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A second major argument in favour of PPs relates to the limited
mental health training of general practitioners (GPs) (3,12,22).
A recent survey revealed that, of the 135.8 million prescriptions
issued for psychoactive medications in 1991, psychiatrists issued
only 17% of those prescriptions. The remaining 83% were issued by
GPs who typically receive only 4 to 12 weeks’ training in mental
health (27–29). Mental health training for Canadian physicians
appears consistent with this figure (12). Equally disturbing is
the fact that many patients seen by GPs and other nonpsychiatric
specialists are frequently misdiagnosed and prescribed medication
unnecessarily. Research shows that, in women alone, depression is
misdiagnosed 30% to 50% of the time, and when antidepressants are
prescribed, patients are often improperly monitored (30). Given
these data, proponents of PPs argue that appropriately trained doctoral-level
psychologists would be more qualified to diagnose mental disorders,
prescribe appropriate medication, and monitor the behavioural effects
of such medication than would nonpsychiatrist practitioners (2).
Further, proponents point out that the reason so many GPs prescribe
psychoactive medication is due to the relative unavailability of
psychiatrists. Thus, advocates claim that granting PPs to psychologists
would benefit those who have limited access to psychiatrists (11,31).
Similarly, it is argued that PPs will enable psychologists to provide
needed mental health services to underserved segments of society,
such as minority children, those living in rural areas, and those
living in chronic care facilities (11,31,32).
Advocates for PPs argue that, because many patients receiving psychotherapy
will consult a psychiatrist for pharmacologic treatment, it would
be less disruptive to have 1 treatment provider (a psychologist)
who can both prescribe and conduct therapy. They argue that being
forced to consult 2 professionals with potentially contrasting views
on how to direct patient care could compartmentalize treatment and
force patients into “divided loyalties” (33–35).
The result is inefficient treatment dissemination and, ultimately,
diminished treatment efficacy. Proponents add that granting prescriptive
authority to psychologists would also result in decreased health
care costs; psychologists charge an average of 14% less than do
psychiatrists for the same service (36). Therefore, proponents believe
PPs for psychologists would facilitate both treatment and recovery
at a lower cost.
A final point argued extensively in the literature is that medications
can influence behaviour. In fact, this is a major target of psychological
research and practice; for this reason, prescribing medications
should become part of the practice of psychology (11,13,22).
Although proponents have presented several compelling arguments
in support of granting PPs to psychologists, their arguments suffer
from several important weaknesses. First, the argument that PPs
would help psychologists gain professional autonomy by expanding
their scope of practice into settings traditionally dominated by
physicians has little empirical basis. This argument assumes that
PPs will lead to 1) the cessation or reduction of physician control
over inpatient services and 2) a dramatic increase in the number
and type of clients psychologists can treat. It is unlikely, however,
that PPs will impact which profession controls inpatient services.
In short, control and, ultimately, responsibility of inpatient services
is a public policy issue that is totally independent of the prescription
privilege issue. Finally, physicians have been opposed to hospital
privileges and any related pursuits thought to encroach on what
they have considered to be their turf for years (10,37). Any endeavour
that threatens to reduce their power over inpatient and hospital
services will likely be met with a fight. To automatically equate
PPs with physician-like control over mental health services is therefore
perhaps overly optimistic.
Second, although there is some evidence demonstrating psychologists’
competence to prescribe, the quality of that competence appears
to vary according to the source of the report. For example, DeLeon,
Folen, and others (24) reported that no quality of care problems
were revealed following the Defence Department’s PDP and concluded
that psychologists could be trained as competent prescribers. Conversely,
the American Psychiatric Association’s Legislative Newsletter
(12) reported that the doctoral-level psychologists who participated
in the PDP received grades in conventional medical and pharmacological
courses that ranged from C– to F. These grades likely reflect
the psychologists’ lack of training in basic sciences (for
example, molecular biology, organic chemistry, and physiology),
which currently are not required for admission to psychology graduate
programs. A notable difference between psychologists and the nonphysician
professions with limited PPs is that they all have a solid biological
science background, which most psychology graduate programs do not
provide (38). In fact, a recent survey of graduate students revealed
that only 7% had completed the minimum number of undergraduate science
prerequisites necessary to undertake psychopharmacology training,
as stipulated in proposed training models (39). Further, surveys
of graduate training directors revealed that 62% to 75% preferred
not to train psychology students to prescribe at the doctoral level,
stating that it would interfere significantly with current programs
(40,41). As a result, currently most doctoral students and psychology
training programs in the US and Canada are ill-prepared or unwilling
to pursue psychopharmacological psychology as a subspecialty.
Some evidence documents psychologists’ competence to prescribe,
but it is difficult to generalize from so few data. To date, the
literature has published the results of 2 American projects (the
PDP and IHS) (25,26), and we are unaware of any published trials
emanating from Canada. Besides, the sample sizes (n = 4 and
n = 1, respectively), upon which conclusions concerning competence
have been drawn, have been small. Clearly, we need more evidence
before concluding that psychologists are capable of prescribing
psychoactive medication safely and effectively.
The argument that focuses on the limited mental health training
of GPs, although convincing, disregards the extensive medical and
pharmacologic training of these physicians, which is a minimum of
4 to 6 years. Further, given that GPs are the front-line service
providers under the current system, it is unlikely that PPs for
psychologists would significantly alter health care—seeking
behaviour or the number of prescriptions written by GPs, unless
GPs decide to refer their patients to psychologists for pharmacologic
treatment. Rather than adding psychologists to the long list of
professionals who can already prescribe, a more constructive solution
would be to provide greater mental health training for front-line
service providers and to promote greater collaboration between GPs
and psychologists.
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Psychologists with PPs could help respond to the mental health
care needs of underserved segments of the population (those living
in rural or regional areas); however, the profession of physician
assistant was created to serve such populations, but only 3% actually
do (42). Advocates have not yet produced data indicating the number
of psychologists seeking PPs for this purpose or the number of psychologists
who would relocate to provide services to a rural population.
Advocates for PPs have argued that having a psychologist who can
both conduct psychotherapy and prescribe would be less disruptive
and more effective than consulting both a psychologist and a psychiatrist
with “potentially contrasting views.” However, this argument
assumes that psychologists would be more qualified than would psychiatrists
to fulfill this dual role. If proponents are arguing a lack of collaboration
between psychologists and psychiatrists, the solution appears to
be improving collaboration (for the benefit of the patient) and
not restructuring the practice of psychology.
The assertion that PPs for psychologists would result in lower
mental health care costs is unlikely, given that psychologists would
be in a position (and would likely be highly motivated) to raise
their fees to reflect their new skills. This assertion is even more
unlikely if you consider how insurance premium costs for psychologists
would likely increase in line with their new responsibilities and
potential liabilities. Interestingly, proponents of PPs discuss
these issues rarely.
Proponents assert that because medications influence behaviour,
prescribing medications should become part of psychological practice
(11,13,22). Subscribing to this argument, however, implies that
psychologists should be able to adopt any physical intervention
that could affect behaviour or psychological functioning, including
neurosurgery or electroconvulsive therapy. The boundaries that the
different mental health professions place on their scope of practice
are what define each profession, and these boundaries promote competency
and quality of care among treatment providers.
Rarely discussed among advocates of PPs is the enormous responsibility
associated with having prescriptive authority, even if that authority
is limited to psychoactive medication. One common problem associated
with taking psychoactive medication is that many patients experience
unpleasant and sometimes severe side effects, which often require
appropriate medical treatment (for example, nausea, constipation,
sexual dysfunction, abnormal heart rhythms, orthostatic hypotension,
and hypertension) (43). Psychologists, of course, would be limited
to prescribing psychoactive medication and thus forced to refer
their patient to a physician for treatment of side effects. In addition,
there is the issue of potentially dangerous drug interactions, knowledge
of which is crucial for patient health and safety. In other words,
psychologists pursing PPs would require extensive knowledge of drug
interactions involving the entire pharmacologic spectrum, which
has never been the domain of psychology.
Also, rarely discussed in the literature is the potential for self-prescription
among psychologists. Given the disproportionally high rate of suicide
resulting from self-prescription overdoses among health professionals
(for example, dentists and physicians) (44–46), this issue
warrants further debate before we open the door to thousands of
additional prescribers.
One of the most fundamental and often ignored issues with respect
to PPs is the profound effect on the definition and future direction
of professional psychology and psychiatry. Psychology has historically
been identified with treatments based on psychological principles
(47). The Psychology Profession Act of Canada (48) specifically
defines the practice of psychology as “the application of professional
psychological knowledge for the purpose of diagnosing, preventing,
remedying or ameliorating human mental, emotional, behavioural,
or relationship difficulties and to enhance human performance and
mental or physical health.” According to this definition, psychology’s
principal activities involve psychological and behavioural interventions
based on psychological knowledge, not psychiatric or pharmacologic
knowledge; thus, prescribing psychoactive medication clearly falls
outside the boundaries of what has been considered psychological
practice.
If psychologists were permitted to add medication to the list of
interventions they currently use, the underlying rationale and organizing
principles of both psychology and psychiatry would be fundamentally
altered. Psychiatry is a medical discipline, focusing on the diagnosis
and treatment of mental disease; psychology was originally conceived
as an academic discipline. Only later did it evolve to include psychological,
cognitive, and behavioural approaches to both evaluating and treating
mental illness. Psychology, however, has grown to develop innovative
and effective treatments for several mental disorders, which should
remain distinct from psychiatric approaches.
The debate on whether psychologists should be granted PPs is still
in its infancy. Pilot projects relating to feasibility and efficacy
are either sparse or incomplete. Although proponents present several
compelling arguments in favour of PPs for psychologists, it is too
soon to tell whether PPs could or should be pursued. What is clear
is that this debate will have a profound impact on both professional
psychology and psychiatry—but one that is likely to take years
to unfold.
In the meantime, psychologists could concentrate their efforts
on improving both the professional and public dissemination of the
services they already provide. For example, 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, wherein psychologists have demonstrated success in improving
treatment adherence and disease outcome in cancer patients (49–51),
coronary artery disease patients (52,53), and HIV sufferers (54,55),
all using psychological interventions. Expanding the quality and
scope of existing psychological therapies, rather than expanding
services to include PPs, may represent more promising and appropriate
goals for psychology at the present time.
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