How to become a prescribing psychologist?

[Tom4705]

Hello everyone, I'm new to this website and I'm a Psychology undergrad who would like to eventually get PSYD and then go for additional training in Psychopharmacology to be able to prescribe to my patients.

To those who have knowledge of the topic OR are prescribing/medical psychologists themselves, my questions are as follows:

What has your experience been like with a combo of therapy + medication? Do you do it in seperate sessions or in one?

2. How much do you make before/after taxes? I know this is personal but I'd greatly appreciate the info, this is essentially my dream career.

3. My original plan was to go to one of the handful of states where psychologists can legally prescribe meds with additional training in psychopharmacology. However, there are more states where nurse practitioners can be licensed without oversight from a MD/DO after training. Would this be a better path? To be a Psychologist+NP as opposed to The pathway specifically for psychologists in those handful of states? What is the difference in terms of additional education time, price, etc?

I would like to have my own private practice and work independently.

Thank you for your time.

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[sfgucadoc]

Hello,

I'm about 18 months into the NMSU RxP program and have been very happy with my decision to do RxP and to study at NMSU specifically. I've spent most of my career as a clinical health psychologist and the RxP training helped connect a lot of dots in medicine that I didn't understand before.

For me, it was more efficient to do the MSCP than to work toward an NP degree. For the three-year MSCP program, the first year is all basic sciences. For an NP degree, I would have had to start with basic sciences but done catch-as-catch-can at a local university or junior college. Most of the accelerated nursing programs want you to go full-time, making it difficult to continue working and support a mortgage and other things middle-aged folks have in their lives. The MSCP programs are generally designed with working psychologists in mind, so easier to fit into my life.

As far as rationale, much of my research and clinical work has focused on improving access to health care for underserved groups, including low-health-literacy patients. I very much appreciated that the NMSU program has as a basic tenet improving patients' understanding of their medication regimen and that "the ability to prescribe is also the ability to UNprescribe." Since a lot of my work is with older adults, helping them understand their often numerous medications with sometimes complicated dosing and helping them potentially get off some medications is a worthwhile goal!

Can't speak to the $$$ piece yet. Also be aware that MD's still have a lot of power and many states require at least some supervision of NP's by an MD and some collaboration between MD's and prescribing psychologists.

On a brighter note, 5 states allow prescriptive authority for psychologists now. Hawaii and Florida may pass RxP laws this year. Texas and California and perhaps others have laws under consideration this year but likely will not get them through their legislatures. But at least they found sponsors for bills, which is more than some states can muster. Also be aware that some psychologists live in non-RxP states but obtain licensure in an RxP states so they can provide telehealth services. You can do something similar with DoD.

Best of luck in your decision.

 

[PsyDr]

1) I am licensed to prescribe in one of those states, but do not live in either. And I do not practice in this area. So, no clue.

2) The public data on prescribing or medical psychologists shows they make $170k+, keeping in mind there are different models of practice.

3) The public data on nurse practitioners shows they average around $105k. Usually, direct entry MSN programs take around 2 years of full time study. You'd have to do this after post doc.

 

[WisNeuro]

On a brighter note, 5 states allow prescriptive authority for psychologists now. Hawaii and Florida may pass RxP laws this year. Texas and California and perhaps others have laws under consideration this year but likely will not get them through their legislatures. But at least they found sponsors for bills, which is more than some states can muster. Also be aware that some psychologists live in non-RxP states but obtain licensure in an RxP states so they can provide telehealth services. You can do something similar with DoD.

Best of luck in your decision.

Remember though, that the law in these states differ dramatically. In some cases to make the law almost moot, as in you are essentially getting a PA/NP degree anyway.

 

[Stagg737]

I'm going to give what may be an unpopular opinion for this sub-forum, but if you want to prescribe medications you should go to medical school. I'm only a psychiatry intern and a significant portion of my patients that I see who are primarily seen by NPs (or even non-psych physicians) have medication lists which make no sense and I'm basically cleaning up the mess made by other providers.

While I have a deep respect of psychologists and love working with them, my experience with them is that they generally don't have the foundational understanding of the medications that should be required to prescribe them. They're often very familiar with the meds, know the classes, and sometimes know the side effects pretty well, but they're lacking in understanding the actual molecular aspect of the medications and are completely lost when non-psych meds are involved. For reference, I'm a psychiatrist in a non-independent practice state who went to med school in a non-independent practice state. While many NPs were pushing for autonomy, every psychologist I worked with thought they were nuts and wanted nothing to do with prescribing.

I'm about 18 months into the NMSU RxP program and have been very happy with my decision to do RxP and to study at NMSU specifically. I've spent most of my career as a clinical health psychologist and the RxP training helped connect a lot of dots in medicine that I didn't understand before.

Sounds like an interesting program. Out of curiosity, how much do they go into non-psychiatric medications? Do they talk about endocrine meds? Neuro? Cardiology? Do they talk about medication interactions with other meds or how our psych meds are going to impact their other medical conditions (unless my severely diabetic patient is acutely psychotic there's certain antipsychotics they're never going to get from me) or how those medical conditions may impact the dosing or types of medications which will or won't work? Asking because there is a massive foundation that needs to be laid before prescribing medications and many clinicians (including physicians) don't understand those interactions well enough to be prescribing psych meds appropriately. The one thing in your post that does make me really happy is your statement about unprescribing.

 

[WisNeuro]

The one thing in your post that does make me really happy is your statement about unprescribing.

This is actually the driving factor that leads me to support RxP. For every great psychiatrist I work with, there are a handful more who just throw random meds at my patients and snow them senseless. In my practice, I see no prescribing differences between MD/DO/NP/PA. I'm not convinced that RxP and expansion of prescribing privileges will lead to any increase in patient safety issues above and beyond what already exists.

 

[psych.meout]

I'm going to give what may be an unpopular opinion for this sub-forum, but if you want to prescribe medications you should go to medical school. I'm only a psychiatry intern and a significant portion of my patients that I see who are primarily seen by NPs (or even non-psych physicians) have medication lists which make no sense and I'm basically cleaning up the mess made by other providers.

While I have a deep respect of psychologists and love working with them, my experience with them is that they generally don't have the foundational understanding of the medications that should be required to prescribe them. They're often very familiar with the meds, know the classes, and sometimes know the side effects pretty well, but they're lacking in understanding the actual molecular aspect of the medications and are completely lost when non-psych meds are involved. For reference, I'm a psychiatrist in a non-independent practice state who went to med school in a non-independent practice state. While many NPs were pushing for autonomy, every psychologist I worked with thought they were nuts and wanted nothing to do with prescribing.



Sounds like an interesting program. Out of curiosity, how much do they go into non-psychiatric medications? Do they talk about endocrine meds? Neuro? Cardiology? Do they talk about medication interactions with other meds or how our psych meds are going to impact their other medical conditions (unless my severely diabetic patient is acutely psychotic there's certain antipsychotics they're never going to get from me) or how those medical conditions may impact the dosing or types of medications which will or won't work? Asking because there is a massive foundation that needs to be laid before prescribing medications and many clinicians (including physicians) don't understand those interactions well enough to be prescribing psych meds appropriately. The one thing in your post that does make me really happy is your statement about unprescribing.

I'd agree that if you know you want to prescribe and have that be the/a focus of your work, then it would probably be better to go to med school and become a psychiatrist (it doesn't really make sense to do it this backwards manner), but I'd also like to see some actual data about the prescription practices, acumen, etc. of different prescribing professionals.

 

[DynamicDidactic]

1) I am licensed to prescribe in one of those states, but do not live in either. And I do not practice in this area.

I am so curious....

 

[DynamicDidactic]

I'm going to give what may be an unpopular opinion for this sub-forum

It is a very contentious debate in clinical psychology, probably not an unpopular opinion. I say the forum reflects the field, we have about a 50-50 spit.

I am not in favor of RxP but the only area I see its usefulness is helping individuals that have received very poor anxiety med management and general over-prescribing.

 

[PsychScience]

It is a very contentious debate in clinical psychology, probably not an unpopular opinion. I say the forum reflects the field, we have about a 50-50 spit.

I am not in favor of RxP but the only area I see its usefulness is helping individuals that have received very poor anxiety med management and general over-prescribing.

I agree- I don't think it's an unpopular opinion among clinical psychologists at all. I think there is a real divide in the field. Personally, I agree if you want to prescribe as a physician, then you should become a physician and have the comprehensive training and education that goes along with that.

 

[964693]

the only area I see its usefulness is helping individuals that have received very poor anxiety med management and general over-prescribing.

This is the exact opposite of its usefulness to me. We all know the research says that for severe depression therapy alone is ineffective, but better in combination with meds. To me the value is in places like IHS and other really rural and isolated places were the clients don't always have access to ANY mental health prescription.

Also why are some of you acting like RxP makes psychs into full medical doctors? I wouldn't be a physician. I'm not going to like set a broken arm and start radiation. Nor would I start prescribing meds for pain and disease. To me RxP can bring psychologists almost back into what psychiatry was meant to be in analytic days, when patients were seen by doctors in the context of therapy. Before psychiatrists became pill dispensers that sold their soul to schedule patients in 15 minute increments. I have worked with many psychiatrists that believed testing was totally unnecessary. If they were anxious prescribe an anxiolytic. If sad, anti-depressant. If parents thought ADHD, screw it, give them a stimulant and if it gets worse stop the stimulant. Most of the psychiatrists I've worked with are as incompetent as most of the psychologists I've worked with.

 

[Ollie123]

I understand someone wanting to go back to get RxP after the fact, but it almost seems silly to plan on from start. There are other options (Psychiatry, Psych NP) that would offer much more opportunity and flexibility. I'm all for new avenues that improve access to care, but this seems a really roundabout way of achieving that goal. One with at least greater potential for untoward consequences and certainly one that requires a whole more work to align.

I think the concern about RxP is not about psychologists trying to turn themselves into family practitioners, but that the line between physical health and mental health is not always crystal clear, plus many psych patients have extensive medical comorbidities. Can a psychologist be trained to prescribe safely in those populations? Maybe, but at some point there is going to be a wall. And depending on how often that wall gets hit...how much are we really doing to improve access to care? I do agree that many psychiatrists are just plain awful. That's a case for raising the bar though...not lowering it.

Somewhat of an aside, but I'm very far from convinced that research says therapy for severe depression is ineffective alone. This was a widespread belief 20 years ago, but I'm not sure it was ever really borne out by the data. Certainly some evidence supporting combo treatment being better than any single mode. Some evidence showing that antidepressants are not very effective for mild-moderate depression (which is probably the overwhelming majority of their use). My read of the literature is that its still a fairly complicated picture and the jury is still out when it comes to depression (barring cases with psychosis).

 

[Stagg737]

To me the value is in places like IHS and other really rural and isolated places were the clients don't always have access to ANY mental health prescription.

The problem with that argument is that when NPs were granted independent practice, access to care in those states did not improve. Only ~20% of NPs end up practicing in areas that are underserved (that includes rural and urban). So while that's a valid argument, it's not panning out in reality and access is just as bad of a problem as ever. Also, you touched on it later but bad prescribing can actually be worse than not prescribing anything at all. No one wants a bunch of people misdiagnosing patients (which I think is far less of a concern with psychologists) and starting a patient on the wrong med which will do nothing but give them side effects or even make things worse. Access to healthcare is meaningless if they're going to be treated inappropriately.

I think the concern about RxP is not about psychologists trying to turn themselves into family practitioners, but that the line between physical health and mental health is not always crystal clear, plus many psych patients have extensive medical comorbidities. Can a psychologist be trained to prescribe safely in those populations? Maybe, but at some point there is going to be a wall. And depending on how often that wall gets hit...how much are we really doing to improve access to care? I do agree that many psychiatrists are just plain awful. That's a case for raising the bar though...not lowering it.

The point on medical co-morbidity and cross-interactions with medical drugs is my point of concern with expanding prescribing rights. How will the patient's antibiotic effect their anti-depressant? If they're on an anti-cholinergic how is that going to impact what you prescribe? What about pain management? What if they're on warfarin or another blood-thinner? If a patient seems to have AMS, what labs are you going to order or a work-up and what meds would you potentially d/c? These are things that physicians have to learn about in med school and idk if they'd get covered in the program mentioned above. I know many NPs are never taught this stuff because I hear them ask about it frequently, but it's important because psych meds are not benign and have a lot of interactions with other meds and medical conditions. I've always been taught that the first thing I do when I see a new patient is to rule out any other medical conditions and look at the patient's current meds (all of them) before considering any medication management, which is something that other fields just aren't trained to do.

Also agree that there are plenty of terrible psychiatrists out there. Even as a med student I encountered one or two that after talking about some of the things they did with other psychiatrists it was painfully obvious that they were clueless. However, I think there is a shift for the better coming in terms of knowledge of psychiatrists. The field is becoming much more competitive to get into and evidence-based medicine is being pushed more (from my personal experience and talking to others). Mental health is also getting much more attention on the national stage and I don't think it's a field where poor physicians are going to be able to hide as easily. Maybe I'm wrong there, but I'm optimistic about the future of the field in terms of those who are entering it.

 

[964693]

when NPs were granted independent practice, access to care in those states did not improve

That's fine, right now the only states/agencies allowing psychologists to prescribe are the states no one wants to live in, which is why they are giving access. Actually I am okay with RxP existing in small pockets, i.e. IHS, specifically to address the lack of providers in the area. I think the current system incentivizes practice in these areas. NY etc won't allow it in my lifetime which is fine, they don't need it.

 

[eclipse77]

The problem with that argument is that when NPs were granted independent practice, access to care in those states did not improve. Only ~20% of NPs end up practicing in areas that are underserved (that includes rural and urban). So while that's a valid argument, it's not panning out in reality and access is just as bad of a problem as ever. Also, you touched on it later but bad prescribing can actually be worse than not prescribing anything at all. No one wants a bunch of people misdiagnosing patients (which I think is far less of a concern with psychologists) and starting a patient on the wrong med which will do nothing but give them side effects or even make things worse. Access to healthcare is meaningless if they're going to be treated inappropriately.

The point on medical co-morbidity and cross-interactions with medical drugs is my point of concern with expanding prescribing rights. How will the patient's antibiotic effect their anti-depressant? If they're on an anti-cholinergic how is that going to impact what you prescribe? What about pain management? What if they're on warfarin or another blood-thinner? If a patient seems to have AMS, what labs are you going to order or a work-up and what meds would you potentially d/c? These are things that physicians have to learn about in med school and idk if they'd get covered in the program mentioned above. I know many NPs are never taught this stuff because I hear them ask about it frequently, but it's important because psych meds are not benign and have a lot of interactions with other meds and medical conditions. I've always been taught that the first thing I do when I see a new patient is to rule out any other medical conditions and look at the patient's current meds (all of them) before considering any medication management, which is something that other fields just aren't trained to do.

Also agree that there are plenty of terrible psychiatrists out there. Even as a med student I encountered one or two that after talking about some of the things they did with other psychiatrists it was painfully obvious that they were clueless. However, I think there is a shift for the better coming in terms of knowledge of psychiatrists. The field is becoming much more competitive to get into and evidence-based medicine is being pushed more (from my personal experience and talking to others). Mental health is also getting much more attention on the national stage and I don't think it's a field where poor physicians are going to be able to hide as easily. Maybe I'm wrong there, but I'm optimistic about the future of the field in terms of those who are entering it.

I just wanted to chime in and say I really appreciate your perspective on this issue. It's helpful to hear about such issues from the angle of a psychiatrist on this forum. And, I echo what many here have already said earlier in this discussion--I think many psychologists here agree with you and are quite concerned about psychologists doing an adequate job prescribing. I get the initial rationale for it, and I'd like to see more outcome data on how psychologists perform relative to MDs or psych NPs, but I would personally not be interesting in seeking rx privileges due to all the complex interactions you already mentioned.

 

[Sanman]

I have had my concerns in the past with psychologist prescribing, but less so now. Having seen some of what is out there, I doubt we will do significantly worse. As it is, it is as two year program after a doctorate. NP is two years after a bachelors degree.

The problems with poor prescribing and terrible care will persist so long as the incentive is on treating quantity and not quality. I do get a better understanding of my patient after weekly psychotherapy than a psychiatrist doing 15 min med checks every 3 mths. That is a function of time, not training. Knowing the patient is key and the basis for having a consistent PCP.

 

[Therapist4Chnge]

If you are not yet in training, then you should consider what you actually want to *do* in day to day practice. If it involves medication management, then you should consider MD/DO/NP.

It’s important to understand the training differences, both in regard to philosophy of each profession, but also practicality. PA is another route, but then you aren’t a fully independent provider and the relation to typical psych work is even farther away. That said, any of these degrees have a *far* clearer path to a job w. far fewer geographic restrictions than psych RxP.

FWIW, I completed the RxP training (residential program, not online) a number of years ago, and it definitely changed my perspective on prescribing. I have done everything but sit for the PEPP....mostly bc I got busy in my academic career and it took a backseat to my clinical and research work. I was not in an RxP state and I didn’t want to leave my university after all of the effort to get there.

The impetus for my pursuit of RxP training wasn’t to prescribe for my day-to-day job, I did it bc I wanted to do research involving polypharmacy and secondarily have it better inform my clinical practice. It also became a built-in fallback option if I ever got tired of neuropsych. However, the more time that passed, the less I wanted to prescribe.

Prescribing is a hassle. Patients can be completely unreasonable. It is difficult not to become a “stack ‘em & wack ‘em” provider bc everything is incentivized for volume. If you open your own practice, you can take more time w each patient, but the economics tank. Frankly, there are many other ways to make the same or better money (with far less liability) than being a prescriber....if you are a good business person, which isn’t the case for the avg clinician.

As for the training, I found the psych RxP training to be pretty good...at least at a place like NMST; I can’t speak to FDU or any of the blended programs. I personally do not like online training and I think it is more limited, but that’s a discussion for another day.

A friend did her NP while I did my training, so we swapped materials, resources, and program experiences. I also compared other NP curriculums and also sought input from other NP students, and I was very underwhelmed. The psych training across programs was really weak and their research training (even as a consumer of research, not a producer) was poor. I know research training isn’t a big area of emphasis, but evaluating research is an important aspect of practice; the psychologist part of me believes this more and more as the years go by. I’m not saying *all* programs lack in these areas, but back when I looked at 4-5 brick & mortar large university based NP programs (in 2005ish). I purposefully looked at some of the best programs bc I knew there were weak programs out there too. I wasn’t happy with the course materials, most were a mile wide and only a few inches deep. To be fair, as psychologists we are taught the “why” and how to get there, while RN programs have very different goals and objectives.

The other glaring issue I saw in the NP training was the difference in how they were taught, which was all about flow charts for decision-making instead of really learning the “why”. It’s akin to the difference between a mechanic and a mechanic tech; both can do the basics, but the mechanic can explain the bigger picture too. I’m a big proponent of understanding the “why”, which means getting into the nitty-gritty and not just learning a handful of meds in each class. I also realized that no matter what training program I did, i’d have to do a ton of extra work to really feel comfortable and confident in my training.

My practica and supervision experiences were eye-opening and at time intimidating. I was fortunate to work with a rockstar academic/dept chair, but the patient mix was rough. Every patient was medically complicated...TBIs/CVAs/Ortho, usually some type of chronic pain, usually DM & high BP, and then one or more psych dx’s. I’m glad I didn’t get a bunch of mild depression with some sleep problem cases bc those wouldn’t have been nearly as instructive.

Reviewing cases w my supervisor and his NP was a great experience, but it threw me into the deep end. I’m thankful for all of my neuro training bc it definitely helped, but I still had to supplement, particularly in regard to lab tests. We had a lot of classroom training and review, but knowing what to ask to know what to order and why...much more nuanced that I originally thought.

Before I decided to pursue RxP training, I looked at a number of NP programs, but the pre-req RN training was just not what I wanted. If I wanted to go into medicine, i’d have pushed harder for an MD/PhD program, but I was warned by MD/PhD students to avoid medicine all together. After talking w many physicians, NPs, and a few PAs... I realized I didn’t want to be a physician and I didn’t want to be a nurse nor a PA. They all can be great options for people, depending what you want to do day to day, but none were a fit for me. I love diagnostic work, evaluation, reviewing the research, and figuring the puzzle out. Establishing long-term patient relationships, <15min appts, writing endless notes, and having to find coverage....ugh.

I believe PAs and NPs can be great prescribers, but it takes a lot of extra work after getting your degree and licensed; the same for psych RxP. After all of this... I found that physicians are best positioned to have a solid foundation from which to build. I underestimated how messy things can get with comorbid medical conditions, then throw in patient non-compliance, formulary limitations, and limited time....headaches abound. Admittedly my field training hours were far more in-depth than the average training experience for psych RxP, but it really opened my eyes. I’m fortunate for the training, but if I ever decide to prescribe, it’s be in a group practice and i’d want to narrow the range of patients i’d take on.

If you read this far, I hope this was helpful.

 

[deleted343839]

this is essentially my dream career.

I'm so curious about this statement. Why not go to medical school and become a psychiatrist?

After all of this... I found that physicians are best positioned to have a solid foundation from which to build. I underestimated how messy things can get with comorbid medical conditions, then throw in patient non-compliance, formulary limitations, and limited time....headaches abound.

So much this. My practice is embedded in a medical clinic and perhaps that shapes my perspective, but I'm always floored when psychologists claim that they "know more about the brain" than physicians and are therefore better able to prescribe psychotropic meds. That's a silly thing to say, but it's not just the brain we're talking about when it comes to medications.

 

[Chalupacabra]

OP, how much exposure do you have to relevant coursework? I took a grad level psychopharm class as well as a neuroscience class with a heavy psychopharm component, in part because I thought I was interested in possibly going this route. I quickly realized that while the baseline knowledge I gained was pretty useful, the thought of ~two years of full time training in the area was incredibly unappealing (as well as the other concerns voiced here).

 

[DynamicDidactic]

To me the value is in places like IHS and other really rural and isolated places were the clients don't always have access to ANY mental health prescription.

The problem with that argument is that when NPs were granted independent practice, access to care in those states did not improve.

That's fine

 

[DynamicDidactic]

This is the exact opposite of its usefulness to me.

Why is that the exact opposite of usefulness?

We all know the research says that for severe depression therapy alone is ineffective, but better in combination with meds.

Do we all know that? I would love to see the evidence.

 

[medium rare]

As already mentioned, there is a steep learning curve after completing RxP or PMHNP training. The same is true for a newly-minted psychiatrist fresh out of residency although considerably less so than for RxP, NP or PA.

As I am both a licensed psychologist and a board certified PMHNP, I can speak to this issue directly and with a fairly unique experience of training and practice. It’s one thing to thoroughly research programs and talk with people going through or who have completed the programs and quite another to actually go through it for yourself.

I found my training in clinical psychology to be extremely helpful in my training as a PMHNP. Good NP programs are solid but even the best have a somewhat limited range of training given the time frame of the program. Graduates are prepared to enter the workforce at a beginning level of practice. There is an expectation one will continue to learn through supervised work or consultation and regular continuing education.

This model does have some limitations and NP colleagues of mine who didn’t have prior psychiatric practice experience as a direct provider have at times struggled with being able to manage the totality of the demands placed on them. Many, if not most, do adapt quickly but, as I mentioned, it is a sharp learning curve.

For me, the combination has worked out extremely well and I very much appreciate the ability to provide integrated psychiatric care. Patients greatly appreciate this, too. Many of my patients seek me out specifically because of my training and dual role. I did not fully realize how much of a demand exists until I was in practice for awhile - my office phone never stops ringing these days. Patients, in general, do not appreciate 10 - 15 minute appointments.

 

[964693]

Why is that the exact opposite of usefulness?

Because unlike NPs, psychs have been given Rx privileges in underserved areas. That's why it's fine for nurses to go do what they want, the circumstances are different and the comparison is thus irrelevant. My diagnosis was based on observations and discussion, not an insult.

 

[psych.meout]

Based on this and the other times you quoted me I'm not convinced you're totally able to read. Because unlike NPs, psychs have been given Rx privileges in underserved areas. That's why it's fine for nurses to go do what they want, the circumstances are different and the comparison is thus irrelevant. And because your replies don't merit a comment on two threads: my diagnosis was based on observations and discussion, not an insult.

This is really uncalled for.

 

[Stagg737]

Because unlike NPs, psychs have been given Rx privileges in underserved areas. That's why it's fine for nurses to go do what they want, the circumstances are different and the comparison is thus irrelevant. My diagnosis was based on observations and discussion, not an insult.

Are you saying that psychologists were given Rx rights in only underserved areas? Because from what I've seen of the legislation this is false.

 

[DynamicDidactic]

@Mvp89 My goal isn't to retread the same stale arguments that have numerous times been posted on here. We have an entire sticky thread dedicated to psychopharm. My goal is to highlight that the rural prescribing argument has long been debunked. Your responses to this have not made sense (or maybe it is my difficulty in reading). You have not posted any evidence or even cogent arguments.

There are numerous posters on SDN who are in support of RxP for valid reasons and I have no bone to pick with them. As I mentioned, while I am not in support of it I see a usefulness for reducing over- and poor-prescribing.

 

[964693]

@Mvp89 My goal isn't to retread the same stale arguments that have numerous times been posted on here. We have an entire sticky thread dedicated to psychopharm. My goal is to highlight that the rural prescribing argument has long been debunked. Your responses to this have not made sense (or maybe it is my difficulty in reading). You have not posted any evidence or even cogent arguments.

There are numerous posters on SDN who are in support of RxP for valid reasons and I have no bone to pick with them. As I mentioned, while I am not in support of it I see a usefulness for reducing over- and poor-prescribing.

Given that your evidence thus far consists of emojis (such a cogent argument), it's fair to say your rebuttal, such that it is, can and should be dismissed out of hand.

 

[psych.meout]

Given that your evidence thus far consists of emojis (such a cogent argument), it's fair to say your rebuttal, such that it is, can and should be dismissed out of hand.

Ok, but can we get to you providing some kind of source for this claim?

We all know the research says that for severe depression therapy alone is ineffective, but better in combination with meds.

 

[futureapppsy2]

As already mentioned, there is a steep learning curve after completing RxP or PMHNP training. The same is true for a newly-minted psychiatrist fresh out of residency although considerably less so than for RxP, NP or PA.

As I am both a licensed psychologist and a board certified PMHNP, I can speak to this issue directly and with a fairly unique experience of training and practice. It’s one thing to thoroughly research programs and talk with people going through or who have completed the programs and quite another to actually go through it for yourself.

I found my training in clinical psychology to be extremely helpful in my training as a PMHNP. Good NP programs are solid but even the best have a somewhat limited range of training given the time frame of the program. Graduates are prepared to enter the workforce at a beginning level of practice. There is an expectation one will continue to learn through supervised work or consultation and regular continuing education.

This model does have some limitations and colleagues of mine who didn’t have prior psychiatric practice experience as a direct provider have at times struggled with being able to manage to totality of the demands placed on them. Many, if not most, do adapt quickly but, as I mentioned, it is a sharp learning curve.

For me, the combination has worked out extremely well and I very much appreciate the ability to provide integrated psychiatric care. Patients greatly appreciate this, too. Many of my patients seek me out specifically because of my training and dual role. I did not fully realize how much of a demand exists until I was in practice for awhile - my office phone never stops ringing these days. Patients, in general, do not appreciate 10 - 15 minute appointments.

I was hoping you would see this thread. Thanks for sharing!

 

[bcliff]

I'm generally in favor of RxP legislation but do worry about the quality of training programs and the quality of trainees who would be drawn to pursue RxP credentialing (e.g., FSPS students struggling to make ends meet). This latter concern is bolstered by the types of programs (e.g., Alliant) I've seen most commonly offering RxP training. Based on principle, if I were to pursue RxP training, I would have a really hard time reconciling with the decision to fund a predatory, FSPS-based program. It does seem though like there still are some reputable, university-based programs available, like FDU (don't know anything about the program/university, but it seems reputable enough?), but consistent with the experiences of others, I don't particularly enjoy online/distance-based education. I believe the brick-and-mortar program in NM is no longer active, correct? Are there other brick-and-mortar RxP programs still operating?

I have worked with some patients, particularly individuals with depression, where it has been exceptionally difficult to establish momentum in terms of regular treatment attendance, behavioral activation, etc., let alone establishing/coordinating care with an entirely different MH provider to provide pharmacotherapy. Additionally, a prescriber who sells a disease model of depression to "our" patient (e.g., "you just need to find the right medication to cure your depression!") could undermine weeks, months, or possibly even years worth of establishing buy-in with a cognitive-behavioral/third-wave treatment rationale. In these scenarios, I've often thought it would be helpful to be able to provide both pharmaco- and psychotherapy services, and use single-case design methodology to measure the effectiveness of pharmacotherapy at achieving symptom reduction. To this point, psychologists' extensive training in research methodology offers us a unique and valuable perspective on pharmacotherapy relative to our colleagues with prescriptive authority from other disciplines. Again though, how many psychologists with solid research design training, particularly training with experimental/single-case design, pursue RxP credentialing?

From my perspective, as someone with training in neuropsychology, I have often found my neuropsych coworkers and supervisors to possess superior training in psychopharmacology relative to our physician colleagues. The major caveat to this point though is that my neuropsych experience has been almost exclusively outside the realm of psychiatry (e.g., oncology) and within the context of interdisciplinary treatment teams, where neuropsychologists have provided their assessment and intervention services in close collaboration with non-psychiatrist physicians and other relevant, non-MH disciplines. Based solely on my experience, I would generally feel more comfortable with an ABPP-CN psychologist with RxP credentialing managing a patient's psychotropic medication in this type of setting, with close communication, coordination, and collaboration with physicians and other allied health professionals, than an MD/DO with minimal training in psychiatry/MH.

Maybe this discussion should be merged with the larger RxP sticky? It's been quiet for a while.

 

[sfgucadoc]

The New Mexico State University RxP program is very much up and running. I'm a current student. However, it is a hybrid brick-and-mortar and online program. I chose it because I felt it was the most rigorous of the available programs when I started in August 2017.

I'm generally in favor of RxP legislation but do worry about the quality of training programs and the quality of trainees who would be drawn to pursue RxP credentialing (e.g., FSPS students struggling to make ends meet). This latter concern is bolstered by the types of programs (e.g., Alliant) I've seen most commonly offering RxP training. Based on principle, if I were to pursue RxP training, I would have a really hard time reconciling with the decision to fund a predatory, FSPS-based program. It does seem though like there still are some reputable, university-based programs available, like FDU (don't know anything about the program/university, but it seems reputable enough?), but consistent with the experiences of others, I don't particularly enjoy online/distance-based education. I believe the brick-and-mortar program in NM is no longer active, correct? Are there other brick-and-mortar RxP programs still operating?

 

[bcliff]

The New Mexico State University RxP program is very much up and running. I'm a current student. However, it is a hybrid brick-and-mortar and online program. I chose it because I felt it was the most rigorous of the available programs when I started in August 2017.

Oh, cool! Maybe it was inactive the last time I checked? Or maybe I was just mistaken? That's good info to have.

 

[sfgucadoc]

NMSU RxcP is a relatively small program compared to some of the other ones. They do a lock-step two-year cohort (but with your 2 practica, it's really a 3-year degree) and I think there was a 2-year period where they didn't take students. We started with 17 students and 2 dropped out. Another cohort starts in August 2019.

 

[sfgucadoc]

I'm going to give what may be an unpopular opinion for this sub-forum, but if you want to prescribe medications you should go to medical school. I'm only a psychiatry intern and a significant portion of my patients that I see who are primarily seen by NPs (or even non-psych physicians) have medication lists which make no sense and I'm basically cleaning up the mess made by other providers.

<snip>

Sounds like an interesting program. Out of curiosity, how much do they go into non-psychiatric medications? Do they talk about endocrine meds? Neuro? Cardiology? Do they talk about medication interactions with other meds or how our psych meds are going to impact their other medical conditions (unless my severely diabetic patient is acutely psychotic there's certain antipsychotics they're never going to get from me) or how those medical conditions may impact the dosing or types of medications which will or won't work? Asking because there is a massive foundation that needs to be laid before prescribing medications and many clinicians (including physicians) don't understand those interactions well enough to be prescribing psych meds appropriately. The one thing in your post that does make me really happy is your statement about unprescribing.

Yes, I do a PRN gig seeing psych pt in medical emergency rooms where I clean up messes made by primary care docs. In addition, I've been on the faculty of two large AMCs for 19 years working with residents in psychiatry and urology and teaching medical students. No profession or specialty has a monopoly on messiness.

APA-designated programs touch on the topics you mentioned with a focus on psych meds. There is some attention paid to non-psych meds but the focus is definitely on the psychotropics.

Take a look at Training comparison among three professions prescribing psychoactive medications: psychiatric nurse practitioners, physicians, and pharmacologicall... - PubMed - NCBI

I don't think anyone in my student cohort thinks we're becoming as proficient as physicians in internal medicine, surgery, etc. but that's not our goal. I think most of us are focused on building on our skills in clinical psychology - talk therapy, patient education, health literacy, patient activation and empowerment, etc. - to provide high-quality mental health care that *may* include psychotropic medication. Most states require at least some contact with the PCP, so it's not like any of us are going to be trying to manage a very complex process with no consultation or collaboration with providers trained in areas in which we have limited expertise.

 

[Tom4705]

Hello,

I'm about 18 months into the NMSU RxP program and have been very happy with my decision to do RxP and to study at NMSU specifically. I've spent most of my career as a clinical health psychologist and the RxP training helped connect a lot of dots in medicine that I didn't understand before.

For me, it was more efficient to do the MSCP than to work toward an NP degree. For the three-year MSCP program, the first year is all basic sciences. For an NP degree, I would have had to start with basic sciences but done catch-as-catch-can at a local university or junior college. Most of the accelerated nursing programs want you to go full-time, making it difficult to continue working and support a mortgage and other things middle-aged folks have in their lives. The MSCP programs are generally designed with working psychologists in mind, so easier to fit into my life.

As far as rationale, much of my research and clinical work has focused on improving access to health care for underserved groups, including low-health-literacy patients. I very much appreciated that the NMSU program has as a basic tenet improving patients' understanding of their medication regimen and that "the ability to prescribe is also the ability to UNprescribe." Since a lot of my work is with older adults, helping them understand their often numerous medications with sometimes complicated dosing and helping them potentially get off some medications is a worthwhile goal!

Can't speak to the $$$ piece yet. Also be aware that MD's still have a lot of power and many states require at least some supervision of NP's by an MD and some collaboration between MD's and prescribing psychologists.

On a brighter note, 5 states allow prescriptive authority for psychologists now. Hawaii and Florida may pass RxP laws this year. Texas and California and perhaps others have laws under consideration this year but likely will not get them through their legislatures. But at least they found sponsors for bills, which is more than some states can muster. Also be aware that some psychologists live in non-RxP states but obtain licensure in an RxP states so they can provide telehealth services. You can do something similar with DoD.

Best of luck in your decision.

Could you go into a bit more depth about the NMSU Rxp program and the MSCP program? Specifically, the cost, potential financial aid, requirements, etc? Also, what do you mean by telehealth services? What does that entail? Keep me posted on your progress!

 

[WisNeuro]

I believe that all of these things are on the website.

 

[sfgucadoc]

Could you go into a bit more depth about the NMSU Rxp program and the MSCP program? Specifically, the cost, potential financial aid, requirements, etc? Also, what do you mean by telehealth services? What does that entail? Keep me posted on your progress!

Here is the website link - Postdoctoral M.S. in Clinical Psychopharmacology (MSCP) Degree | Counseling & Educational Psychology | New Mexico State University . As Wis suggests, it's the best source and a far more complete description than I could probably give you.

Telehealth meaning Rx via telehealth. Many very small towns in NM have no psychiatrist, PMHNP, or psychologist for miles. Some of the NMSU faculty use telehealth to provide services to patients in clinics in those towns. I don't know anything more specific than that at this time. Similarly, a colleague licensed in NM who lives in TX provides telehealth Rx services to military bases in other states and countries. He's ex-DOD but not in their original cohort of RxP folks.

Cheers.

 

[Tom4705]

1) I am licensed to prescribe in one of those states, but do not live in either. And I do not practice in this area. So, no clue.

2) The public data on prescribing or medical psychologists shows they make $170k+, keeping in mind there are different models of practice.

3) The public data on nurse practitioners shows they average around $105k. Usually, direct entry MSN programs take around 2 years of full time study. You'd have to do this after post doc.

1. If you are qualified to prescribe in one of those states, why don't you practice in them? I don't mean to get personal, but it just seems that it would be a waste of all the time+education to get licensed there if you aren't going to practice there. Also, if you don't mind, what state are you referring to?

2. That's an excellent amount of money. Do you have a source for that? Also, could you explain what you mean by different models of practice?

3. Yeah, do you think it would be better to get into and MSN program after your doctorate as opposed to the full Psyche Nurse route?

Thank you for the response.

 

[Tom4705]

Remember though, that the law in these states differ dramatically. In some cases to make the law almost moot, as in you are essentially getting a PA/NP degree anyway.

Why do you say this? In which state do think the law is "almost moot" and why?

 

[Tom4705]

Yes, I do a PRN gig seeing psych pt in medical emergency rooms where I clean up messes made by primary care docs. In addition, I've been on the faculty of two large AMCs for 19 years working with residents in psychiatry and urology and teaching medical students. No profession or specialty has a monopoly on messiness.

APA-designated programs touch on the topics you mentioned with a focus on psych meds. There is some attention paid to non-psych meds but the focus is definitely on the psychotropics.

Take a look at Training comparison among three professions prescribing psychoactive medications: psychiatric nurse practitioners, physicians, and pharmacologicall... - PubMed - NCBI

I don't think anyone in my student cohort thinks we're becoming as proficient as physicians in internal medicine, surgery, etc. but that's not our goal. I think most of us are focused on building on our skills in clinical psychology - talk therapy, patient education, health literacy, patient activation and empowerment, etc. - to provide high-quality mental health care that *may* include psychotropic medication. Most states require at least some contact with the PCP, so it's not like any of us are going to be trying to manage a very complex process with no consultation or collaboration with providers trained in areas in which we have limited expertise.

Do you know which states do and don't require contact with the PCP?

 

[WisNeuro]

Why do you say this? In which state do think the law is "almost moot" and why?

I say this because it's true. Unless it's been changed, it's essentially easier to go ahead and get your NP/PA degree in several of the new states to push forward the legislation, to prescribe than it is to get the RxP equivalent. I'd encourage you to read the statutes on the books in several of these states to get the flavor. At the very least, you'll need to know the statutes in any state in which you think you may practice.

 

[PsyDr]

1. If you are qualified to prescribe in one of those states, why don't you practice in them? I don't mean to get personal, but it just seems that it would be a waste of all the time+education to get licensed there if you aren't going to practice there. Also, if you don't mind, what state are you referring to?

2. That's an excellent amount of money. Do you have a source for that? Also, could you explain what you mean by different models of practice?

3. Yeah, do you think it would be better to get into and MSN program after your doctorate as opposed to the full Psyche Nurse route?

Thank you for the response.

1) I make more money than that, doing my own thing. So it’s not attractive of an option. I did it because:

a) I do some business that having that license is key for. And I have some long term plans for that (no, I won’t give away that business idea).

b) I had the time and cash to do the mscp at the time, and was never going to have more time. I also had a VERY cush “full time” weekend job where I had to be on site at the facility for 12 hrs/day with really almost zero responsibilities. So doing the readings was a helpful way to cope with sitting in an office alone for that time after rounds.

c) why not? At least for me, I like structured educational opportunities. And I am interested in the subject. The practica were also helpful in firming up professional relationships.

d) In my experience in interactions with older psychologists, it’s clear that those that get in on specialties in the early stages have it easier and benefit more than the people who show up late to the specialties. Neuropsych used to be very easy to get into, then they added a bunch of stuff. Rehab is becoming the same.

e) it’s easier to transfer stuff than start anew. While I don’t want to live in NM or LA,

f) I like being a psychologist.

2) Div 55 listserv

3) I think that the M.P./prescribing route pays more, but is a lot less common and therefore less easy. The MSN/NP route is a lot more common and therefore easier. But I’m not a nurse. I’m a psychologist.

 

[sfgucadoc]

<snip>
d) In my experience in interactions with older psychologists, it’s clear that those that get in on specialties in the early stages have it easier and benefit more than the people who show up late to the specialties. Neuropsych used to be very easy to get into, then they added a bunch of stuff. Rehab is becoming the same.

<snip>

I think we're already beginning to see that. IL requires ~ 1900 hours of practicum, with rotations in specific areas. NM requires ~ 500 hours of practicum, and LA requires no practicum. Clearly, the MDieties are trying to discourage RxP by influencing legislators to make practicum requirements so daunting. But I agree with PSYDR that this is also likely a natural evolution of the specialty.