RxP Informational letter
WSPA recently convened an informal workgroup to research the topic of prescriptive privileges for psychologists, sometimes referred to as RxP. The information FAQs on this page was provided by the workgroup Chair, David Shearer, Ph.D., M.S., who is a prescribing psychologist.
There has been some interest expressed by psychologists in our state in launching a legislative effort to get approval for appropriately trained psychologists to prescribe psychopharmacologic medications in Washington. Many of you have probably experienced problems with access to psychiatric prescribers for your patients, especially in our rural areas. The relative scarcity of psychiatric services in our state has been a concern for many of us. Prescribing psychology bills have now passed in five states, most recently in our neighboring state of Idaho. Many more states have active initiatives pursuing prescribing psychology.
While psychologists have been prescribing safely for over 25 years, most psychologists are not familiar with the safety record, training and scope of practice of prescribing psychologists. We would like to take this opportunity to share information about RxP, and later and most importantly, solicit your questions and thoughts about prescribing psychology.
- Question 1:
What is a prescribing psychologist?
- Answer 1:
A Prescribing Psychologist (RxP) is a fully independent, licensed psychologist who has also received specific training and been licensed to prescribe psychotropic medication. A prescribing psychologist is eligible to obtain a DEA registration number.
In practice, a prescribing psychologist has a formulary consisting of psychotropic medications and communicates with the patient’s primary health care practitioner who oversees the patient’s general medical care.
- Question 2:
In what states or institutions can psychologists prescribe?
- Answer 2:
Five states have passed RxP Legislation:
New Mexico 2002
The following federal agencies also credential prescribing psychologists:
Department of Defense: (Army, Navy, Air Force)
US Public Health Service Corps
Indian Health Service
Additionally, organizations in numerous states are currently in various phases of pursuing RxP legislative initiatives.
- Question 3:
Is it safe?
- Answer 3:
Yes! Psychologists have been prescribing safely for over 25 years.
Since the inception of prescribing psychology in 1991 in the Department of Defense, there have been no reported instances of inappropriate or harmful prescribing by RxPs.
In addition, the APA has published practice guidelines regarding psychologists’ involvement in pharmacological issues. The practice guidelines recommend general principles for optimal professional practice.
Research supporting RxP:
47 Medical providers who have worked with a prescribing psychologist overwhelmingly rated RxPs as safe, effective and well-trained (Shearer et al., 2012)
22 Medical providers who have worked with prescribing psychologists overwhelmingly rated RxPs as safe, knowledgeable about psychotropic medication, and would refer patients to them for psychotropic medication management (Linda and McGrath, 2017)
- Question 4:
How much training do RxPs really get?
- Answer 4:
Postdoctoral Master’s Degree in Clinical Psychopharmacology
A licensed psychologist may apply for specialized training to prescribe psychotropic and adjunctive medications. If accepted, the licensed psychologist completes postdoctoral training that is consistent with the American Psychological Association standards for prescriptive authority.
In the states and federal systems in which appropriately trained psychologists now prescribe, licensed psychologists have earned a postdoctoral master’s degree in clinical psychopharmacology. The required coursework can be viewed at http://www.apa.org/education/grad/psychopharmacology.aspx and is outlined in Appendix 1
The postdoctoral master’s degree is followed by a supervised practicum. For example, in New Mexico the psychologist is required to obtain supervision for a minimum of 100 diverse patients seen for at least 400 hours over the course of a year.
Passage of a National Exam
Passage of a national exam is required; currently, that exam is the Psychopharmacology Exam for Psychologists (PEP). The PEP is considered a very rigorous test of knowledge. (More information on the PEP can be found at https://www.asppb.net/page/PEPExam)
Most states require additional supervision before the prescribing psychologist can apply for licensure to independently prescribe. For example, in New Mexico, an RxP is required to be supervised for two additional years (three years total of supervision) by a physician before applying for an independent prescriber’s license.
- Question 5:
How does a prescribing psychologists’ training compare to that of physicians and psychiatric nurse practitioners?
Specialized training for RxP is tailored to the needs of psychologists. Muse and McGrath published an article comparing the graduate training of physicians, psychiatric nurse practitioners, and prescribing psychologists and found psychologists well prepared to prescribe psychopharmacologic medication. See this link for the full article: http://rxpsychology.fdu.edu/Resources/MuseMcGrath2010.pdf
- Question 6:
Doesn't supporting RxP negatively impact the profession?
- Answer 6:
Psychologists who have worked with RxPs see the role as one of expanding on the services that can be provided by psychologists. RxP is another specialty area like neuropsychology, pediatric psychology, health psychology, or forensic psychology. We need psychologists practicing across the spectrum of mental health care to provide a robust and meaningful presence for our state’s mental health network.
- Question 7:
Would RxP in Washington State really improve access?
- Answer 7:
There are approximately 2700 psychologists in Washington. There are less than 600 psychiatrists, and some of those do not accept insurance coverage for medication visits. The wait list for those psychiatrists who do accept insurance often exceeds 6 weeks. If only 10% of licensed psychologists became prescribers we would add more than 250 prescribers statewide. Psychologists already have a much larger presence in underserved rural areas of Washington, where they could significantly improve access.
- Question 8:
What about Psychiatric Nurse Practitioners? Can’t they fill the gap in care?
- Answer 8:
Most of our valued nurse practitioner colleagues (ARNPs) specialize in primary care. The Bureau of Labor (2017) estimated that there are about 3000 registered nurse practitioners in Washington State. The American Association of Nurse Practitioners (2018) reports that nationally about 1.7% of all ARNPs specialize in psychiatric prescribing. This yields an estimate of about 50 psychiatric ARNPs for the entire State of Washington.
- Question 9:
Organized psychiatry has opposed RxP. What do medical doctors who have worked with prescribing psychologists think?
- Answer 9:
Primary care health care providers are responsible for the total health of their patients. They also prescribe the lion’s share of psychotropic medication in the absence of an adequate supply of psychiatric providers. They are in the best position to evaluate the safety, efficacy and utility of prescribing psychologist. Two studies have surveyed primary care doctors WHO HAVE WORKED CLOSELY WITH PRESCRIBING PSYCHOLOGISTS regarding these issues. The results show that primary care health care providers overwhelming view prescribing psychologists as safe, effective prescribers for their patients (see Shearer, et al., 2012; Linda and McGrath, 2017).
- Question 10:
Are RxPs just “mini-psychiatrists?”
- Answer 10:
Not at all. Like other sub-specialties in psychology, RxPs bring their identity as a psychologist to their prescribing work. Prescribing psychologists have the experience and training to recognize the roles of both psychotherapy and medication. Importantly, prescribing psychologists’ expertise provides the opportunity to not prescribe or to stop medications when they are not necessary.
- Question 11:
What is the next step if we choose to pursue prescribing psychology in our state?
- Answer 11:
Expanding the scope of practice for any profession that is regulated by the State requires legislative action. A bill must be sponsored by a legislator in Olympia and must pass through the relevant committee(s) and be voted on by both the State Senate and House of Representatives. Finally, it is submitted to the Governor for signature. We have several legislators in our State who have approached us with interest in sponsoring a prescriptive authority bill for psychologists. Our first step would be working with a legislator to craft a bill that meets the unique needs of our State.
Linda WP, McGrath RE. The Current Status of Prescribing Psychologists: Practice Patterns and Medical Professional Evaluations. Professional Psychology: Research and Practice, 2017; Vol. 48, No. 1: 38-45.
Muse, M. & McGrath, R. (2009). Training Comparison Among Three Professions Prescribing Psychoactive Medications: Psychiatric Nurse Practitioners, Physicians, and Pharmacologically Trained Psychologists. Journal of Clinical Psychology, 66, 96-103
Shearer, D.S., Harmon, C.S., Seavey, B.M., & Tiu, A.Y. (2012). The primary care prescribing psychologist model: Medical provider ratings of the safety, impact and utility of prescribing psychologist in a primary care settings. Journal of Clinical Psychology in Medical Settings, 19(4), 420-429.
Bureau of Labor Statistics on ARNPs
American Association of Nurse Practitioners
Required Coursework for RxP
I. Basic Science
A. Anatomy & Physiology
III. Physical Assessment and Laboratory Exams
A. Physical Assessment
B. Laboratory and Radiological Assessment
C. Medical Terminology and Documentation
Integration of A-C through supervised clinical experience or lab experience in conducting physical exam, ordering psychometric and laboratory tests, understanding results and interpretation
IV. Clinical Medicine and Pathophysiology
A. Pathophysiology with particular emphasis on cardiac, renal, hepatic, neurologic, gastrointestinal, hematologic, dermatologic and endocrine systems.
B. Clinical Medicine, with particular emphasis on signs, symptoms and treatment of disease states with behavioral, cognitive and emotional manifestations or comorbidities
C. Differential Diagnosis
D. Clinical correlations-the illustration of the content of this domain through case study
E. Substance-Related and Co-Occuring Disorders
F. Chronic Pain Management
Integration of A-F through supervised clinical experience or lab experience in taking medical history, assessment for differential diagnosis, and review of systems
V. Clinical and Research Pharmacology and Psychopharmacology
B. Clinical Pharmacology
E. Developmental Psychopharmacology
F. Issues of diversity in pharmacological practice (e.g., sex/gender, racial/ethnic, and lifespan factors related to drug metabolism access, acceptance, and adherence)
Integration of A-F through supervised clinical experience or lab experience in Clinical Medicine and ongoing treatment monitoring and evaluation
VI. Clinical Pharmacotherapeutics
A. Combined therapies - Psychotherapy/pharmacotherapy interactions
B. Computer-based aids to practice
Integration of A-C through supervised clinical experience or lab experience in integrated treatment planning and consultation and implications of treatment
A. Methodology and Design of psychopharmacological research
B. Interpretation and Evaluation of research
C. FDA drug development and other regulatory processes
VIII. Professional, Ethical, and Legal Issues
A. Application of existing law, standards and guidelines to pharmacological practice
B. Relationships with pharmaceutical industry
1. Conflict of interest
2. Evaluation of pharmaceutical marketing practices
3. Critical consumer