thank you for the thoughtful response, that was insightful.
I would also disagree with this comparison. NPs diagnosing and prescribing would be comparable to the midlevels MFTs, LCSWs, and LPPCs for us.
I think a closer comparison would be what if psychologists prescribed as a field. Say we add on additional years of training on top of our already current required study of psychopharmacology, neuroanatomy, biological basis of behavior, etc... How would psychiatry view us integrating that intervention into our psychotherapy practices?
Personally, I am opposed to this and would never do it, even if I could in a limited capacity with things like SSRIs. There are experts like you all who know way more about this than I ever would, because you went to medical school and the following gold standard training channels. But I am curious what you think.
I think the concern from some is that regardless of how well- or ill- trained psychiatrists are, they are ALL able to practice psychotherapy under the law and are seen as experts in it by default and given heightened respect because of the MD.
No problem! It's a reasonable question, but I would not see this as an ok idea. I would MUCH prefer having this conversation in person with people, because there's a lot that can be said about this that I just don't enjoy taking the time to write!
To put it as briefly as I can, legal
regulations applied to medical professions are supposed to be in place to ensure that the interventions applied by the particular profession can be performed with a reasonable assurance of safety
, not necessarily efficacy or mastery. They are determining a reasonable level of entry, not the ceiling. Psychiatric interventions have the very real possibility of causing harm, especially if mismanaged. Psychotherapy, while difficult to master, has a relatively excellent safety profile.
This is why I agree with primary care physicians prescribing medications like SSRI's, but not psychologists (even though psychologists have an obviously superior expertise in certain areas of MH). Let's look at something as seemingly innocuous as the SSRI Prozac. Prozac can lead to hyponatremia with or without SIADH, serotonin syndrome (think of all the patients on 10+ daily medications to look through), upper GI bleeds, etc. You could have a guy on warfarin for AFIB who starts Prozac and a couple of months later has a hemorrhagic stroke (this is a P450 interaction scenario).
A PCP may not be psychologically sophisticated, or even a great listener! But he knows how to screen for and recognize these adverse effects (even manage some). Despite the jokes about psychiatrists not being real doctors, we often take for granted just how ingrained the medical model of interviewing, examining, ruling out medical causes, diagnosing, and treating our patients is within us from medical school and residency. I don't think these things can be picked up in a few extra supplemental training years. If the supplemental training was med school and residency, then sure...you're a doctor now.
The above example was just Prozac! Consider meds like antipsychotics, lithium, SNRI's, TCA's, MAOI's, stimulants, beta-blockers, benzodiazepines, methadone, etc...I know you only said SSRI's, but it's not that simple. This is why I am also against NP's practicing independently. It's not only about their efficacy, it's a matter of patient safety
. In this scenario, I care more about mastery in the sense that they have strong knowledge about what can go wrong.
This was the gist of one of my points in my first post. I think at a minimum psychiatrists are trained enough in residency to ensure to a reasonable degree that they will not cause serious harm to patients from their implementation of the intervention we call "therapy."
I also would personally be against psychologists transitioning to prescribers, because your role is so important to the mental health system. It'd be a shame to lose you guys as psychotherapists.