Why Psychologists Shouldn't PrescribeBeware psychiatrists bearing gifts.

If psychology wants to remain a science based upon the understanding of human behavior — both normal and abnormal — and helping those with the “abnormal” components, it would do well to avoid going down the road of prescription privileges. But perhaps it’s already too late.

We first noted this disturbing trend in 2006, how they were shot down 9 out of 9 times trying to gain prescription privileges in 2007, and why prescription privileges for psychologists will eventually drive psychiatrists out of a job. We also noted that one of the programs setup to help psychologists get prescription training wasn’t a “college” at all.

The fundamental problem with psychologists gaining prescription privileges is the inevitable decline over time in the use of psychotherapy by those same psychologists. This is precisely what happened to psychiatry — they went from the psychotherapy providers of choice, to the medication prescribers of choice. Now it’s hard to find a psychiatrist that even offers psychotherapy.

56 Comments to
Why Psychologists Shouldn’t Prescribe

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  1. Sooooo true! It’s easier for them to write a prescription and get rid of you. I guess we’ll need another form of doctors – psychologists who will really treat your problems, something like bio-psychologists.

  2. I respectfully disagree and would point out that your statements and claims sound more like scare tactics than evidence of a professional downfall. There is plenty of real world data to support the clinical efficacy of prescribing psychologists, as one just has to look at the military, as well as those states that have authorized prescribing psychologists.

    Additionally, there is no sufficient evidence to suggest that it will “dilute psychology’s focus and function.” In those states where psychologists have prescription authority, the practice is well grounded without any indication that psychotherapy is on a decline. On the contrary, the ability to prescribe may actually foster the use of psychotherapy, by causing psychologists to carefully weigh their options, whereas psychotherapy previously may have been taken for granted since “that’s all we do”. A second treatment option (i.e. medications) can put more value into psychotherapy and psychologists, a service and profession that we have undervalued for too long.

    Sure, there may be some psychologists who become “corrupt” and transform into a primarily medication based service. But there are also psychiatrists who provide very good psychotherapy services. The primary treatment focus can go either way, regardless of the profession. It falls more on the person themselves, not the profession.

    I fully support your statement, though, about demonstrating how psychologists can mitigate the impact of money and Big Pharma influence on their practice. Since prescription authority is new to psychologists, and we have seen the damage that it can inflict on other professions, we are in a good position to develop guidelines around interacting with Big Pharma to lessen the chances of negative influence. Additionally, these guidelines should be made universal by the American Psychological Association, possibly through the Ethics Code, to apply to all prescribing psychologists in the United States. It should not be left up to the states to decide.

    “By switching to a heavily prescription-based practice, a psychologist will be able to nearly double their salary.”

    Managed Care, for example, is certainly not going to reimburse twice as much as they are now. Managed Care is not going to reimburse prescribing psychologists at the same rate as a psychiatrist. A prescribing psychologist may be reimbursed more than they are getting now if they bill for medication services in addition to therapy services. However, your statement assumes that psychologists will bill for medication AND therapy services at every visit, which is unlikely. I imagine reimbursement being covered under an “umbrella” service, which includes therapy and/or medications. This amount may be a little more than what psychologists currently receive. However, it could also be less than if the managed care company was reimbursing for a psychiatrist’s service and a psychologist’s service. In the end, managed care pays out less, psychologists can earn a little more, and the tax payers can pay less in health care costs. But to earn twice as much is not likely. For out-of-pocket expenses, though, the story could be a little different. However, it is likely that much of our culture will question the expertise of prescribing psychologists for quite some time. Thus, I do not believe that people will be willing to pay twice as much out-of-pocket to see a prescribing psychologist. The trust and confidence just won’t initially be there. Over time, though, that may change.

    There are close to a handful of states where psychologists have prescription privileges, and having followed them, none of them appear to be having the problems outlined in this article.

    Now maybe it’s because there are too few states and thus too few psychologists to review, but the data so far suggest that prescribing psychologists are a good thing and that the psychotherapy remains as strong as ever.

  3. As a psychiatry resident, I try to tell patients that the medications can only do so much, and that to have lasting change, they need to understand how their past experiences contribute to their current distress, change their maladaptive patterns of behavior, their distorted thinking, etc. I wish I had enough time to do therapy with all of them, but that’s just impossible. And that is why I greatly appreciate having psychologists (and social workers who do psychotherapy) to refer my patients to.

    There are already so many different kinds of psychotherapies out there, with each taking a long time to master. Most clinical psychologists practice only one kind. I think it would strengthen mental health care more for psychologists to learn and integrate more kinds of psychotherapies (such as DBT, IPT, etc.) into their practice, rather than being mired in the world of psychopharmacology.

    I have my own response to Dr. Carlat’s piece on my blog: http://psychiatryfun.blogspot.com

  4. I agree that this is scare tactics. I think that psychologists currently see a minority of patients with mood disorders, and by offering medication, we might be able to get people in the door so that we can follow through with psychotherapy. I don’t think this is a psychiatry/psychology issue; I think most people with mood disorders are treated by their family physician or nurse practitioner who has very little training. By providing psychologists with all the tools, we can work in a more integrated and holistic manner.

    Suggesting that psychologists would suddenly become incompetent is paternalistic.

  5. Dr Wayne… I’m just curious. Psychiatrists found themselves in much the same boat a few decades ago. They had two choices to offer patients: psychotherapy or medication. About 50 years ago, the vast majority of psychiatrists *only* did psychotherapy and prescribed medications “on the side.”

    Gradually, over a *long* period of time, they moved to prescribing more and more often. It happened so slowly and so subtly that I’m not sure there was ever a collective, “Hey, what are we doing here? Why are we abandoning doing psychotherapy?”

    Why are our collective memories so short? Why would psychologists be different in this regard?

    And the most important question — do we have any scientific data to suggest that psychologists would not fall under the same influences psychiatrists did decades ago?

    Managed care and insurance companies reimburse what they reimburse. You don’t have to imagine they’re going to create a new billing code for “integrated care,” unless research shows that “integrated care” results in better or faster patient outcomes.

    Looking at the figures Dr. Carlat quotes in his upcoming book, he charges $75/hour for a med appt. and gets paid about $60. He sees 3 patients an hour (which is generous; some psychiatrists cram in 4/hour). So he makes $180/hour, but after expenses, it’s closer to $130 take home.

    For therapy, he charges on the high side – $150/hour and gets paid $80/$100 by the insurance company (before expenses).

    So compare $80-100 to $180 and yes, you get about double the salary, using the current insurance billing practices and codes.

    Remember, there’s nothing keeping any psychiatrist — including Dr. Carlat — from having a psychotherapy-only or psychotherapy-majority practice (and some psychiatrists do). But the money is too good when you focus on prescribing meds, so they make the conscious decision to pursue the medication path rather than the psychotherapy path.

    If given the choice, certainly one can argue that 2 or 3 decades from now, psychologists won’t follow in the same path as psychiatrists. But call me a pessimist, as I see little reason to keep them from doing so.

    Individual professionals don’t think as some sort of cohesive whole group. They think individually, of their individual gains (or losses).

  6. John:

    Some of my clients who could benefit from medication resist taking it because they have difficulty getting in to see a psychiatrist and don’t have rapport with psychiatrists who only do brief medication management. Others get their psychiatric medication from a primary care physician (PCP) who may not be well trained in fine tuning the prescription for their needs.

    If someone’s psychotherapist is the prescriber, they have a therapeutic alliance and are facilitated in talking through any concerns about medication as an element of their treatment plan. A psychologist would also specialize in fine-tuning psychiatric medication so the prescription would often be more effective with fewer disagreeable side-effects than what they would get from their PCP.

    Also, I believe there’s a shortage of psychiatrists, so people are being underserved and are subject to high costs. Psychiatrists make less than many other medical specialists with greater liability risks and personal stress.

    Psychologists with prescription privileges can help address these deficiencies in current psychiatric practice.

  7. I think that there are several flaws and assumptions in your argument. The first is that a large majority of psychologists who gain prescribing privileges will abandon their extensive clinical training in favor of just prescribing meds in 15 minute intervals. I doubt this will happen. Why would you go through all the trouble of 5 or 6 years of grad school, post-doc fellowships, and further building your practice if you just want to prescribe meds? Why not just go the psychiatrist or even easier psychiatric nurse route to begin with? Furthermore, I would hope that almost every clinical psychology in private practice very much enjoys doing therapy and believes in it. Also, the reimbursement argument is a bit shaky. Many psychologists do not take any insurance and charge their patients $150+ an hour directly. It’s difficult to tell how much insurance companies or patients would reimburse a prescribing psychologist, but I can’t imagine they could get away with doing 4 appts an hour at $75 each! No one is going to pay that out of pocket and insurance companies will likely reimbursement much less because these people who aren’t doctors.

    The way I envision psychologists prescribing meds is that the psychologist will incorporate the med management into the 50-60 minute therapy session and not schedule separate appts. Since most therapists get paid per hour and not for the amount of services rendered, I don’t think this would dramatically change the amount they get reimbursed. Plus, the system is more efficient because the patient only has to go to one appt for both therapy and medication and prescribing therapist already knows what’s going on with the patient.

    I agree though that if the idea of prescribing psychologists catches on, it will psychiatrists some more competition. However, most people DON’T go to psychiatrists. Instead they get them from primary care physicians who likely know little about the disorders they are treating. Psychiatrists typically only treat relatively complex cases and there aren’t enough psychiatrists in the US anyway. I don’t think this will change. Since psychologists will have limits on the kinds of medications they can prescribe and they will lack training in most areas of medical health, psychiatrists will still see complex cases. In fact, they may even be encouraged to start doing therapy again.

  8. As a semi-retired psychiatrist who has been involved in this debate for nearly 20 years, I would respectfully submit that the issue has been muddied by several “red-herring” arguments and linguistic lapses.

    First, the notion that we are merely debating who should “prescribe” is a profound misunderstanding of what pharmacotherapy and medico-legal responsibility entail. It is a bit like asking who should have “cutting” privileges–all physicians, just surgeons, or maybe specially-trained non-physicians?

    In reality, there is no such thing as “prescribing”, apart from a comprehensive understanding of the patient’s physiology; metabolism; co-morbid medical disorders (such as liver dysfunction, thyroid abnormalities, etc.);
    concurrent medications as prescribed by other
    clinicians; drug-drug interactions (including over-the-counter medications); history of drug allergies; and at least a dozen other medical factors that would take too much space to discuss. In short, there is no such thing as “prescribing” apart from the general practice and understanding of medical science.

    The notion that the medical skills required to master these issues can be acquired without extensive medical training is, in my view, both unproven and potentially dangerous to the general public. Generalizations based on a hand-full of psychologists, trained under very carefully-controlled conditions–i.e., in the Department of Defense training program–are not sufficient to overcome this uncertainty, in my view. We would need to evaluate several hundred psychologists, over several years, with careful attention to the kinds of patients they treated; how many of these patients had co-morbid medical illnesses; how many received multiple medications; etc. To my knowledge, we do not have such data.

    Then there are the medico-legal issues: would “prescribing psychologists” be willing to assume full medico-legal responsibility for any adverse drug reactions incurred by their “patients”? Would they be willing and able to manage that well-known, gut-wrenching call at 3 a.m., in which the patient is complaining of a sudden, unexpected side effect of a psychotropic medication? (Psychiatrists routinely handle such calls, and accept the medical and legal responsibility of doing so).

    None of this is to say that physicians in general or psychiatrists in particular have done a stellar job of mastering these fundamental medical issues. As a psychopharmacology consultant for over 20 years, I saw many “nightmare” cases in which the prescribing physician had made very serious errors, engaged in unwarranted polypharmacy, etc. But the solution to this is more rigorous training for primary care and psychiatric physicians–not, in my view, widening the practice of medicine, under the misleading rubric of extending “prescribing privileges”.

    Finally, I, too, lament the decline in the use of psychotherapy by psychiatrists in recent decades; however, many of us still provide this as an integral part of our practice, and many of us strongly advocate increased psychotherapy training during residency. I also believe there is plenty of room for collaborative work between psychologists and psychiatrists, building on and
    appreciating our respective strengths as mental health professionals.

    Ronald Pies MD

    Disclosure: Dr. Pies is now engaged in full-time writing, editing, and teaching; he no longer sees patients in clinical practice and has no personal affiliations with any pharmaceutical companies. He is Editor-in-Chief of Psychiatric Times, where a full disclosure statement may be found. He is also Professor of Psychiatry at SUNY Upstate Medical University; and Clinical Professor of Psychiatry, Tufts University School of Medicine.

    • I just think hands down (I see it everyday -and- I am on the front lines of who needs good MH care– and I’m not talking about private practice, the prison system, or SSI patients)… I see patients getting poor and inadequate) MH/ Behavioral Heath care everyday. I believe that a realistic way to fix this is to grant Rx privileges to doctoral level psych docs (this is one way to solve the problem, not the only way mind you). PhD/ PsyD psychologists need to bridge “gap” / the psychology-medical divide for the survival of mental health treatment. As you note, you have spent many consultations undoing poor work done in all facets of those with Rx privileges/ and MH treatment. Ok, understood, and acknowledged. I just wish we could have a realistic debate about the issues presented here, because time and time again, I see MDs, NPs, and PAs, giving inadequate MH treatment for medication and not checking labs, lithum levels, interaction effects, etc. (not psychiatrists generally but I have routinely dealt with a psychiatrist or 2 getting in over their heads with psychotherapy/ EMDR/ CBT, etc. when not properly trained). I think that that psychologists with Rx or the concept implemented appropriately can fix some of these issues and I also believe that if psychologists don’t bridge the gap with Rx privileges/ or medical psychology (the gap with GP MDs/ as well as psychiatrist)– expect the field of BOTH psychiatry and psychology (to suffer) and possibly go the way of dinosaur as larger systemic issues will push more-and-more on GPs, PCMs, PAs, NPs, and even OTs. I don’t buy your argument about the recommended training being insufficient for Rx Psych Docs. NM, LA, and the DOD has had quite a bit of success with Rx psych docs… And, In line with thinking for arguments sake– I could make a sufficient argument for psychologists to assert that psychiatrists at this point (not the past), but here in the present should/ and are not properly trained to do BH treatment at all and if they do it, the patient outcomes dangerously negative (it can be done easily, but personally, I think it’s a silly argument, but trust me if psychologists had a strong lobby backed by billions of dollars, don’t put it past them, they would pursue this). Again, I don’t think that the Rx psych doc concept is the is the final answer, but I do think rx for doctoral level psychologists would help MH patients and the MH treatment in general; and in the long run, our field/ we all gain. I see most of the arguments on psychiatry’s end –seem to be hidden attempts at protecting pay and services. Not that psychologists are guilt free in this debate either — pushing concepts like access to care issues and cheaper costs (that was not the DOD finding actually it was expensive to train psych’s in this; but I think Rx for psych docs is ultimately cheaper at the individual psychologist level, because most of the psych docs (wanting to do this) would probable fit the bill for this training. I am saddened about the dying/ duel/ symbiotic relationship between psychiatry and psychology, and I think Rx for psych docs will only help this field and our patients. I am sorry, I don’t think psychiatry is the future, nor is purely psychology (and if psychologists are not careful the degree will revert back to a purely research/ academic degree, which means patients wanting the best care will suffer)– Also, if I didn’t work everyday on the cutting edge in this field providing patient care, I don’t think I would understand this… I do not accept that psych docs would not have appropriate training with the recommended Rx curriculum, asserting this point, I would go so far as to say that old guard psychologist as well as psychiatrists who don’t support this want to protect money/ services/ and craft, and not concerned with getting patients the best care they deserve. And psychiatry be warned: if you fight psychology rx privileges to the end, you will be setting in place the real eventual end of psychiatry. No MH patients will benefit from that.

  9. Dr Grohol, thank you for covering this topic here. It is a gray issue, but you have to wonder why there is such polarization by those who benefit from yes or no answers alone.

    Take a poll of not only psychiatrists, but average therapists, those being psychologists/social workers/other licensed and accredited trained therapists of other disciplines, and ask them a few questions:

    1. If not per the term biopsychosocial, what paradigm do you operate on that is not biologically oriented as the primary intervention?
    2. Do you offer therapy as open ended in the beginning, or is it session limited until proven otherwise?
    3. If not able to prescribe, when if ever do you offer the idea of accessing medication in the treatment process?
    4. What do you tell people you do not treat how to pursue mental health care who are in need of it?

    Note not yes or no questions, for the most part.

    And watch, in my opinion, the stammering, change of topic, or frank rationalization of the majority of our peers these days in basically saying “better living through chemistry” and “most mental illness is a biological disorder.”

    Hey, I’ve seen the numbers grow these past 10 years. It is reflective of the adage, “tell the lie enough and it becomes the truth.”

    By the way, Dr Pies, thank you for your disclaimer at the end of your comment. And, since you are not in the trenches as a provider, although you were, think about this question to you.

    When you leave the field, do you really think like a player or just get comfortable as an observer, because you are safe? You really think that having been there means you are fully thinking as an active participant?

    Few retirees stay in the game. And let’s be honest, you won’t jump back in clinically of any significant quantity of your time! And maybe you shouldn’t, you paid your dues.

  10. Gary — I completely agree with you and in this, both Dr. Carlat (and I suspect, most practitioners no matter what their profession) and myself are in agreement. An integrated, single point of care is the preferred, ideal modality. How we get there is an open question.

    Under the current reimbursement system, it doesn’t mater who the professional is, the behavioral economics of the situation are simple and clear — they reinforce for the prescribing of medications over the prescribing of psychotherapy. Otherwise psychiatrists would still be doing a lot more psychotherapy. Until the reimbursement system changes in the U.S., the economics and reinforcements of that system will not change.

    Lynn — I can only say I wish I shared your optimism of human motivations. While I agree little is likely to change in the next 10 years, my concern is much longer-term for the profession. Again, nobody in psychiatry woke up one day and suddenly said, “Hey, we’re going to be the go-to profession for meds-only.” It happened so gradually and subtly, it’s only now when psychiatrists like Dr. Carlat are suggesting there may be something wrong with it.

    Dr Pies reflects many of the realistic, down-to-earth concerns I would echo. While much of the medical training of psychiatrists is perhaps superfluous, the legal system hasn’t yet caught up with that idea. It may be a few more decades before it does. Not being trained as a medical doctor, I have no idea whether 2 years of psychpharm and basic physiology would be sufficient to prescribe psychiatric drugs. Dr Carlat feels like it would be. He definitely feels like most of the 4 years he spent in medical school was a waste of time for what he does in his day to day practice. From an outsider’s POV, I’d have to agree.

    The ideal answer may be somewhere inbetween. Dr Carlat suggests grafting more psychological training onto psychiatry. I, coming from a psychological education, might suggest the opposite — that one could train good prescribers by incorporating the 2 year prescribers training into the existing 4-year didactic training of psychologists. But without changing how services are reimbursed, I would never suggest such a thing as I believe it would decimate the profession of clinical psychology as it did psychiatry.

    Dr Hassman brings up the inevitable — why do such issues always need to be so polarizing? From my limited POV, I suspect it’s because the people arguing them have so much invested in them. You typically don’t find psychiatrists like Dr Carlat saying things like he’s saying, because docs have so much invested in the current system — the way it is. That’s why I’m sure many docs never complained about the lapses of ethics they saw in their colleagues, because they themselves benefited from similar lapses (e.g., in the research world with the cozy pharma relationships).

    Same is true with me. I was trained in a clinical psychology model, so obviously I have some skin in the game for that model. But I’m also someone who thinks the current model of a half dozen (or more!) professionals treating mental concerns through psychotherapy isn’t ideal.

    The idealistic part of me sees the benefits of a single professional in an integrated care model offering their integrated care services — medication + psychotherapy in a thoughtful manner — to their patients. But the pragmatist in me sees that this can never come to pass when you have two seriously entrenched professional associations who have too much to lose to talk to one another about combining forces. And the entrenched training programs who would all have something to lose if such a model were to come to pass. And the lack of any support in changing the reimbursement model in the U.S., since there’s no financial incentive to do so.

    It’s a fascinating discussion to me. But I also see the roads to heck paved with good intentions… so while I see my colleagues’ good intentions in pursuing the integrative model, I see no evidence to support they will be any different when the model actually goes “mainstream” in psychology. As Dr Pies notes, you can’t really tell much based upon a few dozen psychologists scattered throughout the country under fairly carefully controlled conditions.

  11. Well said, Ronald. I will go only to a psychopharmacologist for medication management. I want someone with the deeper medical expertise that you describe. For counseling, I see a wonderful psychologist. My opinion is that the division of labor means that each person can really specialize. I’ve benefited from having both a psychiatrist and psychologist who can talk to each other when needed. Two heads are better than one.

  12. Dr. Grohol,

    Yes, psychiatrists of past had two choices: medications or therapy. However, their therapy choice was initially limited mainly to psychoanalysis, which psychiatrists chose to never fully adopted. Back then (since techniques have advanced since then), given the amount of time needed for psychoanalysis to effect change, it is not suprising that psychiatrists began to prefer medications, since the effects of that treatment could be seen a lot faster than traditional psychotherapy.

    However, psychologists (and psychiatrists if they choose and obtain the training) today we have a much larger number of interventions from which to choose from. The ability to prescribe is one medical intervention among multiple psychological interventions. One could argue that the number of psychological interventions could “protect” psychologists from falling into a rigid treatment schedule of medications only.

    Additionally, your double salary argument is flawed on the principle that it assumes that prescribing psychologists will follow a similar path of medications only. On the contrary, as was already argued by many other individuals, prescribing psychologists may just as well do more integrative care, which I illustrated above, and which does not produce a double salary. So yes, you are correct in that it is *possible* that prescribing psychologists could make twice as much. But as has already been shared, I too do not think psychologists will give up their extensive training, which can actually help resolve the underlying problems, for a treatment intervention that more than not, addresses only the symptoms. Providing integrative care may provide slightly more money per hour, but it won’t be double what psychologists current receive.

    Also, if we are going to speak about the training involved, consider this: one proposed training model for psychologists seaking prescription privileges exceeds the training that APRNs currently undergo.

    If we are to attack the proposed training models for prescribing psychologists as ill-equipped and potentially dangerous, those same arguments would suggest that APRNs should not be prescribing as well.

    That could a discussion for another day…

  13. As part of this discussion, don’t forget that many patients self-prescribe. It’s easy enough for them to obtain any of the SSRI anti-depressants from any of the perfectly legal American online pharmacies. (I’m not talking about the flaky offshore ones).

    All they have to do is go to the right website (I won’t list any here, but they’re easy enough to find), enter some simple information, and a doctor they will never see or talk to will prescribe their chosen Cymbalta, Celexa, or whatnot, all for the price they would pay in a pharmacy w/o insurance reimbursement. It gets sent to them next day Fedex, too.

    Kinda moots out a portion of this discussion, no?

  14. My 8 year old was diagnosed with ODD. I do not agree with this at all. The Dr. put him on medication and it made him so skinny that I took him off of it. She then put him on Vyvanse. I do not want my child on meds AT ALL! He has had a rough life for his young age. She never even talks to him. None of the “Dr.s” do. They just talk to me. I have four children. Ages 8,7,4,& 3. I DO NOT think medicine is the answer. I think if the Dr.s would do their jobs we wouldn’t have to rely on medication at all.

  15. Nice discussion of some thorny issues here. There’s not question that, all things being equal, prescribing psychologists would follow the money and set up 15 minute med check shops. But they aren’t equal. Those who choose to go into a psychology program are different types than those who go to medical school. They are fascinated with human behavior and psychology. And 5 to 7 years of training in psychology deepens that interest and competence. So I believe that it will be the rare psychologist who will choose to chuck therapy for med checks just for the money.

    But there’s another factor here. Prescribing psychologists operate in an environment in which they compete for patients with psychiatrists. Psychiatrists still have, and presumably always will have, the role of the true medical experts, those who you see if you have active concurrent medical problems, or if you require a really complex cocktail of high side effect drugs.

    So in a world where there are both medical psychologists and psychiatrists available, each practitioner will attract patients for whom they are most appropriate. The psychiatrists will get the medically complicated patients, and the psychologists will get the rest–the medically stable patients with mood or anxiety disorders that respond fairly well to a combination of therapy and benign meds such as SSRIs.

    I predict that a medical psychologist who get the reputation of being a med check doc will lose business to the med check psychiatrist across town.

  16. Money is the root of all evil….So basically, if I don’t have the money to treat my child then I’m out of luck? I could go to a perfectly good Dr. about a hundred miles from my home. Pay his $90.00 per hour fee, no telling what his office visit is, at least he would listen. Too many people want a “crutch” or easy “fix” these days. I’d much rather pay all the high dr’s fees and travel to get my son, my family help than give any of us meds. I just don’t have the money.

  17. There are problems with psychologists and primary care physicians prescribing already as they don’t have as much specialized training in psychpharmacology. I want a trained psychiatrist attending to my medication issues and a person well versed in counseling techniques to have therapy with. I would disagree with Daniel as mood and anxiety disorder are not inherently stable. Nor is SSRIs benign or the solution for these disorders. If a person with a mood disorder is transfered from a psychiatrist to a psychologist when stable, who will handle the problems when they are not longer stable? How can a psychologist with a year or two of training deal with drug cocktails of antidepressants,mood stabilizers, antipsychotics, sleeping pills, among other types of drugs. Prescribing becomes complicated very fast when dealing with mood disorders along with schizophrenia and other mental health issues.

    I want a psychiatrist and psychologist who keep in contact.

  18. to Carole,
    That’s certainly your choice. That was my point. Patients with concurrent medical problems, complex medical problems, and those who need to be on meds that require regular blood tests and/or close monitoring (MAOIs, Lithium,etc), should still be seen by psychiatrists as they are now (we hope). There should definitely be limits to what a psychologist would be able to prescribe.

    If you want to see a separate psychiatrist, that’s still going to be an option. However, there is a severe shortage of psychiatrists, especially child psychiatrist in many areas of the country. Most anxious, ADHD, and depressed patients get they meds from Primary care providers that usually have little understanding of complex mental health problems (for example, they often misdiagnose OCD as ADHD in children). PCP also almost always have little time with patients and can’t provide sufficient follow-up. I think that giving psychologists with extra training prescribing rights is a could way to mitigate the effects the lack of psychiatrist, especially psychiatrists who treat children and provide therapy. It’s not a perfect solution but I think it’s acceptable.

  19. I think that psychologists should be able to prescribe meds.. like Stratera and others that are not class 1 or class11 meds.
    perhaps the PSyD and not the PHD Psychologists could perscribe meds. It in most instances the psychologist that knows and deals with the patient. My psychatrist sees me 15 min every 3 months. I take Stratera. So I believe that the psychologist with a PSyD should be able to take medical training and prescribe certian meds. A psychartist is a MD doctor, and from what I understand that person is not limited to only prescribing psychotropic meds.
    My denist can prescribe meds only limited to the medical practice of denistry, like pain meds for absesses in teeth. He can not prescribe anything else.
    I think the only ones who are against the idea of physcologist having the previledge of prescribing only medicines for specific medical needs related to psychatry are the psycharists.
    I had a friend that the “so called psycharistist was in fact was a medical doctor who mainly practiced internal medicine. That is internal of the body from the neck down. This person took a few classes and now works part time for the state They live in at a state where the clinic is operated and employes state and / county/ city workers The doctors there including the internist perscribe all type of psycotropic meds. If a regular doctor MD internal medicine can take classes to be qualified to prescribe and work in a psyco-clinic, what is wrong with a person who is trained in human relations and the afflictions of the mind having the priviledge to prescribe medicines for the persons they treat on a regular basis.

  20. Those 15 minute psychiatry appointments were awful! Finding a psychiatrist who does psychotherapy has been a godsend…

    Prior to finding my current doctor, I had been seeing a psychiatrist in conjunction with therapy for 10 years. Had I known psychiatrists who practice therapy existed, I would have pursued it. Only recently did I discover that there are psychiatrists who still practice therapy; they are primarily psychoanalysts. For this region, I discovered, the majority of them are at retirement age. I’ve also learned that some psychoanalysts have adapted their methods over the years to match current or recent research. The combination, I think, is the best of both worlds. The perspectives of my psychiatrist make more sense to me than those of any therapist I have seen in the past. I regret not finding this type of therapist sooner.

    It’s unfortunate psychiatrists no longer wish to practice psychotherapy. If mental illness is bio-social-psych, then wouldn’t this scenerio be most appropriate? If the medical community believes this is best for patients, shouldn’t more psychiatrists want to practice therapy?

    If the potential downside is therapists jumping ship from therapy to prescribing only – does current research, if any is available, support this anticipated trend? You mention that some states allow non-MDs to prescribe, so what does the research show as a result of the change in regulation?

    I just don’t see that the reimbursement incentives will trump practice methods; instead, my concern is that mental illness will become less of a science. I worry that the field of psychiatry will lose more credibility in the medical community.

    Thanks to those who care enough to write about this or to comment!

  21. I also disagree with Dr. Grohol. This is simply scare tactics, and Dr. Grohol’s arguments are not factually based, rather they are predicated upon personal opinion and false conclusions. There are millions of citizens who require professionals cross trained in both psychpharmocology and psychotherapy. In every venue where psychologists have obtained Rx privileges, the outcome has been excellent and worked to the great benefit of patients.

  22. It has been known for decades that patients appearing in emergency rooms and outpatient practices with apparent “psychiatric” problems—depression, anxiety, psychosis, etc.—frequently have undetected neurological, cardiac, endocrine, or other medical disorders that cause or contribute to their “psychiatric” problems.

    One recent study (Rothbard et al, 2009) of 588 psychiatric inpatients found that 10% were HIV positive; 32% had hepatitis B, and 21% had hepatitis C. Even on the inpatient unit, the treatment team missed a considerable proportion of infectious disease (95% of hepatitis B cases, 50% of hepatitis C cases, and 21% of HIV cases) and metabolic disorders.

    It is one thing to argue that such “complex” cases will wind up being cared for by psychiatrists; it is another to assume that non-physician “prescribers” will obtain the training required to detect such cases in a timely manner–much less treat them safely and
    effectively with medication.

    As for the sort of “training” for psychologist-prescribers proposed by some states–for example, several hundred hours of course work in physiology, pharmacology, etc.—it remains entirely unclear, in my view, that this kind of program will adequately prepare a psychologist (or anybody else) for independent medical practice. If readers consult the excellent papers by Robiner and Pollitt, I think it will become clear why this is so. The references follow at the end of this message.

    Again, let’s be clear: when you hand a patient a prescription for a medication with potentially serious side effects and interactions, you are without any question engaging in the practice of medicine, with all its medico-legal privileges and responsibilities.

    Psychotropic medication is not a “set and forget” pill. Pharmacotherapy is a week-by week, day-by-day process of careful monitoring—not only for potential side effects, but for the effects of concurrent medical illness; infection; changes in the patient’s kidney or liver function; changes in sleep, weight, and appetite; effects of newly-introduced antibiotics or heart medication; and a myriad of other medical factors that pour in to one’s office, every day. It is not enough to say to the patient, “Well, if you have any problems with this medication, go see your primary care doctor.” (When I was actively seeing patients, I had my blood pressure cuff and stethoscope always handy, and would often do circumscribed neurological examinations to check for medication side effects).

    I have great respect for psychologists, psychiatric social workers, and other mental health professionals, from whom I have learned a great deal–some, in fact, are family members!

    But before we acquiesce in a huge, public health experiment such as that proposed by some on this blog site, we need to investigate its safety and efficacy in a large-scale, medically-supervised study, involving hundreds of non-MD “prescribers” and hundreds of patients who have given their informed consent. We have nothing remotely approaching that kind of data.

    What is being proposed with respect to psychologists is analogous to allowing “non-engineer bridge-builders” to construct our nation’s bridges, after they have had “appropriate course work in bridge building”.

    The debate must not be trivialized as one of economic “turf battles.” There are vital scientific and public health questions that lie beneath that turf. We need to answer those questions before we create a very rickety, and potentially dangerous, two-tiered system of mental health care.

    Ronald Pies MD

    P.S. By the way, many of us went into psychiatry precisely because we were and are “fascinated with human behavior and psychology”!

    References:

    Rothbard AB et al: Previously undetected metabolic syndromes and infectious diseases
    among psychiatric inpatients. Psychiatr Serv. 2009 Apr;60(4):534-7.

    Robiner WN et al: Prescriptive authority for psychologists: a looming health hazard? Clinical Psychology: Science and Practice. Vol 9, no. 3, Fall, 2002.

    Pollitt B: Fool’s Gold: Psychologists Using Disingenuous Reasoning to Mislead Legislatures into Granting Psychologists Prescriptive Authority. American Journal of Law & Medicine. Jan 1, 2003 [available at:
    http://www.highbeam.com/doc/1P3-536802481.html

  23. A number of the proponents of prescription privileges for psychologists suggest that Grohol is being overly pessimistic or alarmist, and that psychologists WILL do a fine job of prescribing, and that those who are already doing it are doing a good job, and that it’s needed because we’re somehow better suited to providing a whole package of services than psychiatrists are, and that psychiatrists already provide therapy, so why can’t we just provide meds?

    Well, I’ll start by weighing in with three points- first- that most indications are that plenty of psychologists and psychiatrists are substantially flawed in their primary disciplines, therapy or meds, before even adding a second one; second- that prescribing by psychologists still occurs under such limited circumstances relative to the whole field that it would be an overly facile position to assume that the floodgates for prescribing could be opened to our field without potentially grave consequences; and third- let’s not make the great the enemy of the good- just because it might be great to have psychologists providing integrated services in their personal offices (or wherever!), doesn’t mean that most of them could do a particularly good job of it (though I’m sure some would!).

    These are obviously very complex issues. I’d suggest that right now we can’t state with any certainty what general developments would take place in the field of clinical psychology subsequent to the general availability of prescription privileges for its practitioners. Obviously a substantial body of reasonably rigorous research, much of it in the form of longitudinal studies, would be needed to give us more clarity as to the outcomes, and we should proceed farther from THERE.

    That being said- and as someone who as a graduate student in a PsyD program (10-15 years ago) strongly believed that practicing psychologists could and should be able to prescribe psychotropic medications- I now (as a practicing clinical psychologist) have grave doubts about the consequences of enabling my colleagues to do so. I tend to oppose prescription privileges for them at this time, except perhaps in certain instances (such as greatly under-served areas) with fairly rigorous, well-monitored training requirements and substantial psychiatric oversight. Here’s why:

    First- and this goes for both psychiatrists and psychologists- don’t we have enough to learn and master in our respective fields? In my practice I have had so many patients whose former therapists didn’t even seem to have an active game plan, or an awareness and/or willingness to use or persistently implement empirically-supported approaches for certain clinical disorders, e.g., exposure with response prevention for OCD. A number of studies indicate that most psychologists either haven’t sufficiently trained in certain approaches, or simply choose not to use them.

    I’m certainly not letting psychiatrists off the hook here- I’ve also heard about and encountered numerous instances (even more, in my opinion) of psychiatrists who appear ill-trained or oriented to practice psychotherapy, or even psychopharmacology. I’m not suggesting that they don’t practice psychotherapy at all, but that their profession needs a lot more oversight of their training and (limited) implementation of it. I believe that most psychiatrists DON’T have adequate training to do substantive psychotherapy, at least at the level that they’d want psychologists to be trained to do prescription work!

    In my opinion, behavioral science- its development through research and its applications- are the specialty of clinical psychologists, and it’s broad enough and hard enough to “master” on its own. It’s already given a lot on certain fronts, and has so much more to offer the world, but is still (maybe always WILL be) mired in a long evolutionary struggle to meet its promise. Now a lot of us want to add prescription privileges, which I expect will often (if not usually) dilute both our expertise and our intentions, and thus “dumb down” and generally reduce the effectiveness of our psychotherapy work, while making us more complacent as practitioners.

    Second, money IS an issue. Despite the protestations of many pro-privilege psychogists that our field draws mostly those who are committed to the “whole person” approach to health, and that therefore earnings issues won’t substantially overtake our field- I generally don’t buy it. There’s plenty of social psychology and clinical psychology research findings, as well as in-the-world experience, to demonstrate how strong the allure of money is even for us altruistic professionals. and how sensitive people’s behavior is to large-scale changes in environmental contingencies.

    Sure, many psychologists won’t be sucked in by the money- and plenty of others will. The catch is that since prescribing psychologists would still be allowed to practice psychotherapy, many of them wouldn’t have to make hard choices at first about what was so important to them. These individuals would treat the training as simply- more training- and would attempt to integrate prescribing into the main body of their work, not sacrificing its benefits. Nevertheless, many of them would begin a gradual and substantial drift away from their professional roots.

    In the major city where I practice (and from what I’ve heard/seen in the various cities in which I’ve worked during various stages of training, apparently everywhere else), psychiatrists DO tend to earn a lot more per hour than psychologists, employee to employee or private practitioner to private practitioner- I don’t know how psychologist prescription proponents maintain that there isn’t a large long-term monetary advantage for prescription privileges, if they’re billed out in the way that psychiatric services are. Therefore, due to either evolving desire, or insecurity about income (how many of you out there are particularly confident about your retirement at this time, may I ask?), many, many psychologists who did not choose their field primarily for its remuneration could easily slide into more and more prescribing and less and less psychotherapy practice over time. Cognitive dissonance being what it is, I think that many of them would start to respect the endeavor of psychotherapy less, or at least pay less attention to it, or at times “take the easy way out,” or convince themselves that meds were more deeply or widely or relatively effective than a lot of the available findings suggest they are. And the field as a whole, or large chunks of it, would follow.

    As time went on, practicing psychologists would become progressively more indiscriminate in their devotion to the superior or at least adequate practice and advancement of psychotherapy than they are now (which as I’ve stated, I believe is already a substantial problem).

    A lot more could be said about this, but I’ve been long-winded enough here… simply put, both psychiatry and psychology have enough problems maintaining their excellence or even adequacy, without branching out yet further away from their core disciplines. They need to work more hand-in-hand with each other (and with other disciplines) and with more oversight in both directions, versus each one trying to be the “jack-of-all-trades” for patients’ mental health.

  24. Dr. Joe Dixon wrote:

    I also disagree with Dr. Grohol. This is simply scare tactics, and Dr. Grohol’s arguments are not factually based, rather they are predicated upon personal opinion and false conclusions. There are millions of citizens who require professionals cross trained in both psychpharmocology and psychotherapy.

    Based upon what research are you drawing that conclusion? I think that’s certainly a reasonable suggestion or opinion, but it is not a fact either.

    I’m not sure what’s “scary” about pointing out the history of other professions and the lack of logic used when psychologists make the unsubstantiated claim they won’t follow down the same road. I actually hope I’m dead wrong, because I believe it’s already too late in terms of stopping this train.

    One wonders, too… When do we get to a point that if it’s suggested that psychopharmacology is so easy, why not just make many of these drugs over-the-counter? You know it’s easier to overdose on Tylenol than it is most SSRIs?

    In every venue where psychologists have obtained Rx privileges, the outcome has been excellent and worked to the great benefit of patients.

    Well, let’s see, our N = 3 where N = the military demonstration program, and two states (out of 50, in 10 years’ time). Has there been any research following the outcomes of patients who’ve gone to these prescribing psychologists? I couldn’t find any.

    So let’s not confuse “no evidence” with “evidence that has demonstrated ‘great benefit’ to patients,” ok?

  25. Dr. Rob, thank you for your interesting and insightful perspective.

    It is indeed a complex issue, one that’s hard to do justice on a blog entry. Alas, we try…

  26. For those of us that study the brain as well as behavior, I find it patently absurd to assume that psychotherapy would be dropped, since the literature indicates that psychotherapy out-performs drugs across the board. The majority of psychoactive prescriptions are not written by psychiatrists – they are written by family physicians who have little to no training in neuroscience. I would much prefer to have psychoactive drugs prescribed by someone with board certification in that specific field than my faily practitioner!

  27. As a practicing clinician in the field for 15 years and working on my PsyD. I personally would not want the responsibility that goes with prescribing medications. However, I work with children and adolescents and it is hard to find psychiatrists to refer to. Primary care physicians do not understand the complexity of mental health needs and don’t always help when they prescribe medications for mental health disorders that they don’t truly understand. I would love to see a better partnership between psychiatrists and therapists or primary care physicians and therapists since it’s the therapists who see these clients every week and can truly give the feed back that might be missed in a once every 3 month 15 minute med check. I do believe there needs to be a better answer for the shortage of child/adolescent psychiatrists that we are experiencing.

  28. As a clinical psychologist practicing in a hospital setting, I can say that there is much more about prescription than just medication.

    For hospital psychologists, prescription is about the authority to “prescribe” a treatment in a healthcare setting, whether that prescription be for medication or for psychotherapy. Presently, psychologists working in healthcare settings are beholded to psychiatrists or even psychiatric nurse practitioners to “prescribe” the psychotherapy that we offer.

    Do I want prescription priviledges? Yes. Not just to expand the range of interventions available to me, but to be empowered to decide on a treatment approach without having to be beholden to an MD or a nurse with a master’s degree!

  29. I’m just curious re these providers who want prescribing privileges: can other disciplines who have no real training in their programs be abled to conduct psychological testing?

    Wow, did that question get a lot of intense reactions from psychologists I have spoken to in the past couple of years. Social workers are looking to be credentialed to do this.

    Hmmm, shoe not fitting too well on the other foot!?

  30. If nothing else, I want an MD to be writing my prescriptions, especially since my meds need to be coordinated with my GP.

  31. With all the problems associated with mental health care in this country right now, the thought of allowing psychologists to prescribe medicine is appalling to me. The state of care for patients is bad enough with doctors doing the prescribing–I can’t imagine it would be any better having people that don’t have any medical training make decisions on medications that even trained psychiatrist still have a difficult time with. Things are no better on the psychology end, with the continued lack of proven efficacy for a variety of psychological therapies that are STILL being practiced with no end in sight. People are still suffering even with drugs and even with therapy–seems to me no one has the recipe right just yet in their own respective discipline, so why expand into areas that only make the matter more confusing? How about narrowing your focus to the discipline you chose to work in, excel at those techniques, prove their efficacy, and further advance the good outcome percentages with new work in the field.

    Right now all I see are a bunch of professionals-both psychiatrists AND psychologists that need to get their own houses in order before they start adding more rooms.

  32. Kelly – I wish more people shared your opinion. It seems most people are happy to have their antidepressant prescribed by their family physician, as that is the doctor who is currently doing the vast majority of antidepressant prescribing.

    I also don’t know if psychologists will abandon psychotherapy — it simply is my belief. But I base my belief on the only large-scale, longitudinal data we have — psychiatry. I hope someone does the study that examines medical psychologists practices over time and whether they indeed become more “medicalized” and prescription-oriented. Time will tell.

    Dr. Hassman makes a good point. Psychologists have long farmed out the actual doing of psychological assessments to lesser-trained professionals. Their main interest/focus has been in actually analyzing the data. Such analysis can be learned by anyone, of course, and there’s nothing unique or special about psychology training programs that couldn’t provide such education to other professionals. Heck, computer programs provide a lot of the “analysis” as well these days, so the psychologist’s job has been to synthesize those data into a coherent narrative.

    But again, anyone could be trained to do this.

    So yeah, I think it’s a slippery slope. While psychologists pursue expanding their practice, other professions are always there too, looking to expand their scope of practice as well. It’ll make for an interesting future!

  33. Unfortunately it’s psychology that has been diluted and becoming more irrelevant as time passes.

    It’s no surprise that the public cannot distinguish psychologists from social workers, life coaches, therapists, physicians, etc. because Psychology as a profession cannot seem to clearly articulate or enforce its domain of practice. Do state psychology boards do anything relevant outside the psychology community these days?

    The profession is fundamentally fractured with its own caste system and splinter groups within the field (e.g., PhD., PsyD, I/O, Counseling, Clinical, School, etc.).

    As for prescribing rights, I believe that the data suggests that the majority psychopharmacological prescriptions are written by non-psychiatric physicians. That considered, many residency training programs require merely a 6 week rotation in “behavioral medicine” (I worked in two major university programs). I’d bet that most of the non-psychiatrist behavior medicin prescriptions are based on little to no diagnostic assessment (e.g., meeting basic DSM criteria). I’d love to know how many non-psychiatrists/neurologists have a DSM in their clinic.

    While clearly admitting that there are broader systemic issues that require additional training before ever being ready to competently prescribe, I’d put many post-Clinical Psych PhD student’s knowledge of neuroanatomy, psychophysiology and psychopharmacology against any non-neurologist/psychiatrist post-resident AND nurse practitioner.

    If you really want to make this objective, then look at it from a purely curricular and competency based approach. There is no reason that psychologists cannot be subjected to the same “magic” curricular requirements that physician candidates are subjected to in medical school.

    The reality is that this argument is based primarily on politics and the fear of losing power and/or social relevance on the part of physicians.

    Despite its powers in numbers, the APA is hardly relevant as Dr. Phil (an unlicensed and unethical) is more recognized as what psychology represents to the public and its representatives in the legislature.

    How far has the psychology profession advanced in the last 30 years? In my opinion, not much. Partially because a biopsychological paradigm has become much more founded and prevalent. Rightfully so as we understand that human behavior is governed by much more holistic, dynamic and interdepedent biological/environmental variables.

    The reality is that if psychologists want to prescribe, they’d best be served by obtaining a medical degree to get themselves into the “club.”

  34. I think you bring up many good points, but the basic thesis remains unanswered…What do we do about the regions where there are no or only few prescribers? I live in an area with about 65,000 people and NO prescribers. I am not particularly interested in getting prescription privileges, but we are not blessed in our area of having access to PMHNP’s and psychiatrists. God knows I hate to leave this important job to primary care physicians whom are not normally well-versed in psychotropic medication.

  35. I couldn’t agree more with the arguments in this article. I myself have received psychiatric care from adolescence until now (age 16 to 46), at times from psychiatrists who were supposedly providing psychotherapy along with medication. I must say that while the medication has kept me functional, in fact highly successful, it was not until a year and a half ago that I considered seeing a psychologist in addition to a psychiatrist. I wish I had done it sooner. I am even beginning to take fewer medications and look forward to the day when I need neither a psychologist nor a psychiatrist anymore. The psychologist’s entire approach from the very beginning has been different from that of any of the many psychiatrists I have seen and has done me far more good than all the hundreds of pills I have swallowed in my life. Psychology and psychiatry are two entirely different approaches to treating mental illness. Blurring the lines between the two will only make one become less and less common. Slow, frustrating psychotherapy would probably end up taking a back seat to easy-to-provide, temporary- but quick- fix pills. That would be a shame.

  36. The logic behind limiting scope of practice in order to focus on a particular activity makes no sense to me. Why not insist that psychologists be restricted from using biofeedback, testifying in court, admitting to hospitals, so they’ll be further forced to focus on outpatient psychotherapy? The restrictions of psychology practice doesn’t reflect the essence of psychology — it reflects an historical accident. Since medicine already had a monopoly on treatment, other professions (chiropractic, podiatry, optometry, dentistry, psychology) were forced to “carve out” areas of practice that weren’t too economically threatening to MDs. Psychiatrists restricted their practice to psychopharmacology because they were enabled by psychologists who were willing to pick up all the slack — case management, psychotherapy, referrals, medication compliance, and side effect monitoring. Psychologist prescribing will force psychiatrists to reassess their own practices and add pressure to return to an integration of psychotherapy and medication.

  37. I wouldn’t condemn you if you wanted to expand your practice to, say… sex offenders or child custody evaluations. There’s lots of money in those fields. Why are you condemning those psychologists who want to take a more prominent role in the medical management of patients?

  38. As readers of this website may already know, Gov. Kulongoski has vetoed the bill in question, raising some of the same concerns about it that many of us in the profession did.

    This should not be the time for gloating or recriminations, however. It is a time for psychiatrists and psychologists to work together constructively, in order to increase access to good, comprehensive, mental health care. It is also a time for physicians (both general and psychiatric) to “buff up” their medical and psychopharmacological skills and training, so that what we provide is a model for responsible care–not an easy “target” for others to seize upon, in order to expand their practice into the realm of medical care.

    As a consultant in psychopharmacology for almost three decades, I know that physicians have a long way to go, in achieving a level of excellence in prescribing psychotropics. We all do! But the best way for psychiatrists, PCPs, and psychologists to advance the health care of our patients is to respect the training and expertise of each specialty–and, to advocate for wider access to mental health care in general.

    Ronald Pies MD

  39. Since there is a current and projected shortage of psychiatrists, couldn’t medical schools accept more applicants who will commit to psychiatry and hold them to it? And restrict other specialties where there already might be too many? Offer financial aid and other incentives to those entering psychiatric residencies?

    Or is the medical community inferring they are powerless to trends and bureaucracy?

  40. As far as the idea that Med Schools should offer incentives to attract prospective psychiatrists, I see several flaws in this. First of all, where is the money coming from? I don’t know a lot about medical school, but I think that without state or federal governments stepping in (and possibly NGOs) to pay for incentives, the med schools wouldn’t care is no one becomes a psychiatrist. Not only that, most prospective and first med students don’t know what speciality they want to enter and I can easily see that some students would be too tempted by the immediate incentives to enter psychiatry and would lie on their application or choose the field and hate it.

    I think along with primary care (another in demand speciality), the federal government should provide more incentives for students to train in psychiatry (loan reimbursement,etc) and more importantly, for psychiatrists to treat undeserved communities. The government should also require or encourage them to treat patients with all different types of insurance, incl. medicaid, and medicare. Undeserved area programs already exist, but they should be more widely popularized and more loan reimbursement wouldn’t hurt. I think the max loan reimbursement is $80,000 now? When I a become a clinical psychologist, I plan to take advantage of the program, but I shouldn’t have the $200,000+ loans of some med students.

    I don’t have data, but from what I’ve observed, it’s not a national psychiatrist shortage persay, it’s just that some areas have many many psychiatrists whereas others have none. Also, some psychiatrists are pretty selective about what insurance they will take, leading many out of luck. I am not entirely sure what would rectify this problem, but I think that in addition to better reimbursement, the government should enact a plan to educate Primary care nurses and doctors about mental illness and psychopharmacology. Without the extra training, PCPs and NPs SHOULD NOT be diagnosing and treating mental illness without substantial psychiatric oversight.

    All the pcps I’ve been to have dangerously poor knowledge in this area. I wouldn’t trust any of them to adequately diagnose mental health problems and prescribe any psychotropics. (except maybe SSRIs and ADHD drugs after the patient has been on them awhile). If I had to choose between having my psychologist prescribe me meds and my primary care person, I would choose the psychologist hands down.

  41. To Client Not Therapist:
    I don’t know if modern. scientifically-backed psychotherapy (CBT, biofeedback, lifestyle counseling,etc) is all that different from psychiatry or psychopharmacology. Practitioners of both us a medical model, but recognize the influence of environment and upbringing. Both recognize the importance of using drugs in some cases and changing the lifestyle and relationships of the person. Yes, psychologists have a more non-medical bent and can’t prescribe meds in most cases and psychiatrists have a more medical bent. But I think barring some extremes, such as the psychiatrist who only does 15 min med checks, they are more alike than different in orientation. Most psychologist and psychiatrists recognize the importance of both. This doesn’t include psychoanalysis that is going by the wayside anyway.

    Yes, psychotherapy can be slower and require more activity on the part of the patient than drugs, but the opposite can be true too. There is a huge stigma against using psychotropic drugs and any mental health professional will tell you that most patients are very hesitate to start them. Most depressed patients need to try more than one antidepressant before a “good one” can be found, if that all. (only about 40% respond to the first one). Unless the patient has a really bad side-effect, each med trial takes at least a month or two. For multiple conditions and more complicated ones, it can take 6 months to a year or more to find the combination of drugs and dosages that work. Not exactly a “quick fix.”

  42. Psychiatrists, in the first place undergone thorough study of medicine which, includes biological chemistry not like psychologists… please lets not confuse ourselves, as scientists in nature, the discrepancy of the two profession. In a way or another, both their objective is for the benefit of their clients whether doing psychotherapy or providing prescription.
    It’s not solely pertains to profession per se, it depends likewise, to the person practicing the profession as well.

  43. Hello! I would like to bring up an issue which I feel lies under the subject of who should or should be allowed to prescribed medications and what their motivations(money, balance of power, or debatable competence in the area): I would like more people to ask themselves, “Should medications be prescribed for psychological distress at all?” This question begs some other questions which I will attempt to address here as briefly as possible:

    1. Are these drugs necessary?
    My answer: No. I have been working successfully with clients at all level of distress, even florid psychosis, severe anxity, depression, and suicidality WITHOUT relying on either medications or the pathological, hope-destroying DSM diagnoses. Not to be too cynical, but the only reason in my mind to continue prescribing medications is to continue to subsidize the existence of psychiatry, the profits of the insurance and pharmaceutical industries, and the control over unwanted behavior by those disturbed by it and unable or unwilling to provide real healing care.
    Are these uneccessary drugs even safe or effective?
    My answer: As a clinical psychologist and researcher, I have spent years witnessing the debilitating effects of these drugs on my clients. and the positive effect of reducing or eliminating them from their systems. Time and time again, even severely distressed people, I have found that medication and the depressing theories which support their use only interfere with healing. Symptom reduction is not acceptable as a goal of treatment. Such thinking only results in obscuring and suppressing the roots of distress under a crust of chemicals. Certainly, drugging a person into oblivion makes a person more manageable and less irritating to those in power over them; it’s just not health care.
    I have also spent years trying to find one valid scientific study directly linking any specific psychological distress to any neuro-transmitter. Every study is either tainted with extreme bias such as being paid for by a pharmaceutical company or performed with such shoddy scientific rigor as to be completely invalid on methodological merits. Yet, these studies are still published as proof of the medical model in all the most reputable journals and touted at all the conferences, especially the one paid for by the same drug companies.Ironically, what I did find in my research of these same medical journals, was report after report of the dangers and toxicity of psychotropic drugs. My doctoral work focused on Prozac and I turned up much more evidence of iatrogenic effects of this particular drug than therapeutic effects. I also research th FDA drug approval process and found a horrifying lack of scientific competence in both the clinical trials for Prozac and general approval protocols.
    Whether prescribed by psychiatrists or other physicians, the use of these drugs is marketed to professionals and the public as scientifically proven as safe,effective, and the best treatment they can offer their clients. This is simply not true and there is valid evidence to support my position. I welcome all responses, on or off this particular discussion. Please contact me for recommended reading and/or visit my website and blog at: fullspectrumcenter.org/blog
    Thank you

  44. To Dr. Bingham-
    I once saw a therapist like you who did not believe in diagnosis or the use of medication. I used to be pretty anti-med myself. However, all years of psychotherapy, exercise, light therapy, good nutrition, lifestyle changes, meditation, etc with medication did for me was make me even more depressed and suicidal. I finally saw a competent psychiatrist and after months of trial and error found a combination of meds that worked for me. No side effects really. After my depression limited I was finally able to fully partake in psychotherapy and improve myself. Perhaps I could have gotten better without meds, but I doubt it. Also, as a psych student, I appreciate diagnoses or at least terminology, because it makes it easier to talk about my various issues. Or if I did, I would have lost even more valuable time to the depression. I am sure there are plenty of cases where psychiatric drugs did more harm than good and where the mental health problem could be fixed without therapy, but psychiatric meds do have a place. If I as a psych student know that all psychiatric conditions are biologically based and even though therapy and other means can significantly alter the brain and alleviate the depression or other condition, meds, when used correctly, can accelerate and enhance this process.

  45. whoops I meant “without medication” in the 4th line

  46. To the last poster:
    1. I am glad that after a long search, you have found an approach to your depression and suicidality which works for you…I hope it continues to give you a satisfactory level of relief. You are the one suffering and you will be the one who will experience the consequences, good and bad,of your choice. My position is that freedom of choice of treatment is most important. Too many people are forced either literally or implicitly by the overbearing force of public opinion and medical authority into taking medications without being informed of their dangers and the existence of alternate treatments and theories of the roots of psychological distress. Having said that, I have a few questions which you may choose to ponder and/or research:
    1. Do you know of the body of evidence pointing to the serious, often permanently debilitating effects of long-term use of psychotropic medications? If not,a short Google session may open up a new world of information to you.I notice that you said “no side effects-really” What did you mean? Effects that are not serious to you now may become so after time.
    2. On a logical level, the fact that you found no relief from exploring other ways to address your depression does not necessarily mean that the specific methods or others which you did not try are ineffective…It also does not mean that medication is the best answer. to use your words, you may not have found a “competent” practitioner who could help you find the correct “combination”of methods to address your depression. Integrating methods effectively is a difficult art and, as you have said, can lead to worsening the situation as easily as medications. Needless to say, I am available if you regain interest in finding an approach which relies less on medication.I have worked with many clients to reduce their medications. some eventually discontinue and some simply live with less in their system, finding a balance that works for them. My e-mail is Alexander@fullspectrumcenter.org
    3. Lastly, I must comment on your last statements:

    “If I as a psych student know that all psychiatric conditions are biologically based…”
    This is simply not true. You only “know” this because you have been taught this “fact” and ave accepted it at face value without questioning its validity. As a student, I did not…I spent much time searching for evidence of the validity of the biological medical model…there is no valid proof for the biological basis of psychological distress.
    while there are many studies which are considered evidence, I have yet to find one which is not riddled with either methodological flaws or bias stemming from conflicts of interest. Recently, I have started a blog on this subject at fullspectrumcenter.org

    “and even though therapy and other means can significantly alter the brain and alleviate the depression or other condition”
    I am glad that you feel this to be true..I also agree. However, it begs the question,”might there be a less toxic answer still out there?”

    meds, when used correctly, can accelerate and enhance this process.”

    While this may be true in the short term, I have found that clients will this to be true and in the long term, the healing process is stalled due to the interferenceof medication in accessing the deeper-rooted emotional pain causing psychological distress. In my opinion, if you want to stop feeling your pain rather than address it, medications will do that for you. If symptom management is enough for you, medication can do that, too..for a while. However, I have found that the problem still festers and grows, making higher doses or a continual series of medication switching inevitable.

    hopefully, this post conveys both my support for your current decision, as long as it works for you as well as encouragement to consider certain biases and assumptions concerning medications which are inherent in your perspective and the perspective offered you in your graduate studies.
    Take care,
    Alexander

  47. I completely agree on the grounds of human nature and greed. To those who say, Psychiatrists just want to protect their monopoly, I say: “So you admit you want some of it too?”. Why do you want to prescribe medicine if that’s what a Psychiatrist is for unless you also want a slice of the cake? I, myself, am not a Psychiatrist yet but am looking forward to becoming one seeing the benefits as far as time flexibility and interaction with patients. I’d like to prove that not all Psychiatrists are shrinks and inconsiderate snobs. Isn’t a job something you grow up to want to do? Why does it matter if you get more money or not? If so, then you chose the wrong occupation. Don’t try and steal benefits from other jobs because yours isn’t fulfilling. Psychiatrists complete years of medical training and compete with top notch students all over the world to be able to prescribe medicine. Why should Psychologists who go to half-assed schools be able to partake in the same privileges? Just go to Med School if you’re confident in your skills. I’m sure that option has kept many people who are just in it for the money, out.

  48. Psychiatric meds are not prescribed in a vacuum. Patients have medical conditions and take a variety of other medications. The side effects of psyche meds and the interactions with other medications are complex. Very complex. Consider what is involved with just one major medication – Lithium.

    The blood work, thyroid, lith levels, interactions with other meds, even over the counter meds which can influence the concentration, dehydration. Can a psychologist handle a situation when a patient taking Lithium has voimiting and diarrhea? Or is prescribed a non-steroidal antiinflammatory by their GP?

    It is simply more complex than just offering an AD. And if you give the wrong patient an AD they can become manic and end up hospitalized.

    What about complications such as tardive akathisia?
    I am strongly opporsed to a Psychologist having prescription priviliges. Even with extra training they will not have the general medical background. No one likes the ten mins med adjustment but there is something to be said about expertise which is what a Psychiatrist offers.

  49. Yes…there is something to be said about the expertise which psychiatrists offer, especially those whose inflated, undeserved earnings rest on those woefully inadequate ten-minute adjustment appointments and the blind faith in their competence which the public and professionals are forced to bow down to: in fact, most psychiatrists today do not have the expertise to treat people in psychological distress.They are glorified pharmacists following outdated, dangerous prescription protocols mostly written and funded by pharmaceutical companies who also finance much of the conferences and Hawaiian vacations which members of the APA and AMA can count on to make their already cushy jobs cushier. Please do your own research! I am not making any of these claims up!
    P.S. For more information, please visit my blogsite at fullspectrumcenter.org/blog or e-mail me at alexander@fullspectrumcenter.org
    Alexander

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