Jill Oliveira, a licensed clinical psychologist, usually spends three days a week on Moloka'i, helping doctors with patients who have emotional or mental health needs.

Like in many rural areas of Hawai'i, people on Moloka'i have limited access to psychiatric care and often rely on primary-care physicians or psychologists for help with stress, depression, anxiety or more severe mental disorders. But, unlike psychiatrists and other doctors, psychologists such as Oliveira are not allowed to prescribe medication for patients because they lack medical education and training.

"I've been working on Moloka'i for four years and the access to quality psychiatric care has not changed," Oliveira said, "so I'm dedicated to make something different."

In a close vote, the state House agreed this month to give psychologists the limited ability to prescribe antidepressants to patients at 13 federally qualified community health centers and at health clinics in areas where there is a shortage of mental health professionals. The bill now goes before the Senate, where similar legislation failed last session in an unusual deadlock after one supporter missed the vote because of illness.

For more than two decades, many psychologists have wanted to be allowed to prescribe medications but have been challenged by psychiatrists, who believe psychologists are not medically qualified and could put patients at risk. Only two states, New Mexico and Louisiana, allow psychologists to prescribe drugs, along with the U.S. territory of Guam.

While few dispute that access to psychiatric care is scarce in rural and many urban areas of the state, some believe psychologists are conveniently using access as an excuse to expand their scope of practice without taking the necessary medical training.

"That's like giving an airplane mechanic, who spent many years learning how to repair an airplane, a pilot's license," said psychiatrist Dr. Jeffrey Akaka, medical director of the Diamond Head Community Mental Health Center.

'PSYCH VS. PSYCH'

The "psych vs. psych" conflict is the latest in a series of turf battles among doctors, who previously fought efforts by nurse practitioners, physician assistants, optometrists and osteopaths to gain the authority to write prescriptions. Some psychiatrists say the other disciplines are grounded in medicine while psychologists specialize in counseling and crisis care.

Originally, lawmakers had considered giving psychologists the authority to prescribe a broader array of drugs, including antipsychotic drugs used to treat severe mental health problems such as schizophrenia. An interim task force, which included key lawmakers and psychologists and psychiatrists, met after last session to find a compromise but the sides were unable to agree.

The current House bill would give psychologists narrow prescription rights for antidepressants if they complete psychopharmacological training, one year of supervised practice involving 400 hours of treating at least 100 patients with mental disorders, and a national pharmacology proficiency exam.

Each side has marshalled experts. Opposing the bill are the American Psychiatric Association, the Hawai'i Psychiatric Medical Association, the state Department of Health and the Board of Medical Examiners. The American Psychological Association, the Hawai'i Primary Care Association, and medical directors at community health centers favor the bill.

Several lawmakers said influential lobbyists and advisers have been able to to keep the issue in play at the state Capitol.

Alex Santiago, a former state lawmaker and state Democratic Party chairman, and Patrick DeLeon, chief of staff to U.S. Sen. Daniel K. Inouye, D-Hawai'i, side with psychologists. Santiago, former chairman of the House Health Committee, said he regrets not prodding psychiatrists to cover more rural areas years ago. DeLeon, the former president of the American Psychological Association, has been a leading national advocate for prescriptive authority.

Bob Toyofuku, one of the state's top lobbyists and a veteran Democratic insider, and Lydia Hemmings, wife of state Senate Minority Leader Fred Hemmings, R-25th (Kailua, Waimanalo, Hawai'i Kai), are working with the psychiatrists. Lydia Hemmings is executive director of the Hawai'i Psychiatric Medical Association.

Other lawmakers said the bill may have a better chance this session because of state Rep. Josh Green, D-6th (Kailua, Keauhou), a Big Island doctor who has sided with psychologists. Green, the only doctor in the Legislature, said psychiatrists have tried to use scare tactics.

"They put the fear of God into people, saying it's unsafe. What's unsafe is for people not to have mental health coverage," he said.

State Rep. William "Bud" Stonebraker, R-17th (Hawai'i Kai, Kalama Valley), an opponent of the bill, said psychologists should get a medical education if they want prescription rights and believes psychotropic drugs are overprescribed. He said that a lack of access to psychiatric care should not justify expanding prescription rights to psychologists.

"You could pass anything based on that. That's not the underlying principle on which we pass legislation. I could say there is a lack of attorneys in my house, so I must be able to practice law," Stonebraker said. "No."

SERVING THE POOR

The community health centers and health clinics often serve the poor and vulnerable, including many people who neglect medical conditions until they worsen or are suffering with drug and alcohol abuse. The Waikiki Health Center, in testimony to the House, estimated that 30 percent of its patients are in need of behavioral health services.

At the Wai'anae Coast Comprehensive Health Center, doctors say about two of every three patients have a behavioral element to their health problems.

Oliveira, the psychologist, supervises Native Hawaiian psychology trainees at Tripler Army Medical Center and works with Na Pu'uwai Native Hawaiian Health Care System and also with the Moloka'i 'Ohana Community Health Center. She said psychologists who complete the training and get prescription rights under the bill would work with primary care physicians at health centers and clinics.

"Basically to maintain the status quo of no treatment, particularly in these rural areas, is a significant patient safety issue," she said.

As part of its safety net for the poor, the state provides psychiatric care for young people through the Department of Education and for adults through the Department of Health's community mental health centers.

But psychiatrists say the training for psychologists called for in the House bill is no substitute for the coursework and clinical requirements for doctors, which includes medical school, an internship and residency. The Hawai'i Medical Association and others have urged psychologists interested in prescriptive authority to take the two-year program for advanced practice registered nurses at the University of Hawai'i-Manoa.

"It should be laughable," Akaka, the psychiatrist and nephew of U.S. Sen. Daniel Akaka, D-Hawai'i, said of the training comparisons. "I mean this thing shouldn't have even come up."

Reach Derrick DePledge at ddepledge@honoluluadvertiser.com.