United States General Accounting Office

GAO Report to the Chairmen and Ranking

Minority Members, Committee on Armed

Services, U.S. Senate, and Committee on

National Security, 

House of Representatives

April 1997 DEFENSE HEALTH

CARE

Need for More

Prescribing

Psychologists Is Not

Adequately Justified

GAO/HEHS-97-83

GAO United States

General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-276291 

April 1, 1997

The Honorable Strom Thurmond

Chairman

The Honorable Carl Levin

Ranking Minority Member

Committee on Armed Services

United States Senate

The Honorable Floyd Spence

Chairman

The Honorable Ronald V. Dellums

Ranking Minority Member

Committee on National Security

House of Representatives

The Military Health Services System (MHSS) provides for the mental health

care needs of the approximately 1.7 million active-duty members of the

U.S. armed services. To meet its military readiness requirements, the MHSS

had 478 psychiatrists and 395 clinical psychologists on board in fiscal year

1996.

Some functions of psychiatrists and clinical psychologists overlap. As

physicians, however, psychiatrists are trained in and licensed to practice

medicine and are therefore qualified to prescribe medication for both

mental and physical conditions. Because no medical training is required to

practice clinical psychology, clinical psychologists, whether in the military

or the civilian sector, historically have not been permitted to prescribe

drugs.

This changed for some clinical psychologists in the military when the MHSS

instituted the Psychopharmacology Demonstration Project (PDP) in 1991.

The PDP has trained military psychologists to prescribe psychotropic

medication1

 for mental conditions such as depressive and adjustment

disorders. Before the PDP, MHSS psychologists were not allowed to

prescribe medication. The first PDP participants completed the program in

1994. To date, seven psychologists have finished the PDP training, and the

MHSS has authorized all of them to prescribe certain medications for

mental conditions. An additional three psychologists are expected to

complete the PDP in June 1997.

1

These are drugs that affect psychic function, behavior, or experience.

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The National Defense Authorization Act for Fiscal Year 1996 (P.L.

104-106) required that the PDP end by June 30, 1997, and that we evaluate

the project. On the basis of discussions with your offices, our evaluation

includes (1) an assessment of the need for prescribing psychologists in the

MHSS, (2) information on the implementation of the PDP, and

(3) information on the PDP’s costs and benefits. To develop this

information, we reviewed the military’s needs determinations for

psychiatrists and clinical psychologists. We examined reports and

assessments of the PDP by the Army, the Army Surgeon General’s blue

ribbon panels, and the American College of Neuropsychopharmacology

(ACNP) as well as several articles on the issue of psychologists prescribing

drugs. We also reviewed both a feasibility study and a cost-effectiveness

analysis conducted by Vector Research, Inc. (VRI).2

In addition, we interviewed all PDP participants who completed the project

and others at the facilities where participants were practicing, Department

of Defense (DOD) Office of Health Affairs officials, and other DOD medical

officials. We also met with representatives of the American Psychiatric

Association and the American Psychological Association. Our work was

performed from July 1996 through February 1997 in accordance with

generally accepted government auditing standards.3

Results in Brief The MHSS has more psychiatrists than it needs to meet its current and

upcoming readiness requirements, according to our analysis of DOD’s

health care needs. Therefore, the MHSS needs no prescribing psychologists

nor any other additional mental health care providers authorized to

prescribe psychotropic medication. Moreover, DOD does not even account

for prescribing psychologists when determining its medical readiness

needs.

Although DOD met its goal to train psychologists to prescribe drugs, it

faced many difficulties in implementing the PDP. Not all of these were

resolved. For example, the MHSS never had a clear vision of the prescribing

psychologist’s role, did not meet recruitment goals, and repeatedly

changed the curriculum. Consequently, ACNP recommended in 1995 that

unless these issues were addressed, the PDP should end.

2

Cost-Effectiveness and Feasibility of the DOD Psychopharmacology Demonstration Project: Final

Report, VRI (Arlington, Va.: May 17, 1996). For a detailed description of this study’s methodology and

results, see app. I.

3

See app. II for a more detailed description of our methodology.

Page 2 GAO/HEHS-97-83 Prescribing Psychologists in DOD
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The total cost of the PDP, from start-up through the date the last

participants will complete the program, is about $6.1 million or about

$610,000 per prescribing psychologist, according to our estimate.

Ultimately, the PDP will have added 10 mental health care providers who

can prescribe drugs to an MHSS that already has a surplus of psychiatrists.

Opinions differ on the effect of adding these prescribing psychologists to

the MHSS concerning such issues as quality of care and collaboration

between psychologists and physicians.

Without a clear purpose or role for prescribing psychologists and given the

uncertainty about the extent to which they would replace higher cost

providers, we cannot conclude that the benefits gained from training

prescribing psychologists warrant the costs of the PDP. Training

psychologists to prescribe medication is not adequately justified because

the MHSS has no demonstrated need for them, the cost is substantial, and

the benefits are uncertain.

Background The main mission of the MHSS, which spends more than $15 billion a year,

is medical readiness.4

 This mission requires the MHSS to (1) provide

medical support to active-duty military personnel in preparation for and

during combat and (2) maintain the health of the active-duty force during

peacetime. The Army, Navy, and Air Force all maintain uniformed health

care providers to fill their MHSS medical readiness needs.

To the extent that military space, staff, and other resources are available,

the MHSS may also support DOD’s mission to care for nonactive-duty

beneficiaries (dependents of active-duty members, retired members and

their dependents, and survivors of deceased members). Whenever

nonactive-duty beneficiaries’ need for health care exceeds the MHSS’

resources available to them, DOD purchases services for them from the

civilian health care sector.

The role of psychiatrists and clinical psychologists in meeting the MHSS

medical readiness mission is to provide mental health care that helps

military active-duty personnel perform their duties before, during, and

after combat or some other military operation. Both psychiatrists and

clinical psychologists, whether in the military or civilian sector, provide a

4

According to DOD, “Medical readiness encompasses the ability to mobilize, deploy and sustain field

medical services and support for any operation requiring military services; to maintain and project the

continuum of health care resources required to provide for the health of the force; and to operate in

conjunction with beneficiary health care.” See Medical Readiness Strategic Plan, 1995-2001, DOD

(Washington, D.C.: Mar. 20, 1995).

Page 3 GAO/HEHS-97-83 Prescribing Psychologists in DOD
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variety of mental health services, some of which are similar. Both can

diagnose mental conditions and treat these conditions with

psychotherapy. A degree in medicine is required to practice psychiatry,

however, so psychiatrists may treat mental disorders medically, that is,

with medication. Because medical training is not required to practice

clinical psychology, psychologists are not qualified to prescribe

medication.

To practice medicine, psychiatrists complete 4 years of medical school

and a 1-year clinical internship during which they are trained to evaluate

and treat all types of organic conditions5

 and to perform general surgery.

After this, they complete a 3-year psychiatric residency during which they

learn to evaluate and treat mental conditions and the organic conditions

associated with them. Because psychiatrists practice medicine, they can

diagnose organic as well as mental conditions and treat each with

medication. They consider a full range of possible organic causes for

abnormal behavior when diagnosing a condition. Therefore, they can

distinguish between mental conditions with an organic cause, such as

schizophrenia6

 and bipolar disorder,7 and organic conditions, such as

diabetes and thyroid disease, which have symptoms that mimic a mental

disorder. Organic mental disorders are best treated through a combination

of medication and psychotherapy, according to DOD officials.

Clinical psychologists, on the other hand, practice psychology, not

medicine. Typically, they complete 6 years of graduate school leading to a

doctoral degree and 1 to 2 years of postdoctoral clinical experience.

Clinical psychologists are trained in theories of human development and

behavior, so their general approach to diagnosing and treating mental

illness is psychosocial8

 rather than medical. They are trained to diagnose

and treat all mental conditions and rely on the behavior a patient displays

to diagnose these conditions.

5

These are diseases associated with observable or detectable changes in the organs or tissues of the

body.

6

This is a fundamental mental derangement characterized by loss of contact with the environment;

noticeable deterioration in the level of functioning in everyday life; and disintegration of personality

expressed as disorders of feeling, thought, and conduct.

7

This is a disorder in which the patient exhibits both manic and depressive episodes. Mania is

excitement manifested by mental and physical hyperactivity, disorganization of behavior, and

elevation of mood. Depression is marked by sadness, difficulty in concentration, feelings of dejection

and hopelessness, and sometimes suicidal tendencies.

8

This refers to relating social conditions to mental health.

Page 4 GAO/HEHS-97-83 Prescribing Psychologists in DOD
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The MHSS created the PDP to increase the scope of practice of clinical

psychologists in the military so they could treat their patients with

psychotropic medication when needed. DOD established this project in

response to a conference report dated September 28, 1988, which

accompanied the fiscal year 1989 DOD Appropriations Act (P.L. 100-463).

The report specified that, “given the importance of addressing ‘battle

fatigue,’ the conferees agreed that the Department should establish a

demonstration pilot training program in which military psychologists may

be trained and authorized to issue appropriate psychotropic medications

under certain circumstances.”

The Army’s Office of the Surgeon General was tasked with designing and

implementing the PDP. A blue ribbon panel9

 was formed by the Army

Surgeon General in February 1990 to determine the best method for

implementing the PDP. After considering various models, the panel

endorsed a training model that included course work at the Uniformed

Services University for the Health Sciences (USUHS). In February 1991, the

Chairmen of the Senate and House Subcommittees on Defense of the

respective Committees on Appropriations then recommended that DOD

develop a 2-year training model for the PDP in accordance with the panel’s

recommendations. DOD later formed a committee to develop a suitable

training program to provide clinical psychologists with the knowledge

required for safely and effectively using a limited list or formulary of

psychotropic medication. This committee recommended a special 3-year

postdoctoral fellowship program for the PDP with (1) 2 years of course

work at USUHS, followed by (2) 1 year of clinical experience at Walter Reed

Army Medical Center.

This training began in August 1991 with four participants. For subsequent

classes, however, the PDP consisted of 2 years of training—1 year of

classroom and 1 year of clinical training. Classroom training included

courses at USUHS in subjects such as anatomy, pharmacology, and

physiology. PDP participants’ clinical experience took place on inpatient

wards and outpatient clinics at Walter Reed Army Medical Center in

Washington, D.C., or the Malcolm Grow Medical Center at Andrews Air

Force Base in Maryland. There, participants were trained to take medical

histories and incorporate them into treatment plans and to prescribe

medication for patients with certain types of mental disorders. After their

clinical year, participants received a certificate of “Fellowship in

9

This panel consisted of representatives of the Surgeons General of each of the three services; the

Office of the Assistant Secretary of Defense for Health Affairs; and professional organizations of

psychiatrists, psychologists, and physicians.

Page 5 GAO/HEHS-97-83 Prescribing Psychologists in DOD
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Psychopharmacology for Psychologists” and became known as

“prescribing psychologists.”

Once PDP participants graduated from training, they completed 1 year of

supervised or proctored practice; their respective services assigned

participants to military medical facilities for this 1 year of practice. These

facilities authorized participants to prescribe a specified formulary of

psychotropic drugs. Although the medical education received under the

PDP qualified clinical psychologists to treat mental conditions with

medication, it was less extensive than psychiatrists’ medical training.

Therefore, the MHSS limits prescribing psychologists’ scope of practice.

They may only treat patients between the ages of 18 and 65 who have

mental conditions without medical complications as determined by their

supervisors.

ACNP helped develop and evaluate the PDP. ACNP is a professional

association of about 600 scientists from disciplines such as behavioral

pharmacology, neurology, pharmacology, psychiatry, and psychology.

ACNP’s principal functions are research and education. It conducted several

assessments of the PDP under contract to the Army and made a number of

recommendations on the project’s goals and implementation. One of them

was for DOD to establish a PDP Advisory Council to help develop criteria

and procedures on implementing the PDP. DOD established this council in

1994.

The American Psychiatric Association, American Psychological

Association, and literature on this topic have noted the possible

advantages or disadvantages of allowing psychologists in the civilian

sector to prescribe medication. One article has suggested that training

psychologists to prescribe psychotropic medication could be particularly

beneficial if they were permitted to practice this skill in clinical settings

such as nursing homes, mental institutions, or medically underserved

areas. Some have suggested that using prescribing psychologists could

reduce the cost of care and maintain the continuity of patient care by

eliminating the need to switch patients from psychologists to psychiatrists

when drug therapy is indicated. On the other hand, because prescribing

psychologists would receive only partial training in medicine, some are

concerned about the quality of care these psychologists would be able to

provide.

No state licensing authority allows psychologists to prescribe medication.

A few states are considering legislation, however, that would allow those

Page 6 GAO/HEHS-97-83 Prescribing Psychologists in DOD
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already licensed by the state’s psychologist licensing board to be certified

to prescribe medication after completing certain courses in medicine and

gaining clinical experience. Under legislation introduced in Hawaii in 1997,

psychologists seeking authority to prescribe would have to pass a

standard examination. Legislation proposed in Missouri would require the

development of a specified formulary of drugs for certified prescribing

psychologists.

Number of Mental

Health Care Providers

Is Adequate for

Readiness

Requirements

None of the services needs additional mental health providers capable of

prescribing medication to meet either current or upcoming medical

readiness requirements, according to our review of DOD’s health care

needs. Each service has more than enough psychiatrists, as well as clinical

psychologists, to care for its anticipated wartime psychiatric caseload.

Given this surplus, spending resources to provide psychologists with

additional skill does not seem justified.

Each of the three services has a model and procedures to determine the

number of specific types of health care providers needed to support its

MHSS medical readiness mission. These are based on the types and number

of casualties anticipated under a wartime scenario. About one out of eight

casualties would involve combat stress, according to an Army official.10

Caring for combat stress requires skill in (1) diagnosing combat stress,

including the ability to distinguish it from neurological or other

psychological disorders with like signs and symptoms, and (2) treating a

range of severity levels of combat stress. Psychologists have many but not

all of the skills necessary to treat combat stress and are therefore

included, along with psychiatrists, in the services’ staffing of those who

treat anticipated wartime casualties. Psychologists cannot be substituted

for psychiatrists, however. Even if trained to prescribe drugs,

psychologists are not as equipped as psychiatrists to distinguish between

actual combat stress and certain neurological disorders that appear to be

combat stress. Psychiatrists are also better able to treat more severe or

complicated combat stress cases.

The services have separate requirements for psychiatrists and clinical

psychologists. None of the services has a separate readiness requirement

10Stress is the internal process of preparing to deal with events or situations referred to as “stressors.”

Stress involves physiological reflexes such as increased nervous system arousal, release of adrenaline

into the bloodstream, change in blood flow to different parts of the body, and the like. Stress also

involves emotional responses and the automatic perceptual and cognitive processes for evaluating an

uncertainty or a threat. Combat stressors are those occurring during combat-related activities, whether

from enemy action or other events or situations. They may arise from a soldier’s own unit, leaders, and

mission demands or from the conflict between mission demands and a soldier’s home life.

Page 7 GAO/HEHS-97-83 Prescribing Psychologists in DOD
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for prescribing psychologists. Table 1 shows the number of MHSS

psychiatrists each service has determined it needs11 and the number

assigned or on board for fiscal years 1995 through 1998.12 Table 2 shows

the number of clinical psychologists each service has determined it needs

and the number assigned for fiscal years 1995 through 1998.

Table 1: Psychiatrists by Service:

Number Needed and Assigned to Meet

Readiness Requirements

FY 1995 FY 1996 FY 1997 FY 1998

Service Needed Assigned Needed Assigned Needed Needed

Air Force a 129 a 115 a 107

Army 205 226 205 219 198 228

Navy 105 166 107 144 107 107

Total a 521 a 478 a 442

aNumber is not available.

Table 2: Psychologists by Service:

Number Needed and Assigned to Meet

Readiness Requirements

FY 1995 FY 1996 FY 1997 FY 1998

Service Needed Assigned Needed Assigned Needed Needed

Air Force a 156 a 165 a 207

Army 118 130 118 113 103 98

Navy 135 157 92 117 92 92

Total a 443 a 395 a 397

aNumber is not available.

As these tables show, the MHSS has at least as many uniformed

psychiatrists and clinical psychologists as it needs to meet its current and

upcoming readiness requirements. Our discussions with psychiatry

consultants13 to the Surgeons General of the three services confirm the

picture these numbers portray, and testimony of DOD officials at

congressional hearings is consistent with the views expressed by these

consultants. At a March 1995 Senate Armed Services Committee hearing,

the Assistant Secretary of Defense for Health Affairs stated that on the

basis of DOD staffing guidelines, the MHSS has no shortage of active-duty

11The Air Force could not provide the number of psychiatrists or psychologists needed to meet its

readiness requirements for fiscal years 1995 through 1997. The Air Force Surgeon General, however,

stated in 1995 that his service had a surplus of psychiatrists.

12Projections of readiness requirements are available for all the services only through fiscal year 1998.

Officials from each of the services, however, have observed that as the size of the military declines,

MHSS readiness requirements for psychiatrists beyond fiscal year 1998 should stay the same or

decline.

13These are officials in each branch of the service who represent specific types of health care providers

in that branch.

Page 8 GAO/HEHS-97-83 Prescribing Psychologists in DOD
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physicians in general. The Navy Surgeon General also testified at this

hearing that the Navy has no shortage of psychiatrists. In addition, an

official from the DOD Office of Health Affairs said that DOD has a surplus of

psychiatrists.

Although training psychologists to prescribe medication enables them to

perform functions they do not normally perform, it does not give them all

the skills needed to enable them to substitute for psychiatrists.

Furthermore, the MHSS’ current staffing level of psychiatrists and

psychologists is more than enough to meet its readiness requirements for

caring for psychiatric cases without adding to some psychologists’

capabilities. Therefore, the MHSS seems to have no current or upcoming

need for psychologists who may prescribe drugs.

PDP’s Implementation

Faced Difficulties

Although DOD met the mandate to establish a demonstration project to

train military psychologists to prescribe psychotropic medication for

mental illness, the PDP implementation faced several problems. Some of

these problems have been resolved. The problems include

• the lack of a clearly defined purpose for prescribing psychologists in the

MHSS,

• difficulty recruiting the desired number of participants per class,

• unspecified participant selection criteria,

• repeated changes in the classroom curriculum,

• delays in granting prescribing privileges, and

• unresolved issues involving supervision.

The lack of precedent and experience with authorizing psychologists to

prescribe medication, according to some officials at locations where PDP

participants are stationed, is partly to blame for some of these problems.

These include delays in granting prescribing privileges and disagreements

over the extent of supervision.

Prescribing Psychologists’

Role in the MHSS Not

Clearly Defined

The PDP did not clearly define the role of prescribing psychologists in the

MHSS. The ACNP’s PDP evaluation panel noted in 1992 that the project’s goal

“to train psychologists to issue appropriate medication under certain

circumstances” was “rich with ambiguities.” The project was structured

and revised periodically without specifying the (1) prescribing

psychologists’ duties and responsibilities, (2) types of clinical settings or

facilities their skills would be best suited for, (3) types of psychotropic

Page 9 GAO/HEHS-97-83 Prescribing Psychologists in DOD
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medication psychologists would be qualified to prescribe, and (4) level of

supervision they would require. In September 1995, after the project had

operated for 4 years, the ACNP panel suggested that DOD define clearly how

PDP graduates could be used; this did not take place.

Recruiting PDP

Participants Was Difficult

DOD had difficulty recruiting PDP participants throughout the project. The

recruiting goal, which was not met, was six psychologists for each PDP

class. Since the project started in 1991, 13 psychologists have participated.

Seven have completed it. Three have dropped out, and three are expected

to finish their clinical experience in June 1997 (see table 3). Those who

dropped out did so for various reasons: One left the military. Another

enrolled in the medical school at USUHS. The third left because of

dissatisfaction with the program.

Table 3: Status of Psychologists

Entering the PDP

Year

Entered

the PDP

Left the

PDP

Graduated

from the

PDP

Currently

in the PDP

1991 4 2 2 0

1992 0 0 0 0

1993 2 1 1 0

1994 5 0 4 1

1995 2 0 0 2

Total 13 3 7 3

Because the PDP did not attract enough military psychologists, the program

was opened to civilian clinical psychologists willing to enter the military.

Two of the five PDP participants who began the program in 1994 were

civilians who joined the military to participate in the PDP. Finally, only two

psychologists entered the PDP in 1995.

Candidate Selection

Criteria Were Not Specified

The MHSS established no formal candidate selection criteria for the PDP.

Four classes of candidates had entered the PDP before prerequisites for

participation were first addressed in February 1995. At that time, the PDP

Advisory Council recommended that a candidate for the PDP (1) be on

active duty, in good standing as a psychologist, and have an active state

license to practice clinical psychology; (2) have a minimum of 2 years of

active-duty experience as a clinical psychologist in one of the uniformed

services; (3) agree to meet the service’s payback obligations for

postdoctoral training; and (4) volunteer for the program.

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Curriculum Repeatedly

Changed

The duration, content, and sequencing of PDP training continued to change

after the project began. Originally, PDP training was intended to last for 2

years and consist of both course work and clinical experience during each

year. An additional year of clinical experience was added for the first class

after it began the program, however, because the participants were not

receiving enough clinical experience. Subsequent classes received 2 years

of training as originally planned: the first dedicated exclusively to course

work at USUHS, the second, to clinical practice.

In addition, the curriculum content and sequencing of the courses changed

after the project began. Courses such as neuroscience and

psychopharmacology were added, while others were dropped. In 1995, the

ACNP panel noted that the curriculum for those who started the PDP in 1994

was “markedly different” from the curriculum for participants who started

the PDP in 1991. The panel said at that time that the curriculum needed to

be thought through more thoroughly, using the final scope of practice and

formulary as a starting point. The panel also noted that assessing the

adequacy of the curriculum was difficult because it changed frequently.

The panel saw a need for a well-organized, structured approach to the

design of courses as well as the selection of participants. It recommended

at that time that unless the MHSS addressed these concerns satisfactorily,

the project should end.

Prescribing Privileges for

PDP Graduates Were

Delayed

The first psychologists who completed the PDP faced delays of up to 14

months in getting prescribing privileges at the facilities where they were

assigned possibly due to the facilities’ lack of experience with this type of

provider. Two recent graduates, however, received privileges within 2

months of arriving at their facilities. In each of these cases, PDP officials

visited the facilities where these psychologists had been assigned to

explain the project and training and provide information about the

graduates to facility officials. Facility officials cited these visits as helpful

in resolving their concerns about psychologists’ prescribing privileges.

Supervision of Prescribing

Psychologists Unresolved

The MHSS has not decided who should supervise prescribing psychologists.

In 1994, the MHSS decided that after prescribing psychologists had

completed their clinical year, they would spend the next year practicing

under a psychiatrist’s supervision. The MHSS originally anticipated that

these psychologists would ultimately function independently. All of the

PDP graduates, however, continue to practice under the supervision of a

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psychiatrist, and whether they will ever prescribe independently is

unclear.

The PDP Advisory Council’s February 1995 scope of practice statement,

which has been used as guidance for allowing prescribing privileges for

some PDP graduates, states that prescribing psychologists should prescribe

psychotropic medication only under the direct supervision of a physician.

According to the Advisory Council that developed this statement, PDP

graduates’ prescribing practice should be closely supervised. These

psychologists should then gradually be permitted to practice under less

supervision as they demonstrate their competence.

PDP Was Costly and

Its Benefits Are

Uncertain

Even if the MHSS had a need for additional mental health care providers to

prescribe medication, the cost of meeting this need by training clinical

psychologists to prescribe drugs is substantial. Furthermore, although the

PDP produced additional providers who can prescribe and some facilities

have reported positive experiences with them, determining the PDP’s

cost-effectiveness is impossible at this time.

Cost of PDP The total cost of the PDP will be about $6.1 million through the completion

of the proctored year for those currently in the program—or about

$610,000 per psychologist who completes the program (see table 4).

Table 4: Estimated Cost of PDP by

Training Component and Type of Cost,

FY 1991-98 Type of cost

Training component

Total costs Classroom

year

Clinical

year

Proctored

year

PDP training expenses $1,650,420 0 0 $1,650,420

Student salary plus benefits (minus

productivity benefit) 844,065 333,154 0 1,177,219

Supervisor lost productivity 0 475,810 206,874 682,684

PDP training overhead cost a a a 2,584,199

Total cost $6,094,522

Notes: These estimates assume that the three current PDP participants will complete the clinical

portion of the project in June 1997 and their proctored year in 1998.

Estimates as expressed in 1996 dollars.

aNot available by component.

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On the basis of our previous estimates of the cost of a USUHS medical

education,14 we estimate that the cost of the classroom training for PDP

participants provided by USUHS was about $110,028 per participant per

year. Most of this amount consisted of faculty cost and costs for operating

and maintaining USUHS. The remainder included the cost of research,

development, testing and evaluation, military construction, and other

miscellaneous costs. Our estimate of total cost for PDP training includes

the cost of 12 classroom years of training for 10 PDP graduates as well as 3

years of training for three psychologists who dropped out of the program.

Our estimates of psychologists’ salaries while participating in the PDP are

based the assumption that those entering the project would receive a

salary of $56,071 during their first year in the PDP, $57,571 during their

second year, and $58,985 during their third year.15 Student salaries totaled

$844,065 during the classroom training portion of the PDP, according to our

estimate. This included the salaries of 11 participants for 1 year of

classroom training each, 3 of whom ultimately dropped out of the PDP, and

2 participants for 2 years each.

Because PDP participants treated patients during their clinical and

proctored years, we reduced our salary estimates for these years by a

productivity factor representing the time they spent treating patients. We

used a productivity factor of 50 percent for the clinical year and

100 percent for the proctored year.16 On the basis of these productivity

factors, total participant salary costs for the clinical portion of the PDP

were $333,154, according to our estimates. This accounts for one

participant who dropped out approximately halfway through the clinical

year and another who received an additional year of clinical training.

To estimate faculty and supervisor salaries for the PDP for the clinical and

proctored years, we assumed that one faculty member per psychologist

would devote 40 percent of his or her time per clinical year of training.

Likewise, we assumed that during the proctored year, one supervisor

would spend 20 percent of his or her time supervising each prescribing

14Military Physicians: DOD’s Medical School and Scholarship Program (GAO/HEHS-95-244, Sept. 29,

1995).

15This is derived from VRI’s DOD salary information for its cost-effectiveness and feasibility study

(May 17, 1996).

16PDP participants and their supervisors generally agreed on the basis of their experience that

participants spent about half their time in the clinical year and all of their time in the proctored year

treating patients.

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psychologist.17 On the basis of these assumptions, the total cost of lost

faculty productivity due to training the 10 graduates for 11.5 years18 of

clinical training was $475,810, according to our estimate; the total cost of

lost supervisor productivity was $206,874 for 10 participants for 10

proctored years of practice. The lost productivity cost is based in each

case on an annual salary of $103,437.19

Total PDP overhead cost was $2.58 million, according to our estimate.20

This included the cost of the evaluation contracts ($1.75 million) and

personnel support costs ($830,000) for a PDP Director and a Training

Director for fiscal years 1992 (when the PDP began) through 1998, when

those currently in training are expected to complete their proctored year.

Also included in overhead costs are smaller amounts for invited lecturers,

travel and per diem expenses, supplies, and other miscellaneous expenses

during this time.

If the PDP had attracted a total of 24 participants and all of them had

graduated, the cost would have been about $365,000 per prescribing

psychologist. In addition, the cost per graduate would have been about

$94,000 less than this if the project had progressed beyond the

developmental stage and external evaluations could have been

discontinued. After operating for 7 years, however, the project was only

able to attract about half the number of participants considered optimal

and had not progressed beyond the stage for which external evaluations

were needed.

Perceptions of PDP and Its

Benefits Differ

The PDP increased the number of MHSS mental health care providers who

may prescribe drugs to treat certain mental conditions. This may reduce

psychiatrists’ workloads. Psychiatrists, psychologists, and primary care

physicians, however, have different opinions on the effect of allowing

psychologists to prescribe drugs on the quality of mental health care and

collaboration among these providers.

17These proportions are based on discussions with psychiatrists who supervised PDP participants in

their clinical and proctored years. They generally agreed they had devoted 20 and 40 percent of their

time, respectively, per year to supervising participants.

18This includes 1 year of clinical training for nine graduates, 2 years for one graduate, and 1/2 year for

one participant who dropped out of the PDP halfway through the clinical year.

19This is the cost of the average fiscal year 1996 annual salary and benefits of all DOD psychiatrists as

estimated by VRI in its cost-effectiveness and feasibility study of the PDP.

20This is based on overhead costs contained in PDP annual reports produced by the Army and costs

reported by VRI in its cost-effectiveness and feasibility study of the PDP.

Page 14 GAO/HEHS-97-83 Prescribing Psychologists in DOD
B-276291 

As a result of the PDP, seven psychologists are prescribing medication at

DOD military facilities, and three more are expected to complete clinical

training in the summer of 1997 and receive prescribing privileges some

time after that. The first three participants are seeing mainly patients who

require medication, and one of these temporarily filled a vacancy created

by the departure of a psychiatrist.

Having prescribing psychologists on staff has certain benefits to facilities

where they are assigned. One of these facilities had been experiencing

unusually heavy psychiatrist workloads because it did not have enough

psychiatrists to fill all its psychiatry positions. In the interim, this facility

specifically requested a prescribing psychologist to fulfill some of the

responsibilities of a psychiatrist, reducing the psychiatry workload.

Another prescribing psychologist temporarily saw the patients of a

psychiatrist who transferred to another facility until the facility brought in

another psychiatrist.

VRI obtained perceptions of the PDP by surveying MHSS psychiatrists,

primary care physicians, and psychologists about the possible effects of

allowing psychologists to prescribe medication.21 The most frequent

responses to the survey’s open-ended questions about the potential benefit

of this practice were that it would (1) increase the number of mental

health care providers in the MHSS and (2) reduce psychiatrists’ workloads.

The most frequently noted limitation to allowing psychologists to

prescribe medication was their perceived lack of knowledge about

medicine, physiology, and adverse drug interactions and effects.

Survey results also indicated that psychiatrists, psychologists, and primary

care physicians differed about whether adding prescribing psychologists

to the MHSS was beneficial. Most psychologists responded that training

psychologists to prescribe would improve the quality of mental health care

in the military. Conversely, most psychiatrists believed quality of care

would decline. Furthermore, psychiatrists thought this would undermine

their working relationships with MHSS psychologists; most primary care

physicians responded that this would improve their collaboration with

psychologists. Most psychologists agreed that the authority to prescribe

would enhance their collaboration with MHSS primary care physicians. But

as far as their collaboration with MHSS psychiatrists was concerned, about

half the psychologists believed this would improve such collaboration; the

other half thought it would interfere with it.

21See app. I for a detailed description of this survey.

Page 15 GAO/HEHS-97-83 Prescribing Psychologists in DOD
B-276291 

Cost-Effectiveness of PDP

Undetermined

The cost-effectiveness of having MHSS psychologists prescribe

psychotropic medication is unclear at this time. Determining the

cost-effectiveness of this effort would require information on the

(1) proportion of the time remaining in the military that prescribing

psychologists would have to perform functions that psychiatrists would

normally perform and (2) extent to which having psychologists prescribe

medication would result in fewer psychiatrists in the MHSS. The results of

analyses designed to predict the relative cost-effectiveness of training and

employing psychologists to prescribe compared with other providers with

this authority differ depending on the cost estimates used. VRI’s analysis

concluded that the PDP would prove cost-effective under certain

circumstances. Additional analyses using different cost estimates,

however, suggest that the PDP would not be cost-effective under these

same circumstances.

VRI found that the annual life cycle cost of a prescribing psychologist was

potentially lower than that of a psychiatrist-psychologist combination,

which is typically required to treat an MHSS patient with a mental condition

requiring medication. As table 5 indicates, VRI’s analysis accounted for

acquisition costs (the cost of recruiting people into the military), training

costs, basic and special pay and benefits (such as housing allowances),

health care costs, risk management expenses (for potential malpractice

claims), and retirement costs. It assumed various pay levels for different

types of providers at different stages in their military careers as well as for

different career lengths. It also assumed that PDP enrollees would enter the

project after 6 years as DOD clinical psychologists.

Page 16 GAO/HEHS-97-83 Prescribing Psychologists in DOD
B-276291 

Table 5: Annual Life Cycle Costs of Selected MHSS Providers Based on VRI’s Cost Estimates

Yearly life cycle cost per full-time equivalent

Provider group Accession Training Force Retirement Total Required utilization

Psychiatrists $23,470 $13,864 $112,697 $19,142 $169,173 a

Psychologists 1,134 3,766 66,155 15,849 86,905 a

Psychologists/

psychiatrists (base case

scenario) 10,901 8,182 86,506 17,289 122,878 a

Prescribing psychologists

(start-up case scenario) 1,218 29,296 71,979 17,735 120,227 92.6%

Prescribing psychologists

(optimal case scenario) 1,218 17,197 71,979 17,735 108,128 59.0%

Note: Estimates are expressed in 1996 dollars.

aNot applicable.

Source: VRI data.

VRI estimated the annual life cycle cost of prescribing psychologists given

two scenarios, a start-up case scenario and an optimal case scenario. To

predict the conditions under which the PDP would be cost-effective, VRI

compared the annual life cycle cost of a prescribing psychologist under

the start-up scenario with the life cycle cost of what it refers to as the

“base” scenario. It used the start-up scenario rather than the optimal

scenario because the former accounts for the nonrecurring, fixed (or

start-up) costs actually associated with developing and implementing the

PDP.

22 The base scenario is the annual life cycle cost of the current

psychiatrist-psychologist combination required to treat MHSS mental health

care patients who need medication.

Given the difference in annual life cycle costs between the base and the

start-up scenarios, VRI predicted that the PDP would be more cost-effective

than the base scenario if PDP participants in the start-up period functioned

as prescribing psychologists, rather than traditional clinical psychologists,

for more than 92.6 percent of their time remaining in the military. For this

estimate, VRI assumed that (1) each PDP class would have three

psychologists, (2) prescribing psychologists would be supervised for the

remainder of their military service, (3) supervisory costs after the

proctored year would amount to 5 percent of a physician’s annual salary

22The optimal scenario represents a modification of the start-up scenario. It assumes the PDP is

operating in a long-term, steady state, so start-up costs are excluded and the recurring costs of

supplies and training are set at levels that represent long-term efficiency. It also assumes the optimal

class size of six participants.

Page 17 GAO/HEHS-97-83 Prescribing Psychologists in DOD
B-276291 

per prescribing psychologist per year, and (4) prescribing psychologists

would remain in the military an average of 10.2 years after completing the

PDP.

The validity of VRI’s predictions about the circumstances under which the

PDP would be cost-effective depends on how realistic VRI’s cost estimates

are as well as the other assumptions it used to estimate the annual life

cycle cost of MHSS psychiatrists, psychologists, and prescribing

psychologists. Some of VRI’s estimates were based on scant MHSS

experience in training and employing psychologists to prescribe.

Information about the PDP’s overhead cost that we collected after VRI

completed its work, for example, indicated that overhead cost was lower

than originally thought. Also, VRI’s estimate of the cost of training at USUHS

was lower than our estimate of the cost of this training.

For a more realistic prediction of the circumstances under which the PDP

would be cost-effective, we asked VRI to redo its analysis, replacing its

estimate of $2.89 million for total overhead cost during the start-up period

with an updated estimate of $2.58 million. We also asked VRI to substitute

the $39,969 it used per participant per year for PDP classroom training and

related overhead with $110,028, our estimate of the per student per year

cost of USUHS training, which includes training overhead. See table 6 for

the results of this analysis.

Table 6: Annual Life Cycle Costs of Selected MHSS Providers Based on Our Estimates of Overhead and Training Costs

Yearly life cycle cost per full-time equivalent

Provider group Accession Training Force Retirement Total Required utilization

Psychiatrists $23,470 $13,864 $112,697 $19,142 $169,173 a

Psychologists 1,134 3,766 66,155 15,849 86,905 a

Psychologists/

psychiatrists (base case

scenario) 10,901 8,182 86,506 17,289 122,878 a

Prescribing psychologists

(start-up case scenario) 1,218 32,611 71,979 17,735 123,542 101.85%

Prescribing psychologists

(optimal case scenario) 1,218 26,196 71,979 17,735 117,127 84.01%

Note: Estimates are expressed in 1996 dollars.

aNot applicable.

Source: VRI data.

Page 18 GAO/HEHS-97-83 Prescribing Psychologists in DOD
B-276291 

On the basis of our overhead and training cost estimates, PDP graduates

under the start-up scenario23 could not be cost-effective because they

would have to function as prescribing psychologists more than

101.85 percent of their time remaining in the military. This prediction is

based on the same assumptions that VRI made about PDP class size,

prescribing psychologists’ supervision, supervisory costs, and prescribing

psychologists’ remaining time in the military.

Conclusions In DOD’s mental health care system, the main function of prescribing

psychologists is to care for patients with certain types of mental

conditions that require certain psychotropic medications. According to

DOD’s needs assessments, the MHSS has more psychiatrists to care for these

patients than needed to meet medical readiness requirements. Therefore,

the MHSS has no current or upcoming need for clinical psychologists who

may prescribe medication. In addition, the cost of producing 10

prescribing psychologists was substantial. Regardless of the cost, spending

resources to produce more providers than the MHSS needs to meet its

medical readiness requirement is hard to justify.

The PDP has demonstrated that training psychologists to prescribe drugs,

which increased the number of MHSS providers with this skill, reduced

psychiatrists’ workloads in some cases. A potential benefit of the PDP,

therefore, is the savings associated with prescribing psychologists

delivering some of the services that psychologists in conjunction with

psychiatrists have traditionally provided. These savings result because a

prescribing psychologist can deliver this care with lower personnel-related

costs than the combination of a psychologist and a psychiatrist.

To realize these savings, however, DOD must (1) use a prescribing

psychologist to treat patients who normally would have been treated by a

psychiatrist and a psychologist and (2) replace higher priced providers in

the MHSS with prescribing psychologists. Otherwise, the PDP cannot save

DOD money. Even if the 10 prescribing psychologists from the PDP do, in

certain situations, function as psychiatrists, the PDP is still not guaranteed

to save money. Although prescribing psychologists cannot totally replace

psychiatrists, DOD does not account for the introduction of prescribing

23Again, annual life cycle cost per prescribing psychologist under the start-up rather than the optimal

case scenario was used to predict the cost-effectiveness of prescribing psychologists. The optimal case

scenario assumes the PDP is training six psychologists per class and operating in a long-term, steady

state in which start-up costs associated with project development, such as the cost of external

evaluations, are not incurred. The start-up scenario better represents the PDP, therefore, because it

did not train six psychologists per class and did not reach a steady state. In addition, costs associated

with the PDP’s development were incurred throughout the project.

Page 19 GAO/HEHS-97-83 Prescribing Psychologists in DOD
B-276291 

psychologists in the MHSS when determining its readiness needs for

psychiatrists. Therefore, it is uncertain whether DOD will reduce its

readiness requirement for psychiatrists in response to shifting some of a

psychiatrist’s functions to a prescribing psychologist.

Concerning the PDP’s implementation, DOD has demonstrated that it can

train clinical psychologists to prescribe psychotropic medication, and

these psychologists have shown that they can provide this service in the

MHSS. The implementation faced several problems, however, that persisted

for the PDP’s duration.

Given DOD’s readiness requirements, the PDP’s substantial cost and

questionable benefits, and the project’s persistent implementation

difficulties, we see no reason to reinstate this demonstration project.

Recommendation to

the Congress

In the future, should prescribing psychologists be needed to meet DOD’s

medical readiness requirements, the Congress should require DOD to

(1) clearly demonstrate that the use of those MHSS psychologists who have

been trained to prescribe has resulted in savings, (2) clearly define a

prescribing psychologist’s role and scope of practice in the MHSS compared

with other psychologists and psychiatrists, (3) design a curriculum

appropriate to this role and scope of practice, and (4) determine the need

for and the level of supervision that prescribing psychologists require.

Agency Comments In comments received March 26, 1997, in response to a draft of this report,

the Assistant Deputy Assistant Secretary of Defense (Clinical Affairs)

stated that, on the basis of the methodology employed in this study, DOD

has no objections to its results and recommendations. Department

officials did provide a few technical corrections to the report. We modified

the report as appropriate.

Copies of this report will also be sent to other interested congressional

committees and the Secretary of Defense. Copies will also be made

available to others upon request. This report was prepared under the

direction of Stephen P. Backhus, Director, Veterans’ Affairs and Military

Health Care Issues, who may be reached at (202) 512-7101 if you or your

staff have any questions or need additional assistance. Other major

contributors to this report include Clarita Mrena, Assistant Director;

Page 20 GAO/HEHS-97-83 Prescribing Psychologists in DOD
B-276291 

William Stanco, Senior Evaluator; and Deena El-Attar and Gregory

Whitney, Evaluators.

Richard L. Hembra

Assistant Comptroller General

Page 21 GAO/HEHS-97-83 Prescribing Psychologists in DOD
Contents

Letter 1

Appendix I 

Scope and

Methodology of an

Evaluation of the PDP

by Vector Research,

Inc.

24

Cost-Effectiveness Analysis 24

Feasibility Analysis 26

Appendix II 

Objectives and

Methodology of Our

Evaluation of the PDP

28

Tables Table 1: Psychiatrists by Service: Number Needed and Assigned

to Meet Readiness Requirements

8

Table 2: Psychologists by Service: Number Needed and Assigned

to Meet Readiness Requirements

8

Table 3: Status of Psychologists Entering the PDP 10

Table 4: Estimated Cost of PDP by Training Component and Type

of Cost, FY 1991-98

12

Table 5: Annual Life Cycle Costs of Selected MHSS Providers

Based on VRI’s Cost Estimates

17

 Table 6: Annual Life Cycle Costs of Selected MHSS Providers

Based on Our Estimates of Overhead and Training Costs

18

Abbreviations

ACNP American College of Neuropsychopharmacology

DOD Department of Defense

FTE full-time equivalent

MHSS Military Health Services System

PDP Psychopharmacology Demonstration Project

USUHS Uniformed Services University of Health Sciences

VRI Vector Research, Inc.

Page 22 GAO/HEHS-97-83 Prescribing Psychologists in DOD
Page 23 GAO/HEHS-97-83 Prescribing Psychologists in DOD
Appendix I 

Scope and Methodology of an Evaluation of

the PDP by Vector Research, Inc.

In September 1995, DOD contracted with Vector Research, Inc. (VRI) to

conduct an evaluation of the PDP. The Assistant Secretary of Defense for

Health Affairs requested this study to obtain an evaluation of the PDP that

was independent of those performed by the American College of

Neuropsychopharmacology. VRI’s study was to

• assess the relative cost-effectiveness of training psychologists to prescribe

medication and having them deliver this service in the Military Health

Services System (MHSS),

• identify impediments to integrating prescribing psychologists into the

MHSS, and

• evaluate the potential roles and functions of prescribing psychologists in

DOD.

To accomplish the first objective, VRI compared the annual life cycle cost

of various types of MHSS mental health care providers with the annual life

cycle cost of a prescribing psychologist. To address the remaining two

objectives, VRI conducted what it referred to as a feasibility analysis of the

PDP. VRI issued a report on this work on May 17, 1996.

Cost-Effectiveness

Analysis

To determine the relative cost-effectiveness of training and employing

prescribing psychologists relative to other DOD health care providers, VRI

compared its estimate of DOD’s average annual life cycle cost of a

prescribing psychologist with its estimate of this cost for clinical

psychologists, psychiatrists, physicians specializing in internal medicine,

and physicians specializing in family practice. It calculated these costs on

the basis of three scenarios:

• the “base” case scenario, which is the status quo, a combination of

psychologists and psychiatrists, with no prescribing psychologists in the

MHSS;

• the “start-up” case scenario for prescribing psychologists, which had all

the same elements of the base scenario but accounted for the introduction

of prescribing psychologists into the MHSS; and

• the “optimal” case scenario for prescribing psychologists, which

represented a modification of the start-up scenario.

Costs in the start-up scenario included the nonrecurring, fixed costs

associated with the PDP development and initial implementation as well as

other costs for the PDP that VRI also believed would diminish or disappear

in the long run. The optimal scenario represents the PDP in a long-term,

Page 24 GAO/HEHS-97-83 Prescribing Psychologists in DOD
Appendix I 

Scope and Methodology of an Evaluation of

the PDP by Vector Research, Inc.

steady state, during which no recurring costs associated with start-up and

optimal class size would accrue. In this scenario, VRI set the cost of

supplies and training to levels that indicate long-term efficiency.

Steps in the

Cost-Effectiveness

Analysis

The following are the main steps in VRI’s cost-effectiveness analysis:

1. Calculate life cycle costs for active-duty military psychiatrists, family

practitioners, internists, and clinical psychologists; then calculate the cost

per full-time equivalent (FTE) for each of these by dividing their respective

life cycle cost by their respective expected length of service (length of

service minus unproductive time while in training).

2. Calculate life cycle costs for prescribing psychologists using actual and

anticipated costs for a PDP sized at six and at three psychologists per class;

and then, under both the start-up and base scenarios, calculate the cost

per FTE for prescribing psychologists assuming that they (1) serve as

clinical psychologists before entering the PDP and (2) after which they

prescribe psychotropic medication.

3. Calculate the cost per FTE for the combination of clinical psychologists

and psychiatrists that could be replaced by a prescribing psychologist.

4. Compare the annual life cycle cost per FTE of prescribing psychologists

under start-up and optimal scenarios with the cost per FTE of the

psychologist-psychiatrist combination.

Calculating Life Cycle

Costs

VRI’s estimates of the annual life cycle cost per FTE of various types of

providers accounted for the cost of acquiring each type of provider,

training costs, “force” costs, and retirement costs associated with each.

Acquisition cost is DOD’s cost of recruiting someone into the military.

Training costs include the cost of providing DOD-sponsored training to

military health care providers. Force costs cover basic pay and

allowances, special pay, miscellaneous expenses, and health care benefits

of health care providers during their active-duty careers. Finally,

retirement costs include the cost of retirement pay and retiree health care

benefits.

VRI’s overall estimates of the annual life cycle cost per FTE for different

health care providers were based on a number of cost estimates and

assumptions about these four cost categories that varied somewhat by

Page 25 GAO/HEHS-97-83 Prescribing Psychologists in DOD
Appendix I 

Scope and Methodology of an Evaluation of

the PDP by Vector Research, Inc.

provider and scenario. Following are the major assumptions VRI made

when calculating life cycle cost for prescribing psychologists:

• For cost savings to be realized, the introduction of prescribing

psychologists into the MHSS reduced FTEs for psychiatrists or other

physicians.

• PDP participants had at least 6 years of experience as clinical psychologists

when they entered the PDP.

• The PDP lasted 3 years—1 year for classroom training, 1 year for clinical

experience, and 1 year for proctored practice.

• Each PDP class had three or six psychologists.

• PDP participants required 40 percent of a faculty member’s time during

their clinical year of training and 20 percent of a faculty member’s time

during their proctored year, which took time from faculty members’

patient care.

• After completing the PDP, graduates were able to “safely and effectively”

prescribe medication and were assigned to “utilize their new prescription

skills along with their clinical psychology skills to treat patients that

otherwise would have had to be treated by physicians for their mental

health care.”

• PDP participants continued to practice as prescribing psychologists for the

rest of their military career.

• Prescribing psychologists required supervision amounting to 5 percent of a

psychiatrist’s time for the rest of their military career.

• PDP graduates posed no more of a malpractice risk to DOD than any other

mental health providers delivering the same treatment to the same types of

patients.

• PDP graduates did not receive special pay otherwise paid to psychiatrists

and other physicians in the military.

• Pension rates were based on an average service time for military

pensioners of 22.5 years as determined by a DOD actuarial study.

Feasibility Analysis The objectives of VRI’s feasibility analysis were to assess

• the barriers to employing prescribing psychologists in the DOD health care

system and

• how prescribing psychologists would be used in the DOD health care

system.

To address the first objective, VRI conducted two surveys. It conducted

telephone interviews of about 400 DOD health care providers, including

Page 26 GAO/HEHS-97-83 Prescribing Psychologists in DOD
Appendix I 

Scope and Methodology of an Evaluation of

the PDP by Vector Research, Inc.

psychiatrists, primary care physicians, psychologists, and social workers

to obtain their views on the PDP. This survey measured their awareness of

the PDP, attitudes toward allowing psychologists to prescribe drugs,

participant training, and ultimate ability of psychologists to prescribe

medication. VRI also surveyed DOD medical beneficiaries to determine their

awareness of the relative scope of practice of psychiatrists and

psychologists and the PDP and to measure their attitudes toward allowing

psychologists to prescribe drugs.

To address its second objective, VRI reviewed DOD medical regulations,

records of the PDP Advisory Council, and military health care utilization

data and interviewed PDP graduates and officials familiar with the PDP. VRI

acknowledged that its conclusions about the use of prescribing

psychologists were “conjectures” because of DOD’s lack of experience with

prescribing psychologists.

Page 27 GAO/HEHS-97-83 Prescribing Psychologists in DOD
Appendix II 

Objectives and Methodology of Our

Evaluation of the PDP

The objectives of our evaluation were to

• assess the need for prescribing psychologists in the Military Health

Services System (MHSS),

• provide information on the implementation of the PDP, and

• provide information on the PDP’s cost and benefits.

To address the first objective, we used the need for MHSS psychiatrists as a

proxy for the need for prescribing psychologists because psychiatrists are

the only mental health care providers with full prescribing authority for

which the military determines a readiness need. To assess the need for

additional MHSS psychiatrists, we reviewed the Army, Navy, and Air Force

methods for determining the number they need to fulfill their medical

readiness mission and the results of their determinations. We compared

the number of psychiatrists each branch of the service determined it

needed, both now and in the future, with the number each currently has.

To collect information on the PDP’s implementation, we reviewed many

documents, annual reports, and assessments of the project. These

included periodic evaluations conducted by the American College of

Neuropsychopharmacology under contract to DOD and others done by the

Army Surgeon General’s blue ribbon panels as well as the Army’s annual

reports on the PDP.

We based our estimate of the PDP’s cost on (1) information on cost in the

Army’s annual reports on the PDP, (2) our estimates of the cost of training

provided by the Uniformed Services University of the Health Sciences

(USUHS),24 and (3) estimates of military salaries and benefits and the

productivity of PDP participants and their supervisors found in Vector

Research, Inc.’s (VRI) cost-effectiveness analysis of the PDP. This cost was

calculated in constant 1996 dollars.

To identify the qualitative benefits of the PDP, we interviewed all PDP

participants who completed the PDP and others at the facilities where they

were practicing and representatives of the American Psychiatric

Association and the American Psychological Association. We reviewed

articles that addressed the advantages and disadvantages of allowing

clinical psychologists to prescribe medication. We also examined the

results of a VRI survey of DOD health care providers that collected

information on providers’ perceptions of PDP’s benefits.

24Military Physicians: DOD’s Medical School and Scholarship Program (GAO/HEHS-95-244, Sept. 29,

1995).

Page 28 GAO/HEHS-97-83 Prescribing Psychologists in DOD
Appendix II 

Objectives and Methodology of Our

Evaluation of the PDP

To determine what cost savings or quantitative benefit, if any, might be

realized by enabling clinical psychologists to prescribe medication, we

reviewed VRI’s cost-effectiveness analysis of the program done under

contract to DOD.

25 We compared the results of this analysis with those of a

subsequent analysis VRI did at our request using different assumptions. In

this subsequent analysis, VRI replaced its original assumptions on the

number of participants and level of supervision with information we had

collected about actual program experience. It also replaced its USUHS

training cost estimates with our estimates noted above.

(101494)

25See app. I for a description of VRI’s survey and cost-effectiveness analysis.

Page 29 GAO/HEHS-97-83 Prescribing Psychologists in DOD
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