Colorado, in the middle of a mental health crisis for all ages, has about 3,200 psychologists statewide who provide addiction counseling and talk therapy. What they can’t do is prescribe medications.
When a psychologist thinks one of their patients needs an antidepressant, anxiety medication or an antipsychotic drug, they must refer them to a psychiatrist or other medical doctor. It’s a process that can take months, particularly when trying to find a psychiatrist with an opening, and requires the patient to explain their mental health struggles all over again.
But what if Colorado, like five other states, allowed psychologists to prescribe mental health medications? That’s the goal of legislation introduced at the state Capitol this week, brought forward by a task force of 80 psychologists that formed two years ago.
Psychologists and other supporters of the proposal, including the powerhouse health policy advocate Healthier Colorado, say it’s a step toward increasing access to care in a time when Colorado is desperate for mental health professionals.
But others — specifically medical doctors and psychiatrists — caution that the idea is dangerous. Only people with a medical degree, and with an in-depth knowledge of the side effects of beginning or stopping potent medications, should prescribe them, they say.
Rigorous training required
Psychologists aren’t suggesting they start prescribing meds as soon as a bill is passed. The training requirements are stringent enough that it’s likely many psychologists would not even do it.
Psychologists who already have a doctoral degree would have to go back to school for a postdoctoral master’s degree in clinical psychopharmacology, which would take two years. Then they’d have to pass a national board exam, then go through a year of preceptorship, or working clinical rotations under a licensed prescriber. For the next two years, they would have a conditional prescription certificate in which they could prescribe only under the supervision of a consulting physician.
“It’s definitely not a weekend course on YouTube,” said Jin Lee, a child psychologist who created the task force, a subgroup of the Colorado Psychological Association, to push for the law change. “It’s an arduous process.”
Going forward, psychologists would have to send test results, reports of side effects and prescription changes to their patients’ primary care physicians.
Lee, who is licensed in Colorado and New Mexico, is going through a nearly identical certification process in New Mexico so she can prescribe mental health medications to her patients there. New Mexico was the first state to set up a process to give psychologists authority to write prescriptions. That was about 20 years ago and New Mexico was followed by Idaho, Illinois, Iowa and Louisiana, as well as the U.S. Department of Defense, which allows its psychologists to prescribe medications for those in the military.
For now, there are just five universities in the country that offer the required master’s degree in clinical psychopharmacology. Creating a path for psychologists to prescribe in Colorado could spur the University of Colorado Anschutz Medical Campus to create such a program, supporters of the measure say.
The proposal is just one strategy, and it will take many, to solve Colorado’s mental health crisis, which was made worse by the isolation and stress of the COVID pandemic, Lee said. Children’s Hospital Colorado declared a pediatric mental health emergency in 2021, and suicide has been the leading cause of death for teenagers in Colorado for several years. But the crisis is not only affecting young people.
“It’s across the lifespan of the population here in Colorado,” she said. “And it’s not just the underserved and Medicaid patients — it’s everyone in all four corners who are needing desperate support. If we had plenty of prescribers who are able to prescribe psychotropic medications, or manage the medication, either to increase or decrease or taper off, then we’re not having this conversation.”
Psychologists, she said, are an underused resource.
“I don’t have a prescription pad, but I have enough knowledge and education and training to recommend either starting a medication or tapering down or changing the medication or stopping the medication that they’re on currently,” she said. “But I don’t have the final say in it.”
That means Lee, who has a private practice in Aurora, has to send patients to medical doctors or psychiatrists, of whom there are only about 800 in the entire state and many don’t take Medicaid.
“Families are very frustrated about the fact that they have to go to another provider and then start a relationship from scratch,” Lee said. They end up seeing that doctor or psychiatrist every six months to a year to update their prescription, but have a deeper relationship with Lee, whom they see weekly or monthly.
And in her experience, pediatricians aren’t always comfortable managing mental health medications because it isn’t their area of expertise. Lee previously worked in a pediatrician’s office and in one case, could not help a boy with a complex autism diagnosis because the doctor did not feel comfortable managing the medication, she said.
Integrating mental and physical health care is a better solution, pediatricians say
Instead of allowing nonmedical professionals to prescribe medicine, Colorado should focus its efforts and funding on integrating mental and physical health care, said Dr. Cassie Littler, a Denver pediatrician and president of the Colorado chapter of the American Academy of Pediatrics.
“When we think about pediatrics, we try to think about the ‘medical home,’” she said. “That’s really recognized as the gold standard of care.”
A “medical home” is where patients can get all their health appointments in the same office, where pediatricians and other medical professionals work alongside mental health professionals, including psychologists. The psychologist or therapist in the office sees children for weekly therapy appointments, but the pediatrician — trained to know the side effects and how psychotropic drugs could lead to heart problems or diabetes — decides what medications a child should take.
Littler is concerned that if psychologists were allowed to prescribe, it would lead to less collaboration and more independent child psychologists prescribing pills in private practice.
“We share the goal of finding a solution for the pediatric mental health crisis. We agree there is a problem,” said Littler, who was a pediatrician for several years in Grand Junction before moving to Denver a year ago. “This proposal is taking a step backward, siloing care.”
And, she added, “focusing on medicating children is maybe not where we want to spend our time and money and resources.”
Instead, she hopes state lawmakers invest more in strategies that are already creating mental health care access. Last year, the legislature funded a program that allows pediatricians to call a psychiatrist on the spot if they need advice dealing with a complex diagnosis, such as autism.
And in Grand Junction, Littler’s pediatric office used state grant funds to add a psychologist and a therapist, who would often join the doctor in exam rooms.
The state chapter of the American Academy of Pediatrics is opposed to the proposal, as are the Colorado Psychiatric Society and the Colorado Child & Adolescent Psychiatric Society.
Healthier Colorado, however, says the measure is an opportunity for Colorado to increase access to mental health care by allowing “specially trained psychologists” to prescribe medications. “The best way to prevent serious mental health emergencies, like suicide and hospitalization, is to ensure people have access to mental health treatment and services they need without extended delays,” the group said.
In states that have allowed psychologists to prescribe, suicide rates have dropped. The data is correlatory, but worth pointing out. Suicides decreased by 5%-7% in New Mexico and Louisiana, for example.
New Mexico law is Colorado’s model
Elaine LeVine was the first psychologist in New Mexico — and therefore in any state — to complete the certification process to prescribe mental health medications. Her prescriber number, issued two decades ago, is 0001.
LeVine, who practices in Las Cruces, said Colorado is losing and will continue to lose psychologists to New Mexico if Colorado doesn’t allow them to prescribe. She knows of several Colorado psychologists who spend at least part of their time in New Mexico, including in Las Cruces helping underserved populations along the southern border.
“A child psychologist that can prescribe is like gold,” she said. “We need them very badly, but so does Colorado.”
A key difference in the way psychologists work is that they typically see their patients far more frequently than medical doctors, and they spend a lot more time talking. LeVine said she once met a kindergarten boy who was acting up at school, then sent to a hospital where he was diagnosed with bipolar disorder and put on antipsychotic medication. When LeVine talked to him and his mother, she learned that his behavior problems began soon after his father went to jail for a year after he was caught crossing the border from Mexico.
“He definitely wasn’t bipolar and he wasn’t antisocial,” LeVine said.
The number of prescribing psychologists in New Mexico has held steady around 65 for several years, as some retire and others go through the training. It doesn’t sound like that many, except when considering there are only 90 psychiatrists in the state.
“I know everyone is doing their best, but we just need a lot more competent prescribers,” LeVine said.
She believes some medical professionals are opposed to allowing psychologists to prescribe because they don’t understand how extensive the required training is. And over 20 years, New Mexico psychologists have a good track record of patient care, she said.
“We have research that shows we’re not dangerous,” she said.
The Colorado legislation has bipartisan prime sponsors with Reps. Judy Amabile, a Boulder Democrat, and Mary Bradfield, a Colorado Springs Republican, along with Senate President Steve Fenberg, a Boulder Democrat, and Sen. Cleave Simpson, an Alamosa Republican. The legislation, House Bill 1071, was introduced Thursday.