A review of Pharmacotherapy for Psychologists: Prescribing and Collaborative Roles
By Jeffrey D. Shahidullah and John S. Carlson
The British author and explorer, Freya Stark once remarked: “The most ominous of fallacies: the belief that things can be kept static by inaction.” This revealing aphorism aligns with Robert McGrath and Bret Moore’s rationale for psychologists eluding professional irrelevancy by obtaining prescriptive authority. The prescriptive authority for psychologists (RxP) movement began in the early 1990’s and progress has since been made in garnering RxP in two states (Louisiana and New Mexico) as well as in the military, Public and Indian Health Services. With similar legislative agendas emerging in several other states, the number of states offering prescriptive authority to psychologists will inevitably increase (APA, 2009). The RxP movement has implications for the field of school psychology as the use of psychotropic medication to treat children with emotional and behavioral disorders has increased in frequency over the past several decades (DuPaul & Carlson, 2005). Kubiszyn (1994) points out that appropriately-trained school psychologists may be in the best position of any healthcare provider to make decisions to initiate, terminate, and integrate pharmacological, psychotherapeutic, and educational interventions in the school setting.
“In years past, psychologists were called on for diagnosis of mental disorders and psychotherapy…” (McCormick, 2010, p. 189). However, with the American Psychological Association’s (APA) legislative effort for RxP and push for psychopharmacology training¹, appropriately-trained school psychologists will see their roles change. They will be involved in treatment collaboration and decision-making through psychotropic research (Level 1 training), monitoring/ evaluation (Level 2 training), and prescribing medication (Level 3 training). The RxP debate continues within APA and Division 16 as not all school psychologists’ view this movement positively. 59% of Division 16 members support role expansion to include prescriptive authority for appropriately-trained psychologists; of which, even fewer are interested in prescribing medication themselves (Kubiszyn & Carlson, 1995). Nevertheless, as the prevalence of psychotropic medication in school settings increases, there will be continued scrutiny on the RxP issue as advocates, such as McGrath and Moore, demonstrate how mental health needs can be met by appropriatelytrained psychologists at Levels 1 and 2.
Pharmacotherapy for Psychologists is a clearly written guide that offers a “snapshot” of the RxP movement, including professional issues surrounding prescriptive authority, medical collaboration, future implications for professional identity, and ongoing legislative efforts. The volume is broken up into four parts which provide summation of the RxP literature from the past 20 years or so. Part I covers the rationale for RxP and history of the prescriptive authority movement. Part II covers general practice issues, including the challenges of pharmacotherapy practice, ethical considerations, integration of psychotherapy and pharmacotherapy, and evaluation of drug research. Part III describes issues related to prescribing in specific settings and with specific populations (e.g., schools). Finally, Part IV provides ideas for getting prescriptive authority passed and the future of RxP.
While the authors use most of the book to support the two main altruistic arguments for RxP: (a) greater access to service for underserved populations and (b) improved overall quality of care; they also recognize the fiscal and professional advantages of RxP. Obtaining RxP allows psychologists, as mental health professionals, to evolve. McGrath and Moore (2010) point out that without evolving, psychologists may become irrelevant as other mental health professions continue to grow and expand their roles:
Licensed counselors are conducting psychological testing. Social workers have moved from conducting social needs assessment and case management to providing direct psychotherapy, with reimbursement rates comparable with those of psychologists. Psychiatrists have moved into more traditional medical settings, providing consultation and liaison; more and more they are increasing their expertise in neuroimaging, genetics, and nonpharmacological treatments, such as electroconvulsive therapy and psychosurgery (p. 4).
This observation is offered at the outset of the book and sets the tone for the authors’ adamant RxP advocacy for the rest of the volume.
An informed reader must keep in mind that many of the volumes’ contributors are members of APA’s Division 55 (American Society for the Advancement of Pharmacotherapy) Task Force on Practice Guidelines. Also, the editors of this volume, Robert E. McGrath, PhD and Bret A. Moore, PsyD, ABPP served as former president of APA Division 55 and RxP Chair for Division 19 (Society for Military Psychology), respectively. Unabashedly, the authors demonstrate their advocacy on the RxP issue. The volume includes not only the authors’ opinions on RxP but also those of prescribing psychologists in private practice. The authors detail how needs of clients served by prescribing psychologists in New Mexico and Louisiana are better met (e.g., higher quality of care and greater access to service for underserved populations) because of RxP.
For school psychologists not particularly concerned about ongoing legislative efforts involving RxP, the authors provide information relevant to how school psychologists’ roles and duties may change and offer advice on dealing with situations they may encounter. Even for psychologists without intention to pursue prescriptive authority, they should recognize that the RxP movement will likely offer long-term stability for the profession. The authors posit: “The demand for adequate mental health care far exceeds its current availability and psychologists with prescriptive authority offer a cost-efficient, timely, safe and effective means for addressing shortages of care” (p. 22). Moreover, appropriately-trained school psychologists, who have greater access to students than physicians, can collaborate with physicians to integrate and evaluate pharmacological intervention within existing services. This allows schools to provide more comprehensive treatment for children who fail to respond to school-based services.
While Pharmacotherapy is not, nor claims to be, a comprehensive authority on the RxP issue, more attention could have been paid to prescribing practices in pediatric populations and school settings. Even though psychotropic medication is prescribed for school-aged populations more frequently than in previous years (Medco Health Solutions, 2008), drug research in pediatric populations is years behind that of adults (McCormick, 2010, p. 197). Practitioners often attempt to extrapolate the findings of adult psychopharmacology to children (Vitiello, 2007). This practice raises safety and ethical concerns in pediatric prescribing practices.
Of particular concern is the ethical dilemma faced with “off-label” prescribing to pediatric populations when insufficient efficacy or safety data has been obtained for FDA approval. Off-label prescribing is prevalent as Radley, Finkelstein, and Stafford (2006) found among their sample that 21% of all prescriptions were offlabel; many of which target pediatric populations. Another ethical consideration is the adequacy of monitoring drug-effects in children when prescribed medication has abuse potential or can be toxic. Current prescribers tend to be outside the school setting; thus have little access to prescribed children to assess and monitor dose-response, effectiveness, and sideeffects. This practice raises questions about the medical ethical values of beneficence (act in the best interest of the patient) and nonmaleficence (do no harm). Juxtaposing the appropriately-trained psychologists’ ability to evaluate, monitor, and prescribe in school-based settings with that of the psychiatrists’ would have made the authors’ case for RxP and enhanced pharmacological training for psychologists more salient. A nonpartisan reader interested in an objective portrayal of the sides of the RxP debate may not find the book to be an adequate resource. The authors’ advocacy for RxP makes the text a suitable resource for psychologists who already realize the utility of psychopharmacology training and competency in the field. The volume does include a short section entitled, “Countering the Case against Prescriptive Authority,” which presents the most frequent arguments against RxP (e.g., lack of training, potential overreliance on pharmacological interventions, and the blurring of professional identity). However, given the divergence of opinion on RxP even among psychologists (Kubiszyn & Carlson, 1995), more attention could have been given to this section.
A typical school psychologist may find that much of the book extends beyond their scope of professional needs in regards to its’ coverage of the evolution of training guidelines in pharmacotherapy for psychologists, implications for working in private practice settings, and close examination of The Psychopharmacology Demonstration Project (PDP). While only a portion of Pharmacotherapy addresses RxP implications for working with school-aged children, it does offer practical insights for school psychologists dealing with psychopharmacology issues at Levels 1 and 2 (e.g., assessing effects of psychotropic medication), which align with best practice (Carlson, 2008).
Covering a wide array of RxP related issues in fewer than 250 pages, at no point did the text feel redundant. The volume’s brevity is one of its greatest strengths and lends it well to use by psychologists who understand the importance of research, evaluation, and collaboration with other mental health professionals, teachers and parents on school psychopharmacology issues. Nevertheless, similar to current research trends, this volume does not adequately address the dearth of RxP literature on psychotropic medication for pediatric populations and psychopharmacological issues for school-based psychologists. While McGrath and Moore intend for merely an RxP movement overview, their cause may have been better presented by making the lack of psychopharmacological accountability in school-settings a more central component in their RxP argument.
The RxP movement is a major advancement that may significantly alter the mental health landscape of psychologists along with other mental health professions. However, the underlying roles and functions of helping children succeed in school will not change as a result of obtaining RxP. School psychologists obtaining prescriptive authority merely offers a supplemental evidence-based intervention strategy to add to our “tool-belt” as one of many other tools used in mental health treatment for children. While the RxP movement will likely continue to be a controversial issue for debate in coming years, Pharmacotherapy succeeds in providing a thorough outline of progress made and delineates future goals and objectives.
Is Pharmacotherapy the “prescription for progress”? For professionals in the field of psychology who realize the need and importance of psychopharmacological training for collaboration, evaluation, and prescribing – the answer is yes. For decision-makers outside the field of psychology who fail to realize that appropriately-trained psychologists may be in the best position to provide schoolbased, comprehensive mental health treatment for qualitative, safety and ethical reasons – the answer is yes…but there is still further argument to be made.
American Psychological Association. (2009). Report of the Division 55 (American Society for the Advancement of Pharmacotherapy) Task Force on Practice Guidelines regarding Psychologists’ Involvement in Pharmacological Issues. Retrieved from http://www.apa.org/practice/guidelines/pharmacological-issues.pdf (PDF, 176KB)
Carlson, J. S. (2008). Best practices in assessing the effects of psychotropic medications on student performance. In A. Thomas & J. Grimes (Eds.), Best Practices in School Psychology (5th ed., pp. 1377- 1388). Bethesda, MD : National Association of School Psychologists.
DuPaul, G. J., & Carlson, J. S. (2005). Child psychopharmacology: How school psychologists can contribute to effective outcomes. School Psychology Quarterly, 20, 206-221. doi: 10.1521/ scpq.188.8.131.52511
Kubiszyn, T. (1994). Pediatric psychopharmacology and prescription privileges: Implications and opportunities for school psychology. School Psychology Quarterly, 9, 26-40. doi: 10.1037/h0088840
Kubiszyn, T., & Carlson, C. (1995). School Psychologists’ attitudes toward an expanded health care role: Psychopharmacology and prescription privileges. School Psychology Quarterly, 10, 247-270. doi: 10.1037/ h0088303
McCormick, B. E. (2010). Prescribing for schoolaged patients. In McGrath, R. E., & Moore, B. A. (Eds.), Pharmacotherapy for psychologists: prescribing and collaborative roles. Washington, DC : American Psychological Association.
McGrath, R. E., & Moore, B. A. (Eds.). (2010). Pharmacotherapy for psychologists: prescribing and collaborative roles. Washington, DC : American Psychological Association.
Medco Health Solutions. (2008). Drug trend report. Retrieved from http://www.medcohealth.com/art/drug_trend/pdf/DT_Report_2008.pdf (PDF, 8.6MB)
Radley, D. C., Finkelstein, S. N., & Stafford, R. S. (2006). Off-label prescribing among office-based physicians. Archives of Internal Medicine, 166, 1021-1026. Retrieved from http://archinte.ama-assn.org/cgi/content/abstract/166/9/1021
Jeffrey D. Shahidullah, EdS., NCSP , is a school psychology doctoral student at Michigan State University,East Lansing, MI.
John S. Carlson, PhD., NCSP , is the school psychology doctoral program director at Michigan State University, East Lansing, MI.
Correspondence concerning this article should be addressed to: Jeffrey D. Shahidullah, School Psychology Program, CEPSE , Michigan State University, Erickson Hall, East Lansing, MI 48824-1034.