Psychopharmacology/Advanced Practice Psychology

[texanpsychdoc]

I am currently in a RxP post-doc master's program with the goal to become a prescribing psychologist. I also sit on multiple RxP committees across two states and on a national level, I will say that I've been in discussions with state senators to get support as we are planning on proposing a bill in late 2024 for RxP. I also met with a dean of a division of programs at the AMC I am faculty on and they are very much on board with the prospect of creating a M.S.CP. program there, so that is still evolving. I've submitted papers, data, etc. so we can get the ball rolling on getting this operational in the next two years.

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[medium rare]

I am currently in a RxP post-doc master's program with the goal to become a prescribing psychologist. I also sit on multiple RxP committees across two states and on a national level, I will say that I've been in discussions with state senators to get support as we are planning on proposing a bill in late 2024 for RxP. I also met with a dean of a division of programs at the AMC I am faculty on and they are very much on board with the prospect of creating a M.S.CP. program there, so that is still evolving. I've submitted papers, data, etc. so we can get the ball rolling on getting this operational in the next two years.

The Texas legislature only convenes every two years. And… it’s Texas. I have colleagues in TX who have been actively involved in RxP over the past 2 decades; they’ve given up. I wouldn’t hold my breath…

 

[texanpsychdoc]

The Texas legislature only convenes every two years. And… it’s Texas. I have colleagues in TX who have been actively involved in RxP over the past 2 decades; they’ve given up. I wouldn’t hold my breath…

I serve on the RxP committee in Texas and have been an active member and do know what we are doing as ...I am part of the planning! We will be submitting our bill in November of 2024 hopefully so that we get on the books for early 2025 session. At least that's what our lobbying group has outlined for us in our past meeting a week ago. We have been taking different approaches compared to times past and I am optimistic. I can't speak for your colleagues.

 

[medium rare]

I serve on the RxP committee in Texas and have been an active member and do know what we are doing as ...I am part of the planning! We will be submitting our bill in November of 2024 hopefully so that we get on the books for early 2025 session. At least that's what our lobbying group has outlined for us in our past meeting a week ago. We have been taking different approaches compared to times past and I am optimistic. I can't speak for your colleagues.

Best of luck in the process.

 

[futureapppsy2]

I serve on the RxP committee in Texas and have been an active member and do know what we are doing as ...I am part of the planning! We will be submitting our bill in November of 2024 hopefully so that we get on the books for early 2025 session. At least that's what our lobbying group has outlined for us in our past meeting a week ago. We have been taking different approaches compared to times past and I am optimistic. I can't speak for your colleagues.

What sort of different approaches? I am curious as to how RxP seems to be picking up steam again after essentially crashing and burning a decade-ish ago…

 

[WisNeuro]

I'm not optimistic about TX's chances, but would be glad to be wrong on that. I think WA and HI may be next. NY's bill will get mired in committees until the end of time. AZ's legislature seems to be a mess. PA could happen. I have no idea what's going on in VT.

 

[texanpsychdoc]

What sort of different approaches? I am curious as to how RxP seems to be picking up steam again after essentially crashing and burning a decade-ish ago…

We hired on a lobby group that's been very helpful in re-structuring our approach. The other aspect is that many of us are speaking to various organizations such as nurse and PA groups in Texas to get their support. NAMI recently back tracked their public opposition to Texas RxP and actually endorsed us. We have a website that helps provide useful information to folks as well as a plethora of updated white papers. Myself - I've had meetings with some state senators' policy analysts, especially with a high profile senator. I've also initiated a proposal with a med school here to develop a M.S.CP. program that we will have in our proposed bill to outline a clear path to train prospective providers in our state and elsewhere. Coming up, we will be doing several presentations across the state and continue to meet with key members of committees using a different narrative than maybe what's been used in the past that wasn't as persuasive. You will miss 100% of the shots you don't take, so, we have to continue to try and not have a defeatist attitude. I was advised by some members who have been in this committee much longer than I have that in times past when it was proposed for members to take a grassroots approach and speak with various senators, etc., several committee members would downright not do so because they had fundamental or philosophical differences with the senators' policies. That stuff doesn't phase me....I check that crap at the door and do I what I need to do to achieve the goal(s) I have. Gotta find middle ground. Make small gains.

 

[PsyDr]

I always thought Texas had a decent chance. Their laws seem to be made while intoxicated, and they share borders with two RxP states. AZ seems similar.

There’s only so many things that are legal in 6 states.

 

[NeuroObsessed]

I've also initiated a proposal with a med school here to develop a M.S.CP. program

I’ve been wondering why we haven’t tried to get more med schools to start MSCP programs. It would probably weaken the other sides argument in terms of competence and patient safety, and the training would probably seem more legitimate to legislators and the general public.

 

[WisNeuro]

I’ve been wondering why we haven’t tried to get more med schools to start MSCP programs. It would probably weaken the other sides argument in terms of competence and patient safety, and the training would probably seem more legitimate to legislators and the general public.

Considering the AMA is an active opponent to RxP, can't imagine med schools are looking to royally piss off a majority of their employees and students.

 

[NeuroObsessed]

Considering the AMA is an active opponent to RxP, can't imagine med schools are looking to royally piss off a majority of their employees and students.

True, but it would give them some control of the process, and if they are truly concerned about patient safety, which isn’t an actual issue with prescribing psychologists in the first place, it would be a good position for them to argue to be involved. It’s a reasonable middle ground as we, albeit very slowly, continue to win more states which obviously in turn won’t include them in the training process at all. For us it’d probably be 10x better than getting training at TCSPP and Alliant. At least Alliant has a nursing school now, not sure how much credibility that’ll add to them or their MSCP program, but I’m sure the two programs will work closely together.

 

[WisNeuro]

True, but it would give them some control of the process, and if they are truly concerned about patient safety, which isn’t an actual issue with prescribing psychologists in the first place, it would be a good position for them to argue to be involved. It’s a reasonable middle ground as we, albeit very slowly, continue to win more states which obviously in turn won’t include them in the training process at all. For us it’d probably be 10x better than getting training at TCSPP and Alliant. At least Alliant has a nursing school now, not sure how much credibility that’ll add to them or their MSCP program, but I’m sure the two programs will work closely together.

But, they're not really concerned about patient safety, it's simply a turf was issue. They'll probably fight it pretty hard until about 15 states get it done and then they'll drop it as the horse will have officially left the barn. As for RxP, there are better options than TCSPP and Alliant. We have FDU, NMSU ISU and Drake, I believe.

 

[Therapist4Chnge]

I'm not optimistic about TX's chances, but would be glad to be wrong on that. I think WA and HI may be next. NY's bill will get mired in committees until the end of time. AZ's legislature seems to be a mess. PA could happen. I have no idea what's going on in VT.

TX just seems to be very unfriendly to healthcare providers in general, but maybe they have changed. (highly unlikely). NY is just a mess for politics, top to bottom. I don't know anyone in AZ, but there is definitely a need from what I've been told.

 

[Therapist4Chnge]

But, they're not really concerned about patient safety, it's simply a turf was issue. They'll probably fight it pretty hard until about 15 states get it done and then they'll drop it as the horse will have officially left the barn. As for RxP, there are better options than TCSPP and Alliant. We have FDU, NMSU ISU and Drake, I believe.

I'd recommend FDU and NMSU. I wouldn't recommend Alliant, ever, for anything. I'm not familiar with ISU and Drake, but now I'm curious.

I think more states can achieve Psych RxP, but I don't view Psych RxP as the panacea some believe it could be for the field. The distribution of providers will likely mirror psychiatrists, unless programs and states offer incentives for clinicians to work in rural and underserved areas. Our training as psychologists is being sold short if we just pursue RxP, as most places will want you to Stack & Wack 15-25+/day, which doesn't leave much time for other clinical work, research, etc.

For those curious about prescribing jobs outside of a solo practice, there are definitely options, but recruiters are still hit and miss about understanding psychologists prescribing. Beware of Stack & Wack places who think the vast majority of patients should be 15min med checks, and new patients only need a 30min intake. Those can be a grind, and if their patient mix has more acute cases and more more severe cases, that setup could be a nightmare for some (me included).

I only seriously considered calls from hospital systems that came with faculty appointments/options, which eliminated like 90% of the prescribing calls, who were almost exclusively looking to fill higher-volume out-pt clinics. Full disclosure, me being a neuropsych who worked in head injury was a big draw for most/all of the calls that fit my requirements. I had one military adjacent opportunity (hired as a civilian) where I'd be a neuropsych doing head injury assessment, but I would have time in the out-pt clinic to do therapy, prescribing, or a combo. They were willing to pay me $$$, but I'd have to live in Texas, which was one of the dealbreakers.I also had one hospital system (Louisiana) offer me carte blanche as to how I'd arrange my day. They wanted me as both a neuropsych & also prescriber. We explored some different setups, varying the days I'd do neuropsych and the days I'd be out-pt to prescribe. This was pretty appealing to me, but I ended up going with a different offer for other reasons.

Long story short....most jobs I've seen are for prescribers to work out-pt. If you go this route, work for yourself because most places will just grind you with volume and why give away a % when you should be able to keep everything? You can earn very good money running your own cash practice, and you should be able to fill up pretty quickly and only work 25-40+hr/wk. Since I do quite a bit of legal work as a neuropsych, the money is better just doing the work I am doing now, though as a generalist or other type of specialist, I can definitely see how prescribing could bump up hourly earnings with very little overhead cost added.

 

[texanpsychdoc]

I'm currently in the FDU program (it's a very reputable program). I will say that my meeting with the dean at the med school I am an assistant professor on went extremely well and is very promising. They were the ones proposing the prospect of getting it live in 2 years which aligns well with our committee's efforts to introduce the bill by late 2024 to be considered in the 2025 session. The dean of the division I met oversees multiple programs across disciplines (e.g., DNP, PA), and my pitch to them about adding the M.S.CP. program adds additional value and diversity to a division that already demonstrates such efforts by having similar yet different disciplines and licensed professions.

 

[Tukenkamen]

Anyone by chance currently at ISU’s program/know someone who has attended? Curious about the quality of its curriculum.

 

[NeuroObsessed]

Anyone by chance currently at ISU’s program/know someone who has attended? Curious about the quality of its curriculum.

I can’t answer your question, but while we’re looking at the program, is it really $52,000 for out of state students?

 

[texanpsychdoc]

Just go to FDU....the whole program is about $16,000

 

[Tukenkamen]

I can’t answer your question, but while we’re looking at the program, is it really $52,000 for out of state students?

That sounds about my right. My wife is starting their PA program this Fall and the out of state is about $140k vs $80k for in state. I think their MSCP has quite a bit of funding/scholarships available if I’m remembering correctly.

 

[NeuroObsessed]

That sounds about my right. My wife is starting their PA program this Fall and the out of state is about $140k vs $80k for in state. I think their MSCP has quite a bit of funding/scholarships available if I’m remembering correctly.

If you can get that funding that would be good. Otherwise, FDU, NMSU, and Drake are cheaper options, but keep in mind that Drake isn’t APA designated yet.

 

[PsyDr]

And Utah makes #7.

https://www.cato.org/blog/utah-becomes-seventh-state-let-patients-access-prescribing-clinical-psychologists

 

[WisNeuro]

And Utah makes #7.

https://www.cato.org/blog/utah-becomes-seventh-state-let-patients-access-prescribing-clinical-psychologists

Falling dominoes.

 

[medium rare]

Too bad they’re not falling more quickly.

 

[AbnormalPsych]

Whats the liability landscape like for those of you who are doing this kind of work?

 

[WisNeuro]

Whats the liability landscape like for those of you who are doing this kind of work?

With the trainwrecks of polypharm I see on a weekly basis from primary care and psychiatry, It'd be hard to have higher liability than what is already pretty common in the community.

 

[Sanman]

Whats the liability landscape like for those of you who are doing this kind of work?

That depends, how comfortable are you with really late onset schizophrenia (like age 85)?

 

[quickpsych]

Falling dominoes.

While I think it's a

And Utah makes #7.

https://www.cato.org/blog/utah-becomes-seventh-state-let-patients-access-prescribing-clinical-psychologists

While I think this is a good thing, I had to chuckle when I read surgeons and ENTs are among prescribers authorized to prescribe psych medications. I understand maybe the allowing if for meds to mellow anxiety during a treatment or procedure but should be limited in that fashion for them. I also had to laugh at the AMA's "scope creep" boogey man approach, noted in the article, to , god forbid, allowing other highly trained professionals, some who are more experts in their field than a "well trained" doctor who has little experience in other specialities or fields. The AMA website linked by the article is laughable, it goes on to attack NPs, then say how valuable they are to healthcare. The AMA also has on their site some of their accomplishments including "striking down psychologist prescribing in Hawaii and Washington" and pressuring the VA to "reject" allowing non-doctors to do things the AMA thinks only doctors should do. I'm sure they say "its protecting doctors AND patients!."

Gotta protect those membership dues!

I mean I do agree with ensuring those prescribing medications are competent and that should include supervision by an existing prescriber, but still.

Then again our own APA is too busy saying EMDR is legit while mostly shrugging their shoulders as more midlevels are continuing to do more things usually only psychologists have done.

 

[WisNeuro]

While I think it's a

While I think this is a good thing, I had to chuckle when I read surgeons and ENTs are among prescribers authorized to prescribe psych medications. I understand maybe the allowing if for meds to mellow anxiety during a treatment or procedure but should be limited in that fashion for them. I also had to laugh at the AMA's "scope creep" boogey man approach, noted in the article, to , god forbid, allowing other highly trained professionals, some who are more experts in their field than a "well trained" doctor who has little experience in other specialities or fields. The AMA website linked by the article is laughable, it goes on to attack NPs, then say how valuable they are to healthcare. The AMA also has on their site some of their accomplishments including "striking down psychologist prescribing in Hawaii and Washington" and pressuring the VA to "reject" allowing non-doctors to do things the AMA thinks only doctors should do. I'm sure they say "its protecting doctors AND patients!."

Gotta protect those membership dues!

I mean I do agree with ensuring those prescribing medications are competent and that should include supervision by an existing prescriber, but still.

Then again our own APA is too busy saying EMDR is legit while mostly shrugging their shoulders as more midlevels are continuing to do more things usually only psychologists have done.

It's all just turf warfare and money. Has nothing to do with actual patient welfare in most cases. Our current healthcare system encourages it.

 

[Sanman]

While I think it's a

While I think this is a good thing, I had to chuckle when I read surgeons and ENTs are among prescribers authorized to prescribe psych medications. I understand maybe the allowing if for meds to mellow anxiety during a treatment or procedure but should be limited in that fashion for them. I also had to laugh at the AMA's "scope creep" boogey man approach, noted in the article, to , god forbid, allowing other highly trained professionals, some who are more experts in their field than a "well trained" doctor who has little experience in other specialities or fields. The AMA website linked by the article is laughable, it goes on to attack NPs, then say how valuable they are to healthcare. The AMA also has on their site some of their accomplishments including "striking down psychologist prescribing in Hawaii and Washington" and pressuring the VA to "reject" allowing non-doctors to do things the AMA thinks only doctors should do. I'm sure they say "its protecting doctors AND patients!."

Gotta protect those membership dues!

I mean I do agree with ensuring those prescribing medications are competent and that should include supervision by an existing prescriber, but still.

Then again our own APA is too busy saying EMDR is legit while mostly shrugging their shoulders as more midlevels are continuing to do more things usually only psychologists have done.

While I completely agree with the sentiment, I don't mind surgeons and ENTs having the ability to prescribe psych meds because post-op delirium is not uncommon. That said, if it was that difficult, they should be getting a psych consult.

 

[Fan_of_Meehl]

That depends, how comfortable are you with really late onset schizophrenia (like age 85)?

Still better than coming down with 'Retirement-Induced Service-Connection Deficit Disorder.'

VA is in the middle of an epidemic of that disease. Has been for decades.

And it doesn't respond to medication therapy. At all.

Come to think of it, it doesn't ever respond to psychotherapy, either.

 

[RxPsych]

I'm currently doing my external practicum at a neuropsych PP. I've been at this site less than a year and I'm already used to seeing older adults with age-normative feelings of sadness due to life changes, retirement, etc. being prescribed a cocktail of antidepressants, anxiolytics, mood stabilizers, etc. when they have zero history of mental health concerns except due to the above reasons. Even when individuals begin to lose some functional independence, it's entirely understandable they are sad. Additionally, we have done many evaluations for individuals that are taking drugs such as memantine when all they did was express "short term memory loss" to a neurologist during a 15 minute check up when it's, again, age-normative decline or something as simple as selective attention to their spouse.

It feels like medical malpractice is too strong a term for this and probably inaccurate, yet that's what it feels like to me. The entire perspective of "take a pill and you'll feel better" is troubling in my eyes, particularly since most of these symptoms I'm talking about can likely be alleviated with minor lifestyle changes.

 

[quickpsych]

I'm currently doing my external practicum at a neuropsych PP. I've been at this site less than a year and I'm already used to seeing older adults with age-normative feelings of sadness due to life changes, retirement, etc. being prescribed a cocktail of antidepressants, anxiolytics, mood stabilizers, etc. when they have zero history of mental health concerns except due to the above reasons. Even when individuals begin to lose some functional independence, it's entirely understandable they are sad. Additionally, we have done many evaluations for individuals that are taking drugs such as memantine when all they did was express "short term memory loss" to a neurologist during a 15 minute check up when it's, again, age-normative decline or something as simple as selective attention to their spouse.

It feels like medical malpractice is too strong a term for this and probably inaccurate, yet that's what it feels like to me. The entire perspective of "take a pill and you'll feel better" is troubling in my eyes, particularly since most of these symptoms I'm talking about can likely be alleviated with minor lifestyle changes.

Great points and an excellent educational experience. And I agree age normative sadness should be more strongly recognized and considered.

I agree that the take a pill fix the problem approach is a problem ; however specific to this population I can’t tell you how many patients I meet every week that think or believe indeed a pill can fix it and talk therapy is quackery (it’s not of course).

Have to keep in mind many of the much older population is still of an era where showing too much feeling or emotion was bad, being depressed or anxious was seen as a personal flaw and fault , and you went to your family doctor who fixed you up with a pill to feel better. This also extends to an of that era view on nutrition and health that a pill to fix the problem. Not every patient of course but remember many still grew up during a time when mental health was “you’re someone in an institution” and smoking Camel cigs was endorsed by medical doctors.

And when you have medical providers just throwing a pill at them it reinforces it.

All that said, I think it’s good to normalize and validate the feelings of course but at the same time if the patient appears truly improved by the medication they’re on and seem authentic in sharing they feel it’s helping them then that’s a net positive

 

[AcronymAllergy]

I'm currently doing my external practicum at a neuropsych PP. I've been at this site less than a year and I'm already used to seeing older adults with age-normative feelings of sadness due to life changes, retirement, etc. being prescribed a cocktail of antidepressants, anxiolytics, mood stabilizers, etc. when they have zero history of mental health concerns except due to the above reasons. Even when individuals begin to lose some functional independence, it's entirely understandable they are sad. Additionally, we have done many evaluations for individuals that are taking drugs such as memantine when all they did was express "short term memory loss" to a neurologist during a 15 minute check up when it's, again, age-normative decline or something as simple as selective attention to their spouse.

It feels like medical malpractice is too strong a term for this and probably inaccurate, yet that's what it feels like to me. The entire perspective of "take a pill and you'll feel better" is troubling in my eyes, particularly since most of these symptoms I'm talking about can likely be alleviated with minor lifestyle changes.

To be fair, I suspect a lot of the "take a pill and you'll feel better" philosophy comes from and was driven by patients. Someone sees their doctor and says they're sad. They don't like feeling sad and haven't felt sad like this before. The doctor, their PCP, isn't going to provide psychotherapy, and even if it's recommended, the patient probably doesn't want it ("I'm not crazy, doc," or, "I don't have time for that"). So the doctor has some medicines available that might help, could be taken short-term (e.g., during the time when the sadness might naturally run its course), and probably won't cause substantial side-effects.

 

[PsyDr]

1) I think it is beyond silly it say that say that a physician is not competent to prescribe. That’s just a losing argument.

2) The AMA owns the copyright to the CPT codes, and a substantial amount of very very valuable real estate. They don’t need membership dues for money. They need membership for relevance and collective bargaining.

3) One of the most interesting things I’ve seen on SDN was a psychiatrist saying that psychiatry is the application of medicine to mental healthcare. It makes sense that in that model, physicians are going to use their interventions for mental problems. I think rxp psychologists could do much better in defining how they apply prescribing psychological interventions. We are not there yet. But it is exciting.

 

[Sanman]

To be fair, I suspect a lot of the "take a pill and you'll feel better" philosophy comes from and was driven by patients. Someone sees their doctor and says they're sad. They don't like feeling sad and haven't felt sad like this before. The doctor, their PCP, isn't going to provide psychotherapy, and even if it's recommended, the patient probably doesn't want it ("I'm not crazy, doc," or, "I don't have time for that"). So the doctor has some medicines available that might help, could be taken short-term (e.g., during the time when the sadness might naturally run its course), and probably won't cause substantial side-effects.

Agreed. The problem is when they are still on that med 3 years later with no follow up.

 

[smalltownpsych]

Agreed. The problem is when they are still on that med 3 years later with no follow up.

Especially when it is more serious than I’m just feeling a little depressed or anxious because of stressors. Besides most of the mild to moderate types of symptoms they are treating, the effect is more likely placebo than anything else. I guess the question really is whether or not there is a downside to taking some of these medications long term for someone who doesn’t really need them.

 

[Sanman]

Especially when it is more serious than I’m just feeling a little depressed or anxious because of stressors. Besides most of the mild to moderate types of symptoms they are treating, the effect is more likely placebo than anything else. I guess the question really is whether or not there is a downside to taking some of these medications long term for someone who doesn’t really need them.

There absolutely is. Especially in the older population where liver and kidney function are often compromised. I would love a psychopharm degree just to be able to complete a gradual dose reduction while undergoing psychotherapy and addressing these concerns. Instead, I have clients that bounce between me, their PCP, and sometimes the psychiatrist without enough communication or treatment planning.

 

[medium rare]

There absolutely is. Especially in the older population where liver and kidney function are often compromised. I would love a psychopharm degree just to be able to complete a gradual dose reduction while undergoing psychotherapy and addressing these concerns. Instead, I have clients that bounce between me, their PCP, and sometimes the psychiatrist without enough communication or treatment planning.

Precisely. A big part of why I decided to go back to school to prescribe/manage medication was because of the ongoing difficulty I experienced with cross-provider communication and treatment planning - something that’s nearly impossible to do in the current healthcare environment.

A good amount of my day-to-day work involves reducing meds and/or un-prescribing ineffective or inappropriate medication regimens and integrating psychopharmacology with psychotherapy.

 

[bcliff]

Do prescribing psychologists bill E/M codes? or does the CMS physician definition still impede that? or are those two separate APA / policy issues?

 

[PsyDr]

Do prescribing psychologists bill E/M codes? or does the CMS physician definition still impede that? or are those two separate APA / policy issues?

Prescribing psychologist can bill em codes for any insurance other than Medicare.

 

[eeor1006]

I am interested to see more research on the effectiveness and clinical impact of RxP psychologists. This is exciting.

 

[WisNeuro]

I am interested to see more research on the effectiveness and clinical impact of RxP psychologists. This is exciting.

I'd be interested to see pretty much any good effectiveness and impact research in healthcare. It'd hard to compare RxP research to something that doesn't exist in the first place.

 

[PsyDr]

I am interested to see more research on the effectiveness and clinical impact of RxP psychologists. This is exciting.

It's a 5-7% reduction in suicide rates.

Roy Choudhury, A. and A. Plemmons (2023). "Effects of giving psychologists prescriptive authority: Evidence from a natural experiment in the United States." Health Policy 134: 104846.

 

[NeuroObsessed]

New Mexico also had a pretty big win this past week, expanding their prescriptive scope. I believe it removed most restrictions on what they can prescribe, and just states that they can prescribe meds consistent with the practice of clinical psychopharmacology, allows prescriptions of meds to help protect from or manage side effects that are a result of psychotropic meds, and now allows them to administer injections (previously they could only prescribe them, but I believe administration is allowed only with additional board approved training).