Psychopharmacology/Advanced Practice Psychology

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AlaskanJustin said:
Let me ask. How do we gain a preponderance of evidence without first making it legal to actually do so? Not attacking you I am just genuinely curious how this should be done. Yeah there was the DoD study several years ago but how else should we do these studies? Also, what studies do you mean? Should we give X number of psychologists privileges and follow them over a few years?

This was sincerely not the process followed for other professions, i.e., dentistry... I suppose you could make the argument that dentists get some medical training, but then again if one were to look at the dental curriculum they might change that thought.

Next, do you know what the purpose of an MD/PhD program is? It's clinical research. Also, let me ask, how do you propose this is done? There are (I think up to) 3 schools including UCSF that allow for the phd training to be done in Psychology, but that is purely research, its like doing a masters in psychology with an MD. Anyways could you imagine the sheer amount of training that would take, Initial two years of med school, then 4-5 years of psychology training (including ALL the classes necessary to appease APA) then the final 2 years of medical school... eeeyyyaa... No I don't think that necessarily is the solution...

I think one must also consider the curriculum set up for achieving RxP... two years of dedicated training in things like neuroscience, pharmacokinetics etc (kind of like the first two years of med school, but without the intense dedication to things like infectious disease etc)... yes this training is focused SOLELY on areas effected by psychotropic drugs, but nevertheless how is two years of dedicated training any less than the first two years of med school training in regards to level of information?

Then you have the two years of shadowing/training with a physician, in essence, this is to mimic the two years of clerkships that medical students have to do, but instead of having to do rotations in OBGYN, ER etc, you are only doing psychiatric work/prescribing of psychotropic drugs... so in essence your training is better at this stage.

Yes then you might not have the residency stage, but one could argue that the intensity of the two year practice stage is sufficient.

You are probably right that there needs to be evidence... unfortunately that also is not how the legal system works... legal system and scientific method dont go hand to hand very well. Lets say in ten years 10 studies come out saying RxP has a detrimental effect, THEN yeah the evidence might go to a senate committee hearing and it would be shut down... but it hasnt been shut down in other professions with restricted access, I dont see any logical reason why it would for psychologists either.

AJ
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For solidarity... http://www.nyu.edu/dental/academicprograms/dds/index.html

They take barely as much basic science/biology as a person going through two dedicated years for RxP
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Some facts: psych students are pompous, idealistic and clueless because they somehow believe that the reason the were chosen for the funded PhD is all about them...it is not. Most on here are students and have no idea what practice is about, what RxP is about and choose sides based upon who their favorite prof was/is. Medical students are more humble, but equally as deluded about the depth of their training. Psychologists against RxP is a meaningless topic as most psychologists aren't trained and fear what they have no clue about. Most medical providers love medically trained psychologists over psychiatry because they maintain oversight and control of their patient. APA is lame and useless. RxP is about the future as it was for nurses. Psychiatry would not exist without drugs and they know that. Did I already say that most of these arguments on SDN are meaningless as they come from concepts rather than experience? OK I am tired.
 
AlaskanJustin said:
Let me ask. How do we gain a preponderance of evidence without first making it legal to actually do so? Not attacking you I am just genuinely curious how this should be done. Yeah there was the DoD study several years ago but how else should we do these studies? Also, what studies do you mean? Should we give X number of psychologists privileges and follow them over a few years?

This was sincerely not the process followed for other professions, i.e., dentistry... I suppose you could make the argument that dentists get some medical training, but then again if one were to look at the dental curriculum they might change that thought.

Next, do you know what the purpose of an MD/PhD program is? It's clinical research. Also, let me ask, how do you propose this is done? There are (I think up to) 3 schools including UCSF that allow for the phd training to be done in Psychology, but that is purely research, its like doing a masters in psychology with an MD. Anyways could you imagine the sheer amount of training that would take, Initial two years of med school, then 4-5 years of psychology training (including ALL the classes necessary to appease APA) then the final 2 years of medical school... eeeyyyaa... No I don't think that necessarily is the solution...

I think one must also consider the curriculum set up for achieving RxP... two years of dedicated training in things like neuroscience, pharmacokinetics etc (kind of like the first two years of med school, but without the intense dedication to things like infectious disease etc)... yes this training is focused SOLELY on areas effected by psychotropic drugs, but nevertheless how is two years of dedicated training any less than the first two years of med school training in regards to level of information?

Then you have the two years of shadowing/training with a physician, in essence, this is to mimic the two years of clerkships that medical students have to do, but instead of having to do rotations in OBGYN, ER etc, you are only doing psychiatric work/prescribing of psychotropic drugs... so in essence your training is better at this stage.

Yes then you might not have the residency stage, but one could argue that the intensity of the two year practice stage is sufficient.

You are probably right that there needs to be evidence... unfortunately that also is not how the legal system works... legal system and scientific method dont go hand to hand very well. Lets say in ten years 10 studies come out saying RxP has a detrimental effect, THEN yeah the evidence might go to a senate committee hearing and it would be shut down... but it hasnt been shut down in other professions with restricted access, I dont see any logical reason why it would for psychologists either.

AJ
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good point AJ. i couldn't have stated any better than you did.

who is this s c umbag psycscientist anyway?
 
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stigmata said:
Some facts: psych students are pompous, idealistic and clueless because they somehow believe that the reason the were chosen for the funded PhD is all about them...it is not. Most on here are students and have no idea what practice is about, what RxP is about and choose sides based upon who their favorite prof was/is. Medical students are more humble, but equally as deluded about the depth of their training. Psychologists against RxP is a meaningless topic as most psychologists aren't trained and fear what they have no clue about. Most medical providers love medically trained psychologists over psychiatry because they maintain oversight and control of their patient. APA is lame and useless. RxP is about the future as it was for nurses. Psychiatry would not exist without drugs and they know that. Did I already say that most of these arguments on SDN are meaningless as they come from concepts rather than experience? OK I am tired.
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medical students are more humble? what world do you currently exist in?
 
psycscientist said:
The bottom line for me is that I don't see why psychologists are advocating for alternative training models. There are plenty of models in place under which a psychologist could get training (e.g., MD, NP, etc.). It just seems to me that some psychologists wish to expand their scope of practice in the easiest way possible and this is what they came up with. Most academic psychologists are completely opposed to this movement because it has no scientific backing. I wouldn't be surprised if most of the advocates for RxP were private practitioners who also eschew evidence-based psychosocial treatments.
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I'm not meaning to be facetious, but do you know of or have any data to support this claim (I'm genuinely curious)? I ask because of the small number of psychologists I know who've earned or support RxP, I'd say perhaps half are in some way involved in academia. I'm not saying most academics aren't opposed to it, just that I'd be interested to know the actual proportion/breakdown if it's available somewhere.

Also, none of the RxP providers I know are in the practice of eschewing evidence-based treatment, whatever its form. Quite the contrary--one or two took the psychopharm classes, at least in part, for the purpose of edification and increased pharm awareness, while others are heavily involved in various forms of clinical research.

Edit: As for the model of training itself, I'm perpetually torn between two ideas:

1) The medical school route is the current "gold standard" in terms of prescriptive training (regardless of whether it's the most efficacious or efficient method, I think we can all agree that an MD is pretty much as high as it gets when it comes to medical training, of which prescriptive authority is a subset), and...

2) The case of the PA, which is also a 2-3 year master's (in most cases, I believe) program that allows for a wider scope of practice than RxP in many respects, although requires some type of collaborative supervision in most, if not all, areas

I could be wrong, but the current RxP model seems to be an amalgamation of these two systems. You have the 2-3 year length of the PA program mashed in with the idea that clinical psychologists, while not medically trained, are still doctoral-level providers of mental health services (i.e., are at least on par with psychiatrists as the "cream of the crop" in many of these respects). The thinking, then, might've been something along the lines of, "how can we take a 2-3 year program like that of the PA, narrow its focus to only include psychpharmacological intervention, and apply it to individuals already highly trained in mental health care in such a way as to capitalize on this training and allow for a) reduced redundancy/improved efficiency and b) eventual independent practice?" Thus, in a way it seems to also be calling on the NP process--take someone already trained in an area, and build on this by offering them additional training to the degree necessary to make them competent in new areas of practice.

Yeah, I'm not exactly sure what my point was; just thinking out loud for a bit. Unfortunately, it hasn't helped clear out the haze in my brain at all.
 
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psycscientist said:
I think the DOD study was a promising first step and had much more rigorous training than what RxP advocates would argue is sufficient now. I don't think psychologists should be prescribing without proper medical training, so I would not be the person to design a study to try to show that less training is not harmful. I also don't see what the utility would be to sink research dollars into such a thing when psychologists could easily get adequate training in this area (through MD, NP, etc.) programs if they so desired.
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I suppose my question is, what is it about medical training that makes it so far superior. If you say the two years of basic training plus the two years of clerkships, then that is accounted for. But of course psychiatrists get the additional residency. But what does that mean for DDSs etc? I guess both are equally poor arguments in my opinion A) MDs get more training therefore should be the only ones allowed RxP (by that logic no other professions should be allowed to B) Because other professions like DDSs have RxP psychologists should (I think this is equally as stupid of an argument).

I do get the sense of the argument saying that there are other ways in which to acquire RxP training, and that might be a utilitous argument. However I think a point that still holds is that the training a NP gets is no better for psychotropics, therefore how would pursuing THAT training make a psychologist any better at Rx psychotropics??? I guess that is why I don't think that is a solution either. But again I do understand the logic behind the argument.


I think clinical research is a large purpose of a straight Ph.D. in Clinical Psychology as well. Additionally, there are many MD/PhD programs which take students around 4 years to complete the coursework and research requirements across a variety of research disciplines. They don't hand out doctoral degrees any way you slice it.
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The key difference is that in the PhD programs that are a part of an MD/PhD program the requirements are much less minimal, for instance number of classes is SIGNIFICANTLY reduced, and the amount of required research (i.e., thesis, dissertation etc) is reduced because all they require is a thesis, not a full blown defended dissertation etc. Whereas clinical psych requires a ridiculous number of classes, plus masters thesis and dissertation etc etc. Now tack on having to do the work that an MD student does? Crazzzzyyyy talk 🙂. But no I am definitely not saying they hand them out, just saying the amount of work would be ridiculous.


Probably right? I can't see how any reasonable person would advocate for a case where we wouldn't need evidence. Just look at the psychological treatments that we thought "oh sure, that would be great" that turned out to actually be harmful to people once they were subjected to empirical scrutiny (i.e., stress debriefing). Saying the the legal system and science don't go hand in hand, and therefore we should push for RxP without having to justify ourselves is pretty reckless, in my opinion.
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Just to say, there is a big difference between legal evidence and scientific evidence (at most times anyway) hence why I used the word scientific evidence.

I agree there can be recklessness at times, but then again I think that is a whole different issue (i.e., flaws of what is allowed to be practiced). I guess the legal issue is "is there a reasonable amount of training that can be established to make a reasonable psychologist capable of prescribing medications to the populations they are designated to work with" and notice the word "reasonable" is there twice for a reason. Law likes this word, reasonable, we may ask WTF does that even mean... but hey in the law there doesnt have to be a scientific definition of reasonable.

The bottom line for me is that I don't see why psychologists are advocating for alternative training models. There are plenty of models in place under which a psychologist could get training (e.g., MD, NP, etc.). It just seems to me that some psychologists wish to expand their scope of practice in the easiest way possible and this is what they came up with. Most academic psychologists are completely opposed to this movement because it has no scientific backing. I wouldn't be surprised if most of the advocates for RxP were private practitioners who also eschew evidence-based psychosocial treatments.
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Again I revert back to the original argument. Sure there are indeed modes of training, but would an NP get any more training in psychotropics than a person would gaining RxP for psychologists??? I cannot answer this question, only pose my thoughts about it.

Just one last pedantic point... I think the use of statements like "most academic psychologists" or "most of the advocates" are pretty scientifically unfounded statements too... sorry I know its pedantic, but I think its unfair to make such blanketed statements, particularly about them being non-evidence based practitioners...

Anyho
 
nitemagi said:
Organic - I get that a lot 😀

Histandard - sorry about that, but your first posts came off as inflammatory from an account with very few posts overall. In forums like this that often suggests a troll.

T4C - I was just passed this by a colleague. Interesting site:
http://www.poppp.org
Hope it furthers the discussion, and lends evidence that not all psychologists are in favor of psychologist prescribing.
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I'm not sure anyone claimed that all psychologists are on board with RxP. I'm not supportive of it in its current form, though I think there is room to make it work (w. more clinical hours, required consultation, etc).

psycscientist said:
If psychologists wish to prescribe, then they should push to create MD/PhD programs with a Ph.D. concentration in Clinical Psychology. Anything less is doing the same thing that we get all up in arms about when the master's levels claim that with an extra class or two, they can give and interpret complex neuropsychological batteries.
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The Ph.D. portion of an MD/Ph.D. is 99.9% focused on a niche that directly relates to medicine...and clinical psychology is not that. The focus of MD/Ph.D. programs are to produce academics for medical schools, and there can be quite a bit of pressure to only consider certain areas of research and practice. I looked at a number of MD/Ph.D. programs, and they were very much MD focused with an attempt to cram in research and a dissertation as quickly as possible. Based on the programs I considered, the classroom training is pretty much waived via med classes, with stats, research, and a handful of other classes in the area of interest. There are few fits that would be worse than an MD/Ph.D. in Clinical Psychology.

stigmata said:
Some facts: psych students are pompous, idealistic and clueless because they somehow believe that the reason the were chosen for the funded PhD is all about them...it is not. Most on here are students and have no idea what practice is about, what RxP is about and choose sides based upon who their favorite prof was/is. Medical students are more humble, but equally as deluded about the depth of their training. Psychologists against RxP is a meaningless topic as most psychologists aren't trained and fear what they have no clue about. Most medical providers love medically trained psychologists over psychiatry because they maintain oversight and control of their patient. APA is lame and useless. RxP is about the future as it was for nurses. Psychiatry would not exist without drugs and they know that. Did I already say that most of these arguments on SDN are meaningless as they come from concepts rather than experience? OK I am tired.
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While I do not agree with some of this, I definitely have seen both student sides having no idea of the practical implications of the arguments. I have also seen FPs and GPs strongly supporting RxP psychologists, and mostly in rural/underserved areas...shocking!
 
AlaskanJustin said:
Again I revert back to the original argument. Sure there are indeed modes of training, but would an NP get any more training in psychotropics than a person would gaining RxP for psychologists??? I cannot answer this question, only pose my thoughts about it.
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This is essentially the main point I was trying to get at in my meandering post above yours, I think. Thanks for spelling it out with about 1/3 the verbiage.
 
stigmata said:
One where I train residents every day.
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residents of clown college of surgeons? do you mean that you are a circus director? don't tell me you are a senior MD or a prof, because that would seriously make me go run to the washroom and take a massive D that someone like that would write the way you did
 
histandard said:
residents of clown college of surgeons? do you mean that you are a circus director? don't tell me you are a senior MD or a prof, because that would seriously make me go run to the washroom and take a massive D that someone like that would write the way you did
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:laugh:That made me laugh out loud cause I have no clue what the hell it meant.
 
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AcronymAllergy said:
This is essentially the main point I was trying to get at in my meandering post above yours, I think. Thanks for spelling it out with about 1/3 the verbiage.
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Honestly, I'm pretty familiar with the DoD study, but I'm not sure how the training is being implemented in NM/LA. This may or may not be the case, but the way the question is phrased, it sounds like you're insinuating the medical training outside of psychopharm-specific in, for example, an NP degree, isn't particularly useful in prescribing psychotropics. Again, I'm obviously not in a position of having any medical training, but I do know that at least some psychotropics are degraded into metabolites that can potentially have systemic effects.

histandard, you are a unique snowflake
 
loveoforganic said:
Honestly, I'm pretty familiar with the DoD study, but I'm not sure how the training is being implemented in NM/LA. This may or may not be the case, but the way the question is phrased, it sounds like you're insinuating the medical training outside of psychopharm-specific in, for example, an NP degree, isn't particularly useful in prescribing psychotropics. Again, I'm obviously not in a position of having any medical training, but I do know that at least some psychotropics are degraded into metabolites that can potentially have systemic effects.

histandard, you are a unique snowflake
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No, that's not necessarily what I was insinuating; I apologize for being unclear. Essentially, I was suggesting that the current RxP training model seems to be focused on teaching what it's felt is necessary to competently practice within a limited capacity (i.e., in mental health settings with mental health populations and using mental health treatments). Thus, some of the training received in an NP or PA program may, in fact, be spurious if the RxP psychologist's intended and allowed scope does not include all of those things for which an NP or PA is licensed to assess and treat. However, this is not to say that everything not immediately related to psychopharm is spurious, of course. I would expect RxP to entail an adequate level of instruction in basic areas of biophysiology necessary to safely prescribe (or safely decide not to prescribe), for example.

However, the point also being put forth is whether or not RxP actually provides inferior training to these other well-established routes (i.e., NP and PA).
 
I gotcha, sorry if it seemed like I was putting words in your mouth.

For anyone in an Rx state - to what extent is the ongoing physician supervision actually there? Also, who bares the malpractice burden in the relationship - is it shared, full psych, or full supervising physician?
 
AcronymAllergy said:
No, that's not necessarily what I was insinuating; I apologize for being unclear. Essentially, I was suggesting that the current RxP training model seems to be focused on teaching what it's felt is necessary to competently practice within a limited capacity (i.e., in mental health settings with mental health populations and using mental health treatments). Thus, some of the training received in an NP or PA program may, in fact, be spurious if the RxP psychologist's intended and allowed scope does not include all of those things for which an NP or PA is licensed to assess and treat. However, this is not to say that everything not immediately related to psychopharm is spurious, of course. I would expect RxP to entail an adequate level of instruction in basic areas of biophysiology necessary to safely prescribe (or safely decide not to prescribe), for example.

However, the point also being put forth is whether or not RxP actually provides inferior training to these other well-established routes (i.e., NP and PA).
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Folk! Have any of you actually seen the graduate level training that NP's get. Its a bit frightening to see how little training they actually receive. Of course they come in as a BSN but the existing graduate programs are often 45 hours or less. Vanderbilt (yes the Vanderbilt University) has a program that allows a BSN to become a MSN-level psych NP in 40 semester hours. Folks, this is Vanderbilt training nurses to prescribe psychotropics after *3 semesters* of full time academic course work!

http://www.nursing.vanderbilt.edu/msn/pmhnp_plan.html

The nursing profession is pushing a doctoral level degree for NP's called the DNP degree; but based on content and number of hours its hardly a doctoral degree. Look at what Duke university has created (Yes the Duke University) for a Doctor of Nursing Practice or DNP degree.

http://nursing.duke.edu/wysiwyg/downloads/Duke-Sample-Post-BSN-DNP-Adult-MAT-Plan-2010-r1.pdf

These degree programs are jokes! I have to believe that existing psychopharm training programs for psychologists are vastly superior to what NP's are getting if two of the top educational institutions in the nation have curricula like this for NP's.
 
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Neuropsych2be said:
have you seen the graduate level training that NP's get. Its a bit frightening to see how little training they actually receive. Of course they come in as a BSN but the existing graduate programs are often 45 hours or less. Vanderbilt (yes the Vanderbilt University) has a program that allows a BSN to become a MSN-level psych NP in 40 semester hours. Folks, this is Vanderbilt training nurses to prescribe psychotropics after *3 semesters* of full time academic course work!

http://www.nursing.vanderbilt.edu/msn/pmhnp_plan.html
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3 semesters of online classes and some weekends......

The cost of attendance used for 2010-2011 for a full time MSN student enrolled in three semesters is $73,600.
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It includes living expenses for the time, but that it still ridiculous.
 
I am curious as to how RX training for psychologists does compare to psychiatry training. I can only speak from my own personal experience as a 3rd year psych resident. I've had ~5 years of clinical experience (started seeing patients my 2nd year of medical school). I would say I have seen approximately 3000-4000 patients by now, granted many were not in the field of psychiatry (whether it be delivering babies, touching penises, or trying to keep patients from dying). Whenever I was on medicine or psychiatry nightfloat, I've had to manage a load of 100-150 patients. We see the full gamut of psych patients from the acutely ill ones the moment they hit the emergency room to forensic patients in long term facilities. Approximately how many different patients do RX psychologists see by the time they complete their training? The high exposure to a diversity of clinical scenarios is just as critical as is the number of clinical hours. Is rx training for psychologists designed to match that of a psychiatrist's or is the goal to establish the minimal amount of training necessary in order for psychologist to be able to prescribe safely?
 
Neuropsych2be said:
Folk! Have any of you actually seen the graduate level training that NP's get. Its a bit frightening to see how little training they actually receive. Of course they come in as a BSN but the existing graduate programs are often 45 hours or less. Vanderbilt (yes the Vanderbilt University) has a program that allows a BSN to become a MSN-level psych NP in 40 semester hours. Folks, this is Vanderbilt training nurses to prescribe psychotropics after *3 semesters* of full time academic course work!

http://www.nursing.vanderbilt.edu/msn/pmhnp_plan.html

The nursing profession is pushing a doctoral level degree for NP's called the DNP degree; but based on content and number of hours its hardly a doctoral degree. Look at what Duke university has created (Yes the Duke University) for a Doctor of Nursing Practice or DNP degree.

http://nursing.duke.edu/wysiwyg/downloads/Duke-Sample-Post-BSN-DNP-Adult-MAT-Plan-2010-r1.pdf

These degree programs are jokes! I have to believe that existing psychopharm training programs for psychologists are vastly superior to what NP's are getting if two of the top educational institutions in the nation have curricula like this for NP's.
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I think there's a pretty general feeling in the physician community that NP training is wholly inadequate for unsupervised practice. That being said, the majority of the literature available (making no specific comments about problems with this literature) supports the safety and efficacy of independent advanced practice nursing. Honestly, I've only seen a single article that supports anything but this (in fact supports care team > MD/DO > CRNA), and the article has at least one of the same flaws as the literature supporting APN independent practice (namely, funding source, the ASA, anesthesiologists, vs the AANA, nursing).

How to objectively investigate the efficacy of various providers relative to one another, I think is a tremendous problem without a great resolution.
 
erg923 said:
:laugh:That made me laugh out loud cause I have no clue what the hell it meant.
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it meant that once i found out stigmati was a faculty member, based upon the non-insightful comments this person made, i ran to the washroom to take a massive D or thought maybe s/he meant to say s/he was a faculty member at a circus school
 
loveoforganic said:
Honestly, I'm pretty familiar with the DoD study, but I'm not sure how the training is being implemented in NM/LA. This may or may not be the case, but the way the question is phrased, it sounds like you're insinuating the medical training outside of psychopharm-specific in, for example, an NP degree, isn't particularly useful in prescribing psychotropics. Again, I'm obviously not in a position of having any medical training, but I do know that at least some psychotropics are degraded into metabolites that can potentially have systemic effects.

histandard, you are a unique snowflake
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i get what you mean, but snowflakes by nature are unique. lol
 
loveoforganic said:
I think there's a pretty general feeling in the physician community that NP training is wholly inadequate for unsupervised practice. That being said, the majority of the literature available (making no specific comments about problems with this literature) supports the safety and efficacy of independent advanced practice nursing. Honestly, I've only seen a single article that supports anything but this (in fact supports care team > MD/DO > CRNA), and the article has at least one of the same flaws as the literature supporting APN independent practice (namely, funding source, the ASA, anesthesiologists, vs the AANA, nursing).

How to objectively investigate the efficacy of various providers relative to one another, I think is a tremendous problem without a great resolution.
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Defining and demonstrating clinical efficacy in a comprehensive and adequate way in any area of practice is a thorny question. Look at the psychotherapy wars. If the data were clear and unambiguous, the issue would not continue to fester. While it should be obvious that psychodynamic therapy is vastly superior to CBT across multiple conditions, proving it is problematic 😛. The more I look at NP training, the less impressed I am. However, as doctoral level professionals, I would be loath to have psychologists practicing under the perpetual supervision of physicians as NP's and PA's do.
 
"Is rx training for psychologists designed to match that of a psychiatrist's or is the goal to establish the minimal amount of training necessary in order for psychologist to be able to prescribe safely?"

I'd say the latter!
 
Therapist4Chnge said:
3 semesters of online classes and some weekends......



It includes living expenses for the time, but that it still ridiculous.
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Actually given the amount of money some psych NP are pulling down it is still a potentially good investment.🙁
 
alienist said:
I am curious as to how RX training for psychologists does compare to psychiatry training. I can only speak from my own personal experience as a 3rd year psych resident. I've had ~5 years of clinical experience (started seeing patients my 2nd year of medical school). I would say I have seen approximately 3000-4000 patients by now, granted many were not in the field of psychiatry (whether it be delivering babies, touching penises, or trying to keep patients from dying). Whenever I was on medicine or psychiatry nightfloat, I've had to manage a load of 100-150 patients. We see the full gamut of psych patients from the acutely ill ones the moment they hit the emergency room to forensic patients in long term facilities. Approximately how many different patients do RX psychologists see by the time they complete their training? The high exposure to a diversity of clinical scenarios is just as critical as is the number of clinical hours. Is rx training for psychologists designed to match that of a psychiatrist's or is the goal to establish the minimal amount of training necessary in order for psychologist to be able to prescribe safely?
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Now this is interesting. The issue of work hours has come up previously, with psychiatrists getting a total higher number of patient hours, as well as more diversity and intensity of experience (inpt, outpt, emergency, etc.). Now has anyone compared outcomes (efficacy, safety) controlling for clinical hours? I'm not aware of any. Psychologists on the other hand get more classroom time that is specifically about mental illness.

The DoD pilot project, if I'm understanding it correctly, has significantly more intensive training than the current RxP trainings. Here's the final report (from the DoD) on the project, which I would consider a relatively unbiased source.
http://www.dod.gov/pubs/foi/reading_room/966.pdf
Lots of interesting findings, and I'd say there's data there to support both sides. From the anti-RxP side, all worked under supervising physicians, most thought "short-cut" programs in civilian psychiatry wasn't a good idea, and most said an intensive full-year of inpatient training was indispensable. Trainees had a few to 10 years of clinical experience (post-graduate) prior to enrolling. Their level of medical training was considered on par with a 3rd/4th year medical student (which I don't understand since they're not taught to do physicals), and psychopharm knowledge on par with a 2nd/3rd year resident. Also remember this was an n=10 pilot project.

On the pro-APA (psychological) side, here's their 2003 update on the fate of the original 10:
http://www.apa.org/monitor/feb03/prescribers.aspx
I find it especially interesting that 2/10 decided to go to medical school after it all.

I would also present the idea that psychopharm is never limited to the brain. There are zero medications that only affect the brain, each having systemic effects (SSRI's effects on platelets and bleeding, for example), not to mention med interactions. I'd be curious to see the depth that the current RxP programs train in relevant co-morbidities (how do you identify metabolic syndrome in antipsychotic patients, or do screening EKG's and for whom). A more specific example might be a patient with an AV block who nonetheless needs an antipsychotic. How trained are they in the other cardiac medications (beta blockers, calcium channel blockers, etc) and the potential interaction with each individual antipsychotic for QRS widening, QT prolongation. Then factor in alpha blockade with many of those medications, risk of orthostasis and the fact that both groups of medication affect blood pressure and heart rate as well. It's complex, MOST are undertrained in it as it is (physicians, NP's), so I would argue for raising the bar to setting a new gold standard. RxP is lowering it.
 
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nitemagi said:
...and most said an intensive full-year of inpatient training was indispensable. Trainees had a few to 10 years of clinical experience (post-graduate) prior to enrolling. Their level of medical training was considered on par with a 3rd/4th year medical student (which I don't understand since they're not taught to do physicals), and psychopharm knowledge on par with a 2nd/3rd year resident. Also remember this was an n=10 pilot project.
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I think one of the biggest areas of weakness in RxP training for psychologists is the limit number of required hours of clinical training/mentorship. An intensive full-year is a good place to start. The NP training hours aren't that great either, though I think they would benefit from more required hours too.

As for training to do physicals, it is covered in the RxP training as part of the lab course(s). I don't think it is a sufficient amount of time nor depth to cover it, but others think it is fine in its current form.

nitemagi said:
It's complex, MOST are undertrained in it as it is (physicians, NP's), so I would argue for raising the bar to setting a new gold standard. RxP is lowering it.
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They should have started at the level of NP training, but they were able to get by in multiple states, so it is a much harder argument to make now.
 
On the pro-APA (psychological) side, here's their 2003 update on the fate of the original 10:
http://www.apa.org/monitor/feb03/prescribers.aspx
I find it especially interesting that 2/10 decided to go to medical school after it all.
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Particularly given the very extensive training they underwent - I think few would argue that the DoD level of training isn't sufficient for some level of Rx ability. I wonder if it's largely out of the interest of forming a well-rounded opinion of what's necessary.

Don't find it surprising the APA just had little snippets about what those two were currently up to, however 😛
 
nitemagi said:
Now this is interesting. The issue of work hours has come up previously, with psychiatrists getting a total higher number of patient hours, as well as more diversity and intensity of experience (inpt, outpt, emergency, etc.). Now has anyone compared outcomes (efficacy, safety) controlling for clinical hours? I'm not aware of any. Psychologists on the other hand get more classroom time that is specifically about mental illness.

The DoD pilot project, if I'm understanding it correctly, has significantly more intensive training than the current RxP trainings. Here's the final report (from the DoD) on the project, which I would consider a relatively unbiased source.
http://www.dod.gov/pubs/foi/reading_room/966.pdf
Lots of interesting findings, and I'd say there's data there to support both sides. From the anti-RxP side, all worked under supervising physicians, most thought "short-cut" programs in civilian psychiatry wasn't a good idea, and most said an intensive full-year of inpatient training was indispensable. Trainees had a few to 10 years of clinical experience (post-graduate) prior to enrolling. Their level of medical training was considered on par with a 3rd/4th year medical student (which I don't understand since they're not taught to do physicals), and psychopharm knowledge on par with a 2nd/3rd year resident. Also remember this was an n=10 pilot project.

On the pro-APA (psychological) side, here's their 2003 update on the fate of the original 10:
http://www.apa.org/monitor/feb03/prescribers.aspx
I find it especially interesting that 2/10 decided to go to medical school after it all.

I would also present the idea that psychopharm is never limited to the brain. There are zero medications that only affect the brain, each having systemic effects (SSRI's effects on platelets and bleeding, for example), not to mention med interactions. I'd be curious to see the depth that the current RxP programs train in relevant co-morbidities (how do you identify metabolic syndrome in antipsychotic patients, or do screening EKG's and for whom). A more specific example might be a patient with an AV block who nonetheless needs an antipsychotic. How trained are they in the other cardiac medications (beta blockers, calcium channel blockers, etc) and the potential interaction with each individual antipsychotic for QRS widening, QT prolongation. Then factor in alpha blockade with many of those medications, risk of orthostasis and the fact that both groups of medication affect blood pressure and heart rate as well. It's complex, MOST are undertrained in it as it is (physicians, NP's), so I would argue for raising the bar to setting a new gold standard. RxP is lowering it.
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I especially agree that the key point is this... what exactly does the two years of supervision by a physician entail???

Someone else asked above, who assumes the risk, well, during those two years of supervision the physician assumes all risk (assuming this will make it be done correctly).

One would hope that after the two years of basic training that the two years of supervised "practicum" would consist of extensive psychiatric time, i.e., rounds, etc (such as what was listed before)... If this is NOT present, then I would have no choice but to agree that it is of utmost necessity... I don't think anyone could disagree that experience is indispensable... I think what the debate may come down to... is how much experience is enough???
 
Sure this was posted before, figured I would repost it

  • Psychologists who meet certain requirements specified in the law are eligible to be granted "conditional prescribing certificates."

    To obtain a conditional prescribing certificate, a psychologist must, among other things, within five years of applying complete at least 450 hours of didactic educational instruction in at least the following core areas:
    • Neuroscience;
    • Pharmacology;
    • Psychopharmacology;
    • Pathophysiology;
    • Appropriate and relevant physical and laboratory assessment; and
    • Clinical pharmacotherapeutics.
  • Additionally, an applicant psychologist must, within five years of applying, be certified by a supervising psychiatrist or physician as having completed a supervised clinical practicum involving, among other things, at least four hundred hours treating no fewer than one hundred patients with mental disorders.
  • Finally, the applicant must pass a national certification examination approved by the board of psychological examiners that test’s his/her knowledge of pharmacology in the diagnosis, care and treatment of mental disorders.
  • Following an additional period of clinical supervision, psychologists with conditional certificates are then eligible to be granted "general prescription certificates." Authority for reviewing applications and determining whether applicants meet criteria for conditional or general certificates is vested with the New Mexico state board of psychologist examiners.

    A psychologist with a conditional prescription certificate may apply for a general prescription certificate after successfully completing two years of experience prescribing psychotropic medications under the supervision of a licensed physician. The state board of psychologist examiners is granted authority to develop additional requirements for general certification.
Additional requirements are set forth in the New Mexico law for psychologists to maintain their general prescription certificates, including:

  • No fewer than 20 hours per year of continuing education; and


  • An ongoing collaborative relationship with the health care practitioner overseeing the patient’s general medical care.

Liability of supervising physicians

The New Mexico law specifies that physicians supervising psychologists with conditional prescribing certifications are individually responsible for the acts and omissions of the psychologist while under their supervision. It will be interesting to see if concerns about liability deter physicians from willingness to function as supervisors.
Comparison with DoD curriculum requirements

Even though the DoD curriculum was scaled back after year one, it still required significantly more academic training and clinical training and supervision than the New Mexico law requires. For example, the DoD curriculum required 660 hours of academic training versus 450 for the New Mexico curriculum. Additionally, the DoD curriculum required approximately 1,900 hours of clinical training versus a minimum of 400 hours to be granted conditional certification in New Mexico.
 
hmmm Louisiana does not require the probationary 2-year supervised period... but requires the constant collaborative working with a primary physician... this I am much more hesitant about...
 
Btw, I think discussing NP training is an entirely unrelated issue mostly because they are not mutually exclusive to neuro- or psychiatric illness... its like comparing apples and oranges... yes both are fruit but still...

Not to mention, my understanding is that NPs still are under direct supervision of at least one staff physician... i.e., a physician is ultimately responsible at all times for their practice? Same with a PA...
 
Thanks for the info about liability AJ, had been wondering about that. I can't see physicians being keen on taking on that responsibility without some kind of incentive.

As far as NP's, scope varies by state. Several states allow NP's to function completely independent of any physician supervision.
 
Good post AJ.

Of equal interest is use of the term "Physician" in multiple places, rather than "Psychiatrist." Such as with the 2 years experience. This leaves a loophole for primary care doctors to supervise, for example, which may or may not have been the intention. Family medicine physicians have no particular training in psychiatric medications, aside from a vague requirement for training in "behavioral medicine and mental health." So leaves the door open for the blind leading the blind, frankly. Of course I know many PCP's who're mindful and I respect greatly, but then I hear stories about family practitioners telling my colleagues "You mean there's another SSRI besides Lexapro?" I'd still rather have a physician prescribing, regardless, since they have an understanding and training in medical co-morbidities.
 
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nitemagi said:
Good post AJ.

Of equal interest is use of the term "Physician" in multiple places, rather than "Psychiatrist." Such as with the 2 years experience. This leaves a loophole for primary care doctors to supervise, for example, which may or may not have been the intention. Family medicine physicians have no particular training in psychiatric medications, aside from a vague requirement for training in "behavioral medicine and mental health." So leaves the door open for the blind leading the blind, frankly. Of course I know many PCP's who're mindful and I respect greatly, but then I hear stories about family practitioners telling my colleagues "You mean there's another SSRI besides Lexapro?" I'd still rather have a physician prescribing, regardless, since they have an understanding and training in medical co-morbidities.
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I am sure it was done intentionally, as there has been good support from FPs, PCPs, etc.
 
And the idea isn't bad in theory - more extensive psychopharm knowledge paired with more systemic knowledge. Don't think it would pan out in practice where that nice complement is really actualized, but could be wrong.
 
Therapist4Chnge said:
I am sure it was done intentionally, as there has been good support from FPs, PCPs, etc.
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I'm fairly certain you're correct, as--to the best of my knowledge--in Louisiana the supervisor can be any type of physician. Or, at the least, doesn't specifically need to be a psychiatrist.
 
In the Dutch requirements (highly similar to NM) it says:

"Students will locate a physician who is a psychiatrist or is otherwise highly qualified in the administration of psychotropic medications"
 
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nitemagi said:
Good post AJ.

Of equal interest is use of the term "Physician" in multiple places, rather than "Psychiatrist." Such as with the 2 years experience. This leaves a loophole for primary care doctors to supervise, for example, which may or may not have been the intention. Family medicine physicians have no particular training in psychiatric medications, aside from a vague requirement for training in "behavioral medicine and mental health." So leaves the door open for the blind leading the blind, frankly. Of course I know many PCP's who're mindful and I respect greatly, but then I hear stories about family practitioners telling my colleagues "You mean there's another SSRI besides Lexapro?" I'd still rather have a physician prescribing, regardless, since they have an understanding and training in medical co-morbidities.
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Let me get this straight. You'd rather have a PCP prescribe, with his knowledge of co-morbidities, even he if prescribes the incorrect psychotropic and screws you up?
 
zenman said:
Let me get this straight. You'd rather have a PCP prescribe, with his knowledge of co-morbidities, even he if prescribes the incorrect psychotropic and screws you up?
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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.
 
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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interesting timing.... just had a consult request from our medical wing today... 16 y/o who was recently discharged from an inpatient psych unit with 3mg BID of risperodone. He went to his pcp 5 days ago complaining of restlessness, poor ability to stay still, poor ability to focus, so the pcp prescribed him methylphenadate (immediate release) 10mg BID and dx him with ADHD. Dad said that the kid went off the wall after 3 days of the ritalin, threatning him, complaining that he was being followed, that dad and mom were setting him up, trashed his room. Parents didn't know any better, continued to give the kid the ritalin.

Obviously the pcp didn't take into account that this kid had an underlying bipolar d/o with psychotic features and that his presenting sxs may have been better accounted by akathesia. Kid had to be admitted into the safety room at the hospital for safety reason. Not blamig the pcp here, I know the pcp, very good doc, but simply does not have the time and knowledge to do thorough assessment. I highly doubt that this is a unique situation.
 
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doctorpsych said:
interesting timing.... just had a consult request from our medical wing today... 16 y/o who was recently discharged from an inpatient psych unit with 3mg BID of risperodone. He went to his pcp 5 days ago complaining of restlessness, poor ability to stay still, poor ability to focus, so the pcp prescribed him methylphenadate (immediate release) 10mg BID and dx him with ADHD. Dad said that the kid went off the wall after 3 days of the ritalin, threatning him, complaining that he was being followed, that dad and mom were setting him up, trashed his room. Parents didn't know any better, continued to give the kid the ritalin.

Obviously the pcp didn't take into account that this kid had an underlying bipolar d/o with psychotic features and that his presenting sxs may have been better accounted by akathesia. Kid had to be admitted into the safety room at the hospital for safety reason. Not blamig the pcp here, I know the pcp, very good doc, but simply does not have the time and knowledge to do thorough assessment. I highly doubt that this is a unique situation.
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+1. I see this kind of stuff all the time.
 
doctorpsych said:
Obviously the pcp didn't take into account that this kid had an underlying bipolar d/o with psychotic features and that his presenting sxs may have been better accounted by akathesia. Kid had to be admitted into the safety room at the hospital for safety reason. Not blamig the pcp here, I know the pcp, very good doc, but simply does not have the time and knowledge to do thorough assessment. I highly doubt that this is a unique situation.
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Aren't most 16 yr olds bipolar with psychotic features? Your PCP friend must not have kids!

I think this is not a unique situation. Tell every pcp about "Psychiatry Essentials for Primary Care" by Schneider and Levenson. Nice, easy reading book.
 
doctorpsych said:
interesting timing.... just had a consult request from our medical wing today... 16 y/o who was recently discharged from an inpatient psych unit with 3mg BID of risperodone. He went to his pcp 5 days ago complaining of restlessness, poor ability to stay still, poor ability to focus, so the pcp prescribed him methylphenadate (immediate release) 10mg BID and dx him with ADHD. Dad said that the kid went off the wall after 3 days of the ritalin, threatning him, complaining that he was being followed, that dad and mom were setting him up, trashed his room. Parents didn't know any better, continued to give the kid the ritalin.

Obviously the pcp didn't take into account that this kid had an underlying bipolar d/o with psychotic features and that his presenting sxs may have been better accounted by akathesia. Kid had to be admitted into the safety room at the hospital for safety reason. Not blamig the pcp here, I know the pcp, very good doc, but simply does not have the time and knowledge to do thorough assessment. I highly doubt that this is a unique situation.
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I once did an ER consult on a guy who came in complaining of severe agitation and an unstoppable urge to walk and pace. He was on a huge amount of Geodon. I seem to recall 160 mg qd. I suggested this was akathesia and the ER doc, who is a real good doc, was not quite sure what I was talking about.
 
Neuropsych2be said:
I once did an ER consult on a guy who came in complaining of severe agitation and an unstoppable urge to walk and pace. He was on a huge amount of Geodon. I seem to recall 160 mg qd. I suggested this was akathesia and the ER doc, who is a real good doc, was not quite sure what I was talking about.
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160mg isn't necessarily that high actually. His akathisia could actually be due to too low of a dose if he wasn't taking it with food.

Despite this, it's just as important to rule out other issues such as cardiac conduction abnormalities, interactions, or other issues as well.
 
nitemagi said:
160mg isn't necessarily that high actually. His akathisia could actually be due to too low of a dose if he wasn't taking it with food.

Despite this, it's just as important to rule out other issues such as cardiac conduction abnormalities, interactions, or other issues as well.
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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.
 
nitemagi said:
160mg isn't necessarily that high actually. His akathisia could actually be due to too low of a dose if he wasn't taking it with food.

Despite this, it's just as important to rule out other issues such as cardiac conduction abnormalities, interactions, or other issues as well.
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yep... but the interesting thing is that pcp don't usually do... they don't know that ziprasidone has the higher tendency for qtc pronlogation, or that they should take it with food... or how to dose it appropriately...I see them prescribing tramadol with ssri's all the time without any adjustments (this may not be necessary but at least you should know the potential AE), education about what to look for, etc... so instead, they look to me for help with that... do you still think that the common pcps are better prepared than prescribing psychologists? those guys are so busy that they can't hardly wait to finish their pt's in less than 10min because they have 25+ more waiting for them...
 
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