By Lt. Yaron G. Rabinowitz, OSCAR Psychologist, 2nd Marine Division
Since the Defense Demonstration Project (DDP), which produced the first prescribing psychologists in the 1990s, Navy psychologists have played a prominent role in the prescriptive authority movement (RxP).
We produced more DDP graduates than any other branch, and one of the original prescribing psychologists in Louisiana Capt. Robert Younger, the first state to pass RxP legislation is a senior member of our community. Navy psychologists, such as retired Capt. Morgan Sammons, former specialty leader and current executive officer of National Register of Health Service Psychologists, routinely contribute to national RxP advocacy efforts. Presently, we have two active duty prescribers, four in training, and 12 other Navy psychologists in the early stages of RxP.
In the past, Navy psychologists became credentialed to prescribe through either the Defense Demonstration Project, or later, via a health psychology fellowship at Tripler Army Medical Center. Although the Navy’s formal training program is currently in flux, Navy psychologists can still obtain RxP training independently, and then be credentialed to prescribe in any military treatment facility. The requirements in the DoD and in all states and territories with RxP legislation (LA, NM, IL, and Guam) include completion of a Master’s degree in Psychopharmacology, (the cost can be defrayed by the GI Bill), passing the Psychopharmacology Exam for Psychologists (PEP), and completion of a supervised practicum (the Navy requires 100 patients).
Prescribing psychologists provide a uniquely valuable skillset in military mental health. With extensive training in both psychopharmacology and psychotherapy, they can develop treatment plans that leverage combined modalities. This allows them to make medication decisions in the context of an integrated mental health care treatment strategy, using considerably more data than available with medication management alone. The result is more incisive decision-making, fewer failed medication trials, and because of the synergistic benefit of medication combined with psychotherapy, better outcomes with less medication.
Moreover, by providing both psychotherapy and medication management, prescribing Navy psychologists can offer patients a level of timeliness and responsiveness not otherwise possible. Not only do many patients prefer “one-stop shopping”, but reducing numbers of visits has important organizational implications. Overburdened mental health departments can reduce necessary patient contacts by using a prescribing psychologist for both psychotherapy and medication management, allowing psychiatrists to focus exclusively on patients who do not require psychotherapeutic intervention.
Navy prescribing psychologists also facilitate increased access to care in expeditionary settings in which prescribing mental health providers are scarce. For example, in operational stress control and readiness (OSCAR) settings, prescribing psychologists have relieved the prescribing burden from primary care managers who prescribe the preponderance of psychotropic medications. Likewise, prescribing psychologists provide improved command consultation in force preservation councils by using their expertise to clarify complex medical treatment dynamics and duty limitations. Finally, prescribing psychologists, who work with special duty populations in which psychotropic medication use is incompatible with full duty status, play a critical role in determining whether individuals can be adequately treated without medication
Prescribing Navy psychologists study the dynamic interplay between medical conditions, pharmacological interventions, and psychological symptomatology. Consequently, they are attuned to contributory medical factors and psychological overlays. Their enhanced skillset incorporates psychotherapy, psychopharmacology and advanced differential diagnosis. Indeed, Navy psychologists have successfully identified esoteric physiological problems, like pheochromocytoma, and intervened to mitigate adverse medication events like serotonin syndrome.
Critics contend that prescribing psychologists blur the important distinction between psychology and psychiatry. However, the literature suggests that prescribing psychologists prescribe at a lower rate than psychiatrists and primarily use psychotherapeutic interventions. Furthermore, the ability to prescribe is also the ability to un-prescribe. Navy prescribing psychologists utilize their skills for the vitally important purpose of minimizing or discontinuing unnecessary medications. Helping patients improve without an overreliance on medications can increase the speed with which they are returned to full duty, an advantage for patients and command alike.
Navy psychologists have historically played a significant role in the RxP movement and continue to utilize RxP to improve delivery of care and expand command consultation capabilities. There is definite interest in RxP across the Navy, and those who have pursued RxP have realized significant personal and professional benefits. Prescribing Navy psychologists are positioned to assume a variety of billets and can help address organizational issues of limited resources and prescribers. They are also ideally suited, by virtue of their education and training, to perform well in other advanced areas that require a knowledge of physiological and neurologic processes (e.g., neuropsychology).
Although their path is challenging, Navy psychologists with prescriptive authority are significant assets to their patients, commands, and more broadly, to the Navy Psychology community.