45,000 More Psychiatrists, Anyone?
45,000 More Psychiatrists, Anyone?
Houston, we have a problem. There is a critical shortage of psychiatrists. And the problem is not in Houston alone-- it includes the entire state of Texas, and every other state in the union (Mid-town Manhattan, Boston-- Beacon Hill, and Sacramento Street in San Francisco might be exceptions).
According to the most recent of studies commissioned by the government, America is shy about 45,000 psychiatrists. And the shortage will get worse, because many psychiatrists are reaching retirement age.
Before commenting on possible solutions, let's get a better fix on where this rather astounding number comes from. After all, labor statistics are politically charged quantities because they are often used as ammunition for various stakeholders to win funding for pet programs. So it's important to be skeptical.
The underlying data were published as a series of 3 articles in the October 2009 issue of Psychiatric Services. The research was commissioned by the Health Resources and Services Administration and was done by researchers at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. Here I'll focus on the study by Konrad and colleagues,1 since it provides a good overview of the entire project. To facilitate ease of reading, I am not including all the references to other studies discussed in the original paper. I urge interested readers to peruse the original article for more details.
These researchers started with what they considered to be the most reliable recent estimates of the prevalence of mental illness in this country--the National Comorbidity Survey Replication (NCS-R) of 2001. That study was a random house-to-house survey of more than 9000 people. The authors did not want to simply use the NCS-R's figures at face value because that would have included many people whose mental illnesses are not particularly severe. Instead, they identified only those people who were functionally impaired and who had what they defined as "serious" mental illness--bipolar disorder, major depressive disorder, agoraphobia, generalized anxiety disorder, panic disorder, posttraumatic stress disorder, social phobia, or specific phobia.
You'll notice some glaring omissions here--most notably schizophrenia, substance abuse, and ADHD. Why weren't these included? There are various reasons, some having to do with the quality of the data they had to work with. The NCS-R data, oddly enough, did not include enough questions to reliably diagnose schizophrenia, so the researchers decided they could not come up with reliable prevalence numbers for schizophrenia. What about substance abuse? While the NCS-R data included substance abuse, there is little reliable data on how many substance abuse clinicians are out there, so they omitted this diagnosis from their analysis. And then there were a number of diagnoses the authors considered not serious enough to include--such as ADHD, conduct disorder, oppositional defiant disorder, dysthymia, and a few others.
The bottom line is that given the exclusion of many patients with disorders that required some kind of treatment, the study results are necessarily very conservative. Whatever shortage of services they discover will need to be amplified to make up for these uncounted patients. Nonetheless, using their particularly strict and conservative criteria, they estimated that the 1-year prevalence of "serious mental illness" in the US is 3.9%. The authors note that this estimate is very close to other recent estimates of the prevalence of significant disabling mental illness.
How much mental health treatment do these patients need? Using more data from NCS-R, the researchers stated that "about half of adults with serious mental illness used services; they typically spent 10.54 hours per year (95% confidence interval (CI), 5.46 to 15.63) with nonprescriber mental health professionals and 4.38 hours per year (CI, 3.40 to 5.37) with primary care physicians or prescriber mental health professionals."
Do these numbers sound right? Essentially, they are saying that patients with serious mental illness have about 1 therapy visit per month, and about 20 minutes per month of psychopharm-oriented visits with some prescriber. It sounds fairly realistic as an average, considering that some "stable" patients probably never see a therapist and just see their psychiatrist every 3 months or so for a medication refill, while on the other end of the spectrum, there are very ill patients who have at least weekly therapy sessions and biweekly psychopharmacological visits.
So how many mental health providers are needed? Now that the researchers estimated the number of patients with mental illness, the number of hours of care needed on average by each patient, and the amount of care provided by the average full-time clinician (I don't have the space to detail how they got that statistic, but it was derived from various surveys of practice patterns from the APA and other sources), they could calculate the bottom line--how many clinicians does the US need to treat its mentally ill citizens? They estimated that we need 25.9 psychiatrists per 100,000 population. This is an average number, which varies by county--typically, poorer people need more psychiatric time, so the need for help is greater in poorer counties.
The problem is that we only have roughly 10 per 100,000 practicing full-time psychiatrists in the US, or about 30,000 total. That's 15 per 100,000 too few, and assuming a population of about 300 million, we arrive at the estimated shortage of 45,000 psychiatrists. This is a very rough estimate to be sure--let's call it 45,000 plus or minus 15,000. Either way, it represents a mental health services crisis.
So--what are we going to do to solve this problem? I'm not sure, but here are some potential options:
1. Let's get the primary care physicians (PCPs) to absorb our excess patients. Sorry, but as family practitioner and writer Michael Victoroff once told me, "that donkey is overloaded already." PCPs are dealing with longer wait lists than psychiatrists and they are coping with a vast array of illnesses to manage. Outcomes research has shown that PCPs don't do the best job of treating psychiatric problems. For example, a recent study found that the mental health care dropout rate from PCPs was 32%--more than double the dropout rate from psychiatrists.2
These data are hardly surprising, since PCPs have barely enough time to hand out a pill and refer to a social worker, psychologist, or psychiatrist. And the psychiatrist will often be either unavailable or will refuse the patient's insurance.
2. Let's churn out more psychiatrists. That means expanding residency programs. That's a nice idea, but who is going to foot the bill? Medicare pays for the vast majority of residency slots in the US, and the going rate is upwards of $100,000 per slot. Is Medicare planning to shell out 45,000 3 $100,000 = $4.5 billion to solve the mental health access problem? Unlikely--in fact, we were lucky that President Obama's health care reform package is allocating $168 million to create only 600 more primary care physician residency slots. Most psychiatry residency directors feel lucky if they can simply hold on to the reimbursed positions they have now.
3. Let's train more advanced practice nurses and physician assistants. That might work over the long term, because the economics are more feasible. Physician extenders' training is shorter and less expensive, their incomes are lower, and they typically are more likely to work for underserved populations. One problem: they get very little training in psychology or psychotherapy--limiting their ability to properly diagnose and treat tough cases.
4. Let's give medically trained psychologists prescriptive authority. Though unpopular among psychiatrists, this is an increasingly viable solution. Psychologists with 2-year psychopharmacology masters degrees have been prescribing safely for 20 years in the military and for slightly less than a decade in New Mexico and Louisiana. (For a thorough review of this issue, see the recently published book Pharmacotherapy for Psychologists: Prescribing and Collaborative Roles.3 Our APA maintains an active and expensive lobbying program in order to defeat prescriptive authority legislation as it surfaces yearly in dozens of states. It may be time for us to reconsider whether this is money well spent. In my opinion, our battle against psychologists prescribing represents a short-sighted attempt to defend our professional turf at the expense of our primary responsibility, which is enhancing our patients' access to high-quality care.
Dr Carlat is associate clinical professor of psychiatry at Tufts University School of Medicine in Boston and editor in chief of The Carlat Psychiatry Report--a monthly newsletter on psychopharmacology. The Carlat Psychiatry Blog (www.carlatpsychiatry.blogspot.com) is consistently ranked as one of the 10 most influential health blogs. Dr Carlat is also a regular contributor to "The Couch In Crisis" blog on www.psychiatrictimes.com where this commentary is posted.
References
1. Konrad TR, Ellis AR, Thomas KC, et al. County-level estimates of need for mental health professionals in the United States. Psychiatr Serv. 2009;60:1307-1314.
2. Olfson M, Mojtabai R, Sampson NA, et al. Dropout from outpatient mental health care in the United States. Psychiatr Serv.2009;60:898-907.
3. McGrath RE, Moore BA, eds. Pharmacotherapy for Psychologists: Prescribing and Collaborative Roles.Washington, DC: American Psychological Association; 2010.
References
References
1. Konrad TR, Ellis AR, Thomas KC, et al. County-level estimates of need for mental health professionals in the United States. Psychiatr Serv. 2009;60:1307-1314.2. Olfson M, Mojtabai R, Sampson NA, et al. Dropout from outpatient mental health care in the United States. Psychiatr Serv.2009;60:898-907.
3. McGrath RE, Moore BA, eds. Pharmacotherapy for Psychologists: Prescribing and Collaborative Roles.Washington, DC: American Psychological Association; 2010.
If psychologists have to attend medical school to safely learn to prescribe, then psychiatrists must earn a doctorate in the study of human behavior (psychology) in order to do therapy. Psychiatrists are learning general medicine and pelvic exams while psychologists are learning personality, psychopathology, psychometric theory, and psychotherapy. Yet psychiatrists attempt to do therapy when they have little real training in it or the personality constructs underlying it. Psychiatrists can even order and interpret psych tests when they have NO training in it. Dr. Carlat is to be commended as objective and a rationalist.
If psychologists have to attend medical school to safely learn to prescribe, then psychiatrists must earn a doctorate in the study of human behavior (psychology) in order to do therapy. Psychiatrists are learning general medicine and pelvic exams while psychologists are learning personality, psychopathology, psychometric theory, and psychotherapy. Yet psychiatrists attempt to do therapy when they have little real training in it or the personality constructs underlying it. Psychiatrists can even order and interpret psych tests when they have NO training in it. Dr. Carlat is to be commended as objective and a rationalist.
Delivering babies, et cetera, is something that psychiatrists do before ever entering their four year residency training. Psychiatrists have courses in psychometric testing during their medical college training and during residency. A major part of the psychiatry board exam involves understanding basic concepts in human personality development, as well as psychometrics. You can fit a lot into 8 or 9 years of post-baccalaureate training. And by the way, seeing patients through their pregnancies and knowing what's happening to their bodies is an important part of knowing how to treat them psychiatrically---both empathically and with medications. And yes, we could always return to the pre-Flexner days of medicine. Who would benefit from that? John Bailey, D.O.
Why are non-physicians opining on this webpage? Don't they have their own publications? I guess they all want to play doctor. Julian Bravo M.D.
I think that we should keep it simple: Writing a prescription for a medication follows the making of diagnosis. Arriving to a diagnosis implies to know about multiple illnesses to rule out maladies that present with similar symptoms. For example a twisted ovary can resemble an appendicitis if the affected gland is on the right side. In other words, it takes medical knowledge to differenciate absence seizures from ADHD (I have seem several cases). By the same token a thyroid dysfunction can present as a "psychiatric case." I appreciate the help provided by the prescribing psychologists and pediatrician who treat childhood psychiatric problems but, if I were in their shoes, I would stay away from playing a role for which I am not qualified. Maybe some Forensic psychiatrist or any other expert could enlight us with data on law suits associated with psychiatric medications prescribed by psychologists and pediatricians. Who knows, maybe I am wrong. Manuel Mota-Castillo, M.D. Child psychiatrist Lake Mary, FL
It seems as if Dr Carlat is undermining the value of Psychiatric Nurse Practitioners. His apparent views are not uncommon. As a Psychiatric Nurse Practitioner I have worked with very difficult cases both in the military, in underserved communities and in affluent ones. I am sure that I'm not a rarity. I think that the quality of the provider is dependent in the training and the individual's desire to learn. Just as I have seen very bad Nurse Practitioners I have seen very bad psychiatrists who I would never recommend anyone to. Psychologists are good in what they do but I doubt that a psychopharm course is sufficient to provide a wholistic approach to properly diagnosing a patient's problems. This becomes more evident in the field of consultation liaison or in geri-psych when the problem may be as simply as a UTI or as severe as an endocrine issue. As we are unable to clone the existing psychiatrists or expeditiously train news ones at a reduced cost we should develop better training programs for both psychologists who want to prescribe and for NP/PA programs. I think that the patients would benefit from better trained providers. This refers to psychiatrists, psychologists, NPs/PA. Many of the patients that I have encountered from the affluent to the poor overall prefer their contact with a provider who is knowledgeable, caring, does not appear too aloof and is able to masks the fact that time is limited. Who is this type of prescriber?
Psychologists who have completed a two year postdoctorate master degree in psychopharmacology, supervised clinical training and examination have already been effectively prescribing in Lousiana and New Mexico and through the military. Psychologists with such training are not physicians or the equivalent of psychiatrists. Psychologists and psychiatrists have a long history of collaborative work, and prescriptive authority for those psychologists with advanced postdoctorate training will further support and expand such collaboration. It will make it possible for collaborative efforts to reach undertreated populations and expand the integration of psychopharmacology with behavioral treatments. Moreover, there has been a longstanding collaboration between physicians and psychologists in published research involving psychopharmacology. Such interdisciplinary efforts support the science which forms the basis of the interventions. Both disciplines contribute and are well represented in the neurosciences. Finding common areas of interest to our respective desciplines and ways to support those individuals needing effective interventions could be the best way to address the needs of patients.
The following comments are by Richard B. Stuart, DSW, ABPP. --The Editors Dr Stuart, a licensed psychologist, is Clinical Professor Emeritus, Department of Psychiatry and Behavioral Science, University of Washington and maintains a CBT practice in Seattle, Washington. More Risks Than Benefits If Psychologists Prescribe In his recent article in Psychiatric Times (August, 2010), Dr Carlat(1) calls attention to the need to expand the availability of psychiatric care. He doubts that primary care providers (PCPs) can do more than they already do to manage psychiatric problems, believes that the funds do not exist to expand psychiatric residencies, and faults the training in psychology and psychotherapy obtained by nurse practitioners and physician's assistants. He suggests psychogists should be granted prescription privileges as a way to meet the rising demand for psychiatric services. His recommendation includes a few inaccuracies and a lack of attention to some of the risks inherent in his suggestion. Contrary to his belief that all psychologists who prescribe would all be required to earn a two-year post PhD masters degree in psychopharmacology, currently available programs offer a wide spectrum of content and requirements, some of which consist of distance-learning courses with virtually no background in basic science and little hands-on clinical training. In addition, contrary to his assertion, the currently available substantiation for the claim that the few psychologists authorized to work without psychiatric oversight "have been prescribing safely for 20 years"is based on their own self-report. (These concerns about training and track record have been more fully discussed elsewhere(2) and at www.poppp.org). More seriously, his recommendation is unhinged from key findings in the expanding literature on psychopharmacology. As practicing psychiatrists know well, choosing the correct dose of the optimal drug is not a simple cookbook operation. Appropriate prescription requires extensive training, skill, and medical reasoning. Because physical and mental illness often present with the same symptoms, providers may fail to diagnose the former while concentrating on the latter(3). Since the most seriously mentally ill patients are also those most like to suffer from serious physical illnesses(4) vigilance is essential. The World Health Organization(4) found that "more than 50% of all medications are prescribed, dispensed, or sold inappropriately", and even medically trained providers are often lax in ordering the appropriate lab tests(6). . That this is a serious problem is evidenced by the finding that failure to accurately differentiate between physical and mental illnesses accounts for up to 40 percent of malpractice claims(7). Psychologists who lack medical training are unlikely to be attuned to diagnosing physical illnesses or qualified to order the lab tests to responsibly evaluate them. Compounding the risk is the fact that patients who are most at risk for comorbid mental and physical illnesses are the prime candidates for psychopharmacology. This follows from the results of many studies and meta-analyses that show that antidepressants are most effective with patients suffering from the most serious forms of the illness, and therefore should be used primarily with the most impaired patients (7-10). Similar logic applies to the use of antipsychotics and other strong psychotropic drugs. These patients with complex illnesses are also the most likely candidates for polypharmacy. It is well known that because most drugs lack targeted delivery systems, they disperse throughout the body and impact every organ and tissue they reach. Considerable medical knowledge is often needed for the management of the intended and unintended (aka "side") effects of the drugs, a problem that grows in proportion to the number of drugs taken(11). The need for extremely careful management of drugs is strongly emphasized in a paper by Meeks(12) in the same issue of Psychiatric Times in which he calls attention to need for great caution to avoid the risks commonly associated with prescribing for the elderly. His caution can be expanded to include many other at-risk populations, e.g., children and pregnant women. Management of the combined mental and physical health concerns of all of these vulnerable patients clearly falls beyond the scope of competence of providers who lack medical training. Dr Carlat overlooked a number of safer options for improving access to psychiatric services. He did not discuss the innovative teleconsulting and collaborative methods that are already being used successfully to extend psychiatric expertise to PCPs(13), the development of psychiatric assistants(14), or ways in which the efficiency of psychiatric services can be enhanced. He also neglected to mention that when providers can choose between psychopharmacology and psychotherapy, they opt for the former and abandon the latter(15). Allowing psychologists to prescribe is therefore likely to reduce patients' access to skill-building and insight-oriented interventions at the same time that it exposes them to greater risk of medical error.
Psychologists make significant contributions to the development of empirically substantiated methods of intervention that are effective when combined with medication or as alternatives when drug therapy is inappropriate. Because they lack basic science and medical training, medication management is will not be one of their contributions. Psychologists who wish to prescribe can of course obtain appropriate medical training, but those who are not suitably trained should not be allowed to enter organized medicine through the back door. References
1. Carlat D. 45,000 more psychiatrists, Anyone? Psychiatric Times. 2010; 26; 1-4.
2. Stuart RB, Heiby E. To prescribe or not prescribe: Eleven exploratory questions. Scientific Rev Mental Health Practice, 2007; 5; 4-32.
3. Phelan M, Stradins L, Morrison S. Physical health of people with severe mental illness. BMJ, 2001; 322; 443-444.
4. Morrato EH, Druss B, Hartung DM, Valuch RJ, et. al. Metabolic testing rates in 3 state Medicaid programs after FDA warnings and ADA/APA recommendations for second-generation antipsychotic drugs. Archives of General Psychiatry, 2010; 67: 17-24.
5. World Health Organization. Medicines: Rational use of medicines. 2010. http://www.who.int/mediacentre/factsheets/fs338/en/index.html Accessed July 10, 2010.
6. Dale J, Sorour E Milner G. Do psychiatrists perform appropriate physical investigations for
their patients? A review of current practices in a general psychiatric inpatient and outpatient setting. J Mental Health, 2008; 17: 293-298.
7. Fournier, JC, DeRubeis, RJ, Hollon, SD., Dimijian, S., et. al. Antidepressant drug effects and depression
severity: a patient-level meta-analysis. JAMA 2010; 303: 47-53.
8. Insel TR, Wang S. The STAR*D trial: Revealing the need for better treatments. Psychiatric Services, 2009; 60: 1466-1467.
9. Schiff GD, Galanter WL. Promoting more conservative prescribing. JAMA, 2009; 301:865-867.
10. Parker G. Antidepressants on trial: How good is the evidence? Brit J Psychiatry. 2008; 194; 1-3.
11. Singh H, Graber M. Reducing diagnostic error through medical home-based primary care reform. JAMA, 2010; 304: 463-464.
12. Meeks T. (2010). Drugs, death, and disconcerting dilemmas: An overview of antipsychotic use in
older adults. Psychiatric Times. 2010; 27: 27-22.
13. Unitzer J, Katon, WJ, Fan MY, Schoenbaum M C, et. al. Long-term cost effects of collaborative care for late-life depression. American Journal of Managed Care. 2008; 14: 95-100.
14. Grace GD, Christensen RC. Where are the psychiatric physician assistants? Psychiatric Services. 2010; 61: 95.
15. Mojabai R, Olfsen M. National trends in psychotropic medication polypharmacy in office based psychiatry. Archives of Psychiatry. 2008; 67:26-36.
Clinical Nurse Specialists with masters preparation and certifications have been prescribing psychiatric medications effectively for over ten years in MA. They are also prescribing in over 35 states. Prior to their masters degrees, nurses have psychopharmology experience in giving medications for which they know side effects. They have worked as a medical professionals with other medical providers in medical settings. With masters degrees, certification, and further experience, they only improve their knowledge of medical disease, anatomy and physiology, and interactive medical and psychiatric co-mobidity. This make CNS BH nurses very appropiate to diagnose and treat most psychiatric conditions including bi-polar disorder and complex PTSD. Masters prepared CNS BH nurses learn psychotherapy in their graduate programs. I am one of these professionals and have 32 years experience providing psychotherapy and psychopharmacology in both a medical out patient group practice and in a my own private practice setting.
Geraldine Koppenaal RN CNS Psychiatric Nurse Clinical Specialists have been prescribing psychiatric medications for over ten years in the state of MA. Before these professionals attend graduate school for learning to be psychotherapists and prescribe, the have been nursing professionals working in hospitals and medical settings providing care to patients, giving medications for which they know side effects, and they have already understanding of disease states. Graduate programs for psychiatric nurse specialists only further advance their knowlege of anatomy, physiology, disease states,and interactive physical and psychiatric co-morbidity. I believe this puts them at as better advance to be prescribers and "physician extenders" in the future over psychologists. This is why they received licensure to prescribe in MA a decade ago and psychologists have not. I have 32 years experience as a CNS professional providing psychotherapy and prescribing in both a medical association and private practice setting.I also see complex PTSD, schizophrenic, and bi-polar patients.
As a psychiatric advanced practice nurse with over 30 years experience in the field-18 with autonomous prescriptive authority privileges in the state of WA-I am dismayed at Dr. Carlatt's reference that we have very little training in psychology or psychotherapy. It is a gross misrepresentation of skill sets and knowledge bases to equivocate a PA with a Psychiatric Advanced Practice Nurse. I am the current President of the American Psychiatric Nurses Association as well as the specialty director for psychiatric mental health nursing programs at the Yale University School of Nursing. Our students receive intensive course and clinical work in serious and persistent mental illnesses across the lifespan as well as training in a variety of psychotherapeutic modalities. Psychiatric mental health APRNs are certified by the American Nurses Credentialing Center and are eligible for advanced practice licensure as either a clinical specialist or nurse practitioner including prescriptive authority in all 50 states-17 of which now have autonomous practice.
Somehow the name Elaine Nailler was associated with the below post. The correct author is Mary D Moller.
Dr Carlat, Thank-you for opening up this much needed discussion with such an open-minded perspective. Seems to me there is more than enough demand out there to keep all of us mental health professionals very busy. You mentioned in regard to use of PA's / NP's in psychiatry : "One problem: they get very little training in psychology or psychotherapy--limiting their ability to properly diagnose and treat tough cases." I have the impression here you are referring to PA's or NP's who are generally trained-ie, PA's w/out specialty training or Family Nurse Practitioners. Psychiatric Mental Health Nurse Practitioners are highly trained in principles of psychology, psychopathology and many different schools of psychotherapeutic intervention. I would be interested to know more specifics about content of curricula at the different schools of psychology that are preparing clinicians to prescribe psychoactive medications. Starla Harrison,RN,MSN,PMH-NP Psychiatric Mental Health Nurse Practitioner Dallas, Texas
Starting November 2010, the NCCPA (National Commisssion on the Certification of Physician Assistants) will start the process of credentialing PAs for a Certificate of Advanced Qualification in Psychiatry (and 4 other specialties) based on the completion of a number of criteria ( http://www.nccpa.net/Psychiatry.aspx) that include among other requirements, at least 1 year of direct clinical experience caring for patients under the supervision of a psychiatrist, a competitive exam, and continuing education requirements in psychiatry. Additionally, many PA's, myself included, have supplemented our training with additional skills that help complete our offerings to patients. As Dr. Carlat shows, there are many ways to skin a cat, and PA's so trained and certified will be no less capable than NP's in caring for the psychiatric needs of patients. Roger Cutting, PA-C, PsyD
Dr Bravo's words, "Why are non-physicians opining on this webpage?. . . .I guess they all want to play doctor. " adds nothing to this discussion. It only shows his/her level of intolerance. Is he/she saying that non-physicians should not read publications by psychiatrists? There is a role for everyone in this arena. I have seen many patients who wanted to switch from their psychiatrist to a NP and vice versa. I am also an attorney and I have seen more litigation against psychiatrists than NPs. One may conclude that the more psychiatrists, the more med mal cases for the legal community. Arrogance hinders prudence!!
esteemed author various countries in europe, especially Britain, have welcomed trained psychiatrists from across the world, once their training was deemed appropriate. in the uK, american trained psychiatrists are allowed to work without strictures and preliminary exams. british psychiatry is second to none.
there is another easier and much less expensive and possibly equally meritoriuos option: allowing UK and european trained psychiatrists, who are trained in the english language based training programmes, to enter the US psychiatry, without basic, preliminary and licencing exams. once they are in position in the USA, they can undergo whatever exams or tests US psychiatrists have to undergo.
this is in line with what the USA is all about: migration and merit! regards
I agree that Psych. N.P.'s would be the logical answer. They are trained in Psych. All of their graduate program is focused on Psychiatric Care. However, they are few and far between. In the State of Texas there are no Psych. NP programs in the entire state. I recieved my degree in Michigan and there were only 5 students in that class. Susan Ward, MSN, RN
I totally agree that psychologists should be permitted with additional training to prescribe. However they still should be under the supervision of a psychiatrist assuming that psychiatrist has maintained their general medical knowledge. Thus psychiatrists who work with prescribing psychologists should also be certified to assure that a holistic approach to mental and physical health is maintained. This includes knowledge of alternative medicine. Eric M. Levin MD
The curriculum of post doctoral masters degree programs in psychopharmacology follows American Psychological Association guidelines. It generally takes two years to complete the programs, and one year of supervised experience is required before sitting for the certification exam (PEP). The information is on the American Psychological Association website. Dennis Girard Boston
There is plenty of room at the table for the many wonderfully skilled clinicians who are psychiatric NPs, psychopharm psychologists and up-coming PAs. We need to welcome all approaches to serve those in need. The medical degree is an impressive accomplishment, but has become inflated in this country and using resources that could be directed elsewhere....toward those who need care! Rose Presser PMHNP
The issue is this country is in need of more psychiatrists and not replacing the shortage with other disciplines. Therefore, we should ask the legistrators and educators to come up with answers and impliment it. DBK
NPs are not interested in playing doctors. If we wanted to be doctors, we would have pursued that avenue of education. We are happy in our role and have an important role in health care today. We practice in all areas of health care including psychiatry. And we certainly should have access to up-to-date, unbiased information in the field. Why would any physician want to exclude non-physicians from the information on this website or not allow comments? Even non-physicians may have valuable input. Bravo to Ms. Anderson.
As a psych NP my program was a concentration in psychiatry not just a few courses thrown in.PA programs focus on primary care,emergency medicine and internal medicine. Remember that Psych NP are independent practitioners where as PA's must have a physician present .I worked long and hard for my degree and am as competent as many psychiatrists staring out in practice. The licensure for PA's as well as the education, needs to change if they are going to take on the responsibility for psychiatry.I am afraid we will become a society of "pill pushers" rather then mental health care providers.When would the PA s learn about therapy and have the time to o it? I see PAs in psychiatry as a way in which the medical community is preventing competition from Psych NPs
I wonder where Dr. Carlat obtained his information re the limited psychology/psychotherapy training received by Psychiatric Mental Health Nurse Practitioners. I my Masters Program at the University of Washington Seattle most of the focus was in those areas. Addionally, we needed 1000 hrs of supervised prescriptive experience before we could even that the ANCC Certification Exam.
I am a PMH-NP with 25 years experience and a PhD in my field. I think the more competent folks we have to treat this growing population that are in need is great....but be careful. I recently had a conversation with a PsyD who wants prescription privileges about a patient he want on medication and his knowledge of basic cardiac information was inadequate to say the least. This patient, who was very ill, had had 2 MIs and a stroke. The PsyD had no clinical experience to bring to the care of this patient. Additionally, when I compared my clinical assessment education with his, he essentially had one classroom course with only paper work and almost no practicum time involved. Psychopharmacology takes years of experience and education -- I don't do extensive psych testing because that is not my area of training or expertise, so I defer to those who do. The number of hours spend in medical experience, and assessing all body systems is a necessary strength in prescribing for our patients. Unfortunately, they do not come to us uncomplicated! Superficial knowledge in this area will not get it!
It might be pointed out that those in the field are well aware of the fact that MRI is way superior to a mammogram. Time and time again only MRI have detected tumor involvment in dense breats that mammograms were not able to detect. Isn't it time that Insurance companies stop dictating what options are available.
Richard B. Stuart, DSW commented that psychologists have little scientific or medical training. I had to chuckle at this unintentional humorous comment. Foremost, because unless you have a PhD following your name - as MD's don't, then you, in fact, don't have training in scientific methodology. As a psychologist -who does have a PhD- I took many graduate courses in scientific methodology, not to mention completed a doctoral dissertation - something that is not required of an MD. With regard to medical training, no psychologist would purport to have the equivalent medical knowledge of an MD. However, the fundamental question is: How will people obtain access to medications if there is such a huge absence of psychiatrists? Who is qualified to provide these prescriptions? What are the consequences of allowing either well trained psychologists or NP to do so? In fact the data are in: Psychologists who have had prescription authority have been doing so for dozens of years, with no untoward incident. The same can be said for NP's. Ergo, let psychologists be well trained, not just in New Mexico and Louisiana, but the whole Union, and encourage more mental health training for NPs and allow them greater access to mental health patients.
Imagine a ladder. At the top of the ladder is the most "powerful"person on that ladder. In this case it is Psychiatrists, in the "treatment" of mental illness. Grabbing on their legs to pull themselves up are psychiatric PA's, PhD psychologists, Psychiatric A.R.N.P.'s. A step below, RN's. MSW's, then LPN's etc. Since everyone is pushing themselves up the ladder, it is becoming top heavy. We will soon topple over under the weight of our egos and paychecks. And all the King's Horses and all the King's Men can't put the chaos of "mental health" together again. Those who will suffer the most? Our Patients!
I agree with JDee Richarson. Psychologists do not have the training in biochemistry, physiology, disease processes, and so forth to adequately monitor patients who are being prescribed potentially dangerous medications, and who may also have multiple other medical problems. As I psychiatric nurse practitioner, my expertise is in the medical aspects of prescribing (metabolic monitoring as needed), coordination of care with other medical practitioners, as well as patient teaching. I have at least as much trainng in psychotherapeutic and group techniques as most licensed therapists. I do not pretend to be an expert in psychological testing, or in depth therapy and I do refer my medication patients to competent therapist for all but brief therapies while I primarily handle dignostics and medication management. I believe this is efficient use of a mid level practitioner. Most of my patients think that I am the most thorough and caring "psychiatrist" they have seen--though I always correct them as to my licensure and role. MSN, Psychiatric Mental Health Nurse Practitioner.
Psychologists prescribing? Well, from my experience, Psychologists are not very good at diagnosis, and an accurate dx is the first step to a good treatment plan. They are good at therapy though. D.
hi, i wonder where the present Psychiatrists are finding patients with insurance, theat can afford to pay een a small part of their bill, that can find a Psychiatrist that accepts Medicaid or Medicare, or that doesn't think anything more than a yearly gvisit is beyond their ability to pay. I think the so-called paying patient is becoming rare, and those that can are grabbed hold of by any treating Psychiatrist or therapist . This has appearred to escalate as the economic status, from jobs, to foreclosures, to college expenses, to forced insurance , etc., has just kept right on going down the tubes. John Moloney, MD Peoria, IL
The problem is not a shortage of mental health professionals, whose beneficial effects are very limited, either by drug side-effects, or by limited long-term efficacy of both drugs and CBT. The real problem is a woeful lack of brain-oriented preventive and therapeutic DIETITIANS, plus a dearth of psychiatrists and psychologists interested in NUTRITIONAL NEUROSCIENCE. The common psychobrain disorders, anxiety and unipolar depression, both have nutritional origins: fatty maternal diet (especially since about 1800, in the fat-loving Western nations) produces neurosis by slightly inflaming the placenta, allowing maternal cortisol to reach and re-programme the foetal brain into an anxious organ, by epigenetically impairing glucocorticoid receptor gene expression. About 20-25% of Westerners, and lots of offspring of fat-loving immigrant ethnic groups, are affected--permanently. Anxious offspring often comfort-eat sweet or savoury fatty foods like chocolate or cheese, and end up with diabetes, obesity, vascular disease, arthritis, muscle wasting and Parkinson's disease. Also depression, which abates in two weeks with strict low-fat diet, while the underlying anxiety reverses quickly with Inositol supplement, 5 gm/day (it blocks CRF action, by inhibiting serotonin 2A receptors). Since hearing about Inositol's effects on depression and panic in 1999 (J Levine, Beersheeva, 1997), I have reversed anxiety in 3000 typical cases in family practice: in anyone with a history of childhood shyness or sensitivity, plus lifelong worrying, it never fails, except for a reduced response in cases not adhering to low-fat diet (which causes brain oxidation and inflammation [B Culver, Laramie]). That solves anxiety and common depression. As for the low-prevalence, but more severe, psychobrain disorders, schizophrenia and bipolar disorder have both sprung up in prevalence and severity--along with the neuroses--since about 1800 in the West, with Dr Edward Hare claiming, from his detailed research, that schizophrenia, for example, was rare or unknown in England and Europe before that date, when there was no need to build lunatic asylums (Maudsley Lecture, Brit J Psych 1982). There is no evidence that the genes, acting in isolation, cause anything worse than Mild Schizotypy and Benign Unipolar Hypomania (or Benign Outgoing Personality [BOP] as in Teddy Roosevelt, a successful BOPPER, while Winston Churchill was mixed "BOP"OLAR/BIPOLAR, depending on his current cheese intake). What converts a benign genetic outcome to full-blown malignant psychosis is 1) fatty maternal diet, causing anxiety (up to 2/3 of schizophrenia cases, about half of bipolar 2 cases, and a resounding 93% of bipolar cases), and 2) fatty personal diet (often driven by anxiety-related comfort-eating), which causes faulty, polyunsaturate-depleted cell membranes, with ensuing insulin resistance and widespread oxidation and inflammation, the latter also affecting the brain, both directly (B Culver) and via inflammatory systemic cytokines (B Baune). The challenge in psychiatry, then, is 1) to get our patients on to low-fat diet, 2) to reverse anxiety effectively, which can be done within 7 days with Inositol supplement, 5 gm/day. This simple regimen cures anxiety and unipolar depression within a fortnight (interestingly, Dr M Aboukhatwa, in Philadelphia, has found that antidepressants work mainly by putting more endogenously-synthesized Inositol in expanded neuronal membranes, thus promoting BDNF formation and hippocampal neurogenesis: why not just take Inositol direct, and skip the outmoded drugs, with their side-effects, like impaired libido?--Inositol IMPROVES libido in my anxious patients!). The same dietetic regimen may lead us to The Promised Land in both psychoses as well--I see much better mood, cognition and physical health in my schizophrenia and bipolar cases following diet plus Inositol. In theory, neither anti-psychotic drugs, nor mood-stabilizers, should be needed in the long-term, to successfully reduce these disorders to their pure phenotypes. I have a number of creative BIPOLAR patients now converted back to "BOP"OLAR and healthy lifestyle, whose creativity is now flowering. This corrective Nutritional Neuroscience regimen requires no help from outmoded empirical brain drugs: it is scientific, not empirical, and can be used by ANY mental health professional, from social worker through to fully-fledged psychiatrist. Finally, as a sweetener, Inositol is ALSO anti-ageing! It activates 100s of anti-ageing genes (J Barger, 2008), promising 1) unusual mental and physical energy, and 2) a very long healthy life, to your mental health patients, who will hug you in gratitude, and send you Xmas presents!
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
Sorry, the question mark after NP is a typo.
Normal 0 false false false EN-US X-NONE X-NONE /* 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-fareast-font-family:"Times New Roman"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin;} Relax, we don't need 45,000 more psychiatrists! What we need is a solid medical education and a coherent extension of psychiatric services through better co-ordination with primary care, enhanced association and development of mid-level practitioners and-now coming online--expansion of telemedicine. New technologies have made psychiatric medicine both more complicated and easier to telecommunicate. Such as the $30 million California Telehealth Network launched August 17, funded by a consortium headed up by the Federal Communications Commission. In my county, the Network includes psychiatric consultation and patient support. What we don't need is a new discipline--- with less medical education than nurses--- commissioned to replace psychiatrists. The medical wortkforce will be sorely strained by the demands of healthcare reform and its 32 million newly insured Americans. The psychiatric workforce will be especially strained now that we got our wish for parity. We can expect mid-level practitioners-including psychologists--to intensify their perennial campaigns for wider scope and greater independence. The challenge will be to expand medical care with minimum degradation of quality and fragmentation of delivery, lest we fall into the chaos that prevailed in the days before the Flexner Report. How much medical education is required to provide medical care for people with mental illness and shall there be coherent regulation and equal standards for that medical care? These are the real policy questions posed by those psychologists who seek what is called "prescriptive authority:"Shall the board of psychology to be authorized to create and regulate an independent practice of medicine---for those psychologists whom the board deems qualified to provide medical care. In essence, psychologists are asking their legislatures to create a self-defining, separate and second class system of medical care for people with mental illness---and, ironically, killing parity in the crib. It is crucial that we do not accept--or allow others to frame-the psychology proposal as a "turf" battle. It's a public policy discussion about the future of medical care for the mentally ill. Ronald C Thurston, MD President-Elect California Psychiatric Association
Dear Editor: I was disheartened to read Dr.Carlat's article titled 45,000 More Psychiatrists, Anyone, Published in Psychiatric Times on the August 16, 2010 issue. It was very difficult for me to understand how a fellow physician would recommend that the solution for the shortage of psychiatrist would be granting Non-Physicians prescribing privileges. So it made me remember part of the Hippocratic Oath "I will apply dietic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice." This being said I don't know if we are really keeping our patient's from harm when we assert that by granting psychologist prescribing privileges we are "enhancing our patients access to high quality care". I wonder if high quality care is having somebody that has no medical/biological training to have some hours of pharmacology training and then be granted privileges by the psychology board with-out any oversee. If this is the case why don't we give a pharmacology course to primary school teachers and have them prescribe psycho stimulants. Or if we are concerned about Nurse practitioners not having psychotherapy training we might as well just let the dolphin trainers at the Sea Aquariums prescribe since they certainly are experts in classical conditioning and they at least have Biological backgrounds.
I hope then that we physicians continue to pursue solutions for physician shortage in general without compromising the safety of our patients. Sincerely, Julian Bravo M.D.
It is troubling to read Dr. Daniel Carlat's article in the August issue of Psychiatric Times about the shortage of psychiatrists in our country. However, it is even more disheartening and disturbing to read Dr. Carlat's suggestions that more nurse practitioner's, PAs and prescribing psychologists may solve the problem. I don't see the lack of psychotherapeutic skills as being the main drawback to utilizing more psychiatric nurse practitioners and PAs. What I see as the main problem in correcting the shortage of psychiatrists with nurse practitioners, PAs, or with prescribing psychologists, is that none of them know nearly enough, or in some cases anything, about neuropharmacology, neurophysiology, biochemistry, physiology, endocrinology, neuropathology, or disease processes. In other words, they don't know medicine. In a time in which there is so much being learned about molecular pharmacology, "channelopathies", neuropeptides, neuroendocrine function, neuroimmunology, glutamate and other neglected neurotransmitters, neurosteroids, the effects of thyroid, insulin, metabolic syndrome, cytokines, inflammation, diet, and stress in psychiatric illness, it is disgraceful to suggest that the short fall should be filled in by non-physicians. Psychotherapy hasn't fundamentally changed in 50 years. Some might say 100 years. On the other hand, the science of biological psychiatry is advancing by leaps and bounds. Let's have well trained, medical professionals, i.e., psychiatrists, in place who can understand and utilize this bounty of information. Instead of diluting the science of psychiatry with "psychiatrist-helper", we should increase the ranks of psychiatrists by making the field of psychiatry more desirable to young doctors. If one assumes that the usual market forces are at play in the supply and demand equations for psychiatrists, the remedy should be fairly straightforward. That is, give psychiatrists higher salaries, better working conditions, and a sense of having a future in the field. The shortage would then take care of itself. Scott D. Mendelson, M.D., Ph.D.
Shortage of Psychiatrists In his article, August 2010, in the Psychiatric Times, Dr Carlat mentions PCPs complaining that psychiatrists don't take certain types of insurance: insurance. Insurance companies often cover behavioral health poorly. Years ago I stopped taking Medicaid because I calculated I was paying more in stamps billing them, than I was getting back. Rates for psychiatrists, psychologists and ARNP's are often abysmally low. There isn't any point training someone if there is no income available for them on completion. Nurse practitioners have been replacing psychiatrists in many mental health centers for years and therefore do not increase the number of patients served. Psychologists who were trained to prescribe, twenty years ago in the military, did not get a masters degree in psychopharmacology. They were part of a special program involving 10 psychologists. After getting 7 psychologist prescribers the military abandoned the program partly because it cost more per head than medical school. Psychologists are no more likely to be in under served areas than psychiatrists. Creating a glut of ARNP's and prescribing psychologists here will resolve the shortage of psychiatrists in Australia and New Zealand. Louise Buhrmann, MD Winter Park, Florida
[Dr. Stuart Gitlow sent the following comments] Dr. Carlat's article suggests a potential course of action in which APNs, PAs, and psychologists could provide some of the psychiatric needs of our population. Over the past several decades, we have put a great deal of time and money into ensuring the legitimacy of our medical training. We have increased the board certification requirements. We have added CME and licensure requirements. We have added peer review, quality assurance, best practice guidelines, and we have removed pharmaceutical company bias from trainings. We spend 8 years in training and hundreds of thousands of dollars in tuition and lost opportunity costs, and even then must jump over several more hurdles to become board-certified practicing psychiatrists. Are we now saying that other clinicians, with a fraction of the training and nothing like the oversight that we have to deal with, are just as good? Or even close? Maybe Dr. Carlat is right! And if he is right -- if indeed these other clinicians are just as good -- then why are we causing our medical students to waste the better part of their remaining youth in unnecessary and costly training? Why are we so eager to add requirements that take us away from our offices and families to study -- yet again -- for another board exam? Why don't we simply cut medical school to two years, residency to another two, and call it a day? On the other hand, if we have adequately demonstrated the value in such training and testing, then how can Dr. Carlat possibly be right? How could a psychologist possibly recognize when a non-psychiatric medical illness is to blame for a depressive syndrome? How could an APN recognize when a patient has a medication-induced disorder rather than a primary disorder, something that many physicians miss as well, without having remotely received adequate training? Won't APNs, PAs, and psychologists simply go through the same cycle where the public becomes increasingly distressed about a few bad apples, insists on greater governmental oversight, more training, and more testing, until those clinicians find themselves spending just as long in school and exam rooms as we do? Ultimately there are only two possible hypotheses here: 1) The other clinicians are just as good as we are in which case we've been wasting loads of time, money, and energy on unnecessary training. The other clinicians could very rapidly obtain whatever additional training is necessary and we'd have the need met within a few years. 2) The other clinicians are not just as good, in which case we'd be accepting a marked reduction in quality of provided mental health care by implementing Dr. Carlat's suggestions. There is obviously an imaginary line between the two hypotheses marking the acceptable rate of variability between physicians and non-physicians. Why hasn't anyone suggested actually studying the issue to see which hypothesis is correct and where the imaginary line should be? Stuart Gitlow, MD, MPH, MBA Executive Director,
Annenberg Physician Training Program in Addictive Disease Associate Clinical Professor, Mount Sinai School of Medicine Treasurer & AMA Delegate, American Society of Addiction Medicine
With all due respect to my Tufts colleague and friend, Danny Carlat, I very much agree with the concerns raised by Drs. Mota, Gitlow, and Thurston.
Indeed, to conceive of the debate over "psychologist prescribers"as a mere "turf battle" is to miss entirely the critical scientific issues at stake. Ultimately, I believe we will need an NIMH or National Academy of Sciences "white paper" to resolve the issue of how much medical knowledge is needed to provide safe and effective care for those with psychiatric disorders. At this point, to assume that psychologists trained as "prescribers" possess that level of expertise is to court potential disaster, in my view.
For more on these issues, please see:
http://www.psychiatrictimes.com/display/article/10168/1545667
and
http://www.psychiatrictimes.com/display/article/10168/1552221
Best regards,
Ron Pies MD (Editor-in-Chief Emeritus)
In agreement with Pies & Thurston: In his discussion of the expected shortage of psychiatrists (August 2010), Dr. Carlat raises the familiar concern that opposition to extending prescribing privileges to psychologists is simply a turf battle. He cites a study that claims safe non-MD prescribing in the military and two states.There must be a reason these small experiments have not generated a rush to expand prescribing privileges. His argument emphasizes our obligation to "enhance our patients' access to high quality care." Perhaps a truer reappraisal of underserved areas would conclude that primary care MDs should have access to fellowships in mental health so they could prescribe more expertly as well as address 'ordinary unhappiness' better. As psychiatric training 'churns out' psychopharmacologists with little skill in psychotherapy- it may be best to preserve the focus of psychologists on this domain. It is hard to believe that a two year course in psychopharm can adequately prepare a non-MD to grapple with the many co-morbidities that commonly appear in a psychiatric practice. Pain, hypertension, M.S., migraine, type 2 DM, side effects vs. medical sx, P450 interactions with medical tx, TMJ, et al engage the broadest knowledge base for best practice. If prescribing PhDs depend on back up from a primary care MD, this may require unwieldily coordination involving lots of time with little common language and much liability anxiety. "Safe" prescribing may mean no serious casualties, but it is surely distinct from "high quality care." I trust Dr. Carlat would agree; especially after his public (NYTimes) epiphany regarding the limits of psychopharmacological perspective. Sara Hartley MD Clinical faculty UCB/UCSF Joint Medical Program
- I am in full agreement with Drs. Mendelson and Hartley that the way forward lies in (1) increasing the attractiveness of, and incentives for, the practice of psychiatry; and (2) shoring up training and support for our PCP colleagues. For example, the APA could offer full or partial scholarships for medical students choosing to enter psychiatry; residency programs could provide incentives to graduates who commit at least 3 years to practicing in under-served areas; under-served states could provide financial and housing incentives for psychiatrists to settle there, etc.
With regard to fellowships in pharmacotherapy for PCPs, I think this is a great idea--and one the APA should enthusiastically support. As someone who has taught psychopharmacology to med students, residents, attendings, and PCPs for nearly 30 years, I am convinced that if you give me a well-trained, highly-motivated PCP or family practitioner, I can bring him or her up to speed in psychopharmacology with an intensive, 6-month fellowship. That doesn't mean he or she will function at the level of the APA Textbook of Psychopharmacology--but, in my view, such a PCP will be in a much stronger position
to provide safe and effective pharmacotherapy than a non-physician (though I have worked with excellent CNS's and NPs, and I believe they can play an important ancillary role, as well).Colleagues: for the sake of our patients and our profession, let's avoid the hasty counsels of despair!
Ron Pies MD
- Just to clarify: ideally, my preference regarding fellowships for PCPs would be to include a broader perspective on mental health than just pharmacotherapy--e.g., differential diagnosis, psychodynamic and cognitive approaches, etc. But that might require at least a year or more. --Ron Pies
As a License Professional Counselor in both Georgia and NC who specializes in the management & treatment of bipolar disorder, I am faced daily with the shortage of psychiatrists available in a timely manner to treat the patients I see. The adjunct treatment of therapy/counseling is very important in the treatment of most mental illnesses for education, mangement and support. I am often the eyes and ears for the psychiatrist and in between appointments with their patients. We work as a team to provide the standard of care. Most of the psychiatrists I work with do not have time for providing therapy for their patients. By utilizing other trained mental health professionals, the impact of a lack of psychiatrists can be minimized. I find PCP's trying to treat anxiety and depression often miss a more severe mental health diagnosis and sometimes make a patient worse instead of better in the long run. I don't believe psychologists should be prescribing medications for these same reasons. Unless we provide training--psychiatrict for PCP's and medical for psychologists--neither should be prescribing of mental health conditions. Whatever it takes to get more trained psychiatrists, we need to find the resources to do this. Vilda S. Brannen, M S, NCC, LPC
Of course, the entire argument restsnon the dubious assumption that what these patients need is medication--hence prescribers. I am sure big pharma would love nothing better than to see thousands more prescribers of their grossly oversold products. Being opposed to psychologist prescribing is not just turf. I am a psychologist and train psychologists and think that prescribing psychologists Is a terrible idea.
I appreciate Dr Carlat's analysis of the issues as well as comments on the potential value of the Psychiatric Advanced Practice Nurse (APNs). Just one point to clarify: we have data to support that Psychiatric APNs do indeed practice quite extensively in rural areas. They are prepared to deliver the full range of mental health services. As a profession we value our collaborations with psychiatrists to supply services to populations; ones that facilitate recovery and help individuals achieve mental wellness. Kathleen R Delaney, PMH-NP
Dr. Carlat did not address another reason why fewer medical students are going into psychiatry--reimbursement. Health reform must embrace psychiatry by reimbursing psychiatrists for the work we do, which is complex and not well enough reimbursed through current insurance schemes. This needs to be rectified for numbers of residents to increase.
In addition, Dr. Carlat did not recognize another possibility: providing consultation to primary care physicians. Providing innovative methods to provide consultation will be important in the future and this includes reimbursement for such consultations, both from the primary care side and the psychiatric side.
Adair Parr, M.D., J.D.
Children's National Medical Center
Washington, DC
Interesting article! The figures are probably a "lowball"estimate of the true need, as it does not include all those with chronic schizophrenia alone, which is conservatively another 1% of the population. Obviously we will not be able to produce (or afford to train) enough psychiatrists. As an associate professor in a medical school training program with residents and fellows, and also someone who works collaboratively with advanced nurse practitioners across our state, I have been very impressed with the quality of training that I have seen with our advanced practice nurses. Clearly, this is one way to improve access and coverage. We should FULLY support this route. Telepsychiatry is another underutilized option to serve in a consultative fashion to primary care Physicians, especially in rural settings. Again, a way to cover more people efficiently. Personally, I am now using telepsychiatry to cover our entire state, and it is a very efficient model. Sure beats 4-5 hours of driving!!! I do have some concerns about the prescribing with psychologists, in my experience they do not have enough medical training and in essence you have to run them through an abbreviated version of the first two years of medical school. To me, this is a less efficient way to meet the need. I don't really see it as a"turf battle" anymore, as I and most of my colleagues are way too busy to treat the people we are already treating, and often have to turn away referrals. However, if the training medically is "sufficient", I am not totally opposed to the idea, I just have my doubts about the cost effectiveness, especially when viewed in comparison to nurse practitioners. But in my opinion the shortage already exists, and will only widen as time goes on. Will be interesting to watch as this unfolds. William E Green III MD
With regard to increased utilization of advanced practice providers lack of expertise with difficult cases. This is why the advanced practice provider works in close contact with physician's. The APP can see more routine follow ups freeing the psychiatrist to see more difficult cases and with physician backup can often have the flexibility to see urgent cases in clinic reducing wait time and subsequent exacerbation of a crisis. This team approach can help greatly to address this increase in need. David A. Tullar, PA-C MPAS
This is comical. In Iowa, I have been practicing 2 days a week 12 hours a day; commuting time is 8 hours a week.
I earned $30, 000.00 last year. I am very close to 80 years old. I see literally hundreds for scripts, etc. The U.of Iowa churns out 6 (six) psychiatrists a year. I had a diagnosis of a casncer, so I took medical leave, to get treatment. We tried toget a Telepsychiatry camera hook-up so I could see patients from home. Medicare (Magellan) absolutely refuses to change our contract so that we may meet these needs. In Iowa there are several MHC's that use cameras. They will not give any reason. No PA-C's cn be found. We have had 4 psychiatrists, all of whom have lost their licenses for drinking or using street drugs. We are closing 2 clinics because no M.D. or PA-C can be found. I have been doing the fill-in for 5 years. Three counties are bereft of all psych. services. Magellan & the gov't want to deprive citizens of psych services. Dr. John Duffy
The reason there aren't enough psychiatrists is because in order to become eligible for a position, a person must put in a lot of a time without proper exposure and income.. As a recent graduate with a bachelor's in psychology, too many of these positions require a lot of work experience. Perhaps an entry exam into the position would help. I worked at a group home for a year while finishing my undergraduate. The clients all suffered from BPD, Bi-Polar, and mental retardation. Besides fearing for my life everyday (the clients were extremely violent) I was paid less than a person working at a fast food establishment. My colleagues would often sleep on the job, putting my own life in jeopardy. After a year, I was burn out; frustrated by the field of mental health all together. I've currently taken a position at a major insurance company making more than I would have made in 3 years at the group home. I love psychology and hope to work in the field someday. Dr. Daniel Carlat is right..."That is, give psychiatrists higher salaries, better working conditions, and a sense of having a future in the field. The shortage would then take care of itself."
Excuse my mistake: I quoted Scott Mendelson; NOT Dr. Daniel Carlat. A thousand apologies Mr. Mendelson.
Nurse Practitioners DO have a pathway to receive specialty training in psychiatry. It is called Psychiatric Mental Health Nurse Practitioner (PMHNP). These nurse practitioners typically get a master's degree and get a minimum of 2 years of education including clinical experience with supervision in their specialty.
I know Dr. Carlat is somewhat doctor-centric (hence preferring psychologists over NP's), but utilization of PMHNPs is a very viable alternative to psychiatrists. In my opinion, more viable than giving psychologists precribing privileges!
Laurie Feldman, MSN, PMHNP
My impression, as a clinical social worker in private practice in Pennsylvania is that the worst shortage is psychiatrists who are willing to accept insurance. Only a relatively few psychiatrists are willing to do so, resulting in their practices becoming overburdened and assembly-line in character. For patients willing to pay an exorbitant fee out of pocket, they can get an appointment easily.
Dr. Dan Carlat's article, "45,000 More Psychiatrists, Anyone?"published in the "Psychiatric Times" (August 2010, Vol.27, No.8) was a disappointment on two counts. First was his analysis of the projected need for psychiatrists. Dr. Carlat does a nice job critiquing the data published in a series of articles published in the October 2009 issue of "Psychiatric Services". However, Dr. Carlat makes the same error as the authors of those articles. The analysis of psychiatric need is based on prevalence of disorders with no real discussion about consumer demand. The problem with letting social-community activist psychiatrists determine national policy is they define need based on how many people they can diagnose and not on how many will seek psychiatric care. Some seem to forget that most of the psychiatric care provided is voluntary, a matter of personal choice. And some people, regardless of their "diagnosis", don't value psychiatric services. Until free-market principles and respect for personal autonomy are considered, the actual number of psychiatrists needed, will remain unknown. The second disappointment is Dr. Carlat's preferred solution for the psychiatric physician shortage. The idea of providing psychologists with prescription writing pads is absurd. The case against psychologists' prescription writing privileges has been detailed and discussed many times over and need not reviewed here. What is most surprising is that Dr. Carlat, who writes and publishes a psycho-pharmacologic newsletter, would trivialize pharmacotherapy by equating a psychologist's brief weekend course training with medical school and residency. Dr. Carlat's expectations are very unrealistic. Does anyone, actually believe psychologists will run to poor and underserved neighborhoods and work in the low paying mental health centers? Dream on. Psychologists are no more altruistic than physicians and no less likely to seek profitable practices in affluent areas. The underserved will remain underserved. Most importantly, Dr. Carlat fails to consider the consequences to psychiatric practice if psychologists are given prescription writing privileges. Does Dr. Carlat think medical students will be more or less inclined to seek a career in psychiatry if they can obtain the same practice privileges by forgoing the time, expense, and rigors of medical school and residency training? Psychologists writing for meds will result in significant loss of future psychiatrists. The only benefit of infesting our country with prescribing psychologists is more business for newsletters about psycho-pharmacologic treatment…like the one published by Dr. Carlat. Hmmm, is Dr. Carlat guilty of the same profit motivated biases and distortions, that he has criticized the pharmaceutical companies of having? Nah, perish the thought.
Ethan Kass, DO, MBA
Coral Springs, Florida
Psychiatric Nurse Practitioners seem like the most viable option. As a psychiatrist, my experience with them has been of great benefit to our patients and to my practice. I only wish that, in my rural area, my patients had access to more NP's with psychiatric credentials. Wayne Smith MD Mississippi
The issue is how to increase the number of psychiatrist. This article is side tracked from the primary issue and more focussed on how to replace the gap with non-psychaitrist practitioners in the field of psychaitry by training them to function like a psychiatrist. This does not make sense because this will perpetuate the shortage of psychiatrsit instead of solving the problem and jeopardize the quallity of psychiatric practice. Please come up with better ideas to increse the number of psychiatrist.
Yep, psychiatry says we need more psychiatrists!! No surprise there. We need them to medicate more and more people. More than 10% of the US population isn't enough -- march on to 25%! 50%! Heck, put the drugs in the water -- oh, no, then we wouldn't need psychiatrists -- okay, stop at 75%.
Let's not call it empire-building, or a grab for power. Let's put on our sanctimonious faces and say we're doing it for everybody's good -- even though (according to psychiatry) depression has INCREASED since the introduction of SSRIs and the rate of suicide hasn't change in 30 years.
Psychiatry already assures itself of a stable customer base by prescribing drugs that are almost all truly addictive or cause physical dependency. They tend to be very difficult to quit -- then psychiatry calls withdrawal syndrome relapse. Side effects and withdrawal syndrome can have bipolar symptomology -- creating even more business! Very exciting. Psychiatry is the specialty that makes its own gravy.
When will people of principle stop this? Maybe medical students will start smelling the corruption in this specialty and stay away from it. Psychiatry will have to content itself with the bottom of the barrel in talent, as usual.
I have worked as an RN at a community mental health center with the seriously mentally ill population for 8 years. I will finish my BSN this May and plan to pursue my education as a Psychiatric Nurse Practitioner. For those of us who want to further our skills and education in order to work with this underserved population, more grants and/or other special arrangements are needed. Many RNs who want to become Nurse Practitioners are single mothers who need to keep a fulltime job and insurance and are forced by economics to get into a part-time program of study. It would be great to be able to grants study full-time and receive a stipend and insurance benefits. Angela Garrett, RN
Integrated care is the way of the future in primary care.
I am a Psychiatric Nurse Practitioner and I work with Very acute Psychiatric patients in a state hospital in a forensic speciality. I appreciate Dr. Green's input regarding advance practice nurses in the area of psychiatry. I was an RN in psychiatry for over 25 years in clinical, administration, and education before pursueing the advanced degree and nurse practitioner. I know the education I recieved and resent being called a physician extendor. Psychiatric nurse practitioners are lisensed independent practitioners under the board of nursing in most states. Psychologists are needed in mental health however, do not have medical background in disease management and pharmacology to prescribe. PA's practice under the licensure of a physician and are not speciality certified to my knowledge. I would support more resources into the development of more psychiatrists and psychiatric nurse practitioners and not developing another category of prescribors.