Editor’s note: This commentary is by Dr. Rick Barnett, who is a licensed psychologist-doctorate and licensed alcohol and drug counselor. He is past president and legislative chair of the Vermont Psychological Association. Dr. Barnett currently serves on the Governor’s Health Care Workforce Workgroup and the Blueprint for Health’s Mental Health and Substance Abuse Provider Advisory Committee.
Vermont needs better access to better mental health care with better choices about where and from whom to receive that care. Emergency rooms, inpatient hospitals, community mental health agencies and psychotropic medications from a psychiatrist or primary care provider is what many consider mental health treatment in Vermont. There’s another option that has been successful for over 25 years in the military and for over 10 years in two states (New Mexico and Louisiana). It is being implemented in two more states, and is now being introduced as a bill in Vermont. When passed, this legislation, H.280, will give Vermonters the option of seeing psychologist-doctorates with advanced training in psychopharmacology, also known as prescribing psychologists. These providers demonstrate conservative prescribing patterns, prescribe meds only when appropriate and in the context of traditional talk therapy (best practice for best results), and often help people get off medications that may be unnecessary or harmful.
We have an over-prescription epidemic in this country and it’s not limited to opioids for pain. A recent study in The Journal of Clinical Psychiatry found that 69 percent of those taking SSRIs, the most prescribed antidepressant medications, haven’t ever had depression and 38 percent have never met the criteria for depression, obsessive compulsive disorder, panic disorder, social phobia or generalized anxiety disorder, but take the medications for which these conditions are indicated. A Centers for Disease Control (CDC) report shows a 400 percent increase in antidepressant use from 1988 to 2008.
As a society, we rely on pills because we believe in quick fixes and instant gratification. The public, the medical industry, and politicians are under the influence of the pharmaceutical industry and it shows. A recent study found that 70 percent of Americans take at least one prescription medication, 50 percent take at least two, and between 20 and 25 percent take at least one psychiatric medication in a given year. Antidepressants are the second most commonly prescribed class of drugs, second only to antibiotics. These prescribing practices come at a high cost. In the series “Medicaid by the Numbers,” VTDigger shows how much Medicaid spends on psychotropic medications. Vermont’s landmark legislation in 2009 placed severe restrictions on the pharmaceutical industry’s influence over our health care providers, and now there is consideration of easing those restrictions in bill S.45 . There’s an excellent review of this issue in: Social Science & Medicine (Volume 172, January 2017): “Gifts and influence: Conflict of interest policies and prescribing of psychotropic medications in the United States.”
Most psychotropic prescriptions are written by primary care providers (physicians, nurse practitioners, physician assistants) at hospitals and medical practices. These providers are faced with patient demands for medications as well as difficulty finding a psychiatrist. According to one Vermont psychiatrist quoted in a Seven Days article: “Primary-care physicians are the least able to spend time to figure out the bio-psycho-social assessment, which is what a psychiatrist does,” and continues “if you’re seeing 40 people a day, that’s not going to happen.”
Prescriptive authority for advanced-trained psychologist-doctorates is not just about access to medications. It’s about embracing a psychological, social and biological approach to mental health by listening to patients, cutting back on over-prescribing medications due to patient demand and limited access to specialists.
This isn’t entirely accurate. First, primary care providers can and do spend time with patients to help address their needs. Second, trends in the services provided by psychiatrists have shifted dramatically in favor of 15-minute “med checks” often using symptom checklists to guide treatment and away from spending time listening to patients using psychotherapy approaches. Not only has psychiatry moved away from practicing psychotherapy, it’s also in the midst of a workforce crisis.
A recent report by the Vermont Department of Health shows that 40 percent of active Vermont psychiatrists are 60 or older and may soon retire or reduce hours. A recent study by the Association of American Medical Colleges showed that 59 percent of psychiatrists are 55 or older, the fourth oldest group of physicians. A July 2016 Health Affairs article showed a 10 percent reduction in psychiatrists from 2003 to 2013. And fewer medical students are choosing psychiatry residency programs forecasting an even greater shortage. The result is that wait times to get an appointment with a psychiatrist may range from six to 12 weeks or more. Vulnerable Vermonters, especially in rural areas, have limited access to expert mental health care that may require counseling and medication.
Opponents to prescribing psychologist legislation are mainly psychiatrists with whom psychologists would prefer to continue a collaborative relationship. Organized psychiatry argues that patient safety is at risk due to inadequate training. This is a bogus argument (attempted in the 1950s to bar psychologists from practicing psychotherapy). Of all the prescriptions written to date by civilian and military prescribing psychologists, there have been no reported adverse outcomes or malpractice claims. In the 1990s, the Department of Defense did a pilot program to train psychologists to safely to prescribe psychiatric medications. A 1998 report from this project showed that “all 10 graduates of the PDP filled critical needs, and they performed with excellence wherever they were placed.” The American Psychological Association went on to establish a psychopharmacology training curriculum, including a rigorous standardized exam that clearly demonstrates competency. This training program equals or exceeds that of most currently licensed prescribers. Ironically, the well-known psychiatrist Daniel Carlat, author of the book “Unhinged: The Trouble with Psychiatry,” wrote a blog entitled: Prescribing Psychologists – The Best Thing That Can Happen to Psychiatry.
Prescriptive authority for advanced-trained psychologist-doctorates is not just about access to medications. It’s about embracing a psychological, social and biological approach to mental health by listening to patients, cutting back on over-prescribing medications due to patient demand and limited access to specialists. In a 2012 article in the Journal of Clinical Psychology in Medical Settings, McGrath writes: “One of the important distinguishing features of the prescribing psychologist is that exclusive reliance on medications would represent a violation of our ethical standards as psychologists; this statement is true for no other mental health prescribing profession. Since medication, psychotherapy, and full psychosocial assessment are all basic competencies of the prescribing psychologist, the ethical obligation to provide the best service possible within the competence of the psychologist means a combination of those skills must be employed as they ﬁt the needs of the patient. … The ethical prescribing psychologist applies that combination of skills believed to most likely result in an optimal outcome for the patient.”
Advanced-trained prescribing psychologists are treating patients with or without medications in the Army, Navy and Air Force, in the Indian Health Service and Public Health Service and now four states. If this provider group is good enough for our men and women in uniform, for Native Americans, and for the citizens of four other states, isn’t it good enough for Vermonters? This legislation is about expanding the scope of practice based on competency. Naturopathic physicians, nurse practitioners, optometrists have all been successful in similar efforts. Prescribing psychologists are in an excellent position to provide efficient, integrated care across practice settings. This is about developing better health and mental health care in Vermont. Better access, better quality, better costs and better outcomes. It’s simply better health care with psychology.