The prescriptive authority movement for psychologists: A call for RxP advocacy
In the recent Conference on the Future of School Psychology 2012 (Futures Conference), Dr. John E. Lochman held the keynote address on the topic of advocacy in the field of school psychology. The conference described the role of advocacy as
…a critical skill to influence and create change for the future of our nation's children. School psychology and school psychologists need to further develop effective advocacy strategies to support our children and youth, to enhance the profession, and to incorporate evidence-based assessment and treatment in schools.
In his address, Dr. Lochman described the critical roles that school psychologists can play as advocates in the profession through systems-level and individual opportunities. One important advocacy opportunity that will likely affect change in the profession of professional psychology at all levels is the prescriptive authority movement for psychologists (RxP). This vision has endured since 1984 when Hawaii Senator Daniel Inouye introduced this legislation under Hawaii State Resolution 159. Since then, slow but considerable progress has been made in endeavors such as the Department of Defense's creation of the Psychopharmacology Demonstration Project (PDP) which in 1989 trained 10 psychologists to prescribe, the APA's approval of an RxP training model in 1996, and the passing of RxP legislation in the U. S. territory of Guam, the states of New Mexico and Louisiana, the U. S. Military, and the Indian Health Service. Also, many other states have submitted RxP legislation.
Obviously, this expansion of roles would provide more professional relevancy and security as we develop skills to treat a wider range of patients and integrate into a diverse array of work settings. While the vast majority of school psychologists have no interest in ever obtaining prescriptive authority themselves, the reasons to advocate for this type of legislation within their own state are myriad and include more comprehensive patient care, improved monitoring of compliance and side effects, more thorough psychiatric diagnosis, better integration of educational, psychosocial, and psychotropic interventions, less overmedication/ polypharmacy, more patient follow-up, and fewer mixed messages about treatment. With the increased prevalence of prescribing psychotropic medications to school-age populations (Zito et al., 2003) there is clearly a need for a more efficacious approach to mental health treatment that is different from the current approach whereby primary care physicians (PCPs), who have little training in child and adolescent mental health and demonstrate an overreliance on drugs, are the primary prescribers. The following sections outline two critical reasons for why the ability for appropriately-trained psychologists to prescribe medication is vitally important for the profession and overall patient care.
Limited access to underserved populations
A recent National Health and Nutrition Examination Survey (NHANES) found only half (50.6 percent) of children with a mental disorder had received any type of treatment in the previous year (Merikangas, He, Brody, Fisher, Bourdon, & Korentz, 2010). These survey results also indicate that children are more likely to receive treatment for ADHD than for either mood or anxiety disorders. Other research suggests even lower treatment rates, as only 20-25 percent of children with a mental disorder received any form of specialty service, with the majority failing to receive any service at all, as reported by their families (U.S. Department of Health and Human Services, 1999).
A major reason for this lack of available mental health service is the current shortage of mental health providers. Workforce trends indicate a profound shortage of available psychiatrists as evidenced by recent downsizing of psychiatry residency training programs (Rao, 2003). This trend is even more pronounced among pediatric providers (Kim, 2003; Thomas & Holzer, 2006). Between the years 1980 and 2002, the amount of U.S. child and adolescent psychiatry residency programs decreased from 130 to 114 (Koppelman, 2004). Reasons for this downsizing of programs include, but are not limited to, reduced governmental support for pediatric residency training (see the Balanced Budget Act of 1997) and closure of state hospitals, which housed many of the programs (Koppelman, 2004). Additionally, there is less interest from medical students to pursue child psychiatry as a career path, partly due to financial disincentives of obtaining child psychiatry training coupled with low reimbursement rates from private insurers and Medicaid. (Koppelman, 2004).
While the mental health needs of most children are not adequately met, the needs of specific subsets of youth are even more profound. There is a lack of available pediatric mental health professionals in poor, urban and rural areas (Goldman, 2009). For example, nearly 96 percent of counties nationwide have unmet needs for medication prescribers, with needs in rural counties even more profound (Thomas, Ellis, Konrad, Holzer, & Morrissey, 2009). Further, the majority (87 percent) of designated mental health provider shortage areas (MHPSAs) in the United States are in non-metropolitan areas (Bird, Dempsey, & Hartley, 2001). Because of the significant reliance on PCPs practicing in rural areas, most require long appointment wait-times and limited "face-time" with patients. Consequently, most PCPs will not be able to take the time necessary to conduct a thorough background screening, psychological or psychiatric evaluation, or closely monitor treatment effects and side-effects for dosage titration.
Survey response from practicing psychologists in both urban and rural settings, indicates access to appropriate medication management was their community's most unmet psychological need (Campbell, Kearns, & Patchin, 2006). However, population density factors are not the only barriers to adequate specialty care. Campbell, Kearns, and Patchin (2006) also found significant unmet psychological needs in other underserved groups, specifically those with chronic mental illness and the economically disadvantaged. The maldistribution of PCPs, specifically in poor, urban and rural areas highlights the need for more mental health practitioners to take on further psychopharmacology training to address medication management needs (DeLeon, Fox, & Graham, 1991). Appropriately-trained psychologists are in an excellent position to step in and help undertake prescribing roles to provide access to currently underserved populations.
Restricted continuity of care
Though children spend a significant amount of time in schools, they are prescribed medication by personnel working outside the school. Oftentimes, there is little communication between those providing pharmacological interventions outside the school and those providing social-emotionalbehavioral and/or academic interventions within the school. Without communication and integration of care, service providers are unaware if they are ultimately treating the same deficits or accounting for service that is already being provided by someone else. This disjointed approach to treatment is neither cost nor time effective and creates inherent ethical and safety risks for children.
Frequently, due to time constraints and large case-loads, many PCPs do not use needed treatment follow-up procedures. They prescribe medications and send the child back to school, but fail to inform school personnel about expected medication effects and sideeffects. It is usually not until more serious symptomotology present (e.g., extreme lethargy, mood swings, tics) that the PCP is even made aware of needs for medication titration or discontinuation. The inability to adequately monitor and evaluate drug effects is particularly worrisome given the paucity of safety data in most pediatric medication. In fact, most safety and efficacy data for children is extrapolated from adult drug trials (Vitiello, 2007). As a result, most pediatric drugs are prescribed off-label, or in a manner inconsistent in which they were approved. Between the years 1996 and 2007, there was an almost 6 percent increase in pediatric office visits resulting in the prescription of psychotropic medication from at least two classes (Comer, Olfson, & Mojtabai, 2010).
Many of these drugs, particularly antidepressants, contain "black-box" warning labels, highlighting their risk for suicidality. Further, two or more of these medications are often combined in a treatment regimen (i.e., polypharmacy). For obvious reasons, these practices raise profound ethical and safety concerns within vulnerable pediatric populations.
Even more disconcerting, may be the lack of training that many current prescribers have in pediatric mental health. Recent trends in medical school training have resulted in shortened clinical rotations in psychiatry for future physicians (Serby, Schmeidler, & Smith, 2002). While, the average length of psychiatric clerkship is roughly six weeks, some can be as short as only four weeks. This limited exposure to psychiatric training during medical school, may lead to less confidence in treating specific conditions. In a survey of primary care pediatricians, 46 percent of respondents lacked confidence in their clinical ability to diagnose child or adolescent depression; further, 86 percent lacked confidence in their ability to manage depression pharmacologically. In more severe mental health conditions, PCPs may elect to refer to a mental health specialist (Muse, Brown, & Cothran-Ross, 2011). However, because these referrals are usually limited, most PCPs elect to treat "in-house." Psychologists, with more extensive training in child and adolescent mental health, can provide not only a higher quality of care by implementing less intrusive interventions before a medication is needed, but also provide the long-term follow-up that typically does not occur with the PCP.
Opportunities to advocate
School psychologists have numerous ways to advocate for this vital movement for the field. The first step is to visit the APA Division 55 website for the American Society for the Advancement of Pharmacotherapy (ASAP). Along with APA, ASAP has been pushing for RxP for well over two decades. This website provides the ideal starting point for the practitioner who is curious about learning more about the RxP movement and about all the possible avenues there are in which to advocate. The division publishes a quarterly newsletter entitled "The Tablet" which provides on-going updates regarding RxP legislation efforts. Other methods for advocacy are addressed in the following organization's web resources: APA Public Policy Advocacy Network; APA Government Relations Office (GRO) advocacy guides; APA Center for Psychology in Schools and Education; NASP.
The Balanced Budget Act of 1997, (Pub. L. No.105-33, 111 Stat. 251)
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About the author
Jeffrey D. Shahidullah is a school psychology PhD student at Michigan State University, East Lansing, Mich. He is a member of APA Division 55's American Society for the Advancement of Pharmacotherapy (ASAP) and a contributor to the organization's newsletter, The Tablet. Email for more information on how to advocate for RxP legislation in your own state or the federal level.