Prescription rights for Psychologists: A critical review

MASSEY UNIVERSITY

175.730 - Professional Practice in Psychology

PRESCRIPTION RIGHTS PROPOSAL FOR PSYCHOLOGISTS IN NEW ZEALAND:A CRITICAL EVALUATION

V.M. Westerberg

15 October 2012

175.730.- Professional Practice of Psychology WESTERBERG, V.M.Course Assignment

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“Health can be judged by which people take two at a time - pills or stairs”

(Welsh, as quoted in Housman, 1994)

INTRODUCTION

The New Zealand College of Clinical Psychologists (NZCCP) is currently

undergoing discussions with Health Workforce New Zealand (HWNZ) and the

Ministry of Health (MOH) about granting prescriptions rights for psychologists

(PxRP), specifically for clinical psychologists, following on the footsteps of two

states in the USA.

Health Workforce New Zealand together with its trans-Tasman counterpart,

Health Workforce Australia, are considering taking the exclusivity of

prescribing rights from medical doctors and extend them to other health

professionals like nurses, osteopaths, podiatrists, chiropractors, optometrists,

pharmacists, and psychologists (Australian Psychological Society [APS], 2008).

Key stakeholders in the PxRP like the Zealand College of Clinical Psychologists

(NZCCP) are also the main advocates and proponents of PxRP. Additional

stakeholders like the Royal Australian College of General Practitioners (RACGP)

(Creswell, 2012), the Royal Australian New Zealand College of Psychiatrists

(RANZCP), and the Medical Council of New Zealand (MCNZ) (M. Thorn, personal

communication, April 11, 2012) have expressed grave concerns about PxRP per

se and about the fact that these medical associations are not being included in

the preliminary negotiations about PxRP. Conflict of interests, privileges and

lobbing issues are at stake.


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This work will critically address the risks of PxRP so as to raise awareness in

the academic and professional clinical psychology community regarding

considerations that may not have been taken into account in the midst of a

prescription rights euphoria. In the discussion that follows, the background of

the PxRP claim will be explored together with facts and suggestions about

psychologists competence, training, and educational issues. After public health

needs and safety concerns, cultural and ethico-legal considerations will be

outlined.

All in all, it is the author’s aim to show that psychologists are requesting the

wrong thing, for the wrong reasons, and through the wrong pathway.

DISCUSSION

The USA was the first country to grant PxRP when in 1985 it passed a bill

allowing Hawaii licensed psychologists working for the US Department of

Defence (DOD) to prescribe psychotropics to Government Issues (GIs), that is,

military personnel (APS, 2008; Long, 2005). In 1988, the US DOD went on to

allow specific medical training for psychologists so that they could prescribe

psychotropics under certain circumstances. Guam became the first US territory

to approve the PxRP legislation in 1999, followed by New Mexico in 2002, and

Louisiana in 2004, where psychologists and PxRP are regulated by the Medical

Board authority (APS, 2008), which means that a prescribing psychologist

under Louisiana law can only write a prescription with the patient’s GP's

approval (Long, 2005). Only 5 of the remaining 49 states are currently


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considering granting medically-trained psychologists prescription rights. Bills

keep being turned down, rewritten, and resubmitted (Long, 2005). Worldwide,

only one province in Canada (Alberta) and South Africa have PxRP (APS, 2008).

Lack of public demand (Lavoie & Barone, 2006) and public satisfaction with the

status quo of prescribing rights may explain why no further countries have

PxRP. Nevertheless, the NZCCP has taken the initiative of requesting PxRP to

HWNZ and the MOH. As mentioned previously, the RACGP president Claire

Jackson (Creswell, 2012), the RANZCP, and the MCNZ senior policy adviser

Michael Thorn (M. Thorn, personal communication, April 11, 2012) wonder

how ethical it would be to leave their points of view outside the decision-

making process. These organizations are also concerned about PxRP plans

because of the potential to divide responsibilities and oversight of patient care

and welfare (Creswell, 2012).

Australian Physiotherapy Association president Melissa Locke publicly

expressed the enthusiasm of physiotherapists to be allowed to prescribe

specialty-relevant medication like the entire range of anti-inflammatory drugs

and Botox for the treatment of pain and spasticity in cerebral palsy patients

(Creswell, 2012). Opponents to PxRP are concerned about the safety and ethical

issues that may arise as a result, like inappropriate prescribing for personal

profit, a topic not covered by the HPCA Act (2003). The amount of factors to

take into account when prescribing a drug are not just interactions with other

drugs (legal and illegal) or substances (foods, nutritional supplements, alcohol)

that can be consulted on the internet or on a handbook, they include fluent

working memory for conditions like liver, renal, respiratory, cardiovascular,


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immune, and endocrine-metabolical insufficiency; surgical, pediatric, geriatric,

and obstetric population idiosyncracies; and the pharmacodynamics of drugs

(Brunton, Chabner, & Knollman, 2010). This knowledge is not likely to be

acquired with a few semesters of late full-time training, particularly if the

individual never had training in biological and medical sciences prior to

graduate school. These and further training and safety concerns have been

shown by organizations like Psychologists Opposed to Prescribing Privileges

(POPP, 2007) integrated by an elite of psychologists from universities across

the USA like the University of Nevada, Minnesota, Mississippi, Washington, and

Brown, Drexel and Harvard Universities.

Looking at training and educational backgrounds now, according to Careers NZ

(2012a) and the University of Otago (2012), to become a Psychiatrist in NZ you

need to: enrol immediately after high school, complete the Health Sciences or

Bachelor of Science in Biomedical Science First Year programme with a

minimum of B+ average, complete the 6-year Bachelor of Medicine and

Bachelor of Surgery (BMBS) degree, pass an exam to access internship, work

for 2 years as an intern (supervised junior doctor) in a hospital, pass an exam

for admission in the Medical Council of NZ, complete another 5 years of

specialist training with annual exams, and admission examination to become a

Fellow of the Royal Australian and New Zealand College of Psychiatrists, a

mandatory requirement for practicing Psychiatrists. A minimum of 14 years of

full-time study is required in total. To become a Clinical Psychologist in NZ you

need to: have a Bachelors Degree in Arts or Science (3 years), have a B+ average

to access a Master’s degree in Psychology (2 years) with an additional


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Postgraduate Diploma in Clinical Psychology (2 years) or a Doctorate in Clinical

Psychology (3 years). A minimum of 7 years of full-time study is required.

(Careers NZ, 2012b; Massey University, 2012). In view of these differences, it

could be concluded that, currently, it takes half the effort and time to become a

Clinical Psychologist than to become a Psychiatrist, which may be one reason

behind the shortage of medical doctors in NZ.

Proponents of PxRP claim that medical graduates receive little mental health

training during medical school – just 3 years (i.e., 3 double semesters) -

(University of Otago, 2012) and that it is GPs, and not Psychiatrists, who

prescribe a high percentage of psychotropic medication, sometimes following

the recommendations of a Clinical Psychologist (APS, 2008; Long, 2005). On

reading this, it would, therefore, be logical that the Clinical Psychologists,

exclusively trained in mental health, should have prescription privileges for

psychoactive medication and expect similar health outcomes than medical

doctors.

Indeed, the most prevalent argument against prescription privileges for

Psychologists is the significant differences in training and educational

background between psychologists and medical doctors (APS, 2008; Muse &

McGrath, 2010). While proponents of PxRP refer to the limited prescribing

privileges of non-physicians such as dentists, midwives, and nurses, opponents

counter with the fact that these prescribing professionals have undergraduate

and graduate degrees that concentrate in medical subjects, whereas

Psychologists do not (APS, 2008; Muse & McGrath, 2010; Long, 2005). Because

of these differences, opponents of PxRP may claim that Psychologists will


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require more medical training than currently proposed by the APA (2001) in

order to handle the complexities of combining pharmacology with human

pathophysiology. The APA's proposed training model is significantly shorter

than that required of a GP or a Psychiatrist (APA, 2001) and does not address

undergraduate course structures. That said, the principle is right, “an inmodest

proposal” the APA (2001, n.p.) calls it, meaning that Psychologists should feel

no shame requesting prescription privileges as they are the professionals with

the widest depth and breadth of knowledge of mental health issues.

For Psychologists to be safe prescribing professionals, their training should

start at undergraduate level, which means a complete restructure of the

qualification / degree. Let us take a look at the current situation: Students can

do Psychology as a major in a Bachelor of Arts, a Bachelor of Science or a

Bachelor of Health Science degree. They can complete a major in Business

Psychology in a Bachelor of Arts, or if they already have an undergraduate

degree, they can gain the equivalent of a major in Psychology through a

Graduate Diploma in Arts or Sciences. Psychology can be done in internal or

distance mode, full or part-time. Honours and Master papers are delivered in 5-

day block courses. Is this too diffuse, confusing, unfocused? Could this be one

reason why no NZ University appears in the top 30 universities to study

psychology? (Top Universities, 2012). Maybe there is nothing wrong with this

pathway for most psychologists, maybe it is just not the right one for

prescribing clinical psychologists, and they should develop their own.

Until the last decades of the 20th century, one had to study Medicine to become a

dentist, and in some countries like Finland this is still the case. In most


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countries today -like France since 1965, Australia and NZ since 1970, Italy since

1980, and Spain since 1986 (Wikipedia, 2012) - students can become dental

surgeons by doing the common core first 3 years of medical school fundamental

sciences (Biology, Biophysics, Biochemistry, Pharmacology), medical sciences

(Anatomy, Histology, Embryology, Physiology, Pathology) and humanities and

social sciences. Two more years of specific theoretical and supervised practical

training follow. In a total of 5 years, one can become a prescribing dental

surgeon in most Western countries. How long does it take to become a Clinical

Psychologist in NZ? Around 7 years? How many clinical psychologists would be

willing to add 2 or 3 more years to their 7-year training to become designated

prescribing Psychologists? For those who absolutely want to prescribe, a faster

pathway is going to medical school to able to do so in 5 to 6 years. But for those

who like what psychology is about and think they should have prescription

rights, advocacy of a new undergraduate pathway should be encouraged, one

like that of dentistry, but in the case of psychologists with supervised practice

by a clinical psychologist and (1 year) then by a psychiatrist (1 year). This

approach would be advantageous for students (a shorter, more robust degree at

a fraction of the cost), for governmental bodies (properly trained clinicians), for

clinicians (unquestionable background, authorised vs. designated prescription

rights) and for patients: With properly trained clinical psychologists, who

would go to a GP or a psychiatrist when you can get antipsychotics +

psychotherapy at half the price at a clinical psychologist's office?

The cost of mental health services: An issue to take into account, just like

professional fees. Obviously, prescribing Clinical Psychologists’ wages could be


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expected to go up considerably because of their added competency and

prestige. Given that not all Clinical Psychologists would be willing or interested

in becoming prescribers, two categories of clinicians would emerge with the

possibility for professional tensions. Again, who would go to a simple Clinical

Psychologist when you can get antipsychotics + psychotherapy from the

prescribing ones? Maybe only prescribing Psychologists should be referred to

as Clinical Psychologists. Maybe health users will end up labelling each one. One

thing is clear: prescribing Psychologists may start referring to their health users

as patients, and no longer as clients, as a way to proclaim their higher status.

This is no laughing matter and an issue to take into account and tackle before

frictions lead to sparks.

But, does the public have a say in all this? According to NZ due process, public

consultation through notification, consultation, and participation is required

before any change to current regulations can be made (Legislation, 2012).

Pakeha mental health consumers would very possibly have a favourable

position about the issue, especially if Psychologists, through a new educational

background, are seen as competent a prescriber as a medical professional.

However, in the context of bi-cultural NZ, further medicalisation of Psychology

could have a negative impact on the Maori population - as health consumers or

providers- driving them further away from a biomedical system they consider

foreign and alien to their health models (Durie, 2004). Whether the Maori

population mental health problems will be better served with a wider

availability of psychotropics requires further consideration and study,

preferably with Maori stakeholders. The NZCCP instead of promoting Maori


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health training programmes, promotes a stronger biomedical model which is

also rejected by many Psychologists. This is an approach not likely to be highly

appreciated by the NZ indigenous population. Moreover, has the NZCCP made

any consideration with regard to the approval and impact of PxRP on the Maori

population?

Society demands competent professionals to meet their needs. Medical students

begin their practical work in their second year, just like nursing, dentistry, and

physiotherapy students (University of Otago, 2012; Careers NZ, 2012a).

Psychology students have to wait to do a PhD to interact with a client on their

own, and, even then, do so under supervision initially (Massey University,

2012). This not only gives rise to additional comparative grievances between

medical and psychology students, it is also a waste of time and a misuse of

readily available resources to meet the mental health needs of NZ citizens. A

proposal has been made for psychology students to get involved in early

practical training (Westerberg, 2012). Just like medical, nursing or

physiotherapy students must get involved in practical work, as unpaid trainees

first, in participating hospitals and clinics as part of their Bachelor’s Degree

(Careers NZ, 2012; Carmichael & McCall, 2008), so should psychology students,

in the only context that, like a hospital, provides an unfortunately endless

source of not patients but clients, clients in need of assistance: the correctional

facilities (Westerberg, 2012). This approach parallels that of the US

Government allowing first military psychologists to prescribe psychotropics to

military personnel in military bases and correctional facilities. That’s where the

origin of prescribing psychologists lies.


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However, the main rationale that psychological associations like the APA (2001)

offer regarding the convenience for PxRP is a duty to better serve societal needs

through the provision of mental health care to all citizens, particularly those

who reside in remote or deprived areas, given the lack of availability of

physicians and psychiatrists. Even in large towns, the lengthy waiting times to

receive mental care makes the need of having psychologists prescribe

psychotropics a matter of importance (Long, 2005).

On the other hand, it is doubtful that prescribing psychologists would really

improve health outcomes in rural areas based on “The 2009 Health Needs

Assessment Report” (Ministry of Health, 2009). Additionally, professional

service availability surveys show that both psychologists and psychiatrists often

already serve concurrent areas (Long, 2005). There is no evidence that

psychologists will relocate to cater to rural areas not already served by other

prescribers, or that psychotropic medication needs are not already adequately

being met by the existing medical services. Additionally, making psychotropics

more widely available to the population in deprived areas, where the Maori

population tend to be overrepresented, should be questioned in the context of

the current “Alcohol Reform Bill” to reduce the number of alcohol outlets in

deprived areas in NZ (Ministry of Justice, 2010). Furthermore, recent studies

show the growing concern among GPs regarding psychotropic drug misuse, as

they are the drugs of choice for the commission of suicide. (Sheridan, Jones, &

Aspden, 2012), which is more prevalent in the context of deprivation and

alcohol abuse. Psychotropic abuse is currently regarded as an epidemic in the


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US, where around 45% of the population are on prescription drugs, and is now

second to marijuana abuse (Hernandez & Nelson, 2010).

The 2009 Health Needs Assessment (HNA) Report (Ministry of Health, 2009)

provides information about the health status of NZ population, how it has

varied with regard to previous reports, what health conditions have the

greatest relevance in the population, and how each community compares to the

rest of NZ. Based on this report, each DHB publishes their respective health

reports containing the latest information about key issues like avoidable causes

of mortality and hospitalisations. Incidentally, the latest HNA report for the Bay

of Plenty was performed by Massey University on behalf of the Ministry of

Health. Data regarding Maori vs. non-Maori, male vs. female, children vs. adults

vs. elderly across degrees of areas of deprivation are all included. Based on the

2009 HNA report, 4 out of the top 5 main causes of avoidable mortality in NZ

are the same across ethnicities and these are, in order of frequency: ischaemic

heart disease, lung cancer, diabetes, motor vehicle accidents, and suicide. From

these data, it appears that what NZ needs is more medical professionals than

psychologists with prescribing rights. Psychologists can and do intervene in

suicide prevention, but whether suicide rates can be reduced with a wider

availability of psychotropics is an issue that requires ethical consideration and

scientific research.

Finally, the ethical-legal implications of the PxRP will be discussed. Medical

professionals spend a considerable amount of money on professional

insurances to cover for all the costs of possible malpractice or negligence suits.

If taken to court, prescribing psychologists could be asked to refer to concepts


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like standard of care, breach of duty, causation, and injury (Long, 2005). The

concept of standard of care should, therefore, be defined for prescribing

psychologists, as it would be expected to differ from that of non-prescribing

psychologist and from that of medical doctors. On the other hand, it would be in

the best interest of health service consumers that prescribing psychologists

abode by the same definition of standard of care as GPs and psychiatrists as it

would promote both accountability and protection (Long, 2005). In order to

set the elements of a malpractice action, the prosecution usually calls for an

expert testimony. A GP or a psychiatrist may be asked to take the stand to

evidence the limitations in knowledge and training of the defendant –the

prescribing psychologist - on whose hands the claimant – the patient- had put

his or her health. In this context, the potential liability increase would require

prescribing psychologists to get or vary their malpractice insurance to reflect

the greater practice risks, with wider coverage and more expensive premiums

(Long, 2005). Additional legal issues to be addressed are the scope of the

prescribing psychologist's authority, the requirements to maintain a

prescriptive licence, and the drug formulary range (APS, 2008; Long, 2005).

In the context of NZ, principle number 1 of the Code of Ethics for psychologists

practising in Aotearoa/NZ (Evans, Rucklidge, & O’Driscoll, 2007), statement 1.3,

says that The Treaty of Waitangi “is given priority” in the code. It would be

interesting to see if/how this is reflected in the context of the NZCCP proposal

for PxRP, that is, how the Maori will participate in the decision-making and how

a wider psychotropic availability will be beneficial for Maori welfare and

interests. Principle 2 of the Code of Ethics (Evans, Rucklidge, & O’Driscoll,


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2007), refers to responsible caring. A proposal for PxRP should explain how

making psychotropics more widely available is responsible caring. Statement 2.2

may have to be re-written for prescribing psychologists and be more specific

about the scope of competences, and when a prescribing psychologist should

request an expert second opinion and from whom. In view of the literature

presented in this work regarding what is viewed as an epidemics of alcohol and

drug abuse in NZ, is more psychotropic availability in keeping with principle 4,

statement 4.1, about a commitment to promote societal welfare and social

justice? If so, how?

CONCLUSION

The background for PxRP in NZ is based on the US experience, where

psychologists in 2 out of 51 states have limited prescription rights. Bills in other

states have not been passed, the main reason being serious competency

concerns because of the lack of biomedical educational background and training

in the Psychology curriculum. In the end, it is GPs, who receive 3 double

semesters of mental health training during medical school, who prescribe a

considerable amount of psychotropics. This is so because of the extensive

biomedical education and training received during the first 3 years of medical

school, which is shared by other health professionals, like dental surgeons.

Similarly, some other health professionals like nurses, midwives, pharmacists

and physiotherapists also have undergraduate and graduate degrees that

concentrate in biomedical subjects. This is not the case of Psychologists. For


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Psychologists to be - and be considered by health professionals and the public-

safe prescribers, their training should start at undergraduate level, which means

a complete restructure of the Degree in Psychology to accommodate for the new

professional scope, and do so in 5 years. Hurried, condensed, late training

would be too little, too late, and an additional burden in the form of 2 to 3 years

on top of a 7-year training.

With the new category of professionals within Clinical Psychology, frictions and

prestige issues could be a source of tension among clinicians with prescribers

possibly getting more patients (not clients anymore) and having higher wages,

but also higher premiums in malpractice insurances.

The benefits of PxRP for society, particularly to the Maori population, in the

context of lack of public demand and epidemic substance abuse and suicide

rates statistics, are doubtful. The claim that more psychotropic availability in

deprived areas will be in the best interest of communities is likely not to sell

well, just like the concept that psychologists would be willing to relocate

because there are more of them than GPs or Psychiatrists. Data in the 2009 HNA

report show that what NZ needs is more medical professionals and that the area

in which Psychologists can contribute, suicide prevention, is not likely to be

covered by the administration of psychotropics. Psychologists should focus on

freeing the population from the chronic use of medication for psychological

problems through the use of talk therapies.

Finally, involvement of the Maori population in the PxRP decision-making is

required if the NZ Code of Ethics for Psychologists practising in Aotearoa/NZ is


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to be observed. The code may have to be revised to accommodate prescribing

Psychologists competencies.

So, NZ Psychologists are requesting the wrong thing: prescription rights for the

experts in mental health with no biomedical background, for the wrong reasons

(inexistent societal demand, cater to deprived areas, shortage of

GPs/psychiatrists), and through the wrong pathway (late training) instead of

undergraduate training. Will their request be granted as it is? We will just have

to wait and see.


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Health & Medicine

Prescription rights for Psychologists: A critical review