A bill in the Colorado legislature would allow psychologists who complete additional training to prescribe mental health medications, such as antidepressants.

Everybody agrees that the best thing for patients who need mental health care is a seamless collaboration between all those caring for them, but there’s disagreement on whether letting psychologists prescribe would move the state closer to or further away from that ideal.

And, as with all debates about who can perform certain medical services, money is part of it. Psychologists would be able to bill for additional services, while psychiatrists and primary care doctors could lose some business.

Jin Lee, a Denver psychologist who is leading the push to allow prescribing, said the proposal would require an extensive process, including a two-year master’s degree in psychopharmacology, passing an exam, at least one year working under direct supervision and a two-year conditional license, where the psychologist is required to work with a consulting physician.

“It’s not a weekend course on YouTube,” she said.

The bill, HB23-1071, was introduced Thursday and is sponsored by Sens. Cleave Simpson, R-Alamosa, and Steve Fenberg, D-Boulder, and Reps. Judy Amabile, D-Boulder, and Mary Bradfield, R-Colorado Springs.

Based on other states that allow prescribing, about 10% of Colorado’s roughly 3,000 psychologists might start the process, Lee said. New Mexico, Louisiana, Idaho, Iowa and Illinois all allow psychologists to prescribe psychotropic drugs, as does the U.S. Department of Defense.

Dr. Jennifer Hagman, a psychiatrist at Children’s Hospital Colorado, said she’s concerned psychologists wouldn’t have the necessary background on body systems and pharmacology to prescribe appropriately. Psychiatrists have to complete medical school, while psychologists earn a Ph.D.

“The base they’re attempting to add to is not remotely similar,” she said.

A poll commissioned by the nonprofit Healthier Colorado found 62% of those polled were in favor of allowing psychologists to prescribe after additional training, 26% were opposed and 12% were unsure. It didn’t specify what that training would involve, however, so it’s possible support for a detailed proposal would be higher or lower. The poll was of 1,060 people deemed likely to vote in the 2022 general election.

Kyle Piccola, vice president of communications and advocacy at Healthier Colorado, said the organization is supporting the bill because it sees a problem with access to care. It’s a six- to 12-month wait to see a psychiatrist in Colorado, and patients’ conditions may well get worse in that time, he said.

“We have a system right now that clearly isn’t meeting the needs of everybody,” he said. “This is an additional way we can get people the care they need.”

Most people who take psychotropic medication get it from their primary care provider, so it would be better to integrate psychologists and other therapists into those practices, Hagman said. They could be especially helpful in working with patients on coping skills and assessing how their environment might contribute to depression or anxiety, she said.

“Getting to a prescription is sometimes easier than getting to a psychotherapist,” she said.

Studies have found that mindfulness and medication work about equally well for anxiety, and that cognitive behavioral therapy — a treatment that involves teaching patients to challenge their negative thoughts — and medication were about equally effective for depression. Of course, that doesn’t mean every patient will receive the same benefit from either type of therapy, and some studies have found a combined approach is best.

Kim Lavoie, chair of behavioral medicine at the University of Quebec at Montreal, wrote a review about the lack of evidence for or against psychologists prescribing in 2002, and said there hasn’t been much research since to clear up the picture. Malpractice claims against prescribing psychologists are rare, but there haven’t been head-to-head comparisons of whether their patients do at least as well as those under psychiatrists or primary care doctors.

Lavoie said she’s skeptical of allowing psychologists to prescribe, since they wouldn’t be able to treat medication side effects. Most people who have depression or anxiety also have other health conditions, so they already see a doctor, she said.

“How much does this really streamline the process? I’m not convinced,” she said.

Primary care doctors aren’t extensively trained in mental health conditions and may not be comfortable prescribing psychotropic medications, especially for children, Piccola said. They also may be more likely to misinterpret mental health symptoms — misdiagnosing anxiety as attention deficit hyperactivity disorder and prescribing stimulants that make it worse, for example — he said.

Primary care doctors who need extra guidance have resources, said Dr. Cassie Littler, a pediatrician in Denver. One is the Colorado Pediatric Psychiatry Consultation and Access Program, a publicly-funded tool that lets providers call child psychiatrists or psychologists with questions about managing children’s mental health, she said.

Littler said she thinks money that would go toward allowing psychologists to prescribe would be better spent encouraging primary care doctors and mental health providers to integrate, whether in the same office or through a records-sharing arrangement. Giving another type of provider the ability to prescribe could further fragment care, setting up potential miscommunication, she said.

“Focusing our funding on that kind of resource would be tremendous,” she said.

It might be ideal for a psychologist to pop in and support a primary care doctor when a patient needs it, but that’s not reality, Lee said. What more often happens is that if a primary care provider isn’t comfortable handling psychotropic medication, they refer the patient to a psychiatrist, which can mean a long wait, she said.

“If you can find that utopia, we wouldn’t have a problem,” she said.

A prescribing psychologist would still stay in touch with a patient’s primary care doctor, and could monitor how well a medication is working and if it’s causing side effects during therapy appointments, which happen more often than doctor’s visits, Lee said. They also would be able to wean a patient off a medication that’s not helping or is making the problem worse, she said.

“We’re all in it together. We’re not taking anything away from anyone,” she said.

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