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Psychopharmacology/Advanced Practice Psychology

Discussion in 'Psychology [Psy.D. / Ph.D.]' started by 50960, Dec 6, 2005.

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  1. Psycycle

    Psycycle Psychologist 10+ Year Member

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    So I've been considering going back to school and getting my PA degree, then joining a practice and doing 1/2 therapy 1/2 med management as a longer term career trajectory. I was wondering if anyone might have feedback on if this is a good path to consider? Would like to get away from the turf war, if possible. Obviously I'd be working, in the case of med stuff, under the supervision of a MD or DO.
     
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  3. MamaPhD

    MamaPhD Psychologist, Academic Medical Center 7+ Year Member

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    Well, it sounds good in theory, but is this really a thing? Are there good working models of practicing both as a psychologist and a midlevel in the same position? I'm not saying it can't be done, but it would be an unusual situation and a tricky fit with many practices.
     
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  4. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus 10+ Year Member

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    Most places will want you to prescribe 100% of the time, as it is more profitable. If you ran a private practice, then you could set it up differently.
     
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  5. Fan_of_Meehl

    Fan_of_Meehl 2+ Year Member

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    Being in Louisiana, I've (briefly) considered the 'medical psychologist' route. One of the biggest challenges I see for myself would be inhibiting all of those impulses to do in-depth differential diagnostics, cognitive-behavioral case formulation, and cognitive-behavioral interventions that are challenging enough to fit into a 50-55 minute session (and there's no way I could really do any of that in the context of brief med checks). I feel that--in some very real way--I would have to 'kill the old (psychologist) me' and take a completely different approach to interacting with patients.
     
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  6. MamaPhD

    MamaPhD Psychologist, Academic Medical Center 7+ Year Member

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    Fan_of_Meehl, RxP: The Origin Story :)
     
  7. Fan_of_Meehl

    Fan_of_Meehl 2+ Year Member

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    You do realize that 'RxP' is a mere single letter away from 'R.I.P.'....there's definitely something to that :)
     
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  8. PSYDR

    PSYDR Psychologist 10+ Year Member

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    I have this fantasy of the old school psychoanalyst who occasionally prescribes something. Don't think it works like that unless you have an established private practice.
     
  9. AcronymAllergy

    AcronymAllergy Neuropsychologist SDN Moderator 7+ Year Member

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    Yep, the only folks I know who are actually able to practice that way are in PP. I also wonder about the issues related to practicing at the doctoral/LIP professional in one sense, and in what's technically been considered a mid-level role under the supervision of a physician in another sense.
     
  10. Psycycle

    Psycycle Psychologist 10+ Year Member

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    Thanks for the feedback. Yeah, I'd want to be in private practice doing this route. I am really drawn to the flexibility of private practice, but I don't want to be doing therapy all day. I like therapy, but I can't fathom 8 hours of it each day. A half day of therapy, half day of meds, some teaching, some research - that sounds far more ideal to me. I also love physical medicine.

    What I'm less certain about is whether it would be financially worth it.
     
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  11. erg923

    erg923 Psychologist-Health Insurance Operations 10+ Year Member

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    I actually think an MBA would create more financial ROI (its the only degree I would remotely entertain doing 5 years post phd) , but only if you are interested/willing to get out of doing primarily clinical service work.
     
  12. AcronymAllergy

    AcronymAllergy Neuropsychologist SDN Moderator 7+ Year Member

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    I've also thought about an MBA, although they have a tendency to be expensive. Fortunately, they're also often structured in a way to allow you to work full-time while attending.
     
  13. smalltownpsych

    smalltownpsych 2+ Year Member

    The only thing worse than doing therapy 8 hours a day which is what I do now would be to deal with the patients that the NP who writes the scripts down the hall has to deal with each day. I cringe whenever I get a referral from her because the vast majority of those patients do not really want to or believe that they can get better except through some miracle of medication combinations that is actually making them worse.
    If I was ever to prescribe medications, this would be the only way that I could do it. My fear would be that market pressure, social pressure, and patient pressure would override this fantasy and I would end up being another mid level med manager.
     
  14. psych.meout

    psych.meout 2+ Year Member

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    Hmm, so you're telling me my options are to work hard at making cognitive, behavioral, social, and emotional changes OR just take some pills and not have to change anything about my lifestyle?
     
  15. medium rare

    medium rare Psychologist & Psych NP 7+ Year Member

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    I practice this way every day (as a clinical psychologist and PMHNP) and it works very well for me. I am in full-time private practice and it would be hard to practice in an integrated way working in a CMHC or VA - they would only want me to prescribe. But in private practice, I am able to integrate psychotherapy and medication management seamlessly and it works very well. I see most of my patients for 50 minutes combining therapy and meds and most of my patients seek me out specifically for this reason. I am able to run a very busy and thriving self-pay practice completely free of insurance (and I can't say enough about how enjoyable that part is).

    I would encourage you to check into NP training vs PA training as you have considerably more ability to practice autonomously as a NP vs PA, but both models can work - you would just need to have a physician "supervisor" to practice as a PA.
     
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  16. Psycycle

    Psycycle Psychologist 10+ Year Member

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    Thank you for the input! It's hard to weigh out exactly how to do it. PA is 2 years, you're done, but you have to be supervised. In my state, I'd have to get the DPN, and the hardest year to navigate would be the RN training because I wouldn't be able to work.

    What you're doing is what I'd like to do - pp with little or no insurance. Do you find that it has been financially worth it? I'd lose at least a year of income, plus the cost of school.
     
  17. medium rare

    medium rare Psychologist & Psych NP 7+ Year Member

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    It has been more than worth it financially. My practice is full and I have a waiting/cancellation list for new patients willing to wait to see me (even though I consistently try to refer them if I can't see them in a timely manner). Not taking insurance has not been a problem either. I cannot handle the volume the way it is; if I took insurance it would be entirely overwhelming.

    It would more than make up for losing a year of income, IMO. I took a year off as well when I decided to go back to train as a NP. Keep in mind, if you go the PA route, you will have to pay your physician for supervision per your state's requirements and that could easily amount to $1000/month for as little as 2 hours/month of contact.
     
  18. PSYDR

    PSYDR Psychologist 10+ Year Member

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    Idaho just became the 5th state to sign rxp into law.
     
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  19. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    Too bad these are all states I do not want to live in.
     
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  20. psych.meout

    psych.meout 2+ Year Member

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    What about IL? Chicago is pretty awesome.
     
  21. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    Blech, not that dirty, congested city. My bff lives there, I can visit any time I want, a couple weekends a year is enough for me.
     
  22. tartar

    tartar Postdoctoral Fellow

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    Hi all! Anyone here know of any decent post-doctoral clinical psychopharmacology M.S. programs?
     
  23. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    Not really, recently they seem to have been taken over by the diploma mills.
     
  24. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus 10+ Year Member

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    New Mexico St is probably the only active program I'd recommend. I know some of their faculty (who are solid) and I think their clinical training is some of the best integrated training available for this type of training. /didn't go there
     
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  25. tartar

    tartar Postdoctoral Fellow

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    Oh great, thank you! I'm still torn between NP, PA and psychopharm MS.
     
  26. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus 10+ Year Member

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    It depends what you want to *do* in your day to day practice. If you want to solely prescribe, I wouldn't recommend Psych RxP for a number of reasons I've previously written about on here. I'd rec MD/DO >> NP > PA...based on training + autonomy + earning. NP is probably the best bang for your buck, but I think there are weaknesses in the training when it comes to Psych NPs.
     
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  27. briarcliff

    briarcliff 5+ Year Member

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    anyone know how supervision for RxP works in LA? I was reading the state's law the other day, and I noticed that they used the word "consultation" instead of supervision, which I thought was interesting


    Sent from my iPhone using SDN mobile
     
  28. AnnoyedByFreud

    AnnoyedByFreud 7+ Year Member

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    this is perhaps the most vaguely positive thing I've seen you post about NPs... I'll take it.
     
  29. msc545

    msc545 Clinical Psychologist & Neuropsychologist

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    Sorry to hear this, but not surprised. This may very well be a cultural issue. In my travels, I have noted that some patients from some cultures *expect* medicine or an injection and if they don't get it they feel that they have received inadequate treatment. They cannot be talked out of this, so vitamin pills or an injection of saline may actually go a long way toward helping them and maintaining patient rapport.

    Also, prescribing mild exercise (like 15 minutes of walking per day at normal pace or slower), which actually does help, will also make them feel like something has been done. It helps to actually write these things out on an official prescription pad as it lends weight to the whole intervention. So - therapy, medication, and exercise is the usual protocol for depression, but we know SSRI's are pretty ineffective, and psychotherapy is not useful in many cases, so we substitute placebos for real meds, and forgo the psychotherapy. The exercise is really mandatory. If your patient has a sleep disorder, as do most people who have depression, you also may want to medicate for that in the short term. I have seen pretty good results with fairly refractory depression using these methods or permutations of them.

    I think that the problem with psychiatry is that it is far too medication-focused, and I see psychiatrists shotgunning patients with medications, sometimes as many as six or seven simultaneously, none of which work, but produce plenty of side effects. To be fair, meds for Bipolar I and Schizophrenia do seem to work when other things don't, although they too usually have some pretty unpleasant side effects (Tardive Dyskinesia and diabetes in anti-psychotics, and chronic diaphoresis in meds used for Bipolar I)...but still they work!
     
  30. psych.meout

    psych.meout 2+ Year Member

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    Uh, Wut?
     
  31. nitemagi

    nitemagi Senior Member 10+ Year Member

    :laugh::laugh::laugh:
    Right?

    SSRIs are very effective in certain cases, but sure if you're pooling the data with those who they don't work at all with (potentially explainable through genetic mechanisms like those with serotonin transporter SLC6A4 with S/S genotypes), then sure, they look less effective. This is the problem of using such reductionistic thinking. Either they work or they don't work.
     
  32. DynamicDidactic

    DynamicDidactic Ass of Prof 7+ Year Member

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    To be clear, what "certain cases" are we talking about? The studies, which are often heavily sided toward medication efficacy (e.g., placebo washout groups, favorable outcome measures), often represent typical prescribing habits. More precisely, SSRIs are often prescribed to anyone with depressive affect so, pooled data is a fairly accurate manner of assessing efficacy.

    I view the literature very differently, yes SSRIs work but why do they work. The placebo effect seems to play a strong role but not exclusively. However, the serotonin-hypothesis has very little supporting evidence at this point.
     
  33. DynamicDidactic

    DynamicDidactic Ass of Prof 7+ Year Member

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    I am not aware of any controlled studies indicating that such a low dosage of physical activity treats depressive disorders.

    Work in the short-term but may potentially increase the chronicity of psychotic disorders.
     
  34. nitemagi

    nitemagi Senior Member 10+ Year Member

    Look up BDNF.
     
  35. PSYDR

    PSYDR Psychologist 10+ Year Member

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    @nitemagi : While I'm sure you are aware, I believe dynamic is referring to the works of Dr. Kirsch at MGH when he/she is referring to the placebo effect of SSRIs. There is consistent debate between the likes of Kirsch and Krystal which seem to be predicated upon the statistics used. There was also that debate about tianeptine. An explanation of Kirsch's finding and the STAR*D stuff using genetic polymorphisms would be very interesting. In all seriousness, you should at least submit a letter to the relevant journal about this.

    @DynamicDidactic : There is a consistent and robust evidence base that aerobic exercise has an incredible effect on depression with effect sizes that approximate CBT and SSRI treatment. Behavioral activatoin, which incorporates exercise, has a superior effect size to CBT on meta analysis. There is also very robust data regarding the efficacy of SSRIs, which is also discussed in the Kirsch papers and the STAR*D study.
     
  36. smalltownpsych

    smalltownpsych 2+ Year Member

    I thought behavioral activation was a part of CBT. :confused: In any case, I always recommend physical activity and also sunshine and fresh air and fun. If the patient and I can find one thing that combines all of the above, then all the better.
     
  37. Dian Cecht

    Dian Cecht

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    Are we any closer in Canada for clinical psychologists to prescribe certain medications to treat patients?

    Sent from my LG-H873 using SDN mobile
     
  38. DynamicDidactic

    DynamicDidactic Ass of Prof 7+ Year Member

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    I forgot about this till being bored today. Sorry to retread an old post.

    If you are saying people should be prescribed SSRIs to increase BDNF production, I would say that you are not learning from past mistakes. While the prospect that the therapeutic effect of SSRIs may be due to an increase in BDNF production is interesting and worthwhile to pursue with research, one still falls prey to the same logical fallacies that led to the erroneous serotonin-theory of depression (and the general poorly-supported chemical imbalance theory of depression) - correlation does not mean causation.
     
  39. DynamicDidactic

    DynamicDidactic Ass of Prof 7+ Year Member

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    @PSYDR
    I was commenting earlier (again, sorry to rehash an old post, its been a busy semester) that "15 minutes" is not considered a therapeutic dose, it would have to be longer (i.e., 25-30).

    I disagree with the term "robust data" to support SSRI efficacy. I believe the exact numbers from Kirsch were that 83% of the therapeutic effect came from placebo or 2.5 points lower score on the HAM-D for the SSRI groups. These numbers indicates a statistically significant difference but not what most people would consider a clinically significant difference. The STAR*D study is similarly lacking in clinical significance. While its true that 67% of participants got well after their 4th round of medication, only 3% of the sample remained in the study, got well, and stayed well for a year.

    I'll climb back into my hole now.
     

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