Psychopharmacology/Advanced Practice Psychology

[JockNerd]

I just noticed this, because I don't monitor this thread (not my thing).

Do you worry that trying to be an expert in both psychopharmacology and psychotherapy will end up stretching you too thin in both? It seems like that's why modern psychiatry has drifted more towards medical management rather than psychotherapy...

I don't think the idea that "being stretched too thin" is at all conceivable as the reason behind a movement to meds management in modern psychiatry.

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[solumanculver]

I don't think the idea that "being stretched too thin" is at all conceivable as the reason behind a movement to meds management in modern psychiatry.

Really? Pharmacology and therapy are two completely different fields. It seems obvious that as training in one field grows, training in the other field will suffer... and psychiatrists focus on pharmacology throughout their medical training.

It seems kind of unreasonable to expect the same people to be experts in neurochemistry and psychotherapy... It seems like if you tried to do that, you would be stretched a bit thin.

Also I think that the people who want to do one, don't usually want to do the other... at least that's the case with me.

 

[erg923]

Really? Pharmacology and therapy are two completely different fields. It seems obvious that as training in one field grows, training in the other field will suffer... and psychiatrists focus on pharmacology throughout their medical training.

It seems kind of unreasonable to expect the same people to be experts in neurochemistry and psychotherapy... It seems like if you tried to do that, you would be stretched a bit thin.

Also I think that the people who want to do one, don't usually want to do the other... at least that's the case with me.

Not sure I follow the logic there. For example, I know several neuropsychologists who are certainly experts in functional neuroanatomy and behavioral neuroscience/behavioral neurology, but are also very gifted therapists. I would certainly classify neuroscience and psychotherapy as 2 totally different animals, wouldn't you? They get the therapy training in grad school, and most of the knowledge in in the neuro aspects during internship and a post-doc fellowship in clinical neuropsychology. It certainly takes more and longer training to do both though.

 

[solumanculver]

Not sure I follow the logic there. For example, I know several neuropsychologists who are certainly experts in functional neuroanatomy and behavioral neuroscience/behavioral neurology, but are also very gifted therapists. I would certainly classify neuroscience and psychotherapy as 2 totally different animals, wouldn't you? They get the therapy training in grad school, and most of the knowledge in in the neuro aspects during internship and a post-doc fellowship in clinical neuropsychology. It certainly takes more and longer training to do both though.

Hi,

Well I'm sure there are a lot of people who are experts at neuroscience and therapy... But I wouldn't say that that's the general rule. I think that the general rule is the opposite. Most people who love things like biochemistry and pharmacology tend to dislike things like psychology and sociology, and vice versa.

In any case, I do think that that is one of the reasons that psychiatrists prefer to do medication management over therapy. In order to get into medical school you have to be good at biology, chemistry, and physics. We don't require medical students to have taken psychology.

Of course I realize that some people are good at both psychopharmacology and psychotherapy... that's the classic idea of what psychiatry was supposed to be. But as psychopharmacology develops, the natural inclination of physicians to think about things in terms of molecules and receptors takes over and psychotherapy loses a proportional chunk of the psychiatrists repetoire.

 

[solumanculver]

Not sure I follow the logic there. For example, I know several neuropsychologists who are certainly experts in functional neuroanatomy and behavioral neuroscience/behavioral neurology

They get the therapy training in grad school, and most of the knowledge in in the neuro aspects during internship and a post-doc fellowship in clinical neuropsychology

Can you become an expert in neuroscience in that way? Do psychologists have to take biochemistry and cellular biology? How could you become an expert after a year-long internship?

 

[erg923]

Actually, Internship is one year, post doc fellowship in neuropsychology is 2 additional years. So 3 years total. You can check out the Houston Conference guidelines for training in clinical neuropsychology if you like. And yes, in my neuro psych track within my clinical psych program we have to take neuroscience classes. We have to take neurophysiology, both molecular and functional neuroanatomy/neuroscience, as well as 2 classes in behavioral neurology. The 4 neuropsych assessment courses that are required, while obviously focusing on assessment methods, also facilitate the understanding of brain-behavior relationships. All of this is addition to the therapy training we are receiving during our clinical training. Through internship and fellowship training specializing in neuropsychology (3 years total) you get more exposure doing testing/assessment and diagnosis, more mandatory didactic training in neuroscience, as well as exposure to neurology lectures and grand rounds etc.

While not "neuroscientists" (the Ph.D is in clinical psychology), the practice of clinical neuropsychology requires expertise in neuroscience and brain behavior relationships. As I said previously, I know some (not all of course) neuropsychologists who are very gifted therapists, and utilize this within their practice.

 

[solumanculver]

Actually, Internship is one year, post doc fellowship in neuropsychology is 2 additional years. So 3 years total. You can check out the Houston Conference guidelines for training in clinical neuropsychology if you like. And yes, in my neuro psych track within my clinical psych program we have to take neuroscience classes. We have to take neurophysiology, both molecular and functional neuroanatomy/neuroscience, as well as 2 classes in behavioral neurology. The 4 neuropsych assessment courses that are required, while obviously focusing on assessment methods, also facilitate the understanding of brain-behavior relationships. All of this is addition to the therapy training we are receiving during our clinical training. Through internship and fellowship training specializing in neuropsychology (3 years total) you get more exposure doing testing/assessment and diagnosis, more mandatory didactic training in neuroscience, as well as exposure to neurology lectures and grand rounds etc.

While not "neuroscientists" (the Ph.D is in clinical psychology), the practice of clinical neuropsychology requires expertise in neuroscience and brain behavior relationships. As I said previously, I know some (not all of course) neuropsychologists who are very gifted therapists, and utilize this within their practice.

Hi, thanks. I actually was asking if you had to take any biochem/cell bio in undergrad in order to get into psychology school. I assumed that you had to take it in graduate school.

Yeah, three years seems more reasonable. I thought you meant only during internship.

In any case, I believe that some people are gifted at both therapy and neuroscience, but I kind of think that it's best if we have people who specialize in therapy and people who specialize in pharmacology... kind of like the system we have now, except psychiatrists could give up therapy.

 

[doctorpsych]

In any case, I believe that some people are gifted at both therapy and neuroscience, but I kind of think that it's best if we have people who specialize in therapy and people who specialize in pharmacology... kind of like the system we have now, except psychiatrists could give up therapy.[/QUOTE]

In general, psychiatrists have given up praciticing/providing psychotherapy already... only a minority of psychiatrists still practice some sort of talk therapy, most of the time they are psychoanalytic and they tend to be older and very seasoned. The system that we have now is a split system... but it doesn't work. It's fragmented and inneficient...patients have to see two doctors to get what they ultimately need.

 

[solumanculver]

In general, psychiatrists have given up praciticing/providing psychotherapy already... only a minority of psychiatrists still practice some sort of talk therapy, most of the time they are psychoanalytic and they tend to be older and very seasoned. The system that we have now is a split system... but it doesn't work. It's fragmented and inneficient...patients have to see two doctors to get what they ultimately need.

Hi, well I can't speak on how well our system works... our medical system in general is kind of fragmented. But that's a result of medical science becoming so advanced, no one person has all the necessary expertise... In the current system patients go to physicians to get medication and psychologists to get therapy. This model makes inherent sense to me...

It may make easier one-stop-shopping for patients to see one provider for both medication and therapy... but by doing that you're going to sacrifice just a little more expertise in both areas. It's like saying that it would be better to get your psychiatric medication from your family doctor while he removes your wart... it's definitely time-effective, but wouldn't you rather have a specialist prescribing you medication that could potentially give you metabolic disorders and dyskinesia and agranulocytosis... I would.

 

[Therapist4Chnge]

....but wouldn't you rather have a specialist prescribing you medication that could potentially give you metabolic disorders and dyskinesia and agranulocytosis... I would.

I believe only 15% of psychotropics are prescribed by psychiatrists.....the remaining 85% is done by GP/FP/NP/PA's. I can look up the study later this week, but that is the common % cited. Many FP/GP/NP/PA's get their information from the drug reps. They are put in a really tough position because they are stuck either prescribing something to their patient right then.....or referring to a psychiatrist who may or may not be available, and who the patient may or may not go to see. This is *why* this training makes sense....it is specialized training for someone who will have regular access to the patient.

 

[solumanculver]

I believe only 15% of psychotropics are prescribed by psychiatrists.....the remaining 85% is done by GP/FP/NP/PA's. I can look up the study later this week, but that is the common % cited. Many FP/GP/NP/PA's get their information from the drug reps. They are put in a really tough position because they are stuck either prescribing something to their patient right then.....or referring to a psychiatrist who may or may not be available, and who the patient may or may not go to see. This is *why* this training makes sense....it is specialized training for someone who will have regular access to the patient.

I think you're numbers are right, that's not the issue... I understand that there are a shortage of psychiatrists, but why should the policy solution to that problem be to make prescribing psychologists? Why not just make more psychiatrists? If it were therapists that we were short on, wouldn't it make more sense to amp up production of psychologists, rather than having more psychiatrists do therapy?

What is a prescribing psychologist anyway? It's the definition of psychiatry, minus general medicine and plus more therapy... Why wouldn't prescribing psychologists turn out exactly like the psychiatrists?

I think it makes sense to have one professional to do the therapy, and one to prescribe the medication... once you try to make a super-professional to do it all, then you've diluted both of those... provided your super-professional even turns out doing what you had hoped to begin with.

 

[erg923]

How do you propose "making more psychiatrists" exactly? The field is what it is.....and alot of individuals who go into med school don't want to do it.

 

[solumanculver]

How do you propose "making more psychiatrists" exactly? The field is what it is.....and alot of individuals who go into med school don't want to do it.

No, not at all. Medical students are, by and large, driven by money. Why do you think every medical student wants to be a dermatologist? Premeds going into medical school don't want to be dermatologists...

Since the designation "medical psychologist" conveys more money and prestige, psychologists want to do it... of course there are some people who just want to learn how to prescribe medication out of sheer interest... but I suspect that for most the incentive is financial.

There's nothing wrong with this... that's how we encourage people to take jobs, by offering to pay them... the longer the training, the more the pay.

My point is that if our problem is a shortage of psychiatrists, our solution shouldn't be to create an entirely new class of professional... we could just increase incentives to become a psychiatrist.

 

[doctorpsych]

Hi, well I can't speak on how well our system works... our medical system in general is kind of fragmented. But that's a result of medical science becoming so advanced, no one person has all the necessary expertise... In the current system patients go to physicians to get medication and psychologists to get therapy. This model makes inherent sense to me...

It may make easier one-stop-shopping for patients to see one provider for both medication and therapy... but by doing that you're going to sacrifice just a little more expertise in both areas. It's like saying that it would be better to get your psychiatric medication from your family doctor while he removes your wart... it's definitely time-effective, but wouldn't you rather have a specialist prescribing you medication that could potentially give you metabolic disorders and dyskinesia and agranulocytosis... I would.

I understand you point, but no one is claiming that the training that medical psychologist get is equivalent to one of a psychiatrist. However, the rationale is that with better technology, improved safety, crossing over of education, psychologist can be trained to prescribe psychotropics safely and effectively. Medical psychologist would be not replacing psychiatry, but would serve something like an advance triage of mental health service... or perhaps a pcp type of mental health professional. As noted by t4c, the majority of psych meds are prescribed by pcp who have very little experience with psychology, psychiatry, or mental health in general... but yet, they are prescribing. That is inadequate care. Also, the training that medical psychologist get is more integrative in providing medication management within the context of psychological treatment. In general, psychiatrist mostly only focus on prescribing medications, and in reality, often within a vacum.

As per sacrificing experience, one of the requirements to be accepted into a psychopharm training program is having a psychology license and most of the psychologist who are interested are very seasoned clinicians already. They may be sacrificing some continuing education in the realms of newly developing psychological treatment but on the other hand, they would be keep updated in the psychopharm facet of treatment as well, and a more integrative approach.

check out this video, it's pretty interesting:

http://www.ky3.com/news/local/15967212.html?video=YHI&t=a

 

[solumanculver]

http://www.ky3.com/news/local/15967212.html?video=YHI&t=a

It's pretty interesting, but did you catch the part where the journalist says that prescribing privileges would require "hours of additional training"... I think he should have phrased that a bit differently for better effect. "Hours of training" sounds like "3 hours" or "4 hours"... later on they say "400 hours", but it's still funny.

I understand you point, but no one is claiming that the training that medical psychologist get is equivalent to one of a psychiatrist. However, the rationale is that with better technology, improved safety, crossing over of education, psychologist can be trained to prescribe psychotropics safely and effectively.

Hey, I'm sure that psychologists can be trained to prescribe safely and effectively. After all, psychiatrists are trained to...

My point is really not one about safety, what I'm really getting at is that "prescribing psychologist" is blurring the lines of what a psychologist even is... In our current system, physicians prescribe medicine and psychologists provide therapy. This system makes sense because people go to medical school in order to learn how to prescribe medicine and people, generally, go to psychology school to learn how to do therapy.

The result of this system is that we have two classes of professionals, one who specializes in medicine and neuropharmacology, and one who specializes in behavioral therapies. This should be to the benefit of patients, they are getting the best care on both fronts.

The problem is one of access... there aren't enough of the prescribing-kind of doctor, but there are plenty of the talking-kind of doctor. But the solution doesn't make sense... turn talk-doctors into talk-drug doctor hybrids? Why not just make psychiatry into a more attractive specialty for medical students already going through the extensive process of becoming physicians?

As noted by t4c, the majority of psych meds are prescribed by pcp who have very little experience with psychology, psychiatry, or mental health in general... but yet, they are prescribing. That is inadequate care.

In general, I don't think that there is a problem with pcp's prescribing a lot of psych meds. Pcp's have plenty of experience with psychiatry, there are, after all, the ones prescribing most of the psych meds... as for experience with psychology... why should that matter? All they need is enough experience to refer to a psychologist, just like any other medical or allied health specialty.

Pcp's know a lot about medicine and biology, and they know a lot about medical decision making... That's not inadequate care. Of course, there comes a point when they have to refer to psychiatry, which a good pcp knows how to do.

Medical psychologist would be not replacing psychiatry, but would serve something like an advance triage of mental health service... or perhaps a pcp type of mental health professional.

Hi, this is an interesting idea. What do you mean, exactly? That psychologists would give the first prescription for an anti-psychotic, and then refer to a psychiatrist for follow up? That makes some sense... but how would such a system be legally enforced? What would stop the psychologist from just setting himself up as a psychiatrist anyway?

Also, the training that medical psychologist get is more integrative in providing medication management within the context of psychological treatment. In general, psychiatrist mostly only focus on prescribing medications, and in reality, often within a vacum.

Well I'm not really an expert on this, but what kind of psychological data is important in prescribing medication? It seems like psychotic patients get antipsychotics, regardless of what they have to say about their delusions... bipolar patients get mood stabilizers, etc. In what way would psychological information about the patient change which drugs they would get?

 

[Therapist4Chnge]

The problem is one of access... there aren't enough of the prescribing-kind of doctor, but there are plenty of the talking-kind of doctor. But the solution doesn't make sense... turn talk-doctors into talk-drug doctor hybrids? Why not just make psychiatry into a more attractive specialty for medical students already going through the extensive process of becoming physicians?

For a small sub-set...yes! They have great access to their patients, they don't have to make a referral that may or may not be met. They also have solid Dx training, and then with specialize training they can work with populations in need. They are NOT meant as a replacement, as psychiatrists do a great deal more than just prescribe meds.

In general, I don't think that there is a problem with pcp's prescribing a lot of psych meds. Pcp's have plenty of experience with psychiatry, there are, after all, the ones prescribing most of the psych meds... as for experience with psychology... why should that matter? All they need is enough experience to refer to a psychologist, just like any other medical or allied health specialty.

Talk to GP/FPs that get stuck prescribing psychotropics because there are no referral options for them.....they will disagree that it isn't a problem. They are stuck between a rock and a hard place because they are expected to help everyone, especially in areas that don't have a plethora of other options.

Well I'm not really an expert on this, but what kind of psychological data is important in prescribing medication? It seems like psychotic patients get antipsychotics, regardless of what they have to say about their delusions... bipolar patients get mood stabilizers, etc. In what way would psychological information about the patient change which drugs they would get?

There is a lot of nuance that goes into psychosocial and behavioral assessment. The psychologist has more training in Dx. It is obviously diff. if it is an acute psychotic episode, etc.

 

[solumanculver]

There is a lot of nuance that goes into psychosocial and behavioral assessment. The psychologist has more training in Dx. It is obviously diff. if it is an acute psychotic episode, etc.

Hey, could you go into more detail on this. Of course a lot goes into deciding which medication is right... comorbidities, other medications, whatever. But which psychological factors would make a difference?

Also, in what way would having better training in DSM diagnosis change prescribing habits? It seems like psychiatric medication is all symptom-based anyway...

Thanks

 

[biogirl215]

there aren't enough of the prescribing-kind of doctor, but there are plenty of the talking-kind of doctor.

In rural areas, or even semi-rural ones, there aren't enough of either, frankly. The one thing that keeps me from totally rolling my eyes at my friend who plans to defend in December and wants to live in THIS SPECIFIC CITY, come pretty much anything, is that fact. There aren't a lot of clinicians or psychiatrists here (in fact, our only psych recently retired, and we're the second biggest city in the state!). The end result is that many people get prescribed antidepressants and such by a GP but can't get therapy (which IS shown as an effective treatment/co-treatment by EBM) or psychiatric prescriptions for months upon months.

 

[Therapist4Chnge]

Hey, could you go into more detail on this. Of course a lot goes into deciding which medication is right... comorbidities, other medications, whatever. But which psychological factors would make a difference?

First off psychologists have an advantage of seeing their patients more frequently, which allows for closer monitoring of symptoms. Though more than that, they also have the benefit of assessment measures that can be given (more than a screener or clinical interviews, as that doesn't tease out the really useful information). Obviously you wouldn't do this for everyone, but often symptoms may present the same, but medication decisions aren't JUST about addressing a general symptom, but more specific issues. Cognitive assessments and malingering assessments are the two areas that first came to mind.

Psychiatrists can do a thorough clinical interview at intake (good), but follow-up tends to be tougher, as they are pushed to see too many patients. Psychologists can spend more time with their patients *and* have a better relationship with them.

Also, in what way would having better training in DSM diagnosis change prescribing habits? It seems like psychiatric medication is all symptom-based anyway...

Thanks

See above, I touched a bit on teasing out symptoms.

 

[solumanculver]

First off psychologists have an advantage of seeing their patients more frequently, which allows for closer monitoring of symptoms. Though more than that, they also have the benefit of assessment measures that can be given (more than a screener or clinical interviews, as that doesn't tease out the really useful information). Obviously you wouldn't do this for everyone, but often symptoms may present the same, but medication decisions aren't JUST about addressing a general symptom, but more specific issues. Cognitive assessments and malingering assessments are the two areas that first came to mind.

Psychiatrists can do a thorough clinical interview at intake (good), but follow-up tends to be tougher, as they are pushed to see too many patients. Psychologists can spend more time with their patients *and* have a better relationship with them.

Hi, those are good points, but doesn't it all boil down to psychologists being able to spend more time with their patients? But the only reason that psychiatrists can't spend more time with their patients is that there aren't enough psychiatrists to go around...

So if psychologists started to prescribe, then psychiatrists would be able to spend more time with their patients... but that would happen if we just made more psychiatrists as well.

 

[Therapist4Chnge]

Hi, those are good points, but doesn't it all boil down to psychologists being able to spend more time with their patients? But the only reason that psychiatrists can't spend more time with their patients is that there aren't enough psychiatrists to go around...

So if psychologists started to prescribe, then psychiatrists would be able to spend more time with their patients... but that would happen if we just made more psychiatrists as well.

More psychiatrists wouldn't change that, as the time issue is about billing/reimbursement and health care structure, and not a supply/demand issue. Of course, the low supply doesn't help matters.

 

[biogirl215]

Just to play "devil's advocate" here, wouldn't clinical psychologists with rxp fall into the same "trap" as psychiatrists with med. management being more economically efficient? What would override this? The nature of clinical psychology training? The more limited rxp (if it would in fact be more limited)? Something else? Would this cause clinicians to focus more on meds as a curative major than focusing on therapy or therapy+meds as curative measure, partially because meds are more economically efficient for the clinician? Would clients even request or be willing to utilize therapy any more? Would clinicians need to or be willing to perform it?

 

[Therapist4Chnge]

Just to play "devil's advocate" here, wouldn't clinical psychologists with rxp fall into the same "trap" as psychiatrists with med. management being more economically efficient? What would override this? The nature of clinical psychology training? The more limited rxp (if it would in fact be more limited)? Something else? Would this cause clinicians to focus more on meds as a curative major than focusing on therapy or therapy+meds as curative measure, partially because meds are more economically efficient for the clinician? Would clients even request or be willing to utilize therapy any more? Would clinicians need to or be willing to perform it?

Based on the D.O.D. study and subsequent people who have gotten the training, it seems that the way the prescribing psychologists handle their patients is different than how a psychiatrist handles his/her patients. Taking more meds off and prescribing less, compared to psychiatrists (or other prescribers...I forget. It's been awhile since I read the info).

I think prescribing psychologists come at meds as more from an adjunctive position than a primary tx method. I'd be concerned if this changed, but so far it seems to hold with the prescribers I've talked to and from everything I've read on the subject.

 

[doctorpsych]

My point is really not one about safety, what I'm really getting at is that "prescribing psychologist" is blurring the lines of what a psychologist even is... In our current system, physicians prescribe medicine and psychologists provide therapy. This system makes sense because people go to medical school in order to learn how to prescribe medicine and people, generally, go to psychology school to learn how to do therapy.

No, IMHO, the split system does not make sense, my understanding is the the split treatment modality became popular after the demands of manage care, not based on empirical evidence. If we are discussing ideals, where everyone plays nicely and communicates with each other and all patients builts equal therapeautic relationships with everyone, and access was not an issue, then yes, a split system might work. In practice, this does not happen... what good is it to have a "specialist" but have no access? Even in a large metro area, the waiting time to see a psychiatrist could be longer than two months.

The result of this system is that we have two classes of professionals, one who specializes in medicine and neuropharmacology, and one who specializes in behavioral therapies. This should be to the benefit of patients, they are getting the best care on both fronts.

The reality is that pts are not getting the best of both worlds. that's one of the drives of the RXP movement in psychology.

The problem is one of access... there aren't enough of the prescribing-kind of doctor, but there are plenty of the talking-kind of doctor. But the solution doesn't make sense... turn talk-doctors into talk-drug doctor hybrids? Why not just make psychiatry into a more attractive specialty for medical students already going through the extensive process of becoming physicians?

Psychiatrists are one of the top players in terms of income... didn't money magazine listed psychiatry as one of the top 10 earning professions or something like that? In anycase, I believe organized medicine and other forces have been trying to increase attractibility of psychiatry to medical students for years now... they have done the calculations... the interest continues to dwindle. What else is there to do? the money is there, the lifestyle/hours is there... but still there is a shortage... and I believe the majority of the interests tend to be FMGs. I know many FMGs are very competent, but there is a trend here... what is of interest is what accounts for that trend. As you know, psychiatry is not one of the top choices for residencies among medical students, that's a well known fact.

In general, I don't think that there is a problem with pcp's prescribing a lot of psych meds. Pcp's have plenty of experience with psychiatry, there are, after all, the ones prescribing most of the psych meds... as for experience with psychology... why should that matter? All they need is enough experience to refer to a psychologist, just like any other medical or allied health specialty.

Again, IMHO, that's not correct, pcp's don't have "plenty" of experience, in fact, it is my understanding that most pcp's welcome and on many occassions seek out the consult of psychologist in regards to prescribing psychotropics. For whatever reason, there appears to be a greater barrier in keeping contacts with psychiatrists. I have heard this on numerous occassions personally adn in professional conferences. In the Hawaii effort, I believe that community health care MDs were supporting psychologist's effort to gain RXP.

Pcp's know a lot about medicine and biology, and they know a lot about medical decision making... That's not inadequate care. Of course, there comes a point when they have to refer to psychiatry, which a good pcp knows how to do.

they don't get enough training in psychopharm...

Hi, this is an interesting idea. What do you mean, exactly? That psychologists would give the first prescription for an anti-psychotic, and then refer to a psychiatrist for follow up? That makes some sense... but how would such a system be legally enforced? What would stop the psychologist from just setting himself up as a psychiatrist anyway?

Through the medical psychologist's assessment, he/she would decide whether to treat the patient or make an appropriate referral, whether be a psychiatrist or other medical specialty. The assessment process would continue throughout treatment (e.g. past the initial prescription of an anti-psychotic) and the decision to refer would always be an option. It comes down to sound clinical judgment, ethics and clear decision making. There exists very little legal enforcement in the referral process of other health care practionares as well, they also depend of clinical judgment, e.g. it is the family doctor's decision to refer a pt to specialty doctor, whether he/she does it or not is his/her decision... the doctor can be sued, but the decision still lies with the doctor. BTW, all the above is my opinion, it's not based on a specific guideline.

Well I'm not really an expert on this, but what kind of psychological data is important in prescribing medication? It seems like psychotic patients get antipsychotics, regardless of what they have to say about their delusions... bipolar patients get mood stabilizers, etc. In what way would psychological information about the patient change which drugs they would get?[/QUOTE]

well, there are many specific and nonspecific processes that occurs in therapy and a seasoned clinician would be able to "read" these processes and make clinical decisions based on these. Some of these processes would faciliate the report of symptoms, the attitudes toward taking medications. Others would be the selection of specific psychotropics (e.g. as per 'antidepressants': SSRI's vs., NaSSA, 5-HT/NE RI, SRI/S2 antagonists, etc... or even which medication within each category). I don't think most pcp's have been trained in this knowledge base, correct me if I'm wrong. Combining psychotropics with cbt or to maximize behavioral treatment (e.g. treatment of insomnia, primary or secondary to psychiatric d/o)

 

[solumanculver]

No, IMHO, the split system does not make sense, my understanding is the the split treatment modality became popular after the demands of manage care, not based on empirical evidence. If we are discussing ideals, where everyone plays nicely and communicates with each other and all patients builts equal therapeautic relationships with everyone, and access was not an issue, then yes, a split system might work. In practice, this does not happen... what good is it to have a "specialist" but have no access? Even in a large metro area, the waiting time to see a psychiatrist could be longer than two months.

Hi, this is a problem of access that you're talking about, not a problem with a split system. Of course access to psychiatrists is the problem, but I think the solution is to make more psychiatrists, not make super-psychologists to be both psychologists and psychiatrists.

The reality is that pts are not getting the best of both worlds. that's one of the drives of the RXP movement in psychology.

Sure, that's what's politically driving the movement forward. But I don't think psychologists generally pursue pharmacology in order to help their patients, I think that they're responding to the same factors that drive every professions... increased income and prestige.

My point is that prescribing psychologists, while they are a solution, are not the best solution. The best solution is to increase the number of psychiatrists to meet the demand.

Psychiatrists are one of the top players in terms of income... didn't money magazine listed psychiatry as one of the top 10 earning professions or something like that?

Maybe compared to other professions, but they are among the poorest paid physicians.

In anycase, I believe organized medicine and other forces have been trying to increase attractibility of psychiatry to medical students for years now... they have done the calculations... the interest continues to dwindle. What else is there to do? the money is there, the lifestyle/hours is there... but still there is a shortage...

It's because, in general, the money isn't there.

and I believe the majority of the interests tend to be FMGs. I know many FMGs are very competent, but there is a trend here... what is of interest is what accounts for that trend. As you know, psychiatry is not one of the top choices for residencies among medical students, that's a well known fact.

FMGs are attracted to psychiatry because they can get into psychiatry residencies, not because they want to be psychiatrists. They can get in because psychiatry isn't lucrative/prestigious enough for medical students... well, there aren't the right incentives to meet the demand.

In psychology it's the opposite. Psychiatrists are the de facto leaders in mental health, so for a psychologist to become more like a psychiatrist increases income and prestige. But it creates a kind of professional that is essentially identical to the psychiatrist of 50 years ago... which is what bothers me. If psychologists are becoming psychiatrists (honestly), then what does it mean to be a psychologist? Why even have two professions if it's going to end up as one?

Again, IMHO, that's not correct, pcp's don't have "plenty" of experience, in fact, it is my understanding that most pcp's welcome and on many occassions seek out the consult of psychologist in regards to prescribing psychotropics.

Well, that doesn't make any sense. If PCPs prescribe 85% of psychiatric medication, then they have a lot of experience... As for consulting psychologists... why not? It can't hurt, but if anything it seems like a case of the blind leading the blind... Unless you mean they are consulting these psychopharm psychologists...

For whatever reason, there appears to be a greater barrier in keeping contacts with psychiatrists. I have heard this on numerous occassions personally adn in professional conferences. In the Hawaii effort, I believe that community health care MDs were supporting psychologist's effort to gain RXP.

Well it's because it's hard to train a psychiatrist... it takes 8 years of post-graduate study, and it offers relatively few financial benefits. The shortage is based on economics... That's also the reason for this great interest in psychologists prescribing... because for them it puts them above their peers in income and prestige.

they don't get enough training in psychopharm...

Well, next to psychiatrists, they get the most training in psychopharmacology. I think something like a third of their patients have psychiatric comorbidities... that's a lot... well that statistic was something I heard from an FP, not anything real... I don't know what the real statistic is.

Through the medical psychologist's assessment, he/she would decide whether to treat the patient or make an appropriate referral, whether be a psychiatrist or other medical specialty. The assessment process would continue throughout treatment (e.g. past the initial prescription of an anti-psychotic) and the decision to refer would always be an option. It comes down to sound clinical judgment, ethics and clear decision making. There exists very little legal enforcement in the referral process of other health care practionares as well, they also depend of clinical judgment, e.g. it is the family doctor's decision to refer a pt to specialty doctor, whether he/she does it or not is his/her decision... the doctor can be sued, but the decision still lies with the doctor. BTW, all the above is my opinion, it's not based on a specific guideline.

This plan makes the psychologist identical to a psychiatrist... not a "triage psychiatrist". It's like saying that EM docs should have the option to take on patients on a permanent basis in the ER... Well, it's not the advertised purpose of an EM doc.

Some of these processes would faciliate the report of symptoms, the attitudes toward taking medications. Others would be the selection of specific psychotropics (e.g. as per 'antidepressants': SSRI's vs., NaSSA, 5-HT/NE RI, SRI/S2 antagonists, etc... or even which medication within each category).

Well, unless it's resulting in changing the medication, then these insights have no medical value... Which psychological insights would result in changing someone's medication?

I don't think most pcp's have been trained in this knowledge base, correct me if I'm wrong. Combining psychotropics with cbt or to maximize behavioral treatment (e.g. treatment of insomnia, primary or secondary to psychiatric d/o)

But psych patients already receive combination treatment, if they can afford it. The question is why should it be from the same person necessarily, and would this offset the smaller medical knowledge base that these practitioners would have?

 

[doctorpsych]

Sure, that's what's politically driving the movement forward. But I don't think psychologists generally pursue pharmacology in order to help their patients, I think that they're responding to the same factors that drive every professions... increased income and prestige.

My point is that prescribing psychologists, while they are a solution, are not the best solution. The best solution is to increase the number of psychiatrists to meet the demand.

sure, the potential for economic gains is ONE of the driving factors... but also, there are plenty of other ways, easier ways to make more money than to go back to school to and study psychopharm and to wait and see if a bill will pass in order to prescribe meds... you gotta give credit to where it's due... there's a level of loyalty to the initial motivation in getting into this field, to improve the mental health of pts, you just can't simply ignore that.


Maybe compared to other professions, but they are among the poorest paid physicians.

not correct, peds, family are among the least well paid, psychiatry gets paid well, even over internal... child psychiatrists--huge demand get very lucrative salaries. If you are comparing it to derm or surg, then it's another story, but then again, that's a given... check out the psychiatry forum and you'll see


FMGs are attracted to psychiatry because they can get into psychiatry residencies, not because they want to be psychiatrists. They can get in because psychiatry isn't lucrative/prestigious enough for medical students... well, there aren't the right incentives to meet the demand.

I'm leaving this one alone...

In psychology it's the opposite. Psychiatrists are the de facto leaders in mental health, so for a psychologist to become more like a psychiatrist increases income and prestige. But it creates a kind of professional that is essentially identical to the psychiatrist of 50 years ago... which is what bothers me. If psychologists are becoming psychiatrists (honestly), then what does it mean to be a psychologist? Why even have two professions if it's going to end up as one?

a medical psychologist is a subspetialty within the field of psychology, incorporating research knowledge, applying psychological treatment, and having medications as ONE of the tools for treatment. A psychiatrist, generally only does med management, often in 5-15 min sessions, one session per month (sometimes, one in every two months). Psychiatry is not the "de facto leaders in mental health" in reality, they are perceived to be that way only because they have an M.D. after their name. In fact, the legal system views psychologists and psychiatrists on equal stance, it's written that way in the law.

Well, that doesn't make any sense. If PCPs prescribe 85% of psychiatric medication, then they have a lot of experience... As for consulting psychologists... why not? It can't hurt, but if anything it seems like a case of the blind leading the blind... Unless you mean they are consulting these psychopharm psychologists...

consulting with a psychologist who has formally or informal training in psychopharm... on many occassions, psychologists are often informally managing their patient's medications already.


Well it's because it's hard to train a psychiatrist... it takes 8 years of post-graduate study, and it offers relatively few financial benefits. The shortage is based on economics... That's also the reason for this great interest in psychologists prescribing... because for them it puts them above their peers in income and prestige.

it takes psychologist approximately 6-8 years for doctoral training, it takes approximately two additional years for psychopharm training and one additional year of supervised experience. That's on top of the clinical experience gathered after receiving a license as a psychologist. If you are looking at years of experience, psychologist are more than competitive. The shortage in psychiatry is not due to money, it's already established, and your working psychiatrists will tell you that, perhaps, you don't know that since you are still a student. I'm not knocking on that btw, I'm questioning your exposure to the field. It's mostly due to stigma from medicine, psychiatry is perceived to not be real medical.

Well, next to psychiatrists, they get the most training in psychopharmacology. I think something like a third of their patients have psychiatric comorbidities... that's a lot... well that statistic was something I heard from an FP, not anything real... I don't know what the real statistic is.

again, wrong, pcp's do not get a whole lot of formal psychopharm training... that's also established, talk to your psychiatry fellow... and pcp's will tell you that too... just because they are prescribing 70-85% of the psychotropics does not mean that they have adequate experience, that means that they are prescribing a whole lot of psych meds innapropriately... one line of thought is that this is one of the reasons why we have a crap load of little kids on psychostims, abusers of psychostims, benzo's, hypnotics, etc. PCP's don't have the adequate diagnostic knowlege to appropriately prescribe psychotropics.


This plan makes the psychologist identical to a psychiatrist... not a "triage psychiatrist". It's like saying that EM docs should have the option to take on patients on a permanent basis in the ER... Well, it's not the advertised purpose of an EM doc.

you are not making the right comparison here... medical psychologists would be in the right position to make the appropriate referral if available... continuity of care is imparative in mental health services, medical d/o does not have the same critical need... someone else can easily pick up where another left off... in mental health service, a therapeutic relationship is imperative. A split system is counterintuitive in this matter. In fact, it may work against it... e.g., treatment of panic attacks, if a pt is undergoing panic control training and is inavertendly prescribed a benzo, the panic control training will not work... if the patient were to be treated by one provider, this would not happen.

Well, unless it's resulting in changing the medication, then these insights have no medical value... Which psychological insights would result in changing someone's medication?

yes, changing med regiment would be part of the appropriate steps in treatment.

But psych patients already receive combination treatment, if they can afford it. The question is why should it be from the same person necessarily, and would this offset the smaller medical knowledge base that these practitioners would have?[/QUOTE]

for the most part, combined approach has consistently been shown to be better than a single modality in treatment. Receiving it from the same person would facilitate treatment in many forms, accesability, financially, more importantly effective integration of medications with psychological treatment. This is not really happening in a split system. This was even difficult when I worked, literally next door to a psychiatrist. He saw 4-5 pts/ hour, didn't even have time to pee. I was managing most of my pts. medications informally with his supervision, that's how bad the system is in reality. It may all sound good as you are studying it but it doesn't work in the real world.

 

[Therapist4Chnge]

Maybe compared to other professions, but they are among the poorest paid physicians.

not correct, peds, family are among the least well paid, psychiatry gets paid well, even over internal... child psychiatrists--huge demand get very lucrative salaries. If you are comparing it to derm or surg, then it's another story, but then again, that's a given... check out the psychiatry forum and you'll see

Forensic jobs in CA....routinely $300k. Moonlighting in need areas.....$$. 'Sazi's thread on jobs is a good one to check out to get an idea of salaries out there.

a medical psychologist is a sub-specialty within the field of psychology, incorporating research knowledge, applying psychological treatment, and having medications as ONE of the tools for treatment.

This is how I view it going forward. Just like neuropsychologists utilize specific tools and assessments for their work, medical psychologists utilize their training as one tool (of many) to approach an issue. I think being well grounded in psych theory, research, and assessment make the medical psychologist the ideal candidate to incorporate additional training, which allows another 'tool in the tool box'. Many times people fall into the, "all I have is a hammer, so everything must be a nail" scenario. I believe medical psychologists are uniquely qualified to be much less likely to fall into this trap, and much more likely to utilize the best approach....as they have a wide range of tools to select from.

...pcp's do not get a whole lot of formal psychopharm training... that's also established, talk to your psychiatry fellow... and pcp's will tell you that too... just because they are prescribing 70-85% of the psychotropics does not mean that they have adequate experience, that means that they are prescribing a whole lot of psych meds....

That was my point for bring up the prescribing breakdown numbers.

for the most part, combined approach has consistently been shown to be better than a single modality in treatment. Receiving it from the same person would facilitate treatment in many forms, accessibility, financially, more importantly effective integration of medications with psychological treatment.

Not only does it provide more consistency, but it can address some compliance issues. Compliance is a huge issue in the mental health field, and being able to have regular visits AND have a solid therapeutic relationship can contribute to better compliance. One of the complaints I constantly hear is that patients have is how long they have to wait to see their prescriber, only to leave 5 minutes later and not 'feel' like they were heard or understood (the video above did a nice job of illustrating that point). Unfortunately current prescribers don't have time they should spend with their patients. A medical psychologist would be able to have more contact with their patients (because they see them weekly, not bi-monthly), and would be able to address some of their concerns.

 

[edieb]

RxP Video:

http://youtube.com/watch?v=6cGS1wLxUyY&feature=related

 

[deuist]

That video is ridiculous! First the mother blames Missouri law, claiming that the psychologist cannot prescribe the necessary pills to keep her daughter going. Then, within 30 seconds she states that her daughter should not be on medication because she would get an adverse reaction to antidepressants. I'm confused. Does the mother wanted her to have medication or not?

She then goes on to ask, "Why can't these doctors spend an hour with her like her psychologist?" The answer is because you're not willing to pay for their time! Spend more money and you'll get an hour-long consultation. Don't blame your doctor for crappy insurance reimbursements.

I reject the statement that the psychologist would know best as to which medications should be given. Correct me if I'm wrong, but I didn't know that clinical psychologists were learning pharmacology during graduate school.

Let's call this video what it is: it's propaganda of the worst kind. It tries to blame doctors by claiming that "people are getting hurt." I would love to see psychologists gain prescription rights, but this video is certainly not the way to do it.

 

[Therapist4Chnge]

I reject the statement that the psychologist would know best as to which medications should be given. Correct me if I'm wrong, but I didn't know that clinical psychologists were learning pharmacology during graduate school.

It is covered, though I consider the APA required coursework to be weak (one of my big pet peeves); I can't speak to additional courses that could be taken at various programs.

Blaming physicians isn't the way to go either. Insurance companies are tightening the screws and made a system that can't provide fully for the people in it. There are long waits, and something needs to be done....though I'd like to see the AMA and APA come together and work out something realistic that both sides can deal with. (pipe dream....I know).

To be honest, I'd rather have a consulting setup anyway with someone else, as I think anyone on an island can be problematic if they don't have others to discuss cases with. Unfortunately I think it will have to go state to state. Missouri has a need, and I hope they can get the legislation done.

 

[doctorpsych]

That video is ridiculous! First the mother blames Missouri law, claiming that the psychologist cannot prescribe the necessary pills to keep her daughter going. Then, within 30 seconds she states that her daughter should not be on medication because she would get an adverse reaction to antidepressants. I'm confused. Does the mother wanted her to have medication or not?

She then goes on to ask, "Why can't these doctors spend an hour with her like her psychologist?" The answer is because you're not willing to pay for their time! Spend more money and you'll get an hour-long consultation. Don't blame your doctor for crappy insurance reimbursements.

I reject the statement that the psychologist would know best as to which medications should be given. Correct me if I'm wrong, but I didn't know that clinical psychologists were learning pharmacology during graduate school.

Let's call this video what it is: it's propaganda of the worst kind. It tries to blame doctors by claiming that "people are getting hurt." I would love to see psychologists gain prescription rights, but this video is certainly not the way to do it.

you are right, it did seemed PRish to me... and not necessarily the best one... it does attempt to touch on some important issues though, albeit it's ineffectiveness IMHO. But check this out, this study was recently published regarding the state of mental health care in MN. It has relevance to the intended message of the video. Details can be found at: www.mnhealthplans.org. Summary:
97% of children on antidepressants do not receive the follow-up care recommended by the FDA; and >80% ofpsychotropics prescribed in MN are by primary care physicians.

 

[edieb]

Here is another one:

http://youtube.com/watch?v=rv-ylqwf23I

 

[Therapist4Chnge]

While I was poking around for the D.O.D. findings, I came across this 2003 article from the APA Monitor:

-----------------------------------------------------------------------
DoD-trained psychologists have been paving the way so that others might one day prescribe.
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial] BY MELISSA DITTMANN
..[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial] More than a decade has passed since a pilot program through the Department of Defense (DoD) placed 10 military psychologists in a new role--that of prescribing. These 10 graduates of the Psychopharmacology Demonstration Project (PDP) underwent intensive postdoctoral training in a congressionally authorized program that trained licensed DoD psychologists to prescribe psychotropic medications. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Their actions were monitored and scrutinized over the course of the project. Since the program ended in 1997, studies have made one thing clear: The psychologists did--and those who remain in the military continue to--prescribe psychotropic medications safely and effectively. ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Today, they serve as a model for a possible future generation of prescribing psychologists. In March 2002, New Mexico became the first state in the country to enact a law allowing psychologists who receive postdoctoral training to prescribe psychotropic medications. That training includes, among other elements, 450 hours of coursework, a 400-hour, 100-patient practicum under the supervision of a physician and a requirement to pass a national certification exam. ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]As of December, 12 other states intend to introduce similar legislation in 2003. And that's welcome news to many of the PDP graduates, who agree that being able to prescribe offers numerous benefits, such as greater collaboration with medical colleagues and convenience for patients who no longer have to consult a third party for medication. But, they maintain, prescriptive authority should be reserved for psychologists who have undergone postdoctoral training in psychopharmacology. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Of those who originally received the training, seven are still prescribing as part of their regular practice in the military. The Monitor recently talked with them to see how they have used their prescriptive authority and how this new role has changed them: ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Elaine Orabona Mantell ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Prior to psychopharmacology training, Lt. Col. Elaine Orabona Mantell, PhD, did not receive many referrals for patients with severe psychotic or substance abuse conditions. She spent little time on psychiatric inpatient units working, for example, with bipolar patients in their active manic phases. But after graduating from PDP in 1996, Mantell says an "evolution" has taken place in her career. ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]"Prescribing has broadened the types of patients referred to me," she says. "These experiences have changed my approach to patients insofar as I can never go back to seeing them as purely a cognitive-behavioral challenge because prescribing requires vigilance in observing their physical as well as psychological symptoms." ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]After graduating from PDP, Mantell worked at Keesler Medical Center in Biloxi, Miss., serving as chief of the outpatient psychiatric unit and later chief of the inpatient psychiatric unit. Mantell is now the director of the Behavioral Health, Drug Demand Reduction and Child and Substance Abuse Clinics at Seymour Johnson Air Force Base in North Carolina. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]As a prescribing psychologist, Mantell says the pharmacological element tends to take up more of the session when she works with complicated patients--such as those requiring frequent medication adjustments. So it "requires greater creativity/dedication managing the cognitive behavioral aspect of care," Mantell says. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Having prescriptive authority helps in treating patients with, for example, such neurovegetative symptoms as low energy or poor appetite. Mantell has found patients often benefit from receiving medication for initial relief of symptoms so then they are better apt to implement behavioral strategies to help in the long run. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]"Prescribing is a good tool to have available, but I have found that it does not sustain if individuals do not modify their thoughts and behaviors," she explains. Mantell says she sees a bright future for psychologists with this authority. With greater psychopharmacology training, psychologists--with their research skills and preparation to look at psychosocial influences--are uniquely positioned to reinterpret some of the medical phenomena and recommendations that often remain unchallenged in psychiatry, she adds. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]John Sexton ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]After graduating from the first PDP class in 1994, Cmdr. John Sexton, PhD, began working at the Naval Medical Center in Portsmouth, Va. Sexton became the nation's first independent prescribing psychologist when he wrote his first prescription on Feb. 10, 1995. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Since that time, he says the new role has changed him as a psychologist--for the better. "I think back to how it was before I was able to prescribe, and I can see that I was not as attuned to the biological aspects of some of the psychological disturbances I was seeing," Sexton says. Psychologists need to be more aware of this biological component, he adds, especially since one in seven mental health clinic patients has some form of physical abnormality, such as a thyroid malfunction, that is causing a psychiatric disturbance. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]In 1997, Sexton became the head of the mental health department at the Naval Hospital in Camp Pendleton, Calif., where he managed psychiatrists and psychologists. He now runs the substance abuse rehabilitation department at Navy Medical Center in San Diego, overseeing 70 professionals and para-professionals and continues to serve as a prescribing psychologist. At Camp Pendleton, Sexton saw more than 1,000 new patients in three years and during that time wrote prescriptions to 13 percent of those patients. On the other hand, Sexton found that two of the psychiatrists prescribed to 61 percent and 68 percent of their patients, all of whom had been randomly assigned to the psychiatrists and Sexton. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]"The majority of patients in mental health can be treated without psychotropic medications," Sexton says. "If the patient does not have a serious mental illness, I lead with talk therapy and then add medication if needed. That's different than what psychiatrists usually do--where patients most of the time walk out with a prescription....Very few have the luxury of doing psychotherapy." ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Prescribing psychologists could offer a tremendous benefit to underserved populations, such as rural or inner-city areas where psychiatry isn't as accessible, he says. "We are a different breed," Sexton says. "We are trained differently, and I think we are going to practice differently if managed care gives us the opportunity to practice as we like and in a way that is best for patients." ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]James Meredith ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Lt. Col. James Meredith, PhD, also says psychopharmacology training has made him become more aware of the biological component when treating patients. Since graduating from the DoD program in 1995, he says, "I definitely have learned more--and feel more effective--at treating physical problems that could compound or cause emotional problems." ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Meredith is a life-skills flight commander at Hickam Air Force Base in Honolulu. In this role, he manages and directs the Life Skills Support Center, and family advocacy, substance abuse and drug demand reduction programs. Meredith believes that his psychopharmacology training has enhanced his ability as a psychologist to treat clients. "Most importantly, it has given me more control over the treatment," he explains. "When you divide up treatment and have to share it with another provider, you are not able to provide the same emphasis when you are doing it all yourself." ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]But the true benefit is to the patient, Meredith says. "I am able to work much more with [the patient] on compliance and adjust the medication to certain levels if needed," he says. Meredith also says he frequently sees patients who have been on medications for many years and is grateful that he can now take them off the medication or decrease their dosage if he sees fit. "And then I can see psychotherapy working," he says. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]After graduating from PDP, Meredith served as deputy program director of the Outpatient Mental Health Clinic at Andrews Air Force Base in Maryland for three years. He then spent two years as a mental health flight commander at Kelly Air Force Base in San Antonio, where he doubled the productivity of outpatient psychotherapy and medication management for outpatient mental health patients. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Meredith says incorporating some form of knowledge on psychotropic medications should become a basic skill for psychologists. "They will then be able to more easily collaborate with a physician that is prescribing medication," he says. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Morgan Sammons ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Cmdr. Morgan Sammons, PhD, says his role as a prescribing psychologist has not changed his approach when treating patients. "All patients still do require psychotherapy," he says. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Since 2000, Sammons has been the head of the multidisciplinary mental health department at the Navy Medical Center in Annapolis, Md. He has worked at a number of sites since he gained prescriptive authority in 1994. In 1998, he worked as the head of the mental health department at the U.S. Naval Hospital in Keflavik, Iceland, where he directed a department that included drug and alcohol programs, early childhood intervention and health promotion. He also served as the clinical director of Andrew Rader Community Mental Health Service in Ft. Myer, Va., where he developed mental health services for a rapidly growing clinic that included psychiatrists, psychologists, social workers and family advocacy professionals. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Sammons says he is encouraged that the PDP psychologists have proven themselves as capable prescribers. "There is no published evidence that any of these psychologists do this in any way less safe or effective," Sammons says. "A traditional medical education is not required to do many of these things." ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]With the proper training, Sammons says other psychologists should be able to follow suit. "Any psychologist who is interested and qualified should be able to receive prescriptive authority," he says. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]However, Sammons says it's important to keep the effort in perspective and realize this is not just a fight for psychologists alone in attaining the right to prescribe. He notes that other professionals--such as nurse practitioners, physician assistants, physical therapists and optometrists--are also looking at ways to expand their practice. "It's part of a dramatic change in health care," Sammons says. "It's nonphysicians expanding the scope of their practice....We are part of this trend. It is not just psychology doing it alone." ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Brian Pfeiffer ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Maj. Brian Pfeiffer, PhD, is no longer alone in New Mexico as a psychologist with prescriptive authority. In New Mexican psychologists' pursuit of prescriptive authority, Pfeiffer proved to be an asset. He testified to the state legislature at several key points about the benefits of psychologists receiving this authority and taught a class on psychopharmacology for psychologists. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]For those who were skeptical of prescribing psychologists, Pfeiffer became a model of the effectiveness and safety of a psychologist with this authority. "[The PDP graduates] were studied at numerous points during and after our training," Pfeiffer says. "Uniformly, we had positive patient outcomes. All the data showed that we worked well with other health-care professionals and that we provided safe and effective treatment to our patients." ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]After graduating from the PDP program in 1996, Pfeiffer was assigned to a hospital at Eglin Air Force Base in Fort Walton Beach, Fla., as a staff psychologist. After his first year there, he was promoted to chief of the outpatient clinic and was also granted admitting privileges to the psychiatric unit. Pfeiffer now is the specialty flight commander at Cannon Air Force Base in New Mexico, where he oversees the mental health department as well as the physical therapy unit. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]He says the PDP program adequately prepared him for writing prescriptions. "But just like any other job, a lot of what you learn is learned by doing," he says. "It's obviously broadened my range of experiences. And I think it's only helped to make me more effective in dealing with patients. But it hasn't changed my approach to patients." ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Pfeiffer continues to adhere to the same biopsychosocial spiritual model he used before going through the PDP program. "It's not just looking at the patient's biology and saying 'It's a chemical imbalance, and that's the problem. Now take a pill,'" Pfeiffer says. As always, he adds, it's important to question if distortions in the patient's thinking or other unhealthy behaviors are part of the problem. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Debra Dunivin ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Lt. Col. Debra Dunivin, PhD, says she joined the PDP in 1997 to find out for herself if expanding psychologists' role to include clinical psychopharmacology would be a good idea for the field. And while she acknowledges that prescribing is not for every psychologist, she says because of the potential benefits a prescribing psychologist can offer, "It is important that some of us undertake the extensive training required to do this well. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]"I had not expected when I entered the PDP that I would want a career in the military," she adds. "But the Army has offered me so many interesting opportunities for professional development that I decided to stay beyond the obligated service time." ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Being able to prescribe has tremendously expanded the scope of services Dunivin says she can provide to patients. She considers herself more of a full-service holistic provider. "I've learned new intervention skills in pharmacotherapy that enable me to treat a wider range of conditions without splitting the treatment among different providers," she says. ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]After graduating from PDP, Dunivin became the chief of outpatient psychology service and a prescribing psychologist at Eisenhower Army Medical Center in Augusta, Ga. She now serves as chief of the department of psychology and the director of training for the Clinical Psychology Residency Program at Walter Reed Army Medical Center in Washington, D.C., where she oversees clinical services and training programs. ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]As a prescribing psychologist at Walter Reed, Dunivin has integrated psychopharmacology with traditional psychological interventions, such as when treating patients with severe panic disorder or obsessive compulsive disorder who might need medication. She is also developing innovative programs, for example, in psycho-oncology and women's health. ...[/SIZE].[/SIZE].

Continued.........

 

[Therapist4Chnge]

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]James Parker ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Cmdr. James Parker, PhD, says he fills a void in rural Yuma, Ariz., where he is the only mental health provider at the Marine Corps Air Station's Naval Medical Clinic, which has a patient base of 10,000. Yuma, an underserved community of about 100,000 with no private psychiatrists, could greatly benefit if the state's psychologists were granted prescriptive authority, says Parker, who graduated in 1996 from PDP. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Parker's aim as a psychologist has always been to provide services to patients more efficiently. Being able to prescribe has helped him to do just that. "I'm not necessarily a quick results person, but with some of these conditions, medication will help attain benefits with people more quickly," he says. "Even if it is as simple as giving them a pill to help them sleep better." ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]He says being able to prescribe has changed him. "It strengthened my belief that biological treatments are very critical but that also an integrative approach is needed," he says. "Using only a biological approach or only a psychological approach misses significant parts of a problem." Parker spends a great deal of time working collaboratively with physicians developing Diagnostic and Statistical Manual axis I and axis III treatments best for patients. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Following graduation from PDP, Parker was assigned to Naval Hospital Bremerton in Washington state, where he served in various roles, including head of the psychology division within the multispecialty inpatient and outpatient mental health department, head of the mental health department, and head of the alcohol rehabilitation and substance abuse department. In April 1999, he began his current job as a clinical psychologist at the Marine Corps Air Station in Yuma. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Although he has not had any bad outcomes from prescribing, Parker, whose practice is 50 percent pharmacotherapy, says he is always aware of the possible reactions medications could have. "I think human beings are much more complex than a physical dimension. I appreciate that more than before," Parker says. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]The other graduates ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Here are updates on the other DoD graduates: ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Anita Brown, PhD, left military service in 1999 and therefore can no longer prescribe. Brown, a 1996 PDP graduate, is president of APA's Div. 55 (American Society for the Advancement of Psychopharmacotherapy and is working to identify and develop a prescription movement in her home state of Virginia. She is chair and associate professor in the psychology department at Hampton University. ...[/SIZE].[/SIZE].

[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Gilbert Seda, PhD, a 1997 PDP graduate, is a third-year medical student at Eastern Virginia Medical School and an adjunct professor in psychopharmacology at Regents University. ...[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]Timothy Duke, PhD, also a 1997 PDP graduate, is attending medical school....[/SIZE].[/SIZE].
[FONT=verdana, sans serif, helvetica, arial][SIZE=+1][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][FONT=verdana, sans serif, helvetica, arial][SIZE=-2][FONT=verdana, sans serif, helvetica, arial]SOURCE: http://www.apa.org/monitor/feb03/prescribers.html
...[/SIZE].[/SIZE].
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[Therapist4Chnge]

Another good article.

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My First Six Months of Life as a Conditional Prescribing Psychologist
by: Elaine S. LeVine

Since February 2005 I have been treating patients from a biopsychosocial model in which I provide psychotherapy, assessment of the need for psychotropic medication and medication management. As a conditional prescribing psychologist, I am supervised for two years by an Internist who I meet twice monthly for two-hour sessions. At the end of two years, my charts will be reviewed, and then I may apply for an independent prescribing psychologist certificate. It has been a long gestational process and birth to become a conditional prescribing psychologist, but unequivocally it has been worth all the effort.

In order to give you a sense of why I am finding my experience as a conditional prescribing psychologist so worthwhile, let me begin by telling you what I saw when I opened my eyes; in other words, the nature of my patient load since I have been prescribing.


Percent of Weekly Patients Seeking Medication Management as well as Psychotherapy

As you can see, upon first receiving my prescriptive authority certificate in February 2005, I was responsible for medication management for a very small percentage of my patients. However, in the last two months, I have been involved in medication management for approximately 30%-40% of my patient load. Although I am clearly too ‘young' at this to make long-term predictions, it is interesting to note that my present prescribing load is very similar to what the Department of Defense Prescribing Psychology graduates have described in their long-term practices, that about 30% of my patients are being treated with psychotropics. An intervening factor that must be considered, however, is that in my relatively small community, many patients and physicians are seeking my services because they know that I am providing both psychotherapy and medication management, and they are looking for that particular specialization. Thus, the nature of the population I am serving seems to be changing.

Table 2 summarizes the characteristics of the twenty-five patients for whom I have been managing psychotropic medication since receiving my conditional prescribing psychologist certificate [click here to see table 2]. One factor of importance, I believe, is that a number of my patients have rather serious concurrent medical conditions. Thus, my initial experiences point to the importance of a prescribing psychologist obtaining extensive training in pathophysiology and treatment of medical disorders.

In my brief life as a prescribing psychologist, I have had a number of opportunities to provide psychotropic care to patients who otherwise had none. For example, patient 2 is a teenage boy for whom I helped determine the diagnosis of Prader Willi broad-spectrum disorder. This patient has classic symptoms of Prader Willi; however, chromosomal testing was inconclusive. His pediatrician and family waited three and half months for an appointment with a child psychiatrist. During their first session, the child psychiatrist saw the young man with his mother for about fifteen minutes. He said that he wanted to request records from the pediatrician and myself before prescribing medication. However, he never followed through. In the meantime, I received my prescribing certificate. In collaboration with the pediatrician, I began prescribing for this patient, and his behavior had improved remarkably. Serious symptoms such as his homicidal threats to others, severe cutting, and inability to get along with peers at school have terminated, and he is evidencing reasonable adjustment at school and at home.

I have also had the opportunity to improve care with patients receiving insufficient care. For example, patient 10 is a young man who was treated for a serious psychotic break subsequent to his drug use. The patient had been hospitalized and was maintained on Zyprexa. However, the side effects of this medication were preventing him from taking a sufficient dose to totally manage his primary symptom of thought broadcasting. His ego alien thoughts about others, that he was sure others could hear, disturbed him greatly. His psychiatrist was in the Midwest, although he had moved to New Mexico, in hopes of attending the University. He was only seeing his psychiatrist every three months for a brief follow-up. From what I could determine, there had been no laboratory tests to assess for possible effects of the psychotropics for over two years. Now that he has been involved in psychotherapy and medication management on a weekly basis with me, the psychotic symptomology is limited to very short time intervals occurring quite infrequently. He feels that he is able to manage these episodes (using psychological techniques such as thought stopping and cognitive behavioral restructuring) and is now holding a job and is back in school.

I believe that becoming a conditional prescribing psychologist has also allowed for more holistic care for many of my patients. Because the patients spend more time with their psychologist than their primary care physician, the psychologist often hears of medical symptoms of which the primary care physician is not aware. As a prescriber in a collaborative relationship with the primary care provider, I maintain frequent and thorough communication with the primary care physician, leading to more effective care of the patient's medical condition. For example, case 20 in Table 2, who described a "leaded feeling" in his legs. Because the patient described many vegetative symptoms associated with his depression, both he and the PCP assumed that the sensation in his legs was associated with the anergy of his depression. However, as we worked through his depression, the physical symptoms in his legs did not abate. In working closely with the PCP, we discovered it to be a side effect of the medication he was taking for his high cholesterol.

Relatedly, my practice as a conditional prescribing psychologist has broadened the knowledge base for myself as well as the primary care physician. Some have wondered how well the collaborative relationship would work. In my first six months of life with twenty-five patients, I have worked with nine primary care physicians. Some of them, I had known previously; a number I have never met. They have universally been cooperative, sharing results of laboratory tests and accepting my recommendations for intervention. Several have commented that they see a difference in how a psychologist approaches psychopharmacology than other prescribers. Specifically, they are very interested in the more cautious, systematic way we develop a diagnosis. Others have expressed their appreciation that I seem to use a minimum of medication and rely upon less invasive means to assist patients when possible.

One more advantage of being a prescribing psychologist is that it has been a strong motivation for using a best practice model. Our New Mexico prescribing psychologist act and enabling regulations require prescribing psychologists to maintain extensive documentation of our work. In addition, the desire to make certain that a medication is really helping a patient prompts a psychologist to seek very systematic information about our patients before intervening and to seek very objective data about whether our intervention procedures are working. I have developed a number of forms to help me integrate all the data that I need to make a competent diagnosis from a biopsychosocial model and in order to monitor change. (Those forms are available on the internet through the Southwestern Institute for the Advancement of Psychotherapy, of which I am the Training Director. On that website, www.siaprxp.com, there is a link to the practicum handbook, which includes all the forms developed so far). Over these first six months, I have been developing a rhythm of when to talk about the medication, how to move into the psychotherapy session, how to make sure we cover all of the issues of side effects as well as effects of the medication. This rhythm depends upon making sure that the patient is an equal partner in the entire process of psychotherapy and medication management. I think that as we evolve as a specialization, we will work together to systematize the information that we need and the best methods for conducting a biopsychosocial approach to care.

I am growing every day. Quite frankly, there were times those first few weeks where I felt quite awkward at this new skill I am allowed to use. I wondered if I started the medication a little bit too low, and so the patient got frustrated waiting for an effect, or maybe a bit too high, and felt that, had I started lower, side effects would have been less. Perhaps, the most stressful incident was with one of my first patients for whom I prescribed with a diagnosis of Bipolar II, depressive state primary. It seemed to me the most appropriate medication for his diagnosis was Lamictal. Lamictal, as you may know, has a black box warning for a Stevens Johnson's Syndrome, which is evidenced by a rash. I had looked over the patient's medical forms, talked about his condition, and the benefits and side effects of the medication. I was ready to hand him a prescription when, once more, we went over the side effects, and I mentioned the importance of his telling me if he had a rash. At that point, he pulled up his pant leg and demonstrated the worst case of psoriasis I have ever seen, which he had not mentioned on the medical forms. Would I be able to separate a Stevens Johnson rash from this psoriasis? I did not risk it. I tore up the prescription, and we started again with a trial of Depakote, which has been quite successful for the patient. Because of a strong therapeutic relationship with the patient, this awkward moment did not have troubling consequences for the therapy process.

There are new challenges to face as a prescriber: insurance carriers that will not pay for the best medication, medications that would be excellent for a condition but are too costly for a patient, and the constant challenge of trying to stay abreast of this vast body of literature and to read through and to separate pharmaceutical advertising from rigorous scientific investigation. Clearly, the authority to prescribe medication really is a privilege, and it is a profound responsibility. It is a privilege because the medications can be of major assistance to our patients; but it is a profound responsibility, also, when a patient puts his or her physical as well as their psychological well being in my hands. For example, I never before had a patient say, that I can remember, that a sentence I told them kept them up all night; but I have had a patient already tell me that with a minute amount of medication, they could not sleep all night. I wonder, was my diagnosis right? Should I stop the medication; decrease it; encourage the patient to try a little longer? Are the side effects too great? I am sure as I have more experience, these questions will be easier to answer, but I do not think that the privilege or the responsibility will diminish.

I have heard some say that prescriptive authority is not rocket science, but I am beginning to wonder. The more I learn of the micro world of the neuron, the complexities of neurotransmission, and how these drugs work, it begins to seem as intricate and as profound as the discussion of quantum mechanics and universes folding in on themselves. It is estimated that there are 100 billion neurons in the brain, as many as there are stars in most galaxies. Each neuron can have as many as 10,000 links to others, making, perhaps, one quadrillion linkages in all. The human brain, its charged impulses, and the thoughts and feelings created are worthy of our most thorough, interdisciplinary care . . . a challenge that psychologists are capable and willing to address.

I am hopeful that, over time, our patients, proponents, as well as those opposed to RxP efforts, will view each prescribing psychologist as filling a valuable, professional niche and will embrace psychology's professional growth as it enters the arena of primary care, prevention, and treatment.

SOURCE: http://www.division42.org/MembersArea/IPfiles/Winter06/practitioner/prescribing.php

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[Therapist4Chnge]

Might as well post another article.

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Patient Safety Forum: Should Psychologists Have Prescribing Authority?

Deanna F. Yates, Ph.D. Jack G. Wiggins, Ph.D. , Jeremy A. Lazarus, M.D. , James H. Scully, Jr., M.D. , Michelle Riba, M.D.

While the issue of psychologist prescribing has become a highly politicized debate, the real issues are the need for—and competence of—prescribing psychologists.

Regarding need, the acute shortage of psychiatrists has been well established by both the Surgeon General's Report on Mental Health (1) and the President's New Freedom Commission on Mental Health (2). In part because of this shortage, more than 70 percent of all psychotropic medications are prescribed by nonpsychiatric physicians, typically after six weeks' training in psychiatry.

Psychologists are among the most highly trained doctoral-level providers of mental health services. In addition, psychologists who seek prescribing authority are required to receive a minimum of three years of medical training before they are allowed to prescribe. Furthermore, as part of the existing legislation for prescribing authority, prescribing psychologists are required to collaborate with their patient's primary care physician. The combined extensive mental health and medical training—with ongoing physician collaboration once the psychologists start prescribing—suggests that psychologists are potentially more competent than primary care physicians.

Psychiatry contends that if psychologists want to prescribe they should go to medical school. The issue should not be where psychologists receive their training but, rather, whether psychologists can be trained to safely prescribe psychotropic medications.

The research that we do have demonstrates that prescribing psychologists can be taught to safely prescribe psychotropic medications. Between 1991 and 1997, the Department of Defense trained ten psychologists to prescribe through what is known as the Psychopharmacology Demonstration Project (PDP). Several reviews of the PDP have been conducted, although only a few objective studies have been done. Although the military is unique in terms of cost and need issue, the general consensus is that psychologists in the Department of Defense are safe prescribers.

A study by the American College of Neuropsychopharmacology (3) showed that the "graduates of the PDP filled critical needs, and they performed with excellence wherever they served." According to the U.S. General Accounting Office, "Without exception, these supervisors—all psychiatrists—stated that the graduates' quality of care was good." (4). Although the demonstration project has ended, psychologists continue to train and prescribe in the military.

What about the safety of other nonphysician prescribers? A growing number of nonphysician groups are prescribing, such as dentists, optometrists, podiatrists, and nurse practitioners. The few studies in existence suggest outcomes that are at least equivalent to those of physicians (5). If safety were being compromised by these providers, one could assume that there would have been a public outcry by now, and physician interest groups would certainly not have remained silent on the issue (5). There is no evidence that nonphysician prescribers are less safe than physician prescribers.

Some argue that psychologists receive insufficient medical training to safely prescribe. Here two issues must be considered: the educational requirements for practicing psychology, and the added training required in order that a psychologist be able to prescribe. Psychologists' training begins with a four-year undergraduate degree, as is the case with physicians. Although these degrees generally do not focus on the biological sciences of a premedical education, many psychology students choose electives in the biological sciences, such as biology and chemistry.

After psychologists complete their undergraduate degree, they complete a minimum of seven additional years of training. During the first five years, psychologists take courses in human development and behavior, normal and abnormal psychology, psychological assessment, and statistics. In addition, they take courses in the anatomy and physiology of the brain and the evaluation, diagnosis, and treatment of brain disorders. During these five years, psychologists also have hundreds of hours of practice in which they evaluate, diagnose, and treat patients with mental disorders in both outpatient and inpatient settings. Finally, psychologists complete two yearlong residencies during which they treat patients who have mental disorders, generally in medical settings under the supervision of psychologists and physicians. After completing a national examination, psychologists can apply for licensure.

Prescribing psychologists receive an additional three years of training. The first two years include courses in biochemistry, anatomy and physiology, pathophysiology, neuroanatomy, neurochemistry, neurophysiology, pharmacology, psychopharmacology, physical and neurologic examinations, interpretation of laboratory results, and ethics in prescribing (6). At the same time, they continue to work with patients and use their new knowledge in discussing medications with their patients and other professionals. These two years of course work are then followed by a year of residency during which prescribing psychologists apply what they have learned to their patients while being supervised by a physician. The prescribing psychologist makes recommendations for medication and conducts medication follow-ups with his or her patients, while the medication prescriptions are written by a physician. Prescribing psychologists must then pass a national examination before applying for certification to prescribe. This is far from a "simple psychopharmacology course" or "a crash course in prescribing," as has been suggested by opponents of psychologist prescribing.

Prescribing psychologists receive their medical training not in medical school, but within their own discipline, just as dentists, podiatrists, optometrists, and nurse practitioners do. The only difference is that prescribing psychologists are already licensed and practicing before they even begin their medical training. By the time prescribing psychologists are allowed to prescribe, they have ten years of training postcollege in the treatment of mental disorders. Primary care physicians, on the other hand, while having more general medical training, typically have a four- to eight-week clerkship in psychiatry during medical school. Given this comparison, it would seem likely that prescribing psychologists would be better at prescribing psychoactive medications to their patients than would other nonpsychiatric physicians.

Legislation that will allow qualified psychologists to prescribe has now been passed in two states—New Mexico and Louisiana. In both states, safeguards for the public have been built into the legislation. In New Mexico, after training, a prescribing psychologist will receive a conditional certificate allowing him or her to prescribe for two years under the supervision of a physician. Provided that the prescribing psychologist completes this two-year period successfully and passes a national examination, he or she could then apply for a certificate that would allow nonsupervised prescribing. Even then, prescribing psychologists must collaborate with their patients' primary care physicians. In Louisiana, after a prescribing psychologist has completed the training and passed the national examination, he or she will be certified to prescribe independently; but, as in New Mexico, he or she will be required to confer with the patient's primary care physician on the prescribing psychologist's choice of medications.

In addition to the comprehensive training and legislative safeguards, it should be noted that psychologists see their patients more regularly than do most other providers. As a typical standard of practice, primary care physicians do not follow up with patients as regularly as psychologists do. Psychologists typically see their patients on a weekly or biweekly basis, whereas primary care physicians generally see patients for physical examinations and for treatment of acute medical problems. General practitioners are not in a position to conduct follow-up visits with their patients as regularly as psychologists. Because of the frequent interaction with their patients, and the level of trust and communication inherent in the therapeutic relationship, prescribing psychologists will be in a position to manage medications more efficiently than most physicians. Compared with primary care physicians, psychologists can be expected to more readily address side effects, make appropriate medication changes and adjustments, and monitor the overall efficacy of medication.
In conclusion, the question should not be "Can psychologists safely prescribe?" but rather, "How could they not safely prescribe?"

SOURCE: [SIZE=-1] Psychiatric Services 55:1420-1426, December 2004[/SIZE]
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[Therapist4Chnge]

Useful Citation:

Newman, Russ; Phelps, Randy; Sammons, Morgan T.; Dunivin, Debra Lina; Cullen, Elizabeth A. (2000). Evaluation of the Psychopharmacology Demonstration Project: A retrospective analysis. Professional Psychology: Research and Practice. Dec Vol 31(6) 598-603

Abstract: The U.S. Department of Defense Psychopharmacology Demonstration Project (PDP) to train military psychologists to prescribe psychotropic medications has been one of the most highly scrutinized programs of its kind. This article provides a retrospective analysis of the PDP by examining studies of the project by external sources, including Vector Research, Inc., the U.S. General Accounting Office, and the American College of Neuropsychopharmacology. The authors conclude that the PDP successfully achieved a primary objective for which it was established by demonstrating that licensed psychologists can be trained to provide safe, high-quality pharmacological care. As such, the project serves as a foundation for efforts to include prescription authority in state licensing laws and for the further development of a psychological model for prescribing. (PsycINFO Database Record (c) 2008 APA, all rights reserved)

 

[PsyDr]

Anyone hear anything about how MOPA's Legislative Day went?

 

[edieb]

"Weak Case Against Psychologist Prescribing" story appearing in leading Missouri Newspaper, 4/9/08 Edition

http://www.news-leader.com/apps/pbcs.dll/article?AID=/200804090257/OPINIONS02/804090448

 

[BellaPsyD]

just a quick FYI-

defending my thesis in 2 weeks, but as some of you may remember, I did it on what current med. students (D.O's) think about us gaining RxP and specific referral rates for various drugs, etc.

To completely shorten it up- over 60% SUPPORT it. Seems to be a trend (based on the research I have spent the last year digging up, etc.)

Anyways, thought it'd be nice to share it!

 

[Therapist4Chnge]

just a quick FYI-

defending my thesis in 2 weeks, but as some of you may remember, I did it on what current med. students (D.O's) think about us gaining RxP and specific referral rates for various drugs, etc.

To completely shorten it up- over 60% SUPPORT it. Seems to be a trend (based on the research I have spent the last year digging up, etc.)

Anyways, thought it'd be nice to share it!

Once you get it defended, tweaked and whatnot, I'd love to flip through itt...or at least look at your conclusions....if you don't mind!

 

[BellaPsyD]

of course not! Other than my committee- you're the only one who might ever glance at it, LOL. Defense is April 30th- so a little after that- I'll make sure to contact ya and get your e-mail!

 

[Therapist4Chnge]

[SIZE=-1]therapist4chnge AT studentdoctor.net


[/SIZE]

 

[deleted106747]

Hm. Well, I know I mentioned this before, but if the psychopharm training would be 2 years with the end result of prescribing with the supervision of the MD, why not go to a 2-year PA program? The biggest drawback that I found was that in speaking with a psychiatrist, he explained that the training in psychopharm is relatively short and that one might have to do a lot of research on one's own into the meds. That's fine with me, I've spent a LOT of time doing research and can continue that process!

I was wondering if anyone on here has any thoughts about when would be the best time to do this. Would it be better to work a couple of years and get the license, or to go back to school immediately post internship and then pursue a license as perhaps someone they'd have more incentive to hire due to the PA license? Or would that make them less likely to hire you?

...I wish there was some sort of guidance on all of this. I'm pretty sure I'm going to get the PA degree, but there's very little in the way of resources or guidance out there. It's hard to ask at one's program because you get the feeling that another degree is frowned on - or perhaps that's projection, I dunno.

Anyway, thoughts are most welcome!!!

 

[Therapist4Chnge]

I actually looked into NP and PA programs, and I wasn't wild about the curriculum. What I like about this route is that there is more of a focus on psychotropics, far more than PA and NP programs. I was comparing notes with a friend of mine who went to a pretty good NP program, and they didn't learn nearly as much about pharmacodynamics and phamacokinetics as I would have thought. Obviously this is N=1, but I felt more comfortable about my choice.

Ultimately I'm not going for the training to be a prescriber, though it'd be nice to have that option. I consider it another tool in the toolbox.

 

[deleted106747]

I actually looked into NP and PA programs, and I wasn't wild about the curriculum. What I like about this route is that there is more of a focus on psychotropics, far more than PA and NP programs. I was comparing notes with a friend of mine who went to a pretty good NP program, and they didn't learn nearly as much about pharmacodynamics and phamacokinetics as I would have thought. Obviously this is N=1, but I felt more comfortable about my choice.

Ultimately I'm not going for the training to be a prescriber, though it'd be nice to have that option. I consider it another tool in the toolbox.

Yes, I agree with this. I do wish there was more of a focus on psychotropics but I think that if I spent some time studying them in depth on my own it would be ok. I think your friend is right about it, at least that's what the psychiatrist at my clinic told me as well. I guess I feel that I really want that tool in my toolbox, enough to go for the training - it seems like if a patient could go to one doctor for meds and therapy that would be ideal. Over and over I've heard the frustration from patients about the millions of appointments they have.

 

[deuist]

You have to remember that PA's and NP's are equivalent to technician degrees. There is no way to cram all of that medical knowledge into 2 years.

 

[deleted106747]

You have to remember that PA's and NP's are equivalent to technician degrees. There is no way to cram all of that medical knowledge into 2 years.

Yes, of course. I see myself as primarily a therapist/assessor, but with the ability to prescribe under a physician's authority. Also, since I don't see a clear line between physical and mental illness, I would like to be able to address to some degree the physical stuff that is going on with people as well.

 

[ronin12]

i am reading these posts and keep on getting same buzz words as psychologists can prescribe medicines"safely" "effectively""high quality" 'one stop shop",by going through one year course. it seems people are idealizing the psych patients as completely healthy atheletes. most of psych pts have comorbid medical disorders and list is pretty long. being a psychiatrist you not only treat psychiatric disordes, but also monitor the medical illnesses to intervene appropriately in case of emergency or decompensation . these skills are learnt during med school by rotating over and over to all medical speacialities. psych residency also include mandatory 6 months training of prim care, i.e neurology, medicine, ER etc. drug interaction, effects of psych meds on medical conditions and managing medical ilnesses are daily part of being a psychiatrist. psych pts present with psychiatric symptoms, but ended up at ICU's or medical floors , this happens all the time. how would one be able to identify psychiatric presentation of medical illnesses without going through med school baffles me completely.

 

[Therapist4Chnge]

i am reading these posts and keep on getting same buzz words as psychologists can prescribe medicines"safely" "effectively""high quality" 'one stop shop",by going through one year course.

That is blatantly incorrect, please do not thread crap.

As for the "buzz words", they are based on the DOD research and follow-up work done by current prescribing psychologists.