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The Honolulu Advertiser
Posted on: Thursday, March 30, 2006

Psychologist prescription bill is a must

By Beth Giesting

With the stroke of a pen, Hawai'i lawmakers have the power to improve access to mental healthcare for an estimated 55,000 people served by nonprofit community health centers in our state's poorest and most underserved rural areas.

Their need is dire, and the situation is only getting worse.

The solution is the Hawai'i Primary Care Association's House Bill 2589, which would allow appropriately trained licensed psychologists working at community health centers to prescribe and adjust medication to treat mental-health issues.

Waiting times for these patients to see a psychiatrist range from six weeks to three months. On the Neighbor Islands, where the shortage of psychiatrists is most acute, many patients are told they can't get an appointment at all. In 2005, only five new psychiatrists finished their training in Hawai'i, compared to 34 new psychologists. In 2004, the most recent available data, there were only six psychiatrists serving three of Hawai'i's 13 community health centers, compared to 10 psychologists serving nine of the centers.

The primary opposition to this bill comes from the state psychiatric association. This issue is not new to the Legislature. For more than a decade, psychiatrists have fought giving psychologists the authority to prescribe by promising to improve care in rural areas, yet year after year, the situation has remained dismal.

It's not that psychiatrists don't care. It's just that there are simply not enough of them to go around, and as with many things in life, the poor and the needy go without.

And 55,000 individuals, real people in desperate need of mental healthcare, are at risk and waiting in vain.

This bill is widely supported by the medical directors and administrators of the community health centers and also by the Hawai'i Nurses Association, HMSA, and the Hawai'i Psychological Association. Indeed, the bill was drafted by Rep. Josh Green, vice chairman of the House Health Committee and a Big Island physician who provides emergency room care in a rural setting.

In written testimony supporting the bill, HMSA states that this "could have a large impact for individuals in need of these services."

But is it safe?

Absolutely. Precedent has been set time and time again: Non-medical doctors, including dentists and optometrists, have safely prescribed medication within their areas of expertise for years. In Hawai'i, advanced practice nurses and physician assistants can also prescribe medication.

Moreover, psychologists are already prescribing in New Mexico, Louisiana and within the Department of Defense; the latter has been prescribing for nearly 10 years. In Louisiana, psychologists have written more than 10,000 prescriptions without incident. In fact, there is no record of a patient being harmed by a prescribing psychologist in any of these settings.

Elaine Orabano Mantell, Ph.D., a DOD prescribing psychologist since 1997, reports: "I have never had a single adverse outcome. I have never had a single complaint leveled against me with regard to any of my clinical work, including my use of medications. On the contrary, I continue to receive more referrals than any one individual can handle because the need for treatment is so great."

HB 2589 would require doctorate-level psychologists to undergo four and a half years of intensive supervised training prior to prescribing a limited number of medications for our neediest individuals. This is in addition to the seven years of doctoral training in the diagnosis, assessment and treatment of mental and emotional disorders already required to become a licensed psychologist.

This advanced curriculum is based on the recommendations of a blue-ribbon panel of experts that included input from people in psychiatry, pharmacology and psychology. And just as dentists and optometrists only prescribe medications related to their expertise, appropriately trained psychologists would only prescribe medicines relating to mental health.

The current bill has already been amended to limit the types of medications to address safety concerns.

But most importantly, this bill will improve the safety of the people of Hawai'i by increasing access to high-quality mental healthcare in underserved rural areas.

But can we afford it?

The bill will cost the taxpayer nothing. Psychologists are already working in the rural health clinics. The cost of additional training will be borne by the individual psychologists. The real question is, can we afford not to do this?

We have nothing to lose but the artificial roadblocks that prevent our most underserved populations from getting the care they need.

Beth Giesting is the executive director of Hawai'i Primary Care Association. She wrote this commentary for The Advertiser.