Few Psychologists Can Prescribe in the US — But That’s Starting to Change

This is an exclusive BHB+ story

A small but lively movement in state legislatures may add a new player to the mental health prescriber team.

Several states have recently considered giving specialized psychologists the authority to prescribe and manage patients treated with mental health-related medications. Last year, Utah became the seventh state to create such licensure.

Advocates for the creation of this type of clinical role say the present shortage and a looming shortfall of psychiatrists and other doctors with similar authorities create a crying need for more clinicians who are specialized in treating mental health issues with pharmaceuticals.

“Mental illness doesn’t wait very well,” Ryan Ernst, a neuropsychologist with psychopharmacology licensure in Iowa, told Behavioral Health Business. “There are certain things that you might be able to get away with waiting 90 days to see a doctor about. If you’re going through a high degree of psychological distress or you have a number of serious mental health conditions, you don’t have 90 days to be on a waitlist. That can have disastrous effects.”

Ernst works with Clarinda Regional Health Center in Page County, Iowa. He is also the first-ever prescribing psychologist in the state of Iowa.

Addressing the workforce shortage

Present estimates from the federal government indicate that the supply of psychiatrists is projected to decline in the coming years, followed by a plateau, while projected demand is expected to continue increasing. By 2037, only 47% of demand for adult psychiatric services will be met.

The other states that already have this kind of licensure are Colorado, Idaho, Illinois, Iowa, Louisiana and New Mexico. Similar providers have long existed in other parts of the health care economy. The U.S. Department of Defense piloted giving psychologists prescriptive authority in the 1990s. New Mexico created its own licensing authority for psychologists in 2002.

Other states that have recently seen legislative efforts emerge in their statehouses include, for example, Arizona, Florida, Hawaii, New York, Virginia and Washington.

“I know that psychologists are highly competent treatment providers, and I know that we have the intellectual capacity to learn how to prescribe,” Beth Rom-Rymer, the founder, president, and CEO of the Illinois Association of Prescribing Psychologists, told BHB. “Because there’s such a dearth of good mental health prescribers, I want psychologists to be able to fill the gaps that have been left wide, wide open by other providers.”

Many doctor-focused advocacy groups oppose the movement. For example, the American Medical Association established its present policy position opposing the effort in 1989 and reaffirmed the position in 2019, according to its website.

In Virginia, the state legislature mandated that the commonwealth’s psychology and medical boards collaborate to develop potential standards for granting psychologists the authority to prescribe medications. That working group is to report its findings to the legislature by Nov. 1.

In September, the American Medical Association penned an essay that, in part, concluded that only providers with degrees from medical schools should have this authority, citing the effort underway in Virginia. Without a medical degree, providers “simply do not have the knowledge to safely prescribe,” the essay states.

The essay goes on to argue that efforts like the push to expand psychologist prescribing threaten patient safety and the role of physicians leading “team-based” care models, which are held up as the mainstay and standard for physical health today.

Advocates for expanding prescriptive authority maintain that there is due consideration to the training and limitations of psychologists seeking this scope of practice. In Utah, for example, a provider must already be a licensed psychologist, hold a master’s degree in clinical psychopharmacology and have passed the Psychopharmacology Exam for Psychologists. Additionally, the provider must have completed 4,000 hours of clinical training under the supervision of a physician.

Size, relevance and time

While more states are seeing movements to enable psychologist prescribing, the current corps of these providers is remarkably small — so small that they are rarely considered in the broader behavioral health economy. In their place, nurse practitioners and other so-called physician extenders are looked to to fill the gaps where there is no access to a psychiatrist or other doctors with the authority to prescribe. One report states that there were about 226 prescribing psychologists in the U.S.

Some of the largest outpatient behavioral health providers in the U.S. don’t consider prescribing psychologists in their models, opting instead to invest in traditional care models and use nurse practitioners when needed.

Dan Frogel, CEO of the outpatient mental health provider Thriveworks, said the company focuses on establishing close collaboration between its therapists and its psychiatric nurse practitioners.

“That collaboration — whether with providers inside or outside of our system — is core to our model and commitment to treating the whole person,” Frogel said.

Frogel added his skepticism to the appropriateness of psychologists taking on prescribing authority without the relatively stronger backgrounds in medicine and physician health care.

“I think a hugely untapped area is physician assistants,” Frogel said. “They’re trained in medicine and could help fill a major gap, especially with simpler medication management cases.”

Still, it’s an area that Frogel is watching. He stated there is limited evidence on the outcomes of psychologists who can prescribe due to their small number. For example, there are 226 prescribing psychologists to the estimated 40,000 psychiatric advanced practice registered nurses in the U.S. today.

“Psychiatric NPs start with medical training and can learn therapy, while psychologists start with therapy and may learn medication management later,” Frogel said. “That’s an interesting shift, and so it’s a wait-and-see on how the outcomes compare.

“At Thriveworks, we care less about the title of the prescriber and more about whether the care is coordinated, science-based, and deeply human. That’s what drives better outcomes.”

Opposition questioned

Many point to the proliferation of non-physician prescribers in the U.S. as evidence that the common arguments of scope creep and “you didn’t go to medical school” simply don’t fly in reality.

“If you think about a number of non-physician prescribing professions, none of those went to medical school — APRNs, physician assistants, optometrists, clinical pharmacists,” Deborah Baker, head of the American Psychological Association’s office of professional, legal and regulatory affairs, told BHB, adding that the scope of prescribing authority is varied depending on the role and the state. “That’s a refrain that we’re going to hear over and over again, but I don’t think there’s a lot of juice left in that.”

Further, the association aims to foster collaboration with other care providers. Presently, the burden of caring for those with psychiatric issues falls on primary care providers who, while doctors, don’t have meaningful specialization or training in the treatment of behavioral health issues. Many states require that prescribing psychologists can only treat a patient pharmacologically if the patient has a recorded history of treatment with a primary care provider, Baker said.

“The expectation is that the prescribing psychologist is in regular communication with the treating provider who’s managing the patient’s medical health conditions to make sure that there is good, consistent, coordinated care,” Baker said.

After Illinois passed the prescribing psychologist law in 2014, Rom-Rymer noted a rapid shift in the discourse between advocates of the movement and those opposed to it. Some psychiatrists and medical directors told her they were eager to work with them and recognized the need to fill the void in their respective communities.

“Organized psychiatry continues to oppose us, but the frontline psychiatrists are working hand in hand with us,” Rom-Rymer said.

Ernst, who has also advocated for prescribing authority for psychologists, finds that most opposition to this is centered in academic psychiatry. This translates into reality, with Iowa hospitals being forbidden from allowing prescribing psychologists to train in their facilities. Further, some states, including Iowa, require that prescribing psychologists practice under the supervision of a physician.

“There is a loud voice of opposition that is certainly seen in every state where psychologists try to get prescribing authority,” Ernst said. “My experience has not been that tet sentiment that psychologists should not prescribe and they must go to medical school is necessarily shared with those in clinical practice.”