With the passage of prescriptive authority legislation for psychologists in the state of Iowa, four states join the Department of Defense, Indian Health Service, and territory of Guam in extending prescriptive authority to appropriately trained psychologists. As the APA press release suggests, this is now a well-established mechanism for expanding access to comprehensive mental health care. As psychologists adapt to broad changes in mental health care delivery, particularly the integration of psychological services into the primary care environment, knowledge of and ability to appropriately use psychotropic agents is becoming an increasingly important skill. But it is not simply access that matters here, it is the ability to access a provider who can appropriately balance pharmacological and non-pharmacological treatments to produce better outcomes.
Epidemiological data are clear that medication is the de facto treatment for all common mental disorders in the United States. Most patients with mental disorders are seen by primary care providers, not specialists, and most of those patients get psychotropic medication and no other form of intervention for their condition. I have long called this the “central paradox” in modern psychopharmacological treatment – that is, we know that for most mental disorders psychopharmacological treatments alone do not yield superior long term outcomes – but that is the only form of treatment most patients receive.
Prescribing psychologists can help rectify this paradoxical situation. By judiciously employing both medication and psychobehavioral treatments for those conditions where psychopharmacology is indicated, rather than reflexively writing a prescription for an antidepressant or a tranquilizer with no behavioral intervention, prescribing psychologists can demonstrably improve care for many patients. In my many years as a prescribing psychologist, I was continually reminded that the ability to write a prescription also meant that I could often improve a patient’s condition by simply reducing the number of psychotropics they were taking. When the only mental health tool most primary care providers have available is a prescription, polypharmacy becomes understandably common. “The power to prescribe is the power to unprescribe” is, then, more than a truism – it is a tool that prescribing psychologists can use to improve patient outcomes for many.