Former opponent now favors RxP

By Charles M. Lepkowsky, Ph.D.
May 31, 2019

prescriptionIn the March/April 2016 edition of The National Psychologist I wrote expressing ambivalence about the merits of prescribing privileges for psychologists (RxP).

Events over the past several years have changed my opinion. I now fully support RxP. Here are some reasons why:

*The percentage of psychiatrists who accept private non-capitated insurance is significantly lower than the percentage of physicians in other specialties.
*Among all the medical specialties participating in Medicare, psychiatry has the lowest rate of participation, and the rate of psychiatrist participation is even lower for Medicaid.
*All of these numbers have been on the decline since 2005.

Rather than encouraging psychiatrists to participate in insurance programs such as Medicare, the American Psychiatric Association has published online “how-to” manuals for opting out of Medicare.

These rates of participation demonstrate professional psychiatry’s low investment in providing care to those in need. As a consequence of the small number of psychiatrists accepting insurance coverage of any kind, wait times to see psychiatrists have become unreasonably long.

In Santa Barbara County, California, a bipolar patient who has been going to the same clinic for years told me that the clinic’s wait time between appointments with a psychiatrist is 20 months –almost two years.

In my efforts to help the patient find another psychiatrist in the county, I discovered that:

*Almost no psychiatrists are accepting new patients (whether the psychiatrists accept insurance or not).
*Those psychiatrists accepting new patients have wait times of six to 24 months.

Some research and contact with colleagues in other parts of the country indicates that the situation in Santa Barbara County is not that dissimilar from that in many parts of the nation.

In short, professional psychiatry is not meeting the healthcare needs of the public.

In my previous article, I stated a concern that pursuit of prescriptive privilege validates the perception (of physicians) that professional psychology is encroaching on psychiatry. The statistics I cited above demonstrate that there is plenty of room for prescribers because there are simply not enough psychiatrists to do the job.

I had also expressed concern about damaging the relationship between professional psychology and medicine. Since 2016, the AMA and state medical associations have demonstrated willingness to collaborate with professional psychology in only one context: the integrated primary health care model, in which the psychologist is subordinate to physicians.

Professional psychology is not treated as a friend by the AMA or state medical associations and in that regard, frankly, has nothing to lose by pursuing prescriptive privilege.

In the previous article, I had expressed concerns about the complexities of the human body and medications and the likelihood that prescribing psychologists will be held to a higher standard than prescribing physicians, nurse practitioners and physician’s assistants.

Having researched the curriculum for RxP programs, I am fully assured that the training requirements are more rigorous and more pharmaceutically focused than the training of any of the other specialties listed above.

Finally, I expressed concern about the role of the psychologist as prescriber vs psychotherapist and how that might interfere with the therapeutic alliance. Having spoken to prescribing psychologists and some of the few psychiatrists who do actual psychotherapy, I now believe that medication compliance and feelings about using medication can be addressed as psychotherapy issues.

In summary, I now see RxP as an opportunity for professional psychology to provide care to millions of people who otherwise will simply not receive care. I unequivocally support RxP and encourage psychologists who do not support it to consider some of the issues described above.

Crow is not my favorite dish, but in this instance, I am glad to eat a hearty portion.

References available from author

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Charles M. Lepkowsky, Ph.D., is in private practice in Solvang, Calif. He is a past president of the Santa Barbara County Psychological Association. He taught graduate psychology courses for 14 years. He may be reached at:

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