Psychiatr News August 3, 2007
Volume 42, Number 15, page 2
© 2007 American Psychiatric Association
Governor's Veto Seals Fate of Hawaii Prescribing Bill
Rich Daly
Psychiatrists cite the governor's deep understanding of mental illness
and its treatment, a legislator-education effort, and a solid coalition of
opponents for the demise of a prescribing bill.
Hawaii Gov. Linda Lingle (R) vetoed a bill in July that would have given
psychologists in the state the authority to prescribe psychotropic
medications. The state legislature, which passed the bill on May 1, has opted
to forgo an override vote on the governor's veto.
Among the reasons for the veto that the governor cited in a letter to the
legislature was that the bill (SB 1004) would not have required medical
supervision of the psychologists authorized to prescribe medications. Other
reasons for the veto, she said, were that it did not require psychologists to
obtain "sufficient didactic and clinical training for prescriptive
authority" and that it would allow psychologists to prescribe outside of
Federally Qualified Health Centers (FQHCs)—a component of the bill that
supporters claimed would have limited the prescriptive authority it
granted.
The veto message echoed many of the concerns psychiatrists had raised about
the limited level of training required by the prescribing program,
specifically the lack of classes in cell biology and clinical pharmacology
(Psychiatric News, June 1).
"APA applauds the leadership and continued efforts by patients, their
families, and physicians in Hawaii to ensure that Hawaiians are not subjected
to substandard and potentially dangerous care," said APA President
Carolyn Robinowitz, M.D., in a written statement issued after the veto was
announced July 10. "APA strongly supports its state associations in
their ongoing efforts to vigorously resist efforts to allow psychologists to
practice medicine without the benefit of medical school and supervised medical
residency."
The governor cited opposition to the bill from both the Board of Medical
Examiners and the Board of Psychology in her veto decision. The Board of
Psychology did not want to take on the medical oversight role mandated in the
bill. The Hawaii Psychiatric Medical Association, an APA district branch,
coordinated a coalition of opponents to the bill, which included the AMA and
several consumer groups. The American Society of Anesthesiology and American
Academy of Ophthalmology joined APA in opposing the bill.
Jeffrey Akaka, M.D., a Hawaii psychiatrist and speaker of the APA Assembly,
testified on numerous occasions that the proposed training would leave the
psychologists unprepared to recognize and deal with the complex interactions
of psychotropic medications.
One of the keys to stopping the prescribing bill, Akaka told
Psychiatric News after the veto, was an educational effort directed
at legislators that clarified the extensive biochemistry course work medical
students undertake to understand the impact of medications on various types of
patients.
Supporters of the psychologist-prescribing bill had claimed that it was
modeled on the Department of Defense's Psychopharmacology Demonstration
Project (PDP), which trained a small number of psychologists to prescribe in
the 1990s. However, the governor concluded that the program the bill aimed to
create "differs significantly" from the PDP. The proposed state
program lacked the Pentagon program's specific requirements on the number of
pharmacology classroom hours required and how many months of inpatient and
outpatient care were needed to qualify for a "prescription
certificate."
Bill supporters "were trying to claim that the bill was as intensive
as [the PDP], but the current bill bore no relation to that program,"
Akaka said.
Another difference was that the PDP required close supervision by a
psychiatrist with "advanced training in psychopharmacology," while
the rejected bill only would have required any physician to supervise
psychologists for two hours each week.
The governor also criticized the proposed program because its practicum
training would have taken place in small-scale FQHCs and not the comprehensive
medical centers in which the PDP psychologists trained.
"The clinical experience settings are distinctly different, and the
bill's practicum training is not comparable to that provided in the PDP
model," Lingle said in her veto message.
An expansion in the scope of practice for prescribing psychologists beyond
what was allowed under the PDP also was cited as a reason for her veto.
Psychotropic medication prescriptions by PDP psychologists were limited to
patients aged 18 to 65 with "mental conditions" but without
medical complications as evaluated by a supervising psychiatrist. The state
program would have allowed participating psychologists to prescribe to
patients of any age, including children, and those with medical problems
comorbid with their mental illness.
Concerns about the unique challenges presented by psychotropic use in
minors contributed to opposition to the bill from the American Academy of
Child and Adolescent Psychiatry (AACAP).
"Psychologists are an important part of the treatment team, but do
not have the years of training required to prescribe medication," said
Alfred Arensdorf, M.D., delegate to the Hawaii Council of Child and Adolescent
Psychiatry.
Although proponents of the psychologist-prescribing bill have pushed for
legislative enactment of such a program for more than 20 years, legislative
leaders declined to hold a veto override vote on it during the legislature's
one-day special session for such votes on July 10. A two-thirds majority in
both chambers is required to override a veto.
The need for many more child and adolescent psychiatrists that bill
supporters said prevents access to needed medications could be addressed
through passage of the federal Child Health Care Crisis Relief Act, (S 1572,
HR 2073) which would aim to increase the number of professionals providing
comprehensive clinical mental health care to children and adolescents,
according to AACAP.
Other federal action is needed, Akaka said, to lift burdensome restrictions
on federal funding for psychiatrists in community health centers, which are
readily allowed to fund allied health care workers, such as psychologists.
Akaka said Hawaii has made great progress in recent years to improve access
to care for residents with serious mental illness, evidenced by the success of
a small number of health centers to overcome the extra paperwork needed to
procure federal funding for psychiatrists. Additionally, Hawaii has launched
two telepsychiatry programs to provide care for residents in rural areas of
the island chain.
The governor's veto letter to the legislature is posted at
<www.hawaii.gov/gov/leg/2007-session/Folder.2007-04-13.1315/index_html>
under SB 1004. 
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