Psychopharmacology/Advanced Practice Psychology

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Originally Posted by DoctorLCSW

well, given our "market saturation" and how amenable third-party payers are to us, I am certainly sure savvy Psy.Ders and their "trainers" are very concerned......

From what I have seen, the persons educated at professional schools are a lot lower quality than those educated at universities. Two of the interns at my site are from prof schools (Argosy and Illinois School of Prof Psychology). Their education seems to be very applied driven versus a theory driven model. Hence, they don't come off as practicing psychology by numbers. One of them is psychodynamic but matched with this site that deals with intellectual disability....

Originally Posted by DoctorLCSW

Doctors of Social Work (DSW) are poised to supplant, not supplement, Psy.Ds, esp. those of the fly-by-night degree-mill, industrial office complex/warehouse Argosy/Alliant/Nova paradigm. We are frequently housed in REAL, frequently Ivy-league universities such as Columbia, U. Chicago, etc. We receive rigorous didactic training with advanced, supervised practica in DSM-IVTR, adult/child psychopathology, and evidence-based interventions such as CBT, DBT, and IPT. We get a min. of two years training in multivariate quantitative research, including things like Structural Equation Modeling and Path Analysis, in addition to integration with naturalistic, anthropological methodology including critical ethnography and symbolic interactionism. Moreover, we are conversant with and comfortably ensconsced in managed-care friendly, cost-containment oriented mental health administration. We have a formidable social advocacy/social justice lobbying arm in NASW. We see you, Psy.Ds, and have our sights squarely on your foreheads...we will soon be lobbying for RxPs, admitting privileges, psychometric and neuropsych testing, and all the accoutrements....vive la DSWs!!!

wow, a social worker that knows a little stats and thinks he/she knows it all... buddy, congrats, I do have to give it to you since the vast majority of social workers can't even read and understand a scientific article. You should be basking yourself in your glory since you've reached such a high achievement in your field.... which pretty much all mediocre doctorate psychology programs have, wow congrats!

and you certainly seem to have your social work passion for advocacy (which usually dissapears after a sw becomes an administrator), but again, wake up, LCSW's are never going to get rxp, if your are saying DSW's will, hmmm, how many of you guys are there anyway? us psychs don't have to worry since the majority of LCSW's don't have any interest to purse a higher degree. Most sw that I know openly admit going the social work route in order to avoid taking GRE's... even as your celebrated IVY school such as columbia don't require them... that's just sad...

sw are insurance friendly because they are cheap and willing to take the low payments. That's the reality.

I could hear the sound of LCSW being put in the proper place all the way from Colorado!!

social workers are just as good at psychotherapy as psychologists. Talking is still talking! If you dont like MD's putting down psychology then why do you put down social workers. They can be taught to prescribe like everyone else.

We should get back on topic.....though if you'd like to discuss this further, I suggest making a new thread dedicated to the topic.

-t

I highly doubt CA will change over anytime soon. From the more experienced psychologists with whom I'm spoken, they've told me it's a money issue - the poor states will change over first and the wealthier ones last.

well, most of my DSW mentor's psychotherapy clients are affluent, PRIVATE PAY, full-fee (get the $ame as PhD psychs/even MD psych."object relations" therapists)- with stellar rep as a DBT therapist.....and with managed care, even the garden variety LCSW usually gets, like, ten bucks a session less than PhD/PsyD psychologists-(and usually has FAR more clients)....with TWO years of grad school, to boot....AND usually has a MUCH wider client base; far, far greater/more diverse array of job opportunites (community org, admin, child protective services, forensics, family agencies, nursing home/geropsych, HIV, med/surg, dialysis social work)...Psychologists have FAR more circumscribed areas of practice, ludicrously long training...and, perhaps most significantly-don't forget that EMDR, Thought-Field Therapy, and a host of other wacked "modalities" were promulgated by...TA-DA-Clinical Psychologist charlatans!!!

Psychologists have no more(and frequently fewer) skills (not to mention less abrasive, arrogant personalities) than LCSWs in delivery of psychotherapy(I am intimately familiar with-and unimpressed by the vast majority of psychologists performance-after all, how much therapy training do most of them really get in between incessant self-aggrandizing poster sessions, pretensions of "publication," and grappling with intricacies of multicollinearity, anyhow??) .There is absolutely no skill set that is exclusively their domain, including psych testing, research, RxP-their viability is extremely limited, particularly with the surfeit of pre-fab Psy.Ds looming large....word!!!

Originally Posted by heimlichboy

social workers are just as good at psychotherapy as psychologists. Talking is still talking! If you dont like MD's putting down psychology then why do you put down social workers. They can be taught to prescribe like everyone else.

[QUOTE=DoctorLCSW;4883615]well, most of my DSW mentor's psychotherapy clients are affluent, PRIVATE PAY, full-fee (get the $ame as PhD psychs/even MD psych."object relations" therapists)- with stellar rep as a DBT therapist.....and with managed care, even the garden variety LCSW usually gets, like, ten bucks a session less than PhD/PsyD psychologists-(and usually has FAR more clients)....with TWO years of grad school, to boot....AND usually has a MUCH wider client base; far, far greater/more diverse array of job opportunites (community org, admin, child protective services, forensics, family agencies, nursing home/geropsych, HIV, med/surg, dialysis social work)...Psychologists have FAR more circumscribed areas of practice, ludicrously long training...and, perhaps most significantly-don't forget that EMDR, Thought-Field Therapy, and a host of other wacked "modalities" were promulgated by...TA-DA-Clinical Psychologist charlatans!!!

Psychologists have no more(and frequently fewer) skills (not to mention less abrasive, arrogant personalities) than LCSWs in delivery of psychotherapy(I am intimately familiar with-and unimpressed by the vast majority of psychologists performance-after all, how much therapy training do most of them really get in between incessant self-aggrandizing poster sessions, pretensions of "publication," and grappling with intricacies of multicollinearity, anyhow??) .There is absolutely no skill set that is exclusively their domain, including psych testing, research, RxP-their viability is extremely limited, particularly with the surfeit of pre-fab Psy.Ds looming large....word!!![/QUOT




EMDR is mostly followed by social workers... and enthusiastically too. LCSW, all that you've told us so far is that you are dying to be acknowledged and validated as a psychologist-- not a social worker. This is really a waste of time, look, use that awesome social work training of yours, that you are so earger to be acknowledged with, to figure this out, what does it say about someone who just joined a group and starts off with inflamatory, self-aggrandizing comments? figure it out and let us all know. Oh, boy, if you are examplary of DSW's students and way of thinking... man, that's damn sad for your field.

If you have any opinions about rxp and psychologists, then go ahead and post them, if you don't, reframe from posting your rants or start another thread so you won't be wasting other's time, people who are interested in the topic of this thread.

Originally Posted by doctorpsych

....refrain from posting your rants or start another thread so you won't be wasting other's time, people who are interested in the topic of this thread.

Excellent advice.

-t

well obviously social workers are adequate at psychotherapy it is merely the psychologists ego that tells them they are better at it than the social workers. Secondly pharmacists know about drugs why are they not given prescribing privileges. The psychologists who think prescribing privileges will hit all 50 states are dreaming. Take for example chiropractors they have been pushing for more rights for years. In the state of illinois they got the right to run blood tests a long time ago. But their scope of practice has not really changed in any other state in a really long time. Psychologists just want to be psychiatrists and feel inferior that is why they have to create fancy titles for themselves such as medical psychologist. Well why not create a medical social worker. I enjoy working with social workers better than psychologists because they are less opinionated and listen to the psychiatrist.

hmmm, last time I checked there are medical social workers at most hospitals in the US??

I just wanted to say that I have been reading this thread for a while and have yet to post any comments. But I have had an intense reaction to some of the "I am better than thou based on the degree I have earned" comments that have been flying around. Unless a psychologist or a social worker has adequate (and of course we must operationalize what is adequate) psychopharm training, than neither should be given prescription priveledges. Unfortunately, it is true that many psychiatrists see patients for such a short time and then medication is prescribed. However, there are some really great psychiatrists out there prescribing and doing therapy in conjunction (this is ideal).

However, aside from the prescription topic, my feelings are this. I am becoming slightly irritated by some of the comments that are being posted (particularly by DoctorLCSW). Let us not forget that as mental health professionals, we SHOULD be in the field because of our benevolent intentions and grandiose desires to make the world a little bit better of a place one person at a time. I'm not sure what purpose is being served by denigrating one degree (particularly the psyd). I have been in the profession for several years and will be pursuing my psyd in the fall from a competitive university program. I have no desire to prescribe medicine in the future, nor do I think that the program I am entering will prepare me to do so. However, if requirements were changed, and my preperation (coursework and training) were adequate, I might feel differently.

I am no better than a social worker and I am no less than a PhD psychologist. I'm an intelligent capable human being delving deeper into a field that I love(at the doctoral level) because I think I have a lot to contribute. I'm excited to be surrounded by the best in the field (social workers, psychologists, and MD's alike). My training will be different than someone with an MSW or a DSW or even a PhD and it will take me along a different path, however, this elitist attitute is rediculous. I am ashamed to be hearing some of these comments from people that are in sibling professions to mine. We are supposed to support each other to be excellent and passionate at whatever realm of mental health we have entered.

Just try and remember why you entered this field. Treat your colleagues how you aspire to treat your patients, supervisor's, POI's; with respect and courtesty. Intellectual banter is wonderful, but I think disrespect is inexcusable.

Well said, thankyou.

Originally Posted by heimlichboy

well obviously social workers are adequate at psychotherapy it is merely the psychologists ego that tells them they are better at it than the social workers. Secondly pharmacists know about drugs why are they not given prescribing privileges. The psychologists who think prescribing privileges will hit all 50 states are dreaming. Take for example chiropractors they have been pushing for more rights for years. In the state of illinois they got the right to run blood tests a long time ago. But their scope of practice has not really changed in any other state in a really long time. Psychologists just want to be psychiatrists and feel inferior that is why they have to create fancy titles for themselves such as medical psychologist. Well why not create a medical social worker. I enjoy working with social workers better than psychologists because they are less opinionated and listen to the psychiatrist.

How do you all like Hboy's last sentence, especially the social workers? Well, actually, don't answer that...Hboy is like that annoying little boy on the playground, if we all ignore him he'll eventually go away.

I will never go away because this is my playground. YYYEEEEAAAAAHHHHH!!!!!!!!!!!!!!!!

Its interesting that every profession has its share of turf wars. My wife was very hesitant to get her MSW because she had a BS in psych and wanted to become a therapist. We had done research and were ready to apply to a masters in psych program. However, her father was friends with the head of the local university psych PhD program and he came and talked to us. He implored her to get her MSW instead of psych. Something about the degree being much more flexible and reimbursed by insurance.

Once the kids grow up a bit she's probably heading to PsyD land. Its amazing how much influence insurance and politics have.

Best of luck with the Rxs, just don't become a pill pusher and loose your roots! Rx'ing meds is the easy way out.

Thanks for your thoughts, we appreciate it. I have to say that I have been managing meds for years, and it has not changed me as a psychologist except made me much better and more effective.

extinction burst.

Originally Posted by IndianaOD

Its interesting that every profession has its share of turf wars. My wife was very hesitant to get her MSW because she had a BS in psych and wanted to become a therapist. We had done research and were ready to apply to a masters in psych program. However, her father was friends with the head of the local university psych PhD program and he came and talked to us. He implored her to get her MSW instead of psych. Something about the degree being much more flexible and reimbursed by insurance.

Once the kids grow up a bit she's probably heading to PsyD land. Its amazing how much influence insurance and politics have.

Best of luck with the Rxs, just don't become a pill pusher and loose your roots! Rx'ing meds is the easy way out.

Yeah, unfortunately, insurance companies have a great deal of influence in shaping our healthcare... that's for sure, as per prescription habits of psychologist, from what I hear, the psychologists down in Louisiana have been using their privilege secondary to psychological treatment. I believe that it still is going to be the trend given the tremendous national pressure for them not to become pill pushers. All eyes are on them and nobody wants to screw it up for the rxp movement.

impressive website on rxp in oregon:

http://www.rxporegon.com/default.cfm

ps. got it from the psychiatry thread

Originally Posted by doctorpsych

impressive website on rxp in oregon:

http://www.rxporegon.com/default.cfm

ps. got it from the psychiatry thread

I dropped them a line earlier today. I thought they had a very clean site (most sites aren't), and they did a very good job explaining their position. They definitely hired the right firm to do their work, hopefully they hire the right PAC to do their lobbying.

-t

Today's issue of the American Psychiatric Association's *Psychiatric
News* (vol. 42, #7, April 6) includes an article: "Hawaii Prescribing
Bill Advances Despite Reduced Training Standards" by Rich Daly.

Please note that there are links to the House & Senate bills at the end
of the article.

Here's the article:

The psychologist-prescribing legislation appears to have stronger
support among legislators than in the past but not enough to overcome an
expected veto by the governor.

Two similar bills that would grant Hawaiian psycholog ists prescribing
privileges have advanced in the Hawaii state legislature, despite their
inclusion of lower training standards than previous bills.

Bills were passed in March by the Hawaii House of Representatives (HB
1456) and Senate (SB 1004) that would establish a system to train,
license and credential, and supervise psychologists to prescribe "a
limited formulary of psychotropic medications for the treatment of
mental illness."

The legislation calls for training for psychologists that would include
a two-year postdoctoral program of at least 450 hours of classroom
instruction. Legislation approved by the Hawaii House last year had
required 500 hours of classroom instruction. The bills also would
require a one-year supervised practicum in which at least 100 patients
are treated under the supervision of a "licensed health care provider
who is experienced in the provision of psychopharmacotherapy."

"It should be a no-brainer that you can't replace 11 years of [medical]
training with 11 weeks of class and a year of supervision," said Jeffrey
Akaka, M.D., a Hawaii psychiatrist and speaker-elect of the APA Assembly.

The Hawaii Psychiatric Medical Association (HPMA) strongly opposes the
measures arguing that psychologists lack comprehensive medical training,
accreditation standards, and clinical supervision. District branch
members have been active in lobbying against the proposal.

Both bills have passed the chambers in which they were introduced but
are different enough to require further legislative approval by the
opposite chamber. Among the differences are more limited geographic
areas where psychologists could prescribe and stronger physician
supervision in the Senate bill.

The bill's supporters, including the Hawaii Psychological Association
and Hawaii Primary Care Association--composed of directors of the state's
community health centers--said it would benefit patients at rural
community health centers who can wait from six weeks to three months to
see a psychiatrist.

Psychiatrists dispute the claim that community-based mental health needs
are not being met due to lack of psychiatrists. They report that there
are 17.4 psychiatrists in Hawaii per 100,000 residents, significantly
higher than the national average of 11.2 physicians per 100,000 residents.

CMHCs Lack Psychiatrists

The problem, according to HPMA, is that Hawaii's uninsured and
underinsured residents have insufficient access to psychiatrists through
the state's community mental health centers. Several of the centers have
taken on the additional paperwork needed to obtain federal funding for
staff psychiatrists, but most centers have chosen not to do this, Akaka
said. "The main barrier is funding," he said.

The legislative push for psychologist-prescribing privileges in Hawaii
has been under way for more than 20 years, but this year's bills have
moved further than previous ones. Similar legislation was approved by
the House last year, but the Senate put off approval pending further study.

APA Provides Assistance

Although the governor has taken no formal position on the legislation,
objections raised by the Hawaii State Department of Health suggest to
psychiatrists that Gov. Linda Lingle (R) is unlikely to sign such a
measure, according to opponents of the prescribing bills.

During the current legislative session, APA has again provided
personnel, financial, and strategic support to Hawaii psychiatrists.

"Every year it has been hard fighting this in Hawaii, and this year is
no different," said Paula Johnson, deputy director of APA's Department
of Government Relations.

A January review of data concerning psychologist prescribing by the
Hawaii Legislative Reference Bureau concluded that if the legislature
were to approve a psychologist-prescribing program, it should include a
training model with classroom and clinical training requirements at
least as rigorous as a Department of Defense (DoD) pilot psycholog ist
prescript ive training program in the 1990s. The DoD program, the
Psychopharmacology Demonstration Project (PDP), included at least one
year of full-time classroom training at the Uniformed Services
University of the Health Sciences and one year of full-time clinical
training supervised by a psychiatrist. After privileges were granted,
psychologists remained under the supervision of a psychiatrist for two years.

Akaka and other opponents of the prescribing bills pointed out that in
many areas the proposed training courses fall far short of the DoD
program, which required an 11 times longer supervised practicum and
supervision by psychiatrists, not "a licensed health care provider who
is experienced in psychopharmacotherapy."

As legislators assess the prescribing bills, psychiatrists plan to
emphasize alternative ways the state could address alleged shortcomings
that prescribing advocates say drives their bill.

In addition to several suggested approaches to fund psychiatric services
at the state's federally funded health clinics, psychiatrists have urged
legislators to support the use of telepsychiatry. Eighteen states have
implemented some type of telepsychiatry program to provide services to
otherwise underserved areas.

In 2006 telepsychiatry became available in Hawaii through the Community
Clinic of Maui and the Molokai General Hospital. Psychiatrists go to
each site once each month and provide additional visits through
telepsychiatry. The program also trains psychiatry residents in the use
of telepsychiatry.

A growing base of trained psychiatrists may eventually expand
telepsychiatry services to schools, other community health centers, and
prisons, according to testimony from the Hawaii Psychiatric Medical
Association.

A copy of the House bill is posted at <www.capitol.hawaii.gov/
sessioncurrent/Bills/HB1456_HD1_.htm>. The Senate bill is posted at
<www.capitol.hawaii.gov/sessioncurrent/Bills/SB1004_SD1_.htm>.

Slightly new topic

How do you all think the approval of a drug as an adjunct to psychotherapy (such as MDMA-assisted psychotherapy) would shape this debate. If the drug is being administered during psychotherapy (as opposed to a prescribed chemotherapeutic agent) and dosage/freq. of use may depend on the particular goals of the psychologist/patient, and psychotherapy is largely performed by psychologists, wouldn't this be a very good argument for psychologists gaining at least some script privileges with psychoactive drugs?

What i know about the use of MDMA is that the acute administration causes important neurotoxicity on serotonin fibers and that it may be associated with chronic impairments on cognitive function. I guess psychotherapy along with mdma and dance music might be fun but there is some serious risk.

Originally Posted by Psyduck

Slightly new topic

How do you all think the approval of a drug as an adjunct to psychotherapy (such as MDMA-assisted psychotherapy) would shape this debate. If the drug is being administered during psychotherapy (as opposed to a prescribed chemotherapeutic agent) and dosage/freq. of use may depend on the particular goals of the psychologist/patient, and psychotherapy is largely performed by psychologists, wouldn't this be a very good argument for psychologists gaining at least some script privileges with psychoactive drugs?

Definitely not an argument I'd align myself with. I happen to think there 'might' be a use for MDMA in very defined areas, but I'm still a bit worried about possible long term effects that haven't been adequately evaluated. Definitely more research before doing anything, and even if it is found to be useful, there is no way I'd pair this with psych RxP.

-t

ok interesting response. but what if it wasn't MDMA? i don't really know if there are other drugs out there that could serve the same function but the theory behind the argument itself was more what i was interested in, not the particualr drug.

anyway, MDMA therapy is moving forward in its trials and i will certainly be interested to see where this goes. but you're right it's somewhat separate from rxp psychology in general

I think the concept of drug-enhanced therapy would make RxP beneficial. I still see these as separate issues though, so I think using another controversial topic as a foundation for argument is a bad idea. Get RxP first, deal with things like MDMA afterwards.

As for MDMA specifically, I'm not sure RxP Psychs would be allowed to prescribe it even if it is approved. Admittedly I know far too little about how MDMA-aided therapy would work to comment on its efficacy, but I ASSUME if it does get approval it would be as a pretty highly controlled substance. That makes it unlikely psychologists could prescribe it even in states that currently have RxP. Can medical psychs even prescribe benzos right now? I know so little about this its kind of embarassing...

i agree the argument is very theoretical right now since MDMA is still in Phase II clinical trials. if your talking about approving rxp right now, it would really have no impact. but i was just wondering from the theoretical perspective. and from what i've read, it would actually be more likely that psychologists in a # of states could gain the right to prescribe MDMA than SSRIs and benzodizapines b/c it would be used within the therapy and not as a take home medication. but i'm really not sure about this. and of course it would be highly controlled and not everyone could just do it and there would probably be a long process for certification- psychologists and psychiatrists alike.

Psychologists have an unprecedented chance to reform the delivery of and increase access to mental health services in California.

Please send a letter of support of SB 993 (Aanestad and Calderon) to the Chair and Members of the Senate Business, Professions, and Economic Development Committee. SB 993 (Aanestad and Calderon) will grant prescriptive authority to appropriately-trained psychologists.

As you know, earlier this year, two bills were introduced in the State Senate that would authorize prescriptive authority for appropriately-trained psychologists.

The proponents of SB 822 (Aanestad) and SB 993 (Calderon), both wanting the bill to have the strongest chance of passage, have joined forces to offer one prescriptive authority bill-SB 993 (Aanestad and Calderon).

SB 993 (Aanestad and Calderon) is now jointly sponsored by the California Psychological Association, the American Federation of State, County, and Municipal Employees Local 2620, the National Alliance of Professional Psychology Providers, and the Service Employees International Union.

SB 993 (Aanestad and Calderon) has a very strong chance of passing its first committee-but ONLY if legislators hear from their constituents-YOU!!!

Please take a couple of minutes to send a letter and make a phone call voicing your STRONG SUPPORT of SB 993 (Aanestad and Calderon).

An example letter is attached.

I read yesterday that Mo Bill (SB701) has passed out of the Senate committee. Another piece of News from MO is that the 60 perspective RxP post doctoral students voted to select Alliant University for the MO
training program and are now moving to focus resources on making the
program a success in MO.

Originally Posted by MeghanHF

I read yesterday that Mo Bill (SB701) has passed out of the Senate committee. Another piece of News from MO is that the 60 perspective RxP post doctoral students voted to select Alliant University for the MO
training program and are now moving to focus resources on making the
program a success in MO.

that's great news! looks like things are very active this year!

Hey psychology colleagues, psisci, doctorpsych et al. Have any of you been able to work in medical settings with a psychiatrist? If so, how did that go? I know the AP friggin A is against psychology prescribing because they are a full beaurocracy afraid of change and focusing on the patient. I avoid the APA, and I care about the patients more than my ego...lets talk!

Originally Posted by lusyd

Hey psychology colleagues, psisci, doctorpsych et al. Have any of you been able to work in medical settings with a psychiatrist? If so, how did that go? I know the AP friggin A is against psychology prescribing because they are a full beaurocracy afraid of change and focusing on the patient. I avoid the APA, and I care about the patients more than my ego...lets talk!

I've had mixed experiences, some have been good and respectful. Some have even been supportive of rxp, but my impression was that they were not going to outwardly show support in fear of putting themselve in a jam with their colleagues. However, generally my interactions with psychiatrists have not been egaletarian from their perspective. Almost all of the ones that I've worked with had no real appreciation for psychotherapy and covertly appeared dismissive. Given that you are psychiatrist, what do you think? What are the psychiatrists perception of psychologists? What was your experience working with psychologists? What resolutions are there for both fields to respect one another?

From my experiences, the most support I've seen is from FP's and GP's. I was at a conference last year (FPA) and one of the presentations cited research that found 80-85% of the 'scripts written were from FPs/GPs/NP, etc. I've been told that the FPs/GPs have such a workload, that they just don't have the time to really dedicate to the psych patients who need it. It isn't a knock on them, but because of HMO's and the healthcare system....they are put in a tough position.

There are some psychiatrists that support it, but again....they won't go against the Association.

-t

Originally Posted by doctorpsych

Almost all of the ones that I've worked with had no real appreciation for psychotherapy and covertly appeared dismissive.

From what I have seen, it isn't dismissive as much as it isn't not high on the list of possible solutions. I think medical psychologists view medication as an adjunct to therapy*, and many/most psychiatrists see it as something to do after the medication fails. I happen to work with a couple who are great, and they see the value of therapy, but I know this isn't always the case.

*I think this is where medical psychologists can really make a difference. I think if we can integrate meds management into our caseload, we can provide the kind of service people are looking for, without having to get a referral to get on a waiting list.


-t

I have worked with several medical psychologists, and IMO they are far better trained to treat most of my patients than psychiatrists. Part of the reason is general knowledge, but most of it is attitude. I do not even send consults for psychiatry anymore unless I want to dump a patient, because I do not want the hassle of an ego battle. Psychiatry is the medical profession full of doctors who could not get another residency. In NM we love the new law, and green chile!

A little rough on the psychiatrists, but I'll take some of the green chilli! I really thing medical psychologists are going to fill a much needed gap. I'm looking at New Orleans over NM, but I'm hoping more states pass in the coming year or two.....but I guess time will tell.

-t

Let me know when you get out there as a practicing doc. Psychiatrists are bitter as a general rule and in my experience.

Originally Posted by deanritter

Let me know when you get out there as a practicing doc. Psychiatrists are bitter as a general rule and in my experience.

what type of medicine do you practice? how do you picture the working relationship between medical psychologist and PCPs? if you are in primary care, can you give us some examples from a PCP perspective? Thanks?

I've worked with a few psychiatrists, all were great people and a pleasure to work with.

Then again, these could be the exception rather than the rule. They go by their first names, chose to work in an academic center, and they work under a psychologist who is the director. Also, psych was their first choice residency for all of them

Primary care. In the clinics in which I work we have behavioral medicine providers, and one of them is a psychologist trained to prescribe medications. She is fantastic to work with, and very knowlegeable about both psychopharmacology and relevant medical issues. I have not referred a signle patient to the local psychiatrist in months because they end up on a waiting list, and get seen for a a very brief visit every six months leaving the managing of the medications to me.

Here is a nice summation of the arguments and training (compared to physicians, not just non-physicians)

Psychiatr Serv 55:1420-1426, December 2004

Patient Safety Forum: Should Psychologists Have Prescribing Authority?

Deanna F. Yates, Ph.D. Jack G. Wiggins, Ph.D.
Jeremy A. Lazarus, M.D.
James H. Scully, Jr., M.D.
Michelle Riba, M.D.

While the issue of psychologist prescribing has become a highly politicized debate, the real issues are the need for—and competence of—prescribing psychologists.

Regarding need, the acute shortage of psychiatrists has been well established by both the Surgeon General's Report on Mental Health (1) and the President's New Freedom Commission on Mental Health (2). In part because of this shortage, more than 70 percent of all psychotropic medications are prescribed by nonpsychiatric physicians, typically after six weeks' training in psychiatry.


Psychologists are among the most highly trained doctoral-level providers of mental health services. In addition, psychologists who seek prescribing authority are required to receive a minimum of three years of medical training before they are allowed to prescribe. Furthermore, as part of the existing legislation for prescribing authority, prescribing psychologists are required to collaborate with their patient's primary care physician. The combined extensive mental health and medical training—with ongoing physician collaboration once the psychologists start prescribing—suggests that psychologists are potentially more competent than primary care physicians.


Psychiatry contends that if psychologists want to prescribe they should go to medical school. The issue should not be where psychologists receive their training but, rather, whether psychologists can be trained to safely prescribe psychotropic medications.


The research that we do have demonstrates that prescribing psychologists can be taught to safely prescribe psychotropic medications. Between 1991 and 1997, the Department of Defense trained ten psychologists to prescribe through what is known as the Psychopharmacology Demonstration Project (PDP). Several reviews of the PDP have been conducted, although only a few objective studies have been done. Although the military is unique in terms of cost and need issue, the general consensus is that psychologists in the Department of Defense are safe prescribers.


A study by the American College of Neuropsychopharmacology (3) showed that the "graduates of the PDP filled critical needs, and they performed with excellence wherever they served." According to the U.S. General Accounting Office, "Without exception, these supervisors—all psychiatrists—stated that the graduates' quality of care was good." (4). Although the demonstration project has ended, psychologists continue to train and prescribe in the military.


What about the safety of other nonphysician prescribers? A growing number of nonphysician groups are prescribing, such as dentists, optometrists, podiatrists, and nurse practitioners. The few studies in existence suggest outcomes that are at least equivalent to those of physicians (5). If safety were being compromised by these providers, one could assume that there would have been a public outcry by now, and physician interest groups would certainly not have remained silent on the issue (5). There is no evidence that nonphysician prescribers are less safe than physician prescribers.


Some argue that psychologists receive insufficient medical training to safely prescribe. Here two issues must be considered: the educational requirements for practicing psychology, and the added training required in order that a psychologist be able to prescribe. Psychologists' training begins with a four-year undergraduate degree, as is the case with physicians. Although these degrees generally do not focus on the biological sciences of a premedical education, many psychology students choose electives in the biological sciences, such as biology and chemistry.


After psychologists complete their undergraduate degree, they complete a minimum of seven additional years of training. During the first five years, psychologists take courses in human development and behavior, normal and abnormal psychology, psychological assessment, and statistics. In addition, they take courses in the anatomy and physiology of the brain and the evaluation, diagnosis, and treatment of brain disorders. During these five years, psychologists also have hundreds of hours of practice in which they evaluate, diagnose, and treat patients with mental disorders in both outpatient and inpatient settings. Finally, psychologists complete two yearlong residencies during which they treat patients who have mental disorders, generally in medical settings under the supervision of psychologists and physicians. After completing a national examination, psychologists can apply for licensure.


Prescribing psychologists receive an additional three years of training. The first two years include courses in biochemistry, anatomy and physiology, pathophysiology, neuroanatomy, neurochemistry, neurophysiology, pharmacology, psychopharmacology, physical and neurologic examinations, interpretation of laboratory results, and ethics in prescribing (6). At the same time, they continue to work with patients and use their new knowledge in discussing medications with their patients and other professionals. These two years of course work are then followed by a year of residency during which prescribing psychologists apply what they have learned to their patients while being supervised by a physician. The prescribing psychologist makes recommendations for medication and conducts medication follow-ups with his or her patients, while the medication prescriptions are written by a physician. Prescribing psychologists must then pass a national examination before applying for certification to prescribe. This is far from a "simple psychopharmacology course" or "a crash course in prescribing," as has been suggested by opponents of psychologist prescribing.


Prescribing psychologists receive their medical training not in medical school, but within their own discipline, just as dentists, podiatrists, optometrists, and nurse practitioners do. The only difference is that prescribing psychologists are already licensed and practicing before they even begin their medical training. By the time prescribing psychologists are allowed to prescribe, they have ten years of training postcollege in the treatment of mental disorders. Primary care physicians, on the other hand, while having more general medical training, typically have a four- to eight-week clerkship in psychiatry during medical school. Given this comparison, it would seem likely that prescribing psychologists would be better at prescribing psychoactive medications to their patients than would other nonpsychiatric physicians.


Legislation that will allow qualified psychologists to prescribe has now been passed in two states—New Mexico and Louisiana. In both states, safeguards for the public have been built into the legislation. In New Mexico, after training, a prescribing psychologist will receive a conditional certificate allowing him or her to prescribe for two years under the supervision of a physician. Provided that the prescribing psychologist completes this two-year period successfully and passes a national examination, he or she could then apply for a certificate that would allow nonsupervised prescribing. Even then, prescribing psychologists must collaborate with their patients' primary care physicians. In Louisiana, after a prescribing psychologist has completed the training and passed the national examination, he or she will be certified to prescribe independently; but, as in New Mexico, he or she will be required to confer with the patient's primary care physician on the prescribing psychologist's choice of medications.


In addition to the comprehensive training and legislative safeguards, it should be noted that psychologists see their patients more regularly than do most other providers. As a typical standard of practice, primary care physicians do not follow up with patients as regularly as psychologists do. Psychologists typically see their patients on a weekly or biweekly basis, whereas primary care physicians generally see patients for physical examinations and for treatment of acute medical problems. General practitioners are not in a position to conduct follow-up visits with their patients as regularly as psychologists. Because of the frequent interaction with their patients, and the level of trust and communication inherent in the therapeutic relationship, prescribing psychologists will be in a position to manage medications more efficiently than most physicians. Compared with primary care physicians, psychologists can be expected to more readily address side effects, make appropriate medication changes and adjustments, and monitor the overall efficacy of medication.


In conclusion, the question should not be "Can psychologists safely prescribe?" but rather, "How could they not safely prescribe?"

-t

Don't think that MDs have six weeks of training and then they're done. After two years of basic science to learn how the body would respond to those medications, physicians have lots of training in internal medicine to learn more about clinical aspects of neuropharmacology. The "six weeks" is a time period thrown around to minimize physician training and to try to make grad school in psychology seem more robust than it really is.

You make an excellent point deuist, I never understood that argument myself. Anyone who thinks rotations are the only time in medical school you learn anything doesn't understand the process.

However, a lot of people seem to think the argument is to allow clinical psychologists to prescribe as is. The way I understand it works is they get another 2-3 year "master's" that gives them the fundamental medically-oriented classes one doesn't get in most clinical psych programs. Assuming that is "roughly" comparable to years 1 and 2 of med school (though with a more narrow focus since I don't think the students are dissecting cadavers, etc.), I think the training is extensive enough where they will have as much or more experience with those disorders than FM or IM docs.

The one point that I think still stands is that psychologists simply will not have the background to do differential dx....I'm less confident in their ability to screen for thyroid problems, etc. Then again, how many FM docs actually do their jobs and screen for things like that before passing out the Prozac? Very few that I have seen. Maybe I've just had bad experiences though.

Originally Posted by Ollie123

The one point that I think still stands is that psychologists simply will not have the background to do differential dx....I'm less confident in their ability to screen for thyroid problems, etc. Then again, how many FM docs actually do their jobs and screen for things like that before passing out the Prozac? Very few that I have seen. Maybe I've just had bad experiences though.

This is taught, but just like in medicine, I think it really becomes crystalized in residency and with experience.

-t

Yeah, I figured it was covered to some degree - I'm just not sure that given that psych training is more focused, they would be as likely to catch those sorts of problems as someone with a more generalized training. Given the program is shorter and psychologists won't be rotating through other disciplines (at least not that I know of).

That being said, overall I think that's a fairly minor problem that could be easily addressed as I believe NM did by requiring psychologists to work with the pcp.

I have no problem with a 2-year, post-doc certificate/masters in pharmacotherapy. If physician's assistants can practice with only two years of training, so should psychologists.

Originally Posted by deuist

I have no problem with a 2-year, post-doc certificate/masters in pharmacotherapy. If physician's assistants can practice with only two years of training, so should psychologists.

I couldn't agree more.

(Since I linked to this thread a bit earlier, I figured I should at least check on the where-abouts of it. )

-t

Originally Posted by Therapist4Chnge

I couldn't agree more.

(Since I linked to this thread a bit earlier, I figured I should at least check on the where-abouts of it. )

-t

Yeah, I thought that I'd check it out again as mentioned in the other thread. Doesn't seem to have moved much since the last time I looked at it.