Imagine the following: Steve, a 35-year-old male who is fully vaccinated, has become so afraid of contracting COVID-19 that he feels panicked in public spaces. He knows he needs the help of a mental health professional, but the nearest primary care doctor is 2 hours away, the closest psychiatrist is 5 hours away, and the LCSW he called has a 6-month waitlist.

Prescribing psychologists—clinicians who are trained to provide talk therapy and prescribe medications—have been working in some states since 1991 and are poised to assist Steve and the other 71.9% of people who need—but cannot get—mental healthcare.

About prescribing psychologists. American Psychological Association. Updated January 2022.

Mental health care professional shortage areas. Kaiser Family Foundation. Updated September 30, 2021.

But expansion of the specialty is only possible if state laws change.

 

 

State requirements

In addition to standard doctorate-level training and licensure, psychologists must undergo between 1,500 and 6,000 hours of supervised training to become licensed to prescribe (these rules vary by state). They also must pass a national exam, and may face an additional jurisprudence exam in some states.

Currently, psychologists can prescribe in Louisiana, New Mexico, Illinois, Iowa, and Idaho, as well as within the Indian Health Service, the VA, and the US Public Health Service. Each state has its own rules. For example:

• Prescribing psychologists in Louisiana must complete a postdoctoral master’s degree in clinical psychopharmacology.

• In New Mexico, prescribing rights are granted after completing 450 hours of didactic instruction and a 400-hour supervised practicum.

• Illinois requires prescribing psychologists to train in psychopharmacology and complete a 14-month full-time prescribing psychology residency, along with 1,620 hours of medical rotations in hospitals, clinics, correctional facilities, and community health clinics.

You can find more requirements here. The point, said David Shearer, PhD, is that prescribing psychologists are up to the task. Dr. Shearer is a prescribing psychologist with 14 years of experience who splits his time between a primary care clinic and the Madigan Army Medical Center in Tacoma, WA.

“We’ve got a history of training that goes back for years, and we continue to fine-tune our training,” Dr. Shearer told MDLinx. “And that’s reflected in our skill level—we have a track record that’s outstanding. This is new to a lot of people, but they don’t recognize that we’ve been doing this for over 25 years. Finally, we’re ready now.

This is not a fantasy or hypothetical about how we can help.

The need for more providers is clear and present.

 

Addressing the provider shortage

Joseph Comaty, PhD, is a prescribing psychologist based in Illinois who has been writing prescriptions since 2005. According to Dr. Comaty, several factors will exacerbate the provider shortage, as discussed in an article published by AAMC:

Weiner S. Addressing the escalating psychiatrist shortage. AAMC. February 12, 2018.

 

• Insufficient numbers of medical students pursuing psychiatry to meet the growing need

• The aging of the physician population

• Fallout from the COVID-19 pandemic

For example, in Pope County, Illinois, there are only two mental healthcare providers to serve the county’s 4,470 people. And in Washington state, there are eight providers to support the 13,000 residents of Pend Oreille County.

Comaty said that prescribing psychologists are well positioned to close the care gaps. But prescribing psychologists also provide patients with another advantage: care continuity. Patients don’t have to bounce from provider to provider to receive the full spectrum of mental healthcare.

“Having psychologists who have the expertise in diagnosis, treatment, psychological testing—to give them prescriptive authority—makes it easier for patients to access care in one place, rather than having to go to a psychiatrist for their meds and then a social worker or a therapist for their therapy,” Dr. Comaty said in an MDLinx interview. “Many times, those two people don’t talk to one another, so the patient is not getting the full benefit of comprehensive care.”

Sometimes, effective prescription management is an exercise in subtraction, not addition. Dr. Comaty said that in many cases, prescribing psychologists deprescribe.

“Prescribing psychologists carefully evaluate the drug regimen of their patients and attempt to remove medications that cannot be determined to be effective, or may be interfering with other medications or causing the patient some adverse consequences,” Dr. Comaty said.

 

Expanding prescriptive power

A 2021 study published in Professional Psychology: Research and Practice surveyed 43 prescribing psychologists across the US about their practices.

Peck KR, McGrath RE, Holbrook BB. Practices of prescribing psychologists: Replication and extension. Professional Psychology: Research and Practice. 2021;52(3):195–201.

Among this group, 97% said they had not faced a malpractice claim. The one respondent who did face a claim said it was settled in their favor.

 

Dr. Shearer was also the lead author of a 2012 study published in the Journal of Clinical Psychology in Medical Settings.

Shearer DS, Harmon SC, Seavey BM, et al. The primary care prescribing psychologist model: medical provider ratings of the safety, impact and utility of prescribing psychology in a primary care setting. J Clin Psychol Med Settings. 2012;19(4):420–429.

At the time, he was working in a family medicine practice and asked about 47 of his MD colleagues to answer a confidential, anonymous survey assessing his competence.

 

Noting that the study design was limited by the physicians’ familiarity with him, he said that his colleagues were overwhelmingly supportive because they were so pressed to write psychiatric prescriptions.

“They’re on the front lines with this,” Dr. Shearer said. “But they can’t be a specialist in absolutely everything. They really appreciate having someone who is a specialist in psychopharmacology on board whom they can refer to.”

 

Legislative obstacles

Creating more partnerships like the one Dr. Shearer described is a matter of changing state legislation. That’s a component of Division 55’s mission. Nested within the American Psychological Association, this division disseminates information about prescribing psychology to legislators and the public.

“[Its] main obstacle is legislative,” Dr. Comaty said.

You still have a very strong, organized medicine block that works to prevent further expansion of scope of psychologists in those states.

The American Psychological Association did not respond to an MDLinx request for comment on the expansion of prescribing psychology.

Ultimately, Dr. Comaty felt prescribing psychology is safe, effective, and convenient for patients. The rest is up to policymakers.

“The one argument that the opposition always brings up is that, in simplest terms, we’re going to kill people,” Dr. Comaty said. “In over 25 years, I don't think there's any evidence that we've done that. In fact, I don't know of any deaths that have resulted from psychologists being able to prescribe to the public. So that argument is tired and should be retired by the opposition.”