Psychiatry is one of several medical specialties experiencing a physician shortage. Simply put, there are not enough psychiatrists to provide high quality care to the large number of individuals in need of services, particularly individuals living in disadvantaged inner cities and rural areas. This shortage will increase in the future as the US population increases and substantial numbers of psychiatrists reach retirement age. To address this problem, several stop-gap solutions have been proposed. One of these "solutions" involves allowing psychologists to prescribe and administer medications independently. We believe this plan is extremely short-sighted and would result in major problems for individuals suffering from psychiatric disorders.
Although it may seem technically easy for physicians to write a prescription, the knowledge and skills required to prescribe medications effectively develop over nearly a decade of rigorous training in basic and medical sciences (four years of medical school and four or more years of residency and fellowship training). These skills are maintained by ongoing regular participation in continuing medical education activities.
Several postings ago, we discussed the extensive medical training required for an individual to become a board certified psychiatrist or neurologist, and contrasted this with the training of clinical psychologists. In order to understand the actions and dangers of medications, we believe it is imperative that practitioners undergo detailed coursework in basic and clinical sciences and complement this didactic training with clinical experience involving patients on medical, surgical, pediatric, ob-gyn, neurological, and psychiatric services. Prescribing psychiatric medications effectively involves the integration of information from the fields of molecular biology, genetics, pathology, biochemistry, and neural sciences together with practical knowledge regarding the effects of medications on patients who are ill with conditions that involve multiple body organs.
Some may believe that the lack of training of psychologists in pharmacology can be circumvented by restricting their prescription privileges to younger, healthier persons. Although complications arise more often in the pharmacological management of older persons with medical illnesses, problems with medications are not uncommon even in younger, physically healthy people. Every medication has side effects. Also, many patients who suffer from psychiatric disorders have co-morbid medical disorders that greatly influence responses to medications.
Prescribing medications will only get more complicated in the future - we are entering an era of pharmacologic treatments based on advances in genomic medicine. It is likely that medications will be chosen on the basis of what is best for a particular patient based on his or her genetic makeup. Keeping up with such rapid molecular and genetic advances is difficult enough for physicians with years of basic medical training and experience. We have trouble imagining how psychologists - many of whom lack a strong basic science background - will be able to stay current with such advances.
Present plans propose that psychologists be allowed to prescribe medications after a few years of coursework and supervision. Can a few years of supervised training prepare a psychologist to do a "good enough" job prescribing medications? In our opinion, the skills required to understand the effective use of psychiatric medications cannot be gained by a few years of targeted coursework and supervision. Psychologists may be rigorously trained in research methods and in certain psychological techniques and therapies, but they rarely have the rigorous medical background or the comprehensive testing and requirements for continued education that come with certification by national medical accrediting agencies.
We believe strongly that mental health professionals must work collaboratively in order to maximize effective health care delivery. Psychologists, social workers, counselors, case managers, and persons working in clubhouse settings, all have essential skills needed to help patients with mental illnesses. The unique skills of psychologists are essential in collaborative care models; for example, they can provide individual and group psychotherapies, train and supervise other therapists, administer and interpret psychological tests, integrate new cognitive approaches into treatments, and advance knowledge through research. However, we feel strongly that physicians (including psychiatrists and primary care physicians), and not psychologists, have the training necessary to assume the responsibilities of providing or overseeing the medication component of collaborative mental health care treatment.
We believe that the future of mental health care delivery involves enhanced coordination and collaboration between the primary care sector and the mental health care sector. With the assistance of telemedicine and advances in computer-based technologies, patients in underserved areas should be able to receive mental health care that takes advantage of combining physician expertise in diagnosis and prescribing medications with the expertise of psychologists, social workers, and counselors. Decisions involved in evaluating the risks and benefits of using psychiatric medications in a particular patient are difficult even for practitioners with years of basic medical training and rigorous continuing medical education. Psychologists are highly valued members of the health care team, but we believe that it is not in patients' best interests for psychologists to prescribe medications, and, in effect, practice medicine.
In 1910, medicine entered the modern era with the publication of the Flexner Report. In essence, the Flexner Report concluded that individuals who practice medicine should attend accredited medical schools. The wisdom of this report is still evident today. Patients will no doubt suffer if we fail to heed the lessons of history.
This post was co-written by Eugene Rubin MD, PhD and Charles Zorumski MD. Neither has any financial conflicts of interest involving the pharmaceutical industry.
