A few weeks ago, while tuned in to NPR News during my car ride, a brief segment caught my attention: Utah had passed legislation enabling prescriptive authority for psychologists. This news was unexpected to me; I knew only a handful of states allowed such prescribing privileges, and I wasn't aware Utah was considering such legislation.
During my early days in graduate school, I held no interest in prescribing medication. Had I been inclined, I might have pursued a career as a psychiatrist. However, as I've delved deeper into my role as a psychologist over the years, I've recognized how valuable it would be to not only provide therapy but to also be able to prescribe medication for clients in my private practice. Often, my clients confide that they aren't telling their prescriber about side effects or a lack of symptom relief from their medications. In such circumstances, I find myself coaching my clients on the importance to communicate openly and honestly with their Primary Care Provider (PCP) or psychiatric provider regarding their symptoms and any side effects, ensuring optimal medication adjustments.
Following that car ride, I wanted to better understand Utah's new law for "prescribing psychologists". The prospect excited me; I saw how it could elevate my professional capabilities, greatly benefit my clients, and possibly even be financially rewarding.
However, information was scarce. I stumbled upon an article by the CATO Institute published in early March, shedding light on prescriptive psychologists' roles in providing medication management alongside therapy within the Military Health System since 1999. According to the article, Utah's law S.B. 26 aims to address the state's mental health crisis, easing access to essential medication management for individuals with mental health diagnoses. I've encountered firsthand the struggles faced by clients in accessing such care, despite my efforts to guide them through the process. At times my clients ask me to contact their doctors' offices' directly to communicate with them about symptoms or other concerns. Initiating direct communication with my clients' doctors' offices has usually led to no response or a significantly delayed response. The collaborative approach to mental health care, while ideal, has proven challenging in practice. Even my spouse Janica, a Nurse Practitioner (NP), attests to the difficulties in engaging patients' primary care physicians in collaborative care efforts.
Becoming a Utah Prescribing Psychologist (S.B. 26)
Requirements to Become a Prescribing Psychologist in Utah
Given that I couldn't find much information about how to become a prescribing psychologist in Utah, I read all of S.B. 26 multiple times. Here is a summary of requirements to become a prescribing psychologist:
Hold an active psychologist license in Utah
Earn a two-year post-doctoral master's degree in Clinical Psychopharmacology
Accumulate 2 years or 4,000 hours of supervision
Pass a Psychopharmacology Exam
On the surface, these requirements seem reasonable for developing competence in prescribing psychotropic medication.
In essence, pursuing this path would entail an additional four years of training and financial investment post my Ph.D. I believe that I could manage to continue working as a psychologist in addition to the educational requirement of a two-year Clinical Psychopharmacology master's degree and compensating a supervisor for the required two years of supervision. Financially, this might be feasible.
So let's see what this would allow me to do...
Privileges a Utah Prescribing Psychologist 'Enjoys'
Under S.B. 26, after four more years of specialized training in prescribing psychotropic medications, including understanding crucial aspects like drug interactions, psychotropic drug classes, side effects, pathophysiology, anatomy, genetic factors, and much more, I would gain:
The privilege to only prescribe SSRIs - a first-line antidepressant.
There's a provision in S.B. 26 that could expand the medication list in the future, but as of now, this is the extent of prescriptive authority.
The privilege of establishing and maintaining a collaborative agreement/relationship with every single on of my clients' "healthcare provider[s] currently overseeing the patient's general medical care" to prescribe an SSRI.
For the sake of simplicity, I'm going to refer to such a "healthcare provider" as a PCP in this article, even though there is slightly more nuance to the "healthcare provider" definition.
Practically, that would mean establishing between 10 to well over 60 collaborative relationships where I am required to keep each PCP up to date on every prescriptive move I make.
The Impracticalities of S.B. 26 for Psychologists
The Impracticality of Only Prescribing SSRIs
So... four more years of training to prescribe SSRIs. SSRIs, or selective serotonin reuptake inhibitors, are primarily used to treat anxiety and depression. If my client doesn't respond well to SSRIs, I wouldn't have the option to switch them to an SNRI (serotonin-norepinephrine reuptake inhibitor). Not to mention, I wouldn't be able to offer medications like anxiolytics or benzodiazepines for panic attacks, or mood stabilizers for bipolar disorder.
Given that I could only prescribe an SSRI, most of my clients would probably benefit more from establishing a direct relationship with their Primary Care Provider (PCP) for medication management. PCPs have the flexibility to adjust medications and classes as needed. Additionally, clients must already have an established relationship with their PCP for a prescribing psychologist to be authorized to prescribe an SSRI to them. Sadly, many PCPs have not undergone intensive training specific to diagnosing mental health disorders, or training specific to psychotropic medications. PCPs might disagree with me on this, but all too often I see clients who have been misdiagnosed by their PCPs. The training a psychologist goes through in this area is far and beyond that of a general practitioner. I hope we could at least agree on that last statement. Still, S.B. 26 assumes that PCPs are better suited to prescribe psychotropic medication based on diagnostic findings compared to prescribing psychologists, who have extensive specialized training in mental health diagnoses and specialized training in prescribing psychotropic medications.
The Impracticality of Needing a Collaborative Relationship With Each Client's PCP
Now, let's talk about the collaborative relationship with a PCP. Assuming I only prescribe medication to 15 clients, I'd have to collaborate with 15 different PCPs just for SSRIs. Collaborating with 15 PCPs for 15 clients, especially when many clients don't even have an established PCP who "currently [oversees] their general medical care", seems impractical and exhausting.
Additionally, what incentive do PCPs have to work with me? They can handle medication management independently. If they do request a collaborative fee in order to make it worth their time, what advantage does medication management offer me or my clients after four more years of training?
My experience, along with my spouse's, who is an NP, highlights how challenging it is to collaborate effectively with PCPs. Communication gaps are common, as is a complete absence of communication or return calls, making the process cumbersome.
If the goal is to ensure quality care if I was a prescribing psychologists, why not require me to establish a collaborative agreement with one psychiatrist or psychiatric nurse practitioner to oversee my work, similar to how physician assistants operate in Utah? Physician assistants must, after completing their master's degree, enter into a collaborative agreement with a licensed physician for 10,000 hours, after which they can practice independently.
S.B. 26 Assumptions
Honestly, the wording of S.B. 26 feels like an affront to my intellect and ethical standards as a psychologist. Does it assume I would haphazardly prescribe medications without considering my own competency or my client's well-being? Is four more years of training necessary to prescribe only SSRIs and constantly collaborate with every single client's PCP? If I ever feel uncertain, I always consult, collaborate, and refer to specialists who are better equipped. That's standard practice for me, and standard practice for the whole healthcare industry. If I lack the expertise, I refer out.
I genuinely question the underlying assumptions in S.B. 26 that family physicians, family nurse practitioners, and physician assistants (note: NPs and PAs typically hold master's degrees) are more qualified to prescribe psychotropic medications for mental health than a doctoral-level psychologist with a master's in Clinical Psychopharmacology. My spouse, a Nurse Practitioner, didn't receive sufficient training in mental health diagnoses and psychotropic medications, yet legally, she can prescribe them all (emphasis on 'can'. She generally doesn't prescribe psychotropic medications). She would agree that I would be better suited in this realm than she is.
In all fairness, caution is warranted regarding granting prescriptive authority to psychologists. Scientific evidence regarding how prescribing psychologists compare to other professions remains unclear. Additionally, educational and experience requirements vary widely across states (Robiner, Tompkins, & Hathaway, 2020), making it difficult to evaluate the efficacy and safety of prescribing practices among psychologists. However, there is also evidence indicating that expanding psychologists' prescriptive authority at the state level has had a positive impact on reducing suicide rates (Choudhury & Plemmons, 2021). Additionally, NPR News reported that malpractice lawsuits between psychiatrists and prescribing psychologists are practically indistinguishable, but I haven't found independent data to confirm this statement. So yes, caution is warranted, but the caution and underlying assumptions in S.B. 26 are definitely missing the mark.
The Example of Iowa
Considering Iowa's case, I doubt many psychologists will pursue prescriptive privileges in Utah. Iowa allowed prescriptive psychologists in 2013, granting them authority over psychotropic medications beyond SSRIs (i.e. significantly more prescriptive freedom for psychologists than in Utah). Collaborative relationships with clients' PCPs are required similarly to what Utah requires. Educational standards are comparable to Utah's, with Iowa having clearer defined supervision requirements, which I find reasonable.
How many psychologists do you think embraced prescriptive authority in Iowa to aid their mental health crisis? By the end of 2023, Dr. Scott Young became Iowa's fourth conditional prescribing psychologist. That's four psychologists in a decade, despite Iowa offering more benefits than Utah's law.
Therefore, I doubt S.B. 26 will significantly help Utah address its mental health challenges as intended.
Conclusion
Had S.B. 26 'only' demanded appropriate educational requirements, and required supervision or collaboration with one psychiatrist (instead of collaborating with every client's PCP), I would have eagerly pursued becoming a prescribing psychologist in Utah. I even researched and read through all six masters in clinical psychopharmacology programs available to date. However, the prospect of investing in such extensive education only to prescribe SSRIs and coordinate with PCPs for every client's medication feels daunting and impractical.
If psychologists are intended to limit their scope to prescribing SSRIs and collaborating with PCPs, which has its arguments, the educational standards for Utah prescribing psychologists must be significantly streamlined and simplified to incentivize psychologists to take this path.
In my view, S.B. 26 is unlikely to meaningfully address psychotropic medication accessibility.
Thoughts/Ideas?
If you have insights or thoughts on this matter, please reach out. I value diverse perspectives and learning from others' experiences, especially if you're a prescribing psychologist navigating client-PCP collaborations. How do you manage this? Is it worthwhile? I'm eager to hear from those with more experience or alternative viewpoints.
You can contact me by calling/texting (385) 200-0204 or emailing dominic@truupsychology.com
