PhD vs. MD

[psych101]

Advertisement - Members don't see this ad

I have an ongoing struggle trying to figure out how to explain to the general public the difference between a psychologist and a psychiatrist without having them jump to the instant conclusion that a psychologist is inferior because we don't (usually) prescribe meds. Anybody found a simplistic yet positive way to explain the difference?

 

[Annakei]

I have an ongoing struggle trying to figure out how to explain to the general public the difference between a psychologist and a psychiatrist without having them jump to the instant conclusion that a psychologist is inferior because we don't (usually) prescribe meds. Anybody found a simplistic yet positive way to explain the difference?

Thats tough and I have to explain that to my clients everyday. Well, mostly why am I not able to prescribe meds..why can't I just do therapy with them because often times a social worker/psychotherapist and psychiatrist overalap in in terms of what we discuss in case mgmt.

I explain it as a psychiatrist is a MEDICAL DOCTOR who has been trained to decipher what meds will work to decrease their symptoms. A psychotherapist/psychologist focuses on their psychotherapy and working through their issues.

They often ask if the psychiatrist does therapy and in my experience and at my agency my response is NO THEY DO NOT.. They CAN and may opt to train to do therapy but most in my experience do not.

So in my situation my cleints tend to compartmentalize their treatment and just view the psychiatrist as the doctor who prescribes meds....the therapist deals with their psychological issues and I make sure that both are actually happening and review what actually happens with the psychiatrist and therapist and build on that in our case mgmt sessions.

I dont get the sense that they look down on therapists, just that we don't deal with meds. I dont think that you can CONTROL how they will view the profession. If they have been socialized to think as such then they WILL. You can only assist with enlightening their views a bit..

 

[LM02]

Here’s a variation of what I usually say:

Research has yet to identify one single cause of mental illness, and most professionals agree to approach most disorders from a biopsychosocial perspective. Meaning, there are biological, psychological, and social aspects to be targeted when working with people who are mentally ill.

Typically (although not always so), psychiatrists will focus more on the biological aspects of research and treatment – genetics, neurotransmitter systems, hormones, complex medical comorbidity, pharmacotherapy, etc. And typically (although not always so), psychologists will focus more on the psychosocial aspects of research and treatment – behavior, attitudes and beliefs, skills training, interpersonal factors, life events, psychotherapy, etc. Psychologists are also trained to do structured assessments and testing. MDs go to medical school, where they first receive foundational training in medicine, and then specialize afterward. PhDs attend graduate school, where they specialize from day one, but further specialize during internship and postdoc. Also, the PhD is a research degree by design, whereas MDs may or may not choose to pursue research during their training.

With all of that said, it’s unrealistic to expect that professionals in either field can target certain aspects of an illness in a vacuum. Just as MDs learn psychological theory and treatment, PhDs learn about biological bases of behavior (for example, I took a neuroscience course in graduate school on the HPA Axis). For that reason, both sets of professionals ultimately should approach mental illness from a complete biopsychosocial framework – we just vary in our emphasis when it comes to practice and training. And, for this reason, a teamwork approach is often ideal, so that we can maximize our strengths and pool them together.

 

[PsychEval]

Here’s a variation of what I usually say:

Research has yet to identify one single cause of mental illness, and most professionals agree to approach most disorders from a biopsychosocial perspective. Meaning, there are biological, psychological, and social aspects to be targeted when working with people who are mentally ill.

Typically (although not always so), psychiatrists will focus more on the biological aspects of research and treatment – genetics, neurotransmitter systems, hormones, complex medical comorbidity, pharmacotherapy, etc. And typically (although not always so), psychologists will focus more on the psychosocial aspects of research and treatment – behavior, attitudes and beliefs, skills training, interpersonal factors, life events, psychotherapy, etc. Psychologists are also trained to do structured assessments and testing. MDs go to medical school, where they first receive foundational training in medicine, and then specialize afterward. PhDs attend graduate school, where they specialize from day one, but further specialize during internship and postdoc. Also, the PhD is a research degree by design, whereas MDs may or may not choose to pursue research during their training.

With all of that said, it’s unrealistic to expect that professionals in either field can target certain aspects of an illness in a vacuum. Just as MDs learn psychological theory and treatment, PhDs learn about biological bases of behavior (for example, I took a neuroscience course in graduate school on the HPA Axis). For that reason, both sets of professionals ultimately should approach mental illness from a complete biopsychosocial framework – we just vary in our emphasis when it comes to practice and training. And, for this reason, a teamwork approach is often ideal, so that we can maximize our strengths and pool them together.

Good response. How would a prescribing psychologist describe the differences?

 

[LM02]

Good response. How would a prescribing psychologist describe the differences?

Although I have no intention of becoming a prescribing psychologist (and thus, don't pretend to speak on behalf of those who choose to pursue this path), I'd venture to guess that the overall description wouldn't vary much from what I already posted. At the end of the day, a prescribing psychologist is still, first and foremost, a psychologist.

I imagine you could just adjust the description to add, that for prescribing psychologists, they undergo further specialization in psychopharmacology to be able to further emphasize the biological aspecs of treatment in their practice.

 

[nev]

I feel that psychologists are trained in studying the different subjects in psychology from their Bachelor's till Masters/ PHD. But Psychiatrists study medicine and then a 3 year residency (correct me if I'm wrong) in psychiatric medicne. SO I guess psychologists get more training when dealing with the mind but psychiatrists deal with the problems the braiin causes on the mind..

 

[PsychEval]

I feel that psychologists are trained in studying the different subjects in psychology from their Bachelor's till Masters/ PHD. But Psychiatrists study medicine and then a 3 year residency (correct me if I'm wrong) in psychiatric medicne. SO I guess psychologists get more training when dealing with the mind but psychiatrists deal with the problems the braiin causes on the mind..

Not quite correct. Both psychiatrists and psychologists study the “brain and mind.” For a psychiatrist, there is 1 year of internship and 3 years of residency. Depending on one’s area of interest, a psychiatrist may be more involved with issues of the “mind.” Depending on one’s area of interest, a psychologist may be more focused on the brain. In fact, some psychologists complete sub specialty training and study pathophysiology, human anatomy, biochemistry, neuroscience, physical examination, pharmacology, and psychopharmacology. Some psychiatrists complete subspecialty training in psychoanalysis, child, geriatrics, etc. Not to mention combined residency programs, i.e. internal med/psychiatry, etc.
I think it is most beneficial to state what one does in the linguistically positive. Example: “As a psychologist, I am involved in neuropsychological testing, conduct child custody evaluations, teach anger management classes, prescribe medication, and conduct research.” There does not seem to be a need to state things in the linguistically negative. Example: “As a psychologist, I do assessments and therapy, I don’t do surgery, dentistry, osteopathic manipulative therapy, fly airplanes, dig ditches,practice law, or make referrals to sex surrogates.” It seems inappropriate to conceptualize a profession by what they don’t do, i.e. “psychiatrists don’t do therapy, psychologists don’t prescribe medication.” Identifying what a profession does in the linguistically negative seems strange, not to mention all of the inaccuracies with overgeneralizations. Overall, I still like LMO2’s response.

 

[Primum est non]

Simple approach. Reverse it. Why offer yourself up for your client's evaluation of your scope of capability and authority? Why not nonchalantly say ...

Well the M.D. can't but the Phd can da da blah and more blah and the M.D. can't do blah and blah but the PHD always can do more blah especially since the PHD is certified in blah and blah but the M.D. has not been educated in ....

 

[PublicHealth]

Not quite correct. Both psychiatrists and psychologists study the “brain and mind.” For a psychiatrist, there is 1 year of internship and 3 years of residency. Depending on one’s area of interest, a psychiatrist may be more involved with issues of the “mind.” Depending on one’s area of interest, a psychologist may be more focused on the brain. In fact, some psychologists complete sub specialty training and study pathophysiology, human anatomy, biochemistry, neuroscience, physical examination, pharmacology, and psychopharmacology. Some psychiatrists complete subspecialty training in psychoanalysis, child, geriatrics, etc. Not to mention combined residency programs, i.e. internal med/psychiatry, etc.
I think it is most beneficial to state what one does in the linguistically positive. Example: “As a psychologist, I am involved in neuropsychological testing, conduct child custody evaluations, teach anger management classes, prescribe medication, and conduct research.” There does not seem to be a need to state things in the linguistically negative. Example: “As a psychologist, I do assessments and therapy, I don’t do surgery, dentistry, osteopathic manipulative therapy, fly airplanes, dig ditches,practice law, or make referrals to sex surrogates.” It seems inappropriate to conceptualize a profession by what they don’t do, i.e. “psychiatrists don’t do therapy, psychologists don’t prescribe medication.” Identifying what a profession does in the linguistically negative seems strange, not to mention all of the inaccuracies with overgeneralizations. Overall, I still like LMO2’s response.

Post of the week. 👍

 

[DaffyDoc]

Hi,

Thats tough and I have to explain that to my clients everyday. Well, mostly why am I not able to prescribe meds..why can't I just do therapy with them because often times a social worker/psychotherapist and psychiatrist overalap in in terms of what we discuss in case mgmt.

I explain it as a psychiatrist is a MEDICAL DOCTOR who has been trained to decipher what meds will work to decrease their symptoms. A psychotherapist/psychologist focuses on their psychotherapy and working through their issues.

They often ask if the psychiatrist does therapy -because they are wondering if they can go to the MD and hit two birds with one stone- and in my experience and at my agency my response is NO THEY DO NOT.. They CAN and may opt to train to do therapy but most in my experience do not.

So in my situation my cleints tend to compartmentalize their treatment and just view the psychiatrist as the doctor who prescribes meds -because you are telling them this is so-....the therapist deals with their psychological issues and I make sure that both are actually happening and review what actually happens with the psychiatrist and therapist and build on that in our case mgmt sessions.

I dont get the sense that they look down on therapists, just that we don't deal with meds. I dont think that you can CONTROL how they will view the profession. If they have been socialized to think as such then they WILL. You can only assist with enlightening their views a bit..

 

[DaffyDoc]

Hi,

Here’s a variation of what I usually say:

Research has yet to identify one single cause of mental illness, and most professionals agree to approach most disorders from a biopsychosocial perspective. Meaning, there are biological, psychological, and social aspects to be targeted when working with people who are mentally ill.

Typically (although not always so), psychiatrists will focus more on the biological aspects of research and treatment – genetics, neurotransmitter systems, hormones, complex medical comorbidity, pharmacotherapy, etc. And typically (although not always so), psychologists will focus more on the psychosocial aspects of research and treatment – behavior, attitudes and beliefs, skills training, interpersonal factors, life events, psychotherapy, etc. Psychologists are also trained to do structured assessments and testing. MDs can be trained to do these as well MDs go to medical school, where they first receive foundational training in medicine, and then specialize afterward. PhDs attend graduate school, where they specialize from day one, but further specialize during internship and postdoc. MDs can further specialize e.g., addiction psychiatry and so forth Also, the PhD is a research degree by design, whereas MDs may or may not choose to pursue research during their training. MDs do conduct a lot of research, get training in it if they wish, and experience a lot less red tape than PhDs to conduct the research

With all of that said, it’s unrealistic to expect that professionals in either field can target certain aspects of an illness in a vacuum. Just as MDs learn psychological theory and treatment, PhDs learn about biological bases of behavior (for example, I took a neuroscience course in graduate school on the HPA Axis). For that reason, both sets of professionals ultimately should approach mental illness from a complete biopsychosocial framework – we just vary in our emphasis when it comes to practice and training. And, for this reason, a teamwork approach is often ideal, so that we can maximize our strengths and pool them together.

 

[DaffyDoc]

Although I have no intention of becoming a prescribing psychologist (and thus, don't pretend to speak on behalf of those who choose to pursue this path), I'd venture to guess that the overall description wouldn't vary much from what I already posted. At the end of the day, a prescribing psychologist is still, first and foremost, a psychologist.

I imagine you could just adjust the description to add, that for prescribing psychologists, they undergo further specialization in psychopharmacology to be able to further emphasize the biological aspecs of treatment in their practice.

which means they have to go to school even longer. think about it. 5 years PhD, 2 years postdoc fellowship, 2 years MS in psychopharmacology, Ay!

 

[DaffyDoc]

Simple approach. Reverse it. Why offer yourself up for your client's evaluation of your scope of capability and authority? Why not nonchalantly say ...

Well the M.D. can't but the Phd can da da blah and more blah and the M.D. can't do blah and blah but the PHD always can do more blah especially since the PHD is certified in blah and blah but the M.D. has not been educated in ....

because your response sounds as if you have no couth, no dignity, no respect, etc.

 

[DaffyDoc]

Hi

Not quite correct. Both psychiatrists and psychologists study the “brain and mind.” For a psychiatrist, there is 1 year of internship and 3 years of residency. Depending on one’s area of interest, a psychiatrist may be more involved with issues of the “mind.” Depending on one’s area of interest, a psychologist may be more focused on the brain. In fact, some psychologists complete sub specialty training and study pathophysiology, human anatomy, biochemistry, neuroscience, physical examination, pharmacology, and psychopharmacology. Some psychiatrists complete subspecialty training in psychoanalysis, child, geriatrics, etc. Not to mention combined residency programs, i.e. internal med/psychiatry, etc.
I think it is most beneficial to state what one does in the linguistically positive. Example: “As a psychologist, I am involved in neuropsychological testing, conduct child custody evaluations, teach anger management classes, prescribe medication, and conduct research.” There does not seem to be a need to state things in the linguistically negative. Example: “As a psychologist, I do assessments and therapy, I don’t do surgery, dentistry, osteopathic manipulative therapy, fly airplanes, dig ditches,practice law, or make referrals to sex surrogates.” It seems inappropriate to conceptualize a profession by what they don’t do, i.e. “psychiatrists don’t do therapy -ah, my friend, MDs can perform therapy and yes there are some who do, maybe not 100%, but, they are out there., psychologists don’t prescribe medication.” Identifying what a profession does in the linguistically negative seems strange, not to mention all of the inaccuracies with overgeneralizations. Overall, I still like LMO2’s response.

 

[LM02]

MDs do conduct a lot of research, get training in it if they wish, and experience a lot less red tape than PhDs to conduct the research

I don't dispute the fact that MDs do research, but there is no evidence that there's less red tape to do so. Everyone has to apply for the same research grants, and for the same IRB approval at their universities.

Edited to Add: I work full-time as a researcher in the psychiatry department of a prestigious university-based medical center, and there are actually more PhDs than MDs on the research faculty.

 

[DaffyDoc]

MD = 4 years + variable length residency, often 4 years and in some specialties as many as 8, plus 1 year fellowship. That's 9 years.

PsyD - 3 years + 1 year internship +1 year postdoc (can be a professional job at professional pay levels) +2 years ms psychopharmacology.

That's 7 years to have fairly much full treatment and assessment options.



A two year postdoc in psychology is usually for people pursuing research careers or specializations (e.g., neuropsychology).

If you want to talk about variability, the PsyD is 3 years schooling + 1 year internship + 2 years postdoc + 2 years psychopharmacology = 8 years

MD = 4 years Med school + 3 years Residency (let's just say you wanted to be a family MD) = 7 years. You do not have to do a postdoc fellowship of 1 year.

So, end the end getting a PsyD takes just as much as time as getting a MD. But, in the end MDs get reimbursed very graciously for their learning! Hah!

 

[Psyclops]

Standing ovations to LM02 and PsychEval. Very good synopses. To the OP it seems that DaffyDoc (Quack?) feels the need to add a value judgement to each. I don't think there has to be a clear winner. And to clarify some of the points he muddled. It is very rare indeed for a MD to learn the assessment techniques that psycholgists learn, mostly they aren't intersted in it, and the training required for test administration, interpretation, and psychometrics is extensive.

EDIt: Upon rereading the thread I realize that this is a very old argument. I doubt the OP still reads this.

 

[ProZackMI]

Where does this 3 year PsyD come from? Look, you're comparing apples to oranges here. The MD and PhD or PsyD are very different degrees. One is a professional degree in medicine + residency training, the other is a graduate research (or graduate professional) degree in a social science.

To be a psychiatrist, one usually (and not always) has to have completed a bachelor's degree. Most med schools won't look at you without a BA/BS in any subject (but you must meet specific bio/physics/chem/math and general ed pre-reqs to satisfy admissions requirements). When I was in medical school, we had 3 folks who did not have a completed bachelor's degree; however, they had 3.8 or higher GPA and had about 3 years of undergrad.

Then you need 4 years of medical school. Three years are actual classroom work and the last year is clinicals/clerkships. Don't forget the passage of the USMLE parts I and II. Then comes psychiatric residency which is generally 3 years. I did mine in internal med and psych, so it was 4 years.

If we assume a BA/BS degree, it comes out to 8 years of formal schooling (BA + MD) = 8 and then another 3 years of residency, for a grand total of 11 years of post-secondary education. Only 7 if you only take into account the post-bachelor's training. If you include the internship year, then you get 12 total and 8 post bac.

To become a clinical psychologist, one MUST have a bachelor's degree, usually in psychology, but not always. Some psychologists get an MS/MA prior to PhD/PsyD work, so that's about 2 years for the master's, and then on average 4-6 years of doctoral work (coursework + dissertation). Then, psychologists must go through a one-year APA internship and then pass a state licensing board examination.

So, with a master's that gives us 4 years of undergrad, 2 years for master's, and then about 5 years for PhD and one year of internship for a total of 12 years of schooling. Without the masters, 10 years of schooling. If we are only looking at post-bachelor's training, then 8 years for master's+PhD and 6 years for just the PhD.

The PsyD program at most schools appears to be 4 years post BA/BS + one year internship. So most PsyDs would have less formal training than MDs. Typically, this is because most PsyDs only have a one year internship, whereas MDs have a 3 year residency.

Fellowships are not part of the equation as they are optional and specialized.

So, whoever said the PsyD was only 3 years is wrong; it's usually 4 (and sometimes 5) years in length.

As for describing the differences, I think LM02 did a great job doing this.

 

[Sanman]

Hey, Just to clarify the issues for length of training in a Psyd program. The average length of the program is 4-5 years (PhDs are 5-7 years) with the last year being the internship (This roughly correlates to the MD sub-I or fourth year rotations). Once that is completed and the dissertation or final project is completed, the degree is granted. We then must complete at least one year of supervised clinical work in order to gain licensure, this usually takes the form on a post-doc (2 years for neuropsych). The post-doc roughly correlates with the MD internship. The difference in time of let's say 2-3 years (depending on length od post-doc) for psychiatry comes in the form of residency. So in these three years the psychologist can get a job at professional pay and start earning more than a psychiatry resident.


And to Daffy doc,
You may start out being paid 1.5 times what I will, but you owe 2 to 3 times what I do in loans, so I'm okay with that.

 

[MidwestPsyD]

I find it laughable that in threads of this nature, someone almost always tries to turn it into an issue of "my degree is better than yours."

 

[MidwestPsyD]

To clarify, I'm essentially referring to the "I make more money than you" thing.

 

[PublicHealth]

Americans are so damn competitive and hostile. Sad, isn't it? 🙁

 

[Dr Trek 1]

Someone should change the title of this thread to "PhD vs. MD/DO."

😉

 

[MsAnaF]

we certainly are a competative bunch, aren't we.

 

[Sanman]

Well when you are comparing to of the most competitive fields of study in this country, you tend to get more then a few type A personalities, or they wouldn't be there. And, with all the sacrifice that entails people tend to want to tell themselves it was the best decision in the end, so you get the "my career is better than yours" posters. To which I say, go get a drink and make some friends because your career shouldn't be your life.

 

[Psyclops]

Well it's going to be a big part of it at the very least. You'll be spending more time working per week than you will with you family.

 

[ProZackMI]

To clarify, I'm essentially referring to the "I make more money than you" thing.

It's human nature to a certain extent, but it is rather unseemly at this level. The PsyD/PhD is a different animal than the MD, so it's apples to oranges. I'm a psychiatrist, but I have a great deal of respect for most of my PhD/PsyD colleagues. A psychologist is neither superior or inferior to a psychiatrist. Trying to compare salaries is laughable since such a number has no bearing on competence and efficacy in tx. To compare length of schooling also is ridiculous as it varies from individuals doctors.

 

[MidwestPsyD]

I've seen a couple people mention an ms in psychopharmacology. Does anyone have any good information on this (requirements, coursework, etc)? I would possibly like to specialize in chemical dependency and wonder if something like that would come in handy.

 

[pschmom1]

I find it laughable that in threads of this nature, someone almost always tries to turn it into an issue of "my degree is better than yours."

OMG, DITTO!!!!!

A psychologist is neither superior or inferior to a psychiatrist. Trying to compare salaries is laughable since such a number has no bearing on competence and efficacy in tx. To compare length of schooling also is ridiculous as it varies from individuals doctors.

Again, DITTO!!!!

Is this competition crap ever going to subside? As I said before and I will say again and again and again, WE ARE ALL CHEARING FOR THE SAME TEAM!!!!
I just don't understand the big confliction. IMHO, one can NOT function without the other! This is not a political party here! I don't mean to sound hostile or confrontational, but wouldn't it be nice to remember why we have chosen the careers we have, and appreciate every body's different roles in helping the patients in the mental health realm get well, or give them the tools to live a meaningful life? It's sad to me that I have to defend my decision and reasoning for pursuing psychiatry at times to peers and such, but it's much sadder to have to defend myself amongst others in my field. I guess, not in my field as far as career but school as of now. I hope others on here can set aside their argumentative opinions and understand where I'm coming from.

 

[MeBen]

I am not speaking as a medical professional, only somebody who had for a time an anxiety ‘disorder (hate that word). Most people go to a psychologist or psychiatrist for anxiety and depression that has just gotten out of control. There is no need to ‘drug’ all of these people.

I had it pretty bad. I could barely move, talk, eat or work. I still don’t know how I functioned. Every doctor wanted to put me on meds. I called several psychiatrists that when I said I did not want meds they said go elsewhere. Not come in and we will see what we can do. But,”If you are against meds than I will probably not be able to help you.” (exact quote) I had every medical test known to man (great insurance). MRIs, CT scans, X-rays, PET Scans, CBCs, HIV, STD, H1ac, thyroid, liver blood tests, checked for ever cancer, MS, Parkinson’s, Asthma, Epilepsy, and about a million other things. I was only in my 20s.

I finally saw a psychologist who worked with me using CBT. Within a few months I was better than before. I know I will never have this problem again for one reason. I don’t respond to life pressure the same anymore. Would a drug of fixed that? Would it have ‘cured’ me? Where would I be if I drugged myself and sat on a couch ripping my heart out while the doc said, “Uh huh. Right. Go on” I know some are thinking I must have not been that bad off because I was able to turn around so quick-CRAP. Having anxiety or depression for a long time is not a badge of honor to show how worse off you are over someone else.

I am not saying that a psychiatrist cannot do the same thing. I know drugs help people, I know they save people. But they can become a crutch. I like the idea about an MD being a psychiatrist. Many people with anxiety have psychical symptoms that concern them that are caused by their anxiety. Many thing about the bosy can be explained But I think they need to empasize on dealing with the non-biological issues of psychology. I am sure my ‘chemicals were imbalanced’. I am sure I was causing it with the anxiety. When the anxiety was gone the chemicals went ‘back to normal.’

The funny thing about this is I want to be an DO, but a good old family doctor, not a psychiatrist. My psychologist says I should become a psychologist. He told me I know more about psychology than many of his grad students. However I’d rather just treat sick kids, help fathers get over the flu and help mothers deal with all those colds. And if someone comes in with anxiety issues, I am not going to just write them a script for Xanax and tell them good luck.

 

[pschmom1]

MeBen, I absolutely agree with you. I think therapy is a must, but at the same time people have chemical imbalances that therapy alone cannot treat. Meds are great for helping people relieve anxiety and depression while they are sorting out their troubles in therapy. The meds will alleviate the symptoms while the therapy will give meaning to the symptoms and provide insight and coping techniques to deal with the pressures and sorrows of ones past or present life. People often don't need the meds after therapy, unless of course it is a biological situation in which they may still need them to live a productive life. It's great that you had such a positive experience with therapy and good luck if you decide to pursue psychology 🙂

 

[positivepsych]

MeBen, I absolutely agree with you. I think therapy is a must, but at the same time people have chemical imbalances that therapy alone cannot treat. Meds are great for helping people relieve anxiety and depression while they are sorting out their troubles in therapy. The meds will alleviate the symptoms while the therapy will give meaning to the symptoms and provide insight and coping techniques to deal with the pressures and sorrows of ones past or present life. People often don't need the meds after therapy, unless of course it is a biological situation in which they may still need them to live a productive life. It's great that you had such a positive experience with therapy and good luck if you decide to pursue psychology 🙂

I don't think most people with depression that's not atypical and most people with generalized anxiety disorder have a "chemical imbalance" and that the meds are 'correcting' it. Prove me wrong. We don't even have a great understanding of why meds work well, we perscribe SSRIs for nearly everything (and I believe about half of the effects are due to placebo according to meta-analysis). Psychopharmacology is still in the stone ages.

By the way, the most reliable effect of Prozac is inhibition of libido, not anti-depressant effects. It's just that you can't market a libido inhibitor, so the pharmaceutical companies thought it might be better to market it as an anti-depressant.

 

[Psyclops]

I don't think most people with depression that's not atypical and most people with generalized anxiety disorder have a "chemical imbalance" and that the meds are 'correcting' it. Prove me wrong. We don't even have a great understanding of why meds work well, we perscribe SSRIs for nearly everything (and I believe about half of the effects are due to placebo according to meta-analysis). Psychopharmacology is still in the stone ages.

By the way, the most reliable effect of Prozac is inhibition of libido, not anti-depressant effects. It's just that you can't market a libido inhibitor, so the pharmaceutical companies thought it might be better to market it as an anti-depressant.

McBen, I think it would have been better if you had posted you comments on the psychiatry forum. Some of them need to hear stories like that. Although, I certainly do appreciate your story, especially since it worked out so well.

PP, you bring up some very good points about the placeo efects, and I whole heartedly agree that throwing meds at everything doesn't get us anywhere. But, as to chemical imbalance. What do you think happens to you when you get anxious? What do you think happens when you have any sort of thought in general, let alone emtionally laden ones? There is no dality, every mind state has an associated brain state, generally one that is differnt from others in a chemically. If somone suffers from uncontrollable anxiety, sad feelings, happy feelings, hallucinations, etc. I think it is safe to assume that something has gone awry in thier chemical structure of their brain or body. Now, this doesn't make any etiological or treatment assumptions, but it does make sense to me when people say chemical inbalance. But I hate it when it is used as an excuse.

 

[PublicHealth]

I finally saw a psychologist who worked with me using CBT. Within a few months I was better than before. I know I will never have this problem again for one reason. I don’t respond to life pressure the same anymore. Would a drug of fixed that? Would it have ‘cured’ me? Where would I be if I drugged myself and sat on a couch ripping my heart out while the doc said, “Uh huh. Right. Go on” I know some are thinking I must have not been that bad off because I was able to turn around so quick-CRAP. Having anxiety or depression for a long time is not a badge of honor to show how worse off you are over someone else.

Interestingly, psychologists seeking prescriptive authority talk about a "biopsychosocial" approach to treatment that involves pharmacotherapy and psychotherapy. The medical/prescribing psychologists in the DoD, NM and LA have actually taken more patients off medications and offered psychotherapy than they have prescribed. The role of psychological and neuropsychological assessment in treatment decision-making is also emphasized. In my view, there is a need for this kind of integrated care in psychiatry and psychology. Here's a draft of what Division 55 has to say on the matter: http://www.division55.org/pdf/draftguidelines.pdf

 

[positivepsych]

But, as to chemical imbalance. What do you think happens to you when you get anxious? What do you think happens when you have any sort of thought in general, let alone emtionally laden ones? There is no dality, every mind state has an associated brain state, generally one that is differnt from others in a chemically. If somone suffers from uncontrollable anxiety, sad feelings, happy feelings, hallucinations, etc. I think it is safe to assume that something has gone awry in thier chemical structure of their brain or body. Now, this doesn't make any etiological or treatment assumptions, but it does make sense to me when people say chemical inbalance. But I hate it when it is used as an excuse.

Yes, every thought or feeling causes neurons to fire or some neurotransmitters to shuffle around in the brain. So what? That's reductionistic. For most people who have mild depression or anxiety, it's because of an inability to cope with the difficulties of life.

A psychologist/psychiatrist on SDN once posted that a woman came into her practice right after her husband passed away and was very depressed. She asked for an anti-depressant. The therapist didn't want to give it to her, beacause he said that depression is a natural response to having a loved one die, and that the depression will go away with time as she finishes grieving. She was furious and stormed out of the office because he refused to perscribe.

So what does that tell you? Does she have a "chemical imbalance?" Maybe her grieving caused her seratonin levels to dip a bit, it doesn't mean we should patch it up with an SSRI, because that's not the root of the issue.

People in this society, both psychiatrists (who profit off of 15-min med checks) and patients want convenience. It's easier to pop a pill twice a day than to be in a therapist's office once a week and change the way a person thinks in response to difficulties.

Those of you who are so pro-medications for things like depression, anxiety, ADHD, etc. are single-handedly supporting big pharmaceutical companies that have no concern for the well-being of our society, other than to make a profit. Did you know that Pfizer, the day after 9/11 actually aired a commerical that said "we wish we had a medication to take away the pain." What kind of society would we live in in Pfizer had its way and we popped a pill every time anything mildly difficult or painful happened in our lives? What kind of people would we be?

I understand that medication can be effective at times, but both MDs and PhDs with perscription privlidges need to understand the philosophical implications of what they do when they give someone a pill ("you can't deal with this, so let drugs do it") It's disempowering.

There was a study that compared the effects of 1) prozac, 2) 3x a week of 30 min. cardiovascular excercise, and 3) a combination treatment on depression. The exercised worked just as well as prozac. Interestingly, the combination treatment did not improve as much as the other two groups. The subjects in the combination group didn't know whether their improvement was due to their own efforts in exercising or to the drugs, so it sapped their motivation to work out and they didn't gain any self-efficacy or locus of control, like the people who strictly excercised did.

There's something very powerful when you realize that you're responsible and capable of helping yourself. In my opinion, it's a therapist's job to guide a person in their own healing.

 

[edieb]

I am in Louisiana, so I get to see the medical psychology model at work first hand. I must say that athe reception the medical psychologists (MPs) have received from the public and the medical community as a whole is very positive. People are impressed that the MPs do not just prescribe drugs for all their patients and leave them on those drugs. Rather, the psychoactive drugs are for temporary use only. Sure, there are some patients who will be on drugs for the rest of their lives (e.g., psychotic spectrum disorders, etc.), so the MPs just do med checks with some of their patients. However, these patients are a rarity.

The influence of the MPs is now seeping into our psychology department. In the past few months MPs have presented at length on psychopharmacology and differential diagnosis. The faculty, mostly once opposed to RxP, have come on board, too.

Finally, medical psychology is opening up doors once closed to clinical psychology. Hospital work for psychologists is alive once again. Many of the local MPs do inpatient work in the AM and see their outpatients in the PM. The fact that local hospitals are allowing MPs to prescribe drugs is evidence that is being accepted by the medical establishment

BTW, Public Health, thanks for the head up on the Div 55 call for papers

Interestingly, psychologists seeking prescriptive authority talk about a "biopsychosocial" approach to treatment that involves pharmacotherapy and psychotherapy. The medical/prescribing psychologists in the DoD, NM and LA have actually taken more patients off medications and offered psychotherapy than they have prescribed. The role of psychological and neuropsychological assessment in treatment decision-making is also emphasized. In my view, there is a need for this kind of integrated care in psychiatry and psychology. Here's a draft of what Division 55 has to say on the matter: http://www.division55.org/pdf/draftguidelines.pdf

 

[PublicHealth]

I am in Louisiana, so I get to see the medical psychology model at work first hand. I must say that athe reception the medical psychologists (MPs) have received from the public and the medical community as a whole is very positive. People are impressed that the MPs do not just prescribe drugs for all their patients and leave them on those drugs. Rather, the psychoactive drugs are for temporary use only. Sure, there are some patients who will be on drugs for the rest of their lives (e.g., psychotic spectrum disorders, etc.), so the MPs just do med checks with some of their patients. However, these patients are a rarity.

The influence of the MPs is now seeping into our psychology department. In the past few months MPs have presented at length on psychopharmacology and differential diagnosis. The faculty, mostly once opposed to RxP, have come on board, too.

Finally, medical psychology is opening up doors once closed to clinical psychology. Hospital work for psychologists is alive once again. Many of the local MPs do inpatient work in the AM and see their outpatients in the PM. The fact that local hospitals are allowing MPs to prescribe drugs is evidence that is being accepted by the medical establishment

BTW, Public Health, thanks for the head up on the Div 55 call for papers

Interesting. Any word on how reimbursement is working out for medical psychologists in LA? Psychiatrists lobbied long and hard to get their fair share. I wonder if medical/prescribing psychologists will have to do the same.

Did you see the piece by Sharfstein, current President of the American Psychiatric Association, in the most recent issue of Psychiatric News? Here it is: http://pn.psychiatryonline.org/cgi/content/full/41/9/3
Clearly, psychiatry is concerned about psychologists getting prescriptive authority. But they're really not doing anything about it other than pointing fingers at psychologists and saying, "You're not trained in medicine." I'm not sure how they will handle the access to care issue. Producing a few hundred psychiatrists each year, a third of whom are foreign-trained physicians who do not speak English very well, will not meet needs. I have heard that psychiatrists in HI are suggesting creating a medical school and residency program to train some kind of hybrid family physician/psychologist. Legislators are growing concerned, especially in states like HI. By the way, the United States received a "D" for mental healthcare according to NAMI http://www.nami.org/gtstemplate.cfm?section=grading_the_states&lstid=701.

 

[Psyclops]

Yes, every thought or feeling causes neurons to fire or some neurotransmitters to shuffle around in the brain. So what? That's reductionistic. For most people who have mild depression or anxiety, it's because of an inability to cope with the difficulties of life.

A psychologist/psychiatrist on SDN once posted that a woman came into her practice right after her husband passed away and was very depressed. She asked for an anti-depressant. The therapist didn't want to give it to her, beacause he said that depression is a natural response to having a loved one die, and that the depression will go away with time as she finishes grieving. She was furious and stormed out of the office because he refused to perscribe.

So what does that tell you? Does she have a "chemical imbalance?" Maybe her grieving caused her seratonin levels to dip a bit, it doesn't mean we should patch it up with an SSRI, because that's not the root of the issue.

People in this society, both psychiatrists (who profit off of 15-min med checks) and patients want convenience. It's easier to pop a pill twice a day than to be in a therapist's office once a week and change the way a person thinks in response to difficulties.

Those of you who are so pro-medications for things like depression, anxiety, ADHD, etc. are single-handedly supporting big pharmaceutical companies that have no concern for the well-being of our society, other than to make a profit. Did you know that Pfizer, the day after 9/11 actually aired a commerical that said "we wish we had a medication to take away the pain." What kind of society would we live in in Pfizer had its way and we popped a pill every time anything mildly difficult or painful happened in our lives? What kind of people would we be?

I understand that medication can be effective at times, but both MDs and PhDs with perscription privlidges need to understand the philosophical implications of what they do when they give someone a pill ("you can't deal with this, so let drugs do it") It's disempowering.

There was a study that compared the effects of 1) prozac, 2) 3x a week of 30 min. cardiovascular excercise, and 3) a combination treatment on depression. The exercised worked just as well as prozac. Interestingly, the combination treatment did not improve as much as the other two groups. The subjects in the combination group didn't know whether their improvement was due to their own efforts in exercising or to the drugs, so it sapped their motivation to work out and they didn't gain any self-efficacy or locus of control, like the people who strictly excercised did.

There's something very powerful when you realize that you're responsible and capable of helping yourself. In my opinion, it's a therapist's job to guide a person in their own healing.

I agree wholeheartedly with you. And I think you put the argument very well. But there still exist those folks for whom thier brain chemistry/physiology is innately dysregulated.

 

[PublicHealth]

I agree wholeheartedly with you. And I think you put the argument very well. But there still exist those folks for whom thier brain chemistry/physiology is innately dysregulated.

Agreed. But who is trained to provide BOTH psychopharmacotherapy and psychotherapy in a safe and effective manner?

 

[Psyclops]

Agreed. But who is trained to provide BOTH psychopharmacotherapy and psychotherapy in a safe and effective manner?

I'm not sure what you are getting at here. You seem to be trying to stir up alot of trouble tonight. This was an interesting post on the psychiatry forum..... http://www.cchr.org/index.cfm/7055

 

[Dr Trek 1]

I have not read every post in this thread but I did just want to give my two cents on one issue that is often brought up in these discussions, which there is typically confusion about.

Psychiatrists (MD/DO) can indeed bill insurance for psychotherapy just as psychologists (PhD/PsyD) do. It is a myth that insurance companies will only allow them to do 15 minute med checks. Although there are psychiatrists who limit themselves to med. checks, they can certainly do more and many psychiatry residency programs do give psychiatrists great training in psychotherapy.

 

[PublicHealth]

Although there are psychiatrists who limit themselves to med. checks, they can certainly do more and many psychiatry residency programs do give psychiatrists great training in psychotherapy.

From the President of the American Psychiatric Association:

"Of greater concern for psychiatry is the domination of treatment of mental illness by psychopharmacologic means and the attrition of psychotherapeutic and psychosocial approaches in our practice. Psychopharmacology ascendance in practice has been driven by managed care protocols, which deemphasize the psychotherapeutic skills of psychiatrists and puts a premium on very short-term hospital care, medication management, and reevaluation of diagnosis and treatment. Psychiatrists are often being prohibited from providing psychotherapy. The absence of adequate psychotherapy residency training for many psychiatrists reinforces this regrettable trend. In the decade 1987-1997, Olfson and colleagues found a substantial increase in the proportion of individuals with depression receiving medications and a substantial decline in the use of psychotherapy. In a more recent study by West and colleagues published in Psychiatric Services' "Economic Grand Rounds," the financial incentives for psychiatrists to provide psychopharmacologic treatments in contrast to psychotherapy showed a clear economic advantage to provide medication with brief follow-up visits and a clear financial disincentive to provide psychotherapy. Psychiatrists earn more than $100 less an hour for providing one 45- to 50-minute session of psychotherapy versus providing three medication management visits in the same time."

http://pn.psychiatryonline.org/cgi/content/full/41/9/3

 

[Psyclops]

How does he get that right but so much else wrong. Damn you Scharfstein. I guess he sees this as the answer. I doubt he can convince the myriad of psychiatrists to stop doing just med checks.

 

[Dr Trek 1]

Sorry, I didn't mean to start a commotion.

First off, I will admit that not all psychiatry residency training programs provide quality psychotherapy training. However, if you want to practice psychotherapy as a psychiatrist, there are many residency programs that DO provide it.

Secondly, sure psychiatrists may not make as much doing 50 mins of psychotherapy as compared to 4 med checks, however they get paid at least the same as psychologists for the therapy sessions. This is why some are motivated to stick with med checks. However, they can also do psychotherapy sessions.

 

[Beau Geste]

Sorry, I didn't mean to start a commotion.

First off, I will admit that not all psychiatry residency training programs provide quality psychotherapy training. However, if you want to practice psychotherapy as a psychiatrist, there are many residency programs that DO provide it.

Secondly, sure psychiatrists may not make as much doing 50 mins of psychotherapy as compared to 4 med checks, however they get paid at least the same as psychologists for the therapy sessions. This is why some are motivated to stick with med checks. However, they can also do psychotherapy sessions.

Good luck getting reimbursed for therapy sessions from insurance companies. The nature of insurance companies requires pre-approval for therapy, and if there is a way to cut costs, they'll go the cheaper route.

MDs are typically more expensive, and patients are usually sent to Social Workers or psychologists for the therapy, and then follow up with the MD on their meds.

Yes, there are certain instances where patients see the MD for therapy, but that is not the norm.

I have a good friend who has a MSW and is a LCSW who can attest to this, in addition, I know psychiatrists and psychologists who can attest to this as well.

 

[Doc Samson]

From long personal experience, I can vouch that insurance companies have no problem approving therapy visits with an MD. I know dozens of psychiatrists who have booming psychotherapy practices, and have no problem being reimbursed by insurance.

 

[Dr Trek 1]

From long personal experience, I can vouch that insurance companies have no problem approving therapy visits with an MD. I know dozens of psychiatrists who have booming psychotherapy practices, and have no problem being reimbursed by insurance.

Thank you psychiatrist Dr. Samson.

Although they often do mainly med checks, psychiatrists are still fully able to perform psychotherapy sessions and be reiumbursed just as clinical psychologists, social workers, and counselors.

I worked in a psychiatry department for a long time and know this first hand.

 

[pingouin]

From long personal experience, I can vouch that insurance companies have no problem approving therapy visits with an MD. I know dozens of psychiatrists who have booming psychotherapy practices, and have no problem being reimbursed by insurance.

Doc S, my experiences are much different- similar to what Megboo describes. Regional differences perhaps? I know you're in the northeast and I am... so very not. And perhaps it depends on the company as well. I worked for one of the national MBHOs and if a MD/DO wanted something other than the med checks, let's just say it was something of an ordeal, especially if there was a PhD or masters-level therapist on board as well. It was considered "duplication of services", which I thought was largely BS, as all the docs wanted was a 1/2 hour Q4 or Q6 weeks so they could do a more thorough check-in. God forbid the doc wanted to see the patient on a weekly or bi-weekly basis.

 

[Doc Samson]

Doc S, my experiences are much different- similar to what Megboo describes. Regional differences perhaps? I know you're in the northeast and I am... so very not. And perhaps it depends on the company as well. I worked for one of the national MBHOs and if a MD/DO wanted something other than the med checks, let's just say it was something of an ordeal, especially if there was a PhD or masters-level therapist on board as well. It was considered "duplication of services", which I thought was largely BS, as all the docs wanted was a 1/2 hour Q4 or Q6 weeks so they could do a more thorough check-in. God forbid the doc wanted to see the patient on a weekly or bi-weekly basis.

It may well be a geographic phenomenon, but the 3 biggest insurers in New England (BCBS, Tufts, and Harvard Pilgrim) happily reimburse MDs for therapy. I imagine it may also have something to do with the psychiatrists in a particular locale also... here in Boston (as with NYC, Chicago, SF, etc.) we have a long tradition of psychotherapy by psychiatrists and 4 psychoanalytic institutes. Psychotherapy is very much integral to the identity of psychiatry in New England. I have met psychiatrists from other parts of the country though that see medications/ECT as their chief (only?) responsibility.

If there is another therapist on board, then I imagine that any insurer, no matter where in the country they were, would not pay due to duplication of services, but this would apply to two MDs, two PhDs, two LICSWs, or any combination of the above.

 

[pingouin]

If there is another therapist on board, then I imagine that any insurer, no matter where in the country they were, would not pay due to duplication of services, but this would apply to two MDs, two PhDs, two LICSWs, or any combination of the above.

My argument on behalf of the doctors was always that seeing a patient for 30 min rather than 15 every 4-6 weeks isn't so much "ongoing therapy" as it is actually being able to do a more thorough clinical assessment before making any med changes. To me, that did not duplicate what the primary therapist was providing and could be construed as best clinical practice. Unfortunately, my boss overruled me on this one.

Medicare is suprisingly lax, which is a whole different thread...... but I accidentally saw a patient on the same day she saw her psychiatrist- one the few in our area who does do full hour sessions. (So maybe this happened twice before the "oh no.." moment hit me.. 😳) I fully expected a big fat denial letter once I realized what happened, but they paid out to both of us- him, for a 90807/one hour therapy + med mgmt and me for a 90806/one hour therapy.