Psychopharmacology/Advanced Practice Psychology

[nitemagi]

Boring and stupid...why respond to a constant troll.

Your dismissal of legitimate medical concerns and advocating for a proper medical w/u as trolling is just sad.

Last I checked this was a discussion forum. Would you rather change the sticky title to "RxP Yay!" ?

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[doctorpsych]

no hx of disturbance of consciouness or other ictal sxs suggestive of seizures, when I say medical rule out I meant that pcps/MDs already deemed that his sx's were not medical in nature that they could find, no psychiatrists around... and forget about finding a child adolescent one either... did have phone consult with a psychiatrist today and he agreed with our initial assessment...but I'm going slow with this, not jumping the gun on atypical or meds until I finish with testing/results... the reality is that these types of cases are frequently missed and wrongly treated, my guess is that this kid probably was seen by his pediatrician that had not much time and/or training in psych, had 7 kids crying in the waiting room, was primed by some drug rep or some CE on ADHD, and to appease the parent, psychostims were given out after a 15min visit... this is exactly the reason why medical psychologists are getting more and more accepted in primary care...

Wasn't suggesting he used illicits. Was suggesting that the methylphenidate could be causing the psychosis. And "medically cleared" has no uniform definition, including for psychosis. I think it's great you caught the psychotic sx's, but this is actually where it's important a psychiatrist is involved, because likely if all the pediatrician did was "medically clear" his ADHD, then he's never had a real workup for new onset psychosis. Age of onset for psychosis is usually 20-30 for males. Anyone with onset at any age needs a full medical w/u, including a head scan. Onset outside of that range is much more concerning. Not trying to be oppositional, just pointing out that unless you have an EEG conducted and have documentation of these psychotic sx's (which you noted he had been on for years) prior to the introduction of the stimulant, there's still serious alternatives in the differential diagnosis that need to be ruled out.

 

[nitemagi]

no hx of disturbance of consciouness or other ictal sxs suggestive of seizures, when I say medical rule out I meant that pcps/MDs already deemed that his sx's were not medical in nature that they could find, no psychiatrists around... and forget about finding a child adolescent one either... did have phone consult with a psychiatrist today and he agreed with our initial assessment...but I'm going slow with this, not jumping the gun on atypical or meds until I finish with testing/results... the reality is that these types of cases are frequently missed and wrongly treated, my guess is that this kid probably was seen by his pediatrician that had not much time and/or training in psych, had 7 kids crying in the waiting room, was primed by some drug rep or some CE on ADHD, and to appease the parent, psychostims were given out after a 15min visit... this is exactly the reason why medical psychologists are getting more and more accepted in primary care...

It's good that you have been able to aid in the case. As I'd mentioned, there's no set standard on what "medical clearance" actually means, and this is a gripe in some of the psychiatric and even a little emergency medicine literature. I agree one wouldn't expect a pediatrician to really know what to do to medically clear for any psychiatric condition. I've seen this all too often in emergency rooms where emergency medicine docs say (literally) "You want them medically cleared, [wave their hands in the air], there, they're medically cleared." Furthermore if you're the first person to pick up on any psychotic sx's then the pediatrician really never looked at much to medically clear the pt. Lack of child psychiatrists is a major problem (most underserved medical specialty there is). I would still recommend an EEG, because if seizures are present and causing inattention or other sx's (such as hallucinations from temporal lobe epilepsy), one wouldn't expect full loss of consciousness and a post-ictal state unless the seizure was fully generalized, and might not be picked up if it never was tonic-clonic in nature. Interestingly if this was prodromal (rather than full blown psychotic symptoms), there's also evidence to show that CBT is equally effective to meds in preventing progression to full psychosis. But like everything else, it's understudied. Stimulants certainly can't be helping the matter, regardless.

 

[doctorpsych]

appreciate your acknowledgement

It's good that you have been able to aid in the case. As I'd mentioned, there's no set standard on what "medical clearance" actually means, and this is a gripe in some of the psychiatric and even a little emergency medicine literature. I agree one wouldn't expect a pediatrician to really know what to do to medically clear for any psychiatric condition. I've seen this all too often in emergency rooms where emergency medicine docs say (literally) "You want them medically cleared, [wave their hands in the air], there, they're medically cleared." Furthermore if you're the first person to pick up on any psychotic sx's then the pediatrician really never looked at much to medically clear the pt. Lack of child psychiatrists is a major problem (most underserved medical specialty there is). I would still recommend an EEG, because if seizures are present and causing inattention or other sx's (such as hallucinations from temporal lobe epilepsy), one wouldn't expect full loss of consciousness and a post-ictal state unless the seizure was fully generalized, and might not be picked up if it never was tonic-clonic in nature. Interestingly if this was prodromal (rather than full blown psychotic symptoms), there's also evidence to show that CBT is equally effective to meds in preventing progression to full psychosis. But like everything else, it's understudied. Stimulants certainly can't be helping the matter, regardless.

 

[doctorpsych]

saw another pt. today, self referred 22 y/o female. She stated was prescribed quetiapine 100mg bid with little help for her "anger" except make her tired. She stated has been taking the quetiapine for 1 month now. Pt. initially described herself as "bipolar...moody" because reportedly that's what her pcp told her. She also stated that her pcp told her that she was bipolar because she gets intense bursts of anger and physically assaults her husband at times. Completed intake and it turns out that this pt. endorsed the three main sx's of PTSD coinciding with witnessing the drowning of her cousin, she experiences flashbacks up to 3-4x/day. She did not endorse any other sx's of mania, it seems that her pcp didn't have the time or enough information to ask about ptsd. Pt also seemed to agree more with dx of ptsd rather than bipolar... planning to touch base with her pcp, discontinue quetiapine, start ssri and possibly prazosin. Start cbt and collateral with husband... I wonder how frequently these types of cases get overlooked and are prescribed the wrong meds with significant side effects...

 

[loveoforganic]

doctorpsych, I agree from a (currently) outsider's perspective that non MHP's having the ability to differentiate psychopathology to determine the appropriate treatment plan has low face validity. I may have missed this, somewhere in this giant thread, but to what degree (percent of patients, extent of discussion, etc.) do you collaborate with a physician (psychiatrist or otherwise, specify please, or pharmacist even I suppose) directly? Outside of that collaboration, there is still ongoing physician chart review of some of your work on some kind of regular basis, correct? Have these reviews yielded anything noteworthy?

Again, stressing from an outsider's perspective, the incentive for a physician to maintain a solid collaborative relationship with an rx psychologist doesn't seem to be there, beyond benevolent reasons and "I'm tired of dealing with this MI patient" reasons. Unless there's a financial incentive to collaboration I'm not aware of.

Thanks in advance

 

[edieb]

no hx of disturbance of consciouness or other ictal sxs suggestive of seizures, when I say medical rule out I meant that pcps/MDs already deemed that his sx's were not medical in nature that they could find, no psychiatrists around... and forget about finding a child adolescent one either... did have phone consult with a psychiatrist today and he agreed with our initial assessment...but I'm going slow with this, not jumping the gun on atypical or meds until I finish with testing/results... the reality is that these types of cases are frequently missed and wrongly treated, my guess is that this kid probably was seen by his pediatrician that had not much time and/or training in psych, had 7 kids crying in the waiting room, was primed by some drug rep or some CE on ADHD, and to appease the parent, psychostims were given out after a 15min visit... this is exactly the reason why medical psychologists are getting more and more accepted in primary care...

Thank you for being a pioneer in our field, doctorpsych!

 

[nitemagi]

saw another pt. today, self referred 22 y/o female. She stated was prescribed quetiapine 100mg bid with little help for her "anger" except make her tired. She stated has been taking the quetiapine for 1 month now. Pt. initially described herself as "bipolar...moody" because reportedly that's what her pcp told her. She also stated that her pcp told her that she was bipolar because she gets intense bursts of anger and physically assaults her husband at times. Completed intake and it turns out that this pt. endorsed the three main sx's of PTSD coinciding with witnessing the drowning of her cousin, she experiences flashbacks up to 3-4x/day. She did not endorse any other sx's of mania, it seems that her pcp didn't have the time or enough information to ask about ptsd. Pt also seemed to agree more with dx of ptsd rather than bipolar... planning to touch base with her pcp, discontinue quetiapine, start ssri and possibly prazosin. Start cbt and collateral with husband... I wonder how frequently these types of cases get overlooked and are prescribed the wrong meds with significant side effects...

This screams cluster B/BPD to me, which obviously has a tremendous overlap with PTSD. Quite commonly, even by seasoned psychiatrists, these patients are diagnosed as "bipolar," for various reasons including poor historians, the akiskal-bipolar spectrum and temperament interpretations, minimal response to antidepressants. More commonly I've seen people this age that were diagnosed as "bipolar" in their wayward youth, which hopefully we all know doesn't map out to adult bipolar, but were treated with atypicals and mood stabalizers for their temper dysregulation. Thankfully the field is moving away from calling all of this bipolar, though they may all get some benefit from mood stabalizing medications, and is conceptualizing everything on a spectrum, rather than categorical diagnosis. Quetiapine may not be the worst choice, though certainly isn't the first choice, in bipolar or PTSD.

http://www.ncbi.nlm.nih.gov/pubmed/21597381

 

[medium rare]

no hx of disturbance of consciouness or other ictal sxs suggestive of seizures, when I say medical rule out I meant that pcps/MDs already deemed that his sx's were not medical in nature that they could find, no psychiatrists around... and forget about finding a child adolescent one either... did have phone consult with a psychiatrist today and he agreed with our initial assessment...but I'm going slow with this, not jumping the gun on atypical or meds until I finish with testing/results... the reality is that these types of cases are frequently missed and wrongly treated, my guess is that this kid probably was seen by his pediatrician that had not much time and/or training in psych, had 7 kids crying in the waiting room, was primed by some drug rep or some CE on ADHD, and to appease the parent, psychostims were given out after a 15min visit... this is exactly the reason why medical psychologists are getting more and more accepted in primary care...[/QUOTE]

I concur 100% with this. I see this all the time - almost daily now. As my presence in the local medical community has grown, my practice has become innundated with referrals from all types of physicians; mostly pediatricians (I'm child certified), family and internal medicine, and ob/gyn but also derm and cardiology.

An interesting recent development has been an increasing number of referrals from non-child psychiatrists referring C&A patients to me.

I've worked hard to develop a reputation of competence and diligence in my community, and these physicians (many of whom I don't know) have no problem referring to me as a prescribing psychologist. In fact, I often hear the opposite - they state they prefer to refer to me because they know that I will spend more time with each patient. I even hear this from some psychiatrists in town who are so busy they couldn't spend more time with patients even if they wanted to.

 

[nitemagi]

MR,

You are a psychologist but as a NP there's a higher standard met for medical training that unfortunately isn't met with other prescribing psychologists. I'm sure many physicians are comfortable referring to you, but they might be less comfortable if you weren't a nurse practitioner.

 

[doctorpsych]

I say about 75% of my cases I do psychotropic med management along with psychological tx. On those cases I fully collaborate with their pcps. Reviews are carried out with a combination of internal and external sources. The sense that I get is that in most cases, pcp's just want help because they are frustrated that their attempts of tx were not successful, whether it's because they dont' want to be bothered by them or because they feel dissonance, I welcome all their referrals. In just about all cases, they acknowledge their limited training with mental health tx and meds.

doctorpsych, I agree from a (currently) outsider's perspective that non MHP's having the ability to differentiate psychopathology to determine the appropriate treatment plan has low face validity. I may have missed this, somewhere in this giant thread, but to what degree (percent of patients, extent of discussion, etc.) do you collaborate with a physician (psychiatrist or otherwise, specify please, or pharmacist even I suppose) directly? Outside of that collaboration, there is still ongoing physician chart review of some of your work on some kind of regular basis, correct? Have these reviews yielded anything noteworthy?

Again, stressing from an outsider's perspective, the incentive for a physician to maintain a solid collaborative relationship with an rx psychologist doesn't seem to be there, beyond benevolent reasons and "I'm tired of dealing with this MI patient" reasons. Unless there's a financial incentive to collaboration I'm not aware of.

Thanks in advance

 

[AcronymAllergy]

This screams cluster B/BPD to me, which obviously has a tremendous overlap with PTSD. Quite commonly, even by seasoned psychiatrists, these patients are diagnosed as "bipolar," for various reasons including poor historians, the akiskal-bipolar spectrum and temperament interpretations, minimal response to antidepressants. More commonly I've seen people this age that were diagnosed as "bipolar" in their wayward youth, which hopefully we all know doesn't map out to adult bipolar, but were treated with atypicals and mood stabalizers for their temper dysregulation. Thankfully the field is moving away from calling all of this bipolar, though they may all get some benefit from mood stabalizing medications, and is conceptualizing everything on a spectrum, rather than categorical diagnosis. Quetiapine may not be the worst choice, though certainly isn't the first choice, in bipolar or PTSD.

http://www.ncbi.nlm.nih.gov/pubmed/21597381

I've seen it quite often as well (i.e., borderline diagnosed as bipolar), especially in community mental health settings and with male patients.

 

[doctorpsych]

appreciate that, the reason why I post examples of cases I see is to encourage those interested in rxp and give them real life scenarios on how we are making a difference. For those who are on the fringe, don't let distractors get the best of you.

Thank you for being a pioneer in our field, doctorpsych!

 

[doctorpsych]

agree to a certain extent, the comorbidity between ptsd and bpd is usually associated with repeated trauma of the physical and sexual abuse kind, not in this case... at least from I gather so far; and research on using quetiapine and other atypicals for BPD is small to modest at best. Although her physically aggressive behaviors toward sig other may be indicative of PD, onset of these behaviors coincide with her witnessing of trauma, also her description of her flashbacks, explosive anger, hypervigilance and avoidance lends more support toward ptsd at this point.

This screams cluster B/BPD to me, which obviously has a tremendous overlap with PTSD. Quite commonly, even by seasoned psychiatrists, these patients are diagnosed as "bipolar," for various reasons including poor historians, the akiskal-bipolar spectrum and temperament interpretations, minimal response to antidepressants. More commonly I've seen people this age that were diagnosed as "bipolar" in their wayward youth, which hopefully we all know doesn't map out to adult bipolar, but were treated with atypicals and mood stabalizers for their temper dysregulation. Thankfully the field is moving away from calling all of this bipolar, though they may all get some benefit from mood stabalizing medications, and is conceptualizing everything on a spectrum, rather than categorical diagnosis. Quetiapine may not be the worst choice, though certainly isn't the first choice, in bipolar or PTSD.

http://www.ncbi.nlm.nih.gov/pubmed/21597381

 

[stigmata]

I agree. I see a lot of people get diagnosed with bipolar d/o and/or borderline who are clearly experiencing significant PTSD sxs. However, in many ways the official diagnosis may be less important than properly assessing and responding to symptoms and symptoms histories/progression.

 

[Therapist4Chnge]

I agree. I see a lot of people get diagnosed with bipolar d/o and/or borderline who are clearly experiencing significant PTSD sxs. However, in many ways the official diagnosis may be less important than properly assessing and responding to symptoms and symptoms histories/progression.

I disagree. I think providers get in trouble when they only focus on treating symptoms, as the etiology matters. Nuanced differences matter. Boderline symptoms can look like Bipolar symptoms to some people (particularly generalists), and the treatments are far different. PSTD muddies the waters too, even sub-clinical PTSD symptoms. Providers may mix and match mood stabilizers, anti-psychotics, and maybe an anxiolytic to try and treat the person...and they end up getting sub-clinical responses.

ps. Rereading your response, I realized that your "properly assessing" addresses my nuance comment, so please disregard that portion of my response.

 

[stigmata]

Yes, but medications don't know what diagnosis a person has and in general they don't treat a diagnosis, but specific symptoms. Knowing what meds do, how they do it and why, and applying that to a person is the art of pharmacotherapy. I am not saying diagnosis is not important, but it is a simpler form of informing a treatment plan. Many providers do not have training past that level and don't get why we may use an antidepressant for something other than depression or antipsychotic for depression etc...

 

[nitemagi]

Yes, but medications don't know what diagnosis a person has and in general they don't treat a diagnosis, but specific symptoms. Knowing what meds do, how they do it and why, and applying that to a person is the art of pharmacotherapy. I am not saying diagnosis is not important, but it is a simpler form of informing a treatment plan. Many providers do not have training past that level and don't get why we may use an antidepressant for something other than depression or antipsychotic for depression etc...

True. This can be a slippery slope, though, where chasing symptoms leads to treating really really off-label, and leads to the borderline patient being treated with 6-8 medications to manage their "mood swings." There's little evidence base to support symptom focused treatment in the absence of formal diagnoses, even though it's really the standard of care. Most diagnoses made are in the NOS realm, or ignore relevant data. How many clear cut MDD patients do you see without co-morbidities, substance use?

 

[2012PhD]

saw another pt. today, self referred 22 y/o female. She stated was prescribed quetiapine 100mg bid with little help for her "anger" except make her tired. She stated has been taking the quetiapine for 1 month now. Pt. initially described herself as "bipolar...moody" because reportedly that's what her pcp told her. She also stated that her pcp told her that she was bipolar because she gets intense bursts of anger and physically assaults her husband at times. Completed intake and it turns out that this pt. endorsed the three main sx's of PTSD coinciding with witnessing the drowning of her cousin, she experiences flashbacks up to 3-4x/day. She did not endorse any other sx's of mania, it seems that her pcp didn't have the time or enough information to ask about ptsd. Pt also seemed to agree more with dx of ptsd rather than bipolar... planning to touch base with her pcp, discontinue quetiapine, start ssri and possibly prazosin. Start cbt and collateral with husband... I wonder how frequently these types of cases get overlooked and are prescribed the wrong meds with significant side effects...

Good work. I agree with the PTSD conclusion overall. However, she can also be a bipolar individual whose presentation is more irritable and angry as opposed to manic in the conventional sense. There is a percentage of bipolar individuals who become irritable and rageful during a manic episode. I guess it would depend on when her symptoms began and if they coincided with the trauma. Overtime, one can rule out bipolar or BPD in this case via further assessment.

 

[cara susanna]

From my experience, a lot of individuals who have BPD also have some sort of biological mood issue going on as well, though they may not meet criteria for any specific mood disorder.

 

[Therapist4Chnge]

True. This can be a slippery slope, though, where chasing symptoms leads to treating really really off-label, and leads to the borderline patient being treated with 6-8 medications to manage their "mood swings." There's little evidence base to support symptom focused treatment in the absence of formal diagnoses, even though it's really the standard of care. Most diagnoses made are in the NOS realm, or ignore relevant data. How many clear cut MDD patients do you see without co-morbidities, substance use?

This is what I was getting at, though more concise than I probably would have been.

 

[stigmata]

"There's little evidence base to support symptom focused treatment in the absence of formal diagnoses, even though it's really the standard of care. Most diagnoses made are in the NOS realm, or ignore relevant data. How many clear cut MDD patients do you see without co-morbidities, substance use? "

I am not sure this makes any sense at all. You argue against symptom-based treatment, but you then make the best point for it?? Ignoring diagnosis is stupid, but the bigger problem is ignoring symptoms because you believe in a diagnosis.

 

[nitemagi]

"There's little evidence base to support symptom focused treatment in the absence of formal diagnoses, even though it's really the standard of care. Most diagnoses made are in the NOS realm, or ignore relevant data. How many clear cut MDD patients do you see without co-morbidities, substance use? "

I am not sure this makes any sense at all. You argue against symptom-based treatment, but you then make the best point for it?? Ignoring diagnosis is stupid, but the bigger problem is ignoring symptoms because you believe in a diagnosis.

I didn't argue against it, I said it was a slippery slope. Meaning be careful.

I wrote it's the standard of care, meaning it's what most people do. That doesn't make it evidence based, though. It's arguable as to whether the practice is effective in the absence of evidence to support it. Most studies follow symptom based rating scales, but pt's usually meet criteria for a diagnosis, and it's not clear that the domains of improvement that are reflected by a total score drop (such as on the HAM-D), is matched by the symptoms targeted in symptom focused pharmacotherapy.

I never made the case for ignoring symptoms in the face of a diagnosis. I make the case to be mindful and not miss the forest for the trees.

 

[Therapist4Chnge]

..it's not clear that the domains of improvement that are reflected by a total score drop (such as on the HAM-D), is matched by the symptoms targeted in symptom focused pharmacotherapy.

The sensativity of a self-report measure like the HAM-D is not great, so it complicates things further. I try and get a good mix of objective and subjective data that I can collect in a serial fashion, so the data is more useful over time.

I think many of the problems we are discussing can be mitigated with a proper (and thorough) intake and assessment, in addition to periodic follow-up that includes "intake length" reviews. This is not really feasible with a straight insurance case, particularly out-patient, but I think it holds a lot of value for private pay patients. I wonder how many things are missed because of "pass through" from another provider...it is like a bad game of "Telephone". I do primarily in-patient work now, and it is scary to see how easily a piece of data can be proliferated through a chart without good follow-up. None of this is rocket surgery , but with the real world pressures on providers, it is easy to try and streamline documentation and follow-up.

 

[doctorpsych]

f/u on this kid, saw him with mom today, he was started on risperodone .5mg titrated to 1mg qhs and .5mg qAM. Pt's speech is less circumstantial, more coherent although still somewhat disorganized, not hearing voices talking to him from machines and wind anymore, mom says she doesn't see him talking to himself anymore, she reports he is less withdrawn, more willing to participate in family activities although still stubborn about his videogame time.

It's good that you have been able to aid in the case. As I'd mentioned, there's no set standard on what "medical clearance" actually means, and this is a gripe in some of the psychiatric and even a little emergency medicine literature. I agree one wouldn't expect a pediatrician to really know what to do to medically clear for any psychiatric condition. I've seen this all too often in emergency rooms where emergency medicine docs say (literally) "You want them medically cleared, [wave their hands in the air], there, they're medically cleared." Furthermore if you're the first person to pick up on any psychotic sx's then the pediatrician really never looked at much to medically clear the pt. Lack of child psychiatrists is a major problem (most underserved medical specialty there is). I would still recommend an EEG, because if seizures are present and causing inattention or other sx's (such as hallucinations from temporal lobe epilepsy), one wouldn't expect full loss of consciousness and a post-ictal state unless the seizure was fully generalized, and might not be picked up if it never was tonic-clonic in nature. Interestingly if this was prodromal (rather than full blown psychotic symptoms), there's also evidence to show that CBT is equally effective to meds in preventing progression to full psychosis. But like everything else, it's understudied. Stimulants certainly can't be helping the matter, regardless.

 

[deleted106747]

I continue to have profound doubts about whether it's a good idea, or ethical, to be posting patient info on a public messageboard in the realm of psychology/iatry. I've posted about this before, and been resoundedly voted down, but these things do turn up on a Google search. For the most part these postings seem to have stayed within general info that could be about anyone, but I'd advocate for taking out some of the more personal details in the accounts.

As a patient, I expect I would be devastated if I somehow came across my story posted and discussed among student doctors of any discipline, and particularly so in a territory dispute.

 

[edieb]

I continue to have profound doubts about whether it's a good idea, or ethical, to be posting patient info on a public messageboard in the realm of psychology/iatry. I've posted about this before, and been resoundedly voted down, but these things do turn up on a Google search. For the most part these postings seem to have stayed within general info that could be about anyone, but I'd advocate for taking out some of the more personal details in the accounts.

As a patient, I expect I would be devastated if I somehow came across my story posted and discussed among student doctors of any discipline, and particularly so in a territory dispute.

it is not unethical to post case reports as long as they're de-identified and the patient can't be recognized by those reading. The poster is doing nothing wrong so please don't imply he/she is

 

[deleted106747]

it is not unethical to post case reports as long as they're de-identified and the patient can't be recognized by those reading. The poster is doing nothing wrong so please don't imply he/she is

Ethics are shades of gray. It's my opinion that some - not many, but a few specific - details are too much in these postings. I understand that most will not agree with me on these boards, but I believe we should be erring on the side of caution in what remains a relatievly new medium.

 

[2012PhD]

Ethics are shades of gray. It's my opinion that some - not many, but a few specific - details are too much in these postings. I understand that most will not agree with me on these boards, but I believe we should be erring on the side of caution in what remains a relatievly new medium.

I think exact age, location, and very specific details of the case at the very least should be concealed.

 

[deleted106747]

I think exact age, location, and very specific details of the case at the very least should be concealed.

Agreed. If it was up to me, the forums would have a direct policy about this - perhaps they do, but one that is more easily accessible. I think this issue is particularly salient on the mental health boards.

 

[Therapist4Chnge]

Agreed. If it was up to me, the forums would have a direct policy about this - perhaps they do, but one that is more easily accessible. I think this issue is particularly salient on the mental health boards.

I believe it is a Potter Stewart policy..."I know it when I see it." I was always pretty conservative with what I thought was appropriate to post as a case example, though I don't know if it is different now. Some parts of the forum are closed access and cases are discussed in much more depth, though for open forums...I'd probably recommend only the barest of details. The -iatry forum seems to have a bit more flexibility in this regard. It is tough for MH, as a general surg. case can be discussed without needing to know personal background info, etc.

 

[doctorpsych]

noted, at the same time there's nothing identifiable in my post of cases... but will be mindful

I continue to have profound doubts about whether it's a good idea, or ethical, to be posting patient info on a public messageboard in the realm of psychology/iatry. I've posted about this before, and been resoundedly voted down, but these things do turn up on a Google search. For the most part these postings seem to have stayed within general info that could be about anyone, but I'd advocate for taking out some of the more personal details in the accounts.

As a patient, I expect I would be devastated if I somehow came across my story posted and discussed among student doctors of any discipline, and particularly so in a territory dispute.

 

[Enkidu]

I disagree. I think providers get in trouble when they only focus on treating symptoms, as the etiology matters.

I didn't think that DSM diagnoses had anything to do with etiology. A syndrome is basically just a pattern of symptoms, and DSM diagnoses are all defined as syndromes.

It seems to me that until psychiatric disorders are defined in terms of their actual pathology, then symptomatic treatment with drugs of unknown mechanism is not only pretty good, but pretty much necessary. Likewise with therapy, the mechanism is unknown, and the level of training is not related to the efficacy, and it's being used to treat diseases that we don't understand... but it is still one of the biggest guns in our arsenal.

For what it's worth on the topic of this thread, I have no problems with psychologists prescribing drugs. I wouldn't mind it if social workers prescribed drugs either, as long as the standard of training is equivalent to the training of psychiatrists.

What it looks like to me is that prescribing psychologists are not being fully trained in medicine, which is what they're attempting to practice. It may be an improvement over having no physicians in remote areas, but if psychologists want to follow this path, then they need to demand much more complete training for themselves and their patients. It might make sense for prescribing psychologists to be required to take psychiatry boards, for instance.

 

[CGOPsych]

I didn't think that DSM diagnoses had anything to do with etiology. A syndrome is basically just a pattern of symptoms, and DSM diagnoses are all defined as syndromes.

It seems to me that until psychiatric disorders are defined in terms of their actual pathology, then symptomatic treatment with drugs of unknown mechanism is not only pretty good, but pretty much necessary. Likewise with therapy, the mechanism is unknown, and the level of training is not related to the efficacy, and it's being used to treat diseases that we don't understand... but it is still one of the biggest guns in our arsenal.

For what it's worth on the topic of this thread, I have no problems with psychologists prescribing drugs. I wouldn't mind it if social workers prescribed drugs either, as long as the standard of training is equivalent to the training of psychiatrists.

What it looks like to me is that prescribing psychologists are not being fully trained in medicine, which is what they're attempting to practice. It may be an improvement over having no physicians in remote areas, but if psychologists want to follow this path, then they need to demand much more complete training for themselves and their patients. It might make sense for prescribing psychologists to be required to take psychiatry boards, for instance.

You've touched on an important distinction. Of course psychologists, social workers, and the counter help at McDonald's can and should prescribe if they have the same training as a psychiatrist. When the American Psychological Association surveys psychologists, it only asks if psychologists should prescribe, but without any such details as the amount of training. Some might call that misleading, others may have stronger terms for how this data is misused.

In a survey published in an APA journal, 78 percent of licensed psychologists said prescribing psychologists should have at least the same training as other non-physician prescribers. (This finding was buried in the article.) The APA model act which APA's puppet state organizations must follow, and the curriculum which APA wrote for the puppets and the RxP training programs run by current and former APA officials doesn't even come close to the training required of PA's and APN's.

Your suggestion is appealing. It would be very interesting if the prescribing psychologists had to take the psychiatry boards. Right now they take what APA's PR machine calls a "national test" although they forget to mention that APA wrote that "national test" and also decided the passing score. If you think this is all a production of the APA political department pretending to be a "grass roots movement", you're right.

But here's the rub: If prescribing psychologists have the same medical training as medical providers, why have a completely separate program at all with new laws, a new training system and new supervision systems? That would deprive APA of its opportunity to get into the medical practice business, and lose its chance for a lot of money and power.

 

[deleted106747]

I didn't think that DSM diagnoses had anything to do with etiology. A syndrome is basically just a pattern of symptoms, and DSM diagnoses are all defined as syndromes.

It seems to me that until psychiatric disorders are defined in terms of their actual pathology, then symptomatic treatment with drugs of unknown mechanism is not only pretty good, but pretty much necessary. Likewise with therapy, the mechanism is unknown, and the level of training is not related to the efficacy, and it's being used to treat diseases that we don't understand... but it is still one of the biggest guns in our arsenal.

For what it's worth on the topic of this thread, I have no problems with psychologists prescribing drugs. I wouldn't mind it if social workers prescribed drugs either, as long as the standard of training is equivalent to the training of psychiatrists.

What it looks like to me is that prescribing psychologists are not being fully trained in medicine, which is what they're attempting to practice. It may be an improvement over having no physicians in remote areas, but if psychologists want to follow this path, then they need to demand much more complete training for themselves and their patients. It might make sense for prescribing psychologists to be required to take psychiatry boards, for instance.

I'm a little lost - the equivalent standard of training as a psychiatrist, wouldn't that be 4 years of medical school and 4 years of psychiatry residency? So then it would be a PhD + an MD, without getting an MD?

I'm also unsure about the ideas that a) level of training isn't related to efficacy, and b) that antidepressants have the same effect as an active placebo. Both of these results have appeared in research studies. I just bought The Emperor's New Drugs: Exploding the Antidepressant Myth because I want to read and evaluate what's being said myself.

The reason being is I just haven't seen these findings echoed in my clinical experience. I'm well aware of the plural of anecdote not being data, etc. etc., but it seems to me in my own experience that level of training does matter. I'm not saying that social workers can't be good therapists. But they require, in my informed opinion, much more training post their 2 years. I've seen some horrible damage done by undertrained psychotherapists. Probably more widespread (e.g. I've seen it more often) damage than what I've seen done by poorly prescribed meds. I've also seen patients profoundly helped by medications, and I can't buy that it's just a placebo effect.

 

[Enkidu]

I'm a little lost - the equivalent standard of training as a psychiatrist, wouldn't that be 4 years of medical school and 4 years of psychiatry residency? So then it would be a PhD + an MD, without getting an MD?

Kind of like that. Maybe psychology programs can find a better way to impart that knowledge than the medical schools have. Maybe they can do it faster than the 8 years that psychiatrists go through. I don't know. Whatever training program psychology comes up with, though, they should have to meet the same standards as psychiatrists, because they are essentially doing the same job.

My sense is that psychologists may not have to pass USMLE steps I-III, because they will never get an unrestricted medical license. I would imagine that the medical complications that come up in psychiatric practice are tested on the psychiatry boards and I think that it's reasonable that if psychologists can pass the boards then they will have shown that they are adequately trained to prescribe medicine.

I'm sure that the training will take longer that what prescribing psychologists are going through right now.

One problem with this pschology rxp debate is that it contains elements of protectionism by psychiatry and expansionism by psychology. That's completely normal, but it obscures the substantive issues surrounding adequate training. How much training does it take to prescribe medicine independently? If prescribing psychologists see themselves as forming a complementary and equal career path as psychiatry, then they have to be equally trained.

Is there a licensing exam to provide talk therapy? If there were, would psychologists want psychiatrists to pass it if they were going to specialize in talk therapy?

I'm also unsure about the ideas that a) level of training isn't related to efficacy, and b) that antidepressants have the same effect as an active placebo. Both of these results have appeared in research studies. I just bought The Emperor's New Drugs: Exploding the Antidepressant Myth because I want to read and evaluate what's being said myself.

Well, this really isn't my field of interest. Those could both be false, for all I know. I thought that there was solid data about the level of training for talk therapy, but maybe I (or it) was wrong.

 

[Enkidu]

But here's the rub: If prescribing psychologists have the same medical training as medical providers, why have a completely separate program at all with new laws, a new training system and new supervision systems? That would deprive APA of its opportunity to get into the medical practice business, and lose its chance for a lot of money and power.

Yeah, that's tricky. I guess I think that if prescribing psychology programs are teaching the same material to the same standard, then psychology will have succeeded in showing that it can be a legitimate avenue to prescribe medication to the mentally ill. If this is the power that it wants, then I don't see a problem with doing it this way.

The upside is that psychologists will feel more confident in their training will be legitimized in the medical field. The downside is that fewer psychologists will actually want to spend the time getting this training... but that's the same for medical school. The training is long and difficult and fairly painful.

Prescribing psychologists are essentially trying to have two interrelated professions... I can sympathize with that, because I'm doing the same thing. In my case I'm becoming a physician and a scientist. The training is incredibly painful, but because I believe in the value of having both medical and research training, I'm willing to do it. If prescribing psychologists don't have that level of dedication, than maybe they're getting into it for the wrong reasons.

 

[SingingCow]

Unfortunately, psychiatrists do not need to pass extra board exams to do "talk therapy." Psychologists need to be licensed before they can practice. Even though psychotherapy training for psychiatrists tends to vary, psychiatrists in general appear to be "allowed" to do everything if they so desire.

The above is not based on research but personal observation. So, it may not be accurate at all.

I think there is an assumption that you can't kill someone with bad "talk therapy" but you can with meds. There is also another assumption, and obviously valid, that meds are much more complicated than talking. As some of you have pointed you, I would argue that bad "talk therapy" can do much damage. I would further argue that bad "talk therapy" CAN KILL YOU.

Kind of like that. Maybe psychology programs can find a better way to impart that knowledge than the medical schools have. Maybe they can do it faster than the 8 years that psychiatrists go through. I don't know. Whatever training program psychology comes up with, though, they should have to meet the same standards as psychiatrists, because they are essentially doing the same job.

My sense is that psychologists may not have to pass USMLE steps I-III, because they will never get an unrestricted medical license. I would imagine that the medical complications that come up in psychiatric practice are tested on the psychiatry boards and I think that it's reasonable that if psychologists can pass the boards then they will have shown that they are adequately trained to prescribe medicine.

I'm sure that the training will take longer that what prescribing psychologists are going through right now.

One problem with this pschology rxp debate is that it contains elements of protectionism by psychiatry and expansionism by psychology. That's completely normal, but it obscures the substantive issues surrounding adequate training. How much training does it take to prescribe medicine independently? If prescribing psychologists see themselves as forming a complementary and equal career path as psychiatry, then they have to be equally trained.

Is there a licensing exam to provide talk therapy? If there were, would psychologists want psychiatrists to pass it if they were going to specialize in talk therapy?



Well, this really isn't my field of interest. Those could both be false, for all I know. I thought that there was solid data about the level of training for talk therapy, but maybe I (or it) was wrong.

 

[SingingCow]

Yeah, that's tricky. I guess I think that if prescribing psychology programs are teaching the same material to the same standard, then psychology will have succeeded in showing that it can be a legitimate avenue to prescribe medication to the mentally ill. If this is the power that it wants, then I don't see a problem with doing it this way.

The upside is that psychologists will feel more confident in their training will be legitimized in the medical field. The downside is that fewer psychologists will actually want to spend the time getting this training... but that's the same for medical school. The training is long and difficult and fairly painful.

Prescribing psychologists are essentially trying to have two interrelated professions... I can sympathize with that, because I'm doing the same thing. In my case I'm becoming a physician and a scientist. The training is incredibly painful, but because I believe in the value of having both medical and research training, I'm willing to do it. If prescribing psychologists don't have that level of dedication, than maybe they're getting into it for the wrong reasons.

I actually believe that all practicing psychologists SHOULD have more than basic training in psychopharmacology. I personally am not interested in prescription rights but I find it tremendously helpful when I have some idea about what my patients are taking and how their meds may be affecting them. It terrifies me when I run into colleagues who can't tell the difference between an antidepressant and a anticonvulsant/mood stabilizer.

Also, if you work with the more vulnerable and isolated populations, you may be the very few people your patients see on a regular basis (Most people don't go to their psychiatrists every week.) You can/ may be the only one who will notice side-effects of meds that need to be addressed promptly...

 

[Enkidu]

Unfortunately, psychiatrists do not need to pass extra board exams to do "talk therapy." Psychologists need to be licensed before they can practice. Even though psychotherapy training for psychiatrists tends to vary, psychiatrists in general appear to be "allowed" to do everything if they so desire.

Maybe this can be part of a negotiated settlement between psychology and psychiatry. Increase psychiatry's psychotherapy standards by requiring them to pass psychology boards (if the psychiatrist wants to do psychotherapy) and allow psychologists to prescribe if they pass psychiatry boards (if they're interested in prescribing).

My sense is that this will be a smaller requirement for psychiatrists to bridge than it would be for psychologists, but that may also be pretty fair, particularly since psychiatry is not trying to expand their scope of practice beyond it's historical limit.

I think there is an assumption that you can't kill someone with bad "talk therapy" but you can with meds. There is also another assumption, and obviously valid, that meds are much more complicated than talking. As some of you have pointed you, I would argue that bad "talk therapy" can do much damage. I would further argue that bad "talk therapy" CAN KILL YOU.

Yeah, I think you're right. Talk therapy can do a lot of harm and it has the potential to do a lot of good. Medication, on the other hand, can kill a patient in a very short time with much greater culpability on the prescriber, so it should probably be approached with a lot more caution.

 

[deleted106747]

Kind of like that. Maybe psychology programs can find a better way to impart that knowledge than the medical schools have. Maybe they can do it faster than the 8 years that psychiatrists go through. I don't know. Whatever training program psychology comes up with, though, they should have to meet the same standards as psychiatrists, because they are essentially doing the same job.

My sense is that psychologists may not have to pass USMLE steps I-III, because they will never get an unrestricted medical license. I would imagine that the medical complications that come up in psychiatric practice are tested on the psychiatry boards and I think that it's reasonable that if psychologists can pass the boards then they will have shown that they are adequately trained to prescribe medicine.

I'm sure that the training will take longer that what prescribing psychologists are going through right now.

One problem with this pschology rxp debate is that it contains elements of protectionism by psychiatry and expansionism by psychology. That's completely normal, but it obscures the substantive issues surrounding adequate training. How much training does it take to prescribe medicine independently? If prescribing psychologists see themselves as forming a complementary and equal career path as psychiatry, then they have to be equally trained.

Is there a licensing exam to provide talk therapy? If there were, would psychologists want psychiatrists to pass it if they were going to specialize in talk therapy?

Well, this really isn't my field of interest. Those could both be false, for all I know. I thought that there was solid data about the level of training for talk therapy, but maybe I (or it) was wrong.

I see the role of the prescribing psychologist falling more in the realm of an NP/PA practicing under the supervision of a psychiatrist and would favor a model of training that would follow that route more than the full medical degree. I absolutely agree that it should be longer and more comprehensive than the programs that are out now.

What troubles me is that psychotherapy is viewed as relatively benign and that psychiatrists (and other mental health professionals) often practice it without adequate training. That's where I've been seeing increased expansionism by psychiatry in recent years (and social work), and protectionism by psychologists. Like I said above, I've seen more widespread damage done by bad psychotherapy than bad psychopharm.

Ideally, I'd see the two fields as complementary, if they could get along - with psychologists more trained in psychotherapy/assessment with the option of RxP training along the model of a mid-level practitioner, and psychiatrists more trained in medical models with the option of psychotherapy training along the model of a mid-level practitioner. And each could supervise the other in their area of expertise. I believe the needs of patients could be served well by such a model.

I am uncertain whether there are solid data for the training models of psychotherapy question; research or not I have my doubts from what I've seen at the hospitals where I've worked. Anecdotal, yes.

 

[Enkidu]

I see the role of the prescribing psychologist falling more in the realm of an NP/PA practicing under the supervision of a psychiatrist and would favor a model of training that would follow that route more than the full medical degree. I absolutely agree that it should be longer and more comprehensive than the programs that are out now.

Yeah, then the training standard should be equal to a PA standard. Otherwise psychologists won't even be as good as midlevels... they'd be lowlevels, which I'm sure is not what they want for themselves.

Ideally, I'd see the two fields as complementary, if they could get along - with psychologists more trained in psychotherapy/assessment with the option of RxP training along the model of a mid-level practitioner, and psychiatrists more trained in medical models with the option of psychotherapy training along the model of a mid-level practitioner. And each could supervise the other in their area of expertise. I believe the needs of patients could be served well by such a model.

That's an interesting model. I'm sure it would work, except for the fact that psychiatrists who want to incorporate a significant level of psychotherapy in their practice will not accept midlevel status like a social worker. A more realistic scenario might be for psychiatrists to have to take clinical fellowships in psychotherapy to meet a common standard of psychotherapy providers if they want to make it a large part of their practice. The important thing is for there to be one common exam, just as there is one standard of care.

 

[deleted106747]

Yeah, then the training standard should be equal to a PA standard. Otherwise psychologists won't even be as good as midlevels... they'd be lowlevels, which I'm sure is not what they want for themselves.

That's an interesting model. I'm sure it would work, except for the fact that psychiatrists who want to incorporate a significant level of psychotherapy in their practice will not accept midlevel status like a social worker. A more realistic scenario might be for psychiatrists to have to take clinical fellowships in psychotherapy to meet a common standard of psychotherapy providers if they want to make it a large part of their practice. The important thing is for there to be one common exam, just as there is one standard of care.

I like the idea of a fellowship in psychotherapy for psychiatrists who want to practice a significant amount of psychotherapy. I think, in fact, that several psychiatrists I know would love to do something like that, because they've expressed frustration at how much of their practice is med management, and how little training they get in psychotherapy.

So - if I was master of the mental health universe, there would be a standard of care that would need to be met by psychiatrists to practice psychotherapy (designed by psychologists and psychiatrists) and a med training model for psychologists that follows an NP structure and has a standard of care that needs to be met (designed by psychiatrists and psychologists). Everyone would need to go on being supervised. I don't think anyone in this profession, because of its nature, should be practicing without at least peer supervision.

I'm aware that this will never happen. I also think that neither would exactly be a midlevel in the adjunctive field, because both are heavily trained already in psychology/iatry, unlike a mid-level social work provider or psychiatric NP. This is not only due to the training, but due to the ways of thinking that advanced training engenders.

 

[PsychPhDone]

So - if I was master of the mental health universe, there would be a standard of care that would need to be met by psychiatrists to practice psychotherapy (designed by psychologists and psychiatrists) and a med training model for psychologists that follows an NP structure and has a standard of care that needs to be met (designed by psychiatrists and psychologists).

I've always thought that if psychologists want to prescribe, they need a super ton of extra pharm training. And if psychiatrists want to do therapy, they need a super ton of extra therapy training.

 

[nitemagi]

I've always thought that if psychologists want to prescribe, they need a super ton of extra pharm training. And if psychiatrists want to do therapy, they need a super ton of extra therapy training.

Pharm training isn't medical training. This neglects the fact that medications effect the whole body.

 

[stigmata]

Pharm training isn't medical training. This neglects the fact that medications effect the whole body.

I have to agree, but I wonder why you feel the need to keep repeating this statement?

 

[nitemagi]

I have to agree, but I wonder why you feel the need to keep repeating this statement?

As emphasis in these reductionistic arguments. Not everyone reads the 29 pages of a thread, and online they all too often ignore what's said when it's only said once.

 

[PsychPhDone]

As emphasis in these reductionistic arguments. Not everyone reads the 29 pages of a thread, and online they all too often ignore what's said when it's only said once.

Sorry I didn't elaborate. I'm trying to bust out 3 papers this summer and often forget you guys don't know me personally and can't read my mind. I think pharm training should include thorough medical training. Just as I think therapy training should include thorough psychologically-based training. Years for both types of training. Supervision. Fellowships. Boards. CEUs and periodic recertification.

I have zero interest in pursuing med/pharm training myself - I would want several years of medical training if I were to prescribe and my interest is psychological research, not direct clinical work. If I do any med+ther clinical trials I'd get myself an MD co-author.

 

[Therapist4Chnge]

Sorry I didn't elaborate. I'm trying to bust out 3 papers this summer and often forget you guys don't know me personally and can't read my mind. I think pharm training should include thorough medical training. Just as I think therapy training should include thorough psychologically-based training. Years for both types of training. Supervision. Fellowships. Boards. CEUs and periodic recertification.

...and not just for a small fraction of residency, and/or through a handful of didactics and cases. I know some residency programs offer more opportunities for residents to pick up cases, though this is often at the expense of other training or free time. This setup is far from sufficient for anything more than supportive therapy. I know some wonderfully trained psychiatrists who provide talk therapy, though they all pursued additional institute training and/or significant mentorship to develop their psychotherapy skills.

nitemagi (or other psychiatrist) can you confidently say that the typical psychiatry residency program offers sufficient training in psychotherapy? By sufficient I mean being able to practice independantly, akin to the level of training you expect a person to have as a prescriber. I know you wouldn't want a prescriber with limited training slinging drugs everywhere, just like a psychologist does not want a clinician with limited training in psychotherapy hang a shingle and provide services. So within the context...do you think that the typical residency training program (not one of the handful that put real time and effort into psychotherapy training) provides sufficient training in psychotherapy to their psychiatry residents so that they can practice ethically, effectively, and independantly?

 

[Enkidu]

do you think that the typical residency training program (not one of the handful that put real time and effort into psychotherapy training) provides sufficient training in psychotherapy to their psychiatry residents so that they can practice ethically, effectively, and independantly?

I'm sympathetic to this question, but I wonder how the required standard of psychotherapy training is determined. Is it enough to show that practitioners at a certain level of training have such-and-such level of adverse outcomes (however those are defined)?