New Jersey’s psychologists and psychiatrists are battling over who should be allowed to prescribe psychotropic medications like antidepressants.
For psychiatrists, it’s a matter of patient safety. For psychologists, it’s a question of need and numbers: they contend that there are more New Jerseyans with mental health problems than there are trained professionals to help them.
The issue has come to a head because the state Assembly Regulated Professions Committee released a bill (A-2419)
on December 6 that would allow psychologists who complete a master’s degree in psychopharmacology to prescribe psychotropics.
The bill is vigorously opposed by psychiatrists, who argue that a master’s degree won’t adequately prepare psychologists for the range of potential side effects that psychoactive drugs can cause.
“Medications, just because they’re psychotropic, should not be taken lightly,” said Rusty Reeves, director of psychiatry for the state prison system. “It requires medical training. This training is inadequate.”
Reeves continued, “I understand the idea of nonphysicians prescribing — that horse left the barn long ago. We have nurse practitioners and we have physicians assistants, but those people have genuine medical training, and more so than is specified here [in the bill].”
Psychologists counter that that the practice has already been proven safe in the U.S. military — which has given prescription authority to psychologists for 20 years — and in the two states that allow it, New Mexico and Louisiana.
The two sides also differ on whether there is need for the practice.
In making a case for the bill, Sean Evers, president-elect of the New Jersey Psychological Association, said it would benefit patients’ access to care, as well as freedom to choose their providers. He noted that the growth in mental health services, as well as the pressure on psychiatrists to meet the demand.
Reeves is dismissive of the argument that more mental health professionals are needed, “There are plenty of psychiatrists in this state — you can’t throw a head of arugula without hitting a psychiatrist.”
According to Robert McGrath, director of Fairleigh Dickinson University’s master of science program in clinical psychopharmacology, the bill “both increases the opportunity for people to be evaluated for medication and also decreases the use of medications when they’re really not appropriate.”
McGrath helped found the FDU’s master’s program in 2000, because “we were really disturbed at the lack of availability of appropriate medication care for people with mental disorders.”
The program is one of only three in the country that provide the training that would be necessary under the bill.
Working Toward a Master’s
According to the bill, psychologists who already have doctoral degrees would gain prescriptive authority after they receive the master’s degree or equivalent training, including at least 400 hours of coursework. They then would be able to prescribe the roughly 100 medications used to treat mental health and addictive disorders, a subset of the thousands of federally regulated prescription drugs.
In addition, the bill requires psychologists to consult with the patient’s physician of record before prescribing any medication. While the doctor wouldn’t have to approve, supporters said psychologists would be barred under their code of ethics from prescribing medication against the advice of the doctor.
Assemblyman Patrick J. Diegnan Jr. (D-Middlesex), the bill’s primary Assembly sponsor, said there are reasonable constraints and mandates in the bill.
“I think it’s a common-sense bill,” Diegnan said. “This gives the opportunity to treat the whole patient.”
One bone of contention is if the bill would increase ease of access to psychotropic medications in a country that has seen a sharp increase in their use and abuse since the introduction of Prozac in the 1980s. This uptick occurred when psychiatrists increasingly focused treatment on medication rather than psychotherapy.
Reeves acknowledged that the bill would provide psychiatrists with competition, but added that psychologists have more to gain financially than psychiatrists would lose. Reeves expects that psychologists with prescriptive authority would charge a similar rate to psychiatrists.
“There’s a reason we’re more expensive — it’s because we have eight years of training,” Reeves said. “The psychologists will up their prices comparable to what a psychiatrist will charge, and so they stand to gain a lot there without the adequate training.”
Reeves also questioned why the bill allowed psychologists to prescribe with either a master’s in psychopharmacology “or equivalent training.”
“A master’s is usually a year of training. This doesn’t even require that. All it requires is a minimum of 400 hours of didactic training or lectures, which is 10 weeks. As a doctor and a psychiatrist, I had four years of medical school, and four years of residency. That’s 16,000 hours, as opposed to 400 hours offered here,” Reeves said. (Psychologists could only participate in the proposed program after earning their doctorates.)
Evers argued that primary-care doctors are increasingly prescribing medications for mental health disorders, an area where they may have less training than those who have master’s degrees in psychopharmacology.
“Would you be satisfied if your broken leg, cancer, or heart condition were treated by a family physician instead of a specialist,” Evers said. “Why is that acceptable for individuals with mental disorders?”
He estimated that between 200 and 300 of the state’s roughly 3,000 psychologists would be ready to issue prescriptions “within a few years,” compared with roughly 1,500 psychiatrists.
The practice would also reduce the need for patients to juggle multiple providers.
The coursework includes a course in pharmacology, four courses in psychopharmacology, and studying those medical topics needed for treating mental disorders with medication, Evers said. The psychologists would study “exactly the same texts as physicians and nurses use in learning about anatomy, physiology, pathophysiology, biochemistry, clinical medicine, neuroscience, clinical psychopharmacology, and psychopharmacology.”
He also noted that the psychologists would pay for their own training, eliminating a need for the state to pay.
Visiting the Doctor
Child psychiatrist Anna Vander Schraaf expressed concern that families will be quicker to bring children to psychologists because there is less stigma attached than a visit to a psychiatrist. This could lead to inadequately prepared psychologists prescribing medications, she said.
“As a child psychiatrist, the work of psychopharmacology in the treating of patients is so much more crucial because you work with young children,” she said.
Psychiatrist Nancy Block told lawmakers at the December 6 hearing that psychiatry is arguably the most complex and difficult of any medical specialty.
She added that she also must understand reports from other medical specialists “and know what is going on 100 percent, from top to bottom; that is not what psychologists are equipped to do.”
Nancy Pinkin, a lobbyist representing psychiatrists, said psychotropic drugs can have particularly complex side effects.
“We’re talking about how we should have more and more control on the drugs and the prescriptions and now we’re saying in this particular case, that we’re going the other way,” Pinkin said.
Bill opponent Assemblywoman Amy H. Handlin (R-Monmouth) noted that the legislation doesn’t address primary-care doctors. She expressed concern about the legal implications for doctors who consult with prescribing psychologists.
“If the physician somehow communicates to the psychologist, ‘No you absolutely should not be prescribing this medication,’ it does not appear to me that the psychologist is precluded from going ahead and doing exactly what he or she wants to do,” Handlin said, adding that the “doctor is going to get sued whether or not the doctor ever gave any meaningful guidance, whether the psychologist paid attention.”
Diegnan said the caution that doctors would use in the consultations would be beneficial and that the ethical obligation to psychologists to follow the doctor’s advice would prevent conflicts from arising.
McGrath said the military’s experience licensing psychologists to prescribe medication showed that psychologists actually benefited from more focused training. The military found that a training program that was more extensive than the psychopharmacology master’s degree was inefficient.
FDU’s psychopharmacology training includes coursework in any procedure needed to prescribe the relevant medications, including reading lab test results and doing physical examinations, McGrath said.
“The military thinks that this is an acceptable level of training,” McGrath said.
McGrath argued that because psychologists are trained to treat “the whole patient,” they will be less likely to rely on medications. In many cases where patients currently are receiving three or four psychotropic drugs, psychologists would seek alternative treatments.
“Psychologists are conservative users of medication” in those areas where they have prescriptive authority, he said, noting that some combinations of antidepressants prescribed by primary-care doctors have never been subject to research studies.
The 150 graduates of the program have worked in the two states that allow the practice, the military, and the Indian Health Service.
McGrath said there have been no patient complaints or malpractice suits over prescriptions by psychologists. He also said that the FDU program has 450 hours of coursework, which is consistent with other two-year master’s degree programs.
“We have a record of safe and effective prescribing,” he said. “The bottom line is that there are ways of providing mental healthcare in a more rational fashion by people who know what they’re doing,” particularly compared with doctors who didn’t specialize in psychiatry.
The bill hasn’t been scheduled for a hearing in the Senate.