California Psychiatric Association
Legislative Priorities for 1999
Senate Bill 2050 Literature

Why SB 2050 Is Dangerous

WHAT SB 2050 DOES:

SB 2050 authorizes psychologists who take certain course work in pharmacology and neurology and serve an 800-hour preceptorship to prescribe brain medications, with no physician supervision. The program would be regulated by the Board of Psychology, not the Medical Board.

WHY SB 2050 IS DANGEROUS TO PUBLIC HEALTH AND SAFETY:

• SB 2050 is Based on a Fundamentally Flawed Premise. SB 2050 is based on the premise that since medications prescribed by psychiatrists affect behavior, therefore psychologists, who are trained in human behavior, can prescribe brain medications, without physician supervision, after receiving some training in neurology and use of these medications. The flaws in this premise are twofold: (1) the incorrect assumption that medications are prescribed to treat behavioral problems, rather than medical problems with behavioral symptoms, and (2) the incorrect assumption that the medications only affect the brain rather than the whole body.
  
• Not one state authorizes psychologists to prescribe medication. Does California want its citizens with brain disorders to be the guinea pigs?

• SB 2050 potentially endangers the health and even the lives of our most vulnerable citizens. SB 2050 would have "certified psychologists" spending 80% of their prescribing time the first 3 years serving rural citizens, the poor, seriously and persistently mentally ill, homeless, those in prisons and jails, the disabled, the elderly, and those with special needs due to cultural or language barriers. This bill would have these new prescribers experimenting on the most vulnerable and most medically high risk people in our society. Many of these patients who require brain medications have other serious medical conditions requiring medications, and those in institutions would potentially lose access to medical care under this bill. This bill assumes the patient's only problem is a behavioral one. To protect the health and safety of the patient, and sometimes even the life, the treatment of the other illness and the effects of the other medication must be integrated with the use of the brain medication and other psychiatric treatment.

• Medications are used to treat medical problems, not behavioral ones. The medications used to treat brain disorders whose symptoms are behavioral are among the most powerful available to modern medicine. They are used to treat biological diseases, such as schizophrenia, manic-depression, severe depression, panic disorder, and obsessive-compulsive disorder. They are the product of sophisticated research and development, and can work miracles for many patients. The medications go through the entire body, not just the brain, affecting other body functions and organs, and can have side effects such as convulsions, heart arrhythmia, blood diseases, seizures, severe high or low blood pressure, severe constipation, coma, stroke, or even death or permanent disability. Psychiatrists sometimes prescribe accompanying medications, for example thyroid medications, to minimize those side effects, and thorough medical training is needed to do this.

• The issue is patient safety, not access to care. There is not a shortage of persons legally able to prescribe these medications, because all physicians are legally authorized to prescribe medications for brain disorders, but, despite (or more probably, because of) their medical school educations and family practice residency training, and in the interest of patient care, family practitioners often refer the patients with potential severe brain disorders to specialists.
  
  In February, 1998, the California Medical Association adopted a policy to foster
  increased continuing medical education for family physicians (who are the first health care provider to see about 80% of patients with brain disorders) in diagnosing, treating, and, when appropriate, referring patients with psychiatric brain disorders. It was supported by the psychiatrists and family physicians' associations.
  
  Further, medical schools in California and elsewhere have recognized the need for more psychiatric training for family practice residents, and are now offering combined residencies in family practice and psychiatry. U.C. Davis and U.C. San Diego had such programs approved in 1996. U.C. Davis also has a telemedicine program for psychiatric consultations, in which patients and their doctors in rural primary care clinics can consult by closed circuit with psychiatrists at the U.C. Davis medical center.

• The alleged shortage of psychiatrists in rural California does not exist. Psychologists claim that rural California lacks psychiatrists, citing statistics of the residence addresses of board-certified psychiatrists. The California Psychiatric Association has conducted research through county sources and local telephone books, and has determined not only that all counties have psychiatric coverage, but in many rural counties psychiatric coverage exceeds psychologist coverage. A one-page summary of this research is attached.

• Effective use of medications to treat these brain disorders requires medical training, with a thorough understanding of physiology, chemistry, drug interactions, and medical problems that masquerade as or cause brain malfunctions. Psychiatrists and other physicians are legally required to have 4000 or more classroom hours of medical school, which must include at least 72 weeks of clinical training, 54 of which is in the medical school's hospital, and one year of internship in a medical setting before they may be licensed to practice medicine. To be a psychiatrist, they also must have 4 or more years (with 10,000 to 12,000 hours) of residency. Psychologists are legally required to take only one course in the biological basis of behavior ( and no other courses in human biology) prior to their Ph.Ds., and being licensed to practice psychology. SB 2050 allows psychologists to prescribe brain medications, unsupervised, with some additional training in neurology and pharmacology from a professional school of psychology, plus 800 hours of preceptorship.

• A recent federal pilot project shows that psychologists with substantial training in prescribing medication still require psychiatric supervision. Under the direction of Congress, the federal Department of Defense conducted a pilot project in which Ph.D. psychologists underwent 3 or more years of full-time training in prescribing medications. A program audit by the General Accounting Office concluded that the program was not justified and recommended it be terminated, because after the substantial training, the psychologists still required supervision by a psychiatrist, and even then, the psychologists were allowed to prescribe only to patients between 18 and 65 who had been certified by a physician as having no other medical problem.

• SB 2050 is not a bill about access to care. It is a simple attempt by the psychologists to receive a license to practice medicine by legislative fiat rather than going to medical school. The demand for additional prescribers is from the psychologists who want to write prescriptions, not from consumers. Access to care problems exist because many health insurance programs discriminate in their coverage against brain disorders and diseases, not because of a lack of psychiatrists.

• Psychologists deal with human behavior, not human biology and pathology. Their training is in talk therapy. They are required to take only one course in their graduate work in the biological basis of behavior. Even if SB 2050 is enacted, almost none of their biological training would go below the neck. The proponents of this bill would lead people to believe that the mind can be isolated from the brain and the rest of the body.

• Modern psychiatry looks at patients from an integrated brain-body standpoint, seeking the biological factors (which could be in the liver, pancreas, kidney or thyroid, for example) in the brain disorder. Psychologists are not trained to do this, and may therefore misdiagnose and prescribe an entirely inappropriate medication.

Highlights of Spring, 1996 Survey of Psychiatry in Rural California by California Psychiatric Association:

• Only Alpine County did not have psychiatric coverage (14 patients/ 1200 residents).
• 4 counties had no psychologists (Alpine, Colusa, San Benito and Sierra)
• 11 counties had no psychologists listed in the phone book, and 7 counties had only 1 psychologist (including school psychologists) registered with the Board or in the phone book.
• Physicians outnumber psychologists by between 29 to 1 and 16 to 1! In 14 of the counties, psychiatrists available to treat patients may outnumber psychologists.
• Since telephone listings would reveal those available to treat patients in that county, there may actually be fewer psychologists available in rural California counties than psychiatrists.

* Counties of less than 140,000 population

(1 ) Source: California Dept. Of Finance, July 1995
(2 ) Source: California Medical Board
(3 ) Source: county Mental Health and telephone books
(4 ) Source: first number is psychologists listed in the telephone book, second number is from the Board of Psychology, and includes school psychologists.