BILL ANALYSIS
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|Hearing Date:April 23, 2007 |Bill No:SB |
| |993 |
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SENATE COMMITTEE ON BUSINESS, PROFESSIONS AND ECONOMIC
DEVELOPMENT
Senator Mark Ridley-Thomas, Chair
Bill No: SB 993Author:Aanestad - Calderon
As Amended:April 18, 2007 Fiscal: Yes
SUBJECT: Psychologists: scope of practice: prescribing
drugs.
SUMMARY: Revises the Psychology Licensing Law to authorize a
"prescribing psychologist," as defined, to prescribe and
administer drugs, and requires the Board of Psychology to
establish and administer a certification process to grant
licensed psychologists the authority to write prescriptions.
Existing law:
1)Provides for the licensure and regulation of the practice
of psychology under the Psychology Licensing Law by the
Board of Psychology (Board) in the Department of Consumer
Affairs (DCA). Violation of the provisions of the
Psychology Licensing Law is a misdemeanor.
2)Defines the practice of psychology to include diagnosis,
prevention, treatment and amelioration of psychological
problems and emotional and mental disorders, and the use
of psychological methods to assist a client to acquire
greater human effectiveness or to modify feelings,
conditions, attitudes and behavior which are emotionally,
intellectually or socially ineffectual or maladjustive.
3)Prohibits the practice of psychology from including
prescribing drugs.
4)Authorizes the Board to refuse to issue any registration
or license, or issue a registration or license with terms
and conditions, or suspend or revoke the registration or
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license of any registrant or licensee if the applicant,
registrant, or licensee has been guilty of unprofessional
conduct, as described.
5)Requires the Board to encourage licensed psychologists to
take geriatric pharmacology, psychopharmacology and
biological basis for behavior as part of their continuing
education.
6)Provides for regulation of prescription drug and medical
device dispensing under the Pharmacy Law by the
California State Board of Pharmacy (BOP) within the DCA.
This bill:
1)Makes legislative findings and declarations regarding the
shortage of psychiatrists and qualified professionals to
appropriately prescribe medications and administer
treatments, and states that in order to meet the
increasing demands for services to mentally ill and
disordered persons in California, it is the intent of the
Legislature to grant prescriptive authority to California
licensed psychologists who choose to receive the
appropriate education and training.
2)Revises the provisions of existing law to authorize a
prescribing psychologist, as defined, to prescribe drugs
for the treatment of disorders related to the practice of
a psychologist if certain requirements are met.
3)Establishes certain definitions under the Psychology
Licensing Law:
a) "Prescriptive authority" as authority to prescribe,
discontinue, order, administer, or dispense without
charge, drugs or controlled substances, excluding
narcotics, recognized for or customarily used in the
inpatient or outpatient diagnosis, treatment, and the
evaluation and management of individuals with
psychiatric, mental, cognitive, nervous, emotional,
addictive, developmental or behavioral disorders, and
order or utilize other procedures, consultations,
devices and related tests.
b) "Health service provider" as a licensed
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psychologist duly trained and experienced in
preventive, assessment, diagnostic, and therapeutic
intervention services relative to the psychological
and physical health of consumers and who has done both
of the following:
i) Completed an internship and supervised
experience in health care settings.
ii) Been licensed as a psychologist at the
independent practice level.
c) "Prescribing psychologist" as a health service
provider who has received from the board, a
certificate, as specified, granting prescriptive
authority.
d) "Drug" and "Device" as meaning the same as under
the Pharmacy Law, which includes controlled
substances, dangerous drugs and dangerous devices, as
defined under that law.
e) "Prescription" as meaning the same as under the
Pharmacy Law.
4)Exempts prescribing psychologists, as specified, from the
prescribing prohibition.
5)Requires the Board to:
a) Establish and administer a certification process to
grant licensed psychologists the authority to write
prescriptions.
b) Develop a procedure for
prescribing-psychologists-in-training to prescribe
under the supervision and license of a qualified
prescriber.
c) Develop procedures for the administration of an
appropriate valid nationally recognized examination,
such as the American Psychological Association
Practice Organization's College of Professional
Psychology examination.
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d) Charge applicants reasonable fees to issue and
renew a certificate to cover the administration cost
of the certification process and the examination.
6)Requires each applicant for certification as a
prescribing psychologist to meet specified education and
training requirements, including requirements for
supervised clinical experience under the direction of
qualified prescribers.
7)Requires an approved education and training program to
meet specified requirements, including consistency with
the American Psychological Association's (APA's) training
guidelines for prescriptive authority.
8)Specifies coursework that must be included in the
education.
9)Specifies the targeted clinical competencies shall
include:
a) Physical examination and mental status evaluation,
including knowledge and execution in the proper use of
instruments used in physical examination, such as
stethoscopes and blood pressure measurement devices.
b) Review of systems and medical history interview and
documentation.
c) Assessment indications and interpretation,
including the ability to interpret appropriate tests
such as psychometric, laboratory and radiological
tests for the purpose of making differential diagnosis
and monitoring effects of treatment.
d) Differential diagnosis and integrated treatment
planning, including appropriate processes and the
ability to identify and select the most appropriate
treatment alternatives.
e) Consultation and collaboration, including
understanding the parameters of the role of the
prescribing psychologist and working with other
professionals to effect patient treatment.
f) Treatment management, including application,
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monitoring and modification of treatment.
10)Provides for the clinical training program to, among
other things, demonstrate threshold performance levels,
complete a minimal number of supervised patient contact
hours, and make specified reports to the Board.
11)Requires the Board to establish requirements for the
renewal of a certificate, including continuing education
requirements, and to provide certain information to the
BOP, including a list of prescribing psychologists.
12)Includes as unprofessional conduct, subject to
disciplinary action by the Board, a violation of
particular provisions of law relating to prescribing
drugs.
13)Adds prescribing psychologist to the list of those
authorized under pharmacy law to issue a prescription.
14)Adds prescribing psychologist to the list of those under
whose prescription a psychiatric technician may carry out
medications, administer hypodermic injections, and draw
blood, as specified.
FISCAL EFFECT: Unknown. This bill has been keyed "fiscal"
by Legislative Counsel.
COMMENTS:
1.Purpose. This bill is jointly sponsored by the
California Psychological Association , the National
Association of Professional Psychological Providers
(NAPPP), American Federation of State, County & Municipal
Employees, Local 2620 , and Service Employees
International Union (SEIU). This bill is intended to
increase access to mental health services by authorizing
prescriptive authority for appropriately-trained
psychologists. This measure would allow appropriately
trained psychologists to prescribe medication for the
treatment of mental illness. The training required for
psychologists who prescribe would be a doctoral degree,
internship, licensure, completing additional education
and training in psychopharmacology, completion of
supervised clinical training, and passing a national
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examination in clinical psychophamacology.
The sponsors state that presently, over 80% of psychotropic
medications are prescribed by non-psychiatrists.
Research clearly demonstrates that primary care settings
are not the most effective venues for providing mental
health services. Many in the medical profession are
concerned that many patients are receiving substandard
mental healthcare due to an on-going psychiatric
shortage. For example, NAPPP indicates that throughout
the entire state of California, only 209 psychiatrists
accept Medi-Cal patients.
The Author states that the present law does not address the
severe shortage of competent psychiatrists, which has
resulted in patients, both in the private and public
sector, having little, and in many cases, no access to
integrated mental health treatment. Existing law denies
patients adequate mental healthcare in regions where
psychiatrists and physicians are absent but where
psychologists are plentiful. Existing law promotes split
and cost-ineffective treatment by requiring patients to
be seen by multiple practitioners for the very same
issue. Existing law also places treating psychologists
in the untenable position of being "de facto"
prescribers, where they recommend the medication for
patients that others can prescribe. Psychologists are
then left with the responsibility and potential legal
liability of managing the patient while on medication.
This bill will increase access to competent, cost
effective, integrated mental healthcare by 30% to 40%
while regulating training and testing to insure the
public safety and controlling the number of new
prescribers.
2.Background. Currently only two states, New Mexico and
Louisiana, grant the authority to prescribe to licensed
psychologists. Over the last eleven years, four other
psychologist prescribing bills, each sponsored by the
California Psychological Association, have been
introduced in the Legislature. Although differing in
specific detail, each bill sought to authorize licensed
psychologists to obtain an advanced certification, and
pursuant to that certification be granted authority to
prescribe. Each of those bills, ultimately were not
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enacted. The most successful of the three was AB 1144
(Aanestad) in 2000. That bill passed the Assembly on
Consent, and passed the Senate Business and Professions
Committee on a 4-2 vote. The bill was eventually held in
the Senate Appropriations Committee.
AB 1144 (Aanestad, 2000) would create a new category of
psychologists called a "certified psychologist," who
would be allowed to prescribe drugs to persons from 18 to
65 years of age. The bill also defined a "certified
psychologist" as a California licensed clinical
psychologist who is a graduate of the United States
Department of Defense Psychopharmacology training
program.
SB 2050 (Polanco, 1998) was substantially the same as SB
694 of the previous year. That bill died in the Senate
Business and Professions Committee.
SB 694 (Polanco, 1997) would allow doctoral level
psychologists who receive additional training and who are
certified (pursuant to a certification process to be
administered by the Board of Psychology) to prescribe
medications that are recognized as effective for the
treatment of patients served within the scope of practice
for which psychologists are licensed. That bill was held
in the Senate Business and Professions Committee and
later amended into another subject.
SB 777 (Polanco, 1995) would require the board to establish
and administer a certification program to grant licensed
psychologists prescriptive authority and to develop
procedures for certification with the advice of the State
Department of Health Services and the California State
Board of Pharmacy. The bill would require each applicant
for certification to satisfy certain educational and
training requirements. That bill died without a hearing
in the Senate Business and Professions Committee.
During this same time period, SB 983 (Polanco, Chapter 822,
Statutes of 1998) was enacted to require the Board of
Psychology to: (a) encourage its licensees to take
continuing education in psychopharmacology and the
biological basis of behavior, (b) encourage psychology
doctorate degree programs to include education and
training in psychopharmacology and related topics, and
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(c) develop education and training guidelines for
psychologists whose practice includes patients who may
require psychopharmacological treatment.
3.Legislation This Session. In the current legislative
session, Senator Aanestad introduced SB 822 on February
23, 2007 as a spot bill, which later became a
psychologist prescribing bill, and Senator Calderon
introduced SB 993 also on February 23, 2007. While, both
bills were psychologist prescribing bills, each were
brought forward from separate sponsors, and therefore
appeared to be competing measures. After a series of
meetings agreement was reached by all parties, and a
consensus measure was agreed upon. On April 11, 2007,
Senator Aanestad amended his bill into a different
subject, which still deals with psychologists, but is
unrelated to the issue of psychologists prescribing
drugs. The current amendments in SB 933, which is now
jointly authored by both Senators Aanestad and Calderon,
are the result of that agreement between the Authors and
sponsors of the two bills.
4.Department of Defense - Military Health System
Psychopharmacology Demonstration Project (PDP). From
1991 to 1997 the U.S. Department of Defense Military
Health System conducted a Psychopharmacology
Demonstration Project to train and use military
psychologists to prescribe psychotropic medications. The
training consisted of one year of classroom training with
a specified didactic curriculum, plus one year of
clinical training obtained on inpatient wards and
outpatient clinics at two military medical centers. The
ten psychologists involved in that training program were
assigned to various military hospitals and clinics. A
June 1999 report by the General Accounting Office (GAO)
on the results of the demonstration project indicated
that while initially supervised closely by physicians,
most of the psychologists were ultimately granted
independent status. The report found that the
psychologists generally serve in positions of authority,
treat a variety of mental health patients, prescribe from
comprehensive drug formularies, and carry patient
caseloads that were comparable to those of psychiatrists
and other psychologists at the same facilities.
The PDP figures prominently in all sides of the discussion
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of psychologists prescribing. The American Psychological
Association cites the PDP as evidence showing that
appropriately trained psychologists can prescribe
psychotropic medications safely and effectively. APA
states that the ten prescribing psychologists in the
project treated a wide variety of patients, including
active duty military, their dependents, and military
retirees, with ages ranging from 18 to 65.
According to the 1999 GAO Report, "an outside panel of
psychiatrists and psychologists who evaluated each of the
graduates rated the' graduates' quality of care as good
to excellent." The 1998 American College of
Neuropsychopharmacology review stated that "they had
performed safely and effectively as prescribing
psychologists, and that no adverse outcomes had been
associated with their performance." Several physicians
told the GAO that they came to rely on the PDP
psychologists for information about psychotropic
medications.
On the other side of the question, the California
Psychiatric Association refers to the PDP, arguing that
the studies related to the PDP provide the only reliable
data about psychologist prescribing. They state that the
project was terminated with prejudice by the Defense
Authorization Act of 1997, after a GAO report on the
program concluded it was a failure. They further state
that this bill, SB 993, proposes far less education for
California psychologists than psychologists received in
the PDP. Those psychologists were trained to the level
of nurse practitioners and were required to be closely
supervised by psychiatrists and other physicians; could
only treat active military personnel between the ages of
18-65 years with "uncomplicated" cases (mostly
depression); treated only individuals who were examined
by a physician and given a full medical examination
beforehand; had limited formularies; were subject to
medical chart review by physicians; and, did not see
inpatients nor treat the most severe disorders like
schizophrenia and other psychotic disorders. The GAO
recommended the program be discontinued in 1997 unless
psychologists practiced under psychiatrists. The
California Psychiatric Association further notes that
none of the conditions and safety mechanisms that the PDP
program imposed, most notably physician supervision, are
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required by SB 933.
One outspoken critic of the PDP, Lt. Gen (Ret) Monte B.
Miller, MD, was the United States Air Force Surgeon
General at the inception of the PDP in 1991, writes that
the PDP was terminated with prejudice by the Federal
Defense Authorization Bill of 1997.
He states that all PDP patients received a full medical
evaluation before visiting the psychologist and were
screened so that no patients with complex or severe
mental disorders or major health conditions were
presented for treatment. He states that in evaluating
the PDP, the GAO report stated that "although PDP had
demonstrated that psychologists could be trained to
prescribe, they could not be substituted for
psychiatrists and the training was not justified." In
fact, the GAO report also stated that "PDP graduates
themselves reported weaknesses in general medicine,
physical diagnosis, and use of clinical laboratory
procedures."
In arguing that the PDP is not parallel with the provisions
of SB 993, the California Psychological Association,
states that key vulnerable patient groups for which the
PDP did not address: children, the elderly, patients
with comorbid medical conditions (diseases occurring
simultaneously with one another), patients with severe
and persistent chronic mental illnesses, suicidal and
homicidal patients, and individuals with severe character
pathology. All of these patient groups are allowed
without modification or restriction under this bill.
The sponsors counter with a clear, compelling claim stating
that the psychologists within the Department of Defense
have seen over 160,000 patients with no deaths and no
adverse outcomes. They argue that if psychologists
prescribing is such a terrible policy, there surely would
be some cases of problems where it has been practiced.
The sponsors state that the absence of any demonstrated
problems speaks loud and clear.
5.Arguments in Support.
a) State Mental Health Crisis. The sponsors argue
that according to the National Institute of Mental
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Health, about 1 in 4 adults suffer from a diagnosable
mental disorder in a given year, and 1 in 17 suffers
from a serious mental illness. However, the 1999
Surgeon General's Report revealed that less than
one-third of all people with a diagnosable mental
disorder in the U. S. receive treatment in a given
year.
The sponsors claim that the lack of access to
psychiatrists has resulted in over 80% of psychotropic
medication being prescribed by general practitioners
(non-psychiatrists) with limited training in mental
health and limited time with their patients. While
multiple studies have demonstrated that a combination
of psychotherapy and drug therapy is the most
effective treatment for most mental health problems,
the sponsors claim that Californians are not getting
the most effective treatment. A recent study found
that two-thirds of children prescribed mental health
drugs by their family doctor never saw a mental health
specialist.
The lack of access to Psychiatrists in the community has
made this issue more critical than ever, according to
the sponsors. As of March 2007, there are 11 counties
in California without a single psychiatrist, and an
additional 17 counties that have five or less
psychiatrists.
The sponsors state that the numbers of psychiatrists are
not increasing, citing the National Residency Matching
Program which indicates that a psychiatric residency
is only chosen by 3% of an average medical school
student body. The sponsors contend that it is
incumbent upon the State that we search for innovative
solutions and allow new professionals to be part of
the solution to the state's mental health crisis.
b) State Facilities. The California Psychological
Association argues that state and local public sectors
are in an uncontrolled price battle to find
psychiatrists who don't exist. In the community,
patients, Medi-Cal and health plans are unable to find
psychiatrists at an affordable cost who are available.
They further note that California Prisons, with over
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32,000 mentally ill inmates reported a 67% vacancy
rate for psychiatrists in September 2006. The prison
system is under control of a Federal Court Receiver,
who has begun offering up to $300K per psychiatrist.
Psychiatrists continue to leave county mental health
and the California Department of Mental Health to go
to the prisons, creating another crisis in the public
sector.
The California Department of Mental Health with 6,500
mentally ill patients reported a 40% vacancy rate for
psychiatrists in February 2007. This month (March),
Atascadero State Hospital reported a 70% vacancy rate
for psychiatrists and that there were only 9
psychiatrists on staff to serve over 1300 patients.
On March 21, the Department of Mental Health approved
pay raises for psychiatrists and will now be paying
approximately $24,000 per month per position. Yet,
the vacancies for qualified prescribers continues to
grow with no end in sight.
c) Safety. The sponsors argue that prescribing
psychologists in other states and the military have an
unblemished record of prescribing safely. Opponents
of SB 993 have no evidence to support any claim about
problems with safety. The psychologists within the
Department of Defense have seen over 160,000 patients
with no deaths and no adverse outcomes. Prescribing
psychologists in Louisiana and New Mexico have written
over 40,000 prescriptions with no deaths and no
adverse outcomes. The sponsors state that data has
shown that psychologists employ a behavioral approach
and their prescribing patterns have demonstrated that
they prescribe less medications to fewer patients with
the successful outcomes.
In the discussion of health care reform, California
psychologists are placing a solution on the table that
will increase access to mental health services by
allowing appropriately-trained psychologists to
prescribe medication. The lack of access to
psychiatrists, the crisis in state facilities and the
proven track record of prescribing psychologists in
other states make passage of SB 993 more critical than
ever.
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d) Secret Shopper for Psychiatric Services. One of
the bill's sponsors, the National Association of
Professional Psychological Providers (NAPPP) writes
that recently 420 calls by a mock patient over a six
week period were made to all psychiatrists who were
listed in the SuperPages of Los Angeles County. The
mock patient attempted to obtain an outpatient,
private pay appointment for a medication consult
describing serious symptoms in need of attention.
This survey yielded 229 psychiatrist's offices
resulting in only 28 appointments with a median cost
of $450 for an initial evaluation. Waiting time for
80% of the appointments made exceeded five weeks.
The NAPPP states that with the number of psychotropic
medications entering the market, consumers need and
require professionals who specialize in these types of
medications. As demand for mental health services has
increased and with medications becoming a greater
factor in treatment strategies, the number of skilled
psychopharmacologists is far below that needed to
provide services to California's population.
e) Other Support. The American Psychological
Association (APA) argues in support that a significant
portion of our citizens suffers from a mental or
emotional condition at some time in their lives, but
their needs are not being met by the current health
care delivery system. One such unmet need is in the
area of psychoactive medication treatment. At the
present time, the vast majority of Americans who
receive medications for the treatment of mental
disorders do not obtain them from psychiatrists. In
fact, primary care physicians prescribe over 70% of
all psychotropic prescriptions written. Many
Americans go without treatment altogether, in part,
because many citizens lack access to a psychiatrist.
Training already licensed, doctoral-level
psychologists to prescribe psychotropic medications
would help remedy this problem.
The APA contends that the statistics are startling among
traditionally underserved populations, including
children, the elderly, the chronically mentally ill
and rural Americans. As many as one-fifth of children
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and adolescents meet traditional diagnostic DSM
criteria for at least one mental or emotional
diagnosis and yet, studies show that only a small
percentage of these children receive treatment.
Similarly, conservative estimates suggest that 15
percent of older Americans (at least three million
people) require mental health services. Treatment of
older Americans, who often suffer from multiple
physical and mental conditions, is greatly impeded by
a high incidence of misdiagnosis. The unmet needs of
the chronically mentally ill are also particularly
serious.
The County of Imperial's Probation Department writes in
support that as a rural county in California, their
ability to access appropriate full spectrum mental
health care is limited by geographic isolation as well
as a lack of local mental health providers. The
probation department is a regular consumer of mental
health services for at risk juvenile offenders. We
have many years of experience working with
psychologists who provide assistance to our youth in
our facility.
6.Arguments in Opposition.
a) Significant Expansion of the Scope of Practice. The
California Psychiatric Association opposes the bill,
arguing that SB 993 is unlike any other scope of
practice bill this legislature has seen in the last
decade. It allows an aspiring class of professionals,
in this case psychologists who lack any fundamental
life science medical or education whatsoever, to
practice medicine; prescribe a broad formulary of
powerful medications; and be regulated by a consumer
protection board, the Board of Psychology, which has
absolutely no expertise in medicine or medications.
Contending that the bill would undermine a carefully
crafted statutory scheme of consumer protections that
apply to all regulated professions, and has been
refined over many decades in California, they state
that the specific danger imbedded in SB 993 lies in
its attempting to radically redefine the concept of
what constitutes adequate preparation for acts which
are regulated because state policy says there is a
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risk of harm to consumers in those acts.
b) Factual Clarifications to the Findings and Intent.
The California Psychiatric Association claims that the
high vacancy rates for psychiatrists in the California
Department of Corrections and Rehabilitation (CDCR)
and in Department of Mental Health (DMH) run state
hospitals and other facilities is exceeded only by the
vacancy rate for psychologists. In both the Coleman
and Plata cases, which respectively address
constitutionally inadequate mental health and health
care in the prison population, the state has
mismanaged care and chronically underpaid clinical
staff and those facts taken together have led to
significant vacancy rates across all health care
classifications for psychiatrists, psychologists,
primary care physicians, nurses, social workers,
rehabilitation therapists, psychiatric technicians and
pharmacists. Where salary increases in the CDCR and
DMH have been instituted by the courts, well qualified
individuals in all relevant clinical disciplines are
now being hired to fill hitherto chronic vacancy
rates. State employed psychiatrists, with very
limited exceptions, will not make close to $300,000.
Slightly more than half of all patients seeking care for
psychiatric symptoms seek that care from their family
primary care physician. Family practice and other
primary care physicians have extensive training in the
treatment of mental disorders and are well qualified
to treat straightforward cases of anxiety and
depression. Family practice physicians can consult or
refer to psychiatrists for more complicated or severe
cases of mental illness.
Psychiatric specialty nurse practitioners (NPs) and
physician assistants (PAs) also have the ability to
provide psychotropic medications. The foundational
medical education and training for both far exceeds
that proposed in SB 993 for psychologists. Yet SB 993
proposes independent practice for psychologists free
of any physician supervision, while both NPs and PAs
are authorized to practice only under the supervision
of physicians.
Currently, authorized prescribing professionals, such as
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psychiatrists, family medicine physicians, nurse
practitioners and physician's assistants, exist in
sufficient numbers so that there is no shortage of
prescribing professionals who are well qualified to
prescribe medications for mental disorders.
c) More Reasonable Answers to Providing Access to
Psychiatric Services. The California Psychiatric
Association argues that the number of psychiatrists
being produced across the country, and in California
in particular, is growing and keeping up with or
exceeding the growth of the population, and will
increase rapidly in the near future in California.
California psychiatric residency programs routinely
receive many more applicants than they have available
training slots. One program, a satellite program of
UCLA in Kern County, received over 160 applicants from
all over the world for its 6 training slots.
d) Proposition 63, the Mental Health Services Act
(MHSA) Provides Access Solutions. The MHSA will
provide over $400 million dollars to increase capacity
to train traditionally educated mental health
professionals including adult, child and adolescent
and geriatric psychiatrists among others. Proposition
1D will provide another $400 million to expand the
capacity of University of California (UC) Medical
Schools, including residential training programs, and
to expand the already existing DC network of
telehealth, including telepsychiatry. Together these
two initiatives will take a huge step toward ensuring
that no Californian need go without well qualified
medical professionals to meet their health and mental
health needs.
DMH, with MHSA funds, will soon release a request for
quotations to establish three new psychiatric
residency programs in California which will double the
number of psychiatric nurse practitioners produced,
and will institute advance specialty training programs
for physician assistants in each of the PA training
programs. Coupled with generous loan forgiveness
programs for each, flourishing programs for each
discipline should be up and running in 2008.
Taken together these initiatives obviate the need to
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engage in dangerous medical experimentation with
California citizens by allowing non-medically trained
individuals to practice medicine and prescribe
powerful and dangerous medications.
e) The Bill's Educational Requirements Do Not Match
the Proposed Scope of Practice. The educational
requirements in Section 4 of the bill profess that
psychologists will gain the competencies to: conduct
physicals, take blood pressures, listen to the heart
and lungs with a stethoscope for abnormalities and
signs of organic disease. This section would also
indicate that psychologists so trained would order and
interpret blood and urine tests; take tissue samples
either for culturing or examination under a
microscope; order and interpret x-rays, magnetic
resonance imaging, and CAT scans.
f) Differential Diagnosis. Over 200 medical
conditions mimic mental illness. The education
proposed in SB 993 proposes to render psychologists
competent to conduct differential diagnosis, which is
the process of ruling out literally hundreds of
physical diseases and conditions that can mimic the
symptoms of mental illness but do not as a general
rule respond to psychiatric treatment. For instance,
a patient with psychosis may need massive doses of
B-12 if their psychosis stems from a chemical
imbalance in the body of too much methylmalonic acid.
Or, a patient with dementia and psychosis due to a
form of Anemia also requires B-12, not an
antipsychotic. Patients may suffer from
post-concussive syndrome that presents with anxiety
and depression and needs physician evaluation and
treatment. It's extraordinarily unlikely that a
psychologist with the education described in SB 993
can "make these calls."
g) SB 993 Allows Countermanding of Physician Orders.
The language of SB 993 specifically allows
psychologists to make modifications to treatments that
are provided by physicians. That means if a family
medicine, pediatric or other physician prescribes a
medical regimen,
SB 993 allows a psychologist to make changes to those
regimens, without qualification and without
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consultation with that physician. This doesn't make
sense and is dangerous.
Psychology is a valued and respected profession.
Psychologists are valued colleagues of psychiatrists
and other mental health professionals; skilled,
highly trained and valuable. Psychiatric patients can
be extraordinarily challenging. They are in many
instances ill with other mental health, health or
substance abuse disorders. The medications they are
prescribed are powerful and diverse and they affect
many parts of the body, not just the brain.
h) Other Opposition. The California Consortium of
Chairs of Departments of Psychiatry argues that if a
bill had been put forth allowing psychologists to
treat cancer with chemotherapeutic agents, no one
would seriously entertain such a notion, despite the
extramural training program developed for psychologist
prescribing. Yet, for the treatment of serious
psychiatric disorders, decidedly a challenge for
highly trained, experienced clinicians, we should
allow substandard treatment? Sadly, a proposal of
this nature is typical of the inadequate treatment
that psychiatric patients have endured over the ages.
Now is not the time to trivialize the medical
challenges associated with treating psychiatric
disorders.
The access to psychiatric care is frequently cited as a
rationale for loosening the education and training
requirements to prescribe psychotropic medications,
but in our view this argument is a "red herring."
First of all, there is no guarantee that psychologists
will migrate to under-served areas. Second, there is
a much more sound solution utilizing primary care
physicians and nurse practitioners with consultation
provided via telemedicine.
AFSCME Local 206, the Union of American Physicians and
Dentists have grave concerns about this proposal,
arguing that state law currently requires anyone who
dispenses medication to have a valid medical license
approved under the jurisdiction of the California
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Medical Board. SB 993 seeks to disrupt this process.
Passage of this legislation is dangerous, as it will
allow psychologists who have not had any medical
training to prepare medication prescriptions. This
proposal is ill conceived and of potential harm to all
patients in California. Medicine is not a "dangerous
slippery slope" for questionable clinical care and
treatment, they argue.
The California Society for Clinical Social Work (CSCSW)
believes the legislation is premature, arguing that
there is a crisis in care in the state of California
and nowhere is that more evident than in mental
health. Unfortunately, the community response has
been a piecemeal approach to battling over scope of
practice issues. Each of the mental health care
providers have made efforts to expand their own
ability to reach those in need, and as a result, there
is an angry environment in which some providers feel
as though their scope has been impinged upon and
others are angry that their education exceeds their
ability to practice.
CSCSW affirms the shotgun approach to advancement is
misguided. Instead of each group expending political
capital and grasping for greater scope, they suggest a
Mental Health Care Summit in which all of the scopes
of practice are viewed in total. Such a summit could
also answer the questions regarding the nexus between
education, training and the ability to provide
specific services.
The American Psychiatric Association (APA) states that
under current law in California and 47 other states,
psychologists are prohibited from prescribing drugs.
APA suggests that under this bill, licensed
psychologists would be permitted to write
prescriptions for psychotropic and other brain
medicines after completing some courses that meet the
training requirements set by the California Board of
Psychology, not the Medical Board of California. In
fact, there is no medical involvement or oversight in
this legislation. A student's "supervised clinical
experience" is to be completed "under the direction of
qualified prescribers," who need not be physicians.
Regulations for training to prescribe and to determine
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who is qualified to prescribe would thus be written by
a Board whose members have not been medically trained
and who cannot themselves prescribe.
Mental illnesses such as schizophrenia, major
depression, bipolar disorder, childhood autism, and
post-traumatic disorders, to name some of the most
prevalent, are serious disorders. They are illnesses
involving abnormalities in brain chemistry many with
strong genetic components, affecting the very essence
of being human: our capacity to think, to reason, to
judge reality, and to control our emotions and
behavior. The drugs used to treat them are among the
most powerful and potentially dangerous medications
available in modem medicine. They also affect other
organ systems and interact with other medications.
APA states that diagnosing illness and prescribing
medication to treat it is based on a medical model of
care, not on a psychological construct. This demands
full-time thorough medical education and training in
order to practice safely and effectively.
SUPPORT AND OPPOSITION:
Support:
California Psychological Association (Sponsor)
National Association of Professional Psychological
Providers (Sponsor)
American Federation of State, County & Municipal Employees,
Local 2620
(Sponsor)
Service Employees International Union (Sponsor)
American Psychological Association
California Latino Psychological Association
Central Coast Psychological Association
County of Imperial - Probation Department
Los Angeles County Psychological Association
Orange County Psychological Association
San Francisco Psychological Association
San Mateo County Psychological Association
Santa Clara County Psychological Association
Numerous Licensed Psychologists
Numerous patients/family members
2 Physicians & Surgeons
Opposition:
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AFSCME Local 206, Union of American Physicians & Dentists
American Psychiatric Association
Board of Directors California American Psychiatric Nurses
Association
California Academy of Family Physicians
California Academy of Ophthalmology
California Academy of Physician Assistants
California Consortium of Chairs of Departments of
Psychiatry
California Medical Association
California Psychiatric Association
California Society for Clinical Social Work
California Society of Health System Pharmacists
California Society of Health-System Pharmacists
Citizens Commission on Human Rights, Los Angeles/Hollywood
Chapter
Depression and Bipolar Support Alliance of California
NAMI California
Osteopathic Physicians and Surgeons of California
Numerous Physicians & Surgeons
Consultant:G.V. Ayers