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Mental health is a spectrum and often time you find many of the severe MIs (schizophrenia) to have a much stronger biological correlation than, say, mild depression. Though there are proposed mechanisms (multiple, sometimes) for different ailments, a lot (and certainly many specifics) are still unknown. The psychologist, in general, does not approach it from a medical perspective. Though any good psychologist would be aware depression secondary to thyroid function, typically they aren't looking for this, whereas a psychiatrist (especially inpatient, but I couldn't tell you a whole lot about outpatient) will typically have a thyroid profile done.
 
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billypilgrim37

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Also, I've heard similar statements before, all referring to psychiatry - there are no common parallel statements for other fields of medicine, are there?
Orthopedists are physicians first, carpenters second.

Cardiologists already got hit with the plumber joke earlier in the thread.

OB/GYNs are physicians first, borderlines second...

et cetera
 

loveoforganic

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Ok, I'll revise my statement and say that psychiatry is the only one I've heard it about in a serious context! :p The right parallel statement for this would be physicians first, cardiologists second, etc. anyway.
 

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It'd be fair to point out that for many of the most medical objections we have, DC has admitted that the "neuropsychiatrist" would be the most appropriate care giver. He's not saying that no psychiatrists should go to medical school, just the vast majority of outpatient ones shouldn't.

I think we all still vehemently disagree with this, but it is a different (and less unreasonable) point.
As interesting as the idea of the inpatient-based "neuropsychiatrist" is--I can imagine very few people volunteering for such a specialty. I don't know anyone who either a) loves both neuro and psych enough to do it or b) is good at them both in quite the right way. Aren't there a total of about 6 combined neuro/psych residency programs in the US?

Inpatient psych requires you to KNOW psychiatry, after all. And do some psychotherapy, even. Whereas neuro requires an enthusiasm for LPs and reading MRIs in the middle of the night.

Basically this would amount to being an expert at handling every type of inpatient from the suicidal borderline to the dangerously psychotic person to the myesthenic crisis patient needing intubation to the acute stroke case to the child needing an LP. Plus (unless an equally vast overhaul of neurology occurred as well) apparently all of outpatient neuro would be included in this job description... Unless I am misunderstanding...

What I would guess would happen is these "neuropsychiatrists" would branch off into subspecialties known as "neuro" and "psych." These neuro-"psychiatrists" would be just like today's psychiatrists except they'd be exiled from the outpatient world.
 

billypilgrim37

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These neuro-"psychiatrists" would be just like today's psychiatrists except they'd be exiled from the outpatient world.
That's not quite how I'm reading Carlat's suggestion, but I've read other things he's written about the idea as well, none of which I could really cite. (he also has a book coming out in May, which may be why he's suddenly doing things to drum up a little publicity and controversy).

I don't think he's saying that neurology and psych should be combined, but that perhaps "neuropsych" training would be for severe cases, complicated medical cases, consult psych, geri psych, and would relatively focus on bipolar disorder, schizophrenia, etc. They would still have to be fair interviewers and be skilled at time-limited therapeutic interventions. They would still have outpt practices, but they'd essentially be tertiary care providers.

Basically, the argument comes down to whether you think that MDs are still appropriate to be "first-line" providers of mental health care for depression and anxiety disorders after PCPs have failed with pharmacotherapy and the 30 minute community social worker therapy session didn't help.

And the vast majority of us on the board think, yes, we should. But we're a pretty biased sample, as we are all MDs who have based our decision to pursue this field on the conviction that our medical training was necessary for us to do the work we want to do. I don't disagree. I absolutely agree.

I want to be a child psychiatrist. I don't think you should be able to give a five year old a drug that will give them a heart attack at age 40 unless you've been the one giving CPR during a code of some 40 year old having a heart attack (or, can at least imagine that particular scenario with accuracy). Many non-MDs would say that rationale is stupid. I say it's absolutely essential. But, I went to medical school, and they didn't, and that means there are some things MDs and non-MDs are going to tend to disagree about.
 
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I want to be a child psychiatrist. I don't think you should be able to give a five year old a drug that will give them a heart attack at age 40 unless you've been the one giving CPR during a code of some 40 year old having a heart attack (or, can at least imagine that particular scenario with accuracy). Many non-MDs would say that rationale is stupid. I say it's absolutely essential. But, I went to medical school, and they didn't, and that means there are some things MDs and non-MDs are going to tend to disagree about.
I wonder if we MDs make our work seem too easy to the social workers and psychologists. As a result, many think they can out of ignorance.

Combining neurology and psychiatry is not a new idea. But I wonder how long it would take to fully evaluate a 'neuropsychiatric' patient. 2-3 hours perhaps?
 

Therapist4Chnge

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I wonder if we MDs make our work seem too easy to the social workers and psychologists. As a result, many think they can out of ignorance.
On the flipside, I wonder if MDs/DOs assume they know how to do therapy, interpret assessments*, etc because they attended a seminar and spent a few months seeing a few pts? And then there is MI. I've watched med students, residents, and attending absolutely butcher "motivational interviewing" at a number of facilities.

*Admittedly neurology is more at fault for wanting to interpret neuropsych reports, but the premise is still applicable here.
 

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On the flipside, I wonder if MDs/DOs assume they know how to do therapy, interpret assessments*, etc because they attended a seminar and spent a few months seeing a few pts?
Have to agree, but the potential harm of 'poorly trained therapist' vs. 'poorly trained prescriber' may not be equal.
 

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FYI--this thread rated a mention in the Carlat blog...

(Cute title on the post, BTW.)
 

billypilgrim37

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And then there is MI. I've watched med students, residents, and attending absolutely butcher "motivational interviewing" at a number of facilities.
I've had two pretty intensive MI training experiences, one for about 50 hours with a psychologist who wrote a few of the chapters in the Miller and Rollnick book, and another 100+ directly supervised by an attending who trained w/ Miller and Rollnick and who has participated in some of the major MI trials. And even then, they would probably attack each other if they what each other was doing and calling it MI. And I'd say each was a very skilled therapist with great pt alliance.

Of course, the psychologist was doing it to make people quit smoking and eat their fruits and vegetables, and the psychiatrist was trying to make them quit doing heroin and beating their spouses, but still.
 
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As interesting as the idea of the inpatient-based "neuropsychiatrist" is--I can imagine very few people volunteering for such a specialty. I don't know anyone who either a) loves both neuro and psych enough to do it or b) is good at them both in quite the right way. Aren't there a total of about 6 combined neuro/psych residency programs in the US?
It seems that there might be some agreement to the following scenario.

Psychologists who receive streamlined medical and psychopharm training can safely prescribe certain drugs for certain types of uncomplicated patients. Legislation can easily prevent psychologists from prescribing for patients in inpatient units, from prescribing in consult-liaison services, even to patients who are also being treated with certain other medications that may cause drug interactions. These are all details that can be worked out.

Psychiatrists will still do everything they are doing now. Go to medical school, internship, residency etc.... They will see the toughest patients, ie., the ones that really require four full years of medical school.

This system will at least begin to address the critical shortage of prescribers in the U.S. (which exists in both urban and rural areas, by the way). The most recent estimates by University of North Carolina Scheps Center, published in a series of article in Psychiatric Services, documented "severe" shortages of prescribers in 77% of U.S. counties, and estimated that only 50% of the needs of patients are currently being met.

The problem with simply saying no to non-MD prescribers is that we psychiatrists, the leaders of the mental health world, are offering no realistic solutions.
 
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I am wondering are those medical psychologists in LA really practicing in the underserved or rural areas as they claimed when they first started out, or it just something used to push the agenda?
 

loveoforganic

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Experimental setup -

Matched samples of medical psychologists and psychiatrists by location and type (outpatient/inpatient) of practice.

Random selection of patients/associated notes/treatment for each sample.

Blind presentation of selected cases to two psychiatrists, who will each rate agreement with treatment on a scale of 1-10.

Is there anything you would change about that setup/what validity would you give it/what sample sizes for number of psychologists/psychiatrists and number of cases for each would be acceptable?

Would matched pairing of cases rather than prescribers make more sense? If so, what would the cases be matched on?

Furthermore, in data analysis, what would you control for? Years of practice? Years of practice with prescribing rights?

Edit: A second factor that could be looked at would be case complexity, which could be rated by a psychiatrist as well. The issue would be whether to match cases based on complexity rating before looking at chosen treatment, to control for case complexity in data analysis, or to consider case complexity as a separate variable and see whether medical psychologists even tend to medicate in those cases rated with high complexity.

Appreciate any thoughts on the matter!
 
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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 Parkinson’s 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., Alzheimer’s 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.
 

Doc Samson

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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.
If you crack open the DSM-IV, you might notice a whole bunch of diagnoses that include the words "...due to a general medical condition" or "substance induced..." Physiologic disturbances can result in diagnosable mental illnesses (the most obvious example being delirium). The ability to tell the difference and then manage the patient appropriately is the reason we need psychiatrists who go to medical school and receive residency training that includes medicine and neurology.
 
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something does not compute. Some psychologists pointed out that psychiatrists do not have enough training to do therapy, but some claimed to be competent to prescribed med with limited psychopharm and limited physio, anatomy, drugs interactions..etc..even primary care docs are not comfortable.
 
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Doc Samson: You are correct. However, these are not true "mental disorders" per se. The general medical condition is the true pathology, it just happened to also cause mental symptoms. Hypothetically speaking, treating the underlying physical disorder might relieve all of the symptoms (physical and mental). Physicians should treat the medical condition.

The problem with mental disorder diagnoses is they are made based on symptoms. Is major depressive disorder (the mental disorder) phenomenologically the same as major depressive disorder that results from a stroke? At a symptom level (at least 5 of 9 symptoms) they might be the "same" thing, but the internal experience (e.g., worthlessness, self-criticism, self-hatred) might be completely different. Just wondering...

Again, GMC patients are not the typical patients seen in mental health facilities. I believe you are right when you say psychiatrists by virtue of their medical training are able to treat these types of patients though.
 
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I wonder if one used Tylenol to treat fever, is that treating a symptoms? using diuretics to treat edema, is that treating the symptoms? is chest pain a symptoms? I wonder if symptoms are manifestation of something?
 
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I wonder if the neurologists treating cogwheel rigidity, the tremors, is that treating symptoms or is there such thing as Parkinson?
 

billypilgrim37

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Is major depressive disorder (the mental disorder) phenomenologically the same as major depressive disorder that results from a stroke? At a symptom level (at least 5 of 9 symptoms) they might be the "same" thing, but the internal experience (e.g., worthlessness, self-criticism, self-hatred) might be completely different. Just wondering...
I thought we were past this notion of psychological depression versus biological depression, or the the idea that our disorders were homogenous even within themselves. I mean, is the 24 year old graduate student's major depressive disorder the same as the major depressive disorder of the 43 year old mother of three? I don't know why it would be. Is the 9:00 heroin addict's major depressive disorder even the same as the 9:30 heroin addict's major depressive disorder? I doubt it.
 
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Major depressive disorder as a "mental disorder" may have biological, psychological, and social determinants of course, so technically dividing the disorder into purely biological and purely psychological is not accurate. However, the science behind treatment mild to moderate major depressive disorder (which may or may not have biological factors involved) suggests these forms of depression are highly treatable with psychotherapy, and medication often adds very little to the treatment. Severe major depressive disorder and melacholic depression show a better response to medication and to ECT. Does this make these depressions more biologically determined? Possibly. The point is, given that medical treatment best addresses these types of depression it makes the most sense that physicians focus on treating these types of patients (given that psychotherapy probably does not work).

Disorders are not homogenous like you said.
 

Doc Samson

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Doc Samson: You are correct. However, these are not true "mental disorders" per se. The general medical condition is the true pathology, it just happened to also cause mental symptoms. Hypothetically speaking, treating the underlying physical disorder might relieve all of the symptoms (physical and mental). Physicians should treat the medical condition.

The problem with mental disorder diagnoses is they are made based on symptoms. Is major depressive disorder (the mental disorder) phenomenologically the same as major depressive disorder that results from a stroke? At a symptom level (at least 5 of 9 symptoms) they might be the "same" thing, but the internal experience (e.g., worthlessness, self-criticism, self-hatred) might be completely different. Just wondering...

Again, GMC patients are not the typical patients seen in mental health facilities. I believe you are right when you say psychiatrists by virtue of their medical training are able to treat these types of patients though.
My point here is that not only are we able to treat them, we are (by far and away) the best equipped to diagnose them. While a psychologist may sometimes be able to parse out GMC disorders from primary mental illness, they cannot do so as reliably as a physician. "Ah," you say "but the nonpsychiatric physicians could do that." Not so much - various studies have shown that nonpsychiatric physicians misdiagnose psychiatric illness due to a GMC (specifically delirium) ~60% of the time. Understanding the intersection of soma and psyche requires training in both, and the only folks with that training are psychiatrists.
 

Therapist4Chnge

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My point here is that not only are we able to treat them, we are (by far and away) the best equipped to diagnose them. While a psychologist may sometimes be able to parse out GMC disorders from primary mental illness, they cannot do so as reliably as a physician.
Ruling out medical conditions....yes, but differentials between a class of Dx's seems a lot shakier. Obviously there are good/bad everything, but too often I come across psychiatry notes like, "Anxiety, 300.0 Unspecified", "Depression, 311.0 Unspecified", etc. and then the prescribed medication. It may be fine for billing, but the details matter, at least to the people doing talk therapy, assessments, etc. There is also the issue of Axis-I Dx for billing because an Axis-II won't get reimbursed. The medication may treat some of the symptoms/behaviors so prescribers don't take the time to differentiate further, but it still matters. It is a personal pet peeve because I primarily do assessment and consultation, so I'm brought in to do differentials, and the chart is usually an amalgamation of what seemed to be the popular Dx. at the time, and rarely any significant data to support the Dx.
 
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I do agree with you. If you return to my original posting, I am in favour of the existence of psychiatrists (or neuropsychiatrists). The exact example you give of misdiagnosing delirium is exactly the kind of case I think psychiatrists are best trained to diagnose and treat. I do not think nonpsychiatric physicians can necessarily do this better.
 
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masterofmonkeys

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I've mentioned the various ways strong background in general medicine has helped me out of jams several times over the course of my intern year already. It's also helped with DDx and Tx, such as a patient with AVNRT and PTSD who'd been repeatedly told that his episodic tachycardia was 2/2 his psychiatric disease, who I was able to Dx because I could read an EKG. Or the patient with refractory HTN and a lot of somatic sx of PTSD, who was successfully treated for both with a single medication. Or, well, you get the idea.

I'm a firm believer in physician first, psychiatrist second. And that is as a very psychotherapy-oriented individual (admittedly early in my career to make such pronouncements). I'm also an idealist. So I have a very different idea of how psychiatry should be practices as opposed to how it is practiced.

Sure, the way that psych is currently practiced in the majority of outpt settings, and even inpt, a very strong case can be made for PAs, PNPs, and psychologist-prescribers functioning independently. But I think most here can agree that the way psych tends to be practiced is hardly ideal. Symptom checklists, poor assessment of psychosocial stressors, and even poorer integration of psychosocial and psychopharmacologic treatment.

And I don't care about patient preferences for medication over psychotherapy. Call it paternalism if you will. But the right way to address medical illness is by maximization of lifestyle factors first, and the same is true for psychiatric illness. Whichever category you are tlaking about, lifestyle is ultimately biological. Whether it's the lower SVR in a hypertensive patient who loses adipose tissue, or the improved endocrinologic and neurobiologic functioning of a depressive patient with improved sleep hygiene, these are biological changes that allow the body to adapt to a healthier state. And psychotherapy, as I've ranted about forever, is a biological therapy that directly improves the functioning of the brain. It is always better to fix a patient than sustain them and their illness. And yes, I'm aware that SSRI's do allow a number of beneficial changes in the brain structure itself, and that early antipsychotic therapy can prevent the degradation of the brain seen in psychosis.

As everyone here has gone to great pains to point out, we undergo extremely exhaustive training in order to help our patients achieve health. So patient opinion and proclivity really shouldn't shape what we strive to offer them. It may end up affecting what they accept, but not what we should be doing.

Back off that tangent, I am sick of mind-brain dualism, and mind-body dualism. Silly and stupid ideas whose time has come to die. We keep talking about psychiatric disorders as if they are somehow isolated from causing medical pathology. They really aren't. And at least when it comes to mood and anxiety disorders, it is pure folly to pretend that they are not whole body illnesses. While many psychiatrists don't think in that light, I would hope most people could see the importance of recognizing the involvement and contribution of autonomic nervous system, immune/inflammatory system, and cardiovascular disease in psychiatric illness. A good psychiatrist should be thinking about sympathetic reactivity in their anxiety disorder patients and pharmacotherapies, psychotherapies, and lifestyle interventions that can impact these. Same goes for endocrinologic disturbances that contribute to and evolve from depression.

I am in full agreement with Dr. Carlat that psychiatry needs a reformation, although perhaps not for the same reasons he feels this need be. We have drifted into a very scary territory in which our behaviors in treatment and diagnosis resemble the very worst stereotypes of PAs and NPs, and this is not a good place to be.

Now if you'll excuse me, I'm off to do some heavy squats. Clearly the mindfulness I practice in order to get into the moment, lift with good technique, and push my limitations, the cognitive-behavioral techniques I self-administer to keep going when I hit a plateau, and the confidence I build doing so will have no effect on my mental health. Neither will the changes in sympathetic reactivity, diurnal cortisol profile, GH release during exercise and Stage IV sleep (which is also increased), and down-regulation of inflammatory pathways.

p.s. I stand by my opinion that I'd rather have psychologist-prescribers with adequate training in psychopharm and pathophysiology functioning as 'mid-levels' (although I consider them full equals and colleagues with overlapping area of specialty to our own), than PCPs, NPs, and PAs.
 

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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.[/SIZE].
Just to stir things up a bit, you'd be surprised at all the mental health folks over in shaman land. I've heard two good comments why:

Psychiatrist: "So I can finally help my patients."

Psychologist: "I just can't go back to talk therapy after this."

So is this field fun or what?:laugh:
 

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There are plenty of physicians who work in fields so circumscribed that it would appear they should not have needed 4yrs of Med School. When I was very sick in the hospital, the pulmonologist never touched me except to listen to my lung sounds and never prescribed anything except albuterol in breathing treatments. The Infectious Disease specialist never touched me. The gastroenterologist never touched me before or after the ERCP, though he was active on my case for weeks. The radiologists who read the multiple xrays and CT's never met me, and likely never saw any other portion of the chart. And even the Internist who was the Primary on my case never prescribed anything but the basic IV fluids or "symptomatic" meds (pain, constipation, nausea, insomnia). So, on the surface of things, one could easily argue that each could have adequately treated me with only one year of training, or could have delegated my treatment to a mid-level provider -
but I don't think that would have ended with me back here haranguing all of you, or even breathing at all.

A urologist never really has to be concerned with anything above or below the pelvis. A dermatologist never really has to be concerned with anything past the outer 1/2-inch of the body. A Hand Surgeon never has to encounter any thoracic or abdominal organs, never has to see the central nervous system. HEENT never touches anything below the manubrium, and avoids anything inside the braincase (kind of an important part of "head," don't you think?).
And so on.

And outpatient physicians in all sorts of fields will refuse to treat conditions outside of their specific field. The Endocrinologist won't write antibiotics for an uncomplicated UTI, and the cardiologist won't write pain meds for documented bursitis, and the neurologist won't treat tinea pedis, etc., etc. Even though any first week Intern should be able to properly treat each of those conditions.

So, in regards to the issues about non-MD psychiatric prescribers,
I think we simply have to drop any form of the argument that psychiatry is not a field of medicine because it is circumscribed and because outpatient psychiatrists don't commonly diagnose and/or treat common non-psychiatric medical conditions.

UNLESS someone wants to argue that all these other specialties are not physicians and should not have to go to full-fledged medical school.

Anyone? ... Anyone? ... No?
Well, there you go.

--------------------------------------------------------------

Just to make my own stance very clear and put my bias on record:
You should have to be licensed as a physician if you,
A) treat illnesses involving any major body system; e.g. nervous, cardiovascular, gastrointestinal-digestive, pulmonary, immune, musculo-skeletal, endocrine, dermatologic. OR
B) prescribe or perform treatments that interact with any major body system
C) perform any procedure on the body other than cosmetic, i.e. does not alter the function of any major body system.

UNLESS you are a "mid-level provider" whose work is reviewed by a licensed physician "upon initiation of treatment for each condition for each patient" AND periodically (as determined in writing by the physician in written protocol or on each chart)

I know that this model would dramatically change much of the current non-MD practice in this country, and I don't expect it to be very popular - but there it is.
 

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I do agree with you. If you return to my original posting, I am in favour of the existence of psychiatrists (or neuropsychiatrists). The exact example you give of misdiagnosing delirium is exactly the kind of case I think psychiatrists are best trained to diagnose and treat. I do not think nonpsychiatric physicians can necessarily do this better.
"Necessarily???" Even if nonpsychiatrists could "do it better"--what on earth point would there be to calling a non-physician to "diagnose delirium"? Delirium cases usually occur in the elderly, the post-operative, or the medically ill. So generally you only FIND them in medical hospitals! (Well, I'm no expert, but I don't know of many delirious health adults or children! The one exception might be people who become delirious solely as a result of taking medications. But even that situation is alarming and the person would likely be brought to an ER.).

The whole point of recognizing delirium is so that you can quickly identify the medical issues and correct them so the patient won't die from them. Yeah psychiatrists also try to address the delirium itself, and offer medications and suggestions, but if it were my grandmother being "diagnosed" with delirium, I'd be a whole lot more worried about her worsening UTI on and possible sepsis than about her waxing and waning ability to tell the month and date or draw a clock. If you even suspect delirium, then by definition you must look for a medical cause. I'm sorry but I would not ask a psychologist to intervene in that situation. And not because I doubt they have very fine abilities to detect subtle signs of delirium--but because there are other priorities!

One thing a psychiatrist can do that a non-physician can't--even when it's not the psychiatrist's job (i.e. it's the job of medicine, surgery, neuro or whoever the primary team is)--is order labs, check vitals, look for infection, review medications, run over the past medical history, etc. It might be someone else's job or they might have missed it but we can help prevent bad outcomes for medically sick patients when we do recognize delirium.
 

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I don't think he's saying that neurology and psych should be combined, but that perhaps "neuropsych" training would be for severe cases, complicated medical cases, consult psych, geri psych, and would relatively focus on bipolar disorder, schizophrenia, etc. They would still have to be fair interviewers and be skilled at time-limited therapeutic interventions. They would still have outpt practices, but they'd essentially be tertiary care providers.
But how can you call something "neuropsych" if it doesn't include neurology? I don't consider C/L psychiatry to be "neurology." Or to be "neuropsychiatry." Same for geri psych. What is neurological about geri psych or C/L psych? Nor is treating bipolar equivalent to "neuropsych" in my view. I also imagine neurologists would be offended if we co-opted the name of their profession just to make the inpatient branch of our own specialty sound more "medical" or something. I mean, if he's suggesting we jettison outpatient psych, then he should say that. But don't call inpatient and C/L "neuropsych" unless it's going to encompass "neurology" and all that it entails. I would expect significantly more "neuro" training before I would think you could add this to the name.

I think on the first page of the thread Dr. Carlat did say that someone had proposed combining the two fields, splitting off from the rest of medicine, and he was not in disagreement. So that's why I was asking about how they could ever realistically be combined.

Weird--he has not really answered many of the questions people have asked in this thread. He's given his proposal like it would fly--but I really doubt it would. Most people don't want to do just inpatient psych. Or be limited just to C/L.
 
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Nancysinatra: I think you misread my post, I said non-psychiatric physicians not non-physicians... I never said non-physicians should diagnose delirium. What would be the point of that?
 

whopper

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I strayed away from this debate only because my 70+ hr work week hit a snag where it went to above 80 hrs due to some very bad luck.

I agree that we need to make some changes within our own field to fix the lack of psychotherapy in daily practice.

Even if we don't give psychotherapy, we still need to know it so we can at least work with those who give psychotherapy. If one does not know how DBT works, that person will have trouble understanding a psychotherapist explaining that the patient isn't working well with her mindfulness skills, among several other specific parts of DBT.

As for psychologist-prescribers, I don't see a problem so long as the training is appropriate, and the medical doctor has the final say when it comes the medical aspects. The Oregon-bill in some drafts only recommended 250 clinical hours of training, the equivalent of only 4 weeks of residency, in hours only, with very vague guidelines on what constitutes clinical training. There is no decided formulary, and there are no clear guidelines who on has the final say--the medical doctor or the psychologist-prescriber if the 2 disagree.

Anyone? ... Anyone? ... No?
Well, there you go
Agree. You have to go to medical school to understand how the kidneys work, so if the lithium is adversely affecting the kidneys, you know what's going on.

When medications are prescribed, they don't just affect the brain, they affect the whole body. A psychologist-prescriber advocate in another thread argued that they aren't asking to perform heart surgery, so why be trained in it?. No, but what about patients who had heart surgery and is depressed, or psychotic? Will that heart surgery affect the doctor's decision to prescribe a certain medication? It would for me. It would definitely make me consider certain medications over others, and consider if the heart surgery would make me want to prescribe a psychotropic more or less. Same goes with several other non-mental illnesses such as Parkinson's, lung disorders, several types of surgeries, chronic pain, etc. I would also have to contact the doctor that would be treating the heart condition, and we could make sure all aspects of our treatments complement the other.

Now, all this said, we should aspire for better psychotherapy, but that in and of itself doesn't back the idea of a psychologist-prescriber. We should only advocate the practice if it is safe. Under the current guidelines of the Oregon-bill, a lot of what is going to happen has never been tested yet.

I do, though, appreciate Dr. Carlat's responses. They were much more reasonable than the previous arguments to back the practice of psychologist-prescribers.
 
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nancysinatra

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Do psychologists take general and organic chemistry to get their degrees? That's required premedical training. (Maybe they do, I don't know.) It's not just what we study in medical school that leads to understanding how medications work. I actually wish we had more science and knew more about how drugs work rather than less.

I'm surprised Dr. Carlat is not advocating for the removal of the required bachelor's degree for the Dr. of Mental Health. That seems just totally irrelevant to the patient care we provide. (I don't know about the rest of you but all I learned from my liberal arts degree was some useless idealism, now thoroughly wiped out thanks to my medical experience!) Good grief many colleges require humanities and even English. At some you can even take music, believe it or not. He should demonstrate the relevance of THOSE classes, if you ask me. The premed curriculum even requires physics. By getting rid of all those classes you could save four years!
 
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My doctoral clinical psych program I am in has a neuropsychology track. The coursework includes the following:
1. 4 months Structure and Function of the Brain
2. 4 months Neuropathology and Neurological Diagnosis
3. 4 months Child Neuropsychology - Theory, Research, and Methods
4. 4 months Child Neuropsychology - Assessment
5. 4 months Adult Clinical Neuropsychology - Theory, Research, and Methods
6. 4 months Adult Clinical Neuropsychology - Assessment
7. 4 months Neuropsychology of Developmental Disabilities
8. 4 months Neuropsychology of Aging
9. 4 months Psychopathology

In addition, they also get about 1000 hours of neuropsychological assessment work/psychotherapy with neurological and psychiatric patients.

I'm not suggesting that neuropsychologists should be able to prescribe medications based on this training. However, to me, this does seem like alot of training that involves studying the brain and working with patients with neurological deficits/diseases. My guess is that this is more training in neuro than psychiatrists have. Am I wrong? They definitely do not have training in the human body that one acquires in medical school.
 
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whopper

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Do psychologists take general and organic chemistry to get their degrees? That's required premedical training. (Maybe they do, I don't know.)
Not for a bachelors of arts. General and organic chemistry is required for a bachelor of sciences. Any programs requiring general or organic for a bachelors of the arts is an exception, not the norm.

I have not seen any psychology graduate program requiring general or organic chemistry, though I'm sure there are some around.

While I was in college, I obtained a bachelor of sciences in psychology. The overwhelming majority of psychology-majors, I'd say over 90% of them were in a bachelors of the arts, not sciences.

A problem I experienced in college was several of my professors had to incorporate biology into their curriclum, but did not know biology because at least in the 90s, biology's incorporation into psychology was new to several of these professors. Several of them were thrusted into having to know endocrinology, neurology, etc without any formal education in it.

So, I was in class, and I got questions wrong that I should've gotten right because I actually knew more biology than my psychology professor. It wasn't all of my psychology professors, but it was enough to leave a bad taste in my mouth. I did have some great professors who knew their medically related sciences, but the ratio was about 50-50. IMHO that was not good.

IMHO, general chemistry as well as the first term of organic chemistry should be included in any curriculum that carries graduate level pharmacology. The 2nd term, well hey, IMHO it's just for weeding out students. I have yet to figure out how coating class with 1 layer of silver atoms is going to affect me in medical practice.

I do though, rely on my knowledge obtained from physics (minus the theory of relativity), chemistry, and organic chemistry (first term) to the point where I see why these are relevant for the field of medical practice.
 
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My doctoral clinical psych program I am in has a neuropsychology track. The coursework includes the following:
1. 4 months Structure and Function of the Brain
2. 4 months Neuropathology and Neurological Diagnosis
3. 4 months Child Neuropsychology - Theory, Research, and Methods
4. 4 months Child Neuropsychology - Assessment
5. 4 months Adult Clinical Neuropsychology - Theory, Research, and Methods
6. 4 months Adult Clinical Neuropsychology - Assessment
7. 4 months Neuropsychology of Developmental Disabilities
8. 4 months Neuropsychology of Aging
9. 4 months Psychopathology

In addition, they also get about 1000 hours of neuropsychological assessment work/psychotherapy with neurological and psychiatric patients.

I'm not suggesting that neuropsychologists should be able to prescribe medications based on this training. However, to me, this does seem like alot of training that involves studying the brain and working with patients with neurological deficits/diseases. My guess is that this is more training in neuro than psychiatrists have. Am I wrong? They definitely do not have training in the human body that one acquires in medical school.


You are not entirely wrong about additional neurobiological training for psychiatrists but you are not right either when you assume that neurobiological knowledge, even as extensive as yours, is sufficient for evaluation and treatment of patients.

Dr. Carlat was talking through the top of his hat when he suggested elimination of clinical training for psychiatrists. The whole psychiatric field is in state of chaos solely because the psychiatrists never learned to think like medical doctors but relied on half-baked and mostly false psychoanalytical and psychodynamic models of mental illnesses. Add to that the mushy mess called biopsychosocial approach to psychiatric patients and Dr. Carlat's favorite pastime - bashing pharmaceutical companies and no wonder that no one values MD after psychiatrist's name.

Dr. Carlat is confused. On one hand, he is resisting psychobiological progress that is destroying feeble edifice of Freudian orthodoxy. On the other hand, he wants to remain relevant in the 21st century . He can't have it both ways. When the split widens and your feet are on both sides of chasm, one should think quick.

Psychiatry is moving rapidly away from false beliefs taxonomy toward modern understanding of mental disorders (a very disappointing DSM-V is hopefully just a glitch). To practice modern psychiatry one has to be a physician first and a sub-specialist second. One wouldn't want to take a pt with compound fracture to a half-trained orthopedic doctor who spent lots of time learning about feet and little about anything else (actually these folks are called podiatrists). You wouldn't want your inf. disease specialist know everything about bugs and less about anything else. Why would anyone want half-baked psychiatrist to deal with the organ much more complex and much more interconnected with the rest of the body than any other structure?

I would go the other way and won't allow anyone to practice psychiatry without board certification in primary care.
 
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It seems that there might be some agreement to the following scenario.

Psychologists who receive streamlined medical and psychopharm training can safely prescribe certain drugs for certain types of uncomplicated patients. Legislation can easily prevent psychologists from prescribing for patients in inpatient units, from prescribing in consult-liaison services, even to patients who are also being treated with certain other medications that may cause drug interactions. These are all details that can be worked out.

Psychiatrists will still do everything they are doing now. Go to medical school, internship, residency etc.... They will see the toughest patients, ie., the ones that really require four full years of medical school.

This system will at least begin to address the critical shortage of prescribers in the U.S. (which exists in both urban and rural areas, by the way). The most recent estimates by University of North Carolina Scheps Center, published in a series of article in Psychiatric Services, documented "severe" shortages of prescribers in 77% of U.S. counties, and estimated that only 50% of the needs of patients are currently being met.

The problem with simply saying no to non-MD prescribers is that we psychiatrists, the leaders of the mental health world, are offering no realistic solutions.

Very odd assertions based more on wishful thinking than reality. How, may I ask, a psychologist would identify "certain types of uncomplicated patients" to "safely prescribe certain drugs" if they don't know complexity of mental and physical diseases to begin with?

There is one sure way for a licensed psychologist to learn how to treat patients with medications. It's called medical school.
 

whopper

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A point I disagreed with with Dr. Carlat (and if I'm wrong, I'd like to hear his retort) is that we appear to have a different impression of what a psychiatrist is supposed to do.

He for example brought up an argument for the creation of a further specialized type of psychiatrist who is a type of neuro-psychiatrist. IMHO, that is confusing for me because it just further gets away from the issue of needed psychotherapy training for psychiatrists. Even such a neuropsychiatrist IMHO should have good psychotherapy training.

Another argument he brought up was that there are aspects of mental health treatment where not all aspects of medical school are needed. True, but this argument could be brought up for any aspect of medicine. Any field, for example surgery, if one were to only perform one type of specific procedure or surgery would not require training in several other areas. To make the field more specialized for less training, however, would in essence merely create a technician.

We are still going to need people trained in several areas to be aware of several aspects of what is going on. A psychiatrist fits that needed role.

I do understand that perhaps there could be more beneficial output if for example psychologist prescribers were working with an M.D., but ultimately, there has to be someone medically responsible. A bill that leaves 2 clinicians, with no clear say on who makes the final decision can open a legal can of worms to who is exactly medically responsible should something go wrong.

I'm not suggesting that neuropsychologists should be able to prescribe medications based on this training. However, to me, this does seem like alot of training that involves studying the brain and working with patients with neurological deficits/diseases. My guess is that this is more training in neuro than psychiatrists have. Am I wrong? They definitely do not have training in the human body that one acquires in medical school.
IMHO you likely actually do have more training in specific issues from your curriculum.

No, based on the curriculum you mentioned, I would not say this allows for prescription power (which is not what you are asking for). Like I said, medications go throughout the entire body. To only know what it does in the brain is only fraction of what you have to know. You likely, though, may have much more knowledge than most psychiatrists regarding specific neuroscience based data, and how that data can affect mental states.

I say this because I was a psychology major. Most of the medical data I learned in psychology was much more behaviorally oriented than the medical data I learned in medical school. I took for example, psychoneuroendocrinology in college, and that class gave me far more insight into the effects of hormones in behaviors than anything I learned in medical school. Almost everything I learned about sex hormones in medschool was in relation to the birthing process, bone density, or physical development. Hardly any of it was focused on how those hormones affect behavior or mental states such as maternal bonding, sexual relations etc.
 
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Let's say the training to become a psychologist prescriber is 3 years post Ph.D. 3 years of training in psychopharmacology, medication interactions, distinguishing mental disorders from medical illnesses, learning how to order/read relevant labs, etc. etc.

Isn't this a similar level of training that a primary care physician receives (four years medical school plus 1 year internship subtract some months of learning things that do not ultimately affect psychpharm practice, e.g., surgery)? Over 70% of all psychiatric medications are currently prescribed by PCPs. And isnt this far less training than NPs receive in diagnosis and medication management?

I'm just playing devil's advocate here. As an almost psychologist I don't think I'd want to learn to prescribe medications.
 

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Without appearing to advocate PCPs as ideal prescribers, I must add that a PCP residency is 3 years, plus the prerequisite courses before medical school to be able to study those sciences in much greater detail.
 

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I say this because I was a psychology major. Most of the medical data I learned in psychology was much more behaviorally oriented than the medical data I learned in medical school. I took for example, psychoneuroendocrinology in college, and that class gave me far more insight into the effects of hormones in behaviors than anything I learned in medical school. Almost everything I learned about sex hormones in medschool was in relation to the birthing process, bone density, or physical development. Hardly any of it was focused on how those hormones affect behavior or mental states such as maternal bonding, sexual relations etc.
I'm not sure where you are going with this, but undergraduate psychology and graduate psychology are far far different. Neuroanatomy in undergrad was a cakewalk compared to neuroanatomy taught in a doctoral program. I may have missed your point, as I read it quickly, and if I did, I apologize.

There have been some interesting posts that I'll reply to later, off to do paperwork, ugh.
 

st2205

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I'm not sure where you are going with this, but undergraduate psychology and graduate psychology are far far different. Neuroanatomy in undergrad was a cakewalk compared to neuroanatomy taught in a doctoral program. I may have missed your point, as I read it quickly, and if I did, I apologize.
I must state that where I went to undergrad this was not the case. The neuro department was made up of mostly a combination of the psychology department and the physiology department, with a couple of random others from different schools in the university. They had an undergrad neuroscience program, which was mostly handled and taught by the physiology department, notable exceptions being people from the psych department who didn't have degrees in psychology (PhDs in physiology, pharmacology, and an MD).

Anyhow, with regard to knowing neuro at the level that it's relevant to pharmacology, on average there was a huge knowledge gap between the two different parts of the department. I'm not stating that one had more knowledge in general, but just with regard to things that would be better suited toward understanding the science behind the neurophysiology relevant to psychopharm.

I did somewhat of an unofficial hybrid degree between psychology and neuroscience. I took a couple of graduate neuroscience courses, one of which was the psych department's graduate neuro class with the PhD students who were taking it as their biological emphasis requirement. I was excited for the course thinking they'd dig in a bit deeper, but unfortunately the depth covered was probably only 1/4 of that covered in just the introductory undergrad neuroscience course taught by the phys department.

The point I'm trying to make is that there's a completely different emphasis in training that typically gets misunderstood. Those whose neuroscience training background was in psychology and those whose were in physiology/pharmacology/etc. were totally different. Anyway, neuro's a broad field and I don't feel that on average a psych-trained neuroscientist would have a strong enough footing in understanding the medical physiology of psychopharmacology.

I'm not implying that you were making such an implication. I guess I've responded to many different points from some of the above posts/posters.
 
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My bad... I was always under the impression that becoming a PCP involved a 1 year internship. In some Canadian schools (I just read) PCP residency is 2 years, but in some 3 years.
 
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Let's say the training to become a psychologist prescriber is 3 years post Ph.D. 3 years of training in psychopharmacology, medication interactions, distinguishing mental disorders from medical illnesses, learning how to order/read relevant labs, etc. etc.

Isn't this a similar level of training that a primary care physician receives (four years medical school plus 1 year internship subtract some months of learning things that do not ultimately affect psychpharm practice, e.g., surgery)? Over 70% of all psychiatric medications are currently prescribed by PCPs. And isnt this far less training than NPs receive in diagnosis and medication management?

I'm just playing devil's advocate here. As an almost psychologist I don't think I'd want to learn to prescribe medications.
Hello Alekspsych,

Medical training: PCPs or internist and family practioner and pediatricians have four years of med school where they take a behavioral science course, several weeks of psychiatry rotation, which are then tested on national board exams (usmles 1,2,3) in addition to routine exams while in school. Then 3 additional years of medical/residency training where they treat patients with mental and physical health ailments. So this is 7 years of total training. Then their respective specialty boards.

Psychiatrists take the same route in medical training and exams then 1 year of additional training at the residency level similar to the PCPs. 5 years total then an additional 2-3 years with further training psychotherapy, psychopharm., neuroscience, ect, etc. Then we take our specialty boards Part I and II.

NPs have 2-3 years of medical training with different types of exams. Clearly, the training period between the three are not equal.

Psychotherapy: psychologist wins hand down here with 5-7 years of psychology training. Zero medical training. Generally, PCPs have more training in behavioral science than psychologists do with medical training at this stage.

In fact, no self respecting psychiatrists or primary care doctors would ever make the claim that they can do psychotherapy or perform neuropsychological testing as well or better than PhDs/PsyD with our 1-3 years of training (at least in psychiatry traning, not IM or FP or peds). To the best of my knowledge, no MDs/DOs have lobbied to obtain the right to perform neuropsychological testings, although it can take months to have anyone tested in my area, because we know we won't do as a good a job as our colleagues in psychology. Interestingly, LICSWs can do psychotherapy with just 1-2 years of training.

Clearly, psychiatrists have a number of skills unique only to us. Psychologists have unique skills only available to them.

I'm not against psychologists prescribing if this could improve the lives of some of our patients. Psychologists and social workers outnumber psychiatrists in the US by a rather large margin. And we are overwhelmed as is.....psychiatrists taking up more therapy patients would only decreased our services to patients. However, even with 2-3 years of training I strongly believe PHd/psyD/LICSWs/LMFT/etc need to be supervised by MDs/DOs similarly to the NPs/PAs. For their sakes (licenses, susceptibility to lawsuits, etc) as well as for patients safety. In the end, it is uncertain if adding medical psychologists to the mix would improve accessibility or improve quality of care. The NPs/PAs/crnas have been in primary care, pediatric, anest., surgery, cardio., ortho., etc. for years and there is certainly no shortage of work for the MDs/DOs in these fields or noticeable improvement in the quality of care.
 

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My bad... I was always under the impression that becoming a PCP involved a 1 year internship. In some Canadian schools (I just read) PCP residency is 2 years, but in some 3 years.
The only place in the US where I know that to be a possibility is within the military. In the military you can be a GMO (general medical officer) and function as a PCP with only an internship. But these folks need to complete a residency in order to be able to practice when they get back to civilian life. And having known two people who have been GMOs . . . they said it was the most nerve wracking experience in their lives. They didn't know what they were doing, had really limited support and were afraid they were going to kill people and were relieved to get out of that job and back into a residency program. One of my friends was a GMO on an aircraft carrier after a pediatrics internship. It's really wild.
 

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Neuroanatomy in undergrad was a cakewalk compared to neuroanatomy taught in a doctoral program. I may have missed your point, as I read it quickly, and if I did, I apologize.
No need to apologize. The point was that medical data taught in psychology programs has a different slant than it does in medical programs. E.g. endocrinology in medical school was taught almost purely from a standpoint of medical disorders, and not how hormones can affect emotional states.

All the endocrinology I learned as a psychology major was taught very differently than in medschool. As for graduate level education being more difficult than a bachelors, I'm very aware of that. Several of my friends are in a graduate level psychology program or are doctors in that field.

Psychotherapy: psychologist wins hand down here with 5-7 years of psychology training.
Somewhat agree. Several psychiatry residency programs still psychotherapy very well. Several psychiatrists continue to further sharpen their psychotherapy with later training. Several psychology programs emphasize statistics and resarch over clinical training.

But I very much agree that more psychotherapy training should be done with psychiatrists.
 
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In fact, no self respecting psychiatrists or primary care doctors would ever make the claim that they can do psychotherapy or perform neuropsychological testing as well or better than PhDs/PsyD with our 1-3 years of training (at least in psychiatry traning, not IM or FP or peds)....Interestingly, LICSWs can do psychotherapy with just 1-2 years of training.
It certainly makes since that this is true and we all assume that psychologists would have better outcomes performing psychotherapy compared to psychiatrists or LCSW's. However, does anyone know if any studies have looked at this directly? I can say that some of the best therapists I know are LCSW's.
 
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Somewhat agree. Several psychiatry residency programs still psychotherapy very well. Several psychiatrists continue to further sharpen their psychotherapy with later training. Several psychology programs emphasize statistics and resarch over clinical training.

But I very much agree that more psychotherapy training should be done with psychiatrists.
I see what you are saying. I was referring to the point where legally, psychologists and psychiatrists can practice independently. PhD/PsyD should have several years of therapy training vs. 1-3 for the MDs/DOs. You are absolutely right, many psychology programs focus heavily on research and stats. It depends on which program a PhD/psyD candidate is pursuing. So, some PhDs may have the same level of psychotherapy as psychiatry residents?

My program and the others in the area taught psychotherapy really well, although some may disagree, but in the span of 2-3 years. 2 if the residents choose to fast track into CAP. Several of my classmates and myself pursued further psychotherapy training while working as attendings. Some did psychoanalytic fellowships.
 
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It certainly makes since that this is true and we all assume that psychologists would have better outcomes performing psychotherapy compared to psychiatrists or LCSW's. However, does anyone know if any studies have looked at this directly? I can say that some of the best therapists I know are LCSW's.
i'm not aware of any studies on this topic. But I agree, there are excellent LICSWs therapists all around. As well as psychologists and psychiatrists.