“Prescribing Psychologists:” Practicing Medicine without a License?
“Prescribing Psychologists:” Practicing Medicine without a License?
“Once more unto the breach, dear friends, once more…”— Shakespeare, Henry V, Act III
Dateline: Portland, Oregon, April, 2011
[From the office notes of Prescribing Psychologist, R.X. Sciolus, PhD]
“Ms Malfortuna is a 60-year-old white female with a recent history of significant depressive symptoms, including insomnia, poor appetite, decreased energy, anhedonia, and lack of motivation. She has been in psychotherapy with me for 3 months, but has made little progress, and is now requesting medication. According to her primary care doctor, Dr Basanizo, Ms M has a medical history of early-stage breast cancer, operated on 1 year ago, and is now in a stable remission with no signs of recurrence. She is maintained on chemotherapy (tamoxifen [Nolvidex] 20 mg/day), which Dr B. says she is tolerating well. Ms M. also has a skin infection, for which a dermatologist, Dr Pelle, has prescribed linezolid [Zyvox] 600 mg bid, without reported side effects. I called Dr Basanizo, and he saw no contraindications to an antidepressant trial. Since he was rushing to see his next patient, we did not discuss specific meds. However, Ms M tells me she had a similar bout of depression 5 years ago, and had good results with fluoxetine, without significant side effects. Accordingly, I will give her Rx for fluoxetine 20 mg daily, and see her back here in 1 week. –R.X. Sciolus, PhD, Medical Psychologist
This scenario could easily be played out in the state of Oregon, unless Governor Kulongoski uses his veto pen before April 8. Otherwise, Oregon will become the third state in the country – along with New Mexico and Louisiana – to grant “prescribing privileges” to specially-trained psychologists.1,2 Although the Oregon legislation does require the prescribing psychologist to “. . . maintain an ongoing collaboration with the health care professional who oversees a patient's medical care…”2 it is not clear that the “health care professional” will be a physician who actually monitors and approves the prescriptions written by the psychologist. There is also no requirement that the prescribing psychologists obtain consultation with a psychiatrist; nor are there any restrictions placed on the age, medical comorbidity, or diagnoses of the patients treated by the psychologists.
For the moment, let’s leave Ms Malfortuna and simply note that the prevalence of undetected metabolic, cardiac, and neurological disease among “psychiatric” patients is disturbingly high—- particularly among inpatients and the elderly.3 Let us also note that there are as many as 7000 deaths annually in the US from adverse drug reactions.4 Finally, let’s also briefly acknowledge the tricky medicolegal issues raised by this legislation; for example, 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 AM, in which the patient is complaining of a sudden, unexpected side effect of a psychotropic medication? Psychiatrists, of course, routinely handle such calls, and accept the medical and legal responsibility of doing so. Are physicians also ready to assume the substantial medicolegal risks of “collaborating” with a “prescribing psychologist?”
There is a notion among some non-medical professionals—-and, alas, also among some physicians—-that psychopharmacology is really “no big deal.” Anxiety? You get some buspirone, or maybe a short course of a benzodiazepine. Depression? You get an SSRI. Mania or psychosis?—-send the patient to the emergency room. Side effects and drug interactions? No problem! Just turn on your PDA and see what the drug interaction software says. Fortunately—-with a few notable exceptions—-most commonly-prescribed psychiatric medications are not highly toxic, when taken as prescribed, and under “ideal conditions”; for example, when the patient has no underlying major medical illnesses; takes no concurrently prescribed interacting medications; is not prescribed new medications by another clinician, takes no over-the-counter agents like St John’s Wort, etc. Unfortunately, the “real world” rarely produces ideal conditions. As a psychopharmacology consultant, I spent much of the last 25 years picking up the pieces for some physicians who thought that pharmacotherapy was “no big deal.”
The notion that the medical skills required to master pharmacotherapy can be acquired without extensive medical training is, in my view, both unproven and potentially dangerous to the general public. Generalizations based on the apparently competent performance of a hand-full of psychologists, trained under very carefully-controlled conditions--ie, in the Department of Defense training program5--are not by themselves reassuring. We would need to evaluate several hundred psychologists (and a few thousand patients) over several years, with careful attention to the kinds of patients 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. Until we do, allowing specially-trained psychologists to practice medicine—- for that is what the euphemism “prescribing privileges” deftly conceals—- constitutes a foolish and potentially dangerous decision.6,7
This is not to say that physicians in general or psychiatrists in particular have practiced exemplary pharmacotherapy. As a consultant, I can still remember wondering, in a few instances, whether the referring physician ought to have “prescribing privileges”! Unwarranted polypharmacy, as well as both over- and under-prescription of psychotropics, are all too common. And, yes—I certainly made my share of mistakes along the way, too.
Oh—-but what of our patient, Ms Malfortuna? Alas, she will be lucky to survive her encounter with the “prescribing psychologist,” Dr Sciolus, who has “collaborated” with the very harried PCP, Dr Basanizo. To begin with, the linezolid Ms M. is taking for her skin infection is a nonselective inhibitor of monoamine oxidase; the interaction of an MAOI and the SSRI, fluoxetine, can provoke a severe and potentially lethal serotonin syndrome.8 Then there is the matter of Ms M’s cancer chemotherapy. Fluoxetine is a strong inhibitor of the cytochrome P450 2D6 system (CYP 2D6), which is required to convert tamoxifen to a pharmacologically active drug.9 Unless this error is caught, the patient’s chemotherapy could soon be rendered ineffective.
The case of Ms Malfortuna was meant to illustrate the potential hazards of uninformed prescription of psychotropics; and the inadequacy of poorly-structured “collaboration” between non-physician prescribers and physicians. But wait: as my Tufts and Psychiatric Times colleague Daniel Carlat, MD pointed out to me (personal communication, 3/25/10) a “prescribing psychologist” with access to a good drug-interaction program could easily have checked for the relevant drug interactions in this case and thereby avoided “misfortune.” Point taken—-but are psychiatric physicians really no more than the sum of the data contained in a PDA or the PDR?
Let’s look at another composite case, based on several patients I have evaluated as a consultant:
Mr Senex is a 70-year-old widower who developed a severe, agitated depression after the mortgage on his house was foreclosed. He was in treatment with R.X. Sciolus, PhD, who provided cognitive-behavioral therapy to Mr Senex for 2 months, with only modest improvement in the patient’s depression. Symptoms included poor concentration, severe psychomotor agitation, 15-lb weight loss, anhedonia, and suicidal ideation. Dr Sciolus checked with Mr Senex’s PCP, who reported that the patient was in good health, with no active disease processes or abnormalities on recent laboratory testing. Accordingly, Dr Sciolus began Mr. Senex on paroxetine 10 mg daily, following recommendations for geriatric dosing of this agent. After 2 weeks of treatment, Mr Senex showed no improvement in his depressive symptoms, and Dr Sciolus increased the paroxetine to 20 mg/day. After another week, the patient’s psychomotor agitation appeared worse, and he voiced the view that, “Maybe I’d be better off dead...I feel like I’m crawling out of my skin.” Alarmed by this, Dr Sciolus increased the paroxetine dose to 30 mg/day. The patient reported slight improvement in his mood, but also complained of urinary retention and feeling like, “I’ve got ants crawling inside my legs.” At this point, Dr Sciolus sent Mr Senex for an evaluation with the patient’s PCP, Dr Swampt. After a brief examination, Dr Swampt determined that the patient’s urinary retention was probably due to the anticholinergic effects of the paroxetine, and that the patient’s psychomotor agitation and “antsy” feeling was probably SSRI-induced akathisia. Dr Swampt recommended a reduction in the paroxetine dose (to 20 mg) and added a small dose of the beta blocker, propranolol (20 mg po bid) for the akathisia. Mr Senex reported feeling less “antsy” within 2 days, and his urinary retention abated.
However, within another week, Dr Sciolus noted a change in the patient’s mental status; Mr Senex seemed confused, disoriented, and was unable to recall 3 items after 2 minutes. Dr Sciolus called Dr Swampt, who hypothesized that the anticholinergic effects of the paroxetine might be causing the change in mental status; he suggested to Dr Sciolus that switching to a less anticholinergic SSRI, such as citalopram, might be the best approach. However, the next day, the patient wound up in the emergency room, having been brought there by his son. In the ER, the patient was disoriented, confused, and unable to perform simple calculations. Laboratory studies in the ER revealed hyponatremia (Na+ = 118 mEq/L, nl =135-145), decreased plasma osmolality, and abnormally increased urine osmolality. SIADH (Syndrome of Inappropriate ADH Secretion) was diagnosed, most likely related to the use of paroxetine. (By the way: since paroxetine has “non-linear” pharmacokinetics, doubling the dose may result in a disproportionately large increase in plasma drug levels).10
The case of Mr Senex is hypothetical, and aimed at showing that the “easy” medications in psychopharmacology—-the so-called SSRIs—-are occasionally anything but easy. Antipsychotics or lithium? Don’t even ask. The case also makes the point that a clinician without adequate medical and neurological training is at a substantial disadvantage when it comes to recognizing the nature of certain medical problems, such as akathisia. Akathisia is not commonly-seen with SSRIs, but accounts for perhaps 45% of SSRI-induced extrapyamidal side effects.11 Akathisia is associated with suicidal ideation, and—-even for skilled physicians--may be difficult to distinguish from worsening psychomotor agitation secondary to primary depressive illness. SIADH due to SSRI use may be quite common, and is seen in as many as 12 % of elderly patients, usually within the first few weeks of treatment.12-14
The case of Mr Senex raises the question: does the “prescribing psychologist-collaborating physician” model represent the safest and most cost-effective mental health care system? Would not Mr. Senex have been better served, had Dr Swampt prescribed the SSRI in the first place—ideally, in consultation with a geriatric psychiatrist? To be sure, such consultation is simply not available or feasible in many parts of the country—-but “telepsychiatry” is becoming increasingly available as a means of connecting primary care doctors with outside psychiatric experts.15 Such “virtual” consultation might well have spared Mr Senex some unpleasant and potentially dangerous side effects.
In making my case against “prescribing psychologists,” I don’t want to diminish in any way the enormous contributions to mental health care on the part of psychologists, social workers, nurses, and other professionals. Neither do I necessarily want to apply these arguments to all non-MD “prescribers”--such as clinical nurse specialists working in direct consultation with a psychiatric physician. But let’s be clear: 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).
As the Hippocratic physicians would remind us,
Ars longa,
vita brevis,
occasio praeceps,
experimentum periculosum,
iudicium difficile.
[The] art is long, life is short; opportunity fleeting, experiment dangerous, judgment difficult. And the notion that we will improve patient care by extending the practice of medicine to those without adequate medical training is, indeed, “Fool’s Gold.” 7
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Acknowledgments: I would like to thank John Grohol, PsyD, and Daniel J. Carlat MD, for allowing me to voice some of these concerns on their blog sites: psychcentral.com and http://carlatpsychiatry.blogspot.com/ respectively. I also want to thank Thomas Hansen MD, for providing me with useful references and comments; and Daniel Carlat MD for providing constructive critical feedback on an early draft. The views expressed here, however, are solely my own.
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DR PIES REPLIES
I appreciate the comments from Dr. Klein and Dr. Huff. I can't answer Dr. Klein's question, but based on the comments from Louisiana psychiatrist Dr. Fam on this page ("...the addition of medical psychologists has not noticeably solved the problem or met perceived needs" in Louisiana), I think there is real doubt whether "prescribing psychologists" will greatly increase access to appropriate mental health care in under-served regions.
It's difficult to answer Dr. Huff's "war stories" approach to this issue, as I simply don't accept the notion that these colorful and troubling anecdotes are a scientific measure of the average psychiatrist's competence or professionalism. Of course, one can find evidence of dissatisfaction among patients, with regard to their treatment by internists, surgeons, and--I would wager--psychologists. But even if the level of practice among psychiatrists is not always what I would wish (true enough!), that is hardly an argument for extending medical practice ("prescribing") to those without adequate medical training. It's a bit like arguing, "There was a bridge collapse in our city, and that bridge was built by professional engineers. This shows that we might as well have our next bridge built by grad students in engineering!"
I also disagree with Dr. Huff's premise that it is my job, as a physician, to "prove" that so-called prescribing psychologists have made poor decisions or errors.
On the contrary: in my view, it is your responsibility, Dr. Huff, as a psychologist, to provide the general public and health care authorities the requisite scientific data showing that your "prescribing" colleagues are practicing safe and effective psychopharmacology. As I will indicate in my response to Dr. Mishler [to follow tomorrow], data from the Dept. of Defense program are not directly applicable to psychologists prescribing in New Mexico and Louisiana.
Furthermore, the absence of evidence is not "evidence of absence." The mere absence of adverse reports is not scientific evidence of safe practice, and is notoriously susceptible to whims of reporting, vested interests in concealing adverse reactions, apathy on the part of "collaborating" physicians, fear of malpractice suits, etc. If we applied the same "let's wait for bad reports to trickle in" logic to the safety of medications marketed for medical illnesses, the public outrage would well up like a tsunami!
Incidentally, as someone who has both a sibling and a cousin who are psychologists--and who had wonderful psychologist mentors during residency--I have no vested interest in antagonizing my psychologist colleagues! Nor do I worry about "competing" with psychologists, as I am no longer actively seeing patients.
Rather, for me, it is a matter of science and the public safety to insist that the burden of proof must rest with those who assert medical prerogatives but who omit the time and training required by physicians (or, for that matter, required by clinical nurse specialists, with whom I have collaborated very productively.).
Finally, I do thank Dr. Huff for his kind remarks on my lectures. And, I will add that I often find the reports of neuropsychologists to be extremely useful; indeed, I believe both psychologists and neuropsychologists contribute a great deal to the care and treatment of many patients treated by psychiatrists.
DR PIES REPLIES TO DR MISHLER AND MR MORRIS-OSTROM:
I appreciate Dr. Mishler’s frank critique of my editorial; however, a careful reading of what I actually said will show that Dr. Mishler has attributed views to me that I neither state nor hold. First of all—as one who received invaluable training from psychologists during my residency—I have the utmost respect for psychologists, and in no way suggested that psychologists would be “reckless” or prone to “shirk responsibility.” In my first case vignette—that of Ms. Malfortuna—the “prescribing psychologist” made a good-faith attempt to discuss the patient’s medical condition with the patient’s primary care doctor, who (quite realistically, I believe) was very rushed at the time and did not discuss the case adequately with the psychologist. The errors in that case—failing to recognize two admittedly subtle adverse drug-interactions—could still have occurred if a primary care physician or even a psychiatrist had been caring for the patient. (Indeed, I heard from one experienced psychopharmacologist who was not aware that the anti-microbial, linezolid, was a monoamine oxidase inhibitor). The point of the vignette was not to cast aspersions on psychologists, or to show that “prescribing psychologists” would be uniquely susceptible to errors; but rather, to show that the stakes in “prescribing” are very, very high—indeed, they are sometimes a matter of life and death. If saying so amounts to inspiring “fear”, as Dr. Mishler implies, then I shall have to plead guilty.
The second of my case vignettes involved a complicated set of medical problems, including one endocrine disorder (SIADH due to an antidepressant) and a neurological disorder (akathisia). While I am pleased that Dr. Mishler’s masters-level course used my psychopharmacology Handbook, neither that text nor any psychopharmacology text would adequately equip a psychologist to diagnose endocrine or neurological disorders, or to take appropriate medication management steps in light of such disorders. (Incidentally, by way of disclosure: I have no doubt whatsoever that I could sell a great many more of my psychopharmacology textbooks if the pool of “prescribers” included psychologists—I guess I’ll just have write the Great American Novel!).
The art and science of medicine is more than the study of drug interactions and pharmacokinetics—it is a comprehensive understanding of how these issues are affected by, and impinge upon, the function and dysfunction of the brain, heart, liver, kidneys, pancreas, and skin, in both health and disease. It is not a matter of one’s willingness to assume medical-legal responsibility, as Dr. Mishler seems to assume—it is a matter of whether one has the training to do so. My position is that trying to tease out “prescribing” from the art and science of general medicine is like trying to separate skin from bone, using a paring knife—it can’t be done without injury to the patient.
Dr. Mishler asserts that my characterization of prescribing psychologists “is not based on evidence.” Specifically, Dr. Mishler asserts that “…the records show the psychologists are safely prescribing…” and that “…there are no reports of harm at the hands of prescribing psychologists, not in New Mexico, not in Louisiana and not in the DoD program.” First: let’s be clear that the DoD program was not remotely comparable to the psychologist prescribing systems set up in New Mexico or Louisiana. In the DoD program, a minuscule number of psychologists—ten—were methodically and intensively monitored and supervised by clinical psychiatrists. This is certainly not the case in either New Mexico or Louisiana. Moreover, a study of the DoD program by the American College of Neuropsychopharmacology (ACNP) revealed that while the psychologists performed very well,
“… the majority of psychologists trained by the DoD to prescribe medications treated patients in outpatient clinics rather than hospitals. The majority of patients treated in these settings were diagnosed with adjustment disorders, anxiety disorders or depressive disorders. Only one trainee treated patients with more serious or acute psychiatric conditions in an inpatient setting.” (from NAMI website)
Furthermore, according to NAMI,
“…Even though the DoD curriculum was scaled back after year one, it still required significantly more academic training and clinical training and supervision than the New Mexico law requires. For example, the DoD curriculum required 660 hours of academic training versus 450 for the New Mexico curriculum. Additionally, the DoD curriculum required approximately 1,900 hours of clinical training versus a minimum of 400 hours to be granted conditional certification in New Mexico.”
Not incidentally: the proposed Oregon statute, as I read it, does not even require that the “prescribing psychologist” collaborate with a physician; but rather, with “…the health care professional who oversees a patient's medical care”. Does this mean a physician? A nurse practitioner? A physician’s assistant? The wording clearly does not require any collaboration at all with a psychiatrist, unlike in the DoD program.
Thus, it is not possible to extrapolate from the DoD study to the “natural” conditions faced by psychologists in New Mexico or Louisiana; nor is it scientifically defensible to apply the DoD safety data to the “real-world” of clinical practice in those states. To my knowledge—and if Dr. Mishler has seen “records” or published data to the contrary, I’d welcome the references—there has been no systematic evaluation of prescribing patterns and clinical outcomes among patients medicated by psychologists in these states—none. I do not subscribe to the view—evidently endorsed by Dr. Mishler—that “absence of evidence is evidence of absence.” That is, I do not believe it is scientifically defensible to assert that if there are no reports of death or serious injury among patients medicated by psychologists in these two states, we are therefore entitled to conclude that the psychologists have performed safely and competently. Let me add that such might well be the case—we simply do not know. But relying solely on incoming reports from patients, psychologists, or physicians is not a scientific method of assessing risk.
We would need comprehensive tracking data, concerning the kinds of prescriptions written by these psychologists; whether the prescribed agent was appropriate to the diagnosis; whether the dosing was appropriate; whether co-morbid or underlying medical conditions had been ruled out or considered; whether the prescribing psychologist had adequate consultation with a physician, etc. None of this means I consider the psychologists in these states “dangerous prescribers”, as Dr. Mishler mistakenly infers from my editorial. On the contrary, I would guess that the majority have practiced responsibly and competently—but this misses the point: the general public and the scientific community should not have to “guess” about such a critical issue. We need the actual research.
I suspect that if we were discussing an ingestible product, instead of a service, Dr. Mishler and others (including some psychiatrists) would take a very different position on the matter of what counts as “evidence” of safety. That is, if a drug company produced a new antidepressant, and asserted, in defense of the drug’s safety, “Well, so far, we haven’t gotten any adverse reports back from any patients or doctors,” I would expect the company to be the target of professional ire, consumer outrage, and legal sanctions by the U.S. Food and Drug Administration.
Nor do I buy the notion that the burden of proof rests upon those who caution against extending medical practice to psychologists—for that is what “prescribing” entails. On the contrary: following the dictum, “First, do no harm,” the burden of proof rests firmly on those who would assert the right to practice medicine, having spared themselves the time and inconvenience of standard medical training. When I see such evidence, I may indeed reconsider my position.
Finally, with respect to psychology doctoral candidate Randall L Morris-Ostrom: I appreciate your referring me to the American Psychological Association Recommended Postdoctoral Education and Training Program In Psychopharmacology for Prescriptive Authority. This is indeed a remarkable document, and worth the time of any physician interested in these matters. My first response to the incredibly ambitious curriculum was to think, “My goodness—this sounds remarkably like medical school!” I was astounded to find that among the “clinical competencies that may be associated with the domain of instruction” was coursework in physical examination and “Laboratory and Radiological Assessment”! Furthermore, this coursework is intended to be integrated with “…supervised clinical experience or lab experience in conducting physical exam, ordering psychometric and laboratory tests, understanding results and interpretation.” Indeed, Mr. Morris-Ostrom: if such a curriculum were actually put in place, and required by law for all “prescribing psychologists”, my concerns and misgivings would be greatly allayed. But these are merely theoretical proposals—and I have yet to see any of them written into the laws of Oregon or any other state now granting “prescribing privileges” to psychologists. Indeed, the comprehensive nature of these training proposals does not diminish my belief in the necessity of a thorough medical education, Mr. Morris-Ostrom—it strengthens it.
For further reading: see the Dec. 2004 Psychiatric Services.
References
1. Lund-Muzikant D. Governor wields final say on psychologist. The Bill Lund Report. Online at http://www.thelundreport.org/resource/governor_wields_final_say_on_psychologist_bill.
2. The complete text of the legislation may be found at: http://www.leg.state.or.us/10ss1/measures/sb1000.dir/sb1046.en.html
3. Rothbard AB, Blank MB, Staab JP, et al: Previously undetected metabolic syndromes and infectious diseases among psychiatric inpat ients. Psychiatr Serv. 2009;60:534-537.
4. Cozza KL, Armstrong SC, Oesterheld JR. Drug Interaction Principles for Medical Practice, 2nd ed, Washington DC, American Psychiatric Press, 2003.
5.http://www.nami.org/Template.cfm?Section=Issue_Spotlights&template=/ContentManagement/ContentDisplay.cfm&ContentID=8375
6.Robiner WN, Bearman DL, Berman M, et al. Prescriptive authority for psychologists: a looming health hazard? Clinical Psychology: Science and Practice. 2002;9(3):211-221.
7.Pollitt B. Fool’s Gold: Psychologists using disingenuous reasoning to mislead legislatures into granting psychologists prescriptive authority. Am J Law & Medicine. Jan 1, 2003
8. Sola CL, Bostwick JM, Hart DA, et al. Anticipating potential linezolid-SSRI interactions in the general hospital setting: an MAOI in disguise. Mayo Clin Proc.2006;81:330-334.
9. http://www.breastcancer.org/treatment/hormonal/serms/tamoxifen.jsp
10. Pies R. Handbook of Essential Psychopharmacology. Washington DC, American Psychiatric Press, 2005.
11. Leo RJ. Movement disorders associated with the serotonin selective reuptake inhibitors. J Clin Psychiatry 1996;57:449-454.
12.Jacobson SA, Pies RW, Katz IR. Clinical Manual of Geriatric Psychopharmacology. Washington DC, American Psychiatric Press, 2007.
13. Fabian TJ, Amico JA, Kroboth PD, et al. Paroxetine-induced hyponatremia in older adults: a 12-week prospective study. Arch Intern Med 2004;164:327-332.
14. Fukagawa M, Kurokawa K, Papadakis MA. Fluid & electrolyte disorders. In: Tierney LM, McPhee SJ, Papadakis MA (eds). Current Medical Diagnosis & Treatment. New York, Lange, 2004. 15. Yellowlees P, Burke MM, Marks SL. et al. Emergency telepsychiatry. J Telemed Telecare. 2008;14:277-281.
- From Ron Pies:
Stephen Mack raises an important and unsettling issue: the waning attention given to the art and science of psychotherapy, within the field of psychiatry. Let me say, first, that in my own residency, I was privileged to have had extensive training from some of the best psychotherapists in the field--including, by the way, two wonderful psychologist supervisors. There are many thousands of psychiatrists who are highly-skilled psychotherapists, and many who still integrate psychotherapy into their practice.
That said, I am painfully aware that psychotherapy training has declined in many (though not all) residency programs; and that all too many psychiatrists have been relegated to the role of doing "med checks"and writing prescriptions. (Although, as Glen Gabbard MD has noted on this website, even the infamous "15 minute med check" often requires the skills and knowledge of psychodynamic psychotherapy).
I do not see any easy remedy to these trends, short of a massive reform in psychiatric education. My own (somewhat utopian) view is that psychiatric residency should be extended by another year--expensive, and time-consuming, yes, but there are several precedents for this in various combined residency programs [see my debate with one of my mentors, Dr. Robert Daly, on this website: http://www.psychiatrictimes.com/display/article/10168/1532271].
I believe that there could be a concomitant reduction in the total length of medical school training, as my colleague, Dan Carlat, has proposed on his own blog site. I believe the "fifth year" in psychiatric residency should focus not only on learning the art and science of psychotherapy, but of exposing the resident to the "humanizing" influences of poetry, literature, spiritual traditions, and philosophy. Yes, I know--it sounds a bit naive, but there you have it: my proposal for something I call "encephiatrics" ["brain healing"], and which might better be termed, "person healing."
Best regards, Ronald Pies MD
There is real gold in Dr. Pies article and the commentary, but I think more to be found. Where this leaves us, I believe, is three major challenges: 1.Clarify what is the identity and role of each mental health professional discipline 2. How do we enhance these roles in education? 3. How do we monitor whether adequate quality of care ensues? I would suggest that it is not a long jump between psychologists being permitted to make a DSM psychiatric diagnosis, often laden with medical considerations, to concluding that they should then be able to prescribe medications. If diagnosis leads to treatment, let's clarify our roles in both. The major unique role for general psychiatrists should be careful diagnosing, then combining medication and psychotherapy by one psychiatrist. Training should focus on that. We need a new subspecialty of "qualitists" in medicine in general, and psychiatry in particular, that would have the skills and time to devise and monitor competent clinical care. This would take an extra Fellowship year or two of training, and then should be reimbursed highly by pooled funds to avoid conflict of interests.
- Thanks to Dr. Moffic for the thoughtful comments on my editorial. I agree with the 3 main goals he outlines. With respect to diagnosis, the special report on neuropsychiatric disorders in the March issue of PT leaves little doubt that medically-informed diagnosis is absolutely critical, when faced with so-called "psychiatric"symptoms, such as psychosis. Thus, it is inconceivable to me that a non-medically-trained clinician could justify a final diagnosis of, say, "schizophrenia" without first ensuring that a myriad of neuropsychiatric disorders had been considered and ruled out. Even a skilled psychiatric physician would need outside consultation in ruling out some of the more exotic diseases discussed in, for example, the article by Kayser & Dalmau (on encephalopathies); but the notion that any mental health professional can render a final diagnosis without medical input seems to me very dubious. I think the upcoming DSM-5 ought to stipulate a "provisional" or "pending medical evaluation" category for any diagnoses reached by non-MDs--but I doubt this will ever be the case. That said, I also think we need to maintain a degree of humility re: our own diagnostic skills, since psychiatrists routinely "miss" underlying medical/neurological disease in their patients. I still remember (painfully!) a case of tertiary syphilis that eluded me, many years ago, working in the state hospital setting. But this just points up the need for more skilled medical diagnosis in dealing with "psychiatric" illness! As for psychologists "prescribing" medication, well--
'nuff said on my part! --Ron Pies MD
Dr. Pies has succinctly described real-life scenarios. As a Louisiana psychiatrist, I have also witnessed confusion regarding the 'medical psychologist' among the public. As prescribers, they sign: MP - which in handwriting can easily look like MD. The ambiguity also leads to misrepresentation of discipline and "trade" (does this suggest a legal issue?) Unfortunately, people tend to think that a psychiatrist is no more than a psychologist who prescribes, missing the mission and training of a physician altogether. To make matters worse, as of January 2010, medical psychologists are licensed by the Louisiana State Board of Medical Examiners! I have witnessed, on the other hand, that the need for psychiatrists here has not decreased, and the addition of medical psychologists has not noticeably solved the problem or met perceived needs. LA psychiatrist.
from Ron Pies:
Many thanks, Dr. Fam--it is good to hear from somebody on "the front lines"! This entire "MP"debacle is what, in computer parlance, is known as a "kludge" (usually rhymes with "fudge"); i.e., in J.W. Granholm's definition, "An ill-assorted collection of poorly-matching parts, forming a distressing whole"; or, a "program that has been improvised or 'bodged' together; a hastily improvised and poorly thought-out solution..." [see Wikipedia]. Let us hope--and work to ensure--that this same ill-advised and poorly-studied farrago of "treatment" does not spread to still more states!
- Editorials, Health » A veto is the proper prescription By The Oregonian Editorial Board April 02, 2010, 4:10PM A bill the Legislature passed and sent to the governor to make Oregon only the third state to allow some psychologists to prescribe drugs to treat mental conditions puts the issue of patient access above all others, including safety. It doesn't belong there.
Yes, access to psychiatrists, nurse practitioners and others who can legally prescribe drugs for psychological disorders is a problem in parts of Oregon, especially in rural areas. But if Oregon plunges ahead with a law allowing psychologists to prescribe these drugs, the scant track record in other states suggests that most of the new prescribers still will be clustered in cities.
If there's no promise of much-improved patient access where it is most needed, there is no compelling argument for the bill that sits on Gov. Ted Kulongoski's desk. A spokeswoman for the governor said Kulongoski is still undecided about whether to veto the legislation or sign it into law.
There are many strong, long-standing reasons to maintain the tradition of reserving the power and responsibility of prescription to psychiatrists and other primary care professionals who have extensive training in biology, organic chemistry, physiology and other sciences that help explain how chemicals affect the body.
The large and growing number of drugs now available to treat psychological conditions are enormously complex, and they can and do interact in potentially life-threatening ways with other medications. New research continually reveals previously unknown side effects or interactions with some popular drugs. It makes little sense for Oregon to choose now to lower the high bar it has always maintained for the authority to write prescriptions.
It's true that the Legislature, guided by a work group of psychologists and physicians, sought to balance the issues of patient access and safety. The bill limits eligibility to psychologists with doctoral degrees and would require psychologists to spend at least two years studying how drugs affect the brain and body. Psychologists also would be expected to "collaborate"with the physician overseeing the patient's medical care, but the law is somewhat vague on that point.
That was good enough to satisfy a majority of legislators, who passed the bill over the objections of the Oregon Medical Association and the Oregon Psychiatric Association. It's noteworthy that the one physician in the Oregon Senate, Alan Bates, an osteopathic physician, strongly opposed the bill. "I don't know why we've done this," Bates said in a recent interview.
We don't, either. Most Oregon communities are adequately served by licensed physicians who prescribe psychological drugs and monitor their use. In the most remote places where access is a serious problem, it's hard to imagine that there are many psychologists with Ph.D.s waiting to move in and fill the gaps in medical services.
Oregon has a good, safe and time-tested system regulating drug prescriptions. The governor should veto Senate Bill 1046, and keep it that way.
[sent by Ronald Pies MD]
Dr Pies... If prescribing psychologists are as dangerous as you suggest, why did you have to make up these examples of patient harm? Wouldn't there be plenty of examples of real situations where the prescribing psychologist harmed or even killed their patients? There have been thousands of prescriptions by prescribing psychologists, if they are so reckless, surely there are more than enough examples of harm to discuss. Alas, you had to make up these examples because there are no reports of harm at the hands of prescribing psychologists, not in New Mexico, not in Louisiana and not in the DoD program. None. That would suggest your inflammatory examples are not evidence based...but based on something else. I find it curious that you would presume the post doctoral Masters in Psychopharmacology would not instruct the psychologists about drug interactions, and cytochrome enzymes. That would seem to suggest you haven't reviewed the actual program courses and material. As a graduate, I can assure you we most certainly did study drug interactions, and frequently discussed and reviewed the various cytochrome enzymes involved in psychotropic medications. As I read your post it seemed you were disregarding the postdoctoral education, or were unaware of it, and making comments about psychologists as they are typically trained in their graduate programs. If so, I'd have to agree that the graduate programs do not prepare psychologists to prescribe, that education is post doctoral. I also find it curious that you suggest psychologists would take some sort of adolescent or princess attitude about responsibility. Of course we don't want to be called in the middle of the night, who does? But to suggest we can't or won't comprehend that after hours calls are part of the responsibility of prescribing is a strange innuendo since there's no evidence to suggest as a whole psychologists tend to shirk responsibility. You comments are quite inflammatory and seem to be framed to induce fear, but they are not based in evidence. It makes me a bit sad to see you take the position you have, and to make these not so subtle innuendos about the profession of psychology. In the time since I completed my post doctoral Masters in Psychopharmacology, I have taken additional CE courses to keep fresh while waiting for the legislative process. One of the course I took, and enjoyed, was based on your Handbook of Essential Psychopharmacology. If prescribing psychologists were as poorly trained as you suggest, then the course should have been way over my head. Instead I found it to be a great refresher, and recommended to other Psychopharmacology graduates. I'd like to ask you to consider that your characterization of prescribing psychologists is not based on evidence, and the fear inspiring innuendo is motivated by something other than a concern about harm because the records show the psychologists are safely prescribing. It wouldn't take thousands of prescriptions and years of prescribing for truly dangerous prescribers to start racking up reports of patient harm.
I am sympathetic to the author's concerns. However, he seems to assume that the training of prescribing psychologists will be poor and that the psychologists themselves will not be aware of their own limitations. The American Psychological Association has a model curriculum that I believe responds to some of these concerns: http://www.apa.org/about/governance/council/policy/rxp-model-curriculum.pdf
I think it is worth asking what level of knowledge prescribing psychologists would need to have if they were to prescribe safely and effectively. Should they be required to have the same level of knowledge as a primary care physicians, psychiatrists, or psychopharmacologists? Each group has a very different levels of expertise. Also, along these lines, exactly what level of knowledge is required to prescribe effectively? (I take the answer, "medical school", to be begging the question.)
[disclosure - I am a doctoral student in psychology interested in psychopharmacology. I am doubtful whether I would want to prescribe because I am concerned it would take away from a focus on psychotherapy, but it is an issue that interests me.)
- I appreciate the comments of Dr. Mishler and Mr. Morris-Ostrom, and I will have a detailed response available shortly. --Sincerely, Ronald Pies MD
Malpractice risks and some training requirements tend to diminish the number of psychologists who actually prescribe. I am curious if these laws broadening who can prescribe actually have the desired effect of increasing the prescriber pool, as psychiatrists may choose to locate to states without non-physician prescribers. I work in a state that allows Psychiatric Clinical Nurse Practitioners to prescribe with limited supervision from physicians. There continues to be a shortage of psychiatrists, probably because psychiatrists are paid less than in other states. I do not see this having a positive affect on access to care.
- Thanks to Dr. Huff and Dr. Klein. I will respond in detail soon. --R. Pies MD
Dear Ron Pais.M.D. As always this is good review for all Psychiatrist. Rajendra Trivedi, M. D. CCA and Pain center, Stoneham, Ma 02188
- Thanks to Raj Trivedi for the positive feedback!--Ron Pies MD
I tried to post a comment earlier, but I guess my old (senile) computer didn't get the job done. My argument is that, as a neuropsychologist, I frequently see patients who tell me that their psychiatrist never spends more than about five minutes before handing over a script which essentially is an attempt to minimize the symptoms, rather than dealing with any underlying issues. Many patients, or their parents/guardians, have informed me that their psychiatrist knows virtually nothing about them, nothing about their family dynamics, the multigenerational pattern of abuse in the family, quality of peer relationships, etc. And seriously, what non-MD clinician is going to say, "You know, I think your problems may be related to an underlying physicial condition, so I'm going to refer you to a psychiatrist for a medical workup."Not likely. If there is a hint of organic underpinnings to the patient's clinical presentation, the patient gets referred to their PCP or a neurologist. I've never had a patient tell me that a psychiatrist performed even a rudimentary physical exam. And even when I do make a referral to a psychiatrist, it's not uncommon for the client to call back and lament that every psychiatrist they called has a waiting list of 3-5 months! Then there's the time that a psychiatrist included a comment in his evaluation that the patient appeared to have "average" cognitive ability, when a subsequent IQ test yielded a score in the low 60s. Every child or adolescent I've seen in the past few years who had any sort of behavioral or emotional problems was prescribed medication for ADHD and of course an atypical antipsychotic, because any sort of misbehavior from a child is evidence for a bipolar spectrum disorder. Some of these kids are good students and never get in trouble at school due to behavior problems, but the quality of parenting may be quite poor; no matter, here's your Ritalin and Abilify -- see you next month! Many patients are actually surprised when I inform them that a psychiatrist is actually a physician. So, you can come up with any number of scenarios demonstrating that prescribing psychologists (i.e., those with a Ph.D. and a Post-Doctoral Master's Degree in Clinical Psychopharmacology) will endanger their patients. Where's your proof? Psychologists have been prescribing in two states for several years ... and where is the list of clinical mishaps? Patients do sometimes get harmed by psychiatrists. That's beyond dispute. But where are the reports of prescribing psychologists harming their patients? I'd wager that prescribing psychologists are under tremendous scrutiny from the medical community, but thus far there do not appear to be any medicaton-related mishaps by psychologists. (As an aside, I've enjoyed many of Dr. Pies' lectures on cd over the years and he is truly an outstanding presenter. On this one particular issue I can't help but strongly disagree with his opinion about this important issue.)
This comment did not post on my browser the first time it was submitted. Apologies if it shows up twice. I have read here, and in other comments on different blogs, that folks are conflicted about this issue. Personally, I am not. As I School Psychologist, psychotherapist (20+ years) and more recently, a Registered Nurse and graduate student in Nursing, I have very strong feelings about this issue. Perhaps not the most popular opinion, but here goes....
When I was in clinical psychotherapy practice, I developed a keen interest in how my clients were being medicated. I read a lot, consulted with colleagues and psychiatrists, attended may different types of workshops and trainings (over several years), and thought I had a fairly good understanding of psychotropic medications. I made the decision to become a psychopharmacology specialist 8 years ago. Feeling too old to begin medical school, I decided my best option was to become an Advanced Practice Nurse. First step, Nursing School. Then, Graduate School in Psychiatric Nursing (MS) and Board Certification in Psychiatry, to become a Psychiatric Clinical Nurse Specialist.
After 6 years of graduate training in Psychology, I thought it would be a snap to get another Bachelor's Degree. Was I ever wrong! it was my most difficult and challenging academic experience. In addition to Nursing-specific classes, we were required to take at least 2 Biology classes, Microbiology, Anatomy, Physiology, Pathophysiology, and of course Pharmacology classes, plus 2 years of labs and hospital clinical rotations every semester (including summer sessions). We also had to take a Health and Physical Assessment class, in order to learn how to do comprehensive physical and neurological examinations. In addition, Chemistry and/or Biochemistry were required as prerequisites.
In my graduate training, ALL of these classes were required at advanced levels, plus Psychopharmacology, Advanced Psychopharmacology, and 600 internship hours of psychiatric/clinical rotations.
Was all this really necessary to become competent as a prescriber? Absolutely! Nothing less should be required for a basic level of proficiency in psychopharmacology. It is not enough to know about some of the SSRI's, a few of the benzos and atypical anti-psychotics. Older medicines (TCA's, MAOI's, first generation anti-psychotics)are still being used. Others include injectables and their active metabolites, the methylphenidate and amphetamine salts groups, sedative/hypnotics, SNRI's vs.. SSRI's, generics vs. brand name medications, etc. Plus, new medications are coming out all the time, and one needs to know how to interpret medical research, which is different from psychological research.
It is also essential to have experience with and an understanding of lab values and how to interpret them, polypharmacy, side effects, medical complications of psychoactive drugs, co-occurring medical and psychiatric disorders, detoxification and withdrawal, extrapyramidal side effects, serotonin syndrome, hormonal functions, basic brain chemistry and structure, seizure disorders and other neurological disorders. These are just some of the issues that come with psychopharmacology in clinical practice.
I do not know the specific requirements that Oregon, Louisiana on the Department of Defense have put forth for psychologists who want to obtain prescriptive privileges, but personally cannot support any legislation that does include courses mentioned in this post. As a member of both camps, I believe that thinking you can do more with anything less is grandiose on the part of the practitioner, unethical, and professionally irresponsible. Practitioners need to work within the scope of their practice and professional licensure, and not cross those boundaries. I would not have said this before becoming a nurse.... I really thought I was knowledgeable enough, and would be more than competent with a couple of extra graduate courses in psychopharmacology. I was sincere in my desire to help patients, but I was wrong.
The most helpful approaches include more than one modality. Medicine, therapy, exercise, diet, recovery from substance dependence, meditation, relaxation and play (any and all combinations!) work best for overall health maintenance. If there is a shortage of psychiatrists in your community, refer your clients to a Psychiatric Clinical Nurse Specialist or a Nurse Practitioner with Board Certification in Psychiatry. If you want to prescribe yourself, please consider Nursing or Medical School.
- Dear Dr. McGrath--I very much appreciate and agree with the spirit and substance of your comments. In fact, I hope you will re-post them in the comments section under my latest blog, re: the now vetoed Oregon bill. A little knowledge is a dangerous thing, as you so eloquently state! --Best, Ron Pies MD
I'm a psychologist in Canada, Ontario specifically, and right now anyway prescription privileges are not a big topic of conversation, but I know that some of my colleagues think it would be a good idea. While I'm not necessarily opposed, I persoanlly have no interest, for many of the reasons already discussed. In undergrad I had a room mate who was in his last year of pharmacy and I saw what he was studying. I work closely with nurses and psychiatrists and I see some of what is involved in prescribing psychotropics. We have a patient who had a serious adverse reaction to his meds a few years ago and the attending psychiatrist (who is also a trained pharmacist) spent several weeks getting his medications adjusted properly.
I think the training and general knowledge required to competently prescribe is sufficiently specialized that in order to achieve that competency psychologist would have to undergo extensive training and supervision. As Caroll McGrath described, it is well beyond what many psychologists expect or probably would be willing to do.
Jan Looman, PhD, C. Psych.
- Thank you for this Canadian perspective, Dr. Looman. "Prescribing" (a misnomer if ever there was one) is often a challenge even for an experienced MD-psychopharmacologist, particularly when the patient is taking multiple medications, has several comorbid medical conditions, etc. Ars longa, vita brevis!--Ron Pies MD
I cannot understand why a Ph D or Psy D in psychology would want to practice prescription responsbility without also earning a medical degree first. Dual degrees are doable. They also enhance education and advancement in the practice of both fields. Larry W Zuberbier Ph D retired psychologist, Seattle
Just a brief note to Dr. Pies: Why would anyone prescribe without running a DDI checker? I just did it as a matter of practice (through medscape) and there are severe level 2 warnings on the three med interactions. Red flags. Plus she's 60 y.o. I teach my students to do this (for themselves) and if they find out their pts are taking meds the psychiatrist does not know about, run the DDI and call him or her to inform regardless (of its outcome).
I believe we all have to practice to our highest standard of care.
I thank Dr. Altman for her very pointed question, "Why would anyone prescribe without running a DDI [drug-drug interaction] checker? "In the spirit of Talmudic discourse, I'll answer first by posing a question to Dr. Altman:
Why are there over 1.5 million adverse drug reactions in the U.S. each year?
Normal 0 false false false EN-US X-NONE X-NONE MicrosoftInternetExplorer4 /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-qformat:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin-top:0in; mso-para-margin-right:0in; mso-para-margin-bottom:10.0pt; mso-para-margin-left:0in; line-height:115%; mso-pagination:widow-orphan; font-size:11.0pt; font-family:"Calibri","sans-serif"; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi;} In July 2006 the National Academy of Sciences' Institute of Medicine (IOM) issued a report that was summarized by Marc Kaufman, of the Washington Post, in his July 21, 2006 article about the IOM report: "At least 1.5 million Americans are sickened, injured or killed each year by errors in prescribing, dispensing and taking medications.... Mistakes in giving drugs are so prevalent in hospitals that, on average, a patient will be subjected to a medication error each day he or she occupies a hospital bed.... The report found errors to be not only harmful and widespread, but very costly as well. The extra expense of treating drug-related injuries occurring in hospitals alone was estimated conservatively to be $3.5 billion a year. The IOM report found that some of the more common medication errors involved doctors writing prescriptions that could interact dangerously with other drugs a patient is taking.
And so, evidently, many clinicians are not doing DDI checks; or, they are not getting accurate information on the DDI they are checking. I suspect the former is more often the case. Why don't they check for DDIs? Probably because they think they know more than they do; and because they are rushing to deal with an overwhelming work load. And--because we are all fallible human beings.
But let me be clear: my vignette on Ms. Fortuna was not intended as a claim that prescribing psychologists are necessarily more likely than physicians to fail at checking for a DDI. The vignette was intended to show how high the "stakes" are when one becomes a "prescriber": it is literally a matter of life and death, in many cases. Therefore, it makes clinical sense that we would want those with the highest degree of medical training and expertise to be prescribing and/or supervising prescribing.
To put it another way: when you tell somebody to take a medicine internally, you better be prepared to practice internal medicine. This is completely counter to the nonsense spouted by some who have advocated for "psychologist prescribers"; i.e., that "prescribing is no big deal." On the contrary--it is a very big deal. If you take on that responsibility, you had better be prepared to deal with all the medical and legal consequences. --R. Pies MD
For years I have been asking the APA to take a position on the pervasive practice of allowing non-medical professionals to make medical diagnoses. When I was about to give up on my hopeless quest, Dr. Carlat's position on the issue of prescribing psychologists emerges as an even scarier scenario. I say so because, for example, anything I publish can be dismissed as "coming from that unknown guy down in Florida."In contrast, when somebody with the stature of Dr. Carlat supports the desperate measure of using a magic wand to transform a person without medical training into a prescribing psychiatrist, the opposing corner is going to proclaim "You see?...we are right!" I even oppose pediatricians diagnosing and prescribing Schedule II controlled substances to children, because they don't have the training to identify other conditions that mimic ADHD, nor are most pediatricians aware of the exclusionary criteria in DSM-IV-TR. I can say this because I started my post-graduate training with a full year in pediatrics. Besides, as a C&A fellow, I spent time with pediatric Residents doing their three-month rotation in psychiatry…This would be like my claiming to be an expert in neurology because I did two neurology rotations, adult and child. As Dr. Pies stated "this is a very big deal"…we are talking about lives. Are we forgetting how our colleagues in the C&L setting react when we alert them of drug-drug interactions? …and they are physicians! Have any of you ever been asked by an experienced ICU nurse, "Doctor, why do you want to have an EKG before giving Haldol to this patient?" He or she never heard of the dangers of QTC prolongation associated to psychiatric treatments. A lot more could be said but I just want to remind those who support non-physician prescribing of this fact: the consequences of making a mistake in the interpretation of a psychological test are not the same as those of giving a patient the wrong diagnosis and hence, the wrong medication. Finally, do we remember that nurse practitioners (NPs) are supposed to be supervised by a physician? What is happening in the real world? They work independently and come to us to sign prescriptions of controlled substances they have already decided the patient needs…I would like to have a dollar for every time I have refused to sign a Rx from a NP? of an amphetamine for a patient who is already taking a benzodiazepine for anxiety. Manuel Mota-Castillo, M.D. Lake Mary, Florida
Re: "Prescribing Psychologists:" Practicing Medicine without a License?
Right. Good points. But conversely, there are all of these psychiatrists not practicing psychology at all, or practicing it with little skill. Although ostensibly, they are supposed to have that competence.
From either direction the patient is ill served.
So how would you address that?