The Prescriptive Authority Guidelines were developed to assist boards in maintaining as much consistency as possible when they write regulations for prescriptive authority.
PLEASE NOTE: These Guidelines and Recommendations for Prescription Privileges were developed in 2000. In October 2005, both the ASPPB and the National Register Board of Directors approved Criteria for Approval of an ASPPB/National Register Designated Postdoctoral Program in Psychopharmacology. Building upon the efforts by APA to define the curricula, ASPPB and the National Register have jointly developed criteria and a process for approving such programs since these organizations have extensive experience in credentialing. The joint effort establishes a mechanism for licensing boards and credentialing bodies to be able to identify programs meeting established guidelines. Individuals who have completed their training will be evaluated by the boards and the National Register on an individual basis. See QuickLink, ASPPB/National Register Designated Postdoctoral Program in Psychopharmacology.
In an effort to maintain as much consistency as possible, jurisdictions that have statutory provision for prescription privileges for psychologists are urged to follow, to the extent possible, these guidelines in writing regulations for the certification of individuals for prescription privileges.
- Certifying individuals for prescriptive authority should be separate from and in addition to the generic license, as provided by most states and provinces. Candidates for certification should have been licensed already by a state or province for the independent practice of psychology at the doctoral level, and have the necessary training and experience as a health service provider. A health service provider in psychology means an individual licensed at the doctoral level who is duly trained and experienced (i.e., meets defined criteria of training and experience adopted by the board in rules and regulations) in the delivery of direct preventive, assessment, and therapeutic services to individuals whose growth, adjustment, or functioning is actually impaired or is demonstrably at high risk of impairment (ASPPB, 1998)
- The foundation for prescription privileges education and training should include demonstrated knowledge of human biology, anatomy and physiology, biochemistry, neuroanatomy, and psychopharmacology. This prerequisite may be met by successful completion of a planned sequence of courses at a regionally accredited institution of higher learning, or evidence of completion of a planned sequence of continuing professional education courses offered by an accredited institution of higher learning, or a board-approved provider of continuing professional education, and the passing of examinations covering the content of such a program.
- Education and training for prescription privileges should be at the postdoctoral level. A minimum of three hundred hours of didactic instruction in neuroscience, pharmacology, psychopharmacology, physiology, pathophysiology, physical and laboratory assessment, and clinical pharmacotherapeutics is required.
- The postdoctoral didactic instruction for education in prescription privileges should meet the following requirements: a) be provided by a regionally accredited institution of higher learning or another appropriately accredited provider of instruction and training; b) the entire program of didactic courses and clinical practice should be organized as a coordinated program of instruction; and, c) be provided by faculty with appropriate teaching qualifications in physiology, biochemistry, neuroscience, pharmacology, psychology, pharmacy, medicine, and psychiatry.
- Consideration should be given to the fact that many licensed psychologists are licensed for prescription privileges in another profession, e.g., nursing. For these individuals, part or all of the didactic requirements should be waived prior to allowing them to take the board-approved examination.
- The clinical practicum must be closely supervised, involving exposure to a range of patients and diagnostic categories within the intended area of practice. The ASPPB Supervision Guidelines (1998) provide a standard for supervision which should be followed. A minimum of 100 patients must be supervised on their utilization of medication. Within the individual’s scope of practice both inpatient and outpatient populations should be included as well as a range of ages. Specific recommendations concerning time requirements, appropriate settings, range of patients, and qualification of supervisors are all addressed in the body of this text. Supervisors must assume responsibility for their supervisees and must attest to their readiness to prescribe independently.
- The examination for knowledge in prescription privileges should be developed by a recognized and experienced test developer approved by the state or province. The candidate should take this examination after completing all didactic requirements. The complete specifications for the test should be available to a regulatory board on request. These specifications should indicate provision for an expert working group (EWG) for the development of items with ongoing research to assure and maintain the reliability and validity of the test.
- Individuals must demonstrate, to the satisfaction of their board, that they maintain current knowledge not only with respect to the established medications, but also to newly released medications and their appropriate use in psychopharmacology.
- It is expected that psychologists always practice in ways that are consistent with the APA and CPA Ethical Codes as well as the ASPPB Code of Conduct. Psychologists in training or qualified to prescribe should be mindful of ethical principles in all activities, including their relationship to pharmaceutical companies and other entities that may result in inappropriate dual relationships.
Other Issues to Consider
- Boards should insure that an applicant for prescriptive authority has completed an acceptable written examination no more than 5 years before the date of application for certification. This is to assure that the applicant’s knowledge is current.
- Boards may be concerned about the initial lack of qualified psychologists to participate in complaint and disciplinary procedures concerning psychologists licensed for prescription privileges. Consideration should be given to utilizing members from other professions who are qualified, e.g. physicians, to participate in these actions. Regulations may have to be changed to allow for this provision.
The mission of the Association of State and Provincial Psychology Boards (ASPPB) is to assist member boards in their mission to protect the public. This is accomplished primarily through the provision of information and guidance to member boards regarding regulatory, professional, and legislative issues. As a matter of policy, ASPPB neither endorses nor opposes the current movement within many professional organizations to promote prescription privileges for psychologists.
These guidelines were prepared in an effort both to provide guidance to jurisdictions that have received, or are anticipating statutory approval of, prescription privileges for psychologists, and also to continue ASPPB’s efforts to achieve greater uniformity of standards among jurisdictions when making changes to their acts and regulations. There is not yet a standard for how boards of psychology should regulate prescriptive authority for psychologists if legislatures enact this authority through statutory change.
This document is an effort to assist the member boards of ASPPB in addressing issues related to prescription privileges. It summarizes relevant literature and presents considerations pertinent to the regulation of prescription privileges if such authority is granted within a jurisdiction. Guidelines are proffered to facilitate individual boards in developing regulatory criteria and mechanisms and to promote consistency in how boards might undertake regulating this potential aspect of psychologists’ practice. It is anticipated that guidelines for regulating prescription privileges for psychologists necessarily will evolve and change over time based on the experiences of psychologists, consumers, and regulatory boards.
The charges from the ASPPB Board to the Committee on Education, Training and Oral Examinations were to:
- review the literature concerning the history and current status of prescription privileges for psychologists;
- study the data available on education and training relative to psychopharmacology and prescription privileges for psychologists;
- review regulatory issues and draft guidelines relative to prescriptive authority to promote uniformity among licensing boards in cooperation with the ASPPB Task Force on Model Regulations.
The board or college of psychology in a province or state is the statutory body created to license psychologists, maintain quality of education and training of psychologists, and maintain discipline in order to protect the public.
A client or patient is a recipient of psychological services within the context of a professional relationship. A corporate entity or other organization can be a client when the professional contract is to provide services of benefit primarily to the organization rather than to individuals. In the case of individuals with legal guardians, including minors and legally incompetent adults, the legal guardian will be the client for decision making purposes, except the individual receiving services will be the client for:
- issues directly affecting the physical or emotional safety of the individual, such as sexual or other exploitative dual relationships;
- issues specifically reserved to the individual, and agreed to bythe guardian prior to rendering of services, such as confidential communication in a therapy relationship.
Code of Conduct
A code of conduct is the set of regulatory rules of professional conduct, including the code of conduct recommended by the Association of State and Provincial Psychology Boards (2001), adopted by a board by statute or rule to protect the public welfare by providing rules that govern a professional’s behavior in the professional relationship.
Health Service Provider in Psychology
As defined in the ASPPB Model Act (1998), a health service provider in psychology is an individual licensed under this Act who is duly trained and experienced (i.e., meets defined criteria of training and experience adopted by the board in rules and regulations) in the delivery of direct preventive, diagnostic, assessment and therapeutic intervention services to individuals whose growth, adjustment or functioning is actually impaired or is demonstrably at high risk of impairment. For purposes of certification for prescription privileges, a doctoral degree in psychology is required.
Institution of Higher Education
An institution of higher learning is a university, professional school, or other institution of higher learning that:
- in the United States, is regionally accredited by bodies approved by the Council on Postsecondary Accreditation and the United States Office of Education;
- in Canada, holds a membership in the Association of Universities and Colleges of Canada; or,
- in other countries, is accredited by the respective official organization having such authority.
A license gives an individual the authority to engage in the autonomous practice of psychology. The terms certified, registered, chartered, or any other terms chosen by a jurisdiction used in the same capacity as licensed are considered equivalent terms.
The Professional Examination Service (PES) is the company which is used by ASPPB to create and maintain the Examination for Professional Practice in Psychology (EPPP).
Prescription Privileges/Prescriptive Authority
These two terms are used interchangeably in this document. They indicate the privilege/authority, granted by state or provincial legislation to administer medication only available by prescription.
Professional Psychology Training Program
A professional training program in psychology is a doctoral training program that:
- is a planned program of study which reflects an integration of the science and practice of psychology including practice and internship;
- for applicants receiving their terminal degrees after 1990, is designated as a doctoral program in psychology by the Association of State and Provincial Psychology Boards and the National Register of Health Service Providers in Psychology, or is accredited by the American Psychological Association/Canadian Psychological Association; or,
- meet program criteria as defined in board rules.
There has been considerable interest and discussion in the profession about whether or not psychologists should be granted prescriptive authority. Those in favor argue that prescriptive authority for psychologists would provide greater continuity of care and increased service delivery to under-served populations. Those opposed are concerned that psychologists will lose their therapeutic skills and overemphasize the biological basis of behavior. Nussbaum argues that it is consistent with “imaginative growth” within the profession to adopt prescriptive authority. He states, “Psychologists should be willing to pioneer these new ways of thinking and developing truly integrative psychobiological treatments to capitalize on the drug-behavior interactions that will propel therapeutics to new levels rather than be worried about loss of existing psychotherapy skills. This will lead to an exciting set of questions being raised by psychologists: which drug in which dose in combination with which information/therapy will activate or inactivate which neural processing system to allow this individual client/patient the best success in life?” (Nussbaum, 2001).
The pursuit of prescriptive authority by psychologists has been a matter of discussion and debate within the profession (Gutierrez & Silk, 1998). In the past 18 years there have been 10 opinion surveys on whether or not psychologists should receive prescriptive authority. Walters recently published a meta-analysis which indicated that there is a split of opinion among psychologists, and that most psychologists are supportive of prescriptive authority in principle, but would not take the training themselves. Further, psychologists in training were more enthusiastic then senior psychologists (Walters, 2001).
ASPPB is convinced that there is sufficient interest in prescriptive authority for psychologists to justify the effort by the Committee on Education, Training and Oral Examinations to recommend guidelines for the education and training of psychologists who seek this authority. At least 27 states have task forces on prescription privileges, and several have prepared legislation and made attempts to have this legislation accepted.
Articles in the professional psychological journals dating from the late 1970’s have addressed the issue of expanding the practice of psychology to include prescription privileges. As stated by Fox (1988): “As psychology has grown in knowledge and sophistication, its practitioners have felt increasingly hampered by several constraints that make the full use of their knowledge and skills difficult to exercise: lack of appropriate hospital privileges, inability to control restricted drug use in treating their patients’ emotional or behavioral problems, and restrictions in the use of some physical intervention devices developed and/or commonly used by psychologists” (p. 501). As early as 1979, the American Psychological Association (APA) Board of Professional Affairs (BPA) appointed a task force to examine psychologists’ use of physical interventions, and the first task force report was published in 1981 and revised in 1986 (1981, 1986). In 1990, the APA Council of Representatives established a task force to further examine prescription privileges for psychologists (DeLeon, Fox, & Graham, 1991).
Fox and others have argued that prescription privileges and the “ . . . use of medications is a logical extension of psychological practice” (1988, p. 512). This extension is concerned with enhancing the effectiveness of human coping and behavior through biomedical and psychological/behavioral factors. Fox asserts that prescription privileges for psychologists would serve the public interest in multiple ways. Some examples of how prescription privileges for psychologists might serve the public interest include: psychological research evaluating drug effectiveness; the fact that many symptoms and diseases are behavioral/psychological in nature; and, to enhance the working alliance with non-psychiatric physicians in meeting patient needs. This third argument is further supported by DeLeon’s (1988) stance that psychologists have a responsibility to offer society the best services possible, which includes an integration of biomedical and behavioral variables. Combining psychotherapy and prescriptive authority in the same provider would lead to more efficient and effective treatment.
Several authors have noted the number of health practitioners other than physicians who have gained limited prescription privileges in a variety of jurisdictions (Brentar & McNamara, 1991; Burns, DeLeon, Chemtob, Welch, & Samuels, 1988; Cullen & Newman, 1997; DeLeon, Fox, & Graham, 1991; Fox, 1988). These include nurse practitioners, nurse midwives, optometrists, podiatrists, dentists, and physician assistants. The need in particular areas has also been described, e.g., rural communities, which are served by few psychiatrists and general practitioners who may have limited expertise in prescribing psychoactive medication (Brentar & McNamara, 1991; Buie, 1988; DeLeon, Fox, & Graham, 1991; Martin, 1995).
In 1992, the APA Task Force on Psychopharmacology reported survey data that there were more licensed psychologists than psychiatrists in the U.S. It was also noted that a number of practicing psychologists had already gained substantial knowledge of psychopharmacology through reading and continuing professional education (Smyer, Balster, Egli, Johnson, Kilbey, Leith, & Puente, 1993). Also, in a survey of doctoral programs it was noted that 60% of public and 75% of private universities already offered a psychopharmacology course and may also offer practicum training. However, the Task Force report also noted that more than two-thirds of the psychologists surveyed “ . . . described their training related to psychopharmacological issues as poor” (APA, 1992, p.50) and “ . . . determined that psychologists need substantial training beyond what is currently being provided before they are licensed as independent prescribers of psychoactive medications” (APA, 1992, p.108). The current APA (2000) accreditation criteria for doctoral programs require exposure to the “biological aspects of behavior,” but do not specify what type of exposure is necessary, nor do they require that psychologists be prepared for prescribing on the basis of their doctoral degrees. One recent survey of psychology graduate students (Tatman, Peters, Greene, & Bongar, 1997) revealed that only 25% reported having taken courses in psychopharmacology. In addition, it should be pointed out that some recent studies have found that the results from the surveys of psychologists’ opinions have been inconsistent (e.g., Gutierrez, P.M.& Silk, K.R. 1998, Walters, 2001).
The APA Task Force reported that a survey of 102 U.S. schools of medicine for 1989-1990 conducted by the Association for Medical School Pharmacology revealed that medical students received an average of 104 teaching hours in pharmacology. A California Psychological Association Blue Ribbon Panel report (1995) listed the number of credit hours of pharmacology training for a variety of health providers. Their results indicated 114 hours for physicians, 95 for optometrists, 83.6 for dentists, 75 for nurse anesthetists, and 6 for podiatrists. These numbers illustrate the relatively low number of hours of training received by medical students and others, and thereby offers support for the practicality of training other health care providers in pharmacology.
In 1988, the then Assistant Secretary for Health Affairs in the Department of Defense (DoD) issued a memorandum which directed the Army to begin a pilot project under which military psychologists would be “. . .trained and authorized to issue appropriate psychotropic medications under certain circumstances” (Conf. Rep. No. 100-1002, p. 34, cited by DeLeon, Fox, & Graham, 1991). After responding to numerous objections from organized psychiatry, the Department of Defense pilot demonstration finally began in the early 1990’s. A two-year fellowship program which combined didactic training and practicum experiences was developed. The didactic course work included: “. . .at a minimum, human anatomy and physiology, inorganic chemistry, physiological chemistry, laboratory services, pharmacology, and orientation to the physical exam” (DeLeon, Fox, & Graham, 1991, pp. 384-393). The first trainees’ clinical practicum occurred over a period of approximately eight months on the inpatient psychiatric service unit at Walter Reed Army Medical Center or Bethesda Naval Hospital. The practicum included assessment and treatment of at least 100 psychiatric inpatients who required psychotropic drugs within their treatment regimen. The trainees were supervised by staff psychiatrists and carried an ongoing caseload of 8-12 patients.
Two psychologists graduated from the DoD project in June 1994, while the 1994-96 class contained five fellows and three civilians who agreed to enter active duty as military officers for a three-year term. The Psychopharmacology Demonstration Project (PDP) was monitored and evaluated by the American College of Neuropsychopharmacology (ACNP) and the curriculum was revised based upon ongoing experience (1991). The American College of Neuropsychopharmacology issued its final 85-page report in May of 1998. Its findings and conclusions reported that all 10 graduates of the PDP filled critical needs, performed with excellence, and were highly esteemed, valued, and respected. They were seen as weaker medically than psychiatrists, but it was noted that the PDP was not designed to replace psychiatrists or produce mini-psychiatrists or psychiatric extenders, but to extend psychological practice with prescriptive authority. One indicator of the quality and success of the group was that 8 out of 10 were serving as chiefs or assistant chiefs of clinics. All graduates favored training programs similar to theirs and considered any type of abbreviated program as ill advised. The practice of psychopharmacology was confined to adults ages 18-65 for all graduates. The great majority of the pharmacology patients had adjustment disorders, anxiety, and depression. The medicines prescribed were mostly the newer antianxiety and antidepressant agents, especially the SSRIs. Graduates were initially proctored by psychiatrists and then moved to independent provider status. The graduates also contributed significantly to the training of psychology interns. The report recommended a two-year training program with one year didactic and one year clinical practicum which would include at least a six-month inpatient rotation. The reviewers were impressed with the work of the graduates and their acceptance by psychiatrists and judged the PDP as a “job well done” (ACNP, 1998).
The U.S. General Accounting Office (1999) submitted a report to the Chairman and Ranking Minority Member of the U.S. Senate Committee on Armed Services reviewing the service of nine program graduates who were treating patients, including medications at military clinics and hospitals. Graduates were well integrated at their treatment facilities and were treating a variety of mental health patients, prescribing numerous medications, and carrying caseloads similar to those of psychiatrists in the same facilities. The review concluded that “ . . . the graduates, by reducing the time patients must wait for treatment and by increasing the number of personnel and dependents who can be treated for illnesses requiring psychotropic medications . . . have enhanced the peacetime readiness of the locations they are serving.” They serve as chiefs of clinics or departments evidencing “ . . . high professional esteem” (USGAO, 1999). The granting to them of independent status was viewed as evidence that they needed no more supervision than prescribing providers and that their supervisors (psychiatrists) rated them as providing good to excellent quality of care. Earlier research has supported the accuracy of diagnosis of psychiatric, somatoform, and medical conditions by psychotherapists other than physicians (Sanchez & Kahn, 1991).
Despite the concerns of a minority of psychologists, a 1991 survey of APA members reported 68% of members favoring prescription privileges for psychologists (Youngstrom, 1991). Even with the resistance on the part of psychiatry, the APA Council of Representatives reaffirmed in 1995 a policy first endorsed in 1986 that “ . . . the practice of psychology encompasses both physical and psychological interventions” and “ . . . expanded on this principle to proclaim its express support for prescription privileges for psychologists” (Cullen & Newman, 1997, p. 101). APA then developed model legislation and a model training curriculum that were formally endorsed by the Council in 1996 (APA, 1996a, 1996b). Following that development, many state psychological associations began to examine prescription privileges and develop legislation for their jurisdictions (e.g., Alaska, Arkansas, California, Connecticut, Florida, Georgia, Hawaii, Illinois, Louisiana, Maryland, Missouri, Montana, Nebraska, New Mexico, Oregon, Tennessee, Texas, Washington and Wisconsin). Currently, 27 states have prescription privileges task forces. In anticipation of prescription privilege granting legislation, a variety of postdoctoral psychopharmacology training programs have been developed. (See Appendices A and B).
The current APA (1996b) recommendations for postdoctoral training in psychopharmacology for prescription privileges are based on an initial document prepared by the APA Committee for the Advancement of Professional Practice (CAPP) Task Force on Prescription Privileges with input from other entities, such as the Department of Defense (DoD) Psychopharmacology Demonstration Project (PDP), and the report of the Blue Ribbon Panel of the Professional Education Task Force of the California Psychological Association and California School of Professional Psychology - Los Angeles (CPA-CSPP), and the findings of the American College of Neuropsychopharmacology (ACNP). Whereas the APA (1996b) recommendations provide a model that is likely to set the standard for training psychologists to prescribe, it deserves mention that it differs in some ways from other key documents addressing the requirements for psychopharmacology training, including the 1992 APA Report of the Ad Hoc Task Force on Psychopharmacology and the CPA-CSPP report (1995). The Blue Ribbon Panel report of the CPA-CSPP report summarizes several other proposed model curricula, including the PDP, all of which require more total hours of training than the current APA (1996) model. Similarly, the prerequisites to begin the levels of psychopharmacology training (i.e., undergraduate course work in the biological and physical sciences) outlined by the Ad Hoc Task Force (1992) appear to have been relaxed and are less specific in the APA (1996) model.
Overview of Legal Issues
The regulation of health professions by states was established by the United States Supreme Court in Dent v. West Virginia (1889). That determination recognized the regulation of health professionals as falling within states’ legitimate regulatory powers. The objective of regulating health professionals is to provide protection for the public by restricting the delivery of healthcare to professionals qualified to provide those services.
In the United States, federal laws and agencies, such as the Federal Drug Administration (FDA), regulate how prescription drugs and controlled substances are dispensed. There are no explicit federal prohibitions against the prescribing of drugs by psychologists. The Federal Food, Drug, and Cosmetic Act (FFDCA) authorizes the FDA to classify prescription medications which can be dispensed only by a “practitioner” licensed to administer drugs. The term “practitioner” is not defined within the FFDCA, therefore leaving the definition open to the specification of state legislatures and interpretation of courts. By determining which professionals may be considered practitioners in accordance with the FFDCA, individual states demarcate which professions can be accorded prescription privileges.
The Federal Controlled Substances Act (CSA) complements the FFDCA. It authorizes the Drug Enforcement Administration (DEA) to oversee the distribution of potentially addictive substances so that they are available for appropriate medical purposes while preventing illicit distribution and usage. Five schedules of controlled substances, including psychotropic drugs, classify drugs according to their: a) potential for abuse; b) accepted medical value; and c) likelihood of causing physical or psychological dependence. Only practitioners registered with the DEA are authorized to dispense the drugs that are classified within the DEA schedules. Beginning in 1993, the DEA began authorization of health professionals other than physicians, to register with the DEA to distribute controlled substances, provided the practitioner was licensed within the state to dispense controlled substances in the course of professional practice.
In Canada, the laws and regulations governing the distribution of pharmaceuticals are administered by Health Canada, through the Controlled Drugs and Substances Act (CDSA). Health Canada is a national and international partner in the management of controlled drugs and substances through the administration of the CDSA and its regulations. Canada is a signatory of several international treaties, including the 1988 United Nations Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances.
State and Provincial Issues
Health professionals, including psychologists, are licensed at the state or provincial level, rather than nationally. Changes in psychologists’ and other health professionals’ scope of practice, such as the addition of prescription privileges, require statutory and regulatory changes within each jurisdiction. For psychologists to expand their scope of practice to include prescriptive authority, appropriate regulatory processes would need to be developed and implemented within jurisdictions which permit prescriptive authority. The responsibility of licensing boards would be to provide adequate protection of the public and ensure that psychologists who obtain prescriptive authority have: a) met all requirements for relevant training including curriculum and supervised experiences; b) performed satisfactorily on a national objective examination covering psychopharmacology and related areas of knowledge relevant to the prescription of psychotropic medications; and, c) are engaged in a process of continuing professional education specifically related to psychopharmacology and prescription practices.
Boards would also need to develop mechanisms and requisite expertise to investigate and adjudicate complaints related to the prescriptive practices of psychologists. Certifying prescription privileges for licensed psychologists whether as: a) independent prescribers; b) limited practice prescribers; c) limited formulary prescribers; or, d) various combinations of the above, would require revising licensing laws, as well as modifying relevant statutes and regulations.
At the time of this writing, no states or provinces have prescription privileges for psychologists.1 Guam currently is the only United States territory that has begun to permit psychologists with advanced psychopharmacology training to prescribe medications.2 In Guam, psychologists have limited prescriptive authority to prescribe under the supervision of a physician. Some jurisdictions may actually prohibit psychologists from prescribing, but most are silent on the issue.
Prohibitions to Psychologist Prescribing
Prohibitions against psychologists’ prescribing derive from two sources. First, prescriptive authority has not been included within the domain of psychologists’ professional activities as enumerated within psychology practice acts. The absence of explicit statutory or regulatory language authorizing psychologists to prescribe implies that psychologists are currently prohibited from prescribing within a jurisdiction.
The second type of regulatory barriers to prescriptive authority are other state or provincial laws and regulations, chiefly medical practice acts, which restrict prescriptive authority. Under such statutes and regulations, the authority to prescribe is granted exclusively to physicians and other designated health professionals.
When other groups of health professionals (i.e., nurse practitioners, nurse midwives, nurse anesthetists, physician assistants, podiatrists, optometrists, dentists, and pharmacists) have pursued prescriptive authority, it has been through express authority amending practice statutes and regulations. It may be necessary to amend a jurisdiction’s medical practice act by incorporating an exemption to restrictions on other health professionals within the medical practice act. Another potential way of addressing prescriptive issues within a medical practice act is incorporating prescribing within the psychology practice act, or by adding an alternative mechanism for certifying prescribing. The Doctrine of Implied Repeal allows for an existing statute, such as a jurisdiction’s medical practice act, to be altered (or repealed) by subsequent contradictory legislation, such as amendment of a psychology practice act.
Types of Prescribers
Jurisdictions vary in how, or whether, prescriptive authority is granted to health professionals other than physicians. When a jurisdiction concludes that prescriptive authority for a class of health professionals constitutes an appropriate professional activity, several issues need to be addressed in statutes and/or regulations. Two schemas for classifying prescribers have been established. The first approach is based on the type of practice of the professional group. This includes:
- Limited Practice Prescribers: Professionals who are currently licensed to practice independently (e.g., dentists, podiatrists) whose authority to prescribe is restricted to their scope of practice and is limited relative to that of physicians (e.g., totypes of medications or parts of the anatomy). They do not require the supervision of a physician.
- Physician Extenders: Professionals (e.g., physician assistants, nurse practitioners) whose authority to prescribe may cover a broad range of practice, but who do require the supervision of a physician.
Level of Prescriptive Authority
A second way in which prescriptive authority has been classified refers more specifically to the level of autonomy of the prescriber. Prescriptive authority for health professionals, other than physicians, is granted within one of two levels: a) independent authority; and, b) dependent authority. Independent authority refers to permitting prescribing without physician supervision. It is often granted to some health professionals other than physicians (e.g., dentists, and, in some states, nurse practitioners). Dependent authority refers to permitting prescribing only with physician supervision, or in collaboration, (i.e., with discussion and cooperation) with a physician. Other health professional groups (e.g., physician assistants, nurse practitioners) usually require some level of physician supervision.
A key question legislatures and boards would need to address in considering prescription privileges for psychologists is which level of authority is most appropriate for protecting the public. Some professional organizations within psychology, such as APA (1996a), would prefer that psychologists pursue independent prescriptive authority for several reasons, including a record of successful professional autonomy for services within psychologists’ current scope of practice, as well as logistical and economic considerations. Dependent authority would not alter psychologists’ current independence in providing services within their current scope of practice, but would create a need for psychologists’ prescriptive practices to be overseen in some manner by qualified professionals, e.g., physicians.
Establishing the level of prescriptive authority is a key area for reasoned debate. Legislatures may vary in the extent of prescriptive authority granted. Whereas the supervision inherent in dependent practice would provide some measure of oversight, the effect on public protection would be unclear. Therefore, the increased time and expense may be unwarranted. On the other hand, the limited evidence (i.e., chiefly from the Department of Defense project) about psychologists’ abilities to provide prescriptions safely and independently, may not presume minimal risk. Therefore, how much supervision would be required, for how long, and how supervisory patterns are enforced would need to be addressed very carefully before psychologists are granted independent authority.
Jurisdictions vary in how prescriptive authority is granted to health professionals other than physicians. In addition to specifying which type of authority is granted, jurisdictions also may establish other parameters governing prescription privileges. A range of conditions may be placed on a class of professionals’ prescriptive authority that limits how or where practitioners prescribe. Such limitations may result in practitioners needing to collaborate with professionals with broader prescriptive practices in the treatment of complex conditions. Certain restrictions may be incorporated to address issues of safety, specialization, or quality of care, while others may be intended to increase the potential number of service providers to address the healthcare needs of populations which may otherwise be under-served. Restrictions on the parameters of prescriptive practice include, but may not be limited to the following:
- Restrictions on formulary or drug protocols. Restrictions on a formulary may be through either an “inclusive formulary” which lists medications the health professional is authorized to prescribe or an “exclusive formulary” which lists classes of medications or specific agents that the health professional is prohibited from prescribing.
- Restrictions related to patient groups (e.g., medically healthy persons, or specific age groups).
- Restrictions on the authority to prescribe within certain institutions, settings (medical or psychiatric settings), locations, or types of geographic areas (e.g., rural areas which are under-served by medical personnel).
- Limitations on dosages or number of refills.
Psychology licensure throughout most of North America is based on a generic license. Licensees are granted the privilege of providing those services they are competent to perform which fall within the scope of practice of psychological services within each jurisdiction. If prescription privileges are granted to psychologists, it should not be an expansion of all licensees’ scope of practice. Rather, an additional certification process would be necessary to augment individuals’ scope of practice based on additional didactic training, supervised experience, and passage of an approved examination.
Given that historically, psychology graduate training programs have been offered within a broad range of settings (including non-medical settings) and have been based on heterogeneous models that have typically provided limited training in activities directly related to prescribing, it is generally accepted that additional training and passing of an approved examination would be necessary for psychologists to prescribe. In other words, specific subgroups of psychologists could be accorded prescription privileges through a certification process that is separate from generic licensure. Consideration should be given to the fact that many licensed psychologists have already obtained a license to prescribe in another profession, e.g., as nurse practitioners. For such individuals, regulatory boards should consider waiving part or all of the didactic requirements necessary for taking their approved examination for prescriptive authority. It has been generally accepted that training for prescriptive authority should require health service provider status as a prerequisite. The requirement of additional training would both provide a measure of protection for the public and enhance the credibility of psychologists’ pursuit of prescriptive authority.
Practice Acts of Other Disciplines
If prescription privileges are incorporated within psychology practice acts, the roles and responsibilities of psychologists vis-a vis other health professionals would need to be addressed. For example, nurse practice acts may specify which disciplines’ professionals’ orders are to be followed. In jurisdictions where the nurse practice act specifies that orders must be made by a licensed physician, it would be problematic for psychologists’ orders to be followed by nurses. The Doctrine of Implied Repeal may well not cover such issues within nurse practice acts because of how these statutes are crafted. It would be prudent to coordinate the services of psychologists, nurses, and related health professionals, and for the respective boards of these groups to work toward clarifying policies so that the public is well-served and protected. In addition to the practice acts of health professionals, it is important to review how modifications in the psychology practice act related to prescription privileges might require revision of other statutes, rules, regulations, or policies within jurisdictions. This may be particularly important in terms of pharmacy acts which may designate those classes of practitioners whose prescriptions may be filled by pharmacists.
The most appropriate standard of care for psychologists to meet in prescribing medications is a complex, weighty matter that is subject to controversy. A potential advantage in establishing the standard of care as that of a “reasonably prudent psychologist who is trained to prescribe drugs” is that it affords direct comparisons between prescribing psychologists. On the other hand, a standard of care that compares psychologist prescribers to physicians (i.e., psychiatrists, primary care physicians) might be argued to provide a higher level of public protection by setting a threshold standard that is equivalent to that which exists in current practice. Even if psychology boards and psychology to the attention of boards through complaints. Some case law has established the standard of care of other health professions as needing to meet that of physicians, while other cases have not upheld this standard. In the event that dependent authority is granted in some jurisdictions, not only standards of care but also standards for supervision, may become complex issues for boards, legislatures, and the courts.
Historically, psychologists interested in psychopharmacology usually acquired their knowledge following their doctoral training programs through “elective course work, seminars, workshops, and outside reading” (Brentar & McNamara, 1991, p. 182). The training of other non-physician professionals for prescription privileges varies widely, so many models of training for psychologists have been discussed “such as one to two year postdoctoral training, intensive workshops (similar to continuing professional education programs), and incorporation of training into present graduate programs” (Brentar & McNamara, 1991, p, 183). The various participants in the education and training discussion have concluded that the most effective training model for prescriptive authority for psychologists would be postdoctoral (e.g., APA, 1996b: Brenton & McNamara, 1991; Buie, 1988).
The APA Ad Hoc Task Force on Psychopharmacology issued its report in July 1992. The Task Force strongly supported the need for psychologists to be trained in the effects of psychotropic medications on behavior and recommended three levels of training and practice in psychopharmacology: 1) Basic Psychopharmacology Education, 2) Collaborative Practice, and 3) Prescriptive Privileges. Level 1 assumes knowledge of the biological basis of Neuropsychopharmacology, while levels 2 and 3 require a doctoral degree, continued knowledge acquisition, and practical experience. Levels 2 and 3 course work would include: psychodiagnosis, pathophysiology, therapeutics, emergency treatment, substance abuse treatment, developmental psychopharmacology, and supervised clinical experience. The Task Force also recommended that a survey course in psychopharmacology be required in all APA accredited programs in clinical, counseling, and school psychology (APA, 1992). Similar course work was described by Fox, Schwelitz, and Barclay (1992).
In 1995, the APA Council of Representatives requested that the APA Committee for the Advancement of Professional Practice (CAPP), the Board of Scientific Affairs (BSA), and the Board for Educational Affairs (BEA) jointly develop a model curriculum for training in psychopharmacology. A conference committee representing all three groups produced the recommended postdoctoral training in psychopharmacology for prescription privileges (APA, 1996b) which outlines the requirements for the level 3 curriculum for prescribing. These training guidelines are based upon the review of earlier models proposed in the literature (Brentar & McNamara, 1991; Cullen & Newman, 1997; DeLeon, Fox, & Graham, 1991; Fox, 1988; Fox, Schwelitz & Barclay, 1992; Moses, 1990; Smyer, Balster, Egli, Johnson, Kilbey, Leith, & Puente, 1993) and by a variety of other groups including the DoD demonstration project curriculum (USGAO, 1999), the reports of the Blue Ribbon Panel for the Professional Education Task Force of the CPA-CSPP (1995), and the American College of Neuropsychopharmacology (1998). (See Appendix C).
The postdoctoral training model (APA, 1996b) assumes that all trainees will possess a doctoral degree in psychology, hold a current state license as a psychologist, and practice as a health service provider. Trainees must also demonstrate knowledge of human biology, anatomy and physiology, biochemistry, neuroanatomy, and psychopharmacology as prerequisites. The training curriculum is based upon a minimum of 300 hours of didactic instruction in neuroscience, pharmacology and psychopharmacology, physiology and pathophysiology, physical and laboratory assessment, and clinical pharmacotherapeutics. The APA model recommends that in order to provide the scope of training necessary, faculty with terminal degrees and expertise in the following disciplines would be needed: physiology, biochemistry, neuroscience, pharmacology, psychology, pharmacy, medicine, and psychiatry. The APA model states further that this training program must be provided by a regionally accredited institution of higher learning or another accredited provider of instruction and training. In addition, the model includes recommended contact hours in each didactic area. A clinical practicum is also required and designed to be an intensive, closely supervised experience involving exposure to a range of patients and diagnoses (APA, 1996b).
This APA-recommended curriculum appears to be followed in principle by all the current psychopharmacology postdoctoral training programs in the U.S. Some programs are housed in universities, some are provided by distance learning, and some are free standing. Descriptions of current programs and their curricular offerings may be found through links in the APA website at www.apa.org.