Concerns About Psychologist Prescribing

1. Concerns About Psychologist Prescribing William Robiner, Ph.D., A.B.P.P. Department of Medicine ??? UNIVERSITY OF MINNESOTA MEDICAL SCHOOL

2. Disclosure InformationConcerns About Psychologist PrescribingWilliam N. Robiner, Ph.D., A.B.P.P. I have the following financial relationships to disclose: Consultant for: HealthPartners Stockholder in Medtronic but no pharmaceutical companies Employee of: University of Minnesota I have never received any funding from the American Medical Association or American Psychiatric Association or any of their affiliates. I will not discuss of label use and/or investigational use in my presentation.

3. Prescription Privileges for Psychologists Are Controversial “I don’t think we need to be subliminable about the differences between our views on prescription drugs” George Bush, Orlando, FL September 12, 2000

4. Prescription Privileges for Psychologists Are Controversial Many people, including psychologists, are not fully informed of the issues in the ongoing debate. Many psychologists are reluctant to speak up against the Prescription Privileges (RxP) movement or are indifferent to the issue.

5. Objectives Upon completion of the presentation, participants should be able to: • Summarize diverse concerns about psychologist prescribing • Identify relative limits of the APA Clinical Psychopharmacology Training model and the DoD PDP Program • Identify psychologists’ motives and rationales for pursuing prescription privileges • Decide their position about the controversy about prescription privileges for psychologists

6. What do Consumers Want of Their Psychopharmacologist? “Our Psychopharmacologist is a genius”

7. What Do Consumers Want Of Their Psychopharmacologist? • A knowledgeable, well-trained professional who is as competent to manage their medications and understand their overall health status as well as all other prescribers

8. Why Do Psychologists Want Prescription Privileges? • Money

9. Also, Psychologists Want Prescription Privileges for • Autonomy in clinical practice • Job security • Another marketable skill • Parity with other professions • Giveaways and meals from drug company salespersons

10. “Physician Wannabes” “…if we talk like psychiatrists, if we practice like psychiatrists, we will get our due” “The principal reward for becoming a junior psychiatrist must be financial- a chance to break into what appears to be a profitable market and grab a share of the action” Hubble, M. A. & Miller, S. D. (2001). In pursuit of folly. Bulletin of the Academy of Clinical Psychology, 7, 2-6.

11. Why Do Pharmaceutical Companies Want Prescription Privileges for Psychologists? • Increase revenues via increased sales of medications through more prescribers • More than $24 billion worth of antidepressants and antipsychotic drugs were dispensed in 2008

12. Why Do Some Schools Want Prescription Privileges for Psychologists? • Potential revenues from courses, workshops, and continuing education • Hedge against potential future declines in enrollment in traditional professional psychology programs • Develop potentially new marketable skills for graduates

13. Why Does the APA Want Prescription Privileges for Psychologists? • Potential revenues from courses, workshops, and continuing education • Develop potentially new marketable skills for psychologists • Increased status and power of psychologists in the market and health care system

14. Why Does the APA Want Prescription Privileges for Psychologists? • Potential revenues from advertising dollars for its journals from pharmaceutical companies

15. What Factors Engender Opposition to Prescription Privileges for Psychologists? • Concerns about psychologists’ competence and training (i.e., the training model for RxP) • Concern about adverse effects on the field – what would be lost? • Concerns about the quality and safety of patient care prescribing psychologists would likely deliver

16. What Factors Lead Psychologists to Oppose Prescription Privileges for Psychologists? A personal sense of responsibility to speak truth to power

17. Note the absenceof any financial incentives within psychology for opposing prescription privileges on the previous slides.

18. Who Wants Psychologists to Prescribe? • The prescription movement is notdriven be consumers, physicians, or other mental health providers • NAMI does not support it • It originated with practitioners rather than academicians or scientists • Psychology training directors are equivocal about it • 62% are equivocal (Evans & Murphy, 1997) • Relatively few academic psychologists are interested in developing training programs for it (Hanson et al., 1999) • Raising questions about the feasibility of developing high quality psychopharmacology training programs in settings with limited experience in educating and training psychologists

19. Prescription Privileges are Controversial Among Psychologists • Estimates vary about the percentage of psychologists favoring it(Gutierrez & Silk, 1998,Bush, 2002) • Frederick/Schneiders, Inc. (1990), the largest survey of APA members, found: • 30% strongly supported it and 38% favored it • The rest are opposed or unsure

20. Prescription Privileges are Divisive Among Psychologists A meta-analysis of 17 surveys revealed a lack of consensus (Walters, 2001) • “Opinion… is divided and polarized” • More psychologists than not believe that …organizations like APA should not be spearheading efforts to gain prescription privileges • Psychologists are more supportive of prescription privileges in principle than they are of obtaining the training to prescribe medication • Prescription privileges have the potential to confuse issues of training and identity for future … psychologists

21. Professional Organizations of Psychologists Oppose Prescription Privileges • Society for a Science of Clinical Psychology (Section 3, Division 12) • American Association of Applied and Preventive Psychology (AAAPP) • Committee Against Medicalizing Psychology (CAMP) • Psychologists Opposed to Prescription Privileges for Psychologists (POPPP)

22. Support Is Not Unanimous • 43% of psychologists responding to an APA survey indicted that “full medical training would be required” for prescription privileges(APA, 1992) • Nevertheless, the APA training model is shorter, as well as substantively and procedurallyinferiorto medical school, nurse practitioner training, and other prescribers’

23. It Is About Quality: Not Popularity • Whatever sentiments surveys of psychologists reveal, it is less appropriate to decide this issue on the basis of its popularity among psychologists than on the quality of pharmacologic care that psychologists would provide Bieliauskas, L. A. (1992b). Rebuttal of Dr. Frank’s position. Physical Medicine and Rehabilitation: State of the Art Reviews, 6, 584.

24. It Isn’t Just Up To Psychologists It concerns a range of potential stakeholders • Consumers • Educators • Practitioners in other health disciplines experienced in prescribing • Regulatory and governmental authorities • Food and Drug Administration • Regulatory boards (e.g., Board of Psychology)

25. Historical Highlights • APA (1992) established an Ad Hoc Task Force on Psychopharmacologyto explore the desirability and feasibility of psychopharmacology prescription privileges for psychologists • The Task Force concluded that greater understanding of psychopharmacology would enhance the care that psychologists provide (Smyer et al., 1993)

26. Proposed Levels of Training • The APA Task Force proposed three levels of preparation in psychopharmacology: • Level 1-Basic Psychopharmacology Education • Level 2-Collaborative Practice • Level 3-Prescription Privileges • Whereas the Task Force thought all psychologists providing mental health services should be prepared at Level 1, it did nottake that position for training at Level 3

27. Legal Status of Prescribing • Most states and provinces do notallow psychologists to prescribe • Supervised prescribing by “qualified” psychologists has been passed in Guam, New Mexico, and Louisiana. • It took time for details to be worked out, so we don’t know yet how this experiment is going.

28. Currently under review elsewhere

29. Does New Mexico Lead the Way? • Can you name 2 things that are legal in New Mexico, but not most places? • Cock fighting • Also legal in Louisiana • Psychologist prescribing

30. “Foundation” Definitions • The lowest load-bearing part of a building, typically below ground level • A body or ground on which other parts rest or are overlaid • An underlying basis or principle for something; specific learning skills as a foundation for other subjects

31. Buildings Have Foundations Foundation No Foundation  • Foundations are structurally important • Inadequate foundations can lead to instability of the structure, creating safety risks to users

32. Foundation in Education: Prerequisites • The APA Task Force stated “retraining of practicing psychologists for prescription privileges would need to carefully consider selection criteria, focusing on those psychologists with the necessary science background”(APA, 1992) • This included undergraduate coursework in: • Biology • Chemistry, and • Other areas typifying the pre-medical curriculum

33. Inadequate Foundation • But no physical or biological science prerequisites are required! • Instead, APA uses vague language about trainees’ scientific background

34. Dumbing Down • “Demonstrated knowledge of human biology, anatomy and physiology, biochemistry, neuroanatomy, and psychopharmacology is a necessary prerequisite for embarking on this postdoctoral training • Demonstrated knowledge involves evidence of • (1) successful completion of a planned sequence of courses at a regionally accredited institution of higher learning, OR • (2) evidence of successful completion of a planned sequence of continuing education courses offered by an accredited institution of higher learning or an approved provider of continuing education and passage of an examination covering the content of such a program

35. Are They The Same? ?= Rigorous Coursework Continuing Education

36. Bait and Switch • By deleting the scientific prerequisites APA has ignored the judgment of the importance of scientific backgrounds of its own expertsas well as nearly half of the members it surveyed! • But nevertheless, APA says that members support RxP, even if their favorable statements was based on expectations of more stringent requirements • “PDP-Lite” (Stuart & Heiby, 2007) • “Ersatz training” (Anonymous Member of APA Task Force)

38. Other Non-Physician Prescribers’ • Training is much closer to that of physicians than to psychologists’ • Clinical practice is more focused on physical functioning, including medication effects, than psychologists’

39. Is this good? “Among all the disciplines whose members include non-physician health care providers who prescribe, psychology has the core curriculum with probably the least overlap with traditional medicine” Fox, DeLeon, Newman, et al.., 2009

40. APA Knows Better • Accreditation criteria for all levels of education specify: • Training for practice is sequential,cumulative,graded in complexity Biochemistry Organic Chemistry Inorganic Chemistry

41. Undergraduate Differences* Between Psychologists and Psychiatrists

42. Psychologists’ and Psychiatrists’Pre-Med Courses Robiner, W. N., Bearman, D. L., Berman, M., Grove, W. M., Colón, E., Armstrong, J., Mareck, S., Tanenbaum, R. (2003). Prescriptive authority for psychologists: Despite deficits in education and knowledge? Journal of Clinical Psychology in Medical Settings, 10, 211-222.

43. Arrogance? • Some RxP advocates question the necessity of scientific background for prescribing(Hanson et al., 1999) • Does that denigrate the importance of other scientific disciplines?

44. How Hard Is It To Prescribe? Former APA President, Patrick DeLeon, contends that: "...prescription privileges is no big deal. It's like learning how to use a desk-top computer"(Roan, 1993)

45. But Is It…….Really? Meet Noah Robiner1 • Hobby: Plays with laptop computer • Age: Six years 1 2002

46. Or Is Safe Prescribing More Involved? • Would you have confidence in a prescription from a kindergartener? • Do psychologists want to “play” at being medical doctors too?

47. Differences* Between Psychologists’ and Psychiatrists’ Scientific Coursework

48. Graduate Education in Psychology • Comprises “vastly differing models of study and practice” with “no effort to standardize the training of psychologists”(Klein, 1996) • Some psychology degrees (e.g., school psychology) have relatively limited exposure to psychopathology and psychological treatments, let alone the physical sciencesormedical environments (DeMers, 1994; Moyer, 1995)

49. Where’s the Biology in Psychology Graduate Education? According to the APA Accreditation Commission: Domain B. 3. …The program has…a…coherent curriculum plan that provides the means whereby all students can acquire and demonstrate substantial understanding of and competence in the following areas: • The breadth of scientific psychology, its history of thought and development, its research methods, and its applications. To achieve this end, the students shall be exposed to the current body of knowledge in at least the following areas: biological aspects of behavior….. http://www.apa.org/ed/accreditation/G&P0522.pdf

50. Where’s the Biology in Psychology Graduate Education? • Note the absence of clear guidance from APA about content or credits • Also note that “biological aspects of behavior” is considerably narrower than the biological curriculum for other prescribers (M.D., R.N., etc.) • It does not require any knowledge of human physiology, pathophysiology, anatomy, etc.