Proponents of SB 694 argue that the doctoral-level training undertaken by psychologists qualifies them to deal with mental illness more so than most physicians. They cite a California Supreme Court ruling that psychologists are fully qualified primary care providers with respect to patients with mental illness. Sponsors say that the additional pharmacological training provided for in this bill, coupled with the current level of education and training required for licensure, provides assurance of quality care and consumer/patient protection.
Polanco concurred: "More than 75% of mental health prescriptions are written by general practitioners who have limited training in treating mental illness. It makes good sense to set up a system in which psychologists who meet additional educational requirements would be given the authority to prescribe medication."
Opponents contend that the training provided for in the bill is inadequate. Many feel that as time brings new and significantly more powerful drugs for the treatment of mental disorders to the market, the arguments against psychologists prescribing will increase.
The opposition cites the California Medical Association and the California Psychological Association's six-year demonstration program of the U.S. Department of Defense, wherein psychologists undertook three years of pharmacological training and supervised experience.
In evaluating the program, the General Accounting Office (GAO) noted that "all of the...graduates continue to practice under the supervision of a psychiatrist, and whether they will ever prescribe independently is unclear...We see no reason to reinstate this demonstration project."Public Policy Advocacy
The American Psychiatric Association's public policy regarding the issue is posted on its Web site, and quotes the 1995 testimony of James H. Scully Jr., M.D., the APA's deputy medical director for education. The testimony took place before the Subcommittee on Creation or Expansion of Scope of Practice, Senate Committee on Business and Professions, State of California on California SB 777-Psychologists/ Prescribing Privileges in 1995.
Speaking on psychologists' "adequacy of training," Scully said: "In seeking prescription privileges, psychologists frequently claim that they have 'more advanced training...in the treatment of mental and emotional disorders' than any other health professional. Of course, psychologists making this claim do not count medical school as part of a psychiatrist's training. This is a basic gross misunderstanding. Please understand that to be a psychiatrist, medical school is core, essential, critical."
He continued, "The study of psychology, an academic discipline, focuses on human behavior, not on medical and health sciences or human illness. A substantial portion of a psychologist's training is in statistics, research methodology and experimental psychology. As a physician, a psychiatrist's training begins with basic sciences...in undergraduate studies. This becomes the foundation for learning the health sciences...in medical school, which in turn provides the knowledge and clinical base for a four-year supervised residency to learn, for example, to diagnose illness, order and interpret medical and psychological tests, determine appropriate treatments, including pharmacological treatments, and evaluate and deal with side effects. This physician training occurs primarily in a hospital, where the psychiatrist is regularly caring for seriously ill patients."Lingering Doubts
Another question that continues to haunt the bill's opponents is "Wouldn't it be better just to upgrade general practitioners?"
From his testimony, Scully had this to say: "It is critical to note that more people with a mental illness who seek treatment (43%) get their care from their primary care physicians-not from psychologists, or psychiatrists or any mental health professional. Interestingly, this even includes serious mentally ill patients.
"Only around 40% of all people with mental illness who receive treatment get it from mental health professionals. This is National Institute of Mental Health data. There is some fascinating logic in psychologists' claims that physicians have done such a horrible job in using medication that psychologists are going to fix it all. Prescribing increasingly demands sophisticated, updated skills. Yes, there are problems. But is the solution to train psychologists less thoroughly and let them prescribe? Common sense says no!"
The deputy medical director concluded: "There is a major need for better training for primary care physicians. Patients are going to go to their primary care physicians. In western Europe, where there have been national health programs for many years, the primary care physicians are better trained in psychiatry and are able to handle the simpler cases reasonably well. It will be much more cost-effective to improve psychiatric training for physicians than to train psychologists, medically."
The list of opponents of the bill is long and impressive, including the California Medical Association, California Healthcare Association, Union of American Physicians and Dentists, American Medical Group Association, California Nurses Association, California Association of Ophthalmology, California Academy of Family Physicians, Kaiser Permanente, and the California Alliance for the Mentally Ill, to mention a few.
On a national level, in a recent show of support, the House of Delegates of the American Medical Association unanimously agreed to work closely with local psychiatric societies opposing legislative or ballot initiatives that would authorize psychologists to prescribe.