For people in Hawaii with mental illness, the road to treatment is filled with roadblocks.
Perhaps the biggest challenge is securing a timely appointment with a psychiatrist who can diagnose mental illness and prescribe medication to treat it.
A statewide psychiatrist shortage means many patients must wait up to several months to get prescription drugs that can relieve the symptoms of anxiety, ADHD, depression, post-traumatic stress, schizophrenia and other mental disorders.
Neighbor islanders who need treatment are sometimes forced to board an airplane to Honolulu.
But what if psychologists could join the ranks of practitioners able to prescribe drugs?
A local movement to win prescriptive authority for Hawaii’s psychologists is gearing up for a new legislative session during which advocates say they’ll renew a decades-old fight to compel lawmakers to grant psychologists the power to medically treat their patients with drugs, in addition to talk therapy.
Allowing psychologists to undergo specialized training to prescribe drugs could help lessen the state’s harrowing mental health care crisis — especially in rural areas where there are few, if any, practicing psychiatrists.
But opponents warn that granting psychologists the ability to prescribe could open up vulnerable patients to subpar care. They contend that if psychologists are going to start practicing medicine, then they ought to go to medical school — a requirement for other prescribing practitioners.
It’s a controversial topic with a long history in the islands.
Hawaii lawmakers first considered extending prescriptive powers to psychologists in the 1980s. Most recently, the topic spawned impassioned debate before dying on the floor of the Legislature in 2017.
The closest a bill has come to becoming law was in 2007, when a bill passed that would give psychologists a chance to further their training in order to prescribe.
It was vetoed by then-Gov. Linda Lingle.
Jill Oliveira Gray, an advocate for prescriptive authority, is the co-founder and training director at I Ola Lahui, a nonprofit health program aimed at increasing the number of psychologists available to work with Native Hawaiians and rural communities.
“I came face to face with people who were suffering because they can’t get in to see a prescribing person.” — Jill Oliveira Gray
On a weekly basis, Gray said her trainees encounter patients in medically underserved areas — Waimanalo and Kahuku on Oahu, Hilo on the Big Island and the islands of Molokai and Lanai — who need a new medication or an adjustment to an existing prescription.
Since psychologists can’t prescribe drugs to these patients, Gray said her trainees take on the charge of finding someone who can. But a scarcity of psychiatrists makes this difficult, sometimes impossible, she said.
“For people who are suffering with a lot of stress or mental health symptoms, it’s a big task to call through a list of 10 or 15 psychiatrists only to find none of them are taking new patients or none of them are taking the insurance that the patient has,” Gray said.
“So it becomes our task as the treating psychologist to find the psychiatrist. When we can’t find one, people don’t get the help they need and there is real suffering. This has been the reality since I started working in rural areas since 2001, and it has not gotten better.”
In Gray’s view, adding to the number of practitioners qualified to prescribe psychotropic medication could only help the state’s mental health care access problem.
“When I was in grad school and I heard psychologists want to do this, I thought they were crazy,” Gray said. “I thought, ‘Why would anybody, after all of the years of training we have to go through, want to tack on more training?’ It was only when I was in Hana, Maui, where I came face to face with people who were suffering because they can’t get in to see a prescribing person. Allowing psychologists to prescribe is not the solution, but it is a solution that would really, really help.”
In addition to psychiatrists, doctors, advanced practice registered nurses and physician assistants can also prescribe medication for mental disorders. But many of these practitioners are better equipped and more comfortable treating the body parts below the head.
Psychotropic drugs can have serious side-effects. General practitioners may not be qualified to make a correct diagnosis. They also may not understand how the chemistry of a psychotropic drug interacts with other medications.
To this end, the University of Hawaii Hilo’s College of Pharmacy launched a post-doctoral master’s degree program in clinical psychopharmacology in 2010. The program was designed to equip psychologists with the tools they would need to prescribe medication if such legislation were ever to become law. The first pharmacy school program to win approval from the American Psychological Association, the coursework included training in biochemistry, physiology and pharmacology.
‘If you’re going to be putting chemicals into a body, you should understand chemistry and physiology.’ — Jeffrey Akaka
Recent prescriptive authority bills to hit the legislature have made it a requirement for psychologists to obtain a clinical psychopharmacology degree and pass a national proficiency exam before they can start prescribing.
But the UH program shut down in 2016 after repeated attempts to pass a bill in Hawaii failed and most enrolled students dropped out.
Jeffrey Akaka, a Honolulu psychiatrist and mental health policy advocate who opposes prescriptive authority for psychologists, said the training program was never up to speed with the mastery of knowledge he said ought to be required of people who prescribe psychotropic drugs.
“If you’re going to be putting chemicals into a body, you should understand chemistry and physiology,” Akaka said. “The training program they came up with is totally inadequate. It’s like saying a lawyer that tries malpractice cases, with a couple of extra classes, can start practicing medicine.”
But bill proponents, including groups like the Hawaii Psychological Association and Mental Health America of Hawaii, argue that prescriptive authority for psychologists is an important part of closing the gap in access to mental health treatment — especially for rural islanders and people with public health insurance.
“This is a really major issue,” said Alex Santiago, a social worker and a former state legislator who also served as chair of the state Democratic Party. “It has been portrayed as a turf war between psychologists who want to expand the scope of their practice and psychiatrists who don’t want them to step on what they see as their kuleana. But the real issue is, ‘How do we get care to people that are not getting care?’”
Bracken Gott is Hawaii’s only psychopharmacology student. He’s also the last.
Designed to train psychologists to prescribe medication, the University of Hawaii Hilo’s post-doctoral master’s degree in clinical psychopharmacology shut down to new students in 2016 after a six-year run.
The cancelation came on the heels of the death of a state bill that would have given psychologists who graduate from the program the authority to medically treat their patients.
When the bill died, nine students in the UH program dropped out. But Gott, a private practice psychologist with offices in Honolulu and Kailua, decided to stick it out.
“There really isn’t much of a point unless Hawaii passes a bill that allows psychologists to prescribe,” Gott said of the master’s degree he’s on track to receive in the spring of 2019. “But since I started the program, I wanted to finish it.”
Judi Steinman, the program’s former coordinator, said she is confident that the university could build a new course in the future.
Steinman said some program graduates are actively prescribing medication, just not in Hawaii where the practice is not permitted. Trained psychologists already have prescriptive authority in New Mexico, Louisiana, Illinois, Iowa, Guam and the U.S. military.
One reason why Steinman said she supports the prescriptive authority movement is that psychologists, who often see their patients on a weekly basis, tend to know their patients and their symptoms more intimately than psychiatrists, who typically meet with their patients far less regularly.
“There’s a huge disconnect between the people in our rural communities and what they’re willing to talk to strangers about,” Steinman said. “I believe all the controversy around this issue is just one barrier that, once we are able to get over it, we will all be able to provide better care with psychologists and psychiatrists working more closely together.”
A graduate of the UH psychopharmacology program, Victoria Hanes is now a psychologist and the behavioral health director at the West Hawaii Community Health Center in Kailua-Kona on the Big Island.
Hanes said the federally qualified health center has one part-time psychologist and about 10,000 patient visits per year.
Although she cannot prescribe medication herself, Hanes is using the expertise she gained from her psychopharmacology studies to advise the health center’s primary care doctors who can.
“Psychiatrists’ expertise is awesome for the really severely mentally ill and the medically fragile people who are on tons of medications, and the psychologists like myself who want to be able to prescribe are not trying to replace them,” Hanes said.
“But in primary care we are seeing mild to moderate patients that require support through medications, and there’s no reason that the general public that has mild to moderate depression or anxiety should have to be waiting months on end to see a specialist when those medications could be provided very well in primary care.”
“There’s more than enough work to go around,” she continued.
It’s not just a turf war.
Psychologists are included among the ranks of the most vocal critics of prescriptive authority legislation.
Elaine Heiby, a psychologist and professor emerita of psychology at UH Manoa, said her objection is pinned on what she believes is the inadequate psychopharmacology training program. She is an advisory board member for the national group Psychologists Opposed to Prescription Privileges for Psychologists.
“If the psychologists proposed a sensible amount of training, there would be no reason to object,” Heiby said. “But here we have psychologists with no medical training asserting that they can practice medicine with only 10 or 20 percent of the training that is required for nurses or physicians. There is no reason to think that anyone with that little training could do this safely.”
Gray, the training director at I Ola Lahui, said she would support efforts to increase the training requirements. But for her, the idea that psychologists who want to prescribe should go to medical school doesn’t fly.
“A prescribing psychologist is not going to be doing breast exams and they don’t do gynecological exams,” she said. “So just taking medical school off the shelf isn’t going to work.”
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