Medical Psychologists on path to getting prescribing privileges, AMA/APA oppose

[sasevan]

You question the generalizability of the DoD results; that's only good scientific reasoning BUT how do you answer the question of whether PhD/PsyDs can be safe and effective prescribers unless studies such as these are funded. The little APA lobbied hard against the extension of the DoD project, resulting inadvertantly in the DoD Final Report being the sole example of empirical evidence re medical psychologists. Ironic.

FINAL REPORT

MAY 1998


Prepared for: LTC Thomas J. Williams, USA, MS Program Director, External Monitoring of Graduates of DoD Psychopharmacology Demonstration Project Chief, Department of Psychology Walter Reed Army Medical Center Washington, D.C. 20307


Prepared by: American College of Neuropsychopharmacology 320 Centre Building 2014 Broadway Nashville, TN 37203

American College of Neuropsychopharmacology (ACNP)

Evaluation Panel Report May 1998

Executive Summary

The Psychopharmacology Demonstration Project (PDP) was undertaken by the Department of Defense (DoD) to determine the feasibility of training military clinical psychologists to prescribe psychotropic drugs safely and effectively. The first class entered the PDP in the Summer of 1991, and the last of four classes graduated in the Summer of 1997. The PDP produced a total of 10 prescribing psychologists who undertook post-graduate assignments at military posts scattered throughout the United States.

In January 1998, the DoD contracted with the ACNP to monitor and to provide an independent, external analysis and evaluation of the program and its participants. The ACNP Evaluation Panel was the chief mechanism for performing those functions throughout the program's lifetime. The ACNP Evaluation Panel did its work chiefly by means of frequent, periodic visits to training sites to observe, to interview significant participants, to collect data; providing external assessment of effectiveness and implementation of the PDP program.

In March and April 1998 the Evaluation Panel site visited all graduates of the program. Some had completed their formal PDP training almost four years earlier, and some were only nine months into the post-graduate period. This report includes much detail about the 10 graduates, the 10 sites of their assignments, and the 10 positions they filled. Our Findings and Conclusions, however, have reached beyond the individual. We examined the PDP as one particular training program and correlated its characteristics with its outcomes, as represented in the collective performances of the cohort of graduates.

After the Findings and Conclusions section below, an Introduction and a Brief History of the PDP provide short, detailed accounts of the PDP and the role, influence, and history of the ACNP and the ACNP Evaluation Panel. Next, is a Methodology of the 1998 ACNP Evaluation. Last, is a lengthy section that comprises the bulk of the report, 1998 Practice Profiles of the 10 Graduates. These Profiles report in detail the observations and findings of the 10 site visits. They are presented in sequence by service beginning with Air Force (three graduates), followed by Army (three graduates), then Navy (four graduates). Although there were three female graduates, only masculine pronouns are used to protect identity.

Findings and Conclusions

1. Effectiveness: All 10 graduates of the PDP filled critical needs, and they performed with excellence wherever they were placed. It was striking to the Evaluation Panel how the graduates had filled different niches and brought unique perspectives to their various assignments. For example, a graduate at one site worked lull time on an inpatient unit with his supervising psychiatrist. The psychiatrist said he preferred working with the graduate rather than with another psychiatrist because the prescribing psychologist contributed a behavioral, nonphysician, psychological perspective he got from no one else. On posts where there was a shortage of psychiatrists, the graduates tended to work side-by-side with psychiatrists, performing many of the same functions a 'junior psychiatrist" might perform. In another location, a graduate was based in a psychology clinic but worked largely in a primary care clinic for dependents, thereby providing cost savings for care that otherwise would have been contracted out. Another graduate was the only prescriber for active duty sailors in a psychology clinic that was located near the ships at a naval base. Yet another graduate was to be transferred soon to an isolated base where he will be the only mental health provider. His medical backup will be primary care physicians.

2. Medical safety and adverse effects: While the graduates were for the most part highly esteemed, valued, and respected, there was essentially unanimous agreement that the graduates were weaker medically than psychiatrists. While their medical knowledge was variously judged as on a level between 3rd or 4th year medical students, their psychiatric knowledge was variously judged as, perhaps, on a level between 2nd or 3rd year psychiatry residents. Nevertheless, all graduates demonstrated to their clinical supervisors and administrators that they were sensitive and responsive to medical issues. Important evidence on this point is that there have been no adverse effects associated with the practices of these graduates! Thus, they have shown impressively that they knew their own weaknesses, and that they knew when, where, and how to consult. The Evaluation Panel agreed that all the graduates were medically safe by this standard. In a few quarters, the criterion for "medical safety" was equated with the knowledge and experience acquired from completing medical school and residency, and, of course, no graduate of the PDP could meet such a test.

3. Outstanding individuals: One indicator of the quality and the success of this group of graduates was that eight out of 10 were serving as chiefs or assistant chiefs of an outpatient psychology clinic or a mental health clinic. Two of these chiefs completed their PDP training less than a year earlier. Other indicators of quality and achievement that characterized this cohort were present when they entered the program. They all had not only a doctorate in clinical psychology but also clinical experience that ranged from a few to more than 10 years. All but two had military experience. The characteristics that led to these accomplishments showed again in that this cohort overcame their limited background in traditional scientific prerequisites for medical school. They certainly suggested that the selection standards should be high, indeed, for candidates for any future prescribing psychologist training, be it military or civilian. The opinion of the Evaluation Panel was that the history of the PDP has established that any program with comparable aims must be a post-doctoral program.

4. Should the PDP be emulated? There was discussion at many sites about political pressures in the civilian sector for prescription privileges for psychologists. Virtually all graduates of the PDP considered the "short-cut" programs proposed in various quarters to be ill-advised. Most, in fact, said they favored a 2-year program much like the PDP program conducted at Walter Reed Army Medical Center, but with somewhat more tailoring of the didactic training courses to the special needs, and skills of clinical psychologists. Most said an intensive full-time year of clinical experience, particularly with inpatients, was indispensable. The Evaluation Panel heard much skepticism from psychiatrists, physicians, and some of the graduates about whether prescribing psychologists could safely and effectively work as independent practitioners in the civilian sector. The usual argument was that the team practice that characterized military medicine was an essential ingredient in the success of the PDP that could not be duplicated in the civilian world. The Evaluation Panel urged the graduates collectively to produce their own consensus view on what would constitute an optimal program.

5. Relationships with psvchiatry: Six graduates worked in close, gratifying, and harmonious partnerships with psychiatrists, one in an inpatient setting and the others in outpatient units. A seventh graduate had a similar, but more business-like pattern. The psychiatrists in these partnerships were very competent pharmacotherapists. The remaining three graduates were somewhat isolated from psychiatrists with psychopharmacological expertise. One graduate was an independent provider who directed a military division clinic, and, while the clinic had a staff psychiatrist, he was less experienced in psychopharmacology than the graduate--and openly admitted this. Their relationship also was somewhat strained. The other two graduates worked in very busy settings with other psychologists in one case and with primary physicians in the other. Each treated many patients with medication. Each had an expert proctor who was available by phone, page, and e-mail, but not first hand. Although both were only nine months out of the PDP, and they were doing excellent work by all accounts, the Evaluation Panel believed as a matter of principle that they would benefit more from the experience of closer daily liaison with an expert practitioner.

To be continued:

---

Members don't see this ad.

 

[sasevan]

Continued:


6. Scope of practice and formulary: The practice of pharmacotherapy was restricted to adults age 18-65 for all graduates.. Six graduates had no significant formulary restrictions even though there were slight formulary variations among them. The Navy was most restrictive: One graduate who was completing a third year of proctorship could not prescribe lithium or a number of new agents. Another prescribing psychologist was the most restricted of all graduates. He could treat only active duty patients even though dependents and retirees attended his clinic, and he could not prescribe lithium, depakote, and some newer antipsychotics. The Evaluation Panel considered his restrictions unfounded and unreasonable. A few graduates' formularies comprised lists of specific agents instead of drug classes, and it was difficult to effect changes. The MAOIs were the most common exclusions, being included on only one graduate's formulary. It seemed to the Panel that most of the exclusions derived from someone's untoward local experience, and not from judgments about the graduate's competence. Most graduates regarded the current formulary restrictions as no more than minor nuisances.

7. Psvchologist extenders: The PDP was not designed to replace psychiatrists or produce mini-psychiatrists or psychiatrist extenders, and it did not do so. Instead, the program "products" were extended psychologists with a value-added component prescriptive authority provides. They continued to function very much in the traditions of clinical psychology (psychometric tests, psychological therapies) but a body of knowledge and experience was added that extended their range of competence.

8. Psychopharmacology educators: An unexpected benefit of the PDP was the extent to which the graduates contributed to the training of psychology interns. At every site where graduates were in contact with interns, they had initiated teaching sessions, seminars, or courses in psychopharmacology. At two sites the comments emphasized that the teaching was far better than that provided by psychiatry which tended to be either too abstruse or too glib about the subject. The graduates knew better where to pitch the level of discourse because they better understood the perspective of the psychology interns. Several of the graduates were active in teaching clinical psychopharmacology to residents and other physicians.

9. Career impact: Unfortunately, many graduates appeared likely to leave the service in the near future because of being passed over for promotion. The career impact of the PDP was complex and hard to evaluate. Promotion odds seemed to depend in part on whether one joined the PDP shortly before or well in advance of promotion opportunities. Whatever the reason, departure from service terminates further assessment of outcome (within the service). Those who remain in the service should be monitored annually to maximize the information which can be obtained from the PDP.

10. Variety vs. restriction of caseload: Three graduates had practices that included 90-100% active duty personnel, two had 15-20%. Two graduates treated 60-80% dependents. Three graduates saw no retired personnel, two saw 20-30%, and one had 75% retirees or spouses in his practice. With the exception of one graduate who treated inpatients exclusively, the large majority of the pharmacotherapy patients of the others had disorders in the adjustment, anxiety, and depression disorder spectra. Not surprisingly, the medicines they used were mostly the newer antianxiety and antidepressant agents, especially the SSRIs. On another dimension of practice, the proportion of the caseload treated with pharmacotherapy, there also were wide individual differences: Four graduates treated more than 50% of their patients with medication, and three treated 25% or less. The graduates who saw only active duty patients were exposed to the least depth and breadth of psychopathology, and they gained less experience with medications because of pressures against their use with the active duty group. The diagnoses made and the medications prescribed by the graduates were functions of the military outpatient sample. They essentially mirrored what psychiatrists did with the same population, and, in fact, they differed little from the private practices of the psychiatrists on the Evaluation Panel. The Evaluation Panel believed that the clinical and administrative supervisors should make efforts, whenever possible, to help the graduates maintain and sharpen their clinical skills by expanding the diagnostic breadth of their caseload. The increased diversity and range of severity found on the inpatient service make it an important potential site for additional experience. Family and primary practice medical clinics provide other options.

11. Independent provider vs proctored status: All graduates were initially proctored by psychiatrists. Half of them had advanced to independent provider status, with its standard minimum review of 10% of medication cases. Interestingly, all members of Group C and one from Group D-the last two classes to complete the PDP-were independent. Two other graduates were de facto independent providers. The clinical supervisor in one case and a department head in the other as a matter of principle and philosophy would not propose independent provider status for any prescribing psychologist. These two graduates were members of Groups A and B-one Navy, one AF-and each had been proctored for three years. Both were soon to attain "independence by transfer" through reassignment to sites that had no on base psychiatric oversight or backup. The Evaluation Panel viewed these two graduates as no less effective or safe than their peers. They were caught up in the problem of a lack of a DoD-wide agreed upon set of clearly defined steps from 100% supervision to independent practice.

12. A final comment: As the preceding synopsis and the following detailed report indicate, the PDP graduates have performed and are performing safely and effectively as prescribing psychologists. Without commenting on the social, economic, and political issues of whether a program such as the PDP should be continued or expanded, it seems clear to the Evaluation Panel that a 2-year program-one year didactic, one year clinical practicum that includes at least a 6-month inpatient rotation-can transform licensed clinical psychologists into prescribing psychologists who can function effectively and safely in the military setting to expand the delivery of mental health treatment to a variety of patients and clients in a cost effective way.

We have been impressed with the work of the graduates, their acceptance by psychiatrists (even while they may have disagreed with the concept of prescribing psychologist), and their contribution to the military readiness of the groups they have been assigned to serve. We have been impressed with the commitment and involvement of these prescribing psychologists to their role, their patients, and the military establishment. We are not clear about what functions the individuals can play in the future, but we are convinced that their present roles meet a unique, very professional need of the DoD. As such, we are in agreement that the Psychopharmacology Demonstration Project is a job well done.

Source: ACNP Bulletin, Volume 7, Number 3, Summer 2000

 

[sasevan]

CRITICAL ARGUMENTS THAT SUPPORT RxP

1. Many non-psychiatric physicians and other health care providers are prescribing psychotropic medications for their patients and actually prefer to refer those individuals to psychologists for treatment, including assessment, possible psychotropic medication prescription, and treatment.

a. The number of visits to general physicians in which psychotropic medications were prescribed increased from 32.7M to 45.6M from 1985 to 1994. (The proportion of such visits increased from 5.1% to 6.5%). Should general physicians prescribe in this way? Do they have adequate training to diagnose mental illness? Are they spending sufficient time with patients who present with psychological distress?

b. The federal government, aided by medicine and the pharmaceutical industry, has been advocating for medicating as the primary treatment for mental and emotional disorders by primary care physicians. These physicians have little or no formal training in empirically-based mental health treatments, with the exception of continuing medical education about depression that is usually provided by drug companies.

c. By the year 2020, depression with psychological etiology will be the second leading cause of the non-fatal disabling effects of disease. (Depression currently accounts for 47% of the effects of physical disease and injury.)

2. Individuals usually seek help from primary care physicians when experiencing physical, social, or emotional changes and/or discomfort. Primary care physicians have limited training in psychiatric diagnosis and little training in modern psychological treatment strategies and techniques. Many are uncomfortable making psychiatric diagnoses and tend to ignore or minimize symptoms of mental distress. It is not uncommon for them to attempt to explain symptoms as being solely due to a physical problem.

3. Psychologists have extensive training in biopsychosocial assessment, standardized diagnostic procedures and a wide variety of techniques and skills for the treatment of mental and emotional disorders. Psychologists have learned these fundamentals for providing effective services through an intensive graduate program leading to a doctorate in psychology, as well as an internship and post-graduate experience. The depth and scope of training for psychologists in the mental health and the psychological aspects of disease exceeds that of other health professions.

4. Training in the physiological aspects of mental and behavioral disorders is a part of doctoral-degree programs in psychology; APA accreditation and the psychology state licensure examination require demonstrated baseline competence in the biological, psychological and social bases of behavior.

5. A 1992 survey of hospital-affiliated psychologists indicated that 64% of the respondents already collaborate with physicians regarding psychotropic medication dose, type or toxicity and 41% provide follow-up documentation on the efficacy of the psychotropic medications.

6. Many other non-physician providers who have the legal authority to prescribe include, for example, dentists, podiatrists, advanced nurse practitioners, nurse midwives, optometrists, and physician assistants. In 1997, there were over 160,000 Advanced Nurse Practitioners who were either prescribing or utilizing psychotropic medications in their practices in all 50 states. Psychologists are already prescribing in certain federal programs. They are prescribing informally in other non-governmental settings. This shows that one does not have to attend medical school to learn how to prescribe competently and successfully.

7. Because psychologists will have the ability to prescribe medication does not mean that medications will always be prescribed for their patients. The psychologist may determine that other treatments are more appropriate after she or he is able to complete a comprehensive assessment. Physicians, on the other hand, use medication therapy as their customary and primary treatment intervention. Therefore, if a depressed patient visits a primary care physician, they are likely to be prescribed an antidepressant. If this same patient visits a prescribing psychologist, other equally viable treatment options excluding, or in addition to, antidepressant therapy will be considered. It is important to remember thatthe authority to prescribe is also the authority NOT to prescribe.

8. Psychologists in health care are already practiced in recommending and monitoring psychotropic drugs and serve as an important resource for primary care physicians in their prescribing practices. It is logical to progress to the next level and train psychologists to prescribe independently.

 

[sasevan]

CRITICAL ARGUMENTS AGAINST RxP

Many of the compelling arguments for the aggressive pursuit of RxP have been offered. Several arguments opposing RxP have also been advanced and they are detailed below. These opposing arguments have not been ignored or dismissed. Listed below are some of the common sentiments that have been expressed against RxP, as well as counterpoints to supplement the pro-RxP arguments already outlined in this document.

Argument #1:

?If psychologists want to prescribe medication, they should go to medical school.?

Counterpoints:

A. Psychologists are highly trained specialists in mental health who can be trained to prescribe psychotropic medications, thus utilizing the psychologist?s ability to deliver services that span the full range of mental health services.

B. Psychologists obtain a high level of competency through an extensive education and training process. This normally entails an average of seven years of education beyond the undergraduate degree in a comprehensive academic program that includes practical training experiences and didactics.

C. Almost all states require 1 to 2 years of supervised post-doctoral experience for the granting of licensure.

D. Clinical psychology students receive extensive training in the physiological aspects of mental disorders. In fact, APA accreditation standards require coursework and demonstrated competence in physiological bases of mental disease.

E. The Association of State and Provincial Psychology Boards, which monitors and oversees all state licensure examinations, requires knowledge of common physical disease symptoms and psychophysiology, as well as the effects of major psychotropic drugs and other commonly prescribed drugs on behavior and cognition.

F. Psychology?s recognized competence in the medical and psychological aspects of illness is exemplified by the fact that over 3,000 psychologists are employed on medical school faculties where they participate in a range of health psychology activities, including teaching psychopharmacology courses!

Argument #2:

?Psychologists will become greedy pill-pushers. Prescribing will change the nature of the profession, causing psychologists to quickly write prescriptions and abandon our important psychological model of treatment.?

Counterpoints:

A. Many psychologists are currently informally prescribing medications when they consult with physicians and psychiatrists about the treatment regimens of mutual patients, which includes the use and effects of psychotropic medication.

B. Psychologists have demonstrated that their expertise in treatment allows patients to regain functioning with fewer medications and lower dosages of medication, thus dispelling the fear that psychologists will ?forget their skills? and become ?pill-pushers.?

C. Training in RxP is reserved for licensed psychologists who have been practicing for a minimum of 5 years after the granting of their degree and license. This is to ensure that the new psychologist has sufficiently solidified their professional identity, operating from a well-developed psychological model of intervention.

D. RxP clearly supports a psychological model of prescribing, not a medical model of prescribing. Practice and prescribing according to these two models is philosophically and fundamentally distinct. Psychology views the individual and prescribing from a biopsychosocial framework, whereas medical practice and prescribing focuses on identifying disease and eradicating it.

E. Psychology has a strong identity and it can withstand and flourish with this additional tool for practice.

Argument #3:

?Liability insurance premiums will increase drastically and those who do not prescribe will have to pay higher rates to compensate for those who do prescribe. Doesn?t the likelihood of mis-prescribing increase when psychologists, not physicians, prescribe??

Counterpoints:

A. Over 70% of psychotropic medication in the United States is currently prescribed by non-psychiatric physicians who have minimal training in the detection and management of mental and emotional problems. Psychologists are much better trained and equipped to accurately diagnose and treat mental disorders.

B. Insurance premiums are rated based upon experience. The prescribing experience of Optometrists, Advanced Nurse Practitioners and Physician Assistants demonstrates that non-physician prescribers are as safe as physicians. Therefore, their premiums have not increased and are currently less expensive than the present liability rates for psychologists. Psychologists who oppose RxP fear substantial increases in liability insurance premiums. When medication is prescribed judiciously, as Optometrists and other non-physician prescribers have shown, there is no significant increase in premiums.

Argument #4:

?The education community has not been sufficiently consulted about the RxP scope of practice expansion. Are there going to be mandates to change core psychology curricula to adjust for RxP? Will the fundamentals of graduate psychology training suffer, or will more core courses be added, thus extending the duration of doctoral education??

Counterpoints:

A. The following education/training constituency groups have provided specific input in the development of the RxP movement: Board of Educational Affairs, Board of Scientific Affairs, Division 12 (Clinical), Division 22 (Rehabilitation), Board of Professional Affairs, Committee for the Advancement of Professional Practice, Board of the Advancement of Psychology in the Public Interest, National College of Professional Psychology, APA Council of Representatives, and the APA Board of Directors. Additionally, RxP issues have been included on several cross-cutting agenda items during many sessions of consolidated meetings where several APA constituency groups gather simultaneously to conduct their business meetings.

B. The overall quality of current education of psychology students is valued, important and will not be compromised. However, in some academic settings, the training is dated and practitioner students are not being adequately trained to thrive in the current marketplace. Education should evolve as the field evolves, while preserving the fundamentals of psychology education.

Argument #5:

?Are we just adding RxP because we fear that psychology is losing its distinctive identity to master?s trained individuals? Why should psychologists prescribe if we already have a good relationship with, and accessibility to, psychiatrists and physicians? Will the field begin to devalue psychologists who do not prescribe, thus phasing these psychologists out of the field??

Counterpoints:

A. RxP is an additional tool for psychologists use and it is not intended to replace the unique services that psychologists already deliver.

B. Psychologists already specialize with different populations, diagnoses and treatment approaches, and each specialty area is a respected sub-field of psychology.

C. Certification, not licensure, for RxP extends the current scope of psychological practice. It does not replace it.

D. Psychiatry has historically attempted to obstruct the evolution of psychology. For example, between 1950 - 1970 psychiatrists argued that it was unsafe to permit psychologists to practice outpatient psychotherapy without medical referral or medical supervision. Psychiatry also attempted to prevent psychologists from access to specialized training in psychoanalysis. They also opposed the psychologists? ability to treat patients in hospital settings and Skilled Nursing Facilities. And, psychiatrists unsuccessfully fought to defeat measures that now allow the elderly direct access to psychological care under the Medicare program (OBRA).

 

[thethrill]

I was on call last night, hence my absence from this form. I still firmly believe the bill passed in louisiana was well beyond the scope of what psychologist should be allowed to do. Furthermore, the fashion in which that bill was passed was sleazy at best. The DoD like I have said in the past is a very, very small study of very selective psychologist and should not be extrapolated to include all psychologist. The study is not significantly powered and if it were a medical study would be at best lightly regarded. Furthermore, the military is biased and the study should only be taken with a grain of salt. Argue what you may, but even in the study psychologist were at best at the level of a 2nd or 3rd yeat resident. We had our residency meeting today and out of 7 attendings and 18 residents not one agreed with psychologist gaining prescription writing priviledges. We all have grave concerns and are currently composing a letter to the APA, governor Blanco, and everyone else who will listen. Argue what you may, but you have to agree the bill in Louisiana was poorly written and goes to far to fast. Let's also agree that psychiatrist have much more clinical training than psychologist, on averge psychiatrist graduate with a minimum 35,000 clinic hours. A good psychologist will be lucky to obtaing 1/8 of that in their training. Once again there is a great need for psychologist, but perscribing is a mistake. Again I am not naive and I am aware of turf wars and I am greatly concerned about the dumbing down of what is already considered fringe medicine. Furthermore, I am very aware that when psychologist start prescribing the will be much cheaper then the real deal those driving down reimbursements to psychiatrist. I can not afford to make much less then what current psychiatrist make. I did not go through all of this to have my family and I to struggle, we have struggled long enough. I always be very generous with my time and money, but I am not a martyr. Thankfully I worked very hard through medical school and performed extremely well academically making it easy to obtain an emergency medicine residency. Thus I will be switching as I am sure other psych residents will. The decision to grant psychologist prescription priviledges will have extreme detrimental effects on psychiatry in the near future. I believe psychologist gaining prescription priviledges is inevitable not because they are good at it but because they will be much cheaper at it. This move may be heavily dictated by healthcare costs as opposed to need. This is truly sad, the worst part is listening to people (psychologist) bash psychiatrist who are usually some of the lowest paid most altruistic physicians. Again there is no comparision between the level of a psychiatrist training and that of a psychologist. Finally, SVAS I don't believe you are a psychiatrist. I am not arguing with you and you don't have to defend yourself. If you are a psychiatrist I am sure you don't feel the need to prove it to a 1st year resident like myself that just switched to EM. I agree some changes need to be made to the psychiatry residency format, but for the most part I think psychiatry residencies are appropriately structured. Overwhelming every resident I talk to whether it be IM, Neuro, EM, etc... don't see psychologist writing scripts autonomously as the answer. Everyone one would like to see more psych spots open up and the residency freeze to be lifted by the governement. There are better ways to get help for rural areas then provideing substandard care. Finally, I am proud to be a physician. I ran a code last night in which the patient was awake talking to me in V-tach, then V-fib losing conciousness. And yes SVAS I can read a 12 lead and rhythm strip. I ran the code shocking him multiple times as well as ordering amiodarone and epi, as I intubated this poor 51y.o dude. He survived and is alive without cognitive deficit and went to bypass this AM. I also admitted 5 patients (light night) and had to deal with a DKA, several low BP's and low Hgb's as well as the usual agitation. I am a well trained physician and I can confidently say there is absolutely no comparision between a psychologist and a physician.

 

[Svas]

Argue what you may, but even in the study psychologist were at best at the level of a 2nd or 3rd yeat resident.

What level of resident status would a psychiatric NP achieve? Are you willing to say that NP's are functioning at at 4th year level? 3rd year? 2nd? Do psychiatric NP's have a clinical psychologists background, training, experience, and skill at making mental health diagnoses?


Just random thoughts.


S

 

[dentite001]

Great posts everyone. I'm curious though. Someone mentioned that even if all psychologists were granted prescription, demand would still outweigh supply. I assumed we were just talking about the clinical psychologists becoming medical psychologists. Don't forget, that there are many sub-divisions within psychology, with clinical accepting the fewest each year. Would the clinical psychologists even make a dent in the current demand? Should other psychologists be granted that kind of power?
One final thought. I can see their being an entire backlash against white collar professions and higher education in general. What's the point of entering into a profession with no guarantee to be rewarded for all of your hard work and financial investment. It seems that way in the health profession and others such as the legal profession too. I know many people who went to University and then went back to college or entered into a trade. My landlord, who owns 12 houses was a mechanic. He is retired and enjoying everyday. My neighbour, a doctor still works 12 hours a day at the age of 70 (amazing), and has finally payed off his house. What the hell is going on here?

 

[Anasazi23]

Interesting website:

http://www.rxp.info/

This one made me laugh out loud at least 5 times:
It's a good example of how the RxP psychologists are thinking...

http://home.fuse.net/schafer/prescrib.html

 

[sasevan]

The TRUTH

About AAAPP

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

The American Association of Applied and Preventive Psychology is a scientific Association with over 500 members worldwide. The purpose of the Association is to promote, protect and advance the interests of clinical and preventive psychology in science, professional application, and other means of improving human welfare. We strongly value a research orientation toward clinical as well as preventive work, and placing the consumer and public interest above guild or personal interests. The Association publishes the Journal Applied and Preventive Psychology: Current Scientific Perspectives.

The AAAPP is a fringe group in psychology due to views so extreme that they became a spinoff of the American Psychological Society (APS), which in turn separated in 1988 from the APA in order to promote the academic-research dimension of psychology as the APA began to promote the clinical-applied dimension.

As the APS and the APA reconciled through the 1990s the more extreme element, increasingly losing acceptance in psychology (both in academic-research and clinical-applied circles) became the AAAPP.

AAAPP: 500 members
APS: 13,500
APA: 150,000

The GOOD NEWS

Finally, we can ALL agree that at least some psychologists (AAAPP) should not get RxP

 

[PsychMD]

I will post a very personal post now, so take it with a grain of salt...it is just a skewed and biased personal perspective.

I am utterly depressed (except by your youthful energizing optimistic enthusiasm, Anasazi! I really wish there would be more of you in the real-world practice, but since there are so few psychiatrists around anyway, the chances are pretty slim to find the rarely optimistic one around!). This whole discussion, many of the propagandistic links posted (either pro or con) reveal such corruption and such disregard for public safety, for the very "primum non nocere" concept, that it almost seems to be either institutionalized or even maybe done purposefully...the only conclusion that a casual observer will derive is that the "learned people" are arguing with one another like pompous fools over money while the patient is dying. This is nothing new, of course. I thought the age of Moliere in Medicine/Health-care was dead. But no...it's well and still alive, albeit somewhat dumbed-down, because more people actually want to wear the pompous fool hats too and fight over money and a piece of the pie. Not that I blame anyone. The incomes have realistically gone down across the board and it is increasingly difficult to maintain an income level via private Practice or even via a salary (compared to the late 80's, early '90's) by practicing ethically and judiciously. You either practice the "high quality way", the old fashioned way by allowing LOTS OF TIME for both evaluating/treating patients and reading/continued education for yourself, or you don't. The high-quality way (the artisan way) will clearly be unable to "compete" income-wise with the low-quality-mass production way...since it seems that this concept is now FULLY applied to health-care. The proponents of the assembly line model say that they are "modernizing" the field. The opponents say that this means "death for Medicine as we know it".

Personally, I am one of the ones who are still struggling, with great difficulty, to make a living as one of the artisans. It is quite evident to me that I don't earn even the median income by my way. I just earn enough to support myself and my daughter who is in college. I will continue to work the artisan way because it's the way that makes me feel the most comfortable, ethically and personally, and allows me to be in control and have a life too. But THIS IS increasingly a very "unproductive" way to earn a living, in the current health-care market situation, within this health-care system. My patients are mostly poor/impoverished themselves, by virtue of their illness, so I don't really expect to get loads of money from them. The VERY few patients who do have the ability to pay have long been already "captured" by my "older" more established colleagues. Plus the economy is pretty bad. Who has the money to pay me my current rates? Practically no one.

So, in a depressing way, SVAS, who has joined the mass-production "forces", may be actually right. You want mass psychiatry, you want to earn a living, to support a family, to pay your debts...that's what you get. The artisan skills are seemingly of no value in today's marketplace. This is why IT IS depressing. And I'm not getting into the subject of how bad the PATIENTS have it. The overall quality of care from the point of view of the patients is abysmal. There is no access, there are no services, there are no competent/well-trained professionals available for them. And the saddest part is that our patients, especially the children, are really disenfranchised. They have the least of voice, of clout, of power... to be heard.

From a personal point of view, I have made my peace with myself, I recognize my limitations, I only take on as much work as I can handle, I don't have grandiose aspirations that I can solve the "state of Psychiatry" or of "public Health". It's a hard and rather arduous road. I wouldn't necessarily recommend it to my child...not that she was ever even interested in any field of Medicine.

I TRULY HOPE THAT I AM WRONG. I TRULY HOPE THAT THIS DEPRESSING POINT OF VIEW IS JUST A SKEWED and BIASED INDIVIDUAL ONE. My personal experience does NOT necessarily describe well the current reality. You know why I even came here? JUST TO GET SOME HOPE, from younger colleagues, like Anasazi. And Anasazi, I want to thank you, because your posts have been like cool water to a fevered brow to me. YOU ARE INDEED A HEALER, WORTHY OF YOUR PROFESSION. If I ever needed a psychiatrist for myself, I would choose Anasazi and I would pay him whatever money I had just to be treated by him. Because SVAS, although he may be "right" from a business point of view, or even a Public Health point of view, has stopped being a healer a long time ago. And I can fully understand why. I don't blame Svas. But he DID DEPRESS ME. And he says he is a TEACHER too. Most depressing.

 

[sasevan]

Hi PsychMD,

Change is often very scary for both patients and those who treat them.
Change represents a loss of the familiar, even when what was familiar was impoverishing in some ways.
A loss that is interpreted as self-diminishing may lead to depression.
With patients suffering due to loss and struggling with depression I attempt to help them overcome polarizing and catastrophizing patterns of thinking; to see in change not just loss but also opportunity for gain.
I agree that current changes in mental health (psychologists gaining RxP) will result in status and financial losses to psychiatrists.
I believe that the unjustifiable discrepancy between psych PhD/PsyDs earning about 40% of what psych MD/DOs earn (in Miami, median income for psychologists is 55K and for psychiatrists 135K) is coming to an end.
I also believe that the artificial division in mental health between psychiatrists providing med mgm and psychologists doing testing and therapy is also coming to an end.
For psychiatry these are losses BUT they are also opportunity for gains.
Maybe psychiatrists will once again truly become psychotherapists as well as psychopharmacotherapists.
Maybe they will no longer adhere to the 30 minute psychiatric med eval and 15 minute med check every 30-60 days.
Maybe this change can become the catalyst for psychiatrists to again practice as artists-scientists and not as minions of mangled healthcare.

Maybe I'm naive, but I see a bright future for mental health.
A future where clinical psychiatrists and medical psychologists both make a reasonable living but where making money is not the driving force of their practice; where both are providers of biomedical and psychosocial interventions; where both can champion the biopsychosocial model with physicians and other practitioners; where both work collaboratively with neurologists and neuropsychologists in an increasing understading of the mind-brain connection; where guild monopolies and turf wars are replaced by genuinely compassionate, comprehensive, and collaborative patient care.

Its a future that is possible. Its up to us to make it so. Peace.

 

[Svas]

Because SVAS, although he may be "right" from a business point of view, or even a Public Health point of view, has stopped being a healer a long time ago. And I can fully understand why. I don't blame Svas. But he DID DEPRESS ME. And he says he is a TEACHER too. Most depressing.

I really do understand your frustration. I apologize for making your experience about practice more difficult. That's not my intent. It is, however, my intent to attend to the sweeping numbers of patients that we are *not* treating. We are caring for a minute percentage of the mentally ill population and we can't pat ourselves on the back for that.

Psychiatrists, in general, provide good care. But we provide good care for such a small fraction of the mentally ill that we often forget that there is a massive tidal wave of people NOT being treated, or being treated by people with only a 6 week rotation through psych. The mentally ill are procreating just like everyone else, resulting in an ever increasing number of people with psychological difficulties. We are, in contrast, a diminishing number, with residency number paling in comparison with the task of taking care of such a wave. We have to do something different.

This is not about my making an adaptation so that I can make more money. (Personally, that suggestion is insulting, but I know that your comment was not borne from that attempt, but a reflection of your frustration. At least that's what I'm hoping.) My suggestions to adapt to psychology's desire to add prescriptive authority comes from my belief that psychologists are doctors too. They've got high level skills and can be trained to prescribe within a limited formulary safely.

The impact of adding such a large contingent of knowledgeable providers to care for a broader range of mental health conditions is very exciting. To ignore the suffering of the tidal wave I've discussed above while standing on our very unstable soapbox . . . now that's depressing.

S

 

[DrFocker]

4. Should the PDP be emulated? There was discussion at many sites about political pressures in the civilian sector for prescription privileges for psychologists. Virtually all graduates of the PDP considered the "short-cut" programs proposed in various quarters to be ill-advised. Most, in fact, said they favored a 2-year program much like the PDP program conducted at Walter Reed Army Medical Center, but with somewhat more tailoring of the didactic training courses to the special needs, and skills of clinical psychologists. Most said an intensive full-time year of clinical experience, particularly with inpatients, was indispensable. The Evaluation Panel heard much skepticism from psychiatrists, physicians, and some of the graduates about whether prescribing psychologists could safely and effectively work as independent practitioners in the civilian sector. The usual argument was that the team practice that characterized military medicine was an essential ingredient in the success of the PDP that could not be duplicated in the civilian world. The Evaluation Panel urged the graduates collectively to produce their own consensus view on what would constitute an optimal program.

It seems that the new law in LA requiring only 380 hours of classroom time on weekends without an intensive year of full time clinical experience falls far short of what the Psychologists in the DoD went through. Let's not forget the sample size was only 10! And only a limited number worked "de facto" independently while most had oversight with a limited formulary. The LA law gives an almost unlimited formulary (exceptions being narcotics I believe). And, that link that Anasazi posted where Dr. Schafer brought up a good point: The variability in the quality of PhD graduates. I received a spam email today advertising my new PhD in Psychology or Engineering, or whatever. Who's to prevent them from attaining RxP?

I'll be entering Psych residency in June and was pretty "psyched" about it. My question to some that are going through residency now or have finished and are practicing, what would you do in my position? I'm seriously considering entering FP or IM after my PGY1. I really wanted to do Psychiatry but I have massive loans, and a new wife that would like to start having kids before she's 40. All the hard work and sacrifice we've gone through, is it worth risking spending the next four years in Psych residency with the potential of not being able to make enough to pay back my loans?

 

[Anasazi23]

I'm seriously considering entering FP or IM after my PGY1. I really wanted to do Psychiatry but I have massive loans

So, this is one person confirmed to be quitting his psychiatry residency, and another who is considering leaving.

I'm glad to see that the psychologists' push for Rx privilages is resulting in "increased access to mental health care."

Please stick with it. Be a good physician. Be a good psychiatrist. Psychiatry has endured worse and will remain despite this. The money will come if you're doing what you truly love and what you're best at.

Good luck.

 

[DrFocker]

Thank you for your input and optimism Anasazi. I hate sounding like it's all about the money, but obviously I need it to survive, pay loans, and start a family. I do have to wonder how Psychologists will make it when the mal-practice lawsuits start rolling in. Maybe economics will control what naive politicians can not. Unfortunately, some unlucky patients will suffer or die from this "experiment", but it's out of our hands.

 

[thethrill]

Dr. Focker

I presume Mr. Gaylord Focker . There are many phenomenal fields of medicine. Ultimately you have to love what you do. I truly love medicine and can't imagine doing anything else. But my number one priority is my wife, family and friends. No matter what I do in medicine it will never be as important or as fun as what I do in my personal life and free time. I can not imagine entering a field with so much uncertainty. I am $200,000 in debt. With my wives optometry school debt we will be almost $350,000 in debt. I can not afford to make less than $100,000/yr, especially since my wife and I are going to start a family soon and she will be taking a lot of time off. I am 30 y/o, drive a 92 ford ranger, and haven't been on vacation in over 2 years. I grew up in the hood and I am still struggling today. I am not complaining because I truly have a great life. My wife is an angel and I am surround by many amazing friends, I have truly been blessed. However, you get the point, I need and want to start living my life and that requires a certain amount of financial freedom. I bought new furniture last week for the first time, pretty exciting. If I am one of the top earning physicians I am doing something wrong, either working too much or commiting fraud. My advice is to look around and find something you'll love. My fear with psychiatry is that the field is much my financial strained than other fields because crazy people don't make money and nobody wants to pay for them. Psychologist can rationalize it how they want but they don't have appropriate training to prescribe medications. Rememer all the tough classes you took as an undergrad always getting the best grades, studyig for that God forsaken MCAT, and all those interviews. I had a double major in Bio and Chem 3.85, scored a 28 on the MCAT and didn't get accepted the first time I applied. Got a masters degree, retook the MCAT scored a 31 and then got accepted. Then went through the rigors of medical school. Don't let anybody kid you the vast majority of psychology programs are not nearly as rigorous as medical school. Remember the 3 sets of boards you had to pass I find it insulting to here psychologist compare themselves to psychiatrist. Truth be told there are some bad physicians that skated through medical school, so there is that tail end on the class, but the tail in psychology is much, much, much longer. Soon enough psychologist will get what they ask for and then they will misdiagnose and kill patients. Medicine is very difficult, prescribing medications is very difficult. Mentally ill patients get pregnant, have renal failure, cardiac dz, are diabetic, etc... all of this has to be taken into consideration when prescribing. Without indepth medical training you can not truly appreciate the complexities of medicine. Medicine is changing and all fields have pro's and con's, I wish I had good advice for you but everything is uncertain at this point. If anyone offers "good advice" be suspicious. Do what's best for you. Ultimately I felt emergency medicine would be best for my wife and I, I still get the oppurtunity to help people in a meaningful way while earning a comfortable living with a nice lifestyle. Although that my change soon as well.

 

[PublicHealth]

So, this is one person confirmed to be quitting his psychiatry residency, and another who is considering leaving.

I'm glad to see that the psychologists' push for Rx privilages is resulting in "increased access to mental health care."

Please stick with it. Be a good physician. Be a good psychiatrist. Psychiatry has endured worse and will remain despite this. The money will come if you're doing what you truly love and what you're best at.

Good luck.

Two states give psychologists RxP and the entire field of psychiatry is now doomed. Is it really that bad? Psychiatry has been the bastard stepchild of medicine for years, and only recently, with increased medicalization and reliance on psychopharmacology, has the field become more integrated with other areas of medicine. Keep in mind that most psychologists have stated that they will NOT seek RxP (time will tell). As Anasazi opines, psychiatry will survive, and psychiatrists will continue to treat a range of patients, perhaps even collaborating or sharing practices with "medical psychologists." Arguments about "patients will die!" and "it's not safe!" aside (who's to judge?), maybe allowing psychologists to prescribe under the supervision of psychiatrists may actually be a good move for psychiatry insofar as it will increase the numbers of patients who will have access to behavioral healthcare, reduce time to appropriate evaluation and treatment (indirect suicide prevention in some cases), and ultimately foster the development of integrated pharmacotherapeutic and psychotherapeutic treatments?

 

[quixote1974]

Hmm, it seems to me that giving psychologists prescribing privledges won't really reach out to the people who are really underserved. I'm talking about the chronically mentally ill, who flood the state system, and whose medication needs (psychiatric AND medical) are probably too complicated for most psychologists, and maybe even psychiatrists who don't have a strong medical background.

Most of the psychologists I know work with fairly monied "clients...." Do we really need to give more prozac to these people???

 

[PsychMD]

Dr. Focker, I can empathise with your concerns. Psychiatric practice is hard. But, as I've said before somewhere, this is most likely just a tip of the iceberg or a mirror re. other systemic problems re. health-care in our country. I will post here a copy from a colleague surgeon's post (from another website dedicated to interaction among practicing physicians from different specialties; it is a site with restricted access for MD/DO only which requires licensure verification for access, and it is amazingly good re. interaction with colleagues from different specialties...quite amazing, considering that today we are pretty "fragmented" among different specialties, and inevitable turfs, in the "real-world"):

"...don't despair afterall, it is not just psychiatry that is in a mess. I believe, all of medicine (include surgery) is in a mess. Surgery has splintered off in multiple diretions. Volumes of procedures falling to new interentional procedures and GI and other medical therapies. Many a times it is purely a turf war rathr than what is really good for the patient. Gimmicks have replaced well founded accepted practices. News flashes and Media reporting counts more than peer reviewed works. Many many academicians (use the word loosely) have chosen to go to their local TV station rather than their respective society journals for publiction of their work no matter how terrible it may be. Oh well, I have to run off to the O.R enough of my rant for today".

Dr. Focker, even if you are not inclined towards a surgical specialty, the "grass" is not always "greener" for other specialist colleagues either. It is hard not only for recently graduating residents, but also mid-career physicians who are primarily doing ANY clinical work at this time, especially hard for FP, IM, Peds too, not just Psych. or Surgery.

Obviously, as an individual, your primary "duty" is towards your own well-being and your family's well being. (see theTHRILL's post; BTW, theTHRILL, I personally think you are and will be a wonderful physician; your posts reflect the exact qualities which make our profession proud: well trained, compassionate, motivated, inquisitive, pro-active, always keeping the patient's best interest in mind; be proud of your training and career, no matter what specialty you will choose, you will do great; this is quite evident from your posts).
Most physicians, by virtue of their tradition and training, also feel great responsibility towards their profession AND toward their colleagues, AND their teachers as well, REGARDLESS of specialty. This is the old "Hippocratic" way, I think. This is the primary bond which still unites physicians at this time, in spite of the economics of health-care, or health-care policy/politics. The more recent "acute" conflict is occuring, it seems, since physicians who once exerted (or at least thought they could exert) some degree of control/influence over the profession, or over health-care policies, in general, feel at this time that they no longer have this degree of control/influence, at least not at national level. It was bound to happen, historically, at some point or another. So these are most likely historical/economical trends. But if the Hippocratic "message" has survived for so many centuries, and has apparently survived MUCH worse "Academic" infighting that we see now, it has survived scourges, plagues, wars, revolutions, economic downturns, the industrialization era, etc....I sincerely believe that it won't go down the drain so soon, at least not during our lifetimes, and will most likely survive beyond the "corporatization of health-care" era as well, I hope! So the ESSENTIAL message is POSITIVE.

 

[DrFocker]

Thanks for the insightful perspectives Psych MD, quixote, and thethrill. Obviously, the overriding theme is that all of medicine is changing for better or worse. I, like thethrill, have $200,000 in debts and about all I have to show for it is the clothes on my back and a 98 Honda with almost 200,000 miles on it. I can't conceivably pay off that debt, start a family, and buy a house/car without making over $100,000/year either. I guess I'll have to just stick with Psych in the hopes that everything will work out for the best. Psych is what I want to do and there seem to be similar problems happening in all the specialties. I'll hope for the best, but if worse, comes to worse and I can't make a living as an MD, there is always law school.

 

[PublicHealth]

Damn...everyone took off their gloves. Have we debated all the issues related to psychologist RxP?

Anyone have information regarding which other state(s) besides New Mexico and Louisiana are closest to allowing psychologists to prescribe? I have heard that New England will be toughest because of persistent lobbying by the AMA and American Psychiatric Association in this region. Is the same true of other regions of the country?

 

[lazure]

"Rememer all the tough classes you took as an undergrad always getting the best grades, studyig for that God forsaken MCAT, and all those interviews. I had a double major in Bio and Chem 3.85, scored a 28 on the MCAT and didn't get accepted the first time I applied. Got a masters degree, retook the MCAT scored a 31 and then got accepted. Then went through the rigors of medical school. Don't let anybody kid you the vast majority of psychology programs are not nearly as rigorous as medical school. Remember the 3 sets of boards you had to pass I find it insulting to here psychologist compare themselves to psychiatrist. Truth be told there are some bad physicians that skated through medical school, so there is that tail end on the class, but the tail in psychology is much, much, much longer."

Could you psychiatrists on this list please distinguish the issue of whether psychologists should have the right to prescribe from your illusory beliefs of psychologists as a lesser species that is by definition less intelligent than someone in psychiatry!!! It is actually quite difficult to get into a quality graduate program in psychology (I am ignoring the psychology paper mill schools here), since the good schools will accept 3 to 8 applicants from a pool of 500. We get far superior training in research methods than psychiatry residents do. Based on reading this thread I could conclude that psychiatrists are defensive and have a superiority complex, but I won't given the small and selected sample you represent. I am not surprised that you have difficulty relating to other non-physician mental health professionals given the preconcivied notions you hold onto so strongly.

 

[PublicHealth]

Alright! Lazure put his gloves on! Any psychiatrists care to get in the ring?

 

[Anasazi23]

Ok I'll bite.

Could you psychiatrists on this list please distinguish the issue of whether psychologists should have the right to prescribe from your illusory beliefs of psychologists as a lesser species that is by definition less intelligent than someone in psychiatry!!!

No, silly us...
We feel that you should prescribe after undergoing training in medical school and residency where you learn about human disease, pharmacology (not just psychopharm but those other annoying drugs from about 700 other classes) and other nonsensical things like pathology, microbiology, ob/gyn, cardiology, pulmonology, gastroenterology, etc, etc, etc. By your definition, everyone who is intelligent should be mailed a prescription pad and DEA number to better society.

...We get far superior training in research methods than psychiatry residents do.

That's nice.

...and psychiatrists get far superior training in things that directly effect patient outcome - knowledge of medicine.

You state that psychiatrists have a superiority complex. Perhaps.

I propose that psychologists are attempting to expand their scope beyond its britches due to what I perceive as their inferiority complex (which I strongly feel it is). If the answer to this is also "perhaps," then that is very, very bad for patients.

Psychologists serve an important role on the mental health care team. No one disputes that. That role, however, has been refined over time and was filling a niche that suited them, and patients, well. They are attempting to blur the lines between physician and psychologist. This is about their financial greed, personal greed, attempt to solidify the future of the profession, and desire for parity - not patients.

To believe otherwise, I feel, is naive.

http://pn.psychiatryonline.org/cgi/content/full/38/8/1-a

http://www.psych.org/news_room/pres...DeploresLouisianaGovsDecisiontoSignPPBill.pdf

http://pn.psychiatryonline.org/cgi/content/full/39/10/3

http://pn.psychiatryonline.org/cgi/content/full/39/10/1

 

[sdude]

I used to oppose the idea of any psychologists prescribing medication, but I'm sorry to say I've changed my mind after my (unfortunately somewhat extensive) experience with med-school faculty psychiatrists.

I know there are exceptions, but the intelligent and well-regarded psychiatrists I have seen for depression (and many I have heard about from contacts) seem to have learned everything they know about statistics and neurochemistry from drug company reps. (or Stahl's psychpharm comic book, which is almost as bad).

Ph.D psychologists have extensive statistical training, and would be able to recognize that most of the "studies" done by drug companies are clinically meaningless. They have real research training and would likely demand real, independent studies of drug efficacy and side-effects.

Surpassing most psychiatrists' knowledge of psychpharm and neurochem is simply a matter of reading *The Molecular Basis of Neuropharmacology* by Nester et. al. I don't think it's uncommon for Ph.D psychologists to study much harder books like Cooper and Kandel.

In short, I feel that psychiatrists have dropped the ball in a big way. The closer one looks, the more painfully obvious it is that the profession is merely a distribution channel controlled by the pharmaceutical industry.

Unless psychiatry raises its standards, establishes scientific credibility, and regains its professional independence, it will become increasingly irrelevant to the real business of caring for the mentally ill.

 

[dentite001]

I think everyone would be better off if they just decriminalized marijuana. Seriously, these wonder drugs are hype. 3% above placebo. Junk. I felt depressed once and Celexa did nothing. A little marijuana worked wonders. From what I hear the various sacred cacti(mescaline) can really heal the soul too. Those Indians were WAY ahead of their time.

 

[lazure]

Ok I'll bite.
Quote:
Originally Posted by lazure
Could you psychiatrists on this list please distinguish the issue of whether psychologists should have the right to prescribe from your illusory beliefs of psychologists as a lesser species that is by definition less intelligent than someone in psychiatry!!!
"No, silly us...
We feel that you should prescribe after undergoing training in medical school and residency where you learn about human disease, pharmacology (not just psychopharm but those other annoying drugs from about 700 other classes) and other nonsensical things like pathology, microbiology, ob/gyn, cardiology, pulmonology, gastroenterology, etc, etc, etc. By your definition, everyone who is intelligent should be mailed a prescription pad and DEA number to better society."


And of course, you missed my point entirely. I am objecting to the continued insults to the intelligence of the members of my profession by psychiatry residents on this thread. You have the full right to disagree with psychologists obtaining prescription rights given the inadequate training required. I agree with you and as a psychologist I will not seek prescription rights since if I wanted to I would have gone to med school. You and I talked about this already. But I insist that you and others here state your views without putting down the ability and intelligence quotient of doctoral level professionals. We worked our a$$ off to get where we are as well....

The psychiatry folks here (or many of them at least) seem to be doing a very good job of alienating other mental health professionals by dismissing them as idiots. And then you wonder why psychiatry is no longer respected....

 

[lazure]

Ph.D psychologists have extensive statistical training, and would be able to recognize that most of the "studies" done by drug companies are clinically meaningless. They have real research training and would likely demand real, independent studies of drug efficacy and side-effects.

In short, I feel that psychiatrists have dropped the ball in a big way. The closer one looks, the more painfully obvious it is that the profession is merely a distribution channel controlled by the pharmaceutical industry.

Unless psychiatry raises its standards, establishes scientific credibility, and regains its professional independence, it will become increasingly irrelevant to the real business of caring for the mentally ill.

All excellent points. All the more reason to work together, aint it?

 

[Anasazi23]

I agree with you that to insult the intelligence of psychologists (or any other member of a health care team) in general terms is wrong. You'll notice that I never, in any of my previous posts, made a comment about psychologists' 'intelligence quotients.' In turn, I take it upon myself to apologize for any psychiatrist who has insulted your intelligence.

Next:

I grow weary of saying this, but the above posts beg it again....
Psychopharmacology does not exist in a vacuum. Comorbid medical conditions are not, from the course outlines I've seen, adequately covered (how in the world could they be?) in these masters programs. Public Health posted a curriculum that left me wide-eyed in a previous post. It's worth checking out.

Last point: I'm not sure where the lot of other folks on this thread work or have worked - making comments like "psychiatry is the red-headed, 12-toed bastard stepchild blah blah....," "psychology is no longer respected, etc. I wish all of you could have done the neuropsychiatry rotation I completed as a 4th year med student. The knowledge level, clinical complexities, respect level and most importantly, the level of healing was incredibly outstanding. And in other psychiatric or medical institutions, if I bothered to ask, I always gained medical insight into why treatment regimens were undertaken, and for what specific purposes. On the other hand, if a glut of foreign medical grads, or some other blameable happenstance caused the psychiatrists to become what you perceive as insensitive pill pushers at your respective institutions, then I have a challenge for you.

If one were to look more closely at what psychiatrists are doing, or bother to ask why they are treating in a particular manner, you may be surprised to find that medications are not chosen via the help of a magic 8 ball or roulette wheel with SSRIS replacing red and black numbers. You may not even notice that psychiatrists have comprehensively reviewed charts, interviewed the patient, and are making what they feel are the best decisions based on their respective medical profiles, past medication trials, laboratory abnormalities or predictions, cardiac history, endocrine and kidney functioning, or any other such relevant collateral data.

Don't assume (I'm speaking generally) that because you undertook extensive training in psychological theory, testing, statistics, and the like that this entitles you to make medical decisions via the completion of weekend coursework in hotel lobbies. I challenge you to take the time to inquire as to the treatment plan with this psychiatrist. Find out their thinking. Ask for details. You may be surprised at what you hear.

 

[Anasazi23]

All excellent points. All the more reason to work together, aint it?

That's just the point. The reading I've done on this subject indicates that it indeed "ain't" about working together, but is a battle for increased respect, autonomy, and parity.

To me, psychologists wishing to work together would have made a collaborative effort with psychiatrists to gain the ability to collaboratively prescribe psychoactive medications. They failed to do this, and to the contrary, fought against said collaborative efforts by psychiatry to oversee rxp approval. They failed to agree to prescribe in only the oft-touted mantra "underserved areas," they failed to agree to a "limited formulary." That's right, in LA, psychologists will now prescribe medications completely unrelated to the field of psychiatry. Think I'm wrong? Think that psychologists will be above this reprehensible behavior? I can't wait for the data. I'll bet my life that some psychologist will, out of ignorance or in a legitimate attempt to help a patient, attempt to prescribe a refill of a medication, or even worse, blatently prescribe a medication not considered to be within a psychiatric formulary. Perhaps they'll take data 10 years from now stating that of the 11,000 beta blocker refills they gave, there were only 16 adverse reactions. Therefore, of course, they should be allowed to prescribe all medications without supervision as long as they undergo additional training courses. After all, they ARE "medical psychologists" - another vaguely defined and misleading term meant to confuse both patients and legislators.

Be honest....how do you expect psychiatrists to react? What type of reaction would you expect from what is generally seen as a disrespectful attack on physicians that worked so incredibly hard to become the most comprehensive healer to the medical/psychiatric patient? Psychologists did not react well (and rightfully so) when psychiatric social workers gained therapy reimbursement parity or when bachelors level psychologists make a push for medicare reimbursement. Psychologists are speaking with forked tongues. They are preaching increased access to mental health care, while at the same time attempting to undermine a profession, and are using sinister tactics to obtain rights through legislation rather than education.

Psychiatric patients are not solely psychiatric patients. They are medical patients whose disease is manifesting psychiatrically. Psychiatrists are not solely psychiatrists. They are physicians trained in the specialty of psychiatry. Is this the medical model? Is it different from the psychological model? Yes. It is also the model that has been the most successful and accepted in modern treatment of both medical and psychiatric patients thus far.

To say that psychiatry needs to "establish scientific credibility" is utter idiocy. Psychiatry is what it claims to be and has been.
Medical fundamentalism? You bet. It is also the most logical and effective way to treat medical patients - which psychiatric patients are.

 

[PublicHealth]

Psychologists are speaking with forked tongues. They are preaching increased access to mental health care, while at the same time attempting to undermine a profession, and are using sinister tactics to obtain rights through legislation rather than education.

Quote of the month.

 

[Andrew_Doan]

I posted a response to non-physician groups seeking more medical privileges here:

http://forums.studentdoctor.net/showthread.php?p=1487059#post1487059

 

[mdblue]

I seriously doubt about their own vested interest when people talk of about psychiatry being neglected in current medical environment. This year from my instituition 17 students matched in psych. If it's an indication of anything, psych is one of the "happening" specialties these days.
And I don't know about the "pill-popping" blame on the psychiatrists. If a certain pill can make a patient better in days rather than going thru 5d/wk therapy sessions continued over month, it should be appreciated not discouraged. That's why psychologists themselves are asking for the scripting power.
And w/ all due respect to statistical training to the clinical psychologists, firstly as MDs we do get training in basic statistical methods, and in some countries to be a board-certified psychiatrist you have to complete a full paper on EBM(e.g. critical review in MRCPsych). The same thing holds true for ABPN, however not to that extreme. To what extent one needs to be knowledgable in bio-stat after graduating is a matter of personal choice and it should be left as such.
Also being educated by the drug-rep is like listening to the sales-pitch of your car dealer. Ultimately you decide what's good for you and for the patient(I heard this analogy at APA). To me it makes a lot of sense.
And these days people feel by going thru few webpages or reading a psychopharm text they can be as competent as a fully trained psychiatrist(or a cardiologist/GI whatever for that matter). They just ignore the decision making process which lies behind the med-checks. This is bad for the profession as well as the patients. There was a truth in "Your doc know better". Maybe it has gotten old-fashioned, but it did a lot of good to the people. Atleast I would not be bothered by 2 people who landed in my PES today w/ these horrible experiments of self-medication.
Just my 0.02c.

 

[lazure]

And I don't know about the "pill-popping" blame on the psychiatrists. If a certain pill can make a patient better in days rather than going thru 5d/wk therapy sessions continued over month, it should be appreciated not discouraged.

You know that there are evidence based therapies that have been reliably demonstrated to improve the functioning of patients with depression, anxiety etc. CBT ring a bell? IPT? Similarly, CBT has been used to increase med compliance in individuals with bipolar disorders. While I respect the need for pharmacological treatment for some individuals, I believe that psychiatrists such as you discount psychotherapy while ignoring the empirical evidence.

we do get training in basic statistical methods

yet the concept of effect size appears to elude you when you read the results of drug company studies .... It is easy to show a significant difference between group means with a sample size of 2000.... you know that a small but significant difference is not necessarily clinically significant. The suicidal patient on drug X now thinks of suicide 9 times per day rather than 10. Furthermore, the fact that these studies are sponsored by drug companies doesn't bother you in the least? You don't suspect that null results or contradictory results just failed to be published????

Ultimately you decide what's good for you and for the patient(I heard this analogy at APA). To me it makes a lot of sense.

But what is the quality of the science you use to make the decision?

 

[lazure]

Evidence based psychotherapy such as CBT teaches skills to prevent and/or manage future re-occurances of a given disorder as well the ability to assess when further treatment should be sought. Is there evidence that pharmacological treatment alone will prevent or decrease the severity of future relapses? Or do the drug companies not sponsor long term follow up?

These are real questions and not sarcastic comments (before you jump at me).

 

[Svas]

I know we've been down this road . . . but in contrast to what psychologists are having to take to become eligible . . . I found the following description of a law in one state that enables an NP to prescribe legend drugs. This is a tad scary:

25-23-1-19.5
Advanced practice nurses; authority to prescribe legend drugs
Sec. 19.5. (a) The board shall establish a program under which advanced practice nurses who meet the requirements established by the board are authorized to prescribe legend drugs, including controlled substances (as defined in IC 35-48-1).
(b) The authority granted by the board under this section:
(1) expires on October 31 of the odd-numbered year following the year the authority was granted or renewed; and
(2) is subject to renewal indefinitely for successive periods of two (2) years.
(c) The rules adopted under section 7 of this chapter concerning the authority of advanced practice nurses to prescribe legend drugs must do the following:
(1) Require an advanced practice nurse or a prospective advanced practice nurse who seeks the authority to submit an application to the board.
(2) Require, as a prerequisite to the initial granting of the authority, the successful completion by the applicant of a graduate level course in pharmacology providing at least two (2) semester hours of academic credit.
(3) Require, as a condition of the renewal of the authority, the completion by the advanced practice nurse of the continuing education requirements set out in section 19.7 of this chapter.

S

 

[mdblue]

You know that there are evidence based therapies that have been reliably demonstrated to improve the functioning of patients with depression, anxiety etc. CBT ring a bell? IPT? Similarly, CBT has been used to increase med compliance in individuals with bipolar disorders.
Sorry, I can also provide data as compared to IPT, CBT has not shown to be terribly effective. And statistical manipulations are not only limited to drug-rep studies, it is also seen in studies involving psychotx.
Also as you commented about the quality of psychiatrists, I've had my share of bad Phds-that really means nothing about the specialty in general.


yet the concept of effect size appears to elude you when you read the results of drug company studies .... It is easy to show a significant difference between group means with a sample size of 2000.... you know that a small but significant difference is not necessarily clinically significant. The suicidal patient on drug X now thinks of suicide 9 times per day rather than 10. Furthermore, the fact that these studies are sponsored by drug companies doesn't bother you in the least? You don't suspect that null results or contradictory results just failed to be published????

Plz see my above response. Assuming you are not naive, people make careers out of research work, that's why they get published(and often the team involves PhDs). Again my analogy of buying cars hold true. You make an informed decision based on YOUR appraisal of the study not what the salesman says.

But what is the quality of the science you use to make the decision?
The same quality of science people using to glorify the DoD study in this forum and extrapolating their results in the community setting. It works either way.
BTW, when talking about the scripting power of psychologists, please don't give this crap of bad psychiatrists vs good Psychologists. If psychotherapy was really working miracles for pts, you guys would not have lobbied for scripting power. The pills are making $$, and you want a share of the pie. It's as simple as that, and let's keep it that way. The only loser in the game is the patient. Hopefully after few -ve outcomes(read death/disability) the lawmakers will listen to the dissenting voices.

 

[sasevan]

You have the full right to disagree with psychologists obtaining prescription rights given the inadequate training required. I agree with you and as a psychologist I will not seek prescription rights since if I wanted to I would have gone to med school.

Hi Lazure,

Why "inadequate training required"? What is adequate training, and why?

Why associate prescription rights with med school?

The DoD project demonstrated that psychologists could be trained to function as effective and safe prescribers without going to med school.

In all 50 US states nurse practitioners function as effective and safe prescribers without having gone to med school (and in at least 11 states and DC, NPs do so with full autonomy and full formulary).

Other non-physicians that also prescribe include dentists, optometrists, and podiatrists. All do so without having gone to med school.

From your posts I gather that you highly value being a psychologist, i.e., a scientist and a clinician. Regardless of your own lack of interest in personally pursuing RxP I believe that you could contribute much to this unfolding development in the US (and soon enough, Canada). I invite you to join with those who are promoting what has been empirically demonstrated to be a safe expasion of the clinical skills of psychologists and other non-physicians and not to lend an unjustifiable air of scientific credibility to medical fundamentalism.

Peace.

 

[sasevan]

That's just the point. The reading I've done on this subject indicates that it indeed "ain't" about working together, but is a battle for increased respect, autonomy, and parity.

To say that psychiatry needs to "establish scientific credibility" is utter idiocy. Psychiatry is what it claims to be and has been.
Medical fundamentalism? You bet.

Imagine, psychologists want increased respect, autonomy, and parity? Who do they think they are?

Imagine, psychiatrists needing to establish scientific credibility? How idiotic!

If it's medical fundamentalism to refuse to show respect for psychologists, to give them autonomy, to treat them as equals;
if it's medical fundamentalism to reject the need to establish scientific credibility for psychiatric interventions,
then I'm a MEDICAL FUNDAMENTALIST.

Let me hear you all say it: Yes, YES, I'm a medical fundamentalist.
Clap those hands, stomp those feet, shout it out: YES, I'm a MEDICAL FUNDAMENTALIST!
Be gone psychologists! Stay in your place! Be gone! I said: BE GONE!!! Back to Louisiana. Back to New Mexico. Back to your therapy sessions, to your tests, to your research projects, to your university classes. BACK! BACK!!!

In the name of the APA (the little one) I said: BE GONE!!!


Enough said

 

[Anasazi23]

Enough said

Hardly....

Imagine, psychologists want increased respect, autonomy, and parity? Who do they think they are?

You miss the point entirely. Do you feel that psychologists should attack neighboring professions in order to achieve the increased respect, autonomy, and parity? If you do, then you're a psychological fundamentalist.

Imagine, psychiatrists needing to establish scientific credibility? How idiotic!

I competely forgot, in the past 100 years, psychiatry has yet to publish a study demonstrating the clinical efficacy of the myriad medications, ect, fMRI findings, etc etc etc. The cat's out of the bag folks! The gig is up! We've been found out! Run!!!

If it's medical fundamentalism to refuse to show respect for psychologists, to give them autonomy, to treat them as equals;
if it's medical fundamentalism to reject the need to establish scientific credibility for psychiatric interventions,
then I'm a MEDICAL FUNDAMENTALIST.

You continue to convieniently forget....the psychologists started this. Not the psychiatrists. It was they who wanted to increase their scope. Don't expect to be met with no opposition by the medical community.

Let me hear you all say it: Yes, YES, I'm a medical fundamentalist.
Clap those hands, stomp those feet................................ BACK! BACK!!!

In the name of the APA (the little one) I said: BE GONE!!!

Your cavalier attitude about anyone and their mother taking weekend internet coffee-shop Holiday Inn poolside classes with their grueling practicum of 100 patients being safe to prescribe will change when you get to med school. The scientific and clinical safetynet that is the FDA, clinical experience, medical knowledge and the like did not come to be with fly-by-night cowboy quick "accept anything new and crazy" changes to American medicine. You'll find this out eventually.

p.s. You're not the only one who knows where the "laugh button" is:

 

[sasevan]

Prescriptive Authority for Psychologists: A Matter of Professional Evolution
by Saul Lindenbaum, Ph.D. and Morgan Sammons, Ph.D.

[February 1996; Vol. 23 No. 1]

Dr. Lindenbaum is President of the Maryland Psychological Association. Dr. Sammons is a member of MPA and a graduate of the Department of Defense Psychopharmacology Demonstration Project. The opinions expressed by him in this article represent his views as a private citizen.

This article will focus on three main points. First, the idea is presented that prescriptive authority is an important step in the evolution of the profession of psychology. Second, an overview of other non-physician groups that prescribe is presented. Third, a case is made for a continuation of a respectful dialogue on the issues involved, based on the many areas of common interest and successful collaboration shared by psychiatry and psychology.

It has been about 125 years since the discipline of psychology began to differentiate itself from the field of philosophy, in whose departments it was housed in a number of European universities. This new experimental science soon moved across the ocean to the United States, and the American Psychological Association was formed just over 100 years ago by a small group of academicians. Over the next 50 years psychologists began to broaden their scope, moving out of their laboratories and into industry, child guidance centers and other settings. Psychological testing became a major occupation for many, and a brave few took the radical step of beginning to do psychotherapy.

The Second World War wrought great change in America, and psychologists were not immune to these changes. Thus, about 50 years ago the ideal of the psychologist as a scientist-practitioner was born, and the profession made a dramatic turn toward psychotherapy. About 40 years ago, psychologists began to be certified by the state of Maryland, and the Maryland Psychological Association was formed. Almost 25 years ago, the state recognized psychologists as independent practitioners, and about 15 years ago, certification changed to licensing.

Clearly, this is a profession that has been evolving for more than a century, and is continuing to evolve. To take another relevant example, a psychopharmacology subspecialty has existed within psychology for many years. At this time it is a research and teaching specialty, in which psychologists study the effects of psychoactive drugs, and teach others, including medical students, about them. Many believe that an important next step in the evolution of psychology is the right to prescribe psychoactive medications, as well.

History is clear that when qualified non-physician providers seek the right to independently provide pharmacotherapy, state legislatures have allowed them to do so. Dentists and podiatrists prescribe in all 50 states. The recent successful efforts of optometrists to obtain prescriptive authority is another such example. In all 50 states optometrists have the ability to prescribe diagnostic agents, and they now prescribe therapeutic agents in 46 states. Another example is the increasing discretion given to advanced practice nurses. Nurse practitioners have prescriptive authority in 47 states. In at least four states, psychiatric advanced practice nurses prescribe without physician oversight. Certified registered nurse anesthetists and nurse midwives prescribe in many states with extremely limited oversight, and physician assistants (often with less than a Bachelor's degree) have prescriptive authority in 40 states, with varying levels of physician oversight.

Understanding the successful efforts of other non-physician prescribers should help psychiatrists and psychologists reframe what some have called a turf war between the two professions. We need to keep in mind that the piece of turf in question is relatively small. If we engage in a fierce battle over this small piece of territory, any victories are likely to be Pyrrhic, in that both professions will be damaged and other groups will be more than willing to seek control over the same terrain. Would it not be better to work collaboratively to ensure that those psychologists who do gain prescriptive authority possess the proper training?

We are encouraged by recent developments in California, which illustrate the benefits of cooperation between two previously antagonistic groups, optometrists and ophthalmologists. Optometrists in California have been seeking therapeutic drug prescription authority, and had been engaged in a long, expensive battle with ophthalmologists. Our understanding is that legislators there grew tired of the incessant lobbying from both groups, and asked not to be bothered by members of either group. As a result, optometrists and ophthalmologists sat down together, and jointly drafted a bill which will be supported by both professions during the next legislative session. The bill allows for therapeutic drug prescribing by optometrists, but contains requirements for training sufficient to reassure the ophthalmologists.

We wish to assure our psychiatric colleagues that the decision to seek prescriptive authority is being made only after lengthy debate and with meticulous attention to proper training models. Training for prescriptive authority will be available only to doctorally trained, licensed psychologists. Training will be rigorous and thorough and will encompass studies in the relevant basic and applied sciences, as well as a medically supervised clinical training period. Passage of a standardized examination will be mandated before a psychologist is certified to prescribe psychoactive medications. Most psychologists probably will not seek prescriptive authority. We envision prescribing as a fellowship specialty in psychology with a limited number of practitioners, similar to other subspecialties such as neuropsychology or forensic psychology.

Finally, we must never lose sight of the vision common to both our professions: Ready access to continuity of high quality, affordable mental health services for all those who are in need of it. In private offices, in hospitals, in universities and in research facilities across the country, psychologists and psychiatrists work together every day in a respectful collaboration that is beneficial to both our professions and to the public. In a similar manner, we have worked together on complex legislative issues. It is our hope that the spirit of professionalism that has served us well in these contexts, will continue to guide us in the matter at hand.

How unfortunate that the initial overtures of psychology to work with psychiatry in the expansion of psychopharmacotherapy priviliges for PhD/PsyDs were rebuffed by medical fundamentalists in the little APA.
Psychology attempted to avoid a repeat of the battle that it had had with psychiatry over the expansion of psychotherapy privileges for PhD/PsyDs back in the 1950/1960s.
Unfortunately, 8 years after the publication of this article, we see (as evidenced by the short-sighted actions of the little APA in LA and the posts in this forum) that med fundas are still around. The battle lines are being set up once again. History is repeating itself.
FORTUNATELY, history repeating itself will lead to psychology expanding its scope of practice into psychopharmacotherapy just like it did with psychotherapy.
FORTUNATELY, history repeating itself will ensure that mental health patients will have increased access and improved treatments.
The model of medical psychology is NOT that of psychologists prescribing as psychiatrists.
Just like psychology helped to expand mid-century therapy from the constraints of psychoanalysis so too will it help to expand new century med mgm from its minimalistic and reductionistic tendencies.
FORTUNATELY, diversity in prescribing models will herald a new golden age of mental health, where both psychiatrists and psychologists will develope innovative psychopharmacotherapeutic interventions ever more evidence-based; just as 40 years ago diversity in psychotherapeutic models gave rise to Rogers, Beck, Ellis, etc.
FORTUNATELY, history is repeating itself.

 

[Anasazi23]

You know that there are evidence based therapies that have been reliably demonstrated to improve the functioning of patients with depression, anxiety etc. CBT ring a bell? IPT? Similarly, CBT has been used to increase med compliance in individuals with bipolar disorders. While I respect the need for pharmacological treatment for some individuals, I believe that psychiatrists such as you discount psychotherapy while ignoring the empirical evidence.

No one is denying this. It is the psychologists that are apparently denying themselves by discounting this same evidence and seeking legislation-appointed prescriptive rights. I think you'd be hard-pressed to find a psychiatrist that truly believed therapy was useless.

Furthermore, the fact that these studies are sponsored by drug companies doesn't bother you in the least? You don't suspect that null results or contradictory results just failed to be published????

Why does everyone who bashes psychiatry assume that pharma companies produce research on their medications, and then NOBODY, EVER does a follow-up study at some later date to verify, or replicate the results. Granted, these studies may take some time to come out or be published, but they DO come out. By the way, at my request, I was just mailed a published study by Abbott Laboratories on Depakote ER by a representative I met at the "little APA" convention, as sasevan so effectionately calls it. (Don't need to be a psychiatrist/psychologist to read into this by the way.) The study clearly showed that the use of Depakote ER was of no clinical value in bipolar manics. Like Mdblue states, I'll use that information how I'd like. I'm not a *****ic slave to the pharmaceutical companies.

But what is the quality of the science you use to make the decision?

Do you think that psychiatry is the only field of medicine which suffers from "experience" treatment vs. EBM? All fields of medicine are undergoing a sort of EBM renaissance at this point. Some of these ideas are slow to change despite scientific discrediting. (Is it still necessary for NPO pre-surgery? New evidence suggests not. But find me a surgeon that won't write an NPO order for 12am prior to a cholecystectomy) But, these traditional thoughts and old-world experiences did have value for their time. Every health profession has had some treatments or theories not based in science - including psychology.

Psychiatry, like gastroenterology, like pulmonology, like hematology, etc is producing more EBM clinical studies which already have and will become the standard of care in the future. Therefore, to judge psychiatry as a lone horse by this alone is neither fair nor of value.

 

[sasevan]

Hardly....

You miss the point entirely. Do you feel that psychologists should attack neighboring professions in order to achieve the increased respect, autonomy, and parity? If you do, then you're a psychological fundamentalist.

p.s. You're not the only one who knows where the "laugh button" is:

Fundamentalism is not restricted to medicine.
There are psychologists who absurdly assert that psych PhD/PsyDs are far better diagnostician and therapists than psych MD/DOs.
Notice, I said that this assertion is absurd.
Just like psychiatrists saying the inverse.
I oppose fundamentalism, period. Whether in medicine or in psychology, etc.
The point is that fundamentalism is contraindicated for any discipline that presents itself as scientific.
The problem is that when you and others express your opposition to RxP for psychologists you do it in a way that is patently offensive because of its unashamed embrace of med funda, i.e., that psychiatric ed, training, practice is superior to psychology and that consequently psychologists cannot be permitted to prescribe unless they attain that superior ed and training.
Medical fundamentalism is offensive to me both as a soon to be psychologist AND as a future psychiatrist. Likewise, psychological fundamentalism, etc.
The opposite of med funda is the acknowledgement and appreciation of alternative and complimentary healthcare models.
For me there is beauty in the clinical psychiatry model but also in the medical psychology one.
Because I'm not a psych nor a med funda I can tolerate...no...celebrate the different models.

P.S. I know you know where it is BUT I know how to use it well.

 

[sasevan]

By the way, at my request, I was just mailed a published study by Abbott Laboratories on Depakote ER by a representative I met at the "little APA" convention, as sasevan so effectionately calls it. (Don't need to be a psychiatrist/psychologist to read into this by the way.)

Now that was funny.

 

[sdude]

Psychiatrists are not solely psychiatrists. They are physicians trained in the specialty of psychiatry. Is this the medical model? Is it different from the psychological model? Yes. It is also the model that has been the most successful and accepted in modern treatment of both medical and psychiatric patients thus far.

To say that psychiatry needs to "establish scientific credibility" is utter idiocy. Psychiatry is what it claims to be and has been.

Psychiatrists are very, very necessary. That's why I'm so irritated about the general mediocrity in the field.

I have great respect for psychiatrists who are physicians in the best sense of the word, but the only one whom I've encountered (sadly not in person) has been the late Jerrold Bernstein, who's *Drug Therapy in Psychiatry* opened my eyes to really TREATING mental illness medically. His references are incredibly exhaustive, and he has whole chapters on how to use the MAOI's, the TCA's, how to safely COMBINE MAOI's and TCA's, use TCA's with SSRI's, use all with lithium--he simply refuses to give up. He even tried using Permax as an augmentor to Parnate in some resistant patients he suspected were responding to elavated dopamine, and noted that over half the patients reported a great or significant improvement in symptoms. He discusses side effects and their management in depth. There are pages of charts with tyramine content of common and exotic foods for MAOI patients.

I have never heard of another psychiatrist who was this attentive and aggressive in helping his or her patients recover.

And these days people feel by going thru few webpages or reading a psychopharm text they can be as competent as a fully trained psychiatrist(or a cardiologist/GI whatever for that matter). They just ignore the decision making process which lies behind the med-checks. This is bad for the profession as well as the patients. There was a truth in "Your doc know better". Maybe it has gotten old-fashioned, but it did a lot of good to the people. Atleast I would not be bothered by 2 people who landed in my PES today w/ these horrible experiments of self-medication.
Just my 0.02c.

"decision-making process?", "Your doc know better?"--please; I just ate. You mean prescribing the virtually-untested Zyprexa for every disorder under the sun--to the point that the expense of this drug alone was overwhelming medicaid?

I can't count the number of people I've had to reassure who had been prescribed Zyprexa for depression, anxiety, INSOMNIA, social phobia, etc. who read up on it and thought they had schizophrenia.

The fact that Zyprexa was subsequently shown to cause NMS and TDK, in addition to cool new tricks like orca-grade weight gain, hyperglycemia, and permanent type II diabetes (a stunt even Haldol couldn't pull) seems to have done little to blunt psychiatrists' puzzling enthusiasm for this drug.

You mean dishing out (also virtually untested) Effexor like candy and letting years go by before acknowleding the horrible and disabling withdrawal effects experienced by at least 15% of patients, some of which persisted for more than a year?

You mean ignoring the fact that no study has shown the SSRI's to be effective in MAJOR depression, and that numerous studies show these drugs to have little or no superiority over placebo in treating mild depression?


After 10 years of being a good, crippled patient, I'm afraid I've given up on "Your doc know better." If I still believed that, tomorrow I would obediently take my Effexor and Zyprexa, waddle to the 7-11 for breakfast, and then stare at the TV while waiting for my SSI check.

Instead, I'm popping a couple Parnate and going surfing.

 

[Anasazi23]

P.S. I know you know where it is BUT I know how to use it well.

Am I correct in asserting that because you are a psychologist, you are better trained to know when to appropriately place laughing smiley face thingys? You are a smiley laughing face fundamentalist!

Seriously though, the main point about the fundamentalism thing is this:

You either believe that psychiatric patients are medical in nature or you do not. In medicine, you take the worst case scenario and work downwards in your differential. This is the time-proven logic-driven technique that ensures patient safety.

[simplification] If you assume psychiatric patients are completely environmentally-created, then you do not need medical intervention. Conversely, if you believe all psychiatric patients are medical and not in any way affected by the environment, you do not need therapy (again I'm simplifying).

The safest way to approach this quandry is to assume the worst - that all patients have medical etiologies and comorbidities until proven otherwise. Psychology training programs are looking to skip this step and move straight to psychopharmacological intervention. What might appear to you as dogmatic medical fundamentalism is really a top-down differential approach to the patient as a whole.

 

[Svas]

yet the concept of effect size appears to elude you when you read the results of drug company studies .... It is easy to show a significant difference between group means with a sample size of 2000.... you know that a small but significant difference is not necessarily clinically significant. The suicidal patient on drug X now thinks of suicide 9 times per day rather than 10. Furthermore, the fact that these studies are sponsored by drug companies doesn't bother you in the least? You don't suspect that null results or contradictory results just failed to be published????
QUOTE]

http://jama.ama-assn.org/cgi/content/short/291/20/2457

Empirical Evidence for Selective Reporting of Outcomes in Randomized Trials: Comparison of Protocols to Published Articles
An-Wen Chan, MD, DPhil; Asbj?rn Hr?bjartsson, MD, PhD; Mette T. Haahr, BSc; Peter C. G?tzsche, MD, DrMedSci; Douglas G. Altman, DSc
JAMA. 2004;291:2457-2465.
Context Selective reporting of outcomes within published studies based on the nature or direction of their results has been widely suspected, but direct evidence of such bias is currently limited to case reports. Objective To study empirically the extent and nature of outcome reporting bias in a cohort of randomized trials. Design Cohort study using protocols and published reports of randomized trials approved by the Scientific-Ethical Committees for Copenhagen and Frederiksberg, Denmark, in 1994-1995. The number and characteristics of reported and unreported trial outcomes were recorded from protocols, journal articles, and a survey of trialists. An outcome was considered incompletely reported if insufficient data were presented in the published articles for meta-analysis. Odds ratios relating the completeness of outcome reporting to statistical significance were calculated for each trial and then pooled to provide an overall estimate of bias. Protocols and published articles were also compared to identify discrepancies in primary outcomes. Main Outcome Measures Completeness of reporting of efficacy and harm outcomes and of statistically significant vs nonsignificant outcomes; consistency between primary outcomes defined in the most recent protocols and those defined in published articles. Results One hundred two trials with 122 published journal articles and 3736 outcomes were identified. Overall, 50% of efficacy and 65% of harm outcomes per trial were incompletely reported. Statistically significant outcomes had a higher odds of being fully reported compared with nonsignificant outcomes for both efficacy (pooled odds ratio, 2.4; 95% confidence interval [CI], 1.4-4.0) and harm (pooled odds ratio, 4.7; 95% CI, 1.8-12.0) data. In comparing published articles with protocols, 62% of trials had at least 1 primary outcome that was changed, introduced, or omitted. Eighty-six percent of survey responders (42/49) denied the existence of unreported outcomes despite clear evidence to the contrary. Conclusions The reporting of trial outcomes is not only frequently incomplete but also biased and inconsistent with protocols. Published articles, as well as reviews that incorporate them, may therefore be unreliable and overestimate the benefits of an intervention. To ensure transparency, planned trials should be registered and protocols should be made publicly available prior to trial completion.


Our problem with research, in general . . . goes beyond effect size.

S

 

[Svas]

Seriously though, the main point about the fundamentalism thing is this:

You either believe that psychiatric patients are medical in nature or you do not. In medicine, you take the worst case scenario and work downwards in your differential. This is the time-proven logic-driven technique that ensures patient safety.

Anasazi, this is nothing more than ideological reductionism. You appear to be attempting to reduce a very complex matrix down to a least common denominator. From your point of view, medicine (or the physiologic domain) explains the greatest number of variables. Many people do not agree with you.

This reductionism, I think, is part of the serious problem we're facing. The U.S.'s 60+ year movement/love affair with rampant objectification is partly to blame (despite the very positive impact the movement has made, it sometimes throws the baby out with the bathwater). We look for only those measureable aspects of behavior and forget that it IS the complex matrix of person-ness that we're treating - not just the physiological reaction. We forget that WHAT we're measuring might be "beside the point."

HAM-D scales are a perfect example of this. Anyone know what year the HAM-D's were developed and for what? (Hint . . . you'll have to go back 43 years to get to the publication date . . . and then farther to understand the basis upon which they were developed. ) Our understanding of depression/anxiety is more complex now than is was in 1960. Another ugly example is the tendency for drug companies to simply make up a behavioral scale that suits their need and to report the outcome/publish it AS THOUGH it had been adequately peer assessed. This happens so much within the child psychopharm literature as to be very distressing. As psychiatric professionals, trained (at least basically) in statistics, we should be leading our own revolt against such a ridiculous practice. But, by and large, we're tacit.

The unfortunate consequent of the common psychiatric approach (NOT what is seen in medical school, residency, or at research institutes, but that which is present in most private practices) is that the psychiatrist will use the interview to isolote "Psychopharmacologic Responsive States" or PRS. The, the diagnosis (a topic for another day, but these reliable labels have very serious validity problems) is defined by the clustering of the PRS and a drug is prescribed. The prescription is administered in the sincere belief that as the symptoms are reduced, the patient's debilitating condition will be abated.

The above method is so reductive that it often necessarily ignores what may be bothering the patient most;the psychosocial aspect of the patient's condition. My perception of what commonly goes on in the "real" world looks something like "BIOpsychosocial" as though the psychiatrist is treating the most important aspect. The number of times I've seen children psyciatrically diagnosed with ADHD/ODD being treated with the myriad of available chemicals we have in our toolbox, but their parents HAVE NOT BEEN REFERRED FOR PARENTING TRAINING is astounding. What have we been reading? Are we not aware of the impact this makes to the entire family system? The same is true for patients with depressive/anxious disorders, bipolar disorders, etc., many of whom get treated for their biological "needs" but the psychotherapeutic tools we have available to us are either discounted or ignored.

(As a teacher, I find myself asking, "What are we not doing when we train you? What are we missing? ")

Don't get me wrong, I LOVE diagnosing and treating primarily biological/neurological disorders that present as "behavioral dysfunction." But, for the most part, in the day-to-day practice world, these cases are VERY few in comparison to those that have MUCH greater psychosocial issues. (BTW, I have always wondered why we don't add spiritual to that matric, as in biopsychosocialspiritual, since so many patients seem to struggle with this as well - and NO, I'm not a religious fundementalist . . . at all).

Off to work now. You guys figure this out and let me know the anwers . . . I'll be back later in hopes that these problems have been solved.

(How'd I do?)

 

[Anasazi23]

I'm actually going to quote myself for contextual purposes:

[simplification] If you assume psychiatric patients are completely environmentally-created, then you do not need medical intervention. Conversely, if you believe all psychiatric patients are medical and not in any way affected by the environment, you do not need therapy (again I'm simplifying).

What Svas states is correct, in that this indeed IS reductionism. This is also a simplified view of the patient, (which I pointed out twice). Indeed, medical school and residency goes to great lengths to teach doctors to reduce a complex presentation of symptoms and findings to create a reasonable differential. In this sense, the entire medical educational system is to blame if you find this disagreeable. However, I myself have never subscribed to the notion that patients themselves were reductionist in nature. While I feel that the term "biopsychosocial" is a "feel good" overused garbage-term clinicians and institutions tout to appear comprehensive, it may still have meaning. Any clinician with common sense knows that patients are complex beings, which should be approaced in a "biopsychosocial" manner. To do less than this would to be not fully treating the patient.

I agree that many psychological rating scales are laughable in what we perceive as the changing face and understanding of pathology and wellness. Do I read mechanics magazines? Does it really matter? To the MMPI (copyright 1942) it certainly does. But, an invalid score on a personality test versus a missed medical diagnosis are not one inthe same. Psychology, rather than psychiatry, has the luxury of not having to worry about the gamut of medical conditions manifesting psychiatrically. No one expects a psychologist to pick up a melanoma-inducing depression. If a psychiatrist misses this, the possibility of a malpractice suit exists. Does this make psychiatrists "better" than psychologists? Of course not. The professions each have their strengths and are valuable in the treatment of the psychiatric patient.

Ideological reductionism may be intellecutally unappealing, but in the current mode of practice, given time, money, and knowledge constraints, it may be that which has "survived" or evolved from the primordial soup which is modern medical practice. In a perfect world, psychiatrists would be able to approach the patient in a manner in which Svas describes - biopsychosocialspiritually. As he points out, however, this is often difficult. Following the thread's original purpose then.....if psychiatrists have difficulty approaching psychiatric patients in this fully comprehensive manner, given the knowledge they have of biology, medicine, and psychiatry, then for what purpose are psychologists being given Rx rights? Is this effectively eliminating (despite training courses) the "bio" part of the biopsychosocial? This to me seems like further treatment quality dilution.

 

[PublicHealth]

If a psychiatrist misses this, the possibility of a malpractice suit exists. Does this make psychiatrists "better" than psychiatrists? Of course not.

Hmm.....oversight or Glucksbergian metaphor?