After more than two decades of struggling with psychiatrists and doubtful state lawmakers, some psychologists in Hawai'i may be allowed to prescribe a limited number of drugs to patients they counsel.

Starting in July 2008, qualified psychologists would be able to apply for conditional certificates to prescribe drugs under the supervision of doctors at federally qualified health centers. After two years, and after clearing independent peer review, those psychologists would become eligible for certificates to prescribe drugs more freely to patients in collaboration with doctors at community health centers.

As part of a compromise to win passage at the state Legislature, psychologists agreed they would be allowed to prescribe only from a limited formulary of antidepressant, antianxiety and mood-stabilizing drugs. Psychologists would not be able to prescribe narcotics, antipsychotics, amphetamines or lithium.

But the future of the bill is up to Gov. Linda Lingle. The bill barely passed the state House and Senate, so it is unlikely there are enough votes to override a Lingle veto.

Linda Smith, the governor's senior policy adviser, is reviewing the bill and, because the issue has been so contentious, is still seeking input from experts.

Psychologists have wanted prescribing rights to expand their ability to counsel patients and have said it would help improve access to mental-health treatment in rural or underserved urban areas that lack psychiatrists. But psychiatrists have said that psychologists do not have the equivalent scientific and medical training and could endanger patients.

Only Louisiana, New Mexico and Guam — a U.S. territory — allow psychologists to prescribe medication.

State Sen. Rosalyn Baker, D-5th (W. Maui, S. Maui), said the bill finally passed because "the psychologists did a much better job of communicating the reason it was important to provide this."

MILITARY MODEL

A Legislative Reference Bureau study, completed earlier this year at the request of lawmakers who were unsure about the issue, suggested the state require a training model for psychologists similar to a U.S. Department of Defense psychopharmacology demonstration project in the 1990s.

Retired Army Col. Marvin Oleshansky, the director of training for the project, told lawmakers in a March letter that the bill's training requirements are essentially equivalent to the demonstration project. Psychologists would have to complete 660 hours of psychopharmacological training from accredited schools, a year of supervised practice with at least 400 hours of treating patients with mental disorders, and a national proficiency exam.

"There is a significant need that is out there," said Robin Miyamoto, a clinical psychologist and president of the Hawai'i Psychological Association. "We have a lot of really good quality providers, but I think, recently, the need for mental-health care services and the need for people to either be on medication or have management of medication has increased.

"But our capacity to see those patients hasn't increased."

The Hawai'i Psychiatric Medical Association, however, has dismissed the training requirements in the bill as "crash-course prescribing" for psychologists who have had no medical training.

The association warned that mental-health patients would be discriminated against by potentially substandard care and claimed that patients served by community health centers would be in danger.

Dr. Gina Batacan, an adult and child psychiatrist at Kalihi-Palama Health Center, a federally qualified health center, said there are potential dangers even with the limited formulary in the bill. The Food and Drug Administration, for example, requires "black box" warnings on antidepressants about the risk of suicide among children and adolescents with mental-health problems.

Batacan believes doctors, particularly psychiatrists, should be monitoring antidepressant use among young people.

"I also think the urgency and the need is exaggerated," said Batacan, who added that Hawai'i has above the national average of psychiatrists.

AREAS UNDERSERVED

Psychiatrists agree that the distribution of psychiatrists is clustered on O'ahu, leaving rural and some urban areas underserved. But they say the answers are to provide financial incentives or use innovation, like videoconferencing, to get more psychiatrists into underserved areas.

Psychiatrists have repeated similar arguments for years, including when others, such as advanced nurse practitioners, sought prescribing rights. Psychiatrists now cite the nurses' ability to prescribe drugs as preferable to psychologists because nurses have had medical training.

The Legislative Reference Bureau found no dispute that there is a shortage of mental health services in rural and some urban areas, which helped lead a majority of lawmakers to vote with the psychologists. But the close votes in the Senate — 13-12 — and the House — 27-20-4 — show that lawmakers are being pulled in both directions.

"It always ends up being a pretty controversial issue where there is no consensus yet that it's the right thing to do," said state Sen. David Ige, D-16th (Pearl City, 'Aiea), chairman of the Senate Health Committee. "But it's very clear to me that there are segments of our community that cannot get access to mental-health services."

Reach Derrick DePledge at ddepledge@honoluluadvertiser.com.