In This Issue

Establishing uniform requirements for privileging psychologists to prescribe in federal service

The authors propose a minimum set of criteria to be used for the privileging of psychologists to prescribe psychotropic medications in federal agencies.

By David S. Shearer, PhD, Bret A. Moore, PsyD, and Amy Park, PhD

Disclaimer: The views expressed in this article are those of the authors and do not reflect official policy or position of the Department of the Army, the Department of Defense, the U.S. government or any of the institutional affiliations noted.

As those following the development of prescribing psychology (RxP) are aware, New Mexico, Louisiana, and most recently, Illinois, have passed legislation permitting appropriately trained psychologists to prescribe psychotropic medications. Some limited form of prescription authority is also permitted for psychologists in the state of Indiana and territory of Guam (McGrath, 2010). And currently, several states are in various stages of introducing RxP bills for a vote in their respective legislatures. As those who follow the RxP movement are also aware, the history of psychologists seeking prescription privileges goes back several decades. One of the most important historical RxP events involves the establishment of the Department of Defense Demonstration Project (e.g., Sammons and Brown, 1997) in the early 1990s in which a handful of psychologists underwent rigorous formal training to prescribe psychotropic medication. It is important to note that this was a federal endeavor rather than a state driven program. While individual states have continued to pursue prescription privileges for psychologists, similar efforts have continued in the federal sector with good results.

Currently, appropriately trained psychologists are prescribing psychotropic medication in the Departments of the Army, Navy and Air Force as well as in the Indian Health Service (IHS) and Public Health Service (PHS). The efforts at the state and federal levels have worked synergistically to move the RxP movement forward. In addition, legislative efforts are underway in an attempt to expand these privileges to the Department of Veterans Affairs (H. Kelly, personal communication, March 17, 2015). As a testament to the hard work and success of those who have made advances in the military, required criteria for each of the military services are specified in regulations specific to each service (Navy: BUMEDINST 6320.66E, 2013; Air Force: AFI44-119, 2011; Army: Department of the Army Memo, 2009). However, to date, neither the PHS nor the IHS have specific regulations. Rather the PHS psychologists adhere to service-specific criteria depending on the location of their duty station and the IHS psychologists obtain state licensure to prescribe in either New Mexico or Louisiana (M. Tilus, personal communication, February 27, 2015).

By far the most comprehensive criteria for prescriptive authority for psychologists are outlined by the Department of the Army (DoA, 2009). The Department of the Army permits psychologists to prescribe if they meet the following criteria:

  1. is a graduate of the DoD demonstration project or have a master's degree in psychopharmacology from a regionally accredited university;
  2. obtain a passing score on the Psychopharmacology Examination for Psychologists (PEP);
  3. document one year of supervision by a board certified psychiatrist or psychologist with prescribing privileges in a Military Treatment Facility (MTF); and
  4. apply for prescription privileges within 24 months of passing the PEP. A suggested formulary is provided, but specific formularies are to be determined by the MTF granting prescription privileges.

The Department of the Navy delineates the following criteria (BUMEDINST 6320.66E, 2013):

  1. completion of training in psychopharmacology from a program recommended by the American Psychological Association and
  2. passage of the PEP. There is no specific mention of graduates of the DoD program, but in practice those initial providers have been allowed to continue to prescribe. There is no delineation of required supervision and no specific mention of formulary.

The Department of the Air Force established the following criteria (AFI44-119, 2011):

  1. graduates of the DoD Demonstration Project may continue to prescribe for the Air Force;
  2. completion of a master's degree in clinical psychopharmacology;
  3. passage of the PEP; and
  4. documentation of a minimum of one year of supervision by a psychiatrist or psychologist with prescriptive authority. There is no mention of formulary.

The important commonalities across military services include obtaining a master's degree in psychopharmacology and passing the PEP. However, other important criteria vary between services including whether the master's degree is from an approved or accredited school, if supervision is required, and if so, by whom and where, and if a formulary is recommended. Relatedly, there are several critical issues that need to be addressed. For example, since there are now three states that permit psychologists to prescribe, should the federal sector require state licensure as part of its requirements? Also, since many of the early trained psychologists in psychopharmacology completed certificate programs and not graduate degrees, should an exception be made for these individuals in which the degree requirement is waived?

We propose that as part of the maturing process of the field of RxP we should move toward identifying a uniform set of criteria that can be used across federal settings to privilege psychologists to prescribe psychotropic medication. Decisions to adopt privileging criteria rests with the individual federal entities and they each have an established process in place for recommending and adopting criteria for providers. However, those of us in the field of RxP can assist in this process by preparing a uniform set of recommendations. There are a variety of advantages in having a uniform set of criteria, but perhaps also some potential disadvantages.

Advantages of uniform criteria include further legitimizing the practice of RxP in the federal sector by identifying the highest standards and regulations for privileging. Shared criteria will reduce confusion between federal settings and likely facilitate smooth transfers of RxPs between federal agencies. By taking ownership of this process we can work to ensure that our federal criteria for privileging are neither too lenient nor too restrictive. Taking responsibility to set high, inclusive, attainable and uniform standards for the federal sector is a sign of a maturing field and can put us on par with other prescribing disciplines. Finally, uniform criteria would ensure quality across federal settings.

Some disadvantages might arise from setting uniform standards. New requirements might result in currently privileged RxPs no longer meeting criteria to prescribe in a specific federal agency. Poorly developed criteria could result in recommendations that are too lax and risk delegitimizing the field as a whole. Alternatively, criteria that are unnecessarily restrictive could reduce opportunity and growth for RxP in the federal sectors. Therefore, any recommended changes should be discussed thoroughly and vetted by the various stakeholders to avoid these pitfalls.

With this is mind, the current authors propose a minimum and uniform set of criteria to be used for the privileging of psychologists to prescribe psychotropic medications in federal agencies. The reader should consider this a starting point for further discussion with an eye toward the eventual adoption of a uniform set of criteria. This list is by no means exhaustive and the authors understand these criteria can have significant implications on current and future prescribing psychologists and the field as a whole.

Proposed Uniform Criteria for Privileging Psychologists to Prescribe in Federal Agencies
  • A postdoctorate master's degree in psychopharmacology from a regionally accredited and/or APA-approved graduate program, or a master's degree in psychopharmacology earned during the pursuit and completion of a doctorate in psychology from an accredited graduate program, or a postdoctorate certificate in psychopharmacology that meets APA recommendations prior to a specified year (grandfather clause).
  • Passage of the PEP or other national certifying examination recommended by APA.
  • Documentation of one year of supervision by a licensed prescribing psychologist, board certified psychiatrist, or other board certified physician with specific knowledge of psychotropic medications in a community, state or federal setting.
  • Provide pharmacotherapy to a minimum of 100 patients during the supervisory period.
  • Current licensure from a state permitting psychologists to prescribe, or obtaining such a license within two years of being privileged in a federal agency to prescribe.
  • A statement indicating that medications typically used to treat psychiatric disorders are within the standard formulary of RxPs.
  • A statement regarding the expectation of ongoing competence, continuing education in psychopharmacology and participation in quality management such as peer supervision.

References

Air Force Instruction 44-119. (2011, August 16). Medical quality operations. http://static.e-publishing.af.mil/production/1/af_sg/publication/afi44-119/afi44-119.pdf

BUMEDINST 6320.66E CH-5 (2013, March 11). Appendix G, clinical privileges for allied health specialists. http://www.med.navy.mil/directives/ExternalDirectives/6320.66E%20(with%20changes%201-5).pdf

Department of the Army. (2009). Policy and procedures for credentialing and privileging clinical psychologists to prescribe medications. Houston, TX: Author. https://www.us.army.mil/ suite/files/21527827

McGrath, R. E. (2010). Prescriptive authority for psychologists. Annual Review of Clinical Psychology, 6 , 21–47. doi:10.1146/annurev-clinpsy-090209-151448

Sammons, M. T., & Brown, A. B. (1997). The Department of Defense Psychopharmacology Demonstration Project: An evolving program for postdoctoral education in psychology. Professional Psychology: Research and Practice, 28 (2), 107-112. http://dx.doi.org/10.1037/0735-7028.28.2.107