I am approaching this debate from the perspective of a clinical psychology doctoral student about to complete his Ph.D. I should state upfront, I have the upmost respect for well trained and highly knowledgeable psychiatrists, social workers, and psychologists. The key words there are well trained and highly knowledgeable. I believe appropriate knowledge and training in diagnosis, psychotherapy, and psychopharmacology is the KEY issue in this debate.
Diagnosis: I agree completely with Dr. Carlat that the diagnostic process in mental health is largely psychological. The training experiences of psychiatrists and psychologists allow them to render the exact same mental health diagnoses. In almost all cases of mental disorder diagnosis, medical training (i.e., 4 years of medical school and 1 year of medical internship) is absolutely not required. A true mental disorder diagnosis can be made ONLY if a medical condition has been ruled out. This is the reason all patients should have full physical evaluations to rule out true medical conditions before they are referred over to a mental health specialist for treatment. The important point here is all mental health patients do not have medical illnesses that are causing their psychological symptoms. If they did, they would not be mental health patients, but rather medical patients who should be treated by neurologists, endocrinologists, etc. Here is an example from my clinical experience: a male psychiatric inpatient was referred to me for psychotherapy for depression. Over the course of psychotherapy it became clear to me that his depression was not like other depressions I had seen before (i.e., the patient was also reporting having neurological symptoms). The man was referred to a neurologist and was ultimately diagnosed as having Parkinsons disease and a form of dementia (he did not have depression as a psychological disorder and psychotherapy was terminated). I knew to refer this patient to a neurologist not because of medical training but because of my psychological training. That is, by virtue of my training in psychopathology I knew what a true psychological disorder is like and it was clear in this case that this was not a true psychological disorder.
Another issue relating to diagnosis is that in typical clinical practice diagnoses are not made using the standardized DSM diagnostic criteria. Despite the fact that DSM diagnoses are not perfectly valid and reliable constructs, it is a sad fact that many patients are misdiagnosed when structured interviews are not used (see the work of Zimmerman on bipolar disorder misdiagnosis for a perfect example of this). The fact that almost all psychiatrists and psychologists do not used structured diagnostic interviews is extremely problematic.
Psychotherapy: My training in psychotherapy thus far has included the following: approximately 1000 direct hours of psychotherapy; 200+ hours of reviewing full psychotherapy session recordings; 600 hours of individual/group supervision on psychotherapy cases over 5 years (one year each of CBT, psychodynamic therapy, emotion-focused therapy, and experiential therapy); and 200+ hours of didactics in psychotherapy. I have seen mildly depressed outpatients to severely suicidal borderline inpatients for psychotherapy. While I cannot speak to the actual training hours (didactics, supervision, reviewing therapy session videos) psychiatrists and social workers receive in psychotherapy, I would venture to guess that the training social workers and psychiatrists receive in psychotherapy does not approach the 2000+ hours of didactics, supervision, and practice in psychotherapy that clinical students in doctoral programs such as mine receive. I am not suggesting that social workers or psychiatrists are unable to practice effective psychotherapy; however, I am suggesting the training that the best trained psychologists receive in psychotherapy is far more extensive than the training of the average social worker or psychiatrist. Generally speaking, clinical psychologists (not necessarily all of them) are the best trained professionals in the area of psychotherapy. If social workers and psychiatrists could receive this level of training in psychotherapy that would be incredible for the field of mental health! Generally speaking (based on the scientific literature), psychotherapy should be the primary treatment for most anxiety disorders, most severity levels of depression, and all personality disorders. For psychotic disorders, accurately diagnosed bipolar I disorder, and severe and melancholic depression pharmacological interventions are clearly the empirically-supported treatments.
Psychopharmacology: It is clear that psychiatrists are the only mental health professionals who receive extensive training and supervision in psychopharmacology. Is appropriate training required to understand how to monitor the effects of medications on the various bodily organs and how medications interact with one another, obviously yes! This training is only provided (as of now) in medical school and psychiatric residency training. There is absolutely NONE of this training in even the best clinical psychology doctoral programs. I cannot say, however, if 3 years of didactics and supervision given to a clinical psychology student like myself would allow for the accurate and safe prescription of psychotropics. It might be enough, but it might not this is an empirical question. The bigger problem I have with psychologists prescribing is not the training issue (I do believe a doctoral student is intelligent enough to be appropriately trained to prescribe psychotropics if this type of program was available to him or her), but rather a scientific one. The vast majority of mental health conditions (e.g., anxiety disorders, mild to moderate major depressive disorder, personality disorders) are treated effectively with psychotherapy alone. Generally speaking, medications offer little (if anything) more than psychotherapy in the short-term and less than psychotherapy in the long-term for these conditions. These patients do NOT necessarily need medication. If I have to see another borderline patient who is prescribed five different medications that have never been shown in a single clinical trial to have efficacy in treating BPD
just ridiculous! The same is true for patients with PTSD, who are rarely given PE therapy but mainly given various psychotropics. At the same time, I have worked with patients with various psychotic disorders who refused to take medication, and psychotherapy did not alleviate their hallucinations or delusions. Meciation likely would have. Psychologists, who are generally the best trained in psychotherapy, should be voicing their outrage that patients are being prescribed medications that have never been empirically supported to treat these given conditions, and they should be promoting the use of empirically-supported psychotherapies for treating these conditions. Psychiatrists, the only mental health specialists who are trained to prescribe medications, should treat patients with conditions that most resemble neurological disorders and that benefit from medications (i.e., psychotic disorders, bipolar I disorder, severe and melancholic depression, drug and alcohol intoxication and withdrawal), and patients with neurological conditions that affect cognitive functioning (e.g., Alzheimers disease, traumatic brain injuries). To me, this role makes the most use of the medical training psychiatrists receive. The medical model has little to no use in treating, for example, borderline patients who repeatedly attempt suicide after interpersonal conflicts. Psychiatry can definitely be absorbed into a specialty area of neuropsychiatry. Mental health patients who are being treated with psychotherapy might minimally benefit from medications, which can be managed appropriately by general practitioners/PCPs in collaboration with psychotherapist psychologists and social workers who know infinitely more about psychopathology than GPs/PCPs.
Ultimately, this debate can be resolved by science and not by politics. Diagnoses are most appropriately rendered using structured diagnostic interviews (i.e., a psychological process, not a medical process), which psychiatrists and psychologists have equal training to use (social workers could use these interviews as well if they have appropriate training in psychopathology and psychological diagnosis). Mental disorders should be treated using empirically supported treatments, and whoever has the appropriate training to provide these treatments should provide them. Some mental conditions are best treated by physicians and most others best treated by psychotherapists.
The right parallel statement for this would be physicians first, cardiologists second, etc. anyway.
