Consider the following two clinical scenarios:
A. William, a 62 year-old accountant, has been feeling “depressed” since his divorce 5 years ago. His practice, he says, is “falling apart,” as he has lost several high-profile clients and he believes it’s “too late” for his business to recover. His adult son and daughter admire him greatly, but his ex-wife denigrates him and does everything she can to keep their children from seeing him. William spends most of his days at his elderly parents’ house, a two-hour drive away, where he sleeps in the room (and bed) he occupied in his childhood.
William has been seeing Dr Moore every 1-2 weeks for the last 2 years. Dr Moore has tried to support William’s ill-fated attempts to build up his practice, spend more time with his children, and engage in more productive activities, including dating and other social endeavors. But William persistently complains that it’s “of no use,” he’ll “never meet anyone,” and his practice is “doomed to fail.” At times, Dr Moore has feared that William may in fact attempt suicide, although to this point no attempt has been made.
B. Claudia is a 68 year-old Medicare recipient with a history of major depression, asthma, diabetes, peripheral neuropathy, chronic renal failure, low back pain, and—for the last year—unexplained urinary incontinence. She sees Dr Smith approximately every four weeks. In each visit (which typically lasts about 20 minutes), Dr Smith must manage all of Claudia’s complaints and concerns, and while Dr Smith has made referrals to the appropriate medical specialists, Claudia’s condition has not improved. In fact, Claudia now worries that she’s a “burden” on everyone else, especially her family, and “just wants to die.” She and her daughter ask Dr Smith to “do something” to help.
Each of these scenarios is an actual case from my practice (with details changed to maintain anonymity). Both William and Claudia are in emotional distress, and a case could be made for a trial of a psychiatric medication in each of them.
The problem, however, lies in the fact that only one of these “doctors” is a medical doctor: in this case, Dr Smith. As a result, despite whatever experience or insight Dr Moore may have in the diagnosis of mental illness, he’s forbidden from prescribing a drug to treat it.
I recently gave a presentation to a Continuing Education program sponsored by the California School of Professional Psychology. My audience was a group of “prescribing psychologists”—licensed psychologists who have taken over 500 hours of psychopharmacology course work in addition to the years to obtain their psychology PhDs. By virtue of their core training, these psychologists do not see patients as “diseases” or as targets for drugs. Although they do receive training in psychiatric diagnosis (and use the same DSM as psychiatrists), neuroanatomy, and testing/assessment, their interventions are decidedly not biological. Most of them see psychotherapy as a primary intervention, and, more importantly, they are well versed in determining when and how medications can be introduced as a complement to the work done in therapy. Most states, however (including my own, California) do not permit psychologists to obtain prescribing privileges, resulting in a division of labor that ultimately affects patient care.
Let’s return to the scenarios: in scenario “A,” Dr Moore could not prescribe William any medication, although he followed William through two brief antidepressant trials prescribed by William’s primary care physician (with whom, incidentally, Dr Moore never spoke). When Dr Moore referred William to me, I was happy to see him but didn’t want to see myself as just a “prescriber.” Thus, I had two long phone conversations with Dr Moore to hear his assessment, and decided to prescribe one of the drugs that he recommended. William still sees both Dr Moore and me. It’s arguably a waste of time (and money), since each visit is followed by a telephone call to Dr Moore to make sure I’m on the right track.
Claudia’s case was a very different story. Because Claudia complained of being a “burden” and “wanting to die”—complaints also found in major depression—Dr Smith, her primary care physician, decided to prescribe an antidepressant. He prescribed Celexa, and about one month later, when it had had no obvious effect, he gave Claudia some samples of Abilify, an antipsychotic sometimes used for augmentation of antidepressants. (In fact, Dr Smith told Claudia to take Abilify three times daily, with the admonishment “if you want to stop crying, you need to take this Abilify three times a day, but if you stop taking it, you’ll start crying again.”) Like it or not, this counts as “mental health care” for lots of patients.
Some would argue that the only ones qualified to prescribe medications are medical doctors. They would claim that Dr Moore, a psychologist, might have crossed a professional boundary by “suggesting” an antidepressant for William, while Dr Smith, a physician, has the full ability to assess interactions among medications and to manage complex polypharmacy, even without consulting a psychiatrist. In reality, however, Dr Smith’s “training” in psychotropic drugs most likely came from a drug rep (and his use of samples was a telltale sign), not from advanced training in psychopharmacology. When one considers that the majority of psychotropic medication is prescribed by non-psychiatrists like Dr Smith, it’s fairly safe to say that much use of psychiatric drugs is motivated by drug ads, free samples, and “educational dinners” by “key opinion leaders,” and provided without much follow-up.
Furthermore, Dr Smith’s training in mental health most likely pales in comparison to that of Dr Moore. Psychologists like Dr Moore have five or more years of postgraduate training, 3000 or more hours of clinical supervision, research experience, and have passed a national licensing exam. But they’re forbidden from using medications that have been FDA-approved for precisely the conditions that they are extraordinarily well-equipped to evaluate, diagnose, and treat.
A satisfactory alternative would be an integrated behavioral health/primary care clinic in which professionals like Dr Moore can consult with a psychiatrist (or another “psychiatric prescriber”) to prescribe. This arrangement has been shown to work in many settings. It also allows for proper follow-up and limits the number of prescribers. Indeed, pharmaceutical companies salivate at the prospect of more people with prescribing authority—it directly expands the market for their drugs—but the fact is that most of them simply don’t work as well as advertised and cause unwanted side effects. (More about that in a future post.)
The bottom line is that there are ways of delivering mental health care in a more rational fashion, by people who know what they’re doing. As it currently stands, however, anyone with an MD (or DO, or NP) can prescribe a drug, even if others may possess greater experience or knowledge, or provide higher-quality care. As an MD, I’m technically licensed to perform surgery, but trust me, you don’t want me to remove your appendix. By the same token, overworked primary care docs whose idea of treating depression is handing out Pristiq samples every few months are probably not the best ones to treat depression in the medically ill. But they do, and maybe it’s time for that to change.
Welcome back. I’ll start. I was checking email to avoid work
When I teach biology students I tell them that pharmacy is more intellectually demanding than medicine. I can’t really advocate this: but why not a bigger role for these people, who at their best, really understand drugs and physiology and, likely have some ideas of the effectiveness of drugs because people come back to them on a regular basis.
I went to my GP many years ago, told her I was feeling very depressed and could she give me something for it. She prescribed a drug (think wellbutrin) but never offered a follow up appointment just the admonition to take it and see if it helps. All I could think was the pharmacy rep (and maybe TV ads) were the education she had in deciding if and what to give me.
It was truly ridiculous and very poor practice, to my mind. At the least she should have advised/recommended counseling/counselor and made sure that I agreed to a follow up with her.
If PA’s are now allowed to prescribe I do not see why psychologists with the kind of additional training you related should also not be allowed that ‘privilege’.
(Long time since I have seen a post from you, not sure if I just not been alerted or you have been gone. If the latter hope all is well with you.)
I just retired from clinical psychology after over 40 years in many settings. Most of my settings, especially twenty years in inpatient, provided excellent training and experience with psych meds. Early on, I debated about becoming certified in psychopharmacology but I knew that my state, MA, has a very strong psychiatric presence that would never let psychologists actually prescribe. They don’t seem to mind M.S. level nurses with, realistically, minimal case supervision, becoming mini-psychiatrists in clinics and private practice. SteveMD’s thoughts about PCP’s, unfortunately, are also pretty accurate, IMO.
If the psychologist can prescribe anti-psychotropic medications, what is the difference between the psychologist and the psychiatrist?
Psychologists still won’t be staffing psychiatric wards, nor will they be seeing a great number of psychotic patients. In a perfect world, one would have highly specialized experts in each field; in our world, depression and anxiety are very common, and psychiatrists in dire shortage.
The last thing patients need are more people providing 15 min med checks. This will help the psychologists’ pocketbook, no doubt, but i don’t see this helping patients. As a patient i would need never see a psychologist for med management. Maybe my opinion is biased from seeing some not so bright psychologists while inpatient, but the thought of the psychologists i saw having access to a prescription pad is beyond frightening.
I would sure see one of my Ph.D. colleagues with psychopharmacology certification before a nurse practitioner.
Fifteen minute med checks…the psychiatrist at our clinic sees many more than four people an hour, LOL.
Steve, I wouldn’t want to see a NP for med management, either, but at least the NP can monitor patients’ glucose when the antipsychotics they prescribe give their patients diabetes. Would the clinical psychologist with psychopharmacology certification also be able to order labs?
The fact that the psychiatrist at your clinic sees “many more than 4 people an hour” makes me sad for the patients. i don’t think the answer is more of that.
The best care for both William and Claudia would come from a psychologically sophisticated practitioner who is also knowledgable about medical conditions that present as psychiatric, and/or that add to or complicate mental health matters. (William might have a thyroid condition or cancer, and Claudia clearly needs more than an antidepressant script.) That’s what a psychiatrist should be. If clinical psychologists undergo medical training that makes them more like psychiatrists, then I suppose they should prescribe (and order labs? refer to other medical specialists?) too.
Currently, psychologists lack the medical side of this equation, and psychiatrists increasingly lack the psychological side. I don’t begrudge any psychologist who wants additional training, but I do begrudge psychiatrists and psychiatric training programs that choose to dumb down their (my) profession. Primary care docs are a red herring here: They’re good for straightforward cases of everything from depression to diabetes to sciatica, but should know enough to refer to a specialist when over their heads.
I think Dr. Balt, as usual, has zeroed in on a jugular issue in health care delivery. I heard a lot about integrated care models at the 2012 Academy of Psychosomatic Medicine Annual Meeting in Atlanta this month, and there may be partial solutions, about which I have an upcoming post tomorrow.
Jim Amos, MD
The Practical Psychosomaticist
The article states, “A satisfactory alternative would be an integrated behavioral health/primarybehavioral health/primary care clinic in which professionals like Dr Moore can consult with a psychiatrist (or another “psychiatric prescriber”) to prescribe.”
I would assume this psychiatric consult is not free, and that would be added to the cost of having a more expensive psychologist who can prescribe. This means the patient will end up paying a lot more than if they just saw a cheaper therapist for therapy and a psychiatrist for meds or a psychiatrist for both meds and therapy. It doesn’t make sense to me to pay more to see a prescribing psychologist if they are going to be consulting with a psychiatrist, i could just make my own appointment with the psychiatrist.
If this NAMI article is correct, the DoD will pay 7% more for prescribing psychologists than for a combination of psychiatrists and psychologists. That doesn’t sound cost effective to me.
in addition to added costs for patients, what would a prescribing psychologist do in the following real life examples:
While hospitalized for depression the psych meds i was on caused bladder spasm rendering me incapable of urinating. The psychiatrist wrote an order for me to be cathed and relieved my misery, a NP could have done the same thing. What would a prescribing psychologist be able to do about it? Consult someone else while i was in misery? How long would i have to wait with a full bladder while that happened? Then, i suppose the consulting urologist would want to see me before they ordered anything. I presume i would have to pay for the additional consult because the prescribing psychologist would not be able to handle the side effect? Also, the psychiatrist at another time prescribed some drug sublingual and this relieved the urinary retention. Would a prescribing psychologist know to do this?
Another patient hospitalized at that the same time as me had a syncopal episode due to a drop in blood pressure. If the prescribing psychologist is in charge what are they going to do about that? Call someone else after the nurse calls them, because they cannot handle any medical problems?
Third, while i was in the psych hospital I had an insect or spider bite that resulted in welt on my leg the size of an orange. THe nurse called the psychiatrist. The psychiatrist was able to handle this minor medical issue.
What would the prescribing psychologist do about it were they the one in charge?
If a patient is precribed lithium by a prescribing psychologist, then I would presume the psychologist would want to monitor the patient’s labs so they would know if dose adjustments needed to be made.
Would the patient have to make another appointment with a PCP to get an order for labs, requiring additional time and money? When my psychiatrist wants labs, he orders them. I don’t have to make another appointment with my PCP, I just go get the labs.
i think that a person who is precribing should have the medical background to properly monitor the patient and handle basic stuff that comes up.
These are good points. Should a prescriber know about, and have the authority to order, lab work or EKGs? To handle common medication side-effects? Should he or she know enough general medicine to adjust doses for liver or kidney dysfunction? To be able to reassure a patient that a nonspecific complaint, e.g, itching, is often NOT due to a life-threatening med allergy? The apparent trade-off between psychological and medical expertise is a false dichotomy. A prescribing mental health practitioner needs both — or a quick readiness to refer to someone who can offer them. As “No Thanks” points out, this can often delay care and cost more.
Yeah, he makes a good point…but some insurance companies, maybe even most, only pay for med management. What I mean to say is, if you do think you have any kind of blood pressure problem or whatnot, then you would have to go to your primary care physician or check yourself at a CVS. If your prescribed a medication, and need an ekg cuz your heartrate went up, the pdoc can’t order that. You have to call the GP. The pdoc can adjust your meds for sure, but if they think the liver is affected, blood pressure may be high (do med management pdocs ever check blood pressure?), etc, then all they can do is ask you to contact your GP. They don’t order blood tests in my experience, and if anything goes physically wrong with you then they can’t treat you for it unless it’s to lower or raise dosage.
[…] by Dr. Steve Balt, MD, about a major topic, psychologist prescribing. See the full post at link https://thoughtbroadcast.com/2012/11/25/explain-to-me-again-why-psychologists-cant-prescribe-meds/ for the context of my following remarks, which I hope convey that integrated care models offer one […]
So many arguments for psychologists’ prescribing boil down to; If other eminently unqualified professions – GP’s nurse-practitioners (and I would argue psychiatrists too), why not let psychologists do it too?
There are only a handful of psychiatrists in the country with enough knowledge of actual facts (and who are willing to share them with patients) to allow patients real informed consent. You are not one of them if: you believe DSM is a scientific document; you think “medications” correct chemical imbalances; you don’t take seriously the findings of the WHO studies, that concluded schizophrenia seems NOT to be a lifelong condition; your jaw doesn’t drop at the results of the largely drug free Open Dialogue with first episode psychosis; you think antidepressants actually prevent suicide; you tell patients it’s scientific fact that a “mental illness” is a proven “brain based disorder”; you think clinical trials aren’t shot through with commercially and ideologically based bias by the drug companies that sponsor and control them; that publication bias, ghost writing and scientific fraud don’t make al large number of peer reviewed journal articles misleading, if not dangerous – and it is virtually impossible to tell the good articles from the bad ones; the list is endless.
And really: who – psychiatrist, nurse practitioner, family doc, or psychologist – ever comes remotely near telling patients anything about these issues. Psychologists, social workers, counsellors, primary care physicians simply suggest that patients see psychiatrists, or acquiesce when patients request it. And maybe 1 in 10 thousand psychiatrists will have an honest conversation about the above issues with patients who come to them.
Google “prescribing rights for psychologists”. You’ll find position papers in which psychologists are so self-congratulatory about their qualifications and expertise it is scary. They appear so pleased to have taken courses in psychopharmacology -apparently omitting consideration of how overwhelmingly influenced these courses may be by the myths referred to above. Prescribing privileges do to so many who have them what the ring did to Gollum in Tolkien’s trilogy. The self-assurance that comes with “expertise” opens the door for the thoughtless arrogance about prescribing that has infected psychiatry for decades.
We don’t need more people prescribing – we need a whole lot fewer. If someone really knows the facts about psych drugs and still wants them, that’s their choice – but they need a real shot at informed consent. And let’s not kid ourselves about the financial incentive for psychology’s wanting to get in on the meds business.
“There are only a handful of psychiatrists in the country with enough knowledge of actual facts (and who are willing to share them with patients) to allow patients real informed consent.”
Why is this Peter? It seems crazy. Psychiatrists prescribe drugs that routinely do more, far more, harm than good, and still sleep at night?
I’ve puzzled over this for years. One answer comes from Upton Hawkeye,
Sinclair Lewis, roughly summarized: “It is hard for someone to understand something when their job depends on not understanding it.” But I’ve come to think it’s more than that – psychiatrists are generally a lot smarter and more disciplined than I am, and than most people. They got into and through med school and then residency, which is more than I could do. I think most people decide to become doctors for good reasons – they want to help people.
So what happens? People come to psychiatrists when they are desperate – I think of the Kris Kristofferson song, “Help Me Make It Through the Night”: “I don’t care who’s right or wrong, I don’t try to understand, Let the devil take tomorrow, Lord tonight I need a friend. Yesterday is dead and gone and tomorrow’s out of sight, it’s so sad to be alone, help me make it through the night.”
And psychiatrists are there, desperately wanting to do SOMETHING to help. And our culture has this overwhelming faith in science – antibiotics, vaccinations, heart transplants. I think there’s huge pressure for psychiatrists to provide HOPE – and the subtext coming at them is, “You’re a doctor aren’t you? So where’s the antibiotic for MY problem?”
We need to keep in mind that, although psychiatrists are dispensing the pills, most people in other disciplines – GP’s (also prescribers), psychologists, counselors, social workers, nurses – are going along with it, and are often relieved to duck responsibility by diverting their most difficult clients to psychiatry for a “pill fix.” And millions of suffering Americans embrace the medical model.
There’s also a strong human tendency to reach for simplistic or reductionist answers when we are at our wits end. I hate to get political, but here it is – Obama gets elected, many are dismayed, so they cling to the belief that he was born in Africa. And of course, nothing is more reductionist than the medical model.
Aside from being really mad at psychiatry – which I am often enough – the question is how does it happen that basically good people come to do such bad things? The answer to that holds the promise of making things better.
Without trying to be snide here, psychiatrists, as distinct from clinical psychologists and nurse practitioners, are not at the top of their own professional pantheon. During my time as a clinical psychology doctoral student in the 80’s at a highly rated medical school’s clinical psychology dept., the psychiatry residents were not respected, largely foreign, with minimal understanding of American culture and modest medical training. Psychiatry, IMO, was poorly regarded as a field and this school had difficulty in attracting competent residents, despite its overall prestige level. The profession, over time, was somewhat rescued by new medications but this has snowballed into Big Pharma salivating to help create new diagnostic categories, viz. the DSM V, with several ridiculous and indefensible categories. Psychiatry, as noted, has become a profession of pill pushers, often poorly pushed, at that. Their task, IMO, is to regain the high ground they had during the early analytic days, as limited as that treatment modality might have been for some patients.
I have a carefully annotated copy of Goodwin and Jamison, “Manic Depressive Disease” on my desk. There must be other similar texts for other psychiatric disorders. I would surmise that a psychiatry resident would carefully read about 2,000 pages of text and examine the content of at least a hundred research papers, probably more, during training.
This is especially important since senior faculty are often agenda driven and therefore, sometimes wrong. It must be the case that residents routinely challange senior faculty to encourage the intellectual growth of both the resident and the faculty member.
Is this true?
It is impossible to imagine that anyone would be certified to prescribe dangerous drugs to help control ill defined disorders without this, in spirit, being true.
I am not a medical person, but worked in teaching hospitals and been patient at teaching h ospitals.
I would venture your hypothesis is not true: I have seen residents not challenge because they want to complete their residency, challenging would not be politic, and I have seen attending not take their residents to task when they have caused actual damage by their behavior (in my case missing infection signs (swelling ad severe redness at the operative site) that caused me to lose an implant for pain and not be able to have it re-placed. Maybe something was said in private but when I spoke to the attending about the resident missing the infection he just shrugged his shoulders)
If virtually everything a resident reads incorporates and promotes the medical model’s wrong assumptions, even if he/she does challenge an attending, it will not be over the really important issues. It will be a discussion of whether ability, risperdal or zyprexa is best for patient X – or a lively zoloft vs. prozac debate.
It’s a safe bet that few residents are going to cite Anatomy of an Epidemic or The Emperor’s New Drugs, or the final report on the WHO studies to challenge the fundamental assumptions of psychiatry. Check with Peter Breggin or Grace Jackson about how that goes over – licenses get challenged.
I agree with leejcarroll – it’s unlikely that psychiatric residents will seriously challenge attendings over their discipline’s fundamental assumptions. You write, “It is impossible to imagine that anyone would be certified to prescribe dangerous drugs to help control ill defined disorders without this, in spirit, being true.” That SHOULD be the case, but it is demonstrably not so. Consider that some 70% of psychiatric drugs are proscribed by primary care doctors, and it is clear that they have not gone through such a process – they get most of their “facts” about psych drugs from drug reps.
[…] why-psychologists-can’t-prescribe-meds […]
Thank you Steve for campaigning to devalue our degrees. Yes I’d love to work in a psych ward and lose comfortable private work to prescribing psychologists.
Look at what has happened to anesthesiology. We need to keep mid-levels out. Instead we have physicians like you actively working to give away our turf.
If psychologists wanted to prescribe they should have worked harder and gone to medical school. It’s that simple. I didn’t work my ass off and take on ridiculous loans to get my job stolen out from under me.
Do many appendectomies or liver resections in your psychiatric office?
Recentgrad with an attitude and chip on the shoulder like yours, I would hate to be someone coming to you for anything – except maybe a script.
It starts with trust. Seeking a counselor, in this instance a psychologist, to understand human behavior greater than my own understanding, so I can move through the barrier. ( I had been molested on an ongoing basis as a child which was inhibiting my relationship with my husband). Instead of helping me through my dilmema, I end up with a diagnosis. Fast forward 27 years of pschopharmacological treatment and landing in the mental health system of care, having a diagnostic label if you will is quite detrimental. Patients ” become” their diagnosis and for many it is a dwindling cycle of well intended professionals. Some loose their station in life and certainly become the object of much ridicule, bias and prejudice by people who are very unaware. Doctors, both PC physicians and psychiatrists are seldom ever on the same page. I have experienced a laps in judgment as one thinks the other is doing something that should be done ( such as monitoring blood levels of medications) without there ever being any conversation between the two. Incredibly frustrating for all. The side effects can be a hazard and keep one in a ” mental fog”. This is my bias, but it certainly enables the practitioner to continue prescribing medications as the patient appears to be supplicant. Of course that must mean such medications are being effective. Let me state, that after years of medications, I quit all of them and my quality of life has been restored. I had a diagnosis after one session with that psychologist over 27 years ago who then referred me to a prescribing psychiatrist. To be sure, there are those who benefit from psychotropic medication, but as wS indicated it is far from an exact science. I benefited greatly with the help of a therapist using good ole communication. All psychiatrist I ever had seen, due to time constraints with the exception of a very few ( 2 to be exact in 27 years) employed ” talk therapy” in conjunction with some medication. There should be more concentration of talking vs prescribing to get at what ails an individual. If after a period of time that is ineffective then maybe an introduction of a medication. But please, if that is not working, try more talking and listening, not the aresenal and plethora of medications that are the current practice. There can be resolution of emotional conflict without medication and a restoration to and of life. I am proof positive that such illness is not a lifetime sentence.
I learned statistics and research methods at Harvard. All professors impressed upon us (stats courses were lecture, research was seminar) the murkiness and political battlefield we know as peer reviewed literature. I wonder how many MDs – unless they are as knowledge hungry as some of the above admirably are – understand this? Someone above noted their doubt that any psychiatrist (certainly no PCP) would reference the literature that calls out this murkiness (the list of texts mentioned shows that this person is acutely aware of psychiatry/psychology AND IT’S LIMITATIONS as a field – Anatomy of an Epidemic, WHO, etc.) Why does medical school not require a heavy research component? I am often worried when my doctor isn’t as familiar with the literature on drug XYZ as I am (by the next time he’s prescribed it). This is one area physicians NEED to have (and should want to have) training in.
I’m a PhD student. I have a strong interest in Rx privileges. Someone mentioned monetary gain. While I would be foolish to argue that such isn’t relevant and certainly some PhDs are motivated by that, I’d have to say you must not know many PhDs. If we were $ motivated, why the hell would we choose psychology? (this is the same person above that suggested we aren’t as well educated as MDs). We spend our entire graduate life in the brain. We work hard, and hopefully, we’re given tools to recognize the MASSIVE influence that bigPharma has on Rx. A PhD – in any field – isn’t a walk in the park. I wouldn’t begin to compare it to med school because I haven’t been to med school and frankly, I can’t compare it (I suspect that individual can’t either). We are educated in a similar realm (mind and behavior) but from obviously different models. That’s the truth. Why not just say that rather than “you shouldn’t have done it the easy way by doing a PhD…” that just sounds foolish and young. My point for this paragraph: we are highly educated… caveat: in the mind/behavior only. Our training in physiology is next to none… especially in comparison to the MD NP or PA.
BUT, another post above (I believe Mr. Dwyer’s) hit the nail on the head (sadly) when he said “we’re letting everyone else prescribe, why not at least let the guys who know a good deal about what they’re doing do it also! I CERTAINLY don’t think after my Ph.D. and (hopeful) completion of a post-doc in psychiatry, and post M.S. in Psychopharmacology, that I’ll be “ideally qualified” (remember this phrase) to “fix” all my patient’s issues. But I think Mr. Dwyer is right, who else is? Primary Care Physicians? No. Nurse Practitioners? No. Social Workers? No. Psychiatry? I don’t mean to step on toes, but no… med-management isn’t cutting it. I dare say that I have a TON of learning to do before I’d ever consider myself “ideally qualified” but I certainly have seen too many folks abused (of course unintentionally) by prescribers who a. can’t even interpret warning labels properly (increased thoughts of suicide isn’t the same as increase chance of suicide), b. can’t rip apart a peer reviewed article on XYZ drug, c. can’t sit down with a patient… period lol, d. …so that they can discuss all possible options this patient has at their disposal both pharmacologically and otherwise.
Are we (psychologists) susceptible to getting money-eyes and turning into what “most” of psychiatry has… 10 minute med management sessions? Of course, but I would hope that given our choice to go the long, grad-school, low-return-on-investment, best-care-for-the-client, route, we’ll be less influenced by samples and fancy meals. We should also be more research-based in our prescribing habbits – relying more on raw statistical numbers which we should be able to analyze and skip the sales-jargon and twisting of the pamphlets and even “peer reviewed” articles (as the poster mentioned above). For the record, I don’t mean to bash all of psychiatry either. Iv’e met some amazing psychiatrists. My point is NO ONE is meeting this need. Psychiatry and Psychiatric NPs are the closest, but they lack something. A marriage of both models is ideal – medical and psychological.
Am I capable of prescribing safely? I don’t know yet. I really don’t. I’ve only – personally – completed PhD training (or close) as a psychologist. At this moment, no, I’m not at all capable. But if I went through a pharmacological post-doc masters, and collaborated with other physicians/psychiatrists/NPs, I might think differently. Even more than that (and if this doesn’t make clear my true dedication to my patients, I don’t know what would), I’ve considered a Psychiatric MSN JUST TO MAKE SURE I’m doing the best I can to provide the best care possible (feeling as thought the MSN might be a better medical compliment to my psychological training). Perfect? No. I’d say the PERFECT training possible in 2014 would be the M.D. – Ph.D. But what PhD survivor is going to go to med school after defending? What MD is going to start brushing up on her or his GRE skills after their final rotation? LOL.
My position is this: If I have a strong physiological understanding (which I do not believe is the entire curricula of med school) paired with my psychological understanding – which would include the ability to Rx, UN-Rx (we forget about this too often), order and interpret labs, perform physicals like any advanced practice nurse or PA – then I think I have become the best I can – given our medical, psychological, and academic climate of 2014/15 – to treat a patient.
I think the analogy above was best: you don’t want a psychiatrist removing an appendix, even though they “can”. Part of being a phenomenal clinician is recognizing our limits. My feelings as of right now (as a young, wide-eyed, very green, future clinician) is that current prescribers of psychotropic drugs are OFTEN (not always) overstepping their a. level of training, b. level of pharmaceutical research methods.
I have a friend who worked at McLean in Mass and was on the staff at HarvMed who once commented on the dangers she saw first hand of PCPs Rxing psych drugs (people are still put on benzos “as needed” for years!!!).
I care about people. That’s why I’m on the path I’m on. I want to prescribe so that I can make sure it’s being done safely (med-management is not ideal). I do not believe there is adequate availability of safe prescribers currently. I’m willing to go out and get the training required to do this safely. The argument I won’t swallow, is that such education requires me to also understand how to slice and dice. I would swallow that such education is probably steeper than New Mexico and Louisiana have codified.
What happens when the patient getting the SSRI from the psychologist gets manic? Is the psychologist going to do all the lab work for lithium or depakote? If an antipsychotic is given, with the psychologist be able to appropriately monitor for EPS effects and TD? Not that all most psychiatrists do anyway… But I think there is this thinking that psychiatric drugs are someone safe and not real drugs. I have had a seizure from a combination of antidepressants. I have had seratonin syndrome and lithium toxicity. And I could go on. These are real medications. Yes, in most people an SSRI at a normal dose is safe- but it’s usually not that effective, either, in getting people to remission.
My other fear is that psychologists who prescribe will limit the drugs that they prescribe, and not even tell their patients that there are other options that they just don’t prescribe. So maybe no one gets lithium or an MAOI, etc. from that practitioner, even if that would be the best medication, and referral to a psychiatrist might not be made in a timely manner. And really, when you are in a crisis, you don’t want to be told you have to see another doctor to get evaluated for the right medication. Med changes tend to happen in a crisis.
Of course, we could actually look at data from the several states in which psychologists do prescribe and see how they’ve done.
interesting blog, what do you think of Paxil (Seroxat/paroxetine)? do you prescribe it?
Nope, psychopharmacology is not medicine. Psychologists are not doctors and they should not try to one on T.V. If you wanted to prescribe drugs then you should have gone to medical school. The are far too many organs, interactions, pathways that psychologists know nothing about. 500 hours, a little more then 12 weeks is nothing…until you’ve had to make life and death decisions at 3 am, you just have no idea what your negating as “equivalent.”
1. Medical school is no longer the absolute bar to which prescription privileges are held. At the last psychopharmacology conference I attended (2015), I sat next to several NPs with rx rights. Based on their answers to the quiz questions… well… I’ll just leave it at that.
1a. Research has shown that PCPs quite frequently misdiagnose mental disorders which can lead to patients being on medications that are not appropriate. I wish states would require some level of specialty for anyone wishing to prescribing psychotropics. I cringe when I hear a PCP offer someone clonazepam to help with their “anxiety,” with no other discussion of what research has shown regarding benzos. At that same conference, the entire room is asked several questions about diagnosis and scrip writing. You wouldn’t believe how many questions PSYCHIATRISTS got wrong about identifying the correct diagnosis, and providing proper medication. I left that conference feeling so disheartened about the overall psychotropic-prescription-writing field.
2. Where did you get 500 hours and 12 weeks from?
3. Have you ever compared MSN vs. PhD+MS curricula?
3a. For that matter, have you ever compared PCP vs PhD=MS curricula? It’s quite scary that any doctor can prescribe psychotropics drugs, with no training mental health, beyond the basic medical school curriculum.
4. Are you familiar with research indicating that several PCPs welcome giving up treating mental disorders because they believe mental disorders are BEYOND their scope of practice?
1. If a psychologist is NOT capable of ordering and interpreting the lab work in your hypothetical, then she or he should absolutely not have prescription privileges. I suspect you have never met a prescribing psychologist. I invite you to engage in conversation (even debate) with one, and if possible, get a PCP in room too. The cocktail that you describe seizing from is exactly the basis for my belief that the current state of psychotropic rx rights (with PCPs and NPs) and mental health is failing.
2. You mention that a psychologist may fail to inform their patient about possible pharmacotherapy options. Again, you must not know many psychologists. To do what you hypothesize is MALPRACTICE. With my patients (for whom I do not prescribe) I always discuss medication as a possible part of therapy. This usually involves me explaining to them what their medications do because their psychiatrist or PCP did not. Ironically, most of my patients see me because the DO NOT want medicine… They KNOW a psychiatrist will tell them that’s what they need. However, when I tell them they should consider it, it seems to ring more genuinely (just my experience). The several prescribing psychologists I’ve worked with also follow this same philosophy.
@ Retired psychologist,
This is a great suggestion, however I can tell you that state medical associations (correctly) point out that “lack-of-incidence is not proof of safe-practice.” I mostly agree, however I would point out that there is certainly a statistical correlation. But they are right, just because LA and NM (and IL) don’t have any suits or sanctions, doesn’t automatically mean that RxPs are prescribing safely. It would be quite the foolish fellow who would argue, however, that lack of incidence does’t say “something,” though, at least.
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I would expect this mental counsel isn’t free, and that would be added to the expense of having a progressively costly analyst who can endorse. This implies the patient will wind up paying much more than if they just observed a less expensive advisory for treatment and a specialist for medications or a specialist for the two prescriptions and treatment. It doesn’t sound good to me to pay more to see a recommending analyst in the event that they will be counseling with a specialist,
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Some medication review is needed