Commentary

Rick Barnett: Better health care with psychology

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.

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  • Sean Ryan

    As an LICSW who just moved to the state from Florida, another state considering this legislation I support this bill. I have been practicing mental health and addiction treatment for over 10 years and know first hand the difficulties clients face when it comes to considering medications to augment psychotherapy, as well as, client who are seeking to switch or taper medications. Over prescribing is a considerable problem in the United States along with mis-diagnosis and utilization of medications that are unwarranted. It is time to re-evaluate how we treat addiction and mental illness.

  • Caryn Leistner

    Since psychologists only see a fraction of mental health patients in this state, why are you not advocating that all licensed mental health providers have the opportunity to prescribe after completing specialized training?

    • I’ve been advocating for my licensed mental health counselors and licensed psychologist-masters colleagues to be reimbursed by Medicare, which is currently disallowed. There are various avenues to practice ones profession to the fullest extent of their competence and their are various areas of advocacy we can all work on together.

  • David C Rettew

    So….the remedy for too much psychiatric medication prescribing is to have more non-medically trained prescribers? Interesting logic here.

    • Dr. Rettew, a child psychiatrist, in one of the links, bemoans the fact there are ridiculous waitlists for a psychiatrist appointment. Why would this psychiatrist not want to work with a colleague whose training uniquely qualifies him/her to help Vermonters have better access to better quality care? Non-medically trained? How many nurses regularly struggle with the fact that psychiatrists rarely, if ever, order routine labs prior to intiating a new medication? Basic clinical medicine absent from the clinical practice of “medically trained” prescribers.

    • Charles Dee

      Psychologists undergo 4+ years of comprehensive education, training,
      and supervision in the use of psychotherapeutic interventions. Moreover, we are trained to use the least intrusive intervention(s) with the goal of improving independence and self-awareness for our clients. In contrast, psychotropics are the most invasive form of mental health treatment, even trumping physical restraint in an inpatient mental health setting. As a natural extension of our training in conservative treatment, I am confident that prescribing psychologists are measured and thoughtful when it comes to prescribing psychotropic medications, thus reducing reliance on psychiatric medication.

      Having trained psychiatry residents for 8 years in a university medical center setting, it has been my consistent experience that residents have no formal classroom training in psychotherapy but are expected to learn “on the fly,” while concurrently prescribing medication to a large caseload of patients. Unfortunately, many of my residents found learning about psychotherapy to be inconvenient and time consuming, with the general sentiment that there are plenty of other mental health professionals out there to do the tedious and cumbersome work of therapy. Perhaps this attitude has contributed to the pervasive 15 minute med check culture endemic to psychiatry.

      I strongly believe that prescribing psychologists are in a great position to break the cycle of recurrent 15 minute med checks. We are well-trained with our array of psychotherapeutic interventions, and with the addition of formal training in psychopharmacology (which is currently 2.5 years of coursework beyond the doctoral level, the passing of a comprehensive prescriber’s examination paralleling the psychiatry boards, and at least one year supervised training), we are in an excellent position to work with our clients to help achieve optimal independence using the most effective and least invasive interventions, which may include medication.

      Finally, it is my hope that if RxP for psychologists does not universally pass throughout the United States, this movement will serve as a wakeup call to psychiatrists to return to formal training in psychotherapy and to integrate multi-modal treatments in their care of the vulnerable populations they serve.

  • This new provider group is not new and is not about prescribing more meds thereby adding to the over-prescribing epidemic.
    The education and training required to become licensed at the doctoral-level (6-7 years post bachelors) plus an additional 2 year Master’s Degree in clinical Psychopharmacology which involves basic clinical medicine, pathophysiology, and extensive neuroscience and pharmacology AND 1 year supervised experience with 100+ patients makes prescribing psychologists more than qualified to diagnose and treat mental health issues to the fullest extent of competency.
    Access to high quality mental health treatment can be improved with this legislation. Several psychologist-doctorates in this state would get the additional M.S. degree and 1 year clinical training and many may move here from out of state.

    We have an over-prescription epidemic precisely because the prescription pad may be used too much and reluctantly by current prescribers who may benefit from more extensive mental health and the clinical psychopharm training. Psychiatrists have been increasingly trained to do symptom checklists and med management much to the chagrin of psychiatrists like Daniel Carlat (Newburyport MA, quoted in my article).

    It’s been passed in 4 other states and implemented in 2 of them and in the military with amazing success proving he effectiveness of having more highly qualified clinicians out there cutting costs and improving care while cutting down on the over reliance on meds.

  • Peter Sher

    I support H.280, I believe Vermonters should have the option of seeing psychologist-doctorates with advanced training in psychopharmacology, also known as prescribing psychologists.

    As a family doctor in Hardwick, Vermont I view the lack of access to mental health services as one of the most difficult challenges we face today in our state. For years, there has been an extreme shortage of providers who can prescribe psychiatric medication to meet the needs of suffering patients. Psychiatrists are often totally overwhelmed in our state. Because there are so few, they often burn out from the high patient load, that is why there is a high turnover. This is an issue my fellow family practice colleagues discuss often. In my county, Northeast Kingdom Human Services, often doesn’t have a practitioner employed to prescribe medication to our referred clients suffering from mental illness, nor does its counterpart in Washington County.

    Twenty years ago, September 26, 1996, the federal government passed the Mental Health Parity Act. This bill’s purpose is to ensure the same amount of resources for both mental and physical illness. Unfortunately, for many reasons it has not been implemented. This isn’t just a barrier to our patients mental wellness, it also affects their management of co-existing chronic diseases that the “Single Payer” system demands focus. For example, if a patient of mine is dealing with a severe mental health issue they often don’t have the energy to take care of their other medical conditions (such as diabetes). This lag in treatment in regard to mental health often throw them into a tremendous health crisis. These types of situations ends up costing us our resources which would be better directed toward the prevention of both.

    As family doctors, we are in a unique position. The patients we see over the years, know and trust us, so we are often the first portal to their treatment if they develop a mental illness. As Dr. Barnett pointed out, some patients who come to us would rather just take a pill, without exploring therapy. A therapist, is important because it is often the patient’s ongoing link to managing their mental health and truly becoming their own advocate.

    Family docs also have to address ALL of a patient’s concerns in a very short time (20-30 minutes). In the Northeast Kingdom, where I practice, this isn’t because our practice wants to increase our income ratio per patient, it is solely due to the fact that there aren’t enough of us! Most of us have 150% patient load, because of this, we do not have the time to address each issue of our patient’s issues in the depth that is truly necessary.

    As a family doc in rural Vermont, I fully support psychologists prescribing medications. I believe this bill is incredibly important to our patients. Healthcare needs to be a team effort here!

  • Don Rhoades

    Here is a letter I wrote to Bill Lippert, House H&W Chair:

    To: Rep. William Lippert, MA, Chair, House Committee on
    Health Care

    I am writing to urge you to take up H280. This bill will enable licensed psychologist-doctorates
    with an additional two-year Master of Science degree in psychopharmacology and
    one year supervised training to be authorized by the Board of Psychological
    Examiners to prescribe a specific list of psychotropic medications. In my experience, this level of education and
    training in both mental health and clinical psychopharmacology meets or exceeds
    the level of competency of most other prescribing providers.

    I hold two licenses in Vermont, as a Licensed Mental
    Health Counselor and Licensed Alcohol and Drug Counselor. I see first-hand what the shortage of
    qualified prescribers of psychotropic medications has on the people in need of
    their care. For example, a female
    patient of mine with Bipolar Disorder and Alcohol Dependence has been
    hospitalized many times because she has doesn’t have access to someone
    qualified to prescribe and monitor her medications, like a psychiatrist of psychiatric
    nurse practitioner. She runs out of meds,
    has a crisis, goes to the ER, gets put in the Mental Health Unit or sent to
    Brattleboro, comes out with a supply of medications, runs out of meds, has a
    crisis, and goes back to ER, and repeat.
    It is a horrible situation. Only
    recently was she enrolled as a new patient at Washington County Mental Health,
    which has long waiting lists for new patients.

    To say there is a shortage of qualified psychotropic
    medication prescribers in the state of Vermont is an understatement. It is a crisis. This bill as I understand it would be a
    rational solution to this problem. It
    creates a new provider group already highly competent in treating mental
    illness without medications and but with exceptional training to use
    medications safely, effectively, and only when necessary. It just makes sense. It has been working in other states and the
    military and it will be great for Vermonters.
    Please support this bill now.

    Sincerely,

    Don Rhoades, LCMHC, LADC

  • Ethan Hawkley

    This article is a great example of a “snow job” argument. It presents so many fallacies at once that it would be exhausting to refute each one, and any such attempt would be so long that no one would read it.

    Here are some facts:
    1) There is no shortage of psychiatrists. There is a shortage of reimbursement for anyone to see the most underserved patients. There is no evidence that prescribing psychologists are any more likely to accept a $15/hour reimbursement rate than psychiatrists.
    2) There is no shortage of psychiatrists. There is a shortage of psychiatrists in remote rural communities. There is no evidence that psychologists are likely to move from Burlington to Berkshire once they are granted prescription privileges.
    3) There is no shortage of programs already in place that provide a pathway for psychologists to obtain the rigorous training needed to prescribe medications. Many psychologists have gone on to become physician assistants (PAs), nurse practitioners (NPs), and I’m sure some have even gone on to become psychiatrists. Adding a separate board for prescribing psychologists would make the health care system even more disjointed.
    4) Allowing psychologists to prescribe would result in psychologists doing less psychotherapy. Prescriptive authority for psychologists is controversial within the field of psychology for this very reason.

    States that care about patient safety and high quality mental health care will continue to reject the idea of prescribing psychologists.

    • There is a shortage of psychiatrists factually referenced several times and in several ways in the commentary, even by Vermont psychiatrists and nationally in medical journals, even by psychiatrists who oppose this legislation. Ethan Hawkley himself states “there is a shortage of psychiatrists in rural areas” and prescribing psychologists work in rural areas where legislation has passed. NP’s, PA’s, MD’s, ND’s, Dentists, Optometrists have their training. All can prescribe meds safely and effectively. Prescribing Psychologists (PhD/PsyD with post-doc MS+clinical) practice safely and effectively and have the greatest background in mental health assessment, diagnosis, treatment. This is about competence based on training and education. For over 25 years, prescribing psychologists have demonstrated competence as evidenced by safety and efficacy. It is documented/proven that prescribing psychologists prescribe more conservatively with non-pharma approaches as first-line and/or combined treatment. No other prescribing provider does the same (save older generation psychiatrists who are disgruntled with their own profession).
      The US Military, NM, LA, IA, IL care about access, patient safety, and high quality mental health care. Vermont does too. This legislation represents “one small step for mental health care and one giant leap for the evolution of health care over time”. An Arabian proverb states “when you shoot an arrow of truth, dip the point in honey”.

    • Lynda Marshall

      In response to Mr. Hawkley’s claim that there is no shortage of psychiatrists, I can only say that if you’ve ever tried to hire a psychiatrist for a mental health practice, you might not say that.

      • Ethan Hawkley

        If you have an active job announcement please post a link to it and I will share it with some psychiatrists I know.

  • Lynda Marshall

    I think having a psychologist who is trained in psychopharmacology prescribe meds is an excellent idea! Why do I have to see two different health care providers to address my mental health concerns? That’s not only more expensive (seeing a psychiatrist costs twice as much as my psychologist), it’s also more of a drain on my time. An appropriately-trained psychologist is also in a better position to determine whether meds are even necessary than many physicians, which would avoid unnecessary or ineffective prescriptions–and isn’t that another way to help contain health care costs? To be clear, I have a great deal of respect for physicians of all specialties, but they shouldn’t be the only answer.

  • Bob Hemmer

    We’ve all seen how medical practices have integrated physician’s assistants and nurse practitioners seamlessly at this point. Initially, there was a fair amount of resistance to this from both the medical side and the patient side. That resistance subsided possibly due to the fact that simply more care is needed, diagnostics and treatment are more complex, and I believe it allows physicians more time more time to think through and provide better care using information provided by that medical team.
    So one of the concepts to consider besides access I believe, is having time to think through some very important, very complex issues and determine the best course of care. Adding psychological providers can spread out the patient load and create a tiered system. As such, you come in to see the nurse, it’s more complicated, then you see the NP, still unclear, then you see/consult the doctor. Under such a model, the psychiatrist begin to act more as higher level consultants. Therefore, you would initially see your MD, then a therapist, and then in consultation see a psychologist – practitioner, then see a psychiatrist if needed for further consultation. So, in a simplistic sense, if you have a case of ADHD, it could be managed by a primary care physician working with a therapist. However once there is resulting depression and/or anxiety due to the neurological and/or social ramifications of ADHD, then you would move up the tiers to higher levels of consultation depending upon how complicated the situation gets. This is especially powerful when dealing with children. Years ago I listen to a training tape by Dr. Jonathan Walkup (Hopkins). At one point he was confronted by parent saying “at first you said it was ADHD, then you said it was anxiety, then you said it was depression, now you’re saying it’s bipolar disorder”. What is forgotten in the sequence his children are growing and developing and their brains change over this time. So what was one diagnosis develops into something else as the child grows and develops. A “tiered” level system of consultation would be helpful in such a situation. This model also promotes a Bio-psycho-social model of treatment in which the etiology of symptoms and disorder is seen from many interacting aspects.
    As such I support this bill to add more providers because it can lead to a better continuum of care. And to whoever posted that there are plenty of psychiatrists in Vermont, you should really check that out because it is simply not true. As far as I can tell there are no child psychiatrists with open practices in southwestern Vermont.

  • Lorraine Clodfelter

    With the advanced training described to ensure competence I think patients who have the opportunity to have medication needs met by their psychologist who is most likely to have a thorough understanding of their functioning would benefit tremendously. In my experience, it is often challenging to find medical practitioners to refer clients to who are in need of assessment for possible medication. Many times the wait is lengthy. Prescription privileges for highly trained psychologists would offer a high level of timely and integrated care for patients with complex problems. I would support the passage of this legislation. Thank you Rick for the work you are doing in this regard.

  • Adam Beattie

    “This legislation makes sense. I fully support psychologist-doctorates with a proven safety and efficacy record due to their expertise in mental health assessment and treatment and their in depth education and training in appropriate use of meds. Some patients don’t just want a pill. Some do. This law would help create a more sound approach to mental health treatment. We should all get behind this initiative. If it’s successful in the military and several other states, then it’ll be successful in VT.”

  • Adam Beattie

    This legislation makes sense. I fully support psychologist-doctorates with a proven safety and efficacy record due to their expertise in mental health assessment and treatment and their in depth education and training in appropriate use of meds. Some patients don’t just want a pill. Some do. This law would help create a more sound approach to mental health treatment. We should all get behind this initiative. If it’s successful in the military and several other states, then it’ll be successful in VT.