Psychopharmacology/Advanced Practice Psychology

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greenlion said:
The US has way too many people on powerful pscyh meds as it is. More than anywhere else in the world.
Strangely psychologists have always been the most cognizant of this problem but I suspect they'll change their tune when/if they get to prescribe.

If anything, I'd like bills with more limitations on psych prescriptions and on pharma involvement, rather than throwing out Rx pads to more mental health workers.
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I need to go back and see, but I thought I read in one of the pre-existing states with RxP or the DoD system, prescribing psychologists were as likely to use the privileges to taper people off meds as they were to start a medication.
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WisNeuro said:
I need to go back and see, but I thought I read in one of the pre-existing states with RxP or the DoD system, prescribing psychologists were as likely to use the privileges to taper people off meds as they were to start a medication.
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I don't think anyone actually believes that.
 
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WisNeuro said:
http://www.dod.mil/pubs/foi/Personnel_and_Personnel_Readiness/Personnel/966.pdf

Feel free to read the report. There needs to be more comprehensive research on those in LA and NM, but it is clear that psychotherapy is a front line treatment for certain disorders. Many of the DoD psychs prescribed at a low rate and relied on therapy and either used medication in conjunction or when therapy was deemed ineffective.
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I'm not going to read a 1998 "personnel readiness" report from the military telling me their military psychologists are good.

Realize in the military that their prescribing psychs don't get paid to prescribe more- it's just part of the job. On the other hand prescribing psychs in the civilian world will go down the same road that psychiatrists did- from talk therapy to a mix of therapy and meds to complete medication management.

The reason nobody is going to believe that assertion is simple economics: med management pays more. Psychiatrists do med management so they make more. Psychologists want to do med management to make more. BUT THERE IS ALREADY AN OVER-PRESCRIPTION PROBLEM IN AMERICA.

I hope psychologists can make more in their future doing their important core competency: talk therapy. But I'm not in favor of adding to the over-prescription problem. Especially with lesser trained (non-medical) providers. And frankly the American Psychology Association is never going to convince anyone that Americans needs more psychiatric drugs down their throats - given through them no less.
 
WisNeuro said:
Of course you're not going to read it. You've already made up your mind without any evidence or empirical basis for your argument. Who needs data?
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WHERE'S the data, sir? You handed me a military personnel readiness report from '98 in defense of this claim:

"I need to go back and see, but I thought I read in one of the pre-existing states with RxP or the DoD system, prescribing psychologists were as likely to use the privileges to taper people off meds as they were to start a medication."
 
greenlion said:
Realize in the military that their prescribing psychs don't get paid to prescribe more- it's just part of the job. On the other hand prescribing psychs in the civilian world will go down the same road that psychiatrists did- from talk therapy to a mix of therapy and meds to complete medication management.
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And why did that happen? Do you think it could have something to do with the training model/paradigm of psychiatric practitioners? Perhaps a biological revolution and a need for a "medical identity." Maybe something to do with market demand? Maybe some influence from changing reimbursement structures in the 80s?

I think concluding that this chain events will happen just as it did in medicine is very a very uniformed view of what actually led to the current practice environment for psychitry. Much much ,more at play there than simply "the ability o Rx."
 
The report has data in it. You have given us nothing to support a claim that it's going to be a med prescribing free for all if this happens. There are 0 reported adverse incidents in the DoD about RxP. NM has had the law over a decade. Any data showing an explosion in prescriptions due to RxP? LA has had it for almost a full decade now. I have seen no data suggesting that there are adverse effects of RxP in those states. Where is your data supporting an argument that this will lead to over-prescription and danger?
 
In the absence of data (for the last time your military psych report is irrelevant because it does not apply to civilian reimbursement structure), we go from (1) past history and (2) simple economics. Don't dare make me re-elaborate them!. :) Read my previous post.

Convince me that psychologists are special in that (1) and (2) don't apply to them.

But before you waste any time on any of that answer me this one simple question:
Do we need more psychiatric medications to be dispensed out in the first place?

If not- then you ought to be helping to curb over-prescription rather than trying to get those "privileges" for yourself.
 
You have no data about over-prescription in the first place. At the moment, your argument is an assumption based on your own personal feeling.

Your question makes no sense, it was never part of an argument. More powerful psych medications? The argument is for providing more providers in certain areas that have a dearth of prescribing professionals with the background. Your initial assumptions are groundless.
 
Sorry I meant more psych meds in the first place. Frankly they're all "powerful".

Well- I've said my peace. If you want to emulate psychiatric doctors and forego the psychology profession's core competency than go ahead and try.

BTW- my data of over-prescribing is so ubiquitous that this thread couldn't hold all the links I could find. And I don't have any data from the couple hundred prescribing psychologists- but there is no reason to think they wouldn't add to the problem.
 
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If you actually care- look up over-prescribing in literally ANY psychiatry or psychology archives. I can't believe you haven't heard of this criticism before. Rather than ask me to do your researching for you.

Fully 1 in 5 Americans take Psychiatric drugs (Source: New York Times, "A Dry Pipeline for Psychiatric Drugs", August 19, 2013) Now where exactly aren't psychiatric medications reaching Americans? Where's the "dearth"?
 
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I can't tell if this person is pro psychology or not. Tommy C...is that you?

Look pal, you can be anti Rx all you want. Have a party with it. But don't oppose it due to you supposed ability predict the future when you clearly don't understand how it came to be. People are corruptible, sure, but I have hard time believing that thousand of honest, moral and ethical clinicians will be morphing into 15 med check demons just because they can now write a psych Rx.
 
If your argument is "it won't add to the problem" rather than "it will fix a problem" - then you clearly have other motives than public health.

Look- I'm NOT here to **** with you. If "pro psychology" is to give them whatever they want- than no I don't have such a strong allegiance to any profession.
 
Your beard is weird.
 
A NYT article is not empirical. And as for the dearth, millions of citizens in rural areas who either have no access to psychotropic medication, have to travel hours to get to an appointment, and have to wait very long time periods for appointments would like to talk to you.

Fact is, RxP has been in practice for decades, with all of the data suggesting that it is safe and effective. You have 0 data on your side besides your bad feels.
 
The underlying assumption appears to be meds are bad and therapy is good/better. I don't think that' this dichotomous view is a particularly deep analysis or understanding of MH issues. Is this person mental health professional of some type? I doubt.
 
Giving non-medical doctors Rx prvilieges was long avoided for a reason. If your only tool is a hammer, every problem looks like a nail. For example, consider a case in which a pt presents to a psychologist complaining of palpitations, paresthesias, hyperventilation, diaphoresis, chest pain, dizziness, trembling and dyspnea. The psychologist is going to be thinking "anxiety" but the MD will more often catch mitral valve prolapse and ventricular fibrillations, which could be made worse by certain psychotropic meds.

And suppose a person shows presents to a psychologist's office complaining of fatigue? What sort of differential diagnosis can the psychologist create?

From the Journal of Family Practice:
"Of 100 patients presenting to a primary care physician with fatigue, approximately 25 will be depressed; 25 will have another psychiatric diagnosis, such as dysthymia or anxiety; 15 will have an infection, such as hepatitis, cytomegalovirus, or mononucleosis; 15 will have another physiological cause of fatigue, such as undiagnosed diabetes, anemia, or hypothyroidism; and 20 will remain undiagnosed."
 
Considering we have about 3 decades of time in which some psychologists have had these privileges, any data showing negative consequences from those specific interactions. Or, should we just rely on unfounded conclusions from irrelevant data?
 
How exactly are you going to prove that the Psychologist took 5 years of someone’s lifespan for example by incorrectly prescribing a psychotropic medication who is also on a cholesterol-lowering agent?

Understand that psychiatrists are responsible for pt’s psychiatric health- but psychiatric health does not exist in a CNS vacuum. As a "medical psychologist," are you comfortable treating a hypothyroid-induced depression? Are you comfortable prescribing synthroid with zoloft? Are you even familiar with the complexities of hypothyroidism and aware of the dangers of incorrectly interpreting lab results? Do you know how to properly titrate Depakote for bipolar disorder? Are you comfortable in catching the induced thrombocytopenia that may result? Who will order the lab tests? You? Who will interpret them? Who is going to interpret the EKG on the patient you just put on Geodon? A psychologist? Will you even see the incidental right bundle branch block that the patient should be made aware of?

To answer your question- yes, I would bet damage has already been done.
 
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Longitudinal studies? Lawsuits? In today's litigious society people will exploit mistakes. If you bet damage has been done, there are three decades of data, prove it.

As for all of your questions about what I am comfortable with, of course I'm not. I haven't trained in most of those areas. I am a humble neuropsychologist :) I am not a prescribing psychologist and have not received that specific training. Nice strawman though.
 
You don't seem to have a grasp of the basic realities of lawsuits either: bad subclinical results are hard to prosecute for exactly the example I wrote. i.e. Patient died at 60 instead of 70. Is the psychologist's medical treatment at fault? Defense lawyer: Well the plaintiff also sat on his ass and drank beer a lot. (There's a reason why malpractice is mostly surgical.) Not everyone dies instantly after bad treatment.
Then there's the privacy problems- I doubt psychologists are going to open up their records to scrutiny.

Re: You don't know- of course you don't. I wanted to illustrate a drop of the actual medical expertise that would be required to be truly competent. The problem is you don't want to obtain medical knowledge (e.g. medical school) but want a shortcut and then want to delude lay people into thinking it's just as comprehensive.

Even military psychologists who prescribe don't do it in a vacuum. Their Rx treatment is monitored by physicians even though they have an (actually) strenuous 3 year training from the DoD before they prescribe (No, even in the closely monitored military with healthy patients simply being a "psychologist" is not a credential to practice medicine).

Only the least educated politicians would believe that psychopharmacology can be practiced independently of medicine- as if human beings work like legos. :rolleyes:
 
The fact still remains that there is data showing efficacy of these providers in the context that they work in. You have provided 0 data to substantiate your claims of harm despite 3 decades of practice. You can pontificate all you want, but without any empirical evidence to back anything up it's all naysaying and doomsday prophecies from the street corner.
 
greenlion….I'm still waiting for some actually hard data for any of your baseless claims. I'm not sure of your background, but in our training we are taught to trust in research and data, not "shoot from the hip" and fear monger. Do you know who else ignores research and data….anti-vax'ers, and everyone knows how reliable and unbiased they are about their "issue".
 
Can you guys not read? Prescribing psychologists aren't going to showcase their shortcomings openly. Your argument is like saying 'beauty school cosmetologists should administer botox until you prove to me that they are harmful'! (actually its even worse since the epidermis is obvious to anyone on the street, internal medicine less so).

The truism is especially true here: "a little knowledge is a dangerous thing". If you guys REALLY care about data and public health- put these prescribing psychologists under probation by physicians to assess their care and document it.

If you guys are pro this- you ought to be pro cosmetologists, RNs, chriopractors, physical therapists, social workers- everyone prescribing given this "psychopharmacology" training. Do it until you prove the damage!
 
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The thing is that you haven't been through the training yourself, so you can't speak to it's shortcomings. The only data available shows that it is effective and safe. It wasn't other prescribing psychologists who were evaluating and providing data, it was supervisory MD's. Still, no shortcomings were noted, just exemplary evaluations.
The data is out there, just like the data that is available for psychiatrists. We could all act like GOP pollsters and ignore data that contradicts with our unfounded opinions. Or, we could look at empirical evidence like good scientist-practitioners.
 
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But you already have repeated yourself, many times. You're holding RxP to a standard that doesn't even exist for psychiatrists. The same arguments you made against RxP, without any data, are the same arguments that could be made against MD's prescribing. By your faulty logic, no one should be able to prescribe meds.
 
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You're holding RxP to a standard that doesn't even exist for psychiatrists.
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-WisNeuro

This is the level of ego that we're dealing with.

Wiseneuro, a 2 year weekend course in psychopharmacology (starting with high school chemistry I suppose?) is...well...I'll stop there because I risk offending the actually admirable psychologists who want to practice within their scope of competence/training!
 
I'm just saying that you can't delineate that a profession is not meeting a standard when you haven't defined said standard and provide no data for where that line should be. You are only providing an amorphous moving target for your opinion, with no empiricism involved. That's not how this system works.
 
ok- the "standard" is premed requirements (that by itself will take 2-3 years) , 4 years medical school, full-time residency training of 4 years (and if you want to practice on children than the full-time C/A fellowship training of 2 more years). And of course all the exams and boards throughout. But you already knew that.

But I think what you're asking is "what's the minimum standard" that works and the data to back that up. That I do not know but it has to be much more than what is proposed for RxP. Any case I caution you about this line of thinking. Standards are high (sometimes overly so) in medicine for a reason.
 
greenlion said:
. That I do not know but it has to be much more than what is proposed for RxP. Any case I caution you about this line of thinking. Standards are high (sometimes overly so) in medicine for a reason.
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Ah, the Potter Stewart defense, "I know it when I see it!" What data are available that suggest that the requirements you listed are the safe and efficacious way to determine practice standards? You claim that the RxP is not sufficient and is unsafe for consumers. There are 3 decades of health data available to bolster a claim of harm. No data has come out to that effect. Data has come out to the efficacy and safety of the practice.
 
Data! We got data!
Well sorry to burst your bubble but ontop of everything else the DoD study, commonly cited by psychologists as proof of their safety is, ironically, quite the opposite. It's ironic because one thing that psychology does well, research, was in nearly all ways thrown out the window since they obtained favorable anecdotal results (not data). They prescribed a limited formulary (SSRIs) to non-medically comorbid, non-child, non-geri patients under supervision by a physician. Absolutely irrelevant for autonomous prescribing psychologists in the civilian world.

As for no harmful data (as opposed to positive data) I already explained the problem of subclinical outcomes and treatment privacy. On top of this, I assume the few prescribing psychologists that are out there are also excessively leaning on physician consults - completely eliminating the point of it all.
 
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greenlion said:
Data! We got data!
Well sorry to burst your bubble but ontop of everything else the DoD study, commonly cited by psychologists as proof of their safety is, ironically, quite the opposite. It's ironic because one thing that psychology does well, research, was in nearly all ways thrown out the window since they obtained favorable anecdotal results (not data). They prescribed a limited formulary (SSRIs) to non-medically comorbid, non-child, non-geri patients under supervision by a physician.
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It is data in every sense of the word. Supervisor evaluations are data. I was also talking about all of the health data available in NM, LA, and other DoD since the program has expanded. If this program has been such a scourge on humanity and putting patient's lived in dangers, why hasn't the AMA crunched the numbers to use in their fights against these privileges?

It's becoming a fire hazard with all of the strawmen in here. Call a fire marshal.
 
Read my last paragraph (which references something I've talked about in-depth in an even earlier post). I'm done here with me having to repeat every 2-3 posts.
 
Sign a petition that requires prescribing psychologists in LA/NM to give up their patient/treatment history for scrutiny and I'll give you your data. :)
 
greenlion said:
ok- the "standard" is premed requirements (that by itself will take 2-3 years) , 4 years medical school, full-time residency training of 4 years (and if you want to practice on children than the full-time C/A fellowship training of 2 more years). And of course all the exams and boards throughout. But you already knew that.
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So...that is the standard for other prescribers (e.g. NP, PA, etc)?

Hmm...

greenlion said:
They prescribed a limited formulary (SSRIs)....etc.
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Are you saying they only prescribed SSRIs? If so, both you and I know that is not accurate. As for the limited formulary, that is what is being proposed in places like IL.

I'll give you some time to think of knew incorrect statements and set up some more straw men so that you can change your target(s) again.
 
Therapist4Chnge said:
So...that is the standard for other prescribers (e.g. NP, PA, etc)?

Hmm...
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The outcome data for NP and PA (which is what the RxP guidelines are based on) is actually equivalent in studies to that of physician prescribers.
(Lenz et al. 2004, Mundinger et al. 2000, U.S. Congress Off. Technol. Assess. 1986)

Data!
 
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This came out over the NMPA listserv today:

Historic Stride in New Mexico:

Effective today, all private insurance companies insuring persons in the state of New Mexico, as well as Medicaid, recognize prescribing psychologists' authority to bill Evaluation and Management (E&M) codes at the same compensation rate at their physician colleagues. These codes were previously reserved for doctors of medicine or doctors of osteopathy (M.D./D.O.). This success was brought about by the combined efforts of the New Mexico and American Psychological Association.

This monumental accomplishment comes on top of last year's legislative success of requiring publically funded hospitals delivering services to those with mental or neuropsychiatric illness have at least one clinical neuropsychologist on statff for ever 300 patients and ensuring only neuropsychologists with appropriate board certification have the ability to interperet neuropsychological testing.

We look forward to further advancing the practice of psychology this year. In particular, we are actively working on restrciting sales of psycholgical testing supplies to only those persons with a PhD or PsyD in clinical, counseling or school psychology from an APA-accredited institution.
 
NP and PA is not THE "standard". I know you guys want to race to the bottom in terms of education/expertise so you can make "doctor money" without the credentials, but PAs practice UNDER THE SUPERVISION of physicians. Ditto for many NPs. Even Psych NPs in states where NPs can practice independently of physicians tend to practice under the leadership of psychiatrist(s).

Nevertheless, congratulations on making more money in NM now. Maybe you can start lobbying to do ECTs next? Or perhaps help extend these privileges to other PhDs- social work? sociology? After they too get that oh-so-rigorous and comprehensive "psychopharmacology" training of course. One wonders why America spends trillions in training medical doctors anyhow if this is our healthcare "solution".
 
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Such vitriol. God forbid the healthcare industry adapts to modern challenges and times. We should hearken back to the days of trephination, and sexual assault by physicians under the guise of treating hysteria. Ah, the halcyon days of medicine!

Anyway, I thought you were done with this thread? I knew you'd be back with your apocalyptic sandwich board :)
 
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Not vitriol. Disbelieve, disenchantment.
Still, it seems like US healthcare just gets crappier and crappier without getting cheaper.

I mean essentially you want to become a "junior psychiatrist" (believing that your part-time weekend course replaces med school and residency) But why would such a person cost the same in the same field? Given the risks and the higher consults? :eek:

We should hearken back to the days of trephination, and sexual assault by physicians under the guise of treating hysteria. Ah, the halcyon days of medicine!
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BTW, this is completely uncalled for. Nobody is saying that denying RxP = advocating MDs raping patients. What a nasty thing to say. (are you even a real psychologist?)
 
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I will say that part of the support for RxP comes from providing prescription-related privileges (or at least input into the decision) to folks with a different training background, viewpoint, and often general approach to assessment and intervention, in part because of some of the same factors that drive resistance to RxP--the general societal undercurrent, particularly from a decade or two ago, that Americans were/are highly overmedicated when it comes to MH.

The main worry I have about RxP, particularly if it becomes directly integrated into psychology graduate training rather than being largely postdoctoral, is something I've mentioned before--that it could result in underemphasis of everything that makes a psychologist a psychologist, and thereby could essentially end up training folks who're basically mid-level medical providers rather than folks with a psychologist's expertise in mental health assessment, theory, research, and treatment who are also more informed regarding psychopharmacology (whether or not they actually prescribe).
 
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Illinois prescriptive authority legislation passes House and Senate
The bill awaits the governor’s signature.
By Legal & Regulatory Affairs staff
On May 30, 2014, the Illinois General Assembly passed landmark legislation (SB 2187) allowing properly trained psychologists to prescribe certain medications for the treatment of mental health disorders. If signed into law by the governor, it will make Illinois the third state in the country to grant prescription privileges to psychologists, joining New Mexico and Louisiana.
Illinois Senate Bill 2187 was introduced by Senator Don Harmon (D), President Pro Tem of the Illinois Senate, Senator Dave Syverson (R), Rep. John E. Bradley (D), and Rep. Raymond Poe (R). The bill passed in the Illinois House 94-21-0 with a concurrence vote in the Illinois Senate 57-0. The legislation will be sent by the end of June to Governor Pat Quinn (D) for approval. The governor then has 60 days to consider the bill.
Because the Illinois Psychological Association (IPA) negotiated an eleventh-hour agreement with the state medical, psychiatric and nursing organizations and the bill had key support across the state and strong proponents in the General Assembly, IPA is hopeful that the governor will

Psychology advocates hail the victory as the culmination of several years of tireless and diligent advocacy by IPA under the leadership of President Beth N. Rom-Rymer, PhD. Notably, Illinois is also home to the American Medical Association and internationally renowned medical research centers.
“The rhetoric used against us was fierce and unrelenting,” says Dr. Rom-Rymer. “What brought the state medical and psychiatric societies to the negotiating table were the psychologists' successive legislative victories in both the Senate and the House, the steady growth of psychology’s support from state labor unions and other influential groups, and our steadfastness in staying the course.”
The negotiated agreement allows for collaborative work among the key providers of mental health in the state of Illinois. Although there are significant constraints in the current bill, IPA is confident that, as psychologist providers demonstrate safe and effective prescribing, those constraints will be lifted, just as they have been for advanced nurse practitioners, optometrists and other non-physician prescribers.
The legislation currently stipulates that licensed clinical psychologists in Illinois who want to prescribe must successfully complete advanced education and training in psychopharmacology as well as supervised clinical training in medical rotations, such as emergency medicine, psychiatry, family medicine and internal medicine.
In addition, the current legislation stipulates a collaborative practice agreement between prescribing psychologists and physicians and does not permit psychologists to prescribe for children, adolescents, or seniors age 65 or older, or patients who are pregnant, have serious medical conditions or developmental/intellectual disabilities. The formulary for prescribing psychologists in Illinois does not currently include benzodiazepines and narcotics.

If signed into law, SB 2187 would allow psychology graduate students anywhere in the country to begin their training in clinical psychopharmacology at the predoctoral level and apply for prescriptive authority in Illinois once they complete their doctoral requirements as well as the requirements for the didactic and clinical training in psychopharmacology.
Giving prescriptive authority to licensed clinical psychologists with advanced, specialized training in clinical psychopharmacology will improve access to care and expand options for Illinois residents seeking treatment for mental health conditions. "With state resources stretched to the limit, psychiatrists and other mental health professionals are in short supply," says Dr. Rom-Rymer, adding that the demand for mental health services far exceeds the capabilities of the existing provider network. “This law will help ease the enormous pressure on the state system.”
More than 50 Illinois counties have no inpatient psychiatric services in their hospitals. Another 24 counties have no hospitals at all. Yet 614,000 Illinois residents currently need treatment for serious mental illness. The unmet need is greatest with people who need help the most: underserved low-income, rural and minority populations.
If SB 2187 is signed into law, the next steps will be for the Illinois Clinical Psychologists' Licensing and Disciplinary Board to begin drafting rules to implement the prescriptive authority provisions established by the new law. In addition to the seven current members of the licensing board, the director of the Illinois Department of Financial and Professional Regulation will appoint two prescribing psychologists, a psychiatrist and a primary care physician or a family practice physician to the board. The two licensed prescribing psychologist members of the board and the two physician members of the board shall only deliberate and make recommendations related to the licensure and discipline of prescribing psychologists.
"The quest for prescriptive authority is a journey,” says Dr. Rom-Rymer, “The Illinois Psychological Association has cut away the brush and the brambles and has created a road. Still, we have many more miles to go before we sleep."
 
More than 50 Illinois counties have no inpatient psychiatric services in their hospitals. Another 24 counties have no hospitals at all. Yet 614,000 Illinois residents currently need treatment for serious mental illness.
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This is the type of fear-mongering I'm talking about. Several Illinois counties have >10,000 residents and many of these tiny counties are less than >25 miles from their epicenter to the next county. Why on earth would they all need their own in-patient psychiatric hospital?
And 614,000 Illinois residents currently need treatment? I don't know how they came up with that number because the vast majority of people everywhere have to make an appointment to see a doctor. It's not a big deal. If it's an actual emergency- then there's the ER. Which always has doctors including psychiatrists who consult.

These non-medically trained "prescribing psychologists" won't be treating serious mental illness anyway which makes the above argument even more flimsy. Just over-prescribing Xanax and Ritalin to healthy & wealthy Chicagoans.
 
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