Clinical Psychologists and Psychiatrists: Colleagues or Competitors?

©Dolly Right / Shutterstock.com

On October 6, 2017 the State of Illinois implemented its law granting psychologists who obtain specialized training the right to prescribe certain medications to adult patients. Although Illinois is one of only 5 states in which psychologists have prescriptive authority, the Illinois law will likely have the greatest impact on the country. Illinois contains the nation’s third largest city, has 9 medical schools, and a number of World Class Universities. It will be assumed that the law was vetted in a state with medical and psychological sophistication and it would not have passed the Illinois Legislature and been signed by the governor if it was believed to be dangerous to patients.

The Illinois law provides a template for PhD or PsyD psychology programs to construct a curriculum for graduate students to obtain essential training to meet state educational licensing requirements in the use of medications. This can be accomplished by extending required graduate level training for clinical psychologists by approximately 1 year. Current licensed PhD and PsyD clinical psychologists may also obtain prescriptive authority.  The law is so constructed that these psychologists could obtain essential training part time while maintaining their psychology practices over a number of years.

A review of physician-related scope of practice disputes between ophthalmologists and optometrists, primary care physicians and advanced practice nurses, and anesthesiologists and nurse anesthetists, shows that over 1 to 2 decades after winning approval in key states, the non-physician groups won the right to expanded practice throughout much of the country. If this history serves as a guide, psychologists are likely to obtain prescriptive authority in significant portions of the country within the next 10 years.

Physician groups have argued that the groups asking to expand their scope of practice would not be safe practitioners. They have also made the case that should patients be injured under their care, that restrictions be reasserted on their practices. To date, the latter has not occurred for optometrists, advanced practice nurses, or nurse anesthetists.

In looking ahead, it is not not clear how many doctoral level psychology students will extend their training to obtain this additional practice option or how many clinical psychologists will. The American Psychological Association reports that 3500 doctoral level clinical psychologists graduate each year. In 10 years, we do not know how many students will graduate from states with psychologist prescriptive authority curricular programs. If we assume that half this number do and half of these students obtain prescriptive authority, we would add 750 mental health practitioners who can prescribe to the nearly  1500 new psychiatrists who graduate each year. This will lead to new calculations on the essential make up of the mental health work force. 

Although the Illinois law is likely to become the national template for further psychologist prescriptive authority laws, it has some serious flaws. The most significant is that although psychologists in training must be supervised by either physicians, advanced practice nurses, or psychologists with prescriptive authority and in practice must have a collaborative care agreement with a physician, the physician does not need to be a psychiatrist. A psychologist could complete training and then go into practice without ever having his or her clinical work supervised by a psychiatrist. Imagine a psychiatric resident with a faculty of only primary care physicians? Yet a prescriptive authority training program under the Illinois law is not required to have psychiatrist on its faculty and could use only primary care physicians. 

In coming years when prescriptive authority laws are introduced in new states, psychiatry must balance its response in state legislatures between either defeating these laws or compromising by making them better and safer for patients. This will not  be an easy political choice.

In 10 years the practice landscape will change. Clinical psychologists and psychiatrists will need to reassess who and what they are about and how they should relate to each other. In Illinois today it would be possible to staff an inpatient psychiatric unit with psychologists with prescriptive authority and primary care physicians without any psychiatrists. Although psychologists are not authorized to prescribe for children or for adults over 65, the primary care physician can. This possibility is but one potential example of what the future could look like.