How to Expand Access to Mental Health Care in Texas without Spending Tax Dollars

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

With such a shoddy record, the recently convened Texas Legislature will inevitably debate whether to increase mental health funding. But simply pouring more money into the system isn’t necessarily the best way to boost outcomes.

In fact, one way to increase access to mental health services without expending any taxpayer dollars was put into effect by Texas’ neighbor to the west, New Mexico, two decades ago. Texas’ neighbor to the east, Louisiana, enacted a similar program 17 years ago. Both removed barriers to clinical psychologists being able to prescribe medication.

As in most states, Texas requires clinical psychologists to obtain a doctoral degree in psychology — which averages five years of graduate school — that 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 examination in order to get a license. 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, most commonly a psychiatrist.

Nowadays, that’s not so easy. Roughly half of psychiatrists don’t accept insurance. An initial visit with a psychiatrist can cost as much as $500, and follow‐​up visits range from $100 to 300 per hour. And nowadays, less than 11% of psychiatrists engage in talk therapy — instead, most primarily practice pharmacotherapy.

Suppose psychiatrists are too far away, too expensive, or too booked up to see clinical psychologists’ referrals? In that case, psychologists can always refer patients to a primary care practitioner or any other licensed physician — even a general surgeon like myself —to prescribe mental health medication. In some cases, the psychologist may know more about the drug, dosage and side effects than the practitioner who writes the prescription.

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

As I explain in my briefing paper from the Cato Institute, 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 manage mental health problems medically. It was so successful that today prescribing psychologists — or RxPs — treat patients in the U.S. 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 licensed prescribing psychologists in 1999. In 2002, New Mexico became the first state to allow competent clinical psychologists to prescribe psychiatric meds.

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

Each of the five states where psychologists may prescribe has different licensing requirements. However, they all require RxPs to obtain accredited graduate‐​level training in clinical psychopharmacology (usually a master’s degree), an internship, or some other form of practical clinical experience treating mental health problems with medications and passing the national standardized Psychopharmacology Exam for Psychologists.

New Mexico has the fewest barriers of the five states in which competent clinical psychologists currently prescribe. The state requires RxPs to acquire at least 450 hours of post‐​doctoral didactic instruction and 400 hours of clinical experience in clinical psychopharmacology. Unlike Illinois, New Mexico avoids extraneous didactic and clinical experience requirements. The state allows RxPs to practice independently 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 illnesses. Amid growing mental health needs and a shortage of mental health resources, Texas lawmakers will find that removing barriers to psychologists prescribing medication is a cost‐​free way to help improve access to mental health care.