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From the birth of the idea of extending prescribing privileges to Army clinical psychologists by Senator Daniel Inouye (D-Hawaii) in 1987 to the inception of the ill-founded Department of Defense Psychopharmacology Demonstration Project (PDP), APA's grass roots and Division of Government Relations staff have consistently repeated that medical education and residency training, not legislative fiat, should determine who can decide whether to prescribe medication. Our struggle--ultimately successful--was to persuade the U.S. Congress that the program to train military psychologists to prescribe psychotropic medications was neither wanted nor needed by the military and, by extension, by the nation.
The PDP was established as a rider on a defense appropriations bill by Senator Daniel Inouye, then chair of the Senate Defense Appropriations Subcommittee. Senator Inouye's chief appropriations staffer, Pat DeLeon, is a clinical psychologist on the board of the American Psychological Association. DeLeon's personal advocacy for prescribing privileges--and his long-standing ties to organized psychology--are well known.
In fact, after Senator Inouye's 1987 idea was carried forward by his "inquiry" to William Mayer, M.D., U.S. Assistant Secretary of Defense for Health Affairs, concerning the establishment of a "pilot demonstration project to explore the feasibility and utility" of extending "prescribing practices" to Army clinical psychologists, Dr. Mayer requested assistance from the Secretary of the Army in responding to Senator Inouye. He noted that he had been "receiving weekly calls from Senator Inouye's administrative assistant, Dr. Patrick DeLeon . . . ."
From the start it was recognized that the Defense Department had never requested the PDP, nor did it ask for the money to train prescribing psychologists. Despite hands-on "assistance" from Senator Inouye's office (i.e., one psychology fellow in Senator Inouye's office was selected as a civilian recruit into the military for purposes of participating in the PDP despite the fact that the PDP was supposed to recruit psychologists already in the military), the military had significant trouble attracting military psychologists into the PDP and keeping them in the program. Indeed, of the 10 initial trainees, three dropped out (a 30 percent attrition rate); ironically, one of the three went on to medical school.
Despite problems with recruitment, retention, and the lack of any defined mission or any statement of need by the service branches, the PDP--doubtless benefiting from the personal interest of the chair (later the ranking member) of the Senate subcommittee that directly appropriates funds for all military spending (and the personal interest of his appropriations staffer)--struggled on until late 1995. At that time the program was terminated effective July 1, 1997, as part of the Fiscal 1996 defense authorization bill signed into law by President Clinton in February 1996.
The law terminating the PDP also directed the General Accounting Office, the independent watchdog agency, to conduct a thorough review of the PDP and to report to Congress on its justification. In the interim, the "other APA" has been aggressively lobbying Congress to reinstate the program.
On April 1 the GAO issued the report "Need for More Prescribing Psychologists Is Not Adequately Justified." The title is classic GAO understatement; in fact, the report is a devastating indictment of the entire PDP, concluding that the military health system "needs no prescribing psychologists or any other additional mental health care providers authorized to prescribe psychotropic medication."
Even the casual reader will conclude that the GAO report is a clear, thorough, and dispassionate debunking of the PDP for what it has been all along: a major boondoggle wasting millions of taxpayer dollars while potentially jeopardizing appropriate care of military personnel. As the report states, "Training psychologists to prescribe medication is not adequately justified because the MHSS (Military Health Services System) has no demonstrated need for them, the cost is substantial, and the benefits uncertain."
The report also discloses that the cost of the PDP to date has been $6.1 million, or $610,000 per psychologist "graduate." In keeping with the $600 military toilet seat, we now have, thanks to certain congressionally driven pressures, the $610,000 prescribing psychologist--psychologists who prescribe from a limited formulary and still under the direct supervision of a physician.
Better than the demolition of the PDP, the GAO report not only exposes the PDP as a pork-barrel political program intended to benefit organized psychology's national drive to win prescription privileges, it also explodes the notion that psychologists and psychiatrists are substitutable, even if--I repeat, even IF--psychologists are trained to prescribe psychotropic medications. The GAO report demolishes this favorite canard of the American Psychological Association with just a few quotes:
While it is hoped that the GAO report will reassure Congress that it was absolutely correct in terminating the PDP, we would be foolish to assume that it is the death knell of psychology's efforts to pass prescribing legislation at the state level. Indeed, as we have seen this year, psychology has greatly expanded its efforts to pass such legislation (see page 6). We can expect more of the same.
We can also expect psychology's spin doctors to churn out reams of Ph.D. "reports," "analyses," and "objective assessments" of the GAO report, which--surprise, surprise--will assert that the GAO report is methodologically flawed, not objective, etc., etc., etc., in an effort to bury the report's damage under a mountain of obfuscatory pseudo-scientific babble. This is because the report is so damaging to psychologists' search for a legislative shortcut for medical education and residency training and the contention that trained prescribing psychologists are substitutable for psychiatrists when it is clear that they're not.
That's why the GAO report on the PDP is so helpful: it demolishes the argument that psychologists, however trained, are substitutable for psychiatrists. As the report makes perfectly clear, psychiatry is a medical specialty and psychology is a behavioral science, and no amount of obfuscation can hide the difference. One hopes that common sense will prevail at the other APA and it will abandon this misguided, foolish, economically motivated, and dangerous to quality patient care effort to have psychologists be medical doctors by legislative fiat.
Every legislator in every state should have the GAO report as eloquent testimony of the wisdom of rejecting organized psychology's continuing efforts to self-evaluate and self-determine the qualifications that would substitute for medical education and residency training and win prescribing privileges through the legislative process.
(Psychiatric News, April 18, 1997)