Psychopharmacology/Advanced Practice Psychology

[Therapist4Chnge]

As much as you would like to think that going to medical school makes you 'superior'... and that is the underlying theme of your argument (which you wisely edited from an earlier post today)....

I was wondering where the "ditch digger" comment went, that I could have sworn was included in one of the posts, amongst a bunch of other things that were edited out.

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[silas2642]

medical psychologist are and have been treating schizophrenics and other disorders in the spectrum. the more complicated cases are substance abusers (often comorbid w/ charaterological diff.) and medically compromised geri pts. those populations require a team approach... beyond psychiatry. also, if you want to practice evidenced based treatment, polypharmacy is discouraged. There is no evidence noting that prescribing multiple meds is more efficacious than being conservative. Medical psychologists have been prescribing more than just ssri's and are doing so safely and efficaciously.

If medical psychologists are treating schizophrenics with antipsychotics, they shouldn't be-- they simply don't have the training necessary to medically tx complicated cases. PCP's would be better off medically managing their meds because at least they would know what to look for and interpret labs correctly. This can be a delicate art and science, and living in the ignorance of bliss, thinking that you know what you're doing is dangerous.

 

[doctorpsych]

I was wondering where the "ditch digger" comment went, that I could have sworn was included in one of the posts, amongst a bunch of other things that were edited out.

yeah, and all that crazy talk came from just "you are a med student..."

 

[doctorpsych]

If medical psychologists are treating schizophrenics with antipsychotics, they shouldn't be-- they simply don't have the training necessary to medically tx complicated cases. PCP's would be better off medically managing their meds because at least they would know what to look for and interpret labs correctly. This can be a delicate art and science, and living in the ignorance of bliss, thinking that you know what you're doing is dangerous.

they have been doing so safely for years... prescribing antipsychotics, mood stabilizers and other psychotropics....along with reading labs correctly, getting EKGs, monitoring therapeutic drug levels, etc... these patients are typically REFERRED by pcps to medical psychologist because most pcps don't have the training, nor desire to, or have the time to do so... and psychiatrists are unavailable for whatever reason... medical psychologists are not doing this without appropriate training... medical psychologist also know their limitations and would not foolishly practice in a vacumm.

it wasn't too long ago that psychiatry framed psychology as endangering pts lives because psychologists were being trained to performed psychotherapy...

 

[doctorpsych]

The mod asked us to steer the conversation back towards psychopharm, and you continued with your little rant. Let's agree to disagree, stop the name-calling, and get back on track.

On a different note (actually, the reason I stumbled on this thread): Take a look at the article we're reviewing in my lab. Think a comparable study could yield the same results here in the US?

http://www.eric.ed.gov/ERICWebPorta...&ERICExtSearch_SearchType_0=no&accno=EJ731049

Interesting question... I suspect that treatment modality and adherence to guidelines would interact with type/quality of service provider and behavioral dyscontrol of the treated population. If the latter is controlled, the 'expensive' providers would more likely utilize b-mod/behavioral therapy/skills training in conjunction with psychotropics if deemed necessary. But I suspect that the lower funded programs may relay more on chemical restraints (quicker and perceived to be less expensive) than on psychotherapeutics.

 

[Therapist4Chnge]

Interesting question... I suspect that treatment modality and adherence to guidelines would interact with type/quality of service provider and behavioral dyscontrol of the treated population. If the latter is controlled, the 'expensive' providers would more likely utilize b-mod/behavioral therapy/skills training in conjunction with psychotropics if deemed necessary. But I suspect that the lower funded programs may relay more on chemical restraints (quicker and perceived to be less expensive) than on psychotherapeutics.

Exactly. How many "suicidal" borderlines stroll through, get slapped with a bipolar dx, get meds, stay 72 hours, discharge.....and then do the dance again?

 

[busi26]

Additionally, I remain absolutely unconvinced that the material you cover in a two year master's program is equivalent in medical content to that of 4 years of premed, 4 years of medical school, and 4 years of residency.

The goal of psycholgists prescription privileges is not to make psychologists capable of doing everything that physicans do. No one in this debate has ever claimed that. Psychologists primarily use psychotherapy to treat patients. Psychiatrists primarily use meds. Psychotherapy is superior to meds for most conditions. For some forms of psychopathology, combining psychotherapy and meds may have a greater impact in some patients. How much specific training do physicians have in providing psychotropics to mentally ill patients? Less than 2 years no doubt. However, physicians prescribe over 80% of psychotropic meds.

 

[busi26]

I will remind you folks that the people who have attained prescription privileges (eg, NPs, PAs, etc) did it with the SUPPORT of the physician community. So, you might want to revamp your attitudes about physicians if you ever want any cooperation from them in attaining prescription privileges.

Really, you believe that the majority of physicans supported NPs, optometrists, etc. getting the right to prescribe in their area of training? Not to be condescending, but you really should do a google search for articles on this topic. Physicans were overwhelmingly opposed to NPs and optometrists prescribing.

By the way, a large group of physicians supported prescription privileges in Louisiana. This fact was cited by many legislators in LA as one of the main reasons the bill passed.

 

[Therapist4Chnge]

I will remind you folks that the people who have attained prescription privileges (eg, NPs, PAs, etc) did it with the SUPPORT of the physician community. So, you might want to revamp your attitudes about physicians if you ever want any cooperation from them in attaining prescription privileges.

This is definitely a bit of revisionist history, as it is well known that the AMA and many phyisicians not only opposed mid-levels prescribing, but figuratively yelled from the rooftops that patients would die and no one was safe in the hands of a mid-level with a prescription pad.

 

[RGMSU]

I wouldn't call it hypsersensitivity to respond after about 5 people on here have joined in a collective attack. Nobody responded to Artemis? Why is that? My opinion about psychologists is no more limited than your opinion about psychiatrists or medicine. Are you a psychiatrist? Have you attended medical school? My opinions about psychiatry as a career field are not shaped by this thread. Rather, I feel this thread is indicative of some of the problems with psychiatry. 5-10 min med checks are frequently used by psychiatrists because, if you haven't figured it out yet, many of the problems previously thought to be related to pent up anxiety over not getting an extra popsicle in the first grade are actually due to biochemical/biophysical causes. I'm sure you folks don't want to admit that since you are not trained in biology, chemistry, or physics, nor any derivation thereof. I would argue that psychiatrists still maintain a better relationship with the rest of medicine than psychologists because they share the physician identity. Psychologists are more sophisticated at psychopharm than psychiatrists? I guess that's because of all their deep training in physiology and pharmacology by virtue of a two-year night school program, huh? That's sarcasm for those of you who can't discern that. And psychologists are better at noticing medical side effects than psychiatrists? I guess that's because they are so well-trained in physical diagnosis? You call this the real world? Psychologists are consulting for PCPs - I guess because they know so much more about medicine than family physicians and psychiatrists both right? Your suggestion seems to be that medical school is inferior. Before you become too committed to that statement, go back and edit your grammar and spelling. "Practitionares?" Not familiar with those. Virtually all family physicians complete residency and are boarded, so you're just flat wrong on that one. And your MD friend is full of crap too. I think what you and your friends here want is a team approach excluding psychiatrists so you can feel more relevant. I directly take issue with your statement that polypharmacy is not supported by evidence - shear nonsense. Sure, using as few medicines as possible is desirable, but there are many patients who require more than one overlapping medicine. I guess you're jumping on the band wagon that psychiatrists are "pill pushers" now, right? I edited my comments because I wanted to avoid personally attacking your colleague, as he had done to me. I gave everybody the opportunity to end this bantering, but now you've got me pissed, so don't expect me to stop.

 

[RGMSU]

yeah, and all that crazy talk came from just "you are a med student..."

No, it came from you posting like a condescending ass that I didn't know what I'm talking about because I don't happen to subscribe to your version of the "real world" manufactured in your own little pea brain.

 

[RGMSU]

The goal of psycholgists prescription privileges is not to make psychologists capable of doing everything that physicans do. No one in this debate has ever claimed that. Psychologists primarily use psychotherapy to treat patients. Psychiatrists primarily use meds. Psychotherapy is superior to meds for most conditions. For some forms of psychopathology, combining psychotherapy and meds may have a greater impact in some patients. How much specific training do physicians have in providing psychotropics to mentally ill patients? Less than 2 years no doubt. However, physicians prescribe over 80% of psychotropic meds.

Actually, not true. I'm assuming you're talking about FPs prescribing psychotropics? They see 30-40 patients a day 80 hours a week for 3 years in residency, during which time I'm sure they see plenty of patients with psychiatric manifestations not to mention psychiatry rotation in medical school. I'm sure that winds up to be more patient medical contact than you get through an online psychology PhD or a two-year snake oil salesman master's night program.

 

[RGMSU]

This is definitely a bit of revisionist history, as it is well known that the AMA and many phyisicians not only opposed mid-levels prescribing, but figuratively yelled from the rooftops that patients would die and no one was safe in the hands of a mid-level with a prescription pad.

Many mid-levels still practice on a physician's license because they are required to do so by law in some states. If the physician didn't agree to hire them, they wouldn't have a job in these states. So, yes, I would call that supporting their prescription privileges. Not revisionist history. Everyday reality in the state I'm in.

 

[RGMSU]

Interesting question... I suspect that treatment modality and adherence to guidelines would interact with type/quality of service provider and behavioral dyscontrol of the treated population. If the latter is controlled, the 'expensive' providers would more likely utilize b-mod/behavioral therapy/skills training in conjunction with psychotropics if deemed necessary. But I suspect that the lower funded programs may relay more on chemical restraints (quicker and perceived to be less expensive) than on psychotherapeutics.

Oh, yeah, beautiful article. "Prescriptions frequently violated current guidelines, especially when conducted by general practitioners... Psychiatrists complied more with current guidelines." An anti-family physician/anti-psychiatrist attitude - I can see where that would be right up you folks metaphorical alley. Psychologists to the rescue, right, to relieve the world of all it's big bad drugs and convoluted medical physiology they never learned about? Truth is - as much as some of you hate my posts, you need me on this forum. There's way too much intellectual inbreeding on here without the occasional smart ass medical student coming along.

 

[RGMSU]

For someone who has adopted to go ad hominem and attack grammar, I'm surprised that you aren't aware that this should have been "sheer."

True. My mistake. Not quite as egregious as some of the other posts laden with mistakes that go uncorrected. "Medical psychologist are..." and "vacumm." Need I continue? Again, the difference between the responses some people get on here and the responses I get. I'm surprised you haven't noticed that you have a self-fulfilling, cyclical kind of conversation going on here. As long as one of your psychology colleagues posts something you all agree with, you all support each other and assume that is evidence that what you say is true. It really isn't. It's proof that you all believe the same thing. Then, when someone from outside comes along and posts here, if it doesn't fit the agenda of the thread, you all attack together because you don't want to hear a divergent opinion. It's interesting that nobody chooses to respond specifically to my critiques. (1) There is growing evidence that biochemical/biophysical causes lead to many mental health problems, which would need to be treated with DRUGS. Maybe that's why some psychologists want to prescribe, because they recognize that the etiologies of many of the illnesses that were once thought to be rooted in formative experience are actually rooted in science/genetics. (2) Evidence that psychologists manage medical patients better than family physicians/psychiatrists, other than just the fact that many of you think/say so? About 85% of medical problems can be handled fine by a family physician/general internist/pediatrician, and experience/evidence proves it. The medical model of education is based on generalization followed by specialization in the case of psychiatrists. They have a whole body of general medical knowledge that a psychologist is never exposed to because psychology training doesn't follow the generalization followed by specialization model, nor is it explicitly scientific/medical. There is no core of scientific knowledge attained by most psychologists either (physics, biochemistry, genetics). I have not once seen a psychology student in upper-level science classes, but I have seen many psychology degree programs, even clinical ones, that have little to no science requirement. (3) Polypharmacy is frequently quite necessary and beneficial and not the grand villain. Of course, for people not trained in medicine, I can see where polypharmacy could be a problem in terms of management.

 

[Therapist4Chnge]

MOD NOTE: This is a professional forum, and I expect posters to treat it as such. People on all sides of the discussion need to abstain from personal insults, as that is against SDN Policy, and further comments will be handled with administrative action. -t4c

However, this ribbing is between different members of the same family. We all share a come heritage and training experience. Psychologists do not. The field of medicine has many mid-level providers who have more limited training but are also trained from the start in the medical model.

You are pretty much making this a guild issue, and not a treatment issue. It is understandable that you want to protect your guild, but your assertion that medical psychologists are unable to provide care is not supported by the previous 10 years of data.

Psychologists have no comprehension of the medical complications of medications. They don't know how to recognize medical or neurological complications of different diseases. They don't know how to take a basic physical exam or have any understaning of labs or vital signs.

I would argue that most psychologists would struggle in a number of these areas, but a psychologist who went through the appropriate post-doc training would sufficiently be able to handle these issues.

No major medical, patient, or healthcare organizations support your efforts.

So the hospitals in LA that actively recruit medical psychologists are exempt from your list? There are also hospitals in NM who support prescribing psychologists. There are also prescribing psychologists on military bases. There are also a number of state-level patient advocacy groups that suppose prescription privledges.

The whole idea of getting lobby groups and petitioning for "rights" with substandard knowledge conjures up the image of charlatans and snake oil salesman of the past. The medical community and most of the public is not fooled. You would think that with decades of your efforts to prescribe meds, you would have more to show for it. Not to worry. There will always be some poor folks that seeks a cure for their spinal cord injury from a chiropracter rather than a neurosurgeon....

Politics is a unique animal, and you either understand how it works, or you don't. Instead of arguing outside of this realm, I'll suffice to say that everything from an oral argument through a signed bill requires lobbying groups and positioning....as it is a nature of the beast.

.....many of the problems previously thought to be related to pent up anxiety over not getting an extra popsicle in the first grade are actually due to biochemical/biophysical causes.

As Frued once said, "sometimes a cigar is just a cigar". There has been some limited research supporting the biological basis to some diagnoses, this is still a growing and uncertain field. I welcome any advances we find in this area, though I strongly doubt it all can be traced back to a random sequence of genes, as nature does not function autonomously from nuture. It is more likely that a combination of nuture and nature is at play, and the solution cannot solely be found in a pill.

I'm sure you folks don't want to admit that since you are not trained in biology, chemistry, or physics, nor any derivation thereof.

Some psychologists don't have this training, but anyone in neuropsych/neuroscience areas not only have this training, but are most likely teaching in your medical schools, as they are the specialists in these areas. On a personal note I've had classes in neuroanatomy, neurophysiology, neurochemistry, A&P, etc.

I directly take issue with your statement that polypharmacy is not supported by evidence - shear nonsense. Sure, using as few medicines as possible is desirable, but there are many patients who require more than one overlapping medicine.

Polypharmacy in regard to psychotropics, on average, does not have a wealth of support behind it. There are some studies that support some benefits from polypharmacy, but the vast majority of polypharmacy out there is done as personal preference. There may be instances where certain combinations work, but don't assert that there is hard data that supports psychtropic polypharmacy across the board. In limited, and specific case presentations it may have support, but usually it is not generalizable across "real" patients. Research limitations are typically quite significant in the polypharmacy studies.

Many mid-levels still practice on a physician's license because they are required to do so by law in some states. If the physician didn't agree to hire them, they wouldn't have a job in these states. So, yes, I would call that supporting their prescription privileges. Not revisionist history. Everyday reality in the state I'm in.

Circular logic does not pan out in this instance, as you are assuming since they are present now, that they were welcome then. The initial push (specifically for NPs) was met with a great deal of pushback from both the AMA and the A(Psychiatry)A.

Yeah, I'd love to see how you medical geniuses would reduce a mentally ******ed epileptic's neuroepileptic dosages or pull them off of their BAD polypharmacy regimen and wind up with a patient in status epilepticus.

Polypharmacy has its place, it just isn't with every patient who walks through the door.

.... when someone from outside comes along and posts here, if it doesn't fit the agenda of the thread, you all attack together because you don't want to hear a divergent opinion.

I welcome the discussion, as long as it is done professionally. As I noted above, we all need to make sure our emotions do not get the best of our posts.

 

[PrisonPsych]

True. My mistake. Not quite as egregious as some of the other posts laden with mistakes that go uncorrected. "Medical psychologist are..." and "vacumm." Need I continue? Again, the difference between the responses some people get on here and the responses I get. I'm surprised you haven't noticed that you have a self-fulfilling, cyclical kind of conversation going on here. As long as one of your psychology colleagues posts something you all agree with, you all support each other and assume that is evidence that what you say is true. It really isn't. It's proof that you all believe the same thing. Then, when someone from outside comes along and posts here, if it doesn't fit the agenda of the thread, you all attack together because you don't want to hear a divergent opinion. It's interesting that nobody chooses to respond specifically to my critiques. (1) There is growing evidence that biochemical/biophysical causes lead to many mental health problems, which would need to be treated with DRUGS. Maybe that's why some psychologists want to prescribe, because they recognize that the etiologies of many of the illnesses that were once thought to be rooted in formative experience are actually rooted in science/genetics. (2) Evidence that psychologists manage medical patients better than family physicians/psychiatrists, other than just the fact that many of you think/say so? About 85% of medical problems can be handled fine by a family physician/general internist/pediatrician, and experience/evidence proves it. The medical model of education is based on generalization followed by specialization in the case of psychiatrists. They have a whole body of general medical knowledge that a psychologist is never exposed to because psychology training doesn't follow the generalization followed by specialization model, nor is it explicitly scientific/medical. There is no core of scientific knowledge attained by most psychologists either (physics, biochemistry, genetics). I have not once seen a psychology student in upper-level science classes, but I have seen many psychology degree programs, even clinical ones, that have little to no science requirement. (3) Polypharmacy is frequently quite necessary and beneficial and not the grand villain. Of course, for people not trained in medicine, I can see where polypharmacy could be a problem in terms of management.

Polypharm is *sometimes* necessary. However, if I had a dollar for every drug-seeking substance abuser who comes in to my prison with a community psychiatrist diagnosis of "bipolar" and prescribed the "necessary" combination of Seroquel, Ativan, Xanax, Paxil, Klonopin, and Vistaril (or similar ridiculousness) I would be a very wealthy woman. Unsurprisingly, despite their complaints of how much they need these medications, their "mood swings" do not reappear when we (treatment team consisting of both a psychologist and a psychiatrist) remove them from all of this junk in an environment when they aren't abusing drugs.

I don't know that anyone on here would argue that RxP would be designed to *replace* psychiatrists. However, for medically stable patients on maintenance medications, adding RxP to the mix would allow the psychiatrists to focus on the more complicated cases. Right now, for low-income clients on some form of state/county aid (Medicaid, Medicare, or what they call IPRS out here), the wait time for an emergent non-dangerous case to see a psychiatrist can be several months. If the burden of the routine appointments were shuffled elsewhere (e.g. RxP), the psychiatrists could see these patients on a more efficient timeline.

 

[RGMSU]

I would argue that most psychologists would struggle in a number of these areas, but a psychologist who went through the appropriate post-doc training would sufficiently be able to handle these issues.

Herein lies the difficulty - how can you determine what exactly a person is qualified to practice if education isn't standardized?

As Frued once said, "sometimes a cigar is just a cigar". There has been some limited research supporting the biological basis to some diagnoses, this is still a growing and uncertain field. I welcome any advances we find in this area, though I strongly doubt it all can be traced back to a random sequence of genes, as nature does not function autonomously from nuture. It is more likely that a combination of nuture and nature is at play, and the solution cannot solely be found in a pill.

I wouldn't exactly argue that the research is limited. Again, I think this depends on what literature you're reading. In medical literature, genetic links are becoming more and more likely, while still nebulous. With limited understanding of neurochemsitry, it is difficult to follow the biochemical process back to the genetic precursors that dictate it. Limitations of our understandings don't necessarily indicate that the facts aren't there. We just haven't found them all yet. Whether the solution is found in a pill I think depends on the disease we're discussing. Some people who have depression don't need a pill at all. Some people can't be helped without chemical intervention, no matter how much the causes of their depression are exposed/dealt with.

Some psychologists don't have this training, but anyone in neuropsych/neuroscience areas not only have this training, but are most likely teaching in your medical schools, as they are the specialists in these areas. On a personal note I've had classes in neuroanatomy, neurophysiology, neurochemistry, A&P, etc.

I respect this training. I just don't see much non-neuro physio or chem in there, which gets back to my argument about generalization followed by specialization versus outright specialization from the beginning. This is a much larger topic than just psychology versus psychiatry. I regularly hear arguments about more direct specialization in American education without a broad background first, deeming it "unnecessary." I just don't agree that having the additional general medical knowledge is unnecessary.

Polypharmacy in regard to psychotropics, on average, does not have a wealth of support behind it. There are some studies that support some benefits from polypharmacy, but the vast majority of polypharmacy out there is done as personal preference. There may be instances where certain combinations work, but don't assert that there is hard data that supports psychtropic polypharmacy across the board. In limited, and specific case presentations it may have support, but usually it is not generalizable across "real" patients. Research limitations are typically quite significant in the polypharmacy studies.

I never said across the board. I was referring to the across the board indictment of polypharmacy. The individual cases of its usefulness is what I was referring to. Those individual cases contradict the indictment of it. Are psychotropics overused/underused? I honestly don't know.

Circular logic does not pan out in this instance, as you are assuming since they are present now, that they were welcome then. The initial push (specifically for NPs) was met with a great deal of pushback from both the AMA and the A(Psychiatry)A.

I am aware of the general resistance that existed, but without the individual support of these mid-levels for licensure, they would have never had a license in states where they practice on the physician's license (eg, Texas).

I welcome the discussion, as long as it is done professionally. As I noted above, we all need to make sure our emotions do not get the best of our posts.

I never attacked anybody who didn't attack me first. But, when I stumble across a thread full of statements about how incompetent and foolish family physicians, psychiatrists, medical students, etc, are, I'm going to respond in kind.

 

[RGMSU]

Polypharm is *sometimes* necessary. However, if I had a dollar for every drug-seeking substance abuser who comes in to my prison with a community psychiatrist diagnosis of "bipolar" and prescribed the "necessary" combination of Seroquel, Ativan, Xanax, Paxil, Klonopin, and Vistaril (or similar ridiculousness) I would be a very wealthy woman. Unsurprisingly, despite their complaints of how much they need these medications, their "mood swings" do not reappear when we (treatment team consisting of both a psychologist and a psychiatrist) remove them from all of this junk in an environment when they aren't abusing drugs.

I don't know that anyone on here would argue that RxP would be designed to *replace* psychiatrists. However, for medically stable patients on maintenance medications, adding RxP to the mix would allow the psychiatrists to focus on the more complicated cases. Right now, for low-income clients on some form of state/county aid (Medicaid, Medicare, or what they call IPRS out here), the wait time for an emergent non-dangerous case to see a psychiatrist can be several months. If the burden of the routine appointments were shuffled elsewhere (e.g. RxP), the psychiatrists could see these patients on a more efficient timeline.

I don't believe many people on here would argue that your example of polypharmacy was not excessive. This may be more common than my experience suggests. I have known a psychiatrist or two who overprescribes, but I also know some high quality psychiatrists who do not. I would think rotating medicines in and out on a trial basis for a cocktail determination would be much more useful than adding countless medications and never rotating anything out that clearly hasn't worked. We can agree that medicine should be kept to a minimum. Some of your colleagues disagree with you - they do think they are replacing psychiatrists, even on complicated cases. My argument is that this is dangerous to the psychiatric workforce. I clearly have an interest in psychiatry, but one of my primary reservations about it is the glutting of the market with medical psychologists, driving prices down, etc.

 

[busi26]

Actually, not true. I'm assuming you're talking about FPs prescribing psychotropics? They see 30-40 patients a day 80 hours a week for 3 years in residency, during which time I'm sure they see plenty of patients with psychiatric manifestations not to mention psychiatry rotation in medical school. I'm sure that winds up to be more patient medical contact than you get through an online psychology PhD or a two-year snake oil salesman master's night program.

Wow. It appears that you are attempting to rile up people on this thread and you are not interested in civil debate (e.g., snake oil, online psyc phd). I believe that you said that you wanted a debate and not a name calling session. You have become what you criticized!

I was talking about the fact that GPs prescribe 80% of psychotropic meds. Simple as that. How much in class "TRAINING" do GPs get in SPECIFICALLY prescribing psychotropics to patients with mental health problems? If your argument is that they get plenty of hands on training, then that is surely the case for psychologists prescribing as well. Many physicans recognize their limitations in this area and even ask psychologists for their opinions on particular prescriptions.

 

[busi26]

Many mid-levels still practice on a physician's license because they are required to do so by law in some states. If the physician didn't agree to hire them, they wouldn't have a job in these states. So, yes, I would call that supporting their prescription privileges. Not revisionist history. Everyday reality in the state I'm in.

So hiring people to provide the same services that physicians previously said they could not do is proof that physicians supported their prescription privileges all along? Sounds like flawed logic to me.

 

[doctorpsych]

I respect this training. I just don't see much non-neuro physio or chem in there, which gets back to my argument about generalization followed by specialization versus outright specialization from the beginning. This is a much larger topic than just psychology versus psychiatry. I regularly hear arguments about more direct specialization in American education without a broad background first, deeming it "unnecessary." I just don't agree that having the additional general medical knowledge is unnecessary.

Sure it would be helpful to have all the knowledge of basic sciences; however, I'm inclined to think that most physicians would argue that they don't really use basic sciences in their day to day practice. Most psychiatrists that I encounter frequently complain that the information asked in their boards were simply irrelevant to practice and most of the questions were designed to tap into the broad knowledge. This is found in all specialties. So why not narrow training into what is most relevant. BTW, just to be clear, I never said that medical psychologists' training equates to psychiatrists training or that medical psychologists replaces psychiatrists... don't know where you got that from... as I noted, a big factor pushing the rxp movement is access.

As per my post on polypharm, it was regarding psychotropics.... which I think a lot of psychologist here can give you plenty of examples of... often times we see pts who are being thrown a gamet of psychotropics to account of symptoms almost individually (e.g. 4 or more meds). I believe Stahl and other prominent psychiatrists writes about this and generally discourage polypharm practice. This is not to say that some pts would benefit from it, but generally, efficacy of polypharm is not evidence supported and aggregate advese effects often times clouds any benefits.


I never attacked anybody who didn't attack me first. But, when I stumble across a thread full of statements about how incompetent and foolish family physicians, psychiatrists, medical students, etc, are, I'm going to respond in kind.[/QUOTE]

look for the last time, I never "attacked" you and I never used the words "incompetent" or "foolish" in addressing that you are a medical student.

 

[Therapist4Chnge]

Herein lies the difficulty - how can you determine what exactly a person is qualified to practice if education isn't standardized?

They have an exam, required supervision by a physician, etc.....though I think there is room (and a need) for improvement. I think the hour requirements on the books right now are a bit thin, and I'd like to see a few more required classes (increase pre-reqs. and then add in a couple more classes to the curriculums).

Limitations of our understandings don't necessarily indicate that the facts aren't there. We just haven't found them all yet. Whether the solution is found in a pill I think depends on the disease we're discussing. Some people who have depression don't need a pill at all. Some people can't be helped without chemical intervention, no matter how much the causes of their depression are exposed/dealt with.

Agreed.

I respect this training. I just don't see much non-neuro physio or chem in there, which gets back to my argument about generalization followed by specialization versus outright specialization from the beginning.

I didn't want to list off all of the applicable classes, but they are there. Even so, I would have liked at least another lab class.

I just don't agree that having the additional general medical knowledge is unnecessary.

The general medical knowledge can definitely help inform. I disagree with the statement above (I forget the poster at the moment) that said general medical knowledge isn't used every day....as I think it is quite applicable. I am in a healthcare setting, so I am constantly dealing with co-morbid issues that effect my work (consultation, neuro assessment, etc). I think the proposed training will definitely inform in these areas, though it isn't perfect....as I noted above.

 

[RGMSU]

Wow. It appears that you are attempting to rile up people on this thread and you are not interested in civil debate (e.g., snake oil, online psyc phd). I believe that you said that you wanted a debate and not a name calling session. You have become what you criticized!

I was talking about the fact that GPs prescribe 80% of psychotropic meds. Simple as that. How much in class "TRAINING" do GPs get in SPECIFICALLY prescribing psychotropics to patients with mental health problems? If your argument is that they get plenty of hands on training, then that is surely the case for psychologists prescribing as well. Many physicans recognize their limitations in this area and even ask psychologists for their opinions on particular prescriptions.

Family physicians have plenty of training to practice medicine. How ridiculous for someone who didn't even go to medical school to be criticizing an MD's knowlede of medicine. Absurd. I can see where a family doc might need some help with diagnosis or refer a complex patient to a psychiatrist or refer to a counselor, but they don't need help with managing basic medicine. Give me a break. What exactly do you think we spend all our time learning how to do in medical school and residency? A variety of specialists, including medical colleagues, have attempted for quite some time to suggest that family physicians are incompetent at dealing with routine medical diagnoses and treatments. Yet experience has proven that they save money and reduce complex meandering through the medical system by serving as a one-stop provider for about 85% of peoples' healthcare needs.

 

[RGMSU]

Sure it would be helpful to have all the knowledge of basic sciences; however, I'm inclined to think that most physicians would argue that they don't really use basic sciences in their day to day practice. Most psychiatrists that I encounter frequently complain that the information asked in their boards were simply irrelevant to practice and most of the questions were designed to tap into the broad knowledge. This is found in all specialties. So why not narrow training into what is most relevant. BTW, just to be clear, I never said that medical psychologists' training equates to psychiatrists training or that medical psychologists replaces psychiatrists... don't know where you got that from... as I noted, a big factor pushing the rxp movement is access.

As per my post on polypharm, it was regarding psychotropics.... which I think a lot of psychologist here can give you plenty of examples of... often times we see pts who are being thrown a gamet of psychotropics to account of symptoms almost individually (e.g. 4 or more meds). I believe Stahl and other prominent psychiatrists writes about this and generally discourage polypharm practice. This is not to say that some pts would benefit from it, but generally, efficacy of polypharm is not evidence supported and aggregate advese effects often times clouds any benefits.

look for the last time, I never "attacked" you and I never used the words "incompetent" or "foolish" in addressing that you are a medical student.

You never really know what information you're going to need in a given instance, do you? I'd rather have info I don't use than need info I don't have. What's even worse, I'd rather not be in a situation where I don't know that I'm lacking information and be entirely clueless. I don't think some of you understand just how much knowledge is required to understand general medicine. In the medical school process, we learn everything from head to toe in a great amount of detail anatomically, physiologically, pathologically, therapeutically. Then we go forward and specialize. When you skip over the general education of medical school, you are missing a lot of info. I suppose this is similar to the optometrist model of education, where you skip straight to specialization, compared to the ophthalmologist model. I suppose you can argue whether the extra knowledge is necessary or not (I believe it is helpful), but you can't argue that there's not a huge body of knowledge missing. You implied that I had no real world knowledge because I'm a medical student. Now you know better.

 

[cara susanna]

I dunno, I've heard bad things about family doctors from people in med school.

 

[RGMSU]

Instead of all the bantering, I would like to hear a proposed model of how family physicians, medical psychologists, and psychiatrists overlap. No one on here has defined exactly how a medical psychologist would differ from a psychiatrist or exactly how their purviews of practice would be different. When should a family physician refer to a psychologist or psychiatrist? Are there instances where a family physician should refer to a psychologist versus a psychiatrist or vice versa? Is there any instance where any of you feel a psychiatrist should specifically manage a patient versus a psychologist? Or, bring up specific clinical vignettes that illustrate proper management versus improper management? That would be a much more interesting psychopharmacology thread than finger pointing nonsense. I have heard people on here say the intent of medical psychologists is not to replace psychiatrists, but I haven't seen anyone define the roles of the two relative to each other. I have seen people on here suggest that family physicians sometimes incompetently manage mental health (and I have seen an instance or two of this myself). So what is the role of the family physician compared to the psychologist and the psychiatrist?

 

[busi26]

Family physicians have plenty of training to practice medicine. How ridiculous for someone who didn't even go to medical school to be criticizing an MD's knowlede of medicine.

Twisting my words may cause your veins to pop out of your head, but lets stick to what I say, not what you want me to say.

My question was specifically about the amount of IN CLASS TRAINING physicans get related to using psychotropics. I never suggested that physicians are incompetent. I brought this up because the amount of training that medical psychologists get in this area appears to be a major concern of yours. You did not answer my question... Wonder why?

Your indignation that I would criticize an MD's knowledge of medicine since I didn't go to med school, could easily be reversed. How dare you criticize medical psychologists when you "didn't even go to" 5 years of graduate school to complete your phd in clinical psychology, complete a residency in clinical psychology, or complete a 2 year postdoctoral program solely focused on the use of psychotropic meds.

The bottom line is that properly trained medical psychologists can successfully treat mental illness with a variety of techniques and medications. Evidence over the past 10 years of RXP proves us right. The facts are the facts! Your anecdotal concerns are just that - anecodotal.

 

[RGMSU]

I dunno, I've heard bad things about family doctors from people in med school.

Yes, family docs do get a bad rep in med school. I believe it is undeserved and unfortunate, considering that they are a critical cornerstone of our healthcare system, and the shortage of them at the moment is part of what's crippling our healthcare system. Perpetuation of these stereotypes that family docs are incompetent, psychiatrists are unnecessary, etc, is exactly what is pushing med students away from these fields that people desperately need to go into. We have enough dermatologists doing botox injections. That's why I've pointed out more than once that the disdain for psychiatrists and the willingness to replace them isn't exactly going to help the psychiatry workforce.

 

[RGMSU]

Twisting my words may cause your veins to pop out of your head, but lets stick to what I say, not what you want me to say.

My question was specifically about the amount of IN CLASS TRAINING physicans get related to using psychotropics. I never suggested that physicians are incompetent. I brought this up because the amount of training that medical psychologists get in this area appears to be a major concern of yours. You did not answer my question... Wonder why?

Your indignation that I would criticize an MD's knowledge of medicine since I didn't go to med school, could easily be reversed. How dare you criticize medical psychologists when you "didn't even go to" 5 years of graduate school to complete your phd in clinical psychology, complete a residency in clinical psychology, or complete a 2 year postdoctoral program solely focused on the use of psychotropic meds.

The bottom line is that properly trained medical psychologists can successfully treat mental illness with a variety of techniques and medications. Evidence over the past 10 years of RXP proves us right. The facts are the facts! Your anecdotal concerns are just that - anecodotal.

Well, you don't have the facts about medical education, because we don't do certain amounts of "in-class training." Neuroanatomy, neurophysiology, psychopharmacology, psychiatric pathology are all interspersed throughout our curriculum in the MD program, and they would be interspersed throughout residency as well, as we experience clinical vignettes that illustrate the points being discussed. I will look at a typical med school curriculum and family med residency and psych residency later to calculate up roughly the amount of exposure. It will take some time to look through that. Surely, a psychologist is going to have more specific time spent on psychology, while a family physician is going to have more specific time spent on medicine. I hate to break it to you, but a psychiatrist is going to have more exposure to medicine and mental health together than either the family physician or the psychologist. Which gets back to the question of why replace psychiatrists with medical psychologists and family physicians? Again, I invited specific illustrations of cases where the roles of family physicians, psychologists, and psychiatrists can be demarcated or perhaps intermingled. For those of you who are just wanting to be asses and fight, go fight with somebody else, because I'm sick of listening to you. I have evidenced in multiple posts that I'm trying to stop this nonsense and get back to a meaningful discussion.

 

[doctorpsych]

Is anybody here saying that medschool is worthless? why do you keep misinterpreting what people are posting as a huge personal offense to you. If you are looking for validation that you got accepted into med school--woppie! congrants...who really cares. I agree that having more knowledge is not a bad thing, but the bottom line is that one does not need to go to medschool to properly prescribe psychotropics... it's nice to be able to know all the bones of your body, but how is that going to help me appropriately prescribe Li.

You implied that I had no real world knowledge because I'm a medical student. Now you know better.[/QUOTE]

Let me again remind you that you are a med student and that you are limited to that. You still haven't portrayed yourself in any other way.

 

[RGMSU]

Let me again remind you that you are a med student and that you are limited to that. You still haven't portrayed yourself in any other way.

Being a medical student is not a limitation to my ability to understand the workings of the healthcare system. I'm not looking for any validation. I'm not objecting to anybody's posts at the moment but yours. My posts have more content at the moment than yours do, so I wouldn't say you're exactly illustrating a wealth of experience, other than posting the same thing over and over about your perception of my lack of experience. Again, since this is such a hot topic, I want someone to discuss what the proper roles are for family physicians, psychologists, medical psychologists, and psychiatrists are on a healthcare team. Bring up some specific clinical vignettes where you have seen these roles in action, appropriately or inappropriately. And, no, bones might not help you in prescribing Li, but an understanding of renal function might be helpful, no? And how much "IN CLASS TRAINING" in renal physiology do you complete as a psychology student, to borrow your colleague's words? Do you dissect a kidney in psychology training? Do you examine histology slides of kidney tissue? Since you want to focus on my limitations, how about yours? Let me remind you that you are not a physician, and you are limited by that.

 

[Therapist4Chnge]

When should a family physician refer to a psychologist or psychiatrist? Are there instances where a family physician should refer to a psychologist versus a psychiatrist or vice versa?

I believe in cases where there is a specific need for therapy and medication management, a referral to a medical psychologist would make sense. Some psychiatrists also handle therapy cases, so then it would depend on their area of focus in regard to the talk therapy, and if it would be a better fit than the medical psychologist. Reimbursement/Insurance issues, in addition to accessibility will also play a role in the referral. If the pt. needs psychological testing, a medical psychologist would be the default referral, unless they do not handle the specific testing needed (forensic, neuro, etc), then another referral is needed.

As for examples of when a psychiatrist would be the preferred provider....I've seen sleep cases where a psychatrist was the best referral because they worked with sleep disorders and were able to handle the sleep study portion, and then be available for medication follow-up. An FP or GP may refer to a psychiatrist because they have a built in relationship with the particular provider. though medical psychologists may have the same arrangement. A psychiatrist who is also boarded in neurology would be an invaluable referral if a differential diagnosis is needed in that area, much like a neuropsychologist would be able to provide differental dx. for other areas.

Is there any instance where any of you feel a psychiatrist should specifically manage a patient versus a psychologist? Or, bring up specific clinical vignettes that illustrate proper management versus improper management?

I think certain settings lend themselves to one over the other. In the forensic setting a psychiatrist may be tasked with overseeing the medical staff, so in that setting they would be the obvious choice. In an out-patient setting (ex. college counseling center), their prescriber is most likely part-time and/or a mid-level, so in this setting a staff psychologist who is already there doing therapy may make more sense.

As for proper v. improper management....I think that can get into finger pointing, as anectdotally we all can point to examples where each profession handled itself well or not well.

So what is the role of the family physician compared to the psychologist and the psychiatrist?

The FP for many communities is the Cradle to Grave provider. They are responsible for seeing hundreds of people and providing a range of care. I see the medical psychologist as one component of the treatment, and the psychiatrist as another component. I think the medical psychologist could be the primary referral for psychological/neurological assessment, as well as therapy + medication cases, and the psychiatrist being the referral for both medication evals, as well as for sleep studies*, neurology*, etc.

*as applicable, as I've seen some psychiatrists with specific training and/or boarding in other areas.

 

[RGMSU]

Let me post this again since I got interrupted by a couple more of the kindergarten posts. I'm wanting to hear real opinions on this. I'm not trying to be inflammatory.

Instead of all the bantering, I would like to hear a proposed model of how family physicians, medical psychologists, and psychiatrists overlap. No one on here has defined exactly how a medical psychologist would differ from a psychiatrist or exactly how their purviews of practice would be different. When should a family physician refer to a psychologist or psychiatrist? Are there instances where a family physician should refer to a psychologist versus a psychiatrist or vice versa? Is there any instance where any of you feel a psychiatrist should specifically manage a patient versus a psychologist? Or, bring up specific clinical vignettes that illustrate proper management versus improper management? That would be a much more interesting psychopharmacology thread than finger pointing nonsense. I have heard people on here say the intent of medical psychologists is not to replace psychiatrists, but I haven't seen anyone define the roles of the two relative to each other. I have seen people on here suggest that family physicians sometimes incompetently manage mental health (and I have seen an instance or two of this myself). So what is the role of the family physician compared to the psychologist and the psychiatrist?

 

[Therapist4Chnge]

And, no, bones might not help you in prescribing Li, but an understanding of renal function might be helpful, no? And how much "IN CLASS TRAINING" in renal physiology do you complete as a psychology student, to borrow your colleague's words?

It is important to differentiate between psychologist and medical psychologist, as the training of a medical psychologist is in addition to that of the traditional psychologist training. In my clinical psychology program we did not study Li, renal functioning, etc at length, but in my pharma classes we did.

 

[RGMSU]

I believe in cases where there is a specific need for therapy and medication management, a referral to a medical psychologist would make sense.

Thank you. Finally a reasonable response. I would ask you to look critically at your post and see whether or not you carved out a much larger area of practice for the medical psychologist than for the psychiatrist? We both know many mental health situations respond best to both therapy and medicine in combo. We also both know that it is very financially disadvantageous for a psychiatrist to engage in therapy because of the reimbursement structure as it exists now. Respectfully, if the only example you can come up with that requires a psychiatrist is a sleep study, isn't that a bit of a scanty niche of service? The issue of supervision is definitely a factor - most physicians are very resistant to non-physician supervision. Frankly, they are usually resistant to physician supervision as well. You seem to be suggesting psychiatrists for certain sub-specialization levels (addiction psych, geriatric psych, etc), since you mentioned specific practice areas for which they are boarded? Doesn't this model exacerbate availability of psychiatrists to rural/suburban areas and force them into urban practice areas that support this level of specialization? Isn't one of the primary arguments for medical psychologists to INCREASE mental health services outside urban areas? Honestly, if you can define such a broad purview of practice for medical psychologists and such a tiny purview of practice for psychiatrists, is not the ultimate goal to, de facto, replace the psychiatrist? Or, at least, to elevate the medical psychologist to the equivalent of the psychiatrist?

 

[RGMSU]

It is important to differentiate between psychologist and medical psychologist, as the training of a medical psychologist is in addition to that of the traditional psychologist training. In my clinical psychology program we did not study Li, renal functioning, etc at length, but in my pharma classes we did.

If that educational model covers the necessary material, then why shouldn't the psychiatrist educational model disappear? Is there anyone here who thinks that is good for mental healthcare? Why or why not? Should the two educational models compete against each other? And what is the effect of that on workforce demographics? And, truly, you folks understand that once psychologists discover they can profit more off of medication management alone, the majority of them will do so, just like psychiatrists did. It's just human nature. To play Devil's advocate, if mental healthcare providers can learn to practice in their field without a broad medical education first, then why shouldn't the same model be applied to becoming an orthopedic surgeon? Just learn orthopedic surgery from the beginning instead of going to medical school first? Is that a good idea?

 

[cara susanna]

I think that instead of just putting someone on an SSRI and sending them off, a family doctor should refer someone for psychological treatment (whether it is with a psychiatrist or a psychologist) when it is viewed as necessary, as in beyond the family doctor's level of training. If you refer someone with a severe physical condition like endometriosis to a gynecologist, why not refer someone with severe mental condition to a specialist as well?

Honestly, the reputation I hear of family doctors comes from experience, albeit anecdotal. The med student I know was horrified by the lack of knowledge from the people he was supervised by during his rotation, and it actually turned him off to general practice, into which he had originally intended to go.

 

[RGMSU]

I think that instead of just putting someone on an SSRI and sending them off, a family doctor should refer someone for psychological treatment (whether it is with a psychiatrist or a psychologist) when it is viewed as necessary, as in beyond the family doctor's level of training. If you refer someone with a severe physical condition like endometriosis to a gynecologist, why not refer someone with severe mental condition to a specialist as well?

Honestly, the reputation I hear of family doctors comes from experience, albeit anecdotal. The med student I know was horrified by the lack of knowledge from the people he was supervised by during his rotation, and it actually turned him off to general practice, into which he had originally intended to go.

I agree that the possible need for counseling should be considered, though not everyone with mild depression necessarily needs counseling in my opinion. I don't think counseling would ever hurt, though. Honestly, a lot of people wouldn't do it if their FP suggested it. Plus, different people benefit from different types of counseling. Sometimes a psychologist works for one person whereas a religious leader might work better for another in a more informal, non-medical situation. Not everyone with mild depression necessarily needs an SSRI either. If there is a clear ongoing psychological/psychiatric situation, sure there should be a referral to the appropriate person. If I were an FP, I still would prefer a referral to a psychologist for non-medical therapeutics and a psychiatrist for medical intervention. I have had exactly the opposite experience at my medical school. All the FPs we have teaching us are some of the best docs I've ever met.

 

[doctorpsych]

If that educational model covers the necessary material, then why shouldn't the psychiatrist educational model disappear? Is there anyone here who thinks that is good for mental healthcare? Why or why not? Should the two educational models compete against each other? And what is the effect of that on workforce demographics? And, truly, you folks understand that once psychologists discover they can profit more off of medication management alone, the majority of them will do so, just like psychiatrists did. It's just human nature. To play Devil's advocate, if mental healthcare providers can learn to practice in their field without a broad medical education first, then why shouldn't the same model be applied to becoming an orthopedic surgeon? Just learn orthopedic surgery from the beginning instead of going to medical school first? Is that a good idea?

You are forgetting that a medical psychologist is a psychologist first and prescribing is just one tool. Again, you are missing the point, nobody is equating medical psychologists with psychiatrists.

 

[doctorpsych]

And how much "IN CLASS TRAINING" in renal physiology do you complete as a psychology student, to borrow your colleague's words? Do you dissect a kidney in psychology training? Do you examine histology slides of kidney tissue? Since you want to focus on my limitations, how about yours? Let me remind you that you are not a physician, and you are limited by that.

Dissecting a kidney doesn't really help me prescribe Li appropriately either, but understanding renal functioning, interpreting kidney functioning labs, understanding drug metabolism, understanding therapeautic drug levels will.

 

[RGMSU]

And how much "IN CLASS TRAINING" in renal physiology do you complete as a psychology student, to borrow your colleague's words? Do you dissect a kidney in psychology training? Do you examine histology slides of kidney tissue? Since you want to focus on my limitations, how about yours? Let me remind you that you are not a physician, and you are limited by that.

Dissecting a kidney doesn't really help me prescribe Li appropriately either, but understanding renal functioning, interpreting kidney functioning labs, understanding drug metabolism, understanding therapeautic drug levels will.

Kinda hard to understand the functioning of the kidney without understanding its anatomy first. Of course, since you haven't had the experience of learning the anatomy, I'm sure you would dismiss it as irrelevant, as you have been prone to do thus far in our conversations.

 

[busi26]

Not everyone with mild depression necessarily needs an SSRI either.

The evidence shows that NO ONE with mild depression needs an SSRI. SSRIs don't work in mild depression cases. If you want references, I can provide them.

 

[doctorpsych]

Kinda hard to understand the functioning of the kidney without understanding its anatomy first. Of course, since you haven't had the experience of learning the anatomy, I'm sure you would dismiss it as irrelevant, as you have been prone to do thus far in our conversations.

Again, you are missing the point or you are simply ignoring the point. I'm pointing out what would be relevant in clinical practice. For example, a psychologist who would focus primarily on treatment does not need to be an expert in methodology, although in PsyD programs, they are trained in it, but if you are ultimately not going to be teaching it or handling data, why should they be have to know experimental design to the level of a primarily research focused psychologist? Practiced focused psychologist get the training so they can understand scientific studies and extrapulate appropriate information from it. They don't absolutely need to actually have to run it. Just like a medical psychologist don't need to have touched a cadaver in order to understand how the body works.

 

[RGMSU]

The evidence shows that NO ONE with mild depression needs an SSRI. SSRIs don't work in mild depression cases. If you want references, I can provide them.

I'm going to just ignore certain people on here who have proven to be little more than a nuisance and only respond to the people worth responding to. I have received PMs attacking me and even the school I attend. That's an interesting one since one of our Texas A&M med school faculty is the national president of the AMA currently and our primary teaching hospital, Scott and White, is ranked among the top 15 teaching hospitals in the nation. Try again, doctorpsych. Anyway, I suppose that depends on how we define mild depression. We could discuss the definition of that. Honestly, I was using the term loosely to refer to severity rather than duration. Obviously the SSRI is intended to be a maintenance med. I would welcome references for my own perusal as I have opportunity to survey them. I am always interested in seeing factual information. Nevertheless, I have seen a few patients who I would call mildly depressed (while chronic) who have evidenced a difference on an SSRI versus off. If we refer to depression that is not chronic, then yes, I would agree that an SSRI is useless. Of course, life presents circumstances that can lead to depression without independent biochemical cause, and it would be the duty of any reasonable practitioner to investigate those circumstances and determine what, if anything, could be done about that part of the situation. I would not necessarily discount medical treatment of depression even if specific non-biochemical causes ARE evident in addition to biochemical causes, assuming that there is no way the person can completely remove the environmental causes. No point to throw the baby out with the bath water sort of thing.

 

[doctorpsych]

I'm going to just ignore certain people on here who have proven to be little more than a nuisance and only respond to the people worth responding to. I have received PMs attacking me and even the school I attend. That's an interesting one since one of our Texas A&M med school faculty is the national president of the AMA currently and our primary teaching hospital, Scott and White, is ranked among the top 15 teaching hospitals in the nation. Try again, doctorpsych. Anyway, I suppose that depends on how we define mild depression. We could discuss the definition of that. Honestly, I was using the term loosely to refer to severity rather than duration. Obviously the SSRI is intended to be a maintenance med. I would welcome references for my own perusal as I have opportunity to survey them. I am always interested in seeing factual information. Nevertheless, I have seen a few patients who I would call mildly depressed (while chronic) who have evidenced a difference on an SSRI versus off. If we refer to depression that is not chronic, then yes, I would agree that an SSRI is useless. Of course, life presents circumstances that can lead to depression without independent biochemical cause, and it would be the duty of any reasonable practitioner to investigate those circumstances and determine what, if anything, could be done about that part of the situation. I would not necessarily discount medical treatment of depression even if specific non-biochemical causes ARE evident in addition to biochemical causes, assuming that there is no way the person can completely remove the environmental causes. No point to throw the baby out with the bath water sort of thing.

I had previously responded to one of your post about hypothecals that highlighted the usefulness of medical psychologists. However, my post was withdrawn because you got offended. Admitingly, I can see how some of the language that I used was offensive to the members so I extend my apologies to them. But lets be truthful here, your initial PM titled "Hey Punk" and your follow up pm offering that you are a big guy because you are "6 foot, 180 lbs" was the trigger of my PM responses about your school. It was not intended to offend others from your school. Anyhow, let's keep it civil, I really do want to know your opinion about those scenarios. Do you think most pcp's have the training and experience to treat someone who has severe ocd, debilitating panic disorder, manage a patient on Li or clozaril, managing a pt taking carbamezapine, titrating someone off from a benzo due to dependence, be able to detect prodromal signs of schizophrenia, differentiate schizoid vs psychotic processes, temporarily treat insomnia with a non-benzo hypnotic and get long term therapeautic effects with CBT, differentiate childhood bipolar vs. ADHD, etc....? Like I said before, I know in general, psychiatrists are able to do so, but what if they are not available for whatever reason and a medical psychologist is? For what reason wouldn't a pcp refer these types of cases to a medical psychologist? I'm sure pcp's, with additional training would be able to do so but in general, they don't have the time or, I think, the desire to do so.

Also, in your opinion, where is the threshold in order to prescribe meds? NPs, PAs, dentistry, podiatry, optometry? Should people who received medical training outside of the US not be allowed to practice medicine? Why did the MDs recant their objection to DOs practicing medicine when they first came onto the scene? Also, as I noted in an earlier post, what about GP's, they can practice medicine without completing residency (although this is a rarity, rather than the rule).
According to wiki:

United States
All medical practitioners must hold a license to practice medicine in the United States. The only requirement is that the physician be enrolled in or have completed a year of training, more commonly called a rotating internship. There is generally 4 years of undergraduate college and 4 years of medical school prior to the internship. All licensed medical practitioners who do not complete a three-to ten-year residency, are legally allowed to practice medicine in the state within which they are licensed.

my point is, is the resistance to medical psychologists prescribing psychotropics clinical or politically based?

Question to the group, how do you all think about the proposed health care reform and its impact onto the rxp movement? Do you think medical psychologist would gain more ground in the new healthcare environment?

 

[busi26]

Obviously the SSRI is intended to be a maintenance med. I would welcome references for my own perusal as I have opportunity to survey them. I am always interested in seeing factual information.

I disagree that SSRIs should be intended to be maintenance meds in most patients. Why not prescribe CBT instead? The therapy is briefer, more cost effective, and has lower relapse.

Here is one metaanalysis that suggests that SSRIs should not be used for mild depression. The article is public access so you can just google the title.

Kirsch I. Deacon BJ. Huedo-Medina TB. Scoboria A. Moore TJ. Johnson BT. (2008). Initial severity and antidepressant benefits: A meta-analysis of data submitted to the Food and Drug Administration. PLoS Medicine / Public Library of Science. 5(2):e45.

 

[RGMSU]

(1) I would say severe OCD could likely be handled by a psychologist, shouldn't be handled by an FP unless it is until such time that the person may be referred. If anti-anxiety dosages become quite high, the case should probably go to a psychiatrist. Again, if I were an FP, I would still refer to a psychiatrist, but that is my personal privilege. Texas does not have medical psychologists anyway. (2) Debilitating panic disorder - maybe psychologist, again if highly severe with high anti-anxiety dosages, psychiatrist needed in my opinion. FP shouldn't treat it unless it is until such time that the referral can be made. (3) Li - psychiatrist only because of Li toxicity. (4) Clozaril - psychiatrist only because of box warnings concerning seizures, myocarditis, agranulocytosis. Would prefer an FP over a psychologist on this one because of the multiple internal medicine concerns. (5) Carbamazepine - concerns about aplastic anemia and agranulocytosis, so again - psychiatrist preferred, simple blood tests can reveal the aforementioned conditions so not a huge concern for either psychologist or FP, unless there is coexisting epilepsy that would be affected by dosage changes of carbamazepine or something along those lines, then you would really need a psychiatrist working with a neurologist. (6) Substance abuse titration - psychiatrist for the medical detox because of potential medical crises that could develop, psychologist after detox because much follow through would be needed. FP shouldn't be doing this. (7) Differentiation of childhood bipolar/ADHD - psychologist or pediatrician fine for this. Psychiatrist not explicitly necessary. (8) non-benzo for insomnia - Lunesta and such - might not have a problem with this, but it can be habit forming. I would say a family doc could definitely use this because sleeping difficulties are not inherently psychological nor psychiatric. I wasn't aware that medical psychologists could prescribe controlled substances? Probably disagree with that. (9) I don't have a problem with any of the non-physician prescribers you mentioned as long as they practice under physicians and seek guidance when necessary. My concern about the medical psychologists, at least on this forum, is that they seem quite hostile toward physicians (hah, and medical students), which makes me inclined to think they might not want to work very closely with a psychiatrist. I think a medical psychologist should practice with a psychiatrist on their license, which is the case for NPs and PAs in Texas. I don't see what DOs or FMGs have to do with this at all. Some physicians are well-trained. Some aren't. I suspect the same is true among psychologists. (10) I don't agree with GPs practicing without residency. They should do a residency, and I'm here to tell you that 99.999999% of them do. The trend you're talking about was literally decades ago dude. (11) My objections are obviously clinically based, as I mentioned specific internal medicine examples of thorny issues that could arise and go undiagnosed or improperly dealt with. (12) I haven't heard much mention of psychologists in proposed health reform - I suspect the proposed health reform will hurt all specialists to some extent and favor generalists. The intention will be to save money by reducing referrals, and the insurance companies/government won't care about whether the referral is to a psychologist or a psychiatrist. They will try to get the FP to do EVERYTHING, just like the HMOs did. (13) Don't play like St. Sebastian. You're posts before the "Hey Punk" thing were plenty nasty, and at least two of your comments (1 on a post and 1 on a PM) were rather bizarre sexually charged sorts of statements. I apologize to the other members of the forum as well, though. My behavior was unprofessional, reflected poorly on me and my school, and was driven by a quick temper and lack of patience.

 

[busi26]

Texas does not have medical psychologists anyway.

Not yet, but we are working on that now and should have it passed within 5 years or so.

 

[busi26]

I wasn't aware that medical psychologists could prescribe controlled substances? Probably disagree with that.

Yes, med psychologists can prescribe controlled psychotropics with the exception of narcotics.