Some psychologists may be able to prescribe medications for their patients as part of a pilot program on Kauai, if approved by the state Legislature.
The goal of Senate Bill 847 was to grant qualified psychologists the authority to prescribe psychotropic medications to their patients at community health centers in order to improve access to mental health treatment in Hawaii.
This could include conditions such as anxiety, depression, or post-traumatic stress disorder.
Advocates said the measure would help patients contending with a critical shortage of psychiatrists, and typical waits of three months or more just to get an appointment to get needed medications. Many psychiatrists and doctors who oppose it, however, say psychologists lack medical training, and could endanger communities if allowed to prescribe potentially dangerous medications.
While the original bill would have applied to psychologists working with patients at federally qualified health centers in the state, the latest version gives the green light for a three-year pilot program with health centers on Kauai only.
The Senate Committee on Commerce and Consumer Protection passed the bill on third reading.
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Judi Steinman, co-chair of the American Psychological Association’s national legislative action committee, supports measures granting qualified psychologists the ability to prescribe medications as a practical, viable way to improve treatment outcomes.
There are already seven states that allow qualified psychologists to prescribe certain medications, including New Mexico, Louisiana, Illinois, Iowa, Idaho, Colorado and Utah.
Additionally, federal rules already allow qualified psychologists to prescribe medications for active-duty military patients and their families within the U.S. Department of Defense in Hawaii.
To qualify, licensed clinical psychologists would have to obtain a master’s of science degree in psychopharmacology.
Steinman, also a longtime educator in clinical psyochopharmacology, said studies have shown it to be effective in reducing suicide rates and in addressing mental health gaps in rural areas.
One study, she said, showed that in New Mexico and Louisiana — which have the longest records of psychologists prescribing medications — the suicide rate decreased by 5% to 7%. She said there has been no evidence of increased malpractice rates in these states.
She said her question for legislators is: “What are we waiting for?”
Hawaii would benefit from this, she said, due to its chronic shortage of psychiatrists and lack of coverage on neighbor isles.
While primary care physicians are most often the ones that prescribe medications for mentally ill patients, psychiatrists and advanced practice registered nurses are authorized to do so, as well. But Hawaii is short of all three.
According to the latest Physician Workforce Report, Hawaii is 38.8% short of needed adult psychiatrists, and 47.9% short of demand for child and adolescent psychiatrists.
On neighbor isles, the shortage is more severe.
On Kauai, there is a 69.2% gap for adult psychiatrists, and 45% gap for child/ adolescent psychiatrists. Hawaii County suffers from a 67% shortage of adult psychiatrists, while Maui County suffers from a 60.8% shortage of child/adolescent psychiatrists.
For and against
The bill has been controversial, generating more than 200 pages of testimony from those for and against prescribing psychologists.
It is supported by the Hawaii Psychological Association, Hawaii Mental Health Coalition, two county mayors, and various individuals, including prescribing psychologists from states such as Illinois.
It is opposed by the Hawaii Psychiatric Medical Association, Hawaii Medical Association, Hawaii Association of Professional Nurses, and Hawaii Chapter of the American Academy of Pediatrics.
HPMA testified in strong opposition to the bill, saying that if passed, it “could endanger Hawaii’s most vulnerable residents — our keiki, rural communities, and kupuna — by allowing professionals without medical training to prescribe potentially dangerous medications.”
Psychology is a behavioral science rooted in the humanities, the group said, while medicine is a clinical science grounded in physiology, pharmacology and pathology.
“This distinction matters: most patients with mental illness also have co-occurring medical conditions, making it essential that prescribers understand the whole patient,” said HPMA.
He shared that in Louisiana, for instance, a psychologist failed to account for a 4-year-old’s seizure disorder before prescribing stimulants, which resulted in lasting harm and a lawsuit.
Dr. Helen Blaisdell- Brennan, a doctor with advanced special training in psychiatry, testified against the bill, saying it was not supported by evidence and does not address underlying access challenges facing Hawaii.
Instead, a “collaborative care model” that integrates mental health services into primary care could improve outcomes and reduce overall health care costs.
Kauai Mayor Derek Kawakami testified in strong support of the bill due to a substantial deficiency of psychiatrists on the Garden Isle.
“With a lack of access to appropriate mental health treatment, the consequences are devastating and too often end in suicide,” he testified in writing.
In video testimony, Kawakami said the issue was “near and dear” to his heart, as he could count in his own family about 10 relatives or people he was close to that died by suicide. While it may not have saved them, he believes it would have helped in a small, rural community such as Kauai.
Dr. Jack Lewin, administrator of the State Health Planning and Development Agency, testified that he supported the bill with certain safeguards.
He acknowledged that psychiatrists receive much more training than psychologists by completing four years of medical school followed by specialized training, but believes a team approach could work.
Psychotropic medications are complex and affect multiple body systems, but with limited pharmacopoeia, a master’s degree and ongoing supervision by a psychiatrist for the psychologist, he believes these concerns could be addressed and allow more patients-in-need to be treated effectively and safely.
“It would further establish an appropriate and desirable partnership between psychiatrists and psychologists for the benefit of patients and patient safety,” he testified in writing. “This partnership would also recognize and address the clinical complexity and common occurrence of dangerous medication side-effects of behavioral health medications to assure safety.”
Baby steps
One hitch is that Hawaii is currently devoid of the required master’s degree program for pharmacists. At the moment, interested psychologists would have to go to the U.S. continent to complete the qualification.
Steinman said training was once offered through Tripler Army Medical Center and the University of Hawaii at Hilo Daniel K. Inouye College of Pharmacy, where she served six years as coordinator of the master of science program,
She is hoping that the passage of a bill would bring back demand, motivating schools to set up a master’s of psychopharmacology program locally.
She said the required master’s degree includes lectures on every organ system of the body, and is taught by the same instructors who teach at medical and nursing schools.
Alex Lichton, chair of the Hawaii Psychologist Association’s legislative action committee, said psychologists have been pushing for the measure for years because they want to help.
Some psychologists in Hawaii already have the required training, he said. Roughly one-third of members responding to a survey said they would pursue qualifications to prescribe medications, if possible.
In past years, the group advocated granting all licensed psychologists the ability to prescribe medications and tried again this year with House Bill 2169, which was never scheduled for a hearing.
The Senate bill this year narrowed in on federally qualified health centers serving rural communities, such as the Waianae Coast Comprehensive Health Center, Waikiki Health, and Bay Clinic on Hawaii island.
Lichton said the group still supports the latest version of the bill for a pilot program on Kauai, after which it could potentially be adopted statewide, as a step in the right direction.
“It’s baby steps,” he said.
PSYCHOLOGIST RX BILL
Senate Bill 847
>> The most recent version of the bill establishes a pilot program on Kauai allowing qualified psychologists to prescribe psychotropic medications to their patients at a federally qualified heath center. To be administered by the State Health Planning and Development Agency in partnership with the board of psychology. Requires report to the Legislature on whether it should be expanded, made permanent statewide, or ended.
>> Introduced by state Sen. Dru Kanuha (D, Naalehu- Kailua-Kona)
>> Supported by Hawaii Psychological Association, Hawaii Mental Health Coalition, Kauai Mayor Derek Kawakami and Hawaii County Mayor Kimo Alameda; opposed by Hawaii Psychiatric Medical Association, Hawaii Medical Association, Hawaii Association of Professional Nurses, Hawaii Chapter of the American Academy of Pediatrics.
>> Status: Senate Committee on Commerce and Consumer Protection recommended passage on third reading, as amended.