It always pains me to read the latest news about how psychologists are making a new push to gain prescription privileges, state by state. Last year, psychologists attempts to gain prescription privileges was shot down in nine different states and approved in none.
Despite the …
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I agree that it really does not appear to be enough of an educational requirement, and cetainly not enough, in my opinion, of supervised practice, to be allowed such an important award of privilege.
However, I think many of those years that a psychiatrist spends in medical school hardly relate to the needs of those suffering poor mental health. And a general practictioner, an MD, has the privilege to prescribe the same drugs yet they in general know little about them. I’m appalled that a nurse practitoner can prescribe, and even more flabergasted that a physician’s assistant can also. (No offense to the great nurses and PA’s out there, but no one is qualified without specialty training in the first place.)
Why the upset over allowing psychologists such privilege? We all know the amount of time that the other professionals spend with the patient. Surely even the supervised physician’s assistants, once comfortably settled into the whims of the doctors, are left pretty much on their own. The psychiatrist rarely spends more than 15 minutes with a patient. Certainly the psychologist who meets more often and often for a much longer period of time, is more capable of assessing needs and catching adverse effects of a drug? In fact, I suspect they already are behind most changes that a psychiatrist makes, by alerting either the patient or the psychiatrist to behavior that might prove a medicine change of some sort?
And now, given that research says the antidepressants’ positive effects are mainly driven by the placebo effect, what’s to worry? (Even MDs can be confused by off-label uses of psychotropic meds.) Licensed doctors have been prescribing them (ADs) for a very long time, not realizing they are somewhat bogus. Maybe that’s because they didn’t spend enough time listening to their patients complain how the drugs weren’t working. That’s something of which I doubt the average psychologist could be accused.
drjean
When I worked in the prison system, listening to inmates begging for meds was one of the basic facts of life. Being able to slough them off, er, I mean refer them to the psychiatrist was a great time saver for me. Psychologists don’t need the headaches (not to mention the potential malpractice suits).
Maybe it would be easier and result in better trained practitioners if they just offered more training to MD generalists in psychiatric prescribing. Then more family medicine doctors and internists could prescribe psychoactive drugs from a stronger base of knowledge and training. Lots of MD generalists have specific areas of expertise (my PCP has additional training in orthopedics and sports medicine), so why not just encourage more training in psychiatry and pharmacology for this group?
I think that before psychiatrists start launching attacks, and making statements like “the professional field of clinical psychology believes its graduate school training in behavior and psychology somehow makes it special,” they should take a long look at their selves. Psychiatrists routinely prescribe medications to children without knowledge of possible developmental side effects. I personally know of a psychiatrist that prescribes Risperdol to three and four year old children. While working with adolescents within the justice system, many of the youth I am in contact with are on 4-5 different medications. Again, long term side effects of these medications, when taken alone or in combination with several different medications, are unknown. I also have experience in psychological testing. The place I worked afforded me the benefit of seeing the people I was working with on a daily basis, for up to 2-3 weeks, in varying environments. I administered a variety of tests and often met several times with the individual and their family before making a diagnosis. Yet, when the person was scheduled to see the psychiatrist, they spent an average of 10 minutes with the psychiatrist and without doubt would return with a diagnosis of bipolar and several prescriptions. My greatest fear is not psychologists prescribing medications that have harmful interactions. Instead, my greatest fear is that psychologists will start to spend 10-15 minutes with clients and start prescribing all sorts of medications without a clear understanding of the person and his/her context.
Psychologists believe they can change the model of reimbursement because they are the more well-rounded mental health professional, once they obtain prescription privileges. It is a belief based in ideals, rather than business or economics.
Once prescribing psychologists get a taste of the medication reimbursement schedule (as opposed to their constant fights for reimbursement for psychotherapy services rendered), I have my doubts whether those ideals will hold up. It comes down to simply economics at that point — the more medication appointments you see, the more “easy” money you make. Like many psychiatrists, they’ll end up filling their schedule with as many as possible, and see just a handful of patients a week for therapy.
My other concern is simply one of adequate training. I’m not sure 1 or 2 years’ worth of training really is adequate to capture the knowledge of the human body, its systems, and all of the drug-drug interactions that occur with all of those different diseases, conditions and ailments. I know of no other route that allows for prescribing privileges so quickly (I was surprised to learn how much education and training both physician assistants and nurse practitioners undergo…)
PS – Jack, I’m not a psychiatrist — my training was as a psychologist. Hence the doctorate of psychology that I hold.
I’m concerned about the inadequate training. But I’m also concerned about the medicalization of mental disorder. One thing psychology had going for it was the bio-social aspect that is sorely lacking in much of the psychiatric interventions.
Speaking from a mental patients point of view, I would like to say that I have visited with both a psychiatrist and several psychologists. I, and my psychiatrist, finally decided that I was doing much better receiving both therapy and medication management from my psychiatrist alone. I could never imagine my psychologists prescribing me with medications. Most of the time, I honest didn’t even feel they were listening to me. I realize my situation is unique, because most people aren’t able to find a psychiatrist to treat them and to manage their medications, but I don’t see the need or understand the reasoning behind allowing psychologists to handle the medication management for mental disorders. (I also do not think that general practitioners should be allowed to treat mental illness.)
The comments made in this blog entry are uninformed. Obviously, Dr. Grohol has not investigated all graduate training programs in psychology. In addition, 2 years of graduate training (on top of the 7 graduate training years most psychologists have) is 2 years of concentrated study in psychopharmacology: I do not believe Dr. Grohol could find even one physician of any type (not even psychiatrists) who have 2 exclusive years of graduate work in psychopharmacology. It seems Dr. Grohol is more supportive of “physician assistants” prescribing. PA’s are NURSES with LESS TRAINING than psychologists and certainly do not have 2 years of graduate study in psychopharmacology! The debate about psychologists prescribing should not be based in prejudicial rhetoric such as Dr. Grohol’s. It seems Dr. Grohol (PsyD) in commenting he hopes any study will not be done by psycholgists has a very low opinion for some unknown reason regarding psychologists – and that would include himself. Perhaps Dr. Grohols’ attitude difficulties and low opinion of abilities lie not with psychologists in general, but with himself.
Dr. Grohol makes some excellent points about aspects of the economics of prescribing by psychologists. He might have gone further to discuss the impact of the cost of training in psychopharmacology upon funding for traditional areas of psychology. In the zero-sum game of program finances, every dollar spent on training to prescribe is a dollar less spent on training in social, cognitive, and developmental psychology, psychotherapy, research, etc. The impact of this shift of resources is very likely to force psychology to shift its identity from generic, research-based attempts to understand and relieve human distress to a monofocus on psychopharmacology. There is no reason to believe that psychology will be more resilient in resisting this pressure than psychiatry which has sadly narrowed its focus in this way. That leads to two questions: Do we really want to redefine our profession as a bargain-basement vehicle for the distribution of drugs that have often been irresponsibly promoted by pharmaceutical companies many of whose research flaws and marketing malice are now very well documented?
And do we want to narrow the range of options offered to patients seeking mental health services by predisposing psychologists to offer some (not all, due to inevitable licensing restrictions) drugs when non-biological methods have shown increasingly well-documented positive outcomes? While the economic incentive merits consideration, I hope that psychologists will give greater weight to the ethical (e.g. psychologists will not have training comparable to that of traditional prescribing professions) and philosophical implications of the pursuit of prescription authority. We have done so much to promote human well-being and I regard RxP as a diversion that will significantly detract from our ability to continue this priceless tradtion.
The notion that psychologists are greedy because they want the right to prescribe medication is absurd. Psychiatrists are the ones who rather write out medication orders instead of spending much valued time counseling the patient. It takes ten minutes to write a med-order, but it takes an hour every week to get down to what the problem REALLY IS.
The insurance companies are to blame for this huge mess in mental health too. They rather pay for the medication that costs ten bucks, than for real counseling that a clinical psychologist can provide for a hundred dollars a session. That’s why there are GP’s, nurse practitioners and PA’s prescribing high powered medication who have no knowledge of potential side effects (ie treatment of depression with antidepressants being a huge reason for the increase of suicides).
MD’s (yes, psychiatrists included) and other traditional medication prescribers should not have the ability to give out medication like candy after a ten minute session. Psychologists are the ones who have spent at least four years in intensive clinical training, able to detect the mental and behavioral problems that a person is suffering from…and they know that THIS PROCESS TAKES TIME, NOT A COUPLE OF MINUTES.
I believe that Dr. Grohol is out of touch with the field of Psychology and should reflect on the direction that insurance companies and General Practitioners have taken this country. Pills are not panaceas, however, giving psychologists the tool to prescribe medication will give them autonomy from the greedy and elitist field of psychiatry. The combination of pills and qualified CBT have the best empirically proven track record.
I hope that nobody else takes your meaningless word, Dr. Grohol. The field of Psychology deserves more respect, and people like you only weaken it. (Mass media does enough as it is, why weaken it further?)
“PA’s are NURSES with LESS TRAINING than psychologists and certainly do not have 2 years of graduate study in psychopharmacology!”
Wrong and wrong.
PA’s are almost never nurses; more likely to be former psych techs, radiology techs, physical therapy techs, etc. Most nurses opt for a nurse practitioner program rather than a PA program.
Nurse Practitioner of Psych programs are specialized programs and have intensive focus on neuroanatomy/physiology and psychopharmacology. Licensing varies from state to state, but the states I’m familiar with don’t grant licensure until a NP has fulfilled 4000 hours of clinical supervision and passed a psychopharmacology examination.
Most NP programs nationwide are also moving from masters level to doctorate within the next few years and will allow further specialization and preparation.
Nurse practitioners have full prescriptive authority and function usefully in nearly every medical specialty. They have a deeper background in anatomy and physiology and a more general experience in medicine, drug-drug interactions, and polypharmacy than the majority of psychologists.
Discounting their contribution or capacity in psychology is just a prejudiced, uninformed, knee-jerk reaction from somoene trying to protect their turf. It reminds me very much of the psychiatrists who snub you psychologists.
There is no question, in my mind, that psychologists should have a limited prescriptive authority and should have training available to that end. And there is no question that our current reimbursement models have caused enormous problems in the way that patients are diagnosed and treated.
But please don’t get ahead of yourself in making ill-informed criticisms of other specialists.
Psychologists who prefer collaboration with prescribers rather than prescription privileges for psychologists might be interested in joining Psychologists Opposed to Prescription Privileges for Psychologists (POPPP). More information, including an annotated bibliography detailing why psychologists should not prescribe (given the inadequacy of the APA training model for prescribing) is available at http://www.poppp.org.
After some research that is readily accessible on the internet, I find there are a lot of things missing in this blog. While searching for mental health help for a 17 year old, I came to learn a lot about the various mental health disciplines. Psychologists were willing to figure out what was wrong and work with our MD’s to find the right meds. Psychiatrists came to snap decisions based on their own theories of mental illness and prescribed meds that made the child worse. I’ll take a psychologist anyday. The most amazing thing in the article is the pay disparity between psychologists and psychiatrists. Despite the greater time in specialized mental health training and the greater diversity of skills, Psychologists make nearly $100,000 less? That simply is not right. In addition, Nurse Practitioners with less education and less specialization make more than psychologists! While I do not doubt that most psychiatrists are competent, psychologists have a better understanding of mental health issues and a wider range of interventions to offer. If they are willing to go through another two years of training, plus another year of supervised practice, and pass a rigorous national exam, why not give them prescriptive authority? They have been competently prescribing in the military for decades and in two other states without incident.
Nurse practitioners and physician’s assistants might be more likely to order real lab tests before prescribing psych drugs. These psychologist prescribing bills only allow a psychologist to prescribe psych drugs! I say check what a patient is eating and digesting (check the poop). Order a test for Metallothionein levels, an Immunoglobulin Panel, B vitamin levels, acetylcholine levels, Antigliadin IgG antibody levels. Proceed from there if any are not within the normal parameters. The Standard American Diet is woefully inadequate, and cannot indefinitely maintain a healthy mind or a healthy body. By the way, the Department of Defense Pilot Program trained 10 psychologists from 1991 to 1997 at a cost of $600,000 per psychologist (7 still serving active military personnel on military bases) – and never prescribed for children, the elderly or those with chronic health problems. So the prescribing psychologists in Louisiana and New Mexico are in uncharted territory.
Dr. Grohol,
How many Psychiatrists actually meet with their patients for more than 15 minutes?
I will go ahead and answer that question for you, since we cannot have a dialogue.
The answer is 10%.
That means that 90% of these “highly trained” professionals are prescribing without taking the time to rule out other medical, psychosocial, or environmental causes of the presenting symptoms.
This is how it is done in America at this time.
I have lost a family member because an irresponsible MD prescribed and refilled medication for a person who was an alcoholic. That is tantamount to handing a loaded gun to a baby.
Do you have a better suggestion? The APA seems ok with granting prescription privileges, why not you? Should we let Psychiatrists continue to kill people, then settle through insurance companies, while they collect fat paychecks and laugh?
This shortage was created by the AMA. We need to put the responsibility for each death upon them. Make them accountable for the lack of providers. Make them find a solution, and stop trying to block those who are trying to circumvent or repair the current system.
You are narrow minded, and I can tell that you have no knowledge of the number of malpractice suits that are settled each day.
You should do your homework, because you would change your mind if you knew how bad things really are.
Do you really think that Psychiatrists are actually following a plan? I have interviewed several and I can tell you that many do not follow a treatment plan. I spoke to a Psychiatrist that was clearly incompetent the other day. She actually said: “I don’t care if this medication blows out his liver, he is unstable”.
I said, well maybe we should try therapy and parenting skills training first, because he is only 6. She said: “You don’t know what you are talking about, and I am the Doctor”.
So what we have here is a power play. This is just politics man. Politics = Personal Interest. How is that good for the public?
Pull your head out man.
Give me a break, “concerned therapist”! If you are so concerned that psychiatrists irresponsibly medicate, which I agree too sizeable a percentage do, your solution is have people with NO medical training become pseudo-pharmacologists, fairly much with the agenda to make more money the driving force to this interest? Yes, the problem is there is not enough of a focus on patients being in psychotherapy first, but until providers band together and FORCE insurers to appropriately reimburse for therapy interventions, and by credible therapists, mind you, the quick fix is in, buddy!
Hmm, it seems the responsible psychologists I have met in my travels are opposed to becoming pharmacologists, because, and this is their own rebuttals mind you, it will only drive up their malpractice, decrease the access for therapy, and put their field at risk for less qualified people to try to access those skills psychologists do best, like psychological testing for example.
Careful what you wish for. You complain how bad psychiatrists do what they are legitimately trained to do, you really think psychologists will do a better job?!
I had a psychologist friend ask me how many kidneys are in the human body. Sorry, but that’s not someone I want prescribing me zoloft.
This is just a matter of supply and demand. Insurance companies will do better to pay one psychologist to both prescribe and do psychotherapy than a nurse practitioner and psychologist, or psychiatrist and psychologist to do the same. Also more meds will be prescribed so drug companies will be happy. Who do you think is more powerful; the AMA or Insurance Companies and Drug Companies? Just look at the state of our health care system and you will know – Meds are advertised on TV and Insurance companies dictate treatment options.
With the same person doing both, and/or consulting with a specialized psychiatrist when necessary (like most psychiatrists themselves) care will be more efficient; and again cheaper. The military agrees and has for some time!
Finally, the driving factor in New Mexico and Louisiana was lack of psychiatric care options given its rural population (supply and demand) and I don’t think the presence of specialized Nurse Practitioners changed the result in any way did it?
Psychologists themselves are the biggest stumbling block here – just ask former APA president Dr. Patrick Deleon and/or the author of this article by its tenor.
I don’t think there have been any major scandals in the two states to date and/or in the military re prescription privileges or changes in the way “medical psychologists” practice!
Its coming period.
Not all psychologists are as stupid as some of these people’s friends. And perhaps those people have no right to talk given the fact that they are friends with this idiots. I am a psychology major, and I agree with the idea that psychologists should have the ability to prescribe medication, although I will somewhat agree with this that it could be more. The problem is we want to help these people, and it should be about the patient, not the psychiatrists fearing the loss of money. You people are supposed to be helping patients but you are obviously only concerned about helping your wallets. For ‘professionals’ you are truly sad. And half these people do not understand the idea is we PRACTICE to be able to prescribe its not like psychologists are saying ‘just give us the right’ they are saying, ‘give us the opportunity to learn so we can better help our patients’. Look I have had a psychologist and a psychiatrist (yes I am representative of the psychology majors that have a background of mental illness – that made me want to do psychology) and the psychologist was always there, I barely saw my psychiatrist because time restrictions and massive fees. I would love to have had a psychologist I could see and could prescribe me the medications I needed. And I am sorry to tell you all this, but my psychiatrist messed up my medications several times. Most recently prescribed me cymbalta while I was taking concerta and ultram. To break this down because obviously many psychiatrist do not understand this correlation, there is a disorder called Seretonin Syndrome. The fact is, not all psychiatrists are even good at what they do in regards to prescribing medication, at least psychologists would not be so inclined to just toss a patient on medication without fully evaluating them. You see, psychologists are around patients so much, it will most likely come up in therapy what medications they are taking. With a psychiatrist, well they have no time to figure that out. I agree that without medical background psychologist could make the same mistakes as many psychiatrists before, but there are merits to allowing them to prescribe with proper training. And the training needed, if any one has read anything on it, requires a lot of work with a physician, and if the psychologist does not measure up, they cannot practice. It seems that the argument of psychiatrists are based upon their pockets and ultimately human error, because EVERYONE can make mistakes in regards to prescribing medications. And I say the psychiatrists pockets because people think psychologists want the ability to prescribe for monetary reasons, I am far too early in the game to know about the money to be made, I just assume that it would be costly for a psychologist to get the training because malpractice is not going to happen unless intentional, but with medications psychologists are risking so much more. The idea is, we want to be able to 100% help patients, we recognize in this day and age that medication is crucial for many patients with psychological disorders, and so it is NOT about money, but our desire to help others. Sadly, too many people in this country are far more concerned about their wallets than patients.
Both camps are presenting cogent arguments, when they’re not bemired the others profession. I felt, at times, that I was reliving a petulant sibling rivaling. To the psychiatrist, you over valuing information, and the amount of training needed to prescribe. We live in a day and age where information has become more valuable than the sun and air, to the point where we believe the more information we have, the better chances we can make the right decision. This type of thought has a threshold, and the medical field has surpassed it years ago. Clinical psychology training would need to add a year of physiological studies to the curriculum to qualify for prescription privileges.
Psychologist are the last clinician that spends more than 10 minutes with conscious patients. The time spend should be considered more valuable than any machine, or test, or lab report could ever reveal. Having said that, i believe psychologist, provided sufficient training, would be equally effective and efficient with prescribing as a psychiatrist or internist.
I doubt that you will return to this but I would like to point out what seems to be missing from your writing and what may have been discussed by others that i did not see. the large majority of prescribers of psychotropic medications are primary care physicians. Most of the individuals have only taken a basic rotation in psychiatry and often prescribe meds for conditions that research has shown can be alleviated through therapy (at less risk to the individual experiencing side effects. So when you discuss training perhaps you should consider that aspect. There are some definite concerns that need to be considered about psychologists having prescription privileges but I think you discussion of only one aspect is limited at best.
I have read all of the comments and most of the challenges has come due to the money aspect. The Psychiatrist feel that if Psychologist is able to obtain this priviledge then they will be a fight for patients and demand for them. Most Psychitrist go through four years of medical school and three to four years of residency to become certified as a MD. The MD leanrs a great deal about the biology fo the body and how it works. There is a limit in teaching MDs to actual counsel their patients are trully understand how to evaluate a metal disorder. I have sat in on numerous Psychiatric appointments in which all the doctor mostly focused on was superficial symptoms and not addressing the entire picture of treatment. Psychologist have a lot of schooling and interships, practicums, and additional hours that must be completed to be certified as a Psychologist. The comparison is 2(actual book work), 2(clinical rotations), and 3 or 4(residency) for becoming a psychiatrist. Psychologist 8(masters of psychology, PsyD, masters of pharmacology) and 4(intership, practicum, residency). Evaluating the actual time that it takes to become certified to prescribe medication is faster to go to medical school. There is a sense of change is bad, but in actuality it would be better for the psychoogist to prescribe for the patient safety due to the psychiatrist seeing patient every three months for approximately 15-30 minutes. It becomes a issue of which doctor would you want to go to, one that see you for 30 minutes tops or one that sits and allows you to express concerns, issues, and psychological challenges?
I have read all of the comments and most of the challenges has come due to the money aspect. The Psychiatrist feel that if Psychologist is able to obtain this priviledge then there will be a fight for patients and demand for them. Most Psychitrist go through four years of medical school and three to four years of residency to become certified as a MD. The MD learns a great deal about the biology of the body and how it works. There is a limit in teaching MDs to actually counsel and provide therapy to their patients or trully understand how to evaluate a mental disorder. I have sat in on numerous Psychiatric appointments in which all the doctor mostly focused on was superficial symptoms and not addressing the entire picture of treatment. Psychologist have a lot of schooling and interships, practicums, and additional hours that must be completed to be certified as a Psychologist. The comparison is 2(actual book work), 2(clinical rotations), and 3 or 4(residency) for becoming a psychiatrist. Psychologist 8(masters of psychology, PsyD, masters of pharmacology) and 4(intership, practicum, residency). Evaluating the actual time that it takes to become certified to prescribe medication is faster to go to medical school. There is a sense of change is bad, but in actuality it would be better for the psychologist to prescribe for the patient safety due to the psychiatrist seeing patient every three months for approximately 15-30 minutes. It becomes a issue of which doctor would you want to go to, one that see you for 30 minutes tops or one that sits and allows you to express concerns, issues, and psychological challenges?
I burned out trying to do a pre-med and psych double major, and stuck with psychology only. I was really hoping that the Psy.D programs out there that seemed to have their students doing clinical work early and often in their pursuit of a doctorate would lead to better trained psychotherapists, and I thought those would be very good candidates for additional training to allow supervised prescription privileges.
Why did I want to go this path?
Because I absolutely do NOT think that 15 minutes once a month with a patient is sufficient for a psychiatrist to know just how well the medication is working or whether it needs adjustment. A psychologist who has had additional training would be able to spend the standard 50-minute psychotherapy session once a week, and that would give them far better insight into just how well the medications being prescribed are working.
At the very least, if nothing else, if I were going to model a practice under the current laws, I would have 4-5 psychologists with 1 psychiatrist, so that the therapists could have meetings with the psychiatrist and share notes and be able to give the psychiatrist more insight than he would otherwise have without knowing what was going on in therapy. How many times a depressed/bipolar patient was tearful or exhibited pressured speech during a session, or reported poor sleep, or weight gain, or voices getting louder or quieter.
But is there any reason why a Psy.D could not complete a program similar to the ones that RNs can to become nurse practitioners? Are you against that idea, too, of nurses having prescribing privileges under the supervision of a physician?
And as most people recognize, those who are interested in psychology are generally a little screwed up themselves. Myself, I have recently been diagnosed as Bipolar II (at age 32). I had to go inpatient when my latest bout of depression got severe to get started on the right meds, because no prescribing psychiatrist had openings for at least three months, and I knew that I couldn’t go on feeling that depressed for that long. My therapist is at one clinic, and the one that is finally going to be able to work me in for an appt on July 2nd is in a completely different city. How are they going to communicate with each other so that the psychiatrist is aware of just what is happening in therapy?
Yes, there IS a gap in the care available. We have GPs prescribing antidepressants, when they have very little training at all at how to recognize if the antidepressant is pushing their patient into a hypomanic state (which can happen even if a patient is not actually bipolar). Given that bipolar runs in my family, there was no way I was going to trust a GP to prescribe me the latest and greatest SSRI when I might need a mood stabilizer to go with it.
In my case, my mood is improving greatly with Lamictal and therapy alone, and it’s quite possible if I had just asked my GP for an SSRI that I could have wound up inpatient on the other end of the mood scale. And if you ask any person with Bipolar Disorder, they’ll tell you they’d rather be depressed and still have some insight instead of manic and completely unaware of how messed up their thinking really is. (Some enjoy hypomania, but I don’t personally, because it wasn’t until we went over my history that I saw the times I’d been incredibly productive, personable, and able to get by on 3-4 hours of sleep a night easily really were hypomanic episodes…. there’s no question I have no insight in hypomania either, and insight into my condition is VERY important to me.)
So until a person can get in to see a person actually trained in mental illness who can prescribe without having to wait several months or go inpatient to get immediate care, yes, there IS a care gap, and it needs to be addressed one way or another. More APNs specializing in psychiatry. More PAs who support a main psychiatrist. Or, the far better route in my opinion — give clinical psychologists a pathway to prescription privileges under the supervision of a psychiatrist. They have a far better understanding of mental illness already than a PA does.
I like the idea of getting the additional training necessary for competent prescription privileges for psychologists. Prescription privileges are to help overworked and burdened psychiatrists in the provision of timely and effective service. Collaboration is almost always the best way to treat a patients mental health. This is a new and different idea that is threatening to what are current practices. However its abt what works. In Ontario, there are pretty strict guidelines as to what you can declare as your competence. You need the requisite training and experience and prescription medication is no difference. Danger lies in the extremes.