A psychiatrists perspective:
The case for prescribing psychologists
By Daniel Carlat, M.D.
Psychologists now have prescriptive authority in New Mexico, Louisiana, Guam and all branches of the U.S. Military. Although the RxP movement recently experienced a setback when Oregons governor vetoed a bill that would have authorized prescriptive authority, it is increasingly likely that many more states will pass such bills over the next 10 to 20 years.
The overwhelming majority of psychiatrists are adamantly opposed to RxP, officially citing concerns about patient safety. However, as a psychiatrist who was once involved in the politics of the American Psychiatric Association, I know that the major concern has to do primarily with economics and prestige. Psychiatrists are afraid of losing business to prescribing psychologists, with the consequent diminishment of their power within the mental health community.
I think these concerns are misguided. Regarding patient safety, it is clear that prescribing psychologists have already established a track record of safely and competently prescribing psychotropics. This track record began in 1991, when the Department of Defense developed an experimental program to teach psychologists how to prescribe medications. In 1998, this program was carefully evaluated by the American College of Neuropharmacology, an organization of psychiatrists and psychiatric researchers. This panel concluded that all 10 graduates of the program performed with excellence wherever they were placed, and there were no reports of medication errors or bad patient outcomes.
The program was discontinued because it was not considered to be a cost-effective use of military resources, but over the last few years, the military has hired many prescribing psychologists who have been trained in one of several civilian-based psychoparmacology masters programs. Prescribing psychologists now practice in all branches of the military, and one prescribing psychologist (Major Alan Hopewell) was recently awarded the Bronze Star Medal for meritorious medical service during Operation Iraqi Freedom in 2007-2008.
In Louisiana and New Mexico, it is estimated that several thousand prescriptions have been written by prescribing psychologists. There have been no reported complaints about these practitioners from patients or from collaborating doctors, nor have any malpractice suits been registered involving prescribing psychologists. Thus, it is becoming increasingly clear that the argument about patient safety is a red herring and masks the actual resistance, which regards competition for professional turf and the money that flows from that.
Why would I, a psychiatrist, actively argue in favor of psychologists prescribing? I have two main reasons: First, there is a critical national shortage of psychiatric prescribers, and second, psychiatric practice has become dangerously fixated on psychopharmacological solutions.
Regarding the shortage of psychiatrists, a recent series of articles in the October 2009 issue of Psychiatric Services reported that 96 percent of all U.S. counties have some unmet need for prescribers. In three quarters of counties, the shortage was described as severe, meaning that over half of the medication needs of psychiatric patients are unmet.
It is inconceivable that existing psychiatrists will be able to fill this gap, both because many are reaching retirement age and because there is no indication that more psychiatric residency slots will be created soon. Psychiatric nurse practitioners and physician assistants will help to absorb some of the need, but in my opinion prescribing psychologists will have to become a significant part of the professional landscape if we want to adequately serve the needs of these patients.
Regarding problems with psychiatric practice style, data have shown that psychiatrists are becoming increasingly fixated on brief medication visits and are doing less psychotherapy. In a 2008 article in the Archives of General Psychiatry, researchers found that the percentage of visits to psychiatrists that include psychotherapy dropped from 44 percent in 1996-1997 to 29 percent in 2004-2005. If, as seems likely, this rate of therapy attrition has continued, (about 2 per cent per year), it is likely that fewer than 20 percent of psychiatrist visits now include psychotherapy.
Prescribing psychologists, on the other hand, have continued to emphasize therapy as the bedrock of mental health care, with medications used as adjunctive care when needed. It must be acknowledged that the evidence for this statement is currently anecdotal (based largely on articles written by prescribing psychologists describing their cases, many of which are published in the Division 55 newsletter).
The fact that psychologists begin their training with five to six years focusing on psychosocial approaches implies that they will be able to maintain a healthy balance between psychotherapy and medication approaches. Psychiatrists, on the other hand, begin their training with five years of being steeped in the biomedical model (four years of medical school and one year of medical internship). Even the three subsequent years of psychiatric residency are focused on biomedical approaches to mental illness, though therapy techniques are also intensively taught.
In the future, I predict that prescribing psychologists will become the primary care practitioners of the mental health care system. Patients with psychiatric needs will receive their initial evaluation and treatment from prescribing psychologists, who will combine therapy and medication as needed. Patients with complicated medical or neurological issues will likely be referred to psychiatrists for treatment.
Psychiatry will evolve into a more frankly neuropsychiatric profession, and psychiatrists will likely do more physical exams and become more proficient in ordering and interpreting brain scans and genomic testing, both of which are still in their infancy but are expected to grow in clinical importance over the next decades.
The end result will be a more rational mental health care system in which all patients can routinely receive integrative treatment, rather than the fragmented approach which characterizes most psychiatric treatment today.
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Daniel J. Carlat, M.D., is associate clinical professor of psychiatry at Tufts University School of Medicine, editor-in-chief of The Carlat Psychiatry Report, a monthly newsletter on psychopharmacology, and the author of Unhinged: The Trouble with Psychiatry (Simon and Schuster). He may be contacted at
[email protected].
