Question to you all from a psychiatrist to be...

[worriedwell]

I have recently graduated medical school and am entering psychiatry residency. I would like to ask a question and begin a civilized discussion about a hot topic these days: Prescribing rights.

I have yet to become entrenched in the family of psychiatrists who seem to collectively dislike the idea that psychologists will possibly be prescribing medicine in the near future. There are active lobbies against these rights from the psychiatrist side of things. I have opinions as to the pros and cons, but they are still naive and probably subject to some bias as I have such a medically focused background. But I come here to hear some other points of view.

My question: Do you think psychologists should have the authority to prescribe medicine and if so, under what stipulations (if any)? Any elaboration or discussion on the topic is welcome as long as you are willing to be open minded about a discussion as I think that is a good idea and I am really trying to not fall into the traps of just believing what my colleagues say I should believe.

Thanks for the time.

Worriedwell

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[50960]

I am not sure why Paendrag responded to your query in that manner, but being as this topic has been debated ad-nauseaum in both the psychology and psychiatry forums before, your post may have been seen as trolling.
However, I have seen some of your other posts and do not see you as the trolling type. Psychologists do and have been prescribing for years very safely with the proper training. I think most people, including psychiatrists know that this will inevitably be a national phenomenon much as it has been for nursing, optometry etc.. I am truly clueless why psychiatry is so adamantly against this, and quite frankly intimidated by this whole movement. There will always be a need for psychiatrists. A simple truth will remain true even with RxP; psychologists are the best trained to treat the majority of minor, everyday mental problems, whereas psychiatrists are the best trained to treat severe, inpatient mental illness.

 

[worriedwell]

I am not sure why Paendrag responded to your query in that manner.

I was just kidding around.

You very well may be smarter than me...but I doubt it! Anyway, I think I've come to grips with the fact that it should be acceptable for clinical psychologists to prescribe medicine, but I think that it should entail a rigorous added training component. Nurse practictioners go through two more years of training to be able to do this and rightfully so, not to mention their entire training is medically based. My worry is that psychologists will prescribe without understanding medical interactions and also will not refer patients to psychiatrists for medicine and to rule out medical causes for their psychiatric illness. I know that these things are kind of theoretical and in the real world they only constitute a small percentage of cases, but it isn't so clear cut where we draw the line. Should a social worker with a masters degree be allowed to prescribe? They often function largely in a clinical setting of seeing patients and develop a strong understanding of their disease presentation...so why not? Should antipsychotics with very severe medical consequences be prescribed? Should sexual dysfunction drugs or sleep disorder drugs be included? It just gives me a deep down uncomfortable feeling that I can't totally accept and I'm trying to talk out loud to figure out why. The irony is that I don't even think that its because of me being a psychiatrist but rather just me being a physician in general. Call it ego or whatever, but I just completed a horrifyingly rigorous medical school training and now I'm going on to roughly a years worth of internal medicine internship followed by a year of intensive inpatient supervision where in a supervised setting I'm prescribing medicine and seeing the patient respond during the course of the day. Then I do two years of supervised prescribing in an outpatient setting. I realize talking about this to a potentially hostile crowd may not be the right idea but I'm doing it largely because I know that it is inevitable and I want to feel comforted that it is rigorously and thoroughly initiated. I don't need to vent to psychiatrists who still think it might not happen and who start bashing psychologists. That isn't helpful for my own growth on this subject. But anybody who is reasonable has to admit that additional prescribing training needs to be incorporated and given how intense and long my training is (8 years) before I'm allowed to prescribe in an unsupervised setting, I fail to see how psychologists are going to be willing to adequately take on this responsibility without seriously revamping their training style.

Please, bounce ideas off of me, even if you want to argue. But try not to put me down, I'm sensitive.

Best,
worriedwell

 

[Sanman]

My completely unqualified opinion:

Psychologists will tell you that they devote more time to the training of psychological/ psychiatric phenomena that even psychiatrists overall. They can be well trained to prescribe, if given the opportunity, to deal with a limited formulary. Generally, what they mean is that they are well-trained and not getting the pay they deserve, so they want to prescribe and have more oportunity to make money. Other psychologists will say that it is the wrong direction for psychology to go. These are mostly those in academia and those whose pracrices are still thriving for whatever reason.

Psychiatrists will say that it is dangerous and somebody will die because psychologists don't know enough general medicine. They are really afraid that what is happening to therapy with psychologists and MSW's will happen to prescribing if psychologists have the right. Many psychologists have fewer loans and can underbid psychiatrists.

The truth of the matter is that 90% of the reason this is a big deal is because it is a pissing contest over financial security.

Could Psychologists be trained to prescribe if given the right education? I personally believe that they could. Truth be told, the ability to competently prescribe or do anything else is up to the individual. Will a psychologist kill people by prescribing? Yes, but so do psychiatrists. Should psychologists prescribe? Well I'll leave that up to each of you to decide. Personally, I'll have to see how it affects income, malpractice rates, etc. before I could decide. I don't really have much interest in prescribing, however, what is good for my team is goood enough for me.

 

[psychgeek]

Here are my unapologetically biased 2 cents.

Prescription rights for psychologists is the best solution to a problem without any good solutions. Currently there are not enough psychiatrists to meet the demand for medication management and there does not seem to be any reason to think there every will be a sufficient number of psychiatrists again. Even if a relatively small number of psychologists are interested in making medication part of their practice (say 30%), limited prescription rights for psychologists would increase the mental health service system’s capacity to medicate by a huge amount.

Why is this important? Currently the excess demand for medication is being met primarily by family practitioners. Despite the best intentions, these doctors do not have the training or time in a standard office visit to adequately assess and treat mental illness. They rarely follow-up as often as necessary, they frequently omit critical aspects of a standard initial evaluation (like questions about substance use, SI, and screening for past episodes of mania), and they often fail to keep abreast of the most current research involving the drugs they prescribe.

Yes, I do know that prescribing psychotropic medication is complicated, I know there are potentially life-threatening side effects that can result from even relatively uncomplicated cases, and I know psychologists won’t have as in-depth of an understanding of medicine as psychiatrists. However, the danger posed by all of these concerns is far less than the danger posed by inadequately monitored psychopathology. Consider mood disorders alone. The lifetime prevalence of completed suicide among those who suffer from a mood disorder is 15%. What percentage of patients with uncomplicated medical histories die of SSRI side effects? A thousandth of that? A ten-thousandth?

Only the most zealous of prescription rights advocates envision psychologists replacing psychiatrists. Most of those who support prescription rights see psychologists taking over FPs’ role in prescribing psychotropic meds; if it is a low risk prescription, write it and if it isn’t, refer to a psychiatrist. That said, most psychologists are decidedly lukewarm about prescribing drugs themselves. For every psychologist who wants to prescribe meds, there are three or four (like me) who are in favor of it as long as they don’t have to do it. Many are lukewarm about prescription being a part of psychology. I like doing therapy and did not go through all of this crap so that I could be a Lexapro vending machine. I am worried that psychologists run the risk of having their practices and their field dominated by medication management. It wouldn't even be the fun kind since this would be referred out. I know I would ecstatically abandon my support of prescription privileges if someone could come up with another solution, but I haven’t heard one yet.

 

[worriedwell]

thank you sanman and psychgeek...thats what i'm looking for. some great thoughts that are actually helping me understand this better from other perspectives. i agree that it is largely a pissing contest for financial security (what isn't?). In fact, psychiatrists are at the low end of the pay scale for physicians and there is some level of worry that my measly $120,000 salary won't put food on my table when I compare it to a radiologist who makes $350,000 per year. Its silly I know, but when my reference is all these other physicians, this is the mindset I get into, and anything that threatens to make my salary drop even more makes me defensive. Especially when I could have just as easily choose to be a radiologist but I like what psychiatrists do and I think mental health is so important.

And if it turns out that all the poor prescribing that goes on by FPs shifts to psychologists, I'd be thrilled, that is a great point about meds and I hadn't thought about it. However, its easier to get people to go to an FP than it is to a psychologist for stigma issues. Not to mention that one of the most common presenting signs of mental illness is somatization into physical symptoms, thus meaning that FPs aren't going to be out of the loop, ever. Regular monitoring of mental illness is one thing, but that doesn't neccessarily imply that it is the fault of the MD community that this occurs, it is a societal stigma from getting help from the right people. Having the societal infrastructure in place to "monitor" psychopathology is different than prescribing the medicine. Allowing more people to prescribe medicine doesn't linearly translate to more people having their disease "monitored". You still have to get people to the therapist...thats the hard part.

Anyway, keep the thoughts coming...great stuff.

 

[50960]

Thanks for bringing about this discussion worriedwell. This is not hostile territory, and most of us will welcome a good honest discussion of the issues involved. One of my big points on the issue is I am not terribly excited about prescribing although I am in favor of the training and the legislation. If I had the pad today I would be most interested in my ability to "un-prescribe", and to taper unneeded meds properly. FP docs simply do not have the time or resources to do it. I am RxP trained, work in FP clinics in rural areas, and already do what legislation would give me the "right" to do independently. I have a good relationship with the docs, and they allow me the ability to manage my patient's, but the risk is theirs really. Most of the FP/GP docs I know would love RxP to happen so they are not liable for me, and so they don't have to spend the time doing the scut work part of my recommendations (get LiCo3 level, 300 mg wellbutrin may be a bit much for your new 10 year-old patient etc..)!!

 

[sasevan]

I have recently graduated medical school and am entering psychiatry residency. I would like to ask a question and begin a civilized discussion about a hot topic these days: Prescribing rights.

I have yet to become entrenched in the family of psychiatrists who seem to collectively dislike the idea that psychologists will possibly be prescribing medicine in the near future. There are active lobbies against these rights from the psychiatrist side of things. I have opinions as to the pros and cons, but they are still naive and probably subject to some bias as I have such a medically focused background. But I come here to hear some other points of view.

My question: Do you think psychologists should have the authority to prescribe medicine and if so, under what stipulations (if any)? Any elaboration or discussion on the topic is welcome as long as you are willing to be open minded about a discussion as I think that is a good idea and I am really trying to not fall into the traps of just believing what my colleagues say I should believe.

Thanks for the time.

Worriedwell

Hi Worriedwell,
I'm impressed with your open mindedness about this issue.
I'm a clinical psychologist who strongly believes that psych PhD/PsyD should have the option of exercising RxP.
The initial DoD project and the continued safe and effective prescriptive practice of medical psychologists in the armed forces attest to the fact that properly trained psych PhD/PsyD are safe, effective, and ethical psychopharmacotherapists.
Additionally, mid-level providers such as psych NP have demonstrated that a clinician does need to be a psych MD/DO to safely and effectively prescribe psychotropic medications.
Finally, it is arguably non-psych MD/DO who currently prescribe the majority of psychotropics in order to treat the most common psychiatric conditions such as anxiety and mood disorders.
In some cases non-psych MD/DO work collaborative with health psychologists and other clinical psychologists in order to determine the most appropriate psychopharmacotherapeutic treatment.
Consequently, one can see how de jure psych PhD/PsyD in the armed forces (and now in NM and LA) are exercising RxP and how de facto they are doing almost as much in many other places.

Like Psisci said, medical psychologists could serve an important function in becoming the primary psych clinicians for the more common and easy to manage psych conditions while psychiatrists would remain as the specialist psych clinicians for the more uncommon and more complex psych and med/psych conditions.
Of course, there would be exceptions to this model as some medical psychologists would undoubtedly have hospital privileges in inpatient units while some psychiatrists would prefer a private practice limited to an outpatient population.
This is certainly what I would envision as the result of psychologists gaining RxP and something that I would definitely welcome (and BTW I'm saying this not only as a present day psychologist but also as a future psychiatrist-currently I'm completing my second year of pre-med).
Peace.
P.S. Best of luck in your residency years and beyond.

 

[Pterion]

This is a great thread. There have been great points on both sides of the aisle. I think both (all four?) sides can agree that the needs for mental health care, diagnosis, treatment and management are inadequately met by the primary care gatekeepers. Not to criticize them, but as a previous poster pointed out - they are not adequately trained.

Psychgeek noted loyalty to RxP in the absence of other solutions. A clear solution would be changing the mechanics of third party reimbursement that continues to reward the system for remaining broken. Psychologists are specialists, and should be treated as such. This includes compensation. (Same for psychiatrists, I don't mean to leave you out, Worriedwell). A PCP can refer to psychologist, who can determine behavioral management needs. A psychiatrist can manage pharm.

An analogy: a PCP refers to a cardiologist. The cardiologist identifies a problem that requires the intervention of a differently-skilled colleague and refers to the cardiothoracic surgeon. One is not better than the other, they do different things to the same system. The same is (should be) true in mental health. Each is a specialist, each focuses on different interventions.

Regarding expanding care to the untreated, this is theory. Outcome data from LA and NM should enlighten us all on these points. Psychologists are human and will demonstrate that they are no more immune to market forces than psychiatrists.

Having said all that I realize that Paendrag pretty much summed up my thoughts on this. I have yet to see a compelling reason not to make psychologists' current skill set as valuable in terms of reimbursement as their psychiatric cousins.

 

[PublicHealth]

Update on psychologist RxP issues from Psychiatric Times:

http://pn.psychiatryonline.org/cgi/...STINDEX=0&minscore=5000&journalcode=psychnews

http://pn.psychiatryonline.org/cgi/...elevance&resourcetype=1&journalcode=psychnews

http://pn.psychiatryonline.org/cgi/...elevance&resourcetype=1&journalcode=psychnews

http://pn.psychiatryonline.org/cgi/...elevance&resourcetype=1&journalcode=psychnews

http://pn.psychiatryonline.org/cgi/...elevance&resourcetype=1&journalcode=psychnews

http://pn.psychiatryonline.org/cgi/content/full/40/7/8

 

[rpkall]

Random question:

Why can't psychologist prescribing rights be limited by state and region, based on population density and/or established need for additional mental health professionals? Why can't there be supervised prescribing, whereby a psychologist must consult with a psychiatrist in certain instances--and these regulations can be more "lax" in areas of need? Psychologists can consult by phone, e-mail, teleconference, etc, in difficult issues of management (e.g., polypharmacy cases, potential medical causes, questions about interactions or contraindications, etc).

If this movement is driven by a need to get adequate care to those who need it, isn't that a valid option? Why not grant prescribing privileges only in areas where psychiatrists are few and far between?

 

[PublicHealth]

Random question:

Why can't psychologist prescribing rights be limited by state and region, based on population density and/or established need for additional mental health professionals? Why can't there be supervised prescribing, whereby a psychologist must consult with a psychiatrist in certain instances--and these regulations can be more "lax" in areas of need? Psychologists can consult by phone, e-mail, teleconference, etc, in difficult issues of management (e.g., polypharmacy cases, potential medical causes, questions about interactions or contraindications, etc).

If this movement is driven by a need to get adequate care to those who need it, isn't that a valid option? Why not grant prescribing privileges only in areas where psychiatrists are few and far between?

Much of what you described above is what is currently going on or being worked on in New Mexico and Louisiana.

Main issues surrounding psychologist RxP are safety, and adequacy and depth of training.

 

[50960]

I doubt psychology will ever go for laws that give privileges only in certain underserved areas. However, I do think the LA law is a great model as it requires an MD to be involved.

 

[PublicHealth]

Psisci,

Can you share with us your impressions of the Master's program in clinical psychopharmacology that you completed? Do you think the training prepared you to be a safe and effective psychopharmacotherapist? Why or why not? What aspects of the training do you think should be improved, and how might this training be incorporated into existing programs? Any other pros and cons regarding the program would be very helpful, particularly to people like myself who are skeptical or these Master's programs in psychopharmacology, and the adequacy and depth of training that they provide.

 

[PublicHealth]

The war wages on...http://www.ama-assn.org/amednews/2005/05/16/prsa0516.htm

 

[50960]

Certainly, I will write something tomorrow. I think it would also be interesting to hear your thoughts about what I have already written to you. I can handle disagreement, and I think it would be a good discussion.

 

[psychgeek]

Random question:

Why can't psychologist prescribing rights be limited by state and region, based on population density and/or established need for additional mental health professionals? Why can't there be supervised prescribing, whereby a psychologist must consult with a psychiatrist in certain instances--and these regulations can be more "lax" in areas of need? Psychologists can consult by phone, e-mail, teleconference, etc, in difficult issues of management (e.g., polypharmacy cases, potential medical causes, questions about interactions or contraindications, etc).

If this movement is driven by a need to get adequate care to those who need it, isn't that a valid option? Why not grant prescribing privileges only in areas where psychiatrists are few and far between?

Prescribing rights on anything more regional than a state level is really not feasible. The confusion that would result from, say, a county-level limitation would be enormous. You’d run into situations in which a client could pick up a prescription at the corner store but not at the drug store by his job. Online pharmacies would have to ascertain whether or not the address of the prescribing psychologist is congruent with the address of the recipient. Who would pick the qualifying counties and how? I am not even sure a licensing board would have the legal authority to geographically limit the practice of qualified practitioners (particularly if individual counties disagreed with their designation of “adequately served”).

The basic premise is flawed. There are a large number of psychiatrists in Chicago but that certainly does not mean that all populations within Chicago have acceptable access to medication management. Does this mean that psychologists should have the right to prescribe south of 35th street but not on Michigan Ave? Should they have the right to prescribe only to those without insurance? The issue is one of universal capacity, not regional differences in supply. In all areas of the country there are fewer psychiatrists than there are people who need psychiatric medication. Prescribing rights for psychologists is one way of addressing this discrepancy.

IMO, supervised prescribing may have been a viable option before this debate became so acrimonious. Now I do not think psychologists trust that psychiatrists would make a good faith effort to provide fair supervision. In addition, supervised prescribing would cause a bit of confusion regarding liability. It may be safer to make psychologists completely responsible for their clients’ medication and thus encourage referral than to require consultation on dangerous cases and basically encourage psychologists to retain complicated patients.

 

[50960]

In theory and at the level of the APAs there is a big rift between psychology and psychiatry, but on the ground it really is not that bad.
I feel that the current MS programs for RxP are adequate training to properly interact with patient's GP's, and to make medication recommendations etc. I do not feel they are good enough alone to allow prescribing, although they do prepare one better for prescribing than an NP program does. The missing part in the MS is a good, structured period of supervised practice (residency or the like). I make these statements not like most who really have no knowledge of these programs; I have completed one. The biggest shot I see at these programs is that they are "weekend courses". As most trainings that are designed as second career trainings, they do take place on weekends otherwise nobody would be able to go (we are all FT practicing psychologists). Let's discuss???

 

[PublicHealth]

In theory and at the level of the APAs there is a big rift between psychology and psychiatry, but on the ground it really is not that bad.
I feel that the current MS programs for RxP are adequate training to properly interact with patient's GP's, and to make medication recommendations etc. I do not feel they are good enough alone to allow prescribing, although they do prepare one better for prescribing than an NP program does. The missing part in the MS is a good, structured period of supervised practice (residency or the like). I make these statements not like most who really have no knowledge of these programs; I have completed one. The biggest shot I see at these programs is that they are "weekend courses". As most trainings that are designed as second career trainings, they do take place on weekends otherwise nobody would be able to go (we are all FT practicing psychologists). Let's discuss???

Thank you, psisci. As the sole alumnus (to my knowledge) of an MS in clinical psychopharmacology program, your input is tremendously valuable in this discussion. Can you elaborate a bit regarding the following points:

(1) "I do not feel they are good enough alone to allow prescribing, although they do prepare one better for prescribing than an NP program does."

Which aspects of the MS in clinical psychopharmacology training make it superior to NP programs? I was under the impression that the MS programs lacked in basic medical training, which is what the NP programs tend to emphasize.

(2) "The missing part in the MS is a good, structured period of supervised practice (residency or the like)."

What would you recommend? How many hours/years/patients?

 

[50960]

Not adequate for independent prescribing beacause they do not include an applied component, and that is very important to have before you are treating real people. EG. I have seen keppra increase VPA levels and cause hyperammonemia in some folks. No algorithm will tell you that keppra has any need of hepatic enzymes, but it must somehow..I have seen it.

The MS program has all the basic science courses, and a full year of clinical medicine, but unlike NP programs the courses are taught by specialists (PhD, biochem, MD, clinical med) rather than by nurses. It also has alot more focus on neurochemistry, anatomy and pathology. Grads are much better trained to prescribe psychotropics, but I wouldn't want to see them Rxing for antibiotics etc..

 

[deuist]

Anyway, I think I've come to grips with the fact that it should be acceptable for clinical psychologists to prescribe medicine, but I think that it should entail a rigorous added training component.

In the sates that allows psychologists to prescribe meds (e.g., New Mexico), the psychs generally have to undertake 450 hours of post-PhD courses in biology and pharmacy. Then, just like physician's assistants and nursing assistants, they are only allowed to prescribe under the watchful eye of a physician.