Shrink Vs. Shrink
Ever hear of 'prescribing psychologists'? One state thinks they can fill gaps in mental health care. Psychiatrists doubt it.
Almost every day, Dr. Mario Marquez is frustrated: He can't give his patients the care he thinks they need.
Marquez works with emotionally disturbed and mentally ill schoolchildren in Belen, a town of 7,000 people that lies 40 miles south of Albuquerque. The Belen school district may be small, but its students' problems are not: A significant percentage of the student body has ADHD--attention deficit hyperactivity disorder; depression and suicide are serious problems.
Many of these conditions can be treated effectively with prescription drugs. But that doesn't help Marquez or the kids in his office. That's because Marquez is a clinical psychologist, a trained mental health provider with a Ph.D., not an M.D. As such, he is not authorized to write prescriptions. To get prescription medicines for his clients, Marquez has to refer them either to their family doctor or to a psychiatrist.
But that's where things get tough. Many physicians know a lot less about mental illness than Marquez does. In fact, they often ask him for advice. Getting a student in to see a pediatric psychiatrist is even harder. While Belen is fortunate to have a pediatric psychiatrist who visits the local community mental health clinic one day a week, it often takes four to six weeks to get an appointment with her.
"For the parent of a child who is suicidal or banging his head and having hallucinations," that can be a long and dangerous wait, Marquez notes. If he had prescriptive authority, Marquez adds, he "could help these children on the spot."
Starting next year, Marquez will get his wish. In 2002, New Mexico became the first state in the country to pass legislation allowing certain clinical psychologists who undergo additional training to become "prescribing psychologists." Although the regulations are still being finalized, Marquez already meets most of the new requirements. Consequently, he will soon be able to prescribe the whole gauntlet of psychotropic medications--from anti-anxiety medications to antipsychotic and antimanic drugs used to treat schizophrenia and bipolar disorder.
BREACHES AND BARRIERS
Psychologists have hailed New Mexico's legislation as a breakthrough that will broaden access to high-quality mental health care. The American Psychological Association is now pushing hard to persuade legislators in other states to follow suit. In the past two years, legislators and public health officials in 11 states have considered bills similar to New Mexico's. So far, these efforts have been blocked by the other APA, the American Psychiatric Association. The psychiatrists' argument is succinct: The best preparation for writing prescriptions is medical school.
The dispute between psychologists and psychiatrists over who should control access to medications has enormous public health implications. Roughly 10 percent of the population received some treatment for a mental illness last year. In addition, experts estimate that 28 percent of the population endured at least one episode of mental illness, which means that most people suffering from mental illness aren't being treated for it.
A large part of the problem, particularly for children with mental illnesses and people living in rural areas, has to do with a chronic shortage of mental health providers. As legislators and state officials across the country take up this dispute, they are having to grapple with a more fundamental question: Could licensing psychologists to write prescriptions help address the shortcomings of state and local mental health systems?
For the past two decades, medication--not psychotherapy--has been at the center of innovation for treating mental illnesses. For years, psychologists have argued that allowing them to prescribe medications would be easier and more cost-effective for patients and their insurers. That line of reasoning won them little legislative success. In New Mexico, however, psychologists tried a new argument: It would help address the chronic shortages of mental health providers in underserved areas, particularly in rural regions.
That resonated in New Mexico. The state as a whole has fewer than 100 psychiatrists and only 18 of those practitioners work outside of the two main cities, Albuquerque and Santa Fe.
The presence of psychologists in rural areas, however, is considerably higher. That's because many rural school districts have a clinical psychologist on staff. There are 170 psychologists working in rural New Mexico, out of a statewide total of 400. To Representative Edward Sandoval, a 24-year veteran of the New Mexico legislature who represents Albuquerque, this disparity suggested an obvious course of action: Let prescribing psychologists fill the gaps in public mental health systems across the state.
Not surprisingly, psychiatrists see things differently. "Psychologists and psychiatrists have very different focuses of training," says Dr. Steven Pliszka, the chief of child psychiatry at the University of Texas Medical School in San Antonio. "Treatment is becoming more medically oriented all the time. You get that physician point of view from medical school." As medications become more potent and complex, a medical background will become even more important, Pliszka argues.
Not so, psychologists say. Their primary evidence for this assertion is a pilot program conducted by the U.S. Defense Department in the early 1990s that trained 10 psychologists to write prescriptions. "The most comprehensive assessment found that those psychologists filled critical needs and performed with excellence wherever they served," says Dr. Russ Newman, executive director for professional practice at the American Psychological Association.
But that doesn't mean all psychologists who went through a training regime would do equally well. "The people who went through the DOD program were superb," notes Dr. Oakley Ray, a professor of psychology and psychiatry at Vanderbilt University who conducted one of the assessments of the DOD. "They were not run-of-the-mill clinicians; they were chiefs of services at major hospitals." Moreover, they were prescribing medications in a hospital context where medical advice was close at hand--not on their own in isolated rural settings.
In terms of prescription writing, comparing a psychologist's background to that of a psychiatrist may not be appropriate. Most psychotropic medication prescriptions in this country--75 to 80 percent of them--are written not by psychiatrists but by general practitioners, who don't have much experience diagnosing or treating mental illnesses, to say nothing of the nurse specialists and physician assistants who can also write prescriptions under physician supervision.
"Our concentration for psychotropic medications is much greater than what physicians get for psychotropic medications," says Joan Read, a psychologist in Atlanta. She contends that the medical training psychologists don't get is largely irrelevant for writing scripts. "Dissecting a cadaver would not significantly increase our ability to prescribe psychotropic medications safely and effectively." New Mexico's legislation doesn't limit psychologists to dispensing comparatively safe medications such as Zoloft. Once regulations are completed, prescribing psychologists in the state will most likely be able to prescribe the full range of psychotropic medications, including such potent antipsychotic medications as Clorazil, a drug commonly used to treat difficult cases of schizophrenia. Clorazil is effective but has a dangerous side-effect--it can cause a precipitous drop in white blood cells, which in turn can leave the body open to life-endangering infections. As a result, psychiatrists say it is imperative to take biweekly blood tests and monitor them closely. While psychologists insist that their training will qualify them to undertake such tasks, the prospect makes psychiatrists and their backers nervous.
"You talk about a psychologist prescribing Prozac to someone with a situational disorder and an antipsychotic to someone with a history of schizophrenia, well, that's a very different thing," says Ron Honberg, the national director for policy and legal affairs for the National Alliance for People with Mental Illnesses, one of the nation's largest advocacy groups. New Mexico's law "doesn't differentiate by diagnosis of severity. That's NAMI's biggest concern." It's one of the reasons NAMI does not, for now, support the creation of a new class of "prescribing psychologists."
THE SUPPLY SIDE
Then there's the question of whether allowing psychologists to write prescriptions will increase access to medicinal therapies in rural areas. In New Mexico, with its tradition of having psychologists on staff in rural schools, the answer is clearly yes. But in most other states, rural health providers and experts are skeptical.
"The level of doctoral-level psychologists in rural areas is practically identical to the level of psychiatric practices," says Dennis Mohatt, director of mental health for the Western Interstate Commission for Higher Education, a consortium of 15 largely-rural Western states. "More than 90 percent of psychologists and psychiatrists are concentrated in cities."
David Lambert, president of the National Association of Rural Mental Health and a researcher at the University of Southern Maine, agrees that letting Ph.D. psychologists write prescriptions won't provide much help for rural areas. "The reality is the majority of the workforce there is mid-level--a bachelor's-level social worker," says Lambert. "You don't have a whole bunch of Ph.D. psychologists practicing in rural America. This is not the magic bullet or a solution in and of itself."
At the same time, Lambert points to four decades of largely unsuccessful efforts to increase the number of both psychologists and psychiatrists in rural areas and says that rural America can take whatever help it can get. "Anything that increases the availability of qualified, trained providers out there to do things, we welcome."