Join Date: Jan 2006
My point is really not one about safety, what I'm really getting at is that "prescribing psychologist" is blurring the lines of what a psychologist even is... In our current system, physicians prescribe medicine and psychologists provide therapy. This system makes sense because people go to medical school in order to learn how to prescribe medicine and people, generally, go to psychology school to learn how to do therapy.
No, IMHO, the split system does not make sense, my understanding is the the split treatment modality became popular after the demands of manage care, not based on empirical evidence. If we are discussing ideals, where everyone plays nicely and communicates with each other and all patients builts equal therapeautic relationships with everyone, and access was not an issue, then yes, a split system might work. In practice, this does not happen... what good is it to have a "specialist" but have no access? Even in a large metro area, the waiting time to see a psychiatrist could be longer than two months.
The result of this system is that we have two classes of professionals, one who specializes in medicine and neuropharmacology, and one who specializes in behavioral therapies. This should be to the benefit of patients, they are getting the best care on both fronts.
The reality is that pts are not getting the best of both worlds. that's one of the drives of the RXP movement in psychology.
The problem is one of access... there aren't enough of the prescribing-kind of doctor, but there are plenty of the talking-kind of doctor. But the solution doesn't make sense... turn talk-doctors into talk-drug doctor hybrids? Why not just make psychiatry into a more attractive specialty for medical students already going through the extensive process of becoming physicians?
Psychiatrists are one of the top players in terms of income... didn't money magazine listed psychiatry as one of the top 10 earning professions or something like that? In anycase, I believe organized medicine and other forces have been trying to increase attractibility of psychiatry to medical students for years now... they have done the calculations... the interest continues to dwindle. What else is there to do? the money is there, the lifestyle/hours is there... but still there is a shortage... and I believe the majority of the interests tend to be FMGs. I know many FMGs are very competent, but there is a trend here... what is of interest is what accounts for that trend. As you know, psychiatry is not one of the top choices for residencies among medical students, that's a well known fact.
In general, I don't think that there is a problem with pcp's prescribing a lot of psych meds. Pcp's have plenty of experience with psychiatry, there are, after all, the ones prescribing most of the psych meds... as for experience with psychology... why should that matter? All they need is enough experience to refer to a psychologist, just like any other medical or allied health specialty.
Again, IMHO, that's not correct, pcp's don't have "plenty" of experience, in fact, it is my understanding that most pcp's welcome and on many occassions seek out the consult of psychologist in regards to prescribing psychotropics. For whatever reason, there appears to be a greater barrier in keeping contacts with psychiatrists. I have heard this on numerous occassions personally adn in professional conferences. In the Hawaii effort, I believe that community health care MDs were supporting psychologist's effort to gain RXP.
Pcp's know a lot about medicine and biology, and they know a lot about medical decision making... That's not inadequate care. Of course, there comes a point when they have to refer to psychiatry, which a good pcp knows how to do.
they don't get enough training in psychopharm...
Hi, this is an interesting idea. What do you mean, exactly? That psychologists would give the first prescription for an anti-psychotic, and then refer to a psychiatrist for follow up? That makes some sense... but how would such a system be legally enforced? What would stop the psychologist from just setting himself up as a psychiatrist anyway?
Through the medical psychologist's assessment, he/she would decide whether to treat the patient or make an appropriate referral, whether be a psychiatrist or other medical specialty. The assessment process would continue throughout treatment (e.g. past the initial prescription of an anti-psychotic) and the decision to refer would always be an option. It comes down to sound clinical judgment, ethics and clear decision making. There exists very little legal enforcement in the referral process of other health care practionares as well, they also depend of clinical judgment, e.g. it is the family doctor's decision to refer a pt to specialty doctor, whether he/she does it or not is his/her decision... the doctor can be sued, but the decision still lies with the doctor. BTW, all the above is my opinion, it's not based on a specific guideline.
Well I'm not really an expert on this, but what kind of psychological data is important in prescribing medication? It seems like psychotic patients get antipsychotics, regardless of what they have to say about their delusions... bipolar patients get mood stabilizers, etc. In what way would psychological information about the patient change which drugs they would get?[/QUOTE]
well, there are many specific and nonspecific processes that occurs in therapy and a seasoned clinician would be able to "read" these processes and make clinical decisions based on these. Some of these processes would faciliate the report of symptoms, the attitudes toward taking medications. Others would be the selection of specific psychotropics (e.g. as per 'antidepressants': SSRI's vs., NaSSA, 5-HT/NE RI, SRI/S2 antagonists, etc... or even which medication within each category). I don't think most pcp's have been trained in this knowledge base, correct me if I'm wrong. Combining psychotropics with cbt or to maximize behavioral treatment (e.g. treatment of insomnia, primary or secondary to psychiatric d/o)