5/30/2017

Prescriptive Authority: Psychologist Prescribing Why are we here? Rights: Allowing Prescribing Rights For The Latest on Legislation and Psychologists Is An Essential Step Training To Providing Thousands Of Patients With Access To Comprehensive Mental Health Care John Gavazzi, Psy.D., ABPP Tracy E. Ransom, Psy.D.

Learning Objectives:

1. Describe benefits & challenges of RxP;

2. List the states that have RxP & psychologist experiences in these locations;

3. Discuss PA legislative affairs related to RxP;

4. Describe training program requirements for RxP;

5. Analyze the prescribing rights initiative through group discussion

Why is RxP even a thing? Ethical aspects of RxP

• Fewer psychiatrists and physicians • Beneficence across the country

• Access to high quality mental • Fewer psychiatrists in rural and urban health care areas

• Integration of physical and • Fewer psychiatrists take insurance psychological aspects to care: lower cost/convenience

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Some Themes to Ponder General thoughts

• Organized medicine is not our enemy. • Skills Before Pills Why?

• The authority to prescribe gives you the • Need to unify our organization. Why? authority to take meds away and use psychological interventions • Need a great deal of work with grassroots organizations, such as law enforcement • Psychology is the best medicine and community mental health. Why?

• Psychologists are the best trained to • This will be a long-term, time consuming integrate a biopsychosocial approach. operation

At a Glance Where Can Psychologists prescribe?  RxP will be considered a specialty practice, in which a masters degree in psychopharmacology will be needed Louisiana Idaho

 Over 20 years prescribing in the military, 10+ years in New Mexico, and 10+ years in Louisiana New Mexico Indian Health Services

 Allowing prescribing rights for psychologists is an Illinois essential step to providing thousands of patients All Branches of the US with access to comprehensive mental health Military care. Iowa

Louisiana New Mexico • First prescription in 2005 • First prescription in 2005

• 55 Medical Psychologists in 2009 • Over a decade of prescribing psychologists

• 47 psychologists with RxP Certificate • 112 Medical Psychologists in 2017 • 17 with pending or Initial Conditional RxP • Currently under the Medical Board of Certificate Louisiana • Under the Board of Psychology

• No lawsuits or major setbacks • No lawsuits or setbacks

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In New Mexico, this could Illinois be you

 RxP is still in the rules and regulations phase. Should be finalized July 1, 2017

 Garnered a great deal of support from law enforcement as well as community mental health services

 Many universities are now looking to work with prescribing psychologists to offer education consistent with the law, rules, and regulations

Illinois Iowa

• 5 psychologists will likely be eligible to prescribe July 1, 2017. • Masters degree required

• 10 psychologists will start clinical rotations

• 200 psychologists are in training programs • 2 year conditional certificate currently

• One major medical center in southern Illinois has offered a "signing bonus" and half-time positions for prescribing psychology trainees while • Still involved in rules and regs providing the opportunity for doing the clinical rotations, simultaneous with the half-time paid position.

Iowa Idaho

• Working with the Board of Medicine for rules/regs Just passed the bill, so…….. • Slight delay in the process

• Lengthy process gets longer

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Which states have active Most Salient myths groups?  A prescriber needs a medical school education Legislation Active Groups to prescribe  Nurse practitioners, podiatrists, pharmacists,  New Jersey • Florida • Nebraska and optometrists can prescribe medication • Texas • Maryland  Hawaii • Virginia • Virginia  Prescribing psychologists will increase • New York • California malpractice insurance  North Dakota • Vermont • Arizona  Has not happened in other states • Ontario**  Ohio • Michigan  The Trust has an add-on for prescribing psychologists

 Oklahoma

Psychopharmacology a What are we doing? Specialty with various Names • Not a theoretical or new movement

• RxP • Clinical Psychopharmacology • Division 55: Society for the Advancement of Psychopharmacology • Pharmacotherapy • Prescribing psychologists • RxP as part of a scope of practice for • Prescriptive appropriately trained psychologists has been defined with deliberateness and authority for • Medical psychologists ongoing evaluation psychologists

What are we doing? Milestones for RxP

• Evolution of best practices in training and • 1992 DoD: 10 Graduates Acquired Prescriptive delivery by APA, universities, military programs, Authority and state psychological associations • 1992 APA Council established Ad Hock Task Force on Psychopharmacology • Multidisciplinary input into model legislation, model training program and practice guidelines is from many disciplines and carefully • 1994 CAPP established Task Force on Prescription vetted within the profession Privileges

• Not all psychologists will opt for this • 1995 APA endorsed prescription privileges for specialization psychologists

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Milestones for RxP History of RxP

• First bill introduced in Hawaii in 1989 • 1996 Model Legislation and Training Guidelines

• 1997 PEP Development • APA Task Force officially considered prescribing rights in 1989

• 1999 PEP Finalized • 1984: At the Hawaii Psychological Association Convention, Sen. Daniel • 2008 Revised Training Guidelines Inouye, D-Hawaii, challenges psychology to seek prescriptive authority (RxP) as a • 2011 Practice Guidelines way to address the needs of underserved populations.

History of RxP History of RxP • 1991: The Department of Defense PDP • 1985: Hawaii Psychological Association begins training two Navy psychologists. introduces the first bill seeking to grant prescriptive authority for psychologists. • 1995: The APA Council of Representatives adopts a resolution on prescription privileges for appropriately trained • 1989: APA staff joins the Department of psychologists. The resolution reaffirms that Defense Blue Ribbon Panel to create physical interventions are part of the the curricula for the practice of psychology and supports the Psychopharmacology Demonstration APA seeking prescription privileges for Project (PDP). psychologists.

History of RxP History • 1996: The APA Council of Representatives • 2000: The APA College of Professional approves the Model Legislation for Psychology’s Psychopharmacology Prescriptive Authority and the Examination for Psychologists (PEP) Recommended Postdoctoral Training in becomes available for states and Psychopharmacology for Prescription provinces to use in granting prescriptive Privileges as APA policy. authority to psychologists.

• 1997: The fourth and final PDP class • 2002: In New Mexico, Gov. Gary Johnson graduates. By the conclusion of the PDP, it signs into law a bill that grants prescriptive has successfully trained 10 military authority to psychologists who have met psychologists to prescribe psychoactive certain educational and training medications. requirements.

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History History

2004: Louisiana’s Gov. Katherine Blanco signs the RxP bill into law, granting appropriately trained medical psychologists to 2014: Illinois Gov. Pat Quinn signs the prescriptive prescribe psychotropic medications and emphasizing a authority bill into law, authorizing collaborative relationship between prescribing psychologists licensed Illinois psychologists who have additional and patients’ primary care physicians. specialized training in psychopharmacology to prescribe certain medications for the treatment of 2007: The Hawaiian legislature passes an RxP bill. mental health disorders. Unfortunately the bill was ultimately vetoed by Gov. Linda Lingle on July 10, 2007, and the legislature was unable to override the veto. 2016: Iowa passes legislation granting licensed psychologists who are trained in psychopharmacology with prescriptive authority. 2010: On Feb. 24, the Oregon Legislature passes RxP legislation. The bill is subsequently vetoed by Gov. Ted Kulongoski on April 8. 2017: The Idaho legislature passes an RxP bill. Governor Butch Otter signs the bill into law.

Future APA, VA and RxP

Which states will be next?  I will add the video later

• Hawaii, Ohio, or New Jersey?

What about the VA?

Who prescribes The state of psychiatric practice psychotropic agents? • Psychiatrist wait times 3 to 4 months

• Depending on which study you read, anywhere from 65 to 85% of psychotropic agents prescribed • Only 6,000 psychiatrists completing their by non-psychiatric physicians. program between 2014-2017

• Primary care physicians are on the decline • Many unfilled residency positions – Medicare payment/reimbursement • American Association of American Medical Colleges indicate nationwide deficit of 46,000- • 59% of psychiatrists are currently above the 90,000 primary care physicians by 2025 age of 55

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The state of psychiatric practice Psychology Specialties • 1,309 psychiatrists in Pennsylvania

(1 for every 10,000 citizens)  Clinical  Rehabilitation

• 5% of adults suffer with chronic mental illness  Neuropsychology  Forensic (635,000 in Pennsylvania-1:485)  Pediatric  Counseling

• 28,000 psychiatrists currently nationwide (Telehealth with not solve the problem)  Geropsychology  School

 Health Psychology  Psychopharmacology • Less than 50% of psychiatrists take insurance; other medical specialties are around 3%

Can psychologists Safety issues prescribe safely? There are a variety of apps (Epocrates) to help with adverse effects, medication interactions, and dosing schedules. • Prescribing psychologists have prescribed safely in the military, the U.S. Public Health Service and Indian Health Services for over Most antidepressants have “Black Box Warnings” for suicide. More frequent contacts and the 20 years with no adverse events reported. therapeutic relationship is important to assess, manage, and treat suicidal patients.

• Prescribing psychologists have prescribed More frequent contacts, longer sessions, and safely in New Mexico and Louisiana for over good interpersonal skills aid with improved 10 years with no adverse events reported. therapeutic outcomes.

Legislation in PA: Our best guess

• Master’s degree in • Supervision: 2,000 hours psychopharmacology

• Supervision: Physician • Follow the APA Model Training for RxP • Nationally accredited exam • Avoid pre- and post- doctoral distinction • 20 hours of CE every 2 years • Written collaborative • Prescribing Psychologist agreement with a physician

• Independent practice • Board of Psychology

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APA designation for RxP APA designation for RxP

Proposed Uniform Criteria for Privileging Psychologists to Proposed Uniform Criteria for Privileging Psychologists Prescribe in Federal Agencies (established in 2010) to Prescribe in Federal Agencies (established in 2010)  A post doctorate master's degree in psychopharmacology  from a regionally accredited and/or APA-approved Provide pharmacotherapy to a minimum of 100 graduate program, or a master's degree in patients during the supervisory period. psychopharmacology earned during the pursuit and  completion of a doctorate in psychology from an Current licensure from a state permitting accredited graduate program, or a post doctorate psychologists to prescribe, or obtaining such a certificate in psychopharmacology that meets APA license within two years of being privileged in a recommendations prior to a specified year (grandfather federal agency to prescribe. clause).  A statement indicating that medications typically  Passage of the PEP or other national certifying examination used to treat psychiatric disorders are within the recommended by APA. standard formulary of RxPs.  Documentation of one year of supervision by a licensed  prescribing psychologist, board certified psychiatrist, or other A statement regarding the expectation of ongoing board certified physician with specific knowledge of competence, continuing education in psychotropic medications in a community, state or federal psychopharmacology and participation in quality setting. management such as peer supervision.

Training University of Hawaii program

 University of Hawaii – MS in Clinical  Prerequisites: PhD/PsyD, GPA 3.0+ Psychopharmacology  Length – 2 years  Nova Southeastern – MS in Clinical Psychopharmacology  Practicum requirement: 400 hours, 100  Alliant University – MS in Clinical patients Psychopharmacology  Coursework: 34 semester hours of credit  New Mexico State University – MA in Clinical  Psychopharmacology Classroom training  Fairleigh Dickinson University – MS in Clinical Psychopharmacology

University of Hawaii University of Hawaii Program Program

 Required courses:  Required courses:

 Fall year 1  Fall year 2

 Biochemistry I – Biomolecules (3)  Integrated Pharmacotherapy III (4)  Advanced psychopharmacology (2)  Biochemistry II – Metabolism (3)  Psychopharmacology Practicum (2)  Human Physiology (3)  Spring year 2  Spring year 1  Advanced psychopharmacology II (2)  Integrated Pharmacotherapy I (7)  Law and psychopharmacology (2)  Summer year 1  Psychopharmacology practicum (2)  Integrated Pharmacotherapy 2 (5)  Summer year 2  Psychopharmacology practicum(2)

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Nova Southeastern Nova Southeastern Program Program

 Prerequisites: PhD/PsyD  Introduction to Organic & Biochemistry (1)  Length – 2 years  Computer Based Practice Aids (0.5)  Practicum requirement: 2 x 100 hour practicum  Neurophysiology (1.5) programs  Neuroanatomy (1.5)  Coursework: 33 semester hours of credit  Neurochemistry (1.5 )  Classes meet for 1 weekend a month (Florida), supplemented with online learning  General Pharmacology (4)  Psychopharmacology (4)  Practicum I (2.5 )

Nova Southeastern Alliant University Program Program

 Physical Assessment (3)  Prerequisites: PhD/PsyD, license in good standing

 Pathophysiology (4 )  Length – 28 months  Developmental Psychopharmacology (1.5)  Practicum requirement: None  Chemical Dependency & Pain Management  Coursework: 29.6 semester hours of credit (1.5)  Completely distance learning (first, oldest and  Psychotherapy Pharmacotherapy largest program) Interactions (1)  Pharmacoepidemiology (1)  Professional, Ethical, & Legal Issues (0.5 )  Practicum II Grand Rounds (2.5)

Alliant University Program Alliant University Program

 Required courses:  Required courses:

 Spring year 1  Fall year 2

 Clinical Biochemistry (1.6)  Special populations (child, geriatric, chronic pain, chronic medical conditions, trauma) 2.4  Neuroscience/Neuroanatomy/Neuropathology (2.4)  Advanced psychopharmacology and molecular  Neuroscience/Neurochemistry (1.6) nutrition (4)  Fall year 1  Spring year 3  Neurophysiology and clinical  Special populations 2 (gender, ethnicity, chemical medicine/pathophysiology (5.6) dependency)  Spring year 2  Pharmacotherapeutics (2.4)  Pharmacology/Clinical Pharmacology (4)  Case Seminar (.8)  Physical assessment (2.4)

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New Mexico State University New Mexico State Program University Program

 Prerequisites: PhD/PsyD, current state license in  Required courses:

good standing  Introduction to psychopharmacology for  Length – 25 months psychologists I and II (3 credits each)  Practicum requirement: 400 hours, 100 patients; 80  Clinical Psychopharmacology I and II (3 credits hour practicum with consulting physician each)  Pathophysiology for psychologists I, II, III (3 credits  Coursework: 36 semester hours of credit each for I, II; 6 credits for III)  Live classroom and online program  Psychopharmacology in special populations I and II (3 credits each)

 Practicum (6)

Fairleigh Dickinson Fairleigh Dickinson University Program University Program

 Prerequisites: PhD/PsyD, license in good standing  Required courses:

 Length – 2 years  Biological Foundations of Pharmacological Practice I and II (3 credits each)  Practicum requirement: Optional, depending on prescribing laws of student’s state  Neuroscience (3)  Neuropsychopharmacology (3)  Coursework: 30 semester hours of credit  Clinical Pharmacology (3)  Distance based  Professional Issues and Practice Management (3)

Fairleigh Dickinson Additional training University Program requirements

 Required courses:  100 patients seen with collaboration with

 Treatment issues in psychopharmacology: affective physician disorders (3)  Prescribing psychologists only to prescribe those  Treatment issues in psychopharmacology: psychotic medications falling under the “nervous system disorders (3) and psych” designations on medication formularies  Treatment issues in psychopharmacology: anxiety disorders (3)

 Treatment issues in psychopharmacology: other disorders (3)

 Clinical lab/test prep (optional)

 Clinical Practicum elective (optional)

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Comparison of Training Comparison of Training Programs Programs

Comparison of Training Comparison of Training Programs Programs

Comparison of Training Comparison of Training Programs Programs

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PEP Testing PEP Testing

Competence: Psychopharmacology Examination for Psychologists  What’s up with the PEP? (Psychopharmacology (PEP) Integrating clinical psychopharmacology with the practice Exam for Psychologists) of psychology

 PEP housed in APA practice organization since  Neuroscience 2001  Nervous system pathology  Black out dates of March 31, 2017 to January 2018  Physiology and pathophysiology as PEP transitions from APA practice organization  Biopsychosocial and pharmacologic assessment and to Association of State and Provincial Psychology monitoring Boards (ASPPB)  Differential diagnosis  Pharmacology  Same board that manages the EPPP (Examination  Clinical psychopharmacology for Professional Practice in Psychology)  Research  Professional, legal, ethical, and inter-professional issues

Costs for training The inside line on training

 Education: FDU program  10-20 hours per week of time approximately $15,000 ($3,000 devoted to program per semester/$1,500 per 7.5  Advantages/Disadvantages week course) of online program  Rigors of training (did you like your Biological Psychology  Testing: $395 APA members; coursework in your doctoral $425 non-APA members (might program?) change with ASPPB transition)  Professors and administration

Supporting arguments and opposition regarding psychologist prescribing rights

What do you think?

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