In twenty years, psychologists in countries outside of the United States will have the authority to prescribe psychotropic medications for psychological dysfunction. More and more people will then have better access to a comprehensive, integrated mental health care.
That is what Beth Rom-Rymer predicts. She is a candidate for the presidency (2023) of the American Psychological Association (APA); one of the key leaders of the national prescriptive authority movement in the United States; and co-chair of the international Prescriptive Authority Movement. Psychologists already have prescriptive authority r in five states. Last year, APA established “clinical psychopharmacology” as a specialty for psychologists (one of a total of 18 specializations).
The main reason is the shortage of psychiatrists. The waiting list to see a psychiatrist is long. In addition, licensed clinical psychologists accept remuneration from insurance companies, unlike many psychiatrists.
Prescribing psychologists can more easily reach the vulnerable, the poor, children and the elderly. For patients, in rural areas, distance is often a problem. More psychologists practice in rural areas than psychiatrists. It is in the rural areas that we can make a big difference, says Dr. Rom-Rymer.
Non-prescribing psychologists are often concerned that their patients are not able to be evaluated for medications in a timely enough manner, she continues.
-Even when the patient is able to see a psychiatrist, it is often a very short meeting. Psychiatrists, previously known to thoroughly explore the workings of the mind, now generally spend just 15-20 minutes with each patient. Today, in the United States, psychiatrists do not primarily do psychotherapy but focus on psychopharmacology; the medicine has become the most important part of psychiatric treatment.
The key to successful therapeutic work is the collaborative relationship between patient and therapist. Psychologists specialize in building good therapeutic relationships and effective collaborative relationships with their patients’ other providers, says Dr. Rom-Rymer. Psychologists have come to understand that, whether or not they will be prescribing, it is critical to be trained in Clinical Psychopharmacology, for the welfare of their patients and to effectuate good working relationships with other prescribers.
– Over-prescribing of certain medications is a major problem in the United States. One notable case is psychology professor, Jordan B Peterson, who, after taking benzodiazepines for depression, became addicted. The right to prescribe, is also the right not to prescribe. Prescribing psychologists can, therefore, be part of the solution to over-prescribing, notes Beth Rom-Rymer.
– Psychologists more often choose not to prescribe medication and instead offer a wide range of psychotherapeutic treatments to manage various psychological disorders, including drug addiction.
Arne Thomas Lundqvist, psychologist and unit leader at the general psychiatric clinic in Norway, agrees that psychologists can reduce a pattern of over-prescribing . For several years, he has had a close dialogue with Dr Rom-Rymer about psychologists’ prescriptive authority.
– In Norway, as well as in Sweden, there is a significant shortage of psychiatrists and when they enter the picture, they often meet the patient very quickly and do not have time to get the whole picture. We psychologists often are able to build a more complex understanding of our patients. With the addition of prescriptive authority, we can also make the case for not prescribing medications.
The psychologists in the USA who oppose prescriptive authority highlight the following arguments, says Dr. Rom-Rymer: the training in psychopharmacology may become too great of a burden for psychology students; there is a risk that psychologists, without prescriptive authority, could be seen as second-tier psychologists; and there is a concern that psychologists may follow in the footsteps of psychiatrists, focusing primarily on drugs, and eventually turning their backs on effective psychotherapies.
– But psychologists with prescriptive authority follow their psychological treatment model and do not focus on prescribing medications, says Dr. Rom-Rymer.
One development that she is following, with interest, is the research on hallucinogenic preparations (eg., LSD, marijuana and MDMA). Some research indicates that these drugs, used by well-trained clinicians, can have beneficial therapeutic effects. Rom-Rymer notes that ketamine, historically administered as an anesthetic for animals and in dental care, is another example of a hallucinogenic drug that has been gaining significant stature in the treatment of recalcitrant depression and bipolar disorder. Empirical studies continue. Many psychologists are watching the research on this important new treatment arena in Psychology.
// Fact box //
Today, the states of New Mexico ( 2002), Louisiana (2004), Illinois (2014), Iowa (2016), and Idaho (2017), the US territory of Guam (1998), and some federal jurisdictions have legislated the authority of psychologists to prescribe. Legislation is being prepared in several other states. The educational requirements for prescriptive authority laws differ. A common denominator is that psychologists with the authority to prescribe must have a Master’s degree in Clinical Psychopharmacology and must have completed at least a 400 hour practicum in psychiatry, under the supervision of a psychiatrist or a prescribing psychologist.
In the United States, psychotropic drugs are divided into five different schedules, according to their medical use, their potential for abuse, and their safety or dependence liability. The drugs with the highest abuse potential and dependence risk are on Schedule 1. A drug such as ketamine is on Schedule 3, and benzodiazepines (Xanax, Valium) are on Schedule 4. Ordinary anti-depressants, for instance, SSRIs and antipsychotics are not controlled substances because they are generally not considered at risk for abuse. All prescribing psychologists in the United States can prescribe at least most of the medications on Schedule III; all of the medications on Schedules IV, and V, and, of course, and, of course, all of the non-controlled medications.
Illinois is the state that puts the greatest number of constraints on psychologists’ prescriptive authority. Illinois prescribing psychologists have the authority to prescribe drugs on Schedules 3, 4 and 5, but for Flunitrazepam (Schedule 3). Illinois prescribing psychologists do not have the authority to prescribe the psychostimulants and can only prescribe medicines to patients between the ages of 17-65. In some states psychologists have the authority to prescribe all of the medications on Schedule 2.
Prescribing psychologists in New Mexico are, at present, the only ones allowed to prescribe medications from Schedule 1.
There are 106,000 licensed clinical psychologists in the United States. About 300 have the authority to prescribe. APA has 122,000 members, including students, researchers.
Active prescriptive authority movements are also found in Canada, Brazil, the United Kingdom, South Africa and Taiwan.
Source: Dr. Beth N. Rom-Rymer, a candidate for the presidency (2023) of the American Psychological Association (APA) and one of the leaders of the National Prescriptive Authority Movement in the United States and Co-Chair of IMPAP, The International Movement for Prescribing Psychologists; and Dr. Derek C. Phillips, President of the APA Society for Prescribing Psychology