Psychologists see rural areas as entry point to prescribing

But psychiatrists believe primary care physicians are the ones to fill the void, as shown in the controversies in New Mexico and Nebraska.

By Andis Robeznieks, amednews staff. Dec. 2, 2002.

With less than a dozen psychiatrists to serve the rural communities in the western part of the state, officials with both the Nebraska Medical Assn. and Nebraska Psychiatric Society acknowledge that the state is in the midst of a mental health crisis -- in both rural and urban areas.

But they don't think that allowing psychologists to have prescribing authority is the way to solve the problem. Members of a subcommittee of the state's Rural Health Advisory Commission have tossed the idea around in brainstorming sessions.

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In a recent letter to commission member Todd Stuckey, MD, the presidents of the Nebraska Medical Assn. and Nebraska Psychiatric Society, Michelle B. Petersen, MD, and Janet McGivern, MD, argued that there are better ways to achieve the laudable goals of improving mental health care for the state's rural citizens.

"What the commission decides to do is up to them, but we strongly hope they would move in the direction of changing the psychiatric treatment paradigm," said Dr. McGivern, who has a private psychiatry practice in Omaha.

"Rather than being the sole providers of psychiatric care," she said, she envisions psychiatrists becoming consultants and evaluators working in collaboration with primary care physicians.

So far, only one state allows psychologists prescribing rights -- New Mexico. The issue has been brewing in several other states, and those on both sides of the issue are watching the Nebraska debate closely. Both sides hope to learn what will and will not work for them, as the battle there replicates across the country, especially in other states with significant rural populations.

In Nebraska, primary care physicians provide 60% of treatment for patients with mental illness.

In their letter, Drs. McGivern and Petersen state that primary care physicians already provide about 60% of the treatment for patients with mental illness. And while difficulties may arise in complex illnesses such as schizophrenia and bipolar disorder, they say most of them are adept at treating more common problems such as anxiety and depression.

To improve collaboration and communication, Dr. McGivern is proposing weekly psychiatric training Webcasts that would be interactive and allow participating physicians to type in questions for the instructor.

"I have MDs who are already volunteering to teach it, so that wouldn't be a factor," Dr. McGivern said. "The difficulty may be in getting funding to do the Webcast. We've talked to one Webcaster in Nebraska, and $2,500 per session is the fee he's quoting, but he said it's negotiable."

Dr. McGivern said psychologists' role in this equation should be "playing to their strengths," which she defined as therapy, testing and the ability to spend more time with patients.

National groups already weighing in

Dr. McGivern said patient safety is her primary concern because psychologists do not have the medical training that psychiatrists receive.

But in the current newsletter of the Assn. for the Advancement of Psychology, the group's executive director, Stephen M. Pfeiffer, PhD, called the patient safety argument a "feeble, one-note defense tactic." His words illustrate how nasty the debate could get when national players take the field.

"Psychiatry sees this as a life-or-death matter," Dr. Pfeiffer said. "If psychologists with appropriate training [get prescriptive authority], I would guess that psychiatrists would be of even less importance in the medical firmament."

Dr. Pfeiffer said psychiatrists should recognize that psychologists can help close the mental health gaps that occur in rural communities.

"If we're really talking about helping patients, we shouldn't be putting up these obstacles," he said.

John Blamphin, spokesperson for the American Psychiatric Assn., said he didn't think that national psychologist groups were as interested in helping rural communities as they say, and he is not impressed by any prescribing-training programs he's seen proposed for psychologists.

"That's just a Trojan Horse argument to get their foot in the door," he said. "It sounds great: 400 hours of classroom work. But that's probably just one semester of medical school, and one semester of medical school does not a doctor make."

In New Mexico, the law allowing psychologists to prescribe medicine took effect July 1. It was approved by state legislators swayed largely by the argument that it would make mental health treatment more available to residents in underserved, rural communities. But final details of the actual training program were left in the hands of the medical and psychology boards. Negotiations have been taking place since last summer on those provisions.

"The Legislature spoke. They said, 'Go forth and do this,' " said Charlotte Kinney, executive director of the New Mexico State Board of Medical Examiners. "They feel strongly that this should have been done yesterday, very strongly."

The negotiating committee was expected to present its final recommendations at a joint meeting of both boards Nov. 22, and each board had to give its approval before the program could go forward.

"I think the committee believes it will have a proposal that will make both boards -- and the Legislature -- happy," Kinney said. All outstanding issues are expected to be resolved by December 2003.

Back in Nebraska

The subcommittee of Nebraska's Rural Health Advisory Commission that opened the can of worms over prescribing rights will discuss the issue again Dec. 16.

"The subcommittee has chosen mental health as the top priority to work on this year," said commission member Dr. Stuckey. "One of the brainstorm suggestions that has been brought up is: Would psychologist prescription authority help this process? It is extremely controversial, and it has not been decided whether the Rural Health Advisory Commission will support it or not."

Dr. Stuckey, a family physician from York, a town of 8,000 people about 50 miles west of Lincoln, said the committee would look at the issue when it meets Dec. 16.

"We're looking at the whole gamut, and prescription authority is just one option that's been brought up," he said. "Eventually, the hope is this subcommittee will make some recommendations, take them to the Rural Health Advisory Commission, and the Rural Health Advisory Commission will take them to the Legislature."

Dr. Stuckey said he recognized that a controversy was brewing, and he hopes the national issues don't overwhelm the local questions that need answering.

"The unfortunate thing is, when they start talking about psychologists prescribing, we sort of lose focus on our initial goal," he said. "The problem is people out here have to wait for weeks for help, and they need help now -- if not yesterday."

ADDITIONAL INFORMATION:

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Letter from presidents of the Nebraska Psychiatric Society and Nebraska Medical Assn. to the state's Rural Health Advisory Commission explaining opposition to prescribing authority for psychologists, in pdf (http://www.nebmed.org/news/rural%20health%20psych%20letter.pdf)

Text of New Mexico law, prescriptive authority for psychologists, HB 170 (http://legis.state.nm.us/sessions/02%20regular/bills/house/HB0170.html)

AMA policy H-345.989 opposing the prescribing of medication by psychologists