On March 6, 2002, Governor Johnson signed New Mexico's HB.170 into public law, authorizing appropriately trained psychologists to prescribe. On January 7, 2005, Mario Marquez applied for his "conditional certification." In May 2004, Louisianafollowed suit and medical psychologist John Bolter wrote his first script on January 20, 2005. Both the New Mexico and Louisiana State Psychological Associations had been working on their ultimately successful legislation for over five years. When did psychology's prescriptive authority quest actually begin? In 1984, U.S. Senator Daniel K. Inouye urged the Hawaii Psychological Association to seek this authority. In 1972, visionary APA President, Nick Cummingsraised this possibility with his Board of Directors. In August, 1995, the APA Council of Representatives formally endorsed prescriptive authority as APA. By the end of 2008, Glenn Ally estimated that 200,000 psychotropic medication orders had been written by his Louisiana colleagues. Today, now CSPP Dean Morgan Sammons postulates that between 800-1,000 colleagues have completed their formal psychopharmacological training. The numbers are indeed impressive.
With the passage of President Obama's landmark Patient Protection and Affordable Care Act (P.L.111-148), 32+ million Americans will soon have access to high quality, patient-centered primary care for the first time in their lives. The President's vision calls for the utilization of the most up-to-date advances in communications and computer technology, an emphasis upon prevention and wellness care, and the steady development of comprehensive systems of care (Accountable Care Organizations (ACOs)) throughout the land. Under previous Administrations, these would probably have been considered Health Maintenance Organizations (HMOs – President Nixon) and/or Managed Care (President Clinton). Interdisciplinary care, comparison across diagnoses and patient populations, and reliance upon objective gold standards will increasingly become the norm. The Administration is providing the States with sufficient flexibility to craft the health care environment which best fits their unique situations. Within this broader policy frame of reference, I would suggest that psychology's prescriptive authority quest fundamentally represents an important evolution of the field into primary care health psychology. And, I would also suggest that over the next decade there will be an increasing number of psychologists providing integrated care as employees in organized systems such as federally qualified community health centers (FQCHCs) and ACOs, rather than working in a traditional independent small practice or community mental health center. Times are changing.
As I reflect upon the professional literature over the past 25years, there have been consistent and increasing calls for the integration of mental health (now frequently called "behavioral health") services within primary care. Whether one considers Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention(1979) or the Institute of Medicine reportHealth and Behavior: Frontiers of Research in the Biobehavioral Sciences (1982), the underlying message is very clear. Primary care providers, with considerably less mental health training than psychologists, have been providing care for 60-80% of those with discernible mental health disorders. Most practicing psychologists have been trained in a traditional mental health setting, pursuant to the community mental health center movement of President Kennedy' era, the psychological services organization of the VA, and/or university-based mental health clinics. Collectively we have not been aware of the far reaching community health center initiatives of President Johnson's Great Society era, which represent the federal safety net for millions of Americans.
Those federal (and increasingly civilian) psychologists who do possess prescriptive authority have emphasized that their clinical skills are in definite demand and that their integrated skills have allowed them to clinically modify prescribed regimens of psychotropic medications more appropriately for their patients' benefit. Within the Indian Health Service, pioneers such as Floyd Jennings prescribed with standing orders at the Santa Fe Indian hospital, New Mexico, during the mid-1980s, where quality assurance reviews of cases were quite positive. In June 1994, APA President Bob Resnick attended the graduation ceremony for the first two Department of Defense psychopharmacology training graduates, John Sexton and Morgan Sammons. When one studies the literature for various subpopulations, such as the elderly, children, ethnic minorities, etc., the picture is again quite clear: psychologists with prescriptive authority provide the highest quality of care.
Although I have been involved in this movement over the years, it is impossible to predict with any sense of certainty which will be the next state to enact prescriptive authority legislation. Will, for example, Hawaii andOregon be successful in overcoming their vetoed bills? The numbers of psychologists completing their advanced training continues to grow. As of the Fall of 2010, 276 graduates had been admitted to take the APA PEP (Psychopharmacology Examination for Psychologists) developed by the APAPO Practice Organization's College ofProfessional Psychology. With the advances occurring in educational technology, I would expect that those on their clinical internships will soon have ready access to medication decision protocols. Over the years, slightly more than one third of our State Associations have established task forces to coordinate prescriptive authority activities, with nearly a quarter having introduced relevant legislation. Fundamental change always takes time; oftentimes, longer than one might initially expect. Today, several of the States pursuing prescriptive authority, such as Arizona and New Jersey were initially considered to be among those that their leaders felt would be the "last in the nation" to undertake such action.
Leadership changes, as does the nation's health care environment. Looking over the Congressional landscape, it is evident that we will continue to see an increasing number of non-physician primary care providers adopting the doctoral level of training as their standard and expanding their scopes of practice to fully utilize their clinical expertise. The right to prescribe medications by nurse practitioners and doctors of nursing practice, as well as by clinical pharmacists, for example, continues to mature exponentially across the nation and to be appropriate for their training. They are calling for patients to have the freedom to choose the practitioner of their choice. Sound familiar?
I am confident that psychology's leadership will appreciate the growing importance of proactive vision and action. As the President of the Institute of Medicine has stated: "Dealing equally with health care for mental, substance-use, and general health conditions requires a fundamental change in how we as a society and health care systems think about and respond to these problems and illnesses. Mental and substance-use problems and illnesses should not be viewed as separate from, and unrelated to, overall health and general health care (2006)." Aloha,
Pat DeLeon, former APA President
The National Psychologist – February, 2012
