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Lavoie, K L, & Barone, S. (Jan 2006). Prescription privileges for psychologists: a comprehensive review and critical analysis of current issues and controversies.   CNS Drugs. , 20, 1. p.51(16). Retrieved January 09, 2011, from Expanded Academic ASAP via Gale:http://find.galegroup.com/gtx/infomark.do?&contentSet=IAC-Documents&type=retrieve&tabID=T002&prodId=EAIM&docId=A199865934&source=gale&userGroupName=phspuqc&version=1.0 Abstract:

The debate over whether clinical psychologists should be granted the right to prescribe psychoactive medications has received considerable attention over the past 2 decades in North America and, more recently, in the UK. Proponents of granting prescription privileges to clinical psychologists argue that mental healthcare services are in crisis and that the mental health needs of society are not being met. They attribute this crisis primarily to the inappropriate prescribing practices of general practitioners and a persistent shortage of psychiatrists. It is believed that, as they would increase the scope of the practice of psychology, prescription privileges for psychologists would enhance mental health services by increasing public access to qualified professionals who are able to prescribe. The profession of psychology remains divided on the issue, and opponents have been equally outspoken in their arguments.The purpose of the present article is to place the pursuit of prescription privileges for psychologists in context by discussing the historical antecedents and major forces driving the debate. The major arguments put forth for and against prescription privileges for psychologists are presented, followed by a critical analysis of the validity and coherence of those arguments. Through this analysis, the following question is addressed. Is there currently sufficient empirical support for the desirability, feasibility, safety and cost effectiveness of granting prescription privileges to psychologists?Although proponents of granting prescription privileges to psychologists present several compelling arguments in favour of this practice, there remains a consistent lack of empirical evidence for the desirability, feasibility, safety and cost effectiveness of this proposal. More research is needed before we can conclude that prescription privileges for psychologists are a safe and logical solution to the problems facing the mental healthcare system.

Full Text:COPYRIGHT 2006 Wolters Kluwer Health 

Contents Abstract 1. Background 2. Historical Antecedents and Forces Driving the Prescription Privileges for Psychologists Debate 2.1 The Origins of Clinical Psychology

2.2 The Origins of Modern Psychopharmacology 2.3 Forces Driving the Prescription Privilege Movement 3. Who Can Legally Prescribe? International Prescribing Practices 4. Major Milestones Achieved by the Prescription Privileges for Psychologists Movement 4.1 Recommended Curriculum for Psychopharmacology Training 4.2 The Current Status of the Debate 5. Major Arguments For and Against Prescription Privileges for Psychologists: A Critical Analysis 5.1 Major Arguments for Granting Prescription Privileges 5.2 Major Arguments Against Prescription Privileges 5.3 Critical Analysis 6. Desirability 7. Feasibility 8. Safety 9. Cost Effectiveness 10. Conclusions and Future Directions

1. BackgroundOver the last 2 decades, an important debate has emerged within professional psychology about whether clinical psychologists should be granted the legal right to prescribe psychotropic medications. The major argument from individuals in favour of prescription privileges for psychologists is that mental healthcare services are in crisis, and as a result, the mental health needs of society are not being met. [1-4] The major proponents of granting prescription privileges to psychologists, who include the American Psychological Association (APA) [4] and the American Society for the Advancement of Pharmacotherapy (ASAP, Division 55 of the APA), attribute this crisis to the often inappropriate prescribing practices of general practitioners and a persistent shortage in the number of available psychiatrists. [1,3] It is believed that by increasing psychology's scope of practice, prescription privileges would enhance mental health services by increasing public access to qualified professionals who can prescribe. Despite important advancements in the pursuit of prescription privileges, those in the profession of psychology remain divided on this issue, and opponents have been equally outspoken in their arguments against the proposal. [5-12]Throughout the course of this review, we attempt to put the debate into context by presenting the historical antecedents and current forces driving it. We present the major arguments for and against granting prescription privileges to psychologists, followed by a critical analysis of the validity and coherence of those arguments. Through this analysis, we hope to answer the following question. Is there currently sufficient empirical support for the desirability, feasibility, safety, and cost effectiveness of granting prescription privileges to psychologists?We conducted a literature search of relevant articles published from 1980 to 2005 appearing in the PsychInfo, MEDLINE, EMBASE and Cochrane databases, using 'prescription privileges' and 'psycholog *' as search terms. We also searched relevant popular and professional media publications using Google.2. Historical Antecedents and Forces Driving the Prescription Privileges for Psychologists Debate2.1 The Origins of Clinical PsychologyThe profession of 'clinical psychology' was originally founded in the late 19th century by Lightner Witmer, who established the first American psychology clinic. [13] At that time, the practice of clinical psychology was conceptualised as the application of psychological techniques to the study of the individual. [14] Although clinical psychology has evolved to become a largely

(though not exclusively) practice-based profession, the PhD in clinical psychology was originally developed as a research or academic degree. In fact, the APA's Committee on Training in Clinical Psychology (CTCP) did not consider psychotherapy a central activity of clinical psychologists [15] until after World War II, when the demand for mental health services increased sharply, due to the need to treat the victims of war. A shortage in the number of psychiatrists led the Veteran's Administration (VA) in the US to expand the role of clinical psychologists to include many practice-based activities including psychometrics, diagnostic interviewing and ultimately, psychotherapy. [16,17] Although psychiatrists were initially opposed to psychologists providing psychotherapy, claiming that they lacked proper training, psychotherapy had emerged as a major activity of clinical psychologists by the end of the 1950s, [18] and has continued to be one of their central activities to this day.2.2 The Origins of Modern PsychopharmacologyInterestingly, at about the time clinical psychologists were becoming important psychotherapy service providers alongside psychiatrists, psychopharmacology emerged as a major force in the mental healthcare arena. Many of the psychotropic medications in use today, such as benzodiazepines, chlorpromazine and TCAs were introduced between 1950 and 1960, when Freudian psychotherapy was dominant. This introduction led to a major shift in the conceptualisation of mental illness as a psychological disorder to an emphasis on the medical model. [19,20] Since then, the field of psychopharmacology has made considerable progress as both a basic science and clinical treatment modality for several mental disorders. [21] In the early 1980s, the SSRIs were introduced and they revolutionised modern psychopharmacology. Although they were of comparable effectiveness to the older classes of antidepressants (e.g. TCAs and MAOIs), SSRIs had a more favourable adverse effect profile, making them easier to tolerate and a relatively safer pharmacological alternative for the treatment of many mood and anxiety disorders. [22-26] Their relative safety and perceived ease of administration has also made them more likely to be prescribed by general practitioners, [23,27-29] who are currently responsible for prescribing over 80% of all psychoactive medications. [3,30,31]2.3 Forces Driving the Prescription Privilege MovementSince the inception of this debate approximately 20 years ago, many have asked: why prescription privileges for psychologists, and why now? Understanding the nature and timing of the prescription privileges debate involves the recognition that it is occurring within a larger context of change within and around the practice of clinical psychology. Perhaps the most obvious force driving the current debate is economics, or more specifically, an oversupply of doctoral-level (PhD and PsyD) psychotherapists, who charge more than their master'slevel counterparts, and a concurrent increase in the demand for less costly psychotherapeutic services. [10,17] Research shows that, in most circumstances, psychotherapy may be effectively delivered by non-doctoral-level psychologists, including master's-level psychologists, social workers, counsellors, nurses, and sex therapists. [17,32,33] The concurrent rise of managed care and health maintenance organisations (HMOs) in the US and a need to reduce healthcare costs in Canada's public health system are increasingly leading to the replacement of doctoral-level psychologists with less costly psychotherapists, whenever possible. [34,35] The result: many clinical psychologists are facing the possibility that they are no longer needed to fulfill their psychotherapeutic role, an activity in which they have dominated since the 1950s.An additional force driving the movement for prescription privileges for psychologists involves the rising pharmaceutical company interest in expanding the number of professionals who can prescribe. [10] Drug companies are increasingly sponsoring psychological symposia and

providing research and education grants to clinical psychologists "with a strong psychopharmacology emphasis". [36] Psychotropic medications now occupy a significant proportion of the drug portfolios of the major pharmaceutical giants. In fact, in 2001, the largest increases in drug sales were seen for psychotropic medications. [37] According to IMS Health, a major global healthcare information company, drugs affecting the CNS underwent a sales growth of 16%, to $US45.3 billion in the 12 months prior to May 2002.[37] Moreover, sales of antidepressants experienced 18% growth, to total $US13.4 billion, which accounted for 4.2% of all global pharmaceutical sales. Fluoxetine was the most successful product amongst the drugs affecting the CNS, demonstrating a market share of 21.5%. North America was the highest user of psychoactive drugs, accounting for 74.6% of sales, amounting to a 19% growth rate. It is noteworthy that in Europe, sales fell by 1%, while Africa/ Asia/Australia and Latin America reported only 4.5% and 2.4% increases in sales, respectively. Given the growth and sales records of psychoactive medications in the US, it is perhaps not surprising that the prescription privilege movement is so strong there, relative to other countries (e.g. Canada, the UK). [37]3. Who Can Legally Prescribe? International Prescribing PracticesIn order to appreciate the complexities of obtaining prescriptive authority, it is helpful to understand how prescription privileges are legislated in different countries. In the US, the Food, Drug and Cosmetic Act is responsible for defining whether a drug may be sold over the counter or by prescription only. [2] However, through their respective pharmacy and medical practice acts, individual states determine which professions are authorised to prescribe. [38] In Canada, the Federal Bureau of Human Prescription Drugs decides how drugs are sold, and provincial and territorial governments are responsible for regulating the practice of medicine and pharmacy, often through their colleges or registrars of physicians and/or pharmacists. [39] In the UK, prescribing is regulated by the Medicines and Healthcare products Regulatory Agency (MHRA), an executive agency of the Department of Health. [40]A two-factor classification scheme for prescription privileges was established to specify the degree of prescriptive authority held by a particular profession. The first dimension (independent vs dependent) involves whether physician supervision is required for the individual to be able to prescribe. The second dimension (limited vs unlimited) concerns which categories of drugs may be prescribed. [41] Only physicians have independent and unlimited prescription privileges in the US, but in Canada and the UK, both physicians and dentists have independent and unlimited privileges (table I).Over the years, various non-physician professions, such as dentists, optometrists, and podiatrists, have been granted limited prescription privileges in the US. Prescriptive authority for these professions is limited typically to medications that affect the body systems in their area of practice. [2] The APA is currently advocating for independent privileges, which would be limited to prescribing psychoactive medications. For a summary of professions with various levels of prescriptive authority in the US, Canada, and the UK, see table I.4. Major Milestones Achieved by the Prescription Privileges for Psychologists MovementWhen we wrote our first review on the prescription privileges for psychologists debate, [42] we received a letter stating that advancing prescription privileges for psychologists was "untenable ... [and that it] appears somewhat ludicrous that an article of this nature would grace the pages of the Canadian Psychiatric Association's journal." [43] Since its inception, the movement to gain prescription privileges for psychologists, at least in the US, has shown considerable progress, despite the opinions of those who thought it impossible. For a summary of the major milestones achieved by the movement, see table II.

4.1 Recommended Curriculum for Psychopharmacology TrainingBoth New Mexico and Louisiana have granted limited, independent prescriptive authority to properly trained psychologists, based on training guidelines developed and approved by the APA's Committee for the Advancement of Professional Practice (CAPP) and the APA College of Professional Psychology (a subsidiary of CAPP). In order to undergo training to prescribe, psychologists must have a doctoral degree in psychology, hold a current, valid state license as a psychologist, and have at least 5 years experience as a 'health service provider' psychologist as defined by state law or by the APA. [44] The actual psychopharmacology training programme includes a minimum of 450 hours of didactic training in five core content areas: (i) neuroscience; (ii) clinical and research pharmacology and psychopharmacology; (iii) physiology and pathophysiology; (iv) physical and laboratory assessment; and (v) clinical pharmacotherapeutics. Psychologist trainees must also complete a joint board-approved 80-hour supervised practicum in clinical assessment and pathophysiology and an additional 400-hour practicum treating at least 100 patients with mental disorders. The 400-hour practicum also requires receiving 2 hours of weekly individual supervision, which is reportedly more than physicians receive. [44] To receive certification, trainees must pass a national certification exam, which will grant them a 2-year license to prescribe under the supervision of a physician. At the end of the 2 years, subject to supervisory approval, the psychologist can apply to prescribe independently. [44]4.2 The Current Status of the DebateAs of April 2005, prescription privilege legislation has been introduced to study the prescription privilege issue and/or enact laws enabling psychologists to prescribe in at least 20 US states. [4,44,45,54,55] Nearly half of all the State Psychological Associations have developed a Task Force to address prescription privilege issues in their respective states, and specific training programmes based on the Department of Defense (DoD) training model have been introduced or are being offered in 12 states. [44]Although efforts to obtain prescription privileges for psychologists appear to be moving forward, whether or not psychologists should gain prescription privileges remains hotly debated both within and around professional psychology. The following sections summarise the major arguments presented for and against the movement, followed by a critical analysis of those arguments based on the extent to which they demonstrate the desirability, feasibility, safety, and cost effectiveness of granting prescription privileges for psychologists.5. Major Arguments For and Against Prescription Privileges for Psychologists: A Critical Analysis5.1 Major Arguments for Granting Prescription PrivilegesFirst, the most popular argument put forth by advocates of prescription privileges for psychologists is that there are important public mental health needs that are not being met under the current healthcare system, and that increasing the number of mental health professionals who can prescribe will improve public access to the needed quality mental healthcare. [1-3] Secondly, proponents argue that properly trained clinical psychologists will offer the public a superior quality of mental healthcare services than that currently being delivered by the majority non-psychiatrist physicians (i.e. general practitioners [GPs]) who can prescribe). [1-3] Thirdly, proponents argue that clinical psychologists are highly trained mental health professionals, and that granting them prescription privileges is both a logical extension of their current practice and that it would help circumvent their impending marginalisation in the face of the oversupply in the number of professionals who conduct psychotherapy. [2,56] Finally, proponents argue that granting psychologists prescriptive authority would provide greater continuity of care and would

be less disruptive and more cost effective than having to consult two professionals (a psychologist and a physician) with potentially contrasting views on how to direct patient care. [57-59]5.2 Major Arguments Against Prescription PrivilegesFirstly, the most common argument put forth by opponents of granting prescription privileges to psychologists is that psychologists are simply not qualified to prescribe medication. [60,61] Secondly, opponents claim that there is no societal need to grant psychologists prescriptive authority, nor would psychologists be geographically better situated to serve rural populations than other medical professionals. [60] Thirdly, it has been argued that psychologists have not adequately demonstrated their competence to prescribe psychoactive medication, which may pose an important threat to patient safety. [42,59,62] Fourthly, opponents have pointed to a lack of consensus within professional psychology as to whether prescription privileges should even be pursued, which they claim calls into question the desirability of redefining the practice of psychology to include prescription privileges. [42,60,63,64] Finally, opponents raise concerns about how granting prescription privileges to psychologists would drastically alter the psychological content of graduate and post-graduate training programmes, and how that would negatively impact the future direction of professional psychology. [10,12,38,41]5.3 Critical AnalysisThe questions we seek to answer through this critical analysis are the extent to which the current literature has amply demonstrated the desirability, feasibility, safety and cost effectiveness of granting prescription privileges to psychologists. Our goal is to present an updated and balanced critical analysis of both sides of the argument from the perspective of a scientist-clinical psychology practitioner, in order to assist readers in drawing informed conclusions about this controversial issue.6. DesirabilityThe most popular argument in favour of granting prescription privileges to psychologists is that there is a societal need for greater access to mental health professionals who can prescribe, and that granting psychologists prescriptive authority would serve the public interest by helping to reduce society's mental health burden; this is a highly desirable goal. Advocates appear to be correct on two counts: (i) that the mental health burden of industrialised nations is extensive; and (ii) that there may be increasingly limited public access to mental health professionals (i.e. psychiatrists) who can prescribe.According to the National Institute of Mental Health (NIMH), 44.3 million Americans suffer from a diagnosable mental disorder. [65] Left untreated, mental disorders can cause significant psychological and functional impairment leading to absenteeism and lost productivity, which total nearly $US312 billion annually in the US alone. [63] The acute shortage in the number of available psychiatrists has been documented by both the Surgeon General's Report on Mental Health [66] and the President's New Freedom Commission on Mental Health. [67] Advocates point out that fewer and fewer psychiatrists are being trained, [1] and there was a 7.4% drop in the number of graduates entering new psychiatry residencies between 1997 and 1998. [68] This shortage is expected to increase, with demographic projections predicting that there will be a shortage of over 22 000 adult and 28 000 child and adolescent psychiatrists by 2007. [69] This is particularly true in rural areas, where access to quality mental healthcare is particularly limited. For example, the APA reported that there are only 18 psychiatrists serving the 72% of New Mexicans who live outside the major city centres of Santa Fe and Albuquerque, and that up to

75% of those with a treatable mental disorder are not receiving treatment and must endure waiting times of as long as 6 months. [46]However, what proponents have not adequately demonstrated is that there is actual societal demand for psychologists to be the ones to meet their mental health needs, rather than increasing access to properly trained physicians who can prescribe. The fact remains that it is the APA and a group of psychologists who are advocating granting prescription privileges to psychologists, not the general public. With the exception of one small study, which showed that consumer demand for psychologists obtaining prescription privileges was quite low, [70] we are unaware of any representative surveys of the general population's views on this matter.It has also been argued that maintaining a class of mental health professionals who can offer an alternative to medication can better serve the public interest than adding psychologists to the list of professions who can prescribe. [12] There is also no evidence to suggest that psychologists would be better geographically situated to serve rural populations, as they are generally located in the same areas as physicians, psychiatrists, and other health professionals who have some degree of prescriptive authority (e.g. nurse practitioners). We have not seen any published study presenting data on: (i) the ratio of psychologists to 'other prescribing health professionals' in rural areas; (ii) the number of psychologists currently situated in these areas who would be willing (or able) to undergo the extensive training required to prescribe; or (iii) the number of psychologists in urban areas who would be willing to relocate to serve these populations. Interestingly, the profession of 'physician assistant' was created to help meet the healthcare needs of underserved (e.g. rural) populations, but only 3% of all physician assistants actually do. [71] As of 1997, there were over 160 000 advanced nurse practitioners who were either prescribing or administering psychotropic medication in all 50 states. [44] This number rivals the 152 500 members of the APA (2000), a fraction of whom would likely undergo training to prescribe. [63]Proponents have argued for the desirability of granting prescription privileges to psychologists by stating that psychologists would provide superior mental health (and pharmacotherapy) services than those that are currently being delivered by the majority of non-psychiatrist physicians (i.e. GPs) who can prescribe. Advocates are correct to be concerned about the prescribing practices of many GPs. With the advent of the newer and relatively safer classes of antidepressants (SSRIs and serotoninnorepinephrine [noradrenaline] reuptake inhibitors), GPs have become the largest prescribers of psychoactive medication. Between 60% and 83% of all prescriptions written for psychotropic medications are now written by GPs, who often have <4-8 weeks of training in psychiatry and mental health. [3,31,72] US medical schools typically devote only about 115 hours of classroom teaching to pharmacology (without a particular emphasis on psychopharmacology). [73] In addition, there is evidence to suggest that many patients seen by GPs are misdiagnosed, prescribed inappropriate medication or prescribed medication unnecessarily. [3,74,75] Research shows that, in women alone, depression is misdiagnosed on 30-50% of occasions, and that when antidepressants are prescribed patients are often improperly monitored. [74] Finally, a recent study by De Las Cuevas and Sanz [76] demonstrated an important disparity between the knowledge of GPs and psychiatrists with regards to how to appropriately prescribe benzodiazepines. Less than 43% of GPs (vs 82% of psychiatrists) knew that abrupt cessation of benzodiazepines could cause serious harm. [77] Given these data, proponents of granting prescription privileges to psychologists argue that appropriately trained psychologists would be more qualified to properly diagnose, treat, and monitor the behavioural effects of psychoactive medication than would other non-psychiatrist practitioners. [4]

While no one would argue against the necessity and desirability of providing a higher standard of care to patients with mental disorders, proponents have yet to demonstrate how prescription privileges for psychologists are the logical solution to what appears to be a training issue for GPs. Given that GPs are, and will remain, the front-line service providers under most international healthcare systems, it is unclear how prescription privileges for psychologists would significantly alter the healthcare-seeking behaviour of patients or the number of prescriptions written by GPs (unless, of course, GPs decided to systematically refer their patients to psychologists for pharmacological treatment). Moreover, it is important not to dismiss the extensive basic science, medical and pharmacological training these physicians undergo in preparation to prescribe, which is a minimum of 9-12 years. [78,79] Rather than adding psychologists to the list of professionals who can prescribe, a more logical solution may be to provide greater mental health training to GPs and help promote greater collaboration between GPs and psychologists. [42] Interestingly, the MHRA in the UK recently issued a list of treatment guidelines for GPs on the proper administration of antidepressant therapy, including specific recommendations about dosages, patient communication, and when to use psychotherapy as a first-line therapy. [80] Although this is not necessarily a substitute for additional training, it is an encouraging start.Proponents have argued for the desirability of granting prescription privileges to psychologists by stating that clinical psychologists are highly trained mental health professionals, and granting them prescription privileges would be a logical extension of their current practice. In fact, clinical psychologists do undergo extensive training in multiple areas of mental health and illness, including psychometrics, psycho-diagnostics, neuroscience, psychological and behavioural interventions, basic and clinical research on the aetiology and epidemiology of mental disorders, and even psychopharmacology. [2,44,58,81] Typical graduate programmes last approximately 7 years and many go on to complete more specialised post-doctoral training, which in most states is a requirement for licensure. [2,44,58] However, this debate is not about whether clinical psychologists should be allowed to acquire the credentials to prescribe psychoactive medication. In fact, as it has been previously argued, clinical psychologists who want to obtain prescription privileges can already do so through existing channels. Under existing laws in both North America and the UK, any psychologist who wants to prescribe medications can do so by earning an appropriate qualifying degree in medicine or a related health profession (e.g. nurse practitioner, physician assistant). [6] It remains unclear why the practice of psychology needs to be overhauled for psychologists to obtain prescription privileges. One possible explanation is that the majority of psychologists simply do not have the basic science background that is required for admission into many of these professional training programmes. [10] Nonetheless, proponents of prescription privileges have not adequately justified why psychology should be exempt from the prerequisite training that has been necessary for all other prescribing professions. Although several proposals have been made with regards to providing psychologists with comparable basic science training, this has raised several issues related to feasibility, which are discussed in section 7.Finally, proponents argue that there is a general consensus within professional psychology in favour of pursuing prescription privileges for psychologists, indicating that the majority view it as a worthwhile and desirable goal. [2,3,82] Although it has been repeatedly argued that support for granting prescription privileges to psychologists is widespread and increasing, relatively few studies have actually been published on the issue. [63] A recent meta-analysis of opinion data from practicing psychologists, trainees, and training directors in the US shows that the results of

only 17 surveys have been published in over 20 years of debate. [83] Moreover, an examination of this report by Walters actually reveals an important division within professional psychology, as his analysis concluded that the absolute level of in-principal support for obtaining prescription privileges is only around 50%. Since this report, only two additional surveys on this issue have been published. [84,85] One reported that more than two-thirds of graduate students were in favour of gaining prescription privileges, although less than half would personally undergo training. [84] A more recent survey of psychologists and trainees in Canada also suggests general support for obtaining prescription privileges, although less than half of those surveyed had plans to personally seek training. [85] We are unaware of any survey data from British psychologists, but individual opinions about gaining prescription privileges in the UK appear less favourable compared with the opinions in the US and Canada. [86-88]7. FeasibilityThe major argument of individuals in favour of the feasibility of the prescription privileges for psychologists proposal is that training programmes (e.g. the DoD programme) have already successfully graduated several (n = 10) prescribing psychologists. [47,89] However, whether or not a few military psychologists can be trained to prescribe is not the issue, but rather, the extent to which prescription privilege training can be offered and undertaken by psychologists on a national level without seriously compromising the integrity of psychological training. Opponents have consistently argued that the training required to adequately prepare psychologists to prescribe would have a significant impact on the academic structure and teaching of psychology, and therefore would not be feasible without sacrificing both the substance and quality of current clinical psychology programmes. [6,10,12] To prevent this, current training programmes are proposed to be postgraduate programmes, and would only be offered to licensed psychologists with at least 5 years of experience. [44] Although this proposal appears to protect the psychological basis of graduate or pre-doctoral training, these proposals fail to specify who will incur the financial burden of this additional training, which may include costs to students, training sites, internship settings, tax payers, individual clinicians, and consumers. [90]The Louisiana Psychological Association's model curriculum (which includes over 450 hours of didactic coursework and nearly 500 hours of supervised practicum training) amounts to approximately nine courses offered over least three semesters. To put the costs into perspective, Wagner [90] published a report illustrating how 2 years of extra training in psychopharmacology for approximately ten students per programme, per school in Louisiana (n = 2002 students), would end up costing over $US232 million for the university and professional school programmes combined. When a 2-year delay in earning potential for those undergoing training is factored in, this would amount to an additional income (and tax) loss of over $US180 million. Unfortunately, proponents have failed to demonstrate exactly who would bear this financial burden and if there is government support for such an investment. Until these issues are resolved and there is a firm financial commitment on the part of government and/or training facilities, the feasibility of the granting prescription privileges to psychologists remains questionable.Also related to feasibility is the extent to which proponents have successfully enlisted the support of the medical community, who would remain important providers of patient care and, in most cases, be the ones to refer patients to prescribing psychologists. The American Psychiatric Association has repeatedly stated its firm opposition to granting prescription privileges to psychologists, [60,91] and proponents have failed to produce data demonstrating support or willingness to collaborate from non-psychiatrist physicians (e.g. GPs). In fact, one national survey of family physicians in the US revealed that the majority did not favour granting

prescription privileges to psychologists and would not refer patients to these practitioners for psychopharmacological treatment if such privileges were obtained. [77] Until proponents of granting prescription privileges to psychologists can demonstrate that the medical community will be active and willing collaborators, their efforts are unlikely to succeed.8. SafetyProponents assert that with the proper training, psychologists could prescribe both safely and effectively. This is generally accepted. [6,10,86] Evidence emanating from both the DoD and Indian Health Service (HIS) pilot training projects suggests that psychologists have already been trained to prescribe safely. [47,89,92] At least two independent reviews of the DoD programme have suggested that the ten graduates "performed with excellence" [93] and demonstrated "good quality of care". [94] Additional evidence demonstrating the safety of non-physician prescribers comes from at least one study showing comparable prescribing outcomes in both physician and non-physician prescribers. [95] Advocates of granting prescription privileges to psychologists claim that because there is no evidence that non-physician prescribers are less safe than physician prescribers, there is no reason to believe prescribing psychologists would be any different. [92]However, when evaluating the success of the psychopharmacology training programmes, it is important to note that the ten psychologists trained under the DoD programme prescribed under the close supervision of psychiatrists in a military facility. [94] Moreover, a review of the programme by the American College of Neuropharmacology (ACNP) pointed out that psychologists trained under the programme were limited to treating active military personnel between the ages of 18-65 years with 'uncomplicated' cases, and only after the patients had received full medical evaluations. [93] This suggests that the conditions under which the programme was judged to be 'successful' may not be representative of the prescribing conditions under which most psychologists would be legislated to prescribe. It is also noteworthy that when the US Government Accounting Office audited the programme in April 1997, they recommended it be discontinued unless psychologists practiced under psychiatrist supervision. [94] They were also highly critical of the programme, claiming the military health system had "no demonstrated need" for prescribing psychologists, and that the benefits of training psychologists to prescribe had still not been established.Though there is some evidence documenting psychologists' ability to prescribe safely, it is extremely difficult to draw any firm conclusions from so little data. To date, the results of only one American study (the DoD Project) [47] has been published, and we are unaware of any planned trials based in Canada or the UK. Moreover, the sample size (n = 10) upon which conclusions concerning safety have been drawn is extremely small. Clearly, more research is needed before concluding that psychologists are capable of prescribing psychoactive medication safely and effectively, particularly considering the potential risks involved. Some of the major safety concerns put forth by opponents of granting prescription privileges for psychologists include whether psychologists would know enough to be aware of the gaps in their knowledge and the need to refer the patient to an appropriate physician. [62] This may be especially true when dealing with complex drug interactions, where recognising the limits of one's expertise would be crucial to ensure patient health and safety.Of particular concern is the extent to which psychologists can be relied upon to provide evidence-based treatment, when a significant number continue to use unproven or non-empirically validated methods of psychotherapy. [6,64] If psychologists were granted prescription privileges, they would be obliged to follow the strict prescription guidelines

mandatory for all prescribing professions. The fact that so many psychologists continue to dismiss empirically based psychological methods as superficial, inflexible, simplistic and irrelevant [96] is indeed troubling. Resolving this issue seems to be a more pressing matter for clinical psychology than the pursuit of prescription privileges.9. Cost EffectivenessProponents of prescription privileges for psychologists have argued that granting psychologists prescriptive authority would provide greater continuity of care, which would be less disruptive and more cost effective than having to consult multiple professionals. Advocates argue that under the current system, patients may be forced into 'divided loyalties' when treatment providers do not agree about how to direct patient care. [57,58,66] The result is inefficient treatment dissemination and, ultimately, diminished treatment efficacy. Proponents add that granting prescriptive authority to psychologists would also result in decreased healthcare costs because psychologists charge an average of 14% less than do psychiatrists for the same service, and because patients would be able to meet all their mental health needs in a single visit (to a psychologist). [95] As such, proponents believe granting prescription privileges for psychologists would facilitate both treatment and recovery at a lower cost.The vast majority of psychologists conducting psychotherapy do not practice in the same office, or in close proximity to, the physicians who provide medications.[97] Effective communication and collaboration between providers can be a major challenge with this type of arrangement, but this does not preclude it from being the appropriate mode of mental healthcare delivery. Even if psychologists were granted prescription privileges, their limited prescriptive authority would require them to refer patients back to their primary physician for treatment of any co-morbid medical conditions (which affect approximately 50% of patients with mental illness). [5] The same would be true for the treatment of many of the adverse effects of psychoactive medication (e.g. nausea, constipation, sexual dysfunction, abnormal heart rhythms, orthostatic hypotension and hypertension). [98] For example, a male patient taking paroxetine may request a prescription for sildenafil for the treatment of sexual dysfunction, which would fall outside the prescriptive authority of the psychologist and require referral to a physician. Finally, a closer look at the current prescription privilege legislation in Louisiana reveals a major weakness in the continuity of care argument. According to the Louisiana House Bill 1426, psychologists with prescription privileges are mandated to collaborate with physicians on all matters related to prescribing. [99] Specifically, the law states that medical psychologists are "required to work collaboratively with the patient's physician when prescribing medication". This condition appears to fly in the face of the continuity of care argument, as even prescribing psychologists are required to do what they have effectively been doing for years: collaborating with the patient's physician on matters related to medication.The assertion that granting prescription privileges to psychologists would be more cost effective than current prescribing practices appears unsupported by the current literature. First, proponents have not provided evidence that psychologists would do a better or more cost-effective job of prescribing psychoactive medication than their physician-counterparts (although without psychologists being granted some degree of prescription privileges, it would be impossible to conduct such trials). Secondly, the costs of training psychologists to prescribe are likely to be great. For example, the actual cost of training the ten psychologists to prescribe under the DoD programme totaled $US6 million. [5,94] As previously mentioned, the costs of training in psychopharmacology alone were estimated to reach over $US232 million for just 2 years of extra training. [90] These estimates do not include the costs of delayed earnings, licensure, and

professional liability insurance. For example, it was estimated that a licensure increase of only $US50 would cost the 40 000 American licensed psychologists $US2 million. Similarly, if prescribing psychologists paid the same for liability insurance as psychiatrists, psychologists in California would experience a premium increase of over $US10 000 per year. [90] These added costs for training, licensure, insurance, and delayed earnings would likely encourage psychologists to increase their fees, which would ultimately result in greater costs to consumers and/or third-party payers.Another consideration regarding the cost-effectiveness argument is the myth that drug treatment is more effective and less expensive than psychotherapy. A recent cost analysis of the relative costs of cognitive behavioral therapy versus medication for the treatment of depression determined that the costs of cognitive behavioural therapy alone were significantly lower than for medication alone or combination therapy ($US6809 vs $US12 737 and $US14 572, respectively).[100] This analysis considered all costs related to third-party payments, provider charges and medication costs. More importantly, there is evidence to suggest that many psychological interventions, particularly cognitive behavioural therapy, are at least as effective as medication for the treatment of both mood [101-103] and anxiety disorders, [104] and that the effects of cognitive behavioural therapy are more likely to be maintained over the long-term. [105,106] This suggests that for certain disorders, not only are psychological interventions less expensive, but that they may also be more effective (and longer lasting) than medications. This begs the question: why the push for prescription privileges for psychologists?10. Conclusions and Future DirectionsThe debate about whether psychologists should be granted prescription privileges is still in its infancy, particularly outside North America. However, there does not appear to be compelling evidence of the desirability of granting prescription privileges for psychologists. Pilot projects relating to the feasibility, safety, and cost effectiveness of prescription privileges for psychologists are either sparse or unavailable. Although proponents present several compelling arguments in favour of granting prescription privileges for psychologists, more research is needed before we can conclude that prescription privileges for psychologists are a safe and logical solution to the problems affecting the mental healthcare system.In the meantime, psychologists should concentrate their efforts on improving both the professional and public dissemination of the services they already provide. In particular, they could work on improving collaboration with GPs and psychiatrists to ensure that medicated patients are properly monitored and advised of available psychotherapy options. Psychologists need not go beyond the boundaries of psychological practice to expand into new treatment areas. There have already been important advances in the areas of health psychology and behavioural medicine, where psychologists have demonstrated success in improving treatment adherence, health behaviours and disease outcome in cancer patients, [107-109] obese patients, [110] coronary artery disease patients [111,112] and patients with HIV. [113] Expanding the quality and scope of these interventions may represent a more desirable, feasible, safe and cost-effective goal than the pursuit of prescription privileges at this time.AcknowledgementsThe authors acknowledge the support of their work by the Canadian Institutes of Health Research (CIHR) and the Auger Research Foundation at Hopital du Sacre-Coeur de Montreal. The authors have no conflicts of interest that are directly relevant to the content of this review.References

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[106.] Evans MS, Hollon SD, DeRubeis RJ, et al. Differential relapse following cognitive therapy and pharmacotherapy for depression. Arch Gen Psychiatry 1992 Oct; 49 (10): 802-8[107.] Anderson BL. Biobehavioral outcomes following psychological interventions for cancer patients. J Consult Clin Psychol 2002; 70 (3): 590-610[108.] Fawzy FI, Kemeney ME, Fawzy NW, et al. A structured psychiatric intervention for cancer patients. Arch Gen Psychiatry 1990; 47: 729-35[109.] Halley FM. Self-regulation of the immune system through biobehavioural strategies. Biofeedback Self Regul 1999; 16: 55-73[110.] Berkowitz RI, Wadden T, Tershakovec AM, et al. Behavior therapy and sibutramine for the treatment of adolescent obesity: a randomized controlled trial. JAMA 2003 Apr 9; 289 (14): 1805-12[111.] Linden W, Stossel C, Maurice J. Psychosocial interventions for patients with coronary artery disease: a meta-analysis. Arch Intern Med 1996; 156: 745-52[112.] Guiry E, Conroy RM, Hickey N, et al. Psychological response to an acute coronary event and its effect on subsequent rehabilitation and lifestyle change. Clin Cardiol 1987; 10: 256-60[113.] Kelly JA, Kalichman SC. Behavioral research in HIV/AIDS primary and secondary prevention: recent advances and future directions. J Consult Clin Psychol 2002; 70 (3): 626-39Correspondence and offprints: Dr Kim L. Lavoie, Division of Chest Medicine, Research Center, Hopital du Sacre-Coeur de Montreal, 5400 Gouin W, Montreal, Quebec H4J 1C5, Canada. E-mail: kiml_lavoie@yahoo.caKim L. Lavoie (1,2,3) and Silvana Barone (1,3)(1) Division of Chest Medicine, Research Center, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada(2) Department of Psychology, University of Quebec at Montreal (UQAM), Montreal, Quebec, Canada(3) Department of Psychology, McGill University, Montreal, Quebec, Canada

Table I. Summary of professions with various degrees of prescriptiveauthority in the US, Canada and the UK Health professional US independent unlimited limited Physician Yes Yes No Dentist Yes No Yes Physician assistant No No Yes (a) Pharmacist No No Yes (c) Nurse/nurse practitioner Yes (d) No Yes Health visitor NA NA NA Nurse midwife No No No Optometrist No No Yes Podiatrist/chiropodist No No Yes

Physiotherapist No No No Radiographer No No No Psychologist No No Yes (f) ================================== Health professional Canada independent unlimited limited Physician Yes Yes No Dentist Yes Yes No Physician assistant No No Yes Pharmacist No No No Nurse/nurse practitioner No No No Health visitor NA NA NA Nurse midwife No No No Optometrist No No No Podiatrist/chiropodist No No Yes (e) Physiotherapist No No No Radiographer No No No Psychologist No No No Health professional UK independent unlimited limited Physician Yes Yes Yes Dentist Yes Yes Yes Physician assistant NA (b) NA (b) NA (b) Pharmacist No No Yes Nurse/nurse practitioner No No Yes Health visitor No No Yes Nurse midwife No No Yes Optometrist No No Yes Podiatrist/chiropodist No No Yes Physiotherapist No No Yes

Radiographer No No Yes Psychologist No No No (a) In 40 US states. (b) Physician assistants do not exist in the UK. (c) In eight US states. (d) In 26 US states. (e) In Alberta, Canada only." (f) In the US military, New Mexico and Louisiana only." NA = not applicable. Table II. Summary of major milestones achieved by advocates ofprescription privileges for psychologists in the US [44-53] Date EventNov-84 US Senator Daniel K Inouye (Hawaii) calls for psychologists to seek prescriptive authority to help improve availability of quality mental healthcare 1985 Hawaii State Legislature considers legislation to study the issue of prescription privileges for psychologists 1989 Congress orders DoD to develop pilot training programme in psychopharmacology (training began in 1991) 1990 APA approves the establishment of ad hoc Task Force on Psychopharmacology to study the desirability and feasibility of granting prescription privileges to psychologists 1992 Task Force issues report concluding psychologists could be properly trained to prescribe 1994 DoD training programme graduates its first two prescribing psychologists 1995 APA formally announces endorsement of pursuing prescription privileges for psychologists 1996 APA Council of Representatives formally adopts model prescription bill and training curriculum 1997 APAGS formally announces endorsement of pursuing prescription privileges for psychologists; authorises College of Professional Psychology to develop suitable psychopharmacology exam to be used by state licensing boards 1998 Legislation regarding prescription privileges for psychologists about to be introduced or pending in seven

states (California, Florida, Georgia, Hawaii, Louisiana, Missouri, Tennessee) 1999 US Territory of Guam approves legislation allowing psychologists to prescribe in collaboration with physicians Mar-02 New Mexico becomes the first state authorising properly trained psychologists to prescribe May-04 Louisiana becomes the second state authorising properly trained psychologists to prescribe APA = American Psychological Association; APAGS = AmericanPsychological Association of Graduate Students; DoD = Department of

Defense.Gale Document Number:A199865934

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