Prescriptive authority and psychology: a status report.

The progress of psychology toward the acquisition of prescriptive authority is critically reviewed. Advances made by other nonphysician health care professions toward expanding their scopes of practice to include prescriptive authority are compared with gains made by professional psychology. Societal trends affecting attitudes toward the use of psychotropic medications are reviewed, and the potential influence of such trends on the prescriptive authority movement is examined. A history of the prescriptive authority movement is documented, and recent legislative and policy initiatives are discussed.

Case vignette: the vicissitudes of managed care.

Lee Wilson, age 26, was referred to Dr. Jackson for psychotherapy 5 weeks ago by a friend. Lee has been feeling increasingly depressed about longstanding family issues and the recent breakup of a 2-year relationship with a live-in companion. Over the course of the once-per-week sessions, Dr. Jackson notes persistent suicidal ideation, with vague plans to act if, as Lee puts it, "things get any worse." Just before the sixth session, Dr. Jackson is contacted by a reviewer for the managed care health insurance program covering Lee's therapy. The reviewer informs Dr. Jackson that the company will not authorize payment for further psychotherapeutic care. Dr. Jackson knows that Lee is in need of continued treatment and fears that terminating therapy at this time could result in increased suicide risk. Lee's income could cover only a small portion of Dr. Jackson's usual fee. Dr. Jackson does not wish to abandon Lee, but he already provides a significant amount of reduced-fee service to other clients. Is the health insurance carrier's stance ethical? Should Dr. Jackson be expected to treat Lee for the foreseeable future at a greatly reduced fee? How should Dr. Jackson handle this situation?