PsyDRxPnow

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From the American Psychiatric Association

Letters
A Patient's Perspective on Psychologist Prescribing
To the Editor: Contributors to the Patient Safety Forum in the December issue debated the contentious question of psychologist prescribing (1). In the hope that your readers are interested not only in the views of the two "warring factions" but also in those of patients, I am writing to offer my observations as a consumer of psychiatric services for more than 30 years.
A majority of prescriptions for antidepressants and anxiolytics are currently written by internists and general practitioners. These physicians are poorly trained to make initial psychiatric diagnoses and have little time for follow-up assessments. Few can remain current with the deluge of new research information pertaining to the myriad conditions they encounter on a daily basis, such as congestive heart failure, diabetes, dyslipidemia, and autoimmune diseases. Swamped by new information, internists and general practitioners are understandably susceptible to marketing messages from sales representatives hawking the latest minor modification to an antidepressant that is being touted as "an important clinical breakthrough."

Fortunately, serious errors in prescribing are nearly impossible in view of the fact that the similarities between the leading drugs to treat depression and anxiety disorders vastly exceed their relatively trivial differences. Indeed, the most serious treatment errors made by internists and general practitioners in this area are apt to be overlooking the value of psychotherapy or selecting a new branded drug when a generic would do. The homogeneity among these classes of drugs also enormously simplifies prescribing for psychologists. Furthermore, because psychologists are unlikely to be high-volume prescribers, they would attract fewer visits from sales representatives offering "information" and drug samples that may improperly influence treatment selection.

Dr. Scully makes the point that "many nonpsychiatric illnesses cause or worsen psychiatric symptoms ... [including] endocrine disorders, diabetes, malignancies, heart disease, and infections." The implication is that psychologists would likely overlook these problems. I have been treated by six psychiatrists during my years of experiencing depression and anxiety, and none has yet suggested that drug therapy be preceded by a battery of tests to detect any occult illness. These psychiatrists were all board certified; two were from the National Institute of Mental Health, and one was the former medical director of a large psychiatric hospital. Clearly, precious little in the way of medical triaging is being offered in psychiatrists' offices—most likely because it simply is not necessary.

Until there are meaningful clinical differences between drugs used to treat the most common psychiatric disorders, or an accurate way to predict patients' responses to the drugs, psychologists who are well trained in basic psychopharmacology are likely to offer pharmacologic care of equal or higher quality than that offered by general practitioners and internists. Indeed, psychologists' awareness of the added scrutiny that their treatment selections may attract is apt to foster a far more circumspect approach to prescribing—and a willingness to make referrals to specialists—than prevails in the current system.

It is time that professionals set aside their claims about who "cares more" about patients' welfare and instead allow progress in clinical care to supersede petty turf battles.


John S. Ensign, M.P.H.

Footnotes

Mr. Ensign, who lives in Shirley, Massachusetts, was formerly a public health advisor at the U.S. Food and Drug Administration. He is currently employed as an independent pharmaceutical market analyst.

Reference


Should psychologists have prescribing authority? Psychiatric Services 55:1420–1426, 2004
 

OldPsychDoc

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He uses a lot of big words and some compelling personal experience to say roughly what I said in my last post on the subject: that it is unlikely to result in a system significantly riskier than that we have now.

Thanks for sharing it.
 

Anasazi23

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PsyDRxPnow said:
From the American Psychiatric Association

Letters
A Patient's Perspective on Psychologist Prescribing
To the Editor: Contributors to the Patient Safety Forum in the December issue debated the contentious question of psychologist prescribing (1). In the hope that your readers are interested not only in the views of the two "warring factions" but also in those of patients, I am writing to offer my observations as a consumer of psychiatric services for more than 30 years.
Keep in mind that the most influential and important psychiatric patient representative group, National alliance for the mentally ill, are adamantly OPPOSED to psychologists' prescribing. They cite that they, as a group, do not advocate for undereducated prescribers - that this contributes to the problem.

A majority of prescriptions for antidepressants and anxiolytics are currently written by internists and general practitioners. These physicians are poorly trained to make initial psychiatric diagnoses and have little time for follow-up assessments.
People keep assuming that GPs are "poorly trained" to make these assessments and to write prescriptions. The implications of this are not supported by research. While they are unarguably poorly trained compared to psychiatrists, they are infinately more trained than any psychologist will be to administer medications in general. These physicians know how and when to consult psychiatry. Do psychologists? Arguably not. They don't recognize key symptom clusters and disease states. This is not their training, and will continue to be ignorant of these issues despite the weekend training courses.


Few can remain current with the deluge of new research information pertaining to the myriad conditions they encounter on a daily basis, such as congestive heart failure, diabetes, dyslipidemia, and autoimmune diseases.
Says who?

Swamped by new information, internists and general practitioners are understandably susceptible to marketing messages from sales representatives hawking the latest minor modification to an antidepressant that is being touted as "an important clinical breakthrough."
This is a tired argument posed by psychologists...again, unsupported. For mindless fools who have no interest in American medicine, the ins and outs of the pharmaceutical industry and marketing ploys, who try to practice in the US, this may be true. For the rest of the physicians in practice, drug reps are supplemental information, and act as a springboard for their own independant investigation. Psychiatrists here will likely remember the geodon Qtc issue and the warring marketing ploys by opposing company reps. We all made our decisions about how concerned we should be after reading the independant articles. Psychologists will not be prepared to assess their comfort level in administering cardiac-sensitive medications such as these. They haven't attended medical school.

By the way, what evidence is there that psychologists will somehow be immune to drug rep influence? A profession traditionally treated like crap by the healthcare system will arguably be much more "wooed" by a good looking drug rep giving them free plastic clocks or continuing ed ski trips.


Fortunately, serious errors in prescribing are nearly impossible in view of the fact that the similarities between the leading drugs to treat depression and anxiety disorders vastly exceed their relatively trivial differences.
Wow....okay then.

Indeed, the most serious treatment errors made by internists and general practitioners in this area are apt to be overlooking the value of psychotherapy or selecting a new branded drug when a generic would do. The homogeneity among these classes of drugs also enormously simplifies prescribing for psychologists.
This simply makes no sense. Because drug classes are similar, prescribing is simplified? This is asinine. Because inotropic agents have similar mechanisms of action, why not let psychologists prescribe them too? After all, it is therefore "simplified." Jeezzz......

Furthermore, because psychologists are unlikely to be high-volume prescribers, they would attract fewer visits from sales representatives offering "information" and drug samples that may improperly influence treatment selection.
Why should psychologists be less volume prescribers? Operating on another assumption that they will do more therapy and less prescribing? I again make the challenge to the AMA as I did on another thread....FIND the psychologists that prescribe outside their scope, (antibiotics, inappropriate refills of medications, etc) and revoke their licenses. They WILL do it, it WILL happen, and it is absolutely unethical and unacceptable.

Dr. Scully makes the point that "many nonpsychiatric illnesses cause or worsen psychiatric symptoms ... [including] endocrine disorders, diabetes, malignancies, heart disease, and infections." The implication is that psychologists would likely overlook these problems. I have been treated by six psychiatrists during my years of experiencing depression and anxiety, and none has yet suggested that drug therapy be preceded by a battery of tests to detect any occult illness. These psychiatrists were all board certified; two were from the National Institute of Mental Health, and one was the former medical director of a large psychiatric hospital. Clearly, precious little in the way of medical triaging is being offered in psychiatrists' offices—most likely because it simply is not necessary.
Anecdotal stories are not persuasive. "My uncle Jeff smoked since he was a kid and lived to be 99." Meaningless......

Every patient that is admitted to my service gets "a battery of tests."
Will psychologists order these batteries of tests to look for "occult illness?" Their training dictates piss poor understanding of these lab results....how does this solve the problem?

Until there are meaningful clinical differences between drugs used to treat the most common psychiatric disorders, or an accurate way to predict patients' responses to the drugs, psychologists who are well trained in basic psychopharmacology are likely to offer pharmacologic care of equal or higher quality than that offered by general practitioners and internists. Indeed, psychologists' awareness of the added scrutiny that their treatment selections may attract is apt to foster a far more circumspect approach to prescribing—and a willingness to make referrals to specialists—than prevails in the current system.
I fear more the cowboy psychologist that finally thinks they are a "real doctor" because they get a sphygmomanometer on ebay and listen to a cardiac sound .wav file on the internet, thinking they can look cool walking to the bagel shop with a stethescope around their neck and get the respect they've been yearning for.

By the way, the original author needs to understand the difference between drug type and drug class.

It is time that professionals set aside their claims about who "cares more" about patients' welfare and instead allow progress in clinical care to supersede petty turf battles.


John S. Ensign, M.P.H.
The American healthcare system is crumbling. This is evidenced by myriad changes in malpractice insurance premiums, lawsuit awards, managed care restrictions, and the like. This is simply one more shortsighted short cut that does little to help the essential problem, and creates a lower standard of care by definition. Does progress in clinical care mean giving a prescription pad to every profession that demands it? Why not to teachers who take weekend courses in ADHD so they can have quieter classrooms? Seriously...why not? Because they don't have a phd?

Psychology itself is in a last-ditch effort to salvage its sinking ship. The reimbursement rates comparable to masters' clinicians are worrisome to them, while the plethora of questionable quality PsyD students with their insurmountable debt load flooding the market poses other problems. Some feel that PsyD psychologists represent a lower standard of care for clinical psychology. How is it a wise idea to give these people Rx pads? The states instituting this give no restriction to PhDs, it's ANYONE with a clinical psych doctorate, including school psychologists who are 15 years removed from school and have never seen a schizophrenic in their lives....scary stuff. Their perpetuated lie made to legislators concerning "access to underserved" is just that...a lie. I also recommend that when studies show no psychologists flocking to the poor impoverished outskirts of New Mexico, the privilage be revoked, since it was billed as a precipitant of this fabricated need.

The worst part of this whole thing is the inability to properly study the outcomes that psychologists will purport. Simply detailing adverse effect rates misses the point. There are countless other subtleties involved in prescribing that are very difficult to quantify.