How to expand access to mental health care in Texas without spending tax dollars

Texas ranks last among the 50 states and the District of Columbia in access to mental health care, according to a recent survey by Mental Health America.

With such a poor track record, the newly convened Texas legislature will inevitably debate whether to increase funding for mental health care. But simply putting more money into the system is not necessarily the best way to improve results.

A way to increase access to mental health care without spending tax dollars was pioneered two decades ago by Texas’ neighbor to the west, New Mexico. Texas’ neighbor to the east, Louisiana, ran a similar program 17 years ago. Both have removed barriers for clinical psychologists to prescribe drugs.

As in most states, Texas requires clinical psychologists to earn a doctorate in psychology — which is an average of five years of graduate school — which must include at least 1,750 hours of supervised clinical training, complete a postgraduate internship of at least another 1,750 hours, and pass a standardized proficiency exam to become licensed. Unlike many other states, Texas also requires clinical psychologists to pass a jurisprudence exam.

Clinical psychologists diagnose mental health problems and engage in talk therapy. Under current Texas law, if their patients require medication to facilitate psychotherapy, psychologists must refer them to licensed prescribers, usually a psychiatrist.

Nowadays it’s not so easy. About half of psychiatrists do not accept insurance. An initial visit to a psychiatrist can cost as much as $500, and follow-up visits range from $100 to 300 per hour. And today, less than 11% of psychiatrists engage in talk therapy—instead, most primarily practice pharmacotherapy.

What if psychiatrists are too far away, too expensive, or too booked up to see referrals from clinical psychologists? In that case, psychologists can always refer patients to a general practitioner or other licensed physician – even a general surgeon like myself – to prescribe mental health medications. In some cases, the psychologist knows more about the drug, the dosage and the side effects than the practitioner who writes the prescription.

But in Texas, only licensed physicians can prescribe psychiatric drugs.

As I explain in my Cato Institute briefing paper, the Department of Defense began a pilot program in the 1990s to expand the workforce of prescribing military mental health providers. They developed a program, supervised by psychiatrists, that taught clinical psychologists psychopharmacology and trained them to treat mental health problems medically. It was so successful that today prescribing psychologists — or RxPs — treat patients in the US Public Health Service Commissioned Corps and the Indian Health Service.

Impressed with how RxPs can increase access to medically assisted mental health care, the Territory of Guam was licensed to prescribe psychologists in 1999. In 2002, New Mexico became the first state to allow skilled clinical psychologists to prescribe psychiatric drugs.

Louisiana followed three years later. That state’s licensing board calls RxPs “medical psychologists.” In the years that followed, states as diverse as Idaho, Iowa, and Illinois removed regulatory barriers to psychologist prescribing.

Each of the five states where psychologists can prescribe has different licensing requirements. However, all require RxPs to complete accredited graduate-level training in clinical psychopharmacology (usually a master’s degree), an internship, or some other form of hands-on clinical experience in drug treatment of mental health problems, and pass the National Standardized Psychopharmacology Exam for Psychologists .

New Mexico has the fewest barriers of the five states in which skilled clinical psychologists currently prescribe. The state requires RxPs to acquire at least 450 hours of postgraduate didactic instruction and 400 hours of clinical experience in clinical psychopharmacology. Unlike Illinois, New Mexico avoids external didactic and clinical experience requirements. The state allows RxPs to practice on their own, but only after a primary care provider supervises them for two years.

Prescribing clinical psychologists have a nearly 30-year track record of providing skilled, comprehensive mental health care to people with mental illness. Amid growing mental health needs and a shortage of mental health resources, lawmakers in Texas will find that removing barriers to psychologists prescribing drugs is a free way to help improve access to mental health care.

Jeffrey A. Singer, MD, practices general surgery in Phoenix and is a senior fellow at the Cato Institute. He wrote this column for the Dallas Morning News.

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How to expand access to mental health care in Texas without spending tax dollars

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