95 psychologists completed the survey.

Should Australian psychologists with appropriate additional training be permitted to prescribe psychoactive medications?
No reservations	48.4%
Some reservations	32.6%
Too many reservations to support the notion	10.5%
Require further information	2.1%
Completely opposed	3.2%
No response provided	3.2%

 

How important is it for the APS to undertake advocacy for Australian psychologists to gain prescriptive authority?
High priority	51.6%
Medium priority	22.1%
Low priority	14.7%
Uncertain	6.3%
No response provided	5.3%

 

If Australian psychologists gained prescriptive authority, would you undertake the training to become a prescribing psychologist?
Definitely would	47.4%
Likely to	16.8%
Unsure	15.8%
Unlikely to	13.7%
Definitely would not	4.2%
No response provided	2.1%

Survey of psychology education experts

One hundred and ten emails were sent to members of the following groups inviting them to participate in an online survey: Heads of Department and Schools of Psychology Association, university postgraduate psychology course coordinators, APS Program Development and Accreditation Committee, Australian Psychology Accreditation Council, APS Board of Directors and the APS Prescription Rights Working Group. Forty-two participants completed parts of the survey and 33 completed the entire survey.

What should be the minimum prerequisite qualification required to undertake training to become a prescribing psychologist?
State registration as a psychologist	10.8%
Professional Masters degree	32.4%
Professional Doctorate degree	35.1%
PhD (including professional coursework)	10.8%
Other	10.8%

 

If a professional postgraduate degree was a minimum prerequisite, what specialisation of postgraduate study would be most suitable (more that one selection allowable)?
Clinical psychology	93.8%
Clinical neuropsychology	62.5%
Health psychology	34.4%
Counselling psychology	15.6%
Sport psychology	6.3%
Educational and developmental psychology	3.1%
Other	9.4%

 

Would the US model of training be appropriate and adequate to train prescribing psychologists in Australia?
Suitable	57.5%
Unsure of suitability	15.2%
US training too extensive	9.1%
More coursework required in training	12.1%
More clinical training required	6.1%

 

Should a period of supervised practice under the supervision of a medical practitioner, or specifically a psychiatrist, be undertaken after successful completion of the training?
Supervision with a psychiatrist	56.7%
Supervision with any medical practitioner	30.0%
No supervision period required	13.3%

 

The survey results are currently under consideration by the PRWG and further investigation of APS member attitudes towards prescription rights for psychologists will be undertaken.