March 20, 2023
Colorado Governor Jared Polis signed House Bill 1071 a week ago which allows Colorado psychologists to prescribe mental health or psychiatric medications to their patients. This bill passed into law despite objections from psychiatrists, who are medical doctors.
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Is this crafty, expanding the supply of much-needed mental healthcare workers? Or is this crazy, on par with hiring based on diversity rather than competence? Let’s take it apart and see.
Many people believe that psychiatrists and psychologists are more or less the same, but based on training they are not, even though they treat the same diseases and patients.
Psychiatry training includes a college degree, four years of medical school, then an additional four years of psychiatry residency training. Some psychiatrists complete an additional 1-2 years of fellowship training in such fields as child and adolescent psychiatry, addiction, forensic, or geriatric psychiatry.
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Clinical psychologists, after their college degree, obtain either a master’s or doctoral degree, taking an additional 2-5 years.
Post college training for a psychiatrist is at least eight years, for a clinical psychologist, from 2-5 years. Is this difference important or relevant?
Is a paralegal the same as an attorney? A paralegal needs a two-year associate degree while an attorney needs three years of law school after four years of college, a five-year educational difference.
Psychologists and psychiatrists both care for a variety of mental health patients and both are essential parts of a woefully understaffed mental health-care system in America.
These “turf battles” are common in the health-care world. Examples include ophthalmology versus optometry, internists versus nurse practitioners, midwives versus obstetricians, or anesthesiologists versus nurse anesthetists.
For most routine care, the differences are insignificant, but medicine isn’t always routine. For many centuries, midwives delivered babies. For a normal delivery, no problem. Not so for an umbilical cord tight around the baby’s neck, a placenta previa, or other unusual birth presentations that need the skills of an obstetrician.
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Flying a plane may be routine for a junior pilot but when weather, engine failure, or myriad other mishaps occur, experience can be the difference between life and death. Ask the passengers on Captain Sully Sullenberger’s flight, which he landed safely in the Hudson River.
Could a novice pilot have handled the same scenario? Fortunately, this was a rare occurrence, but these one-off events don’t announce themselves in advance.
This new Colorado law is not just the right to prescribe psych meds. There are several significant hoops for psychologists to first jump through. As the Colorado Sun noted:
The law creates a path for psychologists to write mental health prescriptions, requiring that they receive a postdoctoral master’s degree in clinical psychopharmacology. They also would have to pass a national board exam and go through a year of preceptorship under a licensed prescriber. For the following two years, they would have a conditional prescription certificate allowing them to prescribe medications only under the supervision of a consulting physician.
So, an additional master’s degree, standardized exam, preceptorship, and supervision totaling five years would be required before a psychologist could prescribe prescription psychiatric meds on his own.
To me this seems a reasonable amount of additional training rather than simply giving psychologists a green light to prescribe. Will it be foolproof? Hardly. Psychiatrists often prescribe many different medications or combinations before finding the best therapy. This is called the art of medicine and will continue to challenge psychiatrists and psychologists.
There are not enough practicing psychiatrists currently. Insurance reimbursement is inadequate, and many psychiatrists do not accept insurance, preferring cash or credit card, to cover the costs of practice and earning a living commensurate with 8-10 years of training post college.
Many patients wait months for an appointment with a psychiatrist, and if in crisis, the emergency room or self-care won’t cut it. More than half of U.S. counties lack a single psychiatrist.
The Psychiatric Times notes the shortage:
The COVID-19 pandemic has exacerbated the psychiatry shortage, particularly in rural areas and small towns. Depression, anxiety, grief, and substance abuse have soared during the pandemic, but 111 million Americans live in a psychiatry shortage area, according to the US Department of Health and Human Services — and the current shortage of 6% is expected to be between 14,280 and 31,109 psychiatrists by 2024. The number of physicians entering specialties increased between 2003 and 2013; however, during that same period, the number of physicians entering psychiatry decreased by 0.2%.
Psychiatry is the third oldest medical specialty for age with the average age of practicing psychiatrists at 55 years old, meaning younger medical school graduates are choosing other specialties and the shortfall will increase as practicing psychiatrists cut back their workload or retire.
Low compensation is another challenge, especially for younger physicians saddled with six-figure student loan debts from college and medical school.
Increasing insurance payments would help, but that’s paddling upstream against continued payment cuts to physicians. Shortening a psychiatry residency from four to three years would help, but one could then argue that mandating an additional five years of training for psychologists is accomplishing the same thing in a different way.
America faces a mental health crisis, and increasing the supply of practitioners to care for the numerous patients in need is absolutely necessary. Five states already allow psychologists to prescribe prescription psych medications, including New Mexico, which instituted a similar law 20 years ago.
AI may replace physicians at some point, but think of that as a self-driving car. It works well most of the time under optimal conditions. But when things are not routine, there is nothing like the human brain to sort things.
As Colorado is on the vanguard of other mental health issues including legalized marijuana and mushrooms, it makes sense that Colorado would be leading the charge on expanding mental healthcare. Especially and ironically since these substance laws might have pushed some individuals toward needing such care.
This Colorado law seems sensible and measured, aimed toward alleviating a major healthcare shortage. Time will tell how this experiment plays out. Hopefully for the good.
Brian C Joondeph, MD, is a physician and writer.
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