Earlier this year, Utah became the seventh state to allow psychologists with the proper training to prescribe psychotropic medications, giving supporters reason to hope that more states might support expanding this scope of practice.
However, the American Psychiatric Association -- and some psychologists -- oppose granting psychologists this privilege, arguing that the training offered is insufficient and could jeopardize patient safety.
The controversy over whether psychologists should be allowed to prescribe is as old as the so-called RxP movement itself, which began in the early 1990s.
Psychologists have not rushed to become licensed prescribers. After three decades, an estimated 226 psychologists -- representing just 0.14% of all those licensed in the United States -- have been authorized to prescribe in the six states and one territory where it has been legalized, according to a just-published study in Clinical Psychology.
These are Colorado, Idaho, Illinois, Iowa, Louisiana, New Mexico, and Guam. Data from the study show that only 73 psychologists are prescribing in New Mexico, which authorized it in 2002.
Less is known about the number of psychologists who are prescribing under allowances in the Department of Defense, Indian Health Service and US Public Health Service.
Some psychologists -- and the American Psychological Association (APA) -- believe that the persistence of the opioid epidemic coupled with a continued lack of access to mental health care for millions of Americans will bring more legislators on-side.
"I feel like we're on an upswing again," Deborah Baker, director of legal and regulatory policy for the APA, told Medscape Medical News. "The access issue continues to be a perennial kind of driver." She noted that at least six states pursued expanding privileges this year.
Robert Trestman, MD, chair of the American Psychiatric Association's Council on Healthcare Systems and Financing, said he doesn't see new momentum. The interest in having psychologists prescribe "continues to trickle based on just the frustration that people have about not getting adequate access to psychiatry," he told Medscape Medical News.
While states may be trying to increase access to care, granting psychologists privileges is "not a very effective way of doing it," said Trestman, Chair of Psychiatry and Behavioral Medicine at Virginia Tech Carilion School of Medicine in Roanoke. Psychologists are needed to deliver psychotherapy, he said. "It makes almost no sense to try to make them into pseudo medical professionals," said Trestman. "It just exposes people to risks."
William Robiner, PhD -- author of Clinical Psychology study -- is a long-time opponent of RxP. The psychologist told Medscape Medical News he's concerned about patient safety and "about some of the disingenuous reasons" that psychologists want to prescribe. Among these are the ability to increase status and income, said Robiner, a professor of medicine at the University of Minnesota Medical School, Minneapolis, and a board member of Psychologists Opposed to Prescription Privileges for Psychologists.
Only PhD and PsyD psychologists are eligible for RxP training, which entails a master's in clinical psychopharmacology. After receiving the master's, they must pass the Psychopharmacology Examination for Psychologists and then are only permitted to prescribe medications for mental health disorders.
They must also obtain a Drug Enforcement Administration license but can't write prescriptions for schedule 2 medications. In some states, psychologists can prescribe buprenorphine and other opioid use disorder medications.
The APA has developed guidance for master's programs, which currently number just over a handful in the United States.
At Fairleigh Dickinson University in New Jersey, students enrolled in the master's program -- a distance-learning format -- complete 10 courses over five 15-week semesters. The curriculum spans a range of topics, from foundational sciences and legal and ethical considerations to strategies for treating specific disorders.
Derek Phillips, PhD, the program's executive director, said that when he took the position in 2020, enrollment was capped at 45 students, but "we were not routinely enrolling the maximum." Now, even with class size increased to 60 "we are consistently full and have a waitlist," he told Medscape Medical News.
Interest is being driven in part by new laws in Colorado (2023) and Utah, said Phillips. But many are enrolling without intending to write a prescription, he said. The degree gives graduates the ability to better collaborate with other clinicians, teach clinical psychopharmacology, and be expert witnesses in medico-legal cases, he said.
In addition, the training gives students "a balanced and thorough biopsychosocial understanding of our patients," he said. Students also see the "potential of being able to be a 'one-stop-stop' of mental health services," said Phillips.
The American Board of Professional Psychology is developing a board certification in clinical psychopharmacology.
The APA states on its website that prescribing psychologists have "more training in diagnosing and treating (including prescribing) mental health disorders than primary care physicians."
However, critics argue that the training falls short. Most psychologists, said Robiner, have not completed the undergraduate prerequisites -- such as anatomy, physiology, and chemistry -- that are required for other prescribing professionals.
In a 2019 article comparing the training of prescribing professionals, Robiner and colleagues reported that psychiatrists undergo 4- to 6-week rotations during medical school and accumulate 8000 clinical hours focused on psychiatric conditions over the course of their 4-year residencies.
States set requirements for clinical hours for prescribing psychologists, but they are generally elective and completed after individuals receive a master's degree.
Robiner said psychologists aren't trained in evaluating drug-related adverse events. "If you show a psychologist a rash, they have no idea whether that rash might be a medication adverse effect or poison ivy," he said.
Trestman pointed out that many psychotropic medications have black box warnings. "The risk of toxicity is by no means trivial, and the majority of people who are seeking care in psychiatry have multiple comorbidities," he said. "Giving people the equivalent of more or less 10 weeks of training is just woefully inappropriate," Trestman said.
Psychology's main argument for expanding its scope of practice is that it will increase the number of clinicians available to provide behavioral and mental health care.
Critics said that is a failed experiment, in part because so few psychologists have become prescribers, but also because most psychologists practice in the same areas as psychiatrists. Both specialists tend to cluster in urban regions, which already have high clinician density, said Trestman.
Psychologists are not practicing in underserved rural areas, as even APA data show. A 2018 APA snapshot of the workforce found that the highest density of psychologists was in Washington, DC, Massachusetts, and New York. South Carolina, West Virginia and Mississippi had the fewest number of psychologists per 100,000 people.
The University of Washington Rural Health Research Center reported in 2022 that in 2021, almost half of rural counties did not have a psychologist compared with 15.7% of urban counties.
Psychiatrists also are concentrated on the coasts and New England, according to a study by Ohio State researchers. The highest densities were in Washington, DC (79 per 100,000), Massachusetts (45.3), Rhode Island (42.6), Connecticut (38.6) and Vermont (37.7), whereas the lowest densities were in Idaho (11.8), Mississippi (11.8), Wyoming (12.4), Alabama (13.1), and Indiana (13.5). The study estimated that there were 57,163 psychiatrists responsible for the care of 333,287,557 Americans. "Clinical psychologists, psychotherapists, and counselors can provide alternative forms of intervention, though access to such services is also poor in rural areas," wrote the authors.
The APA counters with data it says shows that RxP may have increased access. Using the number of psychology practices as a proxy for supply, the authors reported that practices grew in New Mexico, Illinois, Iowa, and Idaho -- states that have implemented prescription privileges. Overall, there was an increase of 0.8047 practices per 100,000 residents per county.
However, the access argument "is seriously challenged by the reality of the limited number of psychologists who complete the pathway to prescribing," Robiner and his colleague Tanya Tompkins countered in Clinical Psychology. They note that in Idaho -- a state with shortages of psychologists and psychiatrists -- just 10 of the state's 615 psychologists had prescriptive authority. An estimated 5131 nonpsychologists are prescribers.
Robiner and Tompkins noted that it's not clear why so few psychologists are pursuing RxP but that many seem to be unaware of the possibility.
There is not a large body of literature assessing the harms or benefits of prescribing privileges for psychologists.
Baker shared several studies by Phillip Hughes, PhD, an outcomes researcher at the Eshelman School of Pharmacy, University of North Carolina at Chapel Hill. In one study, Hughes found that patients of prescribing psychologists had a 24% lower rate of adverse drug events than patients of psychiatrists. Psychologists' patients had lower rates of psychotropic polypharmacy but similar rates of emergency room use.
In another paper Hughes suggested that deaths attributable to mental illness had declined in New Mexico after it passed its law. There was no change in Louisiana.
With little evidence of harm -- and ongoing provider shortages -- making use of nonphysician prescribers is gaining traction with policymakers, claims the psychology association's Baker, adding that in Utah, the Republican governor was the biggest supporter.
But psychiatrists argue that it's more important to increase their numbers. Congress agreed in 2021 and 2023 to add 1200 new residency slots -- in every specialty -- to ease physician shortages. The Centers for Medicare & Medicaid Services recently announced that 70% of the new slots for July 2025 will go to primary care and psychiatry.
"Once those positions are in place, it will be four more years before the first crop of new psychiatrists come out," noted Trestman. "None of these fixes are quick," he said.
Baker, Robiner, and Trestman reported no relevant financial relationships.