Psychopharmacology/Advanced Practice Psychology

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medium rare said:
I agree. 160 mg QD Geodon is unlikely to cause akathisia in most cases. Geodon gets a bad rap because it can actually be agitating at lower and sub-therapeutic doses and does not get absorbed well unless taken with a meal, preferably a meal with a decent amount of fat. I come across patients all the time who say, "you mean I need to take this with food?" and then can't stop commenting on how well it works when they take it with a meal.
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My rapidly aging hippocampus makes recalling the dosage difficult given that this was over a year ago. ;) It may have been that dosage TID rather than QD or it may have been a much higher dosage. My surprise came from the fact that this ER physician did not know what I was talking about.
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nitemagi said:
Yes.
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hummm....so regardless whether it works or not... point proven, its a waste of time in trying to have a discussion with folks who don't understand or appreciate data... well, anyway, all I can say is that my employer is very supportive of prescribing psychologist and they are going forward in recruiting more of us... fortunately, they are data driven, they take into account that having psychologist with psychopharm knowledge help out their medical staff tremendously, cut down on their medical staff's time... bottom line is that it makes them money....

oh, and a few weeks ago, there was a psychiatrist that contacted us looking for opportunities... apperantly the psychiatrist was burning out and did not feel was getting enough money, our CEO said may be interested only if it was part time and as a consult to various clinics because the psychiatrist was asking for a lot of money... heard from the grapevine that it was more than double my salary... and I already make pretty darn good money (I doubled my previous salary).
 
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Psychiatry residents are those who could not get into other residency programs while psychology residents are generally the best of the best.
 
Unfortunately your sticks and stones will come with "health care reform", and the "dummying down of medicine" which will pave the way for the eradication of psychiatry....which I dread and think is a sign of everything wrong with medicine, specifically psychiatry. Look what nurses have done to primary care.....wake up.
 
I offer higher functioning pts psychotherapy all the time before starting any medication. I explain how therapy works and the time investment that is needed for it to be successful. As soon as pts hear this they say they would rather try a med first and that they just don't have the time to come to weekly appts. Pts in this day and age just want a quick fix rather than having to do any work. If pts agreed to therapy more often I'm sure psychologists would not be trying to get prescribing rights.
I would be happy for psychologists to prescribe after they graduate from an accedited medical school and pass the boards.

Psychologists prescribing comes up every year in the Illinois legislature and amazingly, has not passed yet. A few years ago, social workers in Illinois wanted to be allowed to administer psychological testing. The response of the Illinois Psychology Association? "If you want to do psych testing, go back to school and get your doctorate."
Wise psychologists recognize that their liability insurance is less than $1000 while for psychiatrists, it is in the $18-20K range in this state. If they want to take on the liability, have at it! However, I believe this is more the baby of psychology's professional organizations than a strong desire of most practicing psychologists.
And let's face it...none of us believe that prescribing psychologists are going to be setting up shop in dilapidated urban areas or remote parts of Montana.


 
nitemagi said:
The health care reform is actually making the way for the normalization and incorporation of psychiatrists into general medical care, with psychiatrists serving as consultants within the medical home.

I'm wide awake, thanks.

http://www.psychiatrictimes.com/news/content/article/10168/1568806
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that article points at parity, for all in the mental health care system... and like everything else, economics will dictate who the market is going to go to. Medical psychologist will be optimally placed... providing med management, testing, psychotherapy, etc...

You are absolutely right, the good psychiatrists will be delegated to be consultants... I know that in some markets, psych NPs are already being preferred over psychiatrists... for example, the New England area, many places rather pay psych NP's mid to high 90's over the 150-200+ k that psychiatrists are asking for... what I hear is that the market is dictating for psychiatrist to do inpatient hospital work, while psych NPs do the outpatient work... and there is still a huge lag of providers...
 
doctorpsych said:
that article points at parity, for all in the mental health care system... and like everything else, economics will dictate who the market is going to go to. Medical psychologist will be optimally placed... providing med management, testing, psychotherapy, etc...
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Any studies on the economics of testing? E.g. cost-benefit analyses?
 
stigmata said:
Psychiatry residents are those who could not get into other residency programs while psychology residents are generally the best of the best.
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Not if they are getting their degree from a diploma mill on an online university.
 
dlm13cwru said:
Not if they are getting their degree from a diploma mill on an online university.
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They still need to pass the licensure exam, complete the clinical training, post-doc hours, etc....just like the caribbean/int'l students need to pass the physician equivalent. Those programs can be as bad or worse in regard to acceptance rates, attrition, etc.
 
Therapist4Chnge said:
They still need to pass the licensure exam, complete the clinical training, post-doc hours, etc....just like the caribbean/int'l students need to pass the physician equivalent. Those programs can be as bad or worse in regard to acceptance rates, attrition, etc.
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But I'm sure passing the physician equivalent (Steps 1, 2ck, 2cs, 3 and ABPN written and oral boards), medical school, and residency and/or fellowship is much more difficult.
 
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dlm13cwru said:
But I'm sure passing the physician equivalent (Steps 1, 2ck, 2cs, 3 and ABPN written and oral boards), medical school, and residency and/or fellowship is much more difficult.
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...and your data to support this assertion?

Psych programs have comps, internship, post-doc, national exam, etc....so there are still as many hoops to jump through before licensure.
 
Both are very difficult but for different reasons. I have taught in primary care residencies for years. One thing for certain is that it much more difficult to get into a PhD/PsyD program than it is medical school.
 
Therapist4Chnge said:
...and your data to support this assertion?

Psych programs have comps, internship, post-doc, national exam, etc....so there are still as many hoops to jump through before licensure.
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I have met Ph.D. students who are also physicians. Fielding has 3 I know personally. They all tell me that med school and a a clinical psychology program are both about equally tough but for different reasons. The skill sets and cognitive demands are different. They say med school involves massive memorization and an almost unbelievable work load. The cognitive skills are mainly convergent thinking and memorization. They say clinical psych less intense but the process is much longer, more grueling and involves more divergent thinking aand lots of reflective practice. Its the sprint versus marathon. My impression from them is that the two kinds of training are so different in terms of process that direct comparisons are difficult.
 
stigmata said:
Psychiatry residents are those who could not get into other residency programs while psychology residents are generally the best of the best.
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Some of the best physicians in any specialty I know are psychiatrists. So are some of the worst. The problem with psychiatry are the foreign-trained physicians who immigrate and are unable to practice in their first specialty but who eventually become psychiatrists with pre-existing language and cultural barriers intact.
 
stigmata said:
Both are very difficult but for different reasons. I have taught in primary care residencies for years. One thing for certain is that it much more difficult to get into a PhD/PsyD program than it is medical school.
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Depends on how you're reading the statistics. Your sample is of those that made it. Only about a third of those that start out as pre-med in undergrad go on to apply, and of those applying only a third get in. The pre-requisites filter a lot of people out along the way.

What's the ratio of Ph.D. applicants to acceptances?
 
nitemagi said:
Depends on how you're reading the statistics. Your sample is of those that made it. Only about a third of those that start out as pre-med in undergrad go on to apply, and of those applying only a third get in. The pre-requisites filter a lot of people out along the way.

What's the ratio of Ph.D. applicants to acceptances?
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I have a double major in Chemistry and psychology. All I can say is that my psychology courses did not even compare to OChem and PChem!
 
Ochem is easy...enough people. BTW, I am meeting with the only psychiatry group around tomorrow so they can figure out how to get referrals from me. I was contacted by their "rep" at the hospital because I am doing all of their work. Luckily, I am happy for it...it should be interesting.
 
nitemagi said:
Yes. Despite the risk of being "screwed up," as you say, that risk is still lower with a pcp than it is with a prescribing psychologist, who knows even less.
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last week had another exemplary referral from one of our pcps... 19 y/o male who has been treated for panic attacks for OVER A YEAR with alprazolam ALONE, now asking for more than 4 mg a day (pretty sure he has already), the pcp is frustrated because this kid has been making multiple frequent appointments and when he doesn't get his po benzo's, he goes to the ER... well, to say the least, the pcp feels pt is not getting any better and alluded admittingly that it is highly possible that this kid has a iatrogenic benzo dependence...

long story short after eval...pt. has comorbid PTSD with flashbacks and explosive anger problems (and depression) which he never reported to his pcp... and when I asked why didn't he, his answer was "because she didn't ask..." again pointing at the lack of knowledge or time of the pcp. After a long session, he agreed to switch to clonezepam with the goal of tritrating off, while adding sertraline to address the underlying flashbacks...additionally doing panic control training with some TFCBT...
 
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doctorpsych said:
last week had another exemplary referral from one of our pcps... 19 y/o male who has been treated for panic attacks for OVER A YEAR with alprazolam ALONE, now asking for more than 4 mg a day (pretty sure he has already), the pcp is frustrated because this kid has been making multiple frequent appointments and when he doesn't get his po benzo's, he goes to the ER... well, to say the least, the pcp feels pt is not getting any better and alluded admittingly that it is highly possible that this kid has a iatrogenic benzo dependence...

long story short after eval...pt. has comorbid PTSD with flashbacks and explosive anger problems (and depression) which he never reported to his pcp... and when I asked why didn't he, his answer was "because she didn't ask..." again pointing at the lack of knowledge or time of the pcp. After a long session, he agreed to switch to clonezepam with the goal of tritrating off, while adding sertraline to address the underlying flashbacks...additionally doing panic control training with some TFCBT... so is this pt better served by a pcp or a medical psychologist?
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Somehow I think I've said it before...

the plural of anecdote is not data.

Show actual research that x# of medical psychologists do better than x # of PCP's. Otherwise, yes most patients are better served by their PCP's. That doesn't control for some bad PCP's. But that's the nature of the anecdote.

"Wow, I had this incompetent physician who didn't know what he was doing with any medications, but gee willikers, sure am glad the medical psychologist came to the rescue to teach us how medications really work."

Without studies, these anecdotes are only that.
 
So study it, you seem all trained to do research and be pedantic about it!
 
nitemagi said:
Somehow I think I've said it before...

the plural of anecdote is not data.

Show actual research that x# of medical psychologists do better than x # of PCP's. Otherwise, yes most patients are better served by their PCP's. That doesn't control for some bad PCP's. But that's the nature of the anecdote.

"Wow, I had this incompetent physician who didn't know what he was doing with any medications, but gee willikers, sure am glad the medical psychologist came to the rescue to teach us how medications really work."

Without studies, these anecdotes are only that.
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too early for formal comparative studies but there will be soon...but the point now is that it's a fact that pcps as a whole are not provided with adequate education and clinical experience to treat mental health pts adequately...
 
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nitemagi said:
Pot...kettle.

It shouldn't be my job to do research to refute your anecdotes. But I guess no one else has done any on it in the many years medical psychologists have been around.
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Well your only way to refute the anecdotes so far as been to repeatedly voice your opinion? How is that research?
 
stigmata said:
Well your only way to refute the anecdotes so far as been to repeatedly voice your opinion? How is that research?
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I have just as many anecdotes of community psychologists diagnosing patients with ADHD that have anxiety or any of a number of medical conditions they didn't even know existed, or referrals from psychologists with zero medical training telling me what medication they think I should prescribe.

I've already posted data earlier in this thread, including follow-up on the navy program, which has higher standards than all the current RxP programs, and which states that they were found to have the medical education of at best a 3rd year medical student. I'd rather have a PCP with 7 years medical training prescribing medications that affect multiple organ systems and interact with a host of other possible conditions and medications than a psychologist with 2 or less years of medical training (as is currently the training).
 
nitemagi said:
I'd rather have a PCP with 7 years medical training prescribing medications that affect multiple organ systems and interact with a host of other possible conditions and medications than a psychologist with 2 or less years of medical training (as is currently the training).
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How about an FP or GP with little interest or time to handle psychotropics v. NP or PA who working with psychotropics every day?

How about someone with 6-8 years of doctoral level training in mental health AND 2 additional years of pharma training & then mentorship for a year with an MD/DO and then an on-going consultative relationship with an MD/DO?
 
Therapist4Chnge said:
How about an FP or GP with little interest or time to handle psychotropics v. NP or PA who working with psychotropics every day?

How about someone with 6-8 years of doctoral level training in mental health AND 2 additional years of pharma training & then mentorship for a year with an MD/DO and then an on-going consultative relationship with an MD/DO?
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Excellent point, which illustrates IMHO that we're arguing based on the extremes to prove a point. Do all psychologists in RxP have 6-8 years of doctoral training? Maybe a majority, but not all. What degree is that consultative relationship, and is it with someone with any actual expertise, or just the undereducated leading more undereducated (which is sadly the standard throughout much of medical education, but I digress).

Do all PCP's have an interest in psychotropics? No. Would it be more accurate to say none of them do? I don't believe that's the truth either. The truth is that PCP's are busy, and want to help the patient, and work with the tools they have. Trying to compare the two extremes of each profession may move closer to an idea that RxP has a place and in certain circumstances may be superior to PCP's, BUT there's far too many unknown variables in the RxP training to really guarantee any level of competency in its current state.
 
nitemagi said:
Excellent point, which illustrates IMHO that we're arguing based on the extremes to prove a point. Do all psychologists in RxP have 6-8 years of doctoral training? Maybe a majority, but not all. What degree is that consultative relationship, and is it with someone with any actual expertise, or just the undereducated leading more undereducated (which is sadly the standard throughout much of medical education, but I digress).

Do all PCP's have an interest in psychotropics? No. Would it be more accurate to say none of them do? I don't believe that's the truth either. The truth is that PCP's are busy, and want to help the patient, and work with the tools they have. Trying to compare the two extremes of each profession may move closer to an idea that RxP has a place and in certain circumstances may be superior to PCP's, BUT there's far too many unknown variables in the RxP training to really guarantee any level of competency in its current state.
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yes, all rxp psychologist have at least 6 years (most often longer) of doctoral training, then get at least 1 year of post-doc hours to qualify for a national license exam, pass the exam and then be allowed to enroll into a post-doc in psychopharm, then pass another national exam, and then COLLABORATE with pcps...and yes, one of the major reasons why medical psychologist fit so well in the scheme of things as it is right now is that pcp are way too busy to learn about psychopharm and behavioral health. They don't get enough education about it. These are facts, not extreme points...nothing unknown about these points...
 
doctorpsych said:
yes, all rxp psychologist have at least 6 years (most often longer) of doctoral training, then get at least 1 year of post-doc hours to qualify for a national license exam, pass the exam and then be allowed to enroll into a post-doc in psychopharm, then pass another national exam, and then COLLABORATE with pcps...and yes, one of the major reasons why medical psychologist fit so well in the scheme of things as it is right now is that pcp are way too busy to learn about psychopharm and behavioral health. They don't get enough education about it. These are facts, not extreme points...nothing unknown about these points...
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1. Can you produce a study showing the average number of years a psychologist spends working on their degree?
2. They're busy, that doesn't mean they're all too busy.
3. "Collaborating" is a nebulous term with no oversight, specifics, requirements, or penalties
4. Your argument stands on the benefit of collaborating with PCP's, yet you simultaneously critique PCP's for not having training in the area where they're supervising psychologists. So how is that safe or an improvement?
 
nitemagi said:
I have just as many anecdotes of community psychologists diagnosing patients with ADHD that have anxiety or any of a number of medical conditions they didn't even know existed, or referrals from psychologists with zero medical training telling me what medication they think I should prescribe.

I've already posted data earlier in this thread, including follow-up on the navy program, which has higher standards than all the current RxP programs, and which states that they were found to have the medical education of at best a 3rd year medical student. I'd rather have a PCP with 7 years medical training prescribing medications that affect multiple organ systems and interact with a host of other possible conditions and medications than a psychologist with 2 or less years of medical training (as is currently the training).
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So you have stated. But I say who cares?
 
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nitemagi said:
1. Can you produce a study showing the average number of years a psychologist spends working on their degree?
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Per the APA: http://www.apa.org/ed/accreditation/about/research/years-to-complete.aspx

These data are from 2003; from what I've heard, this number has generally increased for most programs since then. These data would indicate that, combined, the average years until degree completion for clinical psych Ph.D. and Psy.D. students falls between 6 and 7. This, of course, does not include the one year of post-doctoral supervision required by the majority of states for licensure.
 
By the way, you do not see me on the psychiatry side posting about how many patients I see who have been diagnosed with bipolar disorder by psychiatrists who aren't. You are just trolling.
 
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Trolling involves antagonizing for the sole purpose of antagonizing.

This is a thread about a scope of practice. If on the psychiatry forum psychiatrists were posting about our movement to take over psychological testing, then I would most definitely hope that psychologists went there to post about their position on the matter.

I don't think it would really matter if a psychologist took 20 years to get their PhD. That isn't medical training.
 
nitemagi said:
I don't think it would really matter if a psychologist took 20 years to get their PhD. That isn't medical training.
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You can't have it both ways. You can't count ALL of medical school as applicable and NONE of clinical psychology training in relation to MH and pharma knowledge. No one is claiming that clinical psychology training = medical training, it obviously is not. Though I think you can concede that there is at least some knowledge/training that is highly applicable.

Now take that knowledge/training and add two additional years of pharma training, at least one year of clinical training/mentorship, and continued consultation or a limited formulary. This training is at least in line with NP and PA training for prescribing. I'm not a fan of a limited formulary in place of required collaboration, but that is putting the cart before the horse. I'm not taking an extreme stance to make a point, quite the opposite. I'm looking at a much more moderate comparison, as talking in extremes does not do anyone any good.
 
Therapist4Chnge said:
You can't have it both ways. You can't count ALL of medical school as applicable and NONE of clinical psychology training in relation to MH and pharma knowledge. No one is claiming that clinical psychology training = medical training, it obviously is not. Though I think you can concede that there is at least some knowledge/training that is highly applicable.

Now take that knowledge/training and add two additional years of pharma training, at least one year of clinical training/mentorship, and continued consultation or a limited formulary. This training is at least in line with NP and PA training for prescribing. I'm not a fan of a limited formulary in place of required collaboration, but that is putting the cart before the horse. I'm not taking an extreme stance to make a point, quite the opposite. I'm looking at a much more moderate comparison, as talking in extremes does not do anyone any good.
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I didn't say mental health training has no value. I said it isn't medical training, and listing the number of years of training to get a PhD doesn't make someone any more competent in pathology, pharmacology, or physiology.

What is hinted is this idea that medications are an isolated entity, or that psychotropics don't have effects in multiple organ systems. NP's and PA's (which I could argue are both also very problematic) at least have extensive exposure to physiology, pathology, etc. Nurses rotate through all the traditional medical rotations in their training. It isn't comparable, sorry.

Even for psychiatrists there was a movement back in the day (80's) to remove the intern year and take out the internal medicine rotations amongst other things. The results were deemed to be undertrained less competent psychiatrists, so they went back to 4 years of residency instead of 3.
 
Oh this is perfect timing for this bit of info. I gave a grand rounds lecture today on advances in cellular metabolism constructs and l-methyl-folate at the local hospital which houses a psychiatric inpatient facility. All 5 psychiatrists were present and made a point of showing their support. 3 of them were older and had never heard of "medical foods". Not all psychiatrists are problematic by any means, and those who are secure welcome others and are interested in other training models. Nitemagi is a resident, hardly anywhere near knowing what is really going on. Treat him/her that way.
 
nitemagi said:
I didn't say mental health training has no value. I said it isn't medical training, and listing the number of years of training to get a PhD doesn't make someone any more competent in pathology, pharmacology, or physiology.

What is hinted is this idea that medications are an isolated entity, or that psychotropics don't have effects in multiple organ systems. NP's and PA's (which I could argue are both also very problematic) at least have extensive exposure to physiology, pathology, etc. Nurses rotate through all the traditional medical rotations in their training. It isn't comparable, sorry.

Even for psychiatrists there was a movement back in the day (80's) to remove the intern year and take out the internal medicine rotations amongst other things. The results were deemed to be undertrained less competent psychiatrists, so they went back to 4 years of residency instead of 3.
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I believe there's been talk of one of the psychopharm coursework providers (I forget which one) attempting to include an in-person practicum of sorts. No clue what it would actually entail, but I believe it called for various rotations and collaborations. Again, I'm not sure of the specifics, or of how serious they are about including it.

As for physio, pathology, and pharm training, I do know that those classes are (as would be expected) required and included in the current psychopharm training. How they compare to NP or PA classes in those subjects areas I don't know, although I would imagine the latter likely provided at least some type of framework for the former.
 
AcronymAllergy said:
I believe there's been talk of one of the psychopharm coursework providers (I forget which one) attempting to include an in-person practicum of sorts. No clue what it would actually entail, but I believe it called for various rotations and collaborations. Again, I'm not sure of the specifics, or of how serious they are about including it.

As for physio, pathology, and pharm training, I do know that those classes are (as would be expected) required and included in the current psychopharm training. How they compare to NP or PA classes in those subjects areas I don't know, although I would imagine the latter likely provided at least some type of framework for the former.
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Coursework is a bit of the battle. Rotating and seeing the illnesses clinically is another aspect.

Stigmata, Fascinating how my questioning of RxP makes you have to challenge my credentials. I haven't been making this personal about you. But rather than respond with any actual data or real counterarguments you have to make this personal about me.
 
Not personal at all, but I teach residents and I know how much they don't know. Some are aware of this, and some are not. Simple as that.
 
nitemagi said:
Exactly. Proper training, residency, and mentorship with experts is essential to competent practice.
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:laugh:

We are probably a lot closer on these issues than you realize. I think you under-estimate some of the core training in both clinical programs and also in the pharma classes, and I probably over-estimate the mentorship that some of the RxP psychologists receive during their clinical year(s). There is definitely room for improvement (raising pre-req classes, req. classes, and req. clinical/supervision hours), I just hope those things get addressed before more states jump on the bandwagon.

stigmata said:
So is experience outside of the training bubble.
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There is quite a difference between the private practice setting, VA hopsitals, and academic medical centers. I've worked in all three, and it appears that the longer the non-psychiatrist physician is away from their residency, the more open to collaboration they become. I admittedly don't work much with Psychiatry, so I can't really comment on how open or not they are to non-physician prescribers. I've worked with a variety of physicians from Primary Care, Internal Medicine, PM&R, Neurology, NeuroSurg, and Derm, and none were as adversarial as I've seen from psychiatrists on here.
 
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Experience is fine, but highly variable, and more subject to bias, reinforcement of bias "well in my clinical experience...," and derailment from a standard of care.

I distinguish between "collaboration," and presenting oneself as having "expertise."

Those specialties are interesting you listed T4C, but perhaps asking an opthalmologist about their thoughts of optomotrists seeking rights for eye surgery would be more comparable, or Anesthesiologists with nurse anesthetists, or psychologists about social workers doing therapy and psychological assessment.
 
nitemagi said:
1. Can you produce a study showing the average number of years a psychologist spends working on their degree?
2. They're busy, that doesn't mean they're all too busy.
3. "Collaborating" is a nebulous term with no oversight, specifics, requirements, or penalties
4. Your argument stands on the benefit of collaborating with PCP's, yet you simultaneously critique PCP's for not having training in the area where they're supervising psychologists. So how is that safe or an improvement?
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#1 was clearly answered already, #2 can you tell me how many pcps have received some sort of advanced training with psychotropics?, #3 collaborating, means collaborating, see my example below, #4 who said pcps are supervising psychologist?

A perfect example of working collaboration... one of our pcps that I work very close with asked me for a consult on a 15 y/o adolescent that was brought in by his guardian "demanding" Adderall XR, the cc was that he couldn't concentrate, wasn't completing work at school and the guardian specifically said he was "ADD". The pcp was not sure if it was adhd and needed help with dx. We concurred to rule potential medical factors... he did the medical part, I ordered labs for him, (no thyroid problems, no anemia, etc), he completed physical and neurological, which were unremarkable...he went on to his next pt... I went into the room, completed my part, turned out that guardian specifically asked for Adderall XR simply because two of her grandchildren were taking it. After further discussions with the kid, onset of sx's began 2 years ago (ruling out ADHD), turns out he is very embarrassed that his bio mom had been drinking so badly that many of his classmates started making fun of him. Set him up with further sessions, will consider ssri if necessary.

That's collaboration...pcp not supervising me, he asked for my assistance, I helped, the pt. wins...
 
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