The New Psychiatry

Dr. Caralat,

Would you refer a psychotherapy patient for medication to a psychiatrist whose undergraduate education included no biology, chemistry or other pre-med courses, who did not have to take the MCAT or any other test, nor did he take any pre-requisite coursework prior to beginning his medical education, and whose entire medical education consisted of the equivalent of 20 semester hours of coursework which was all obtained online?

Doctor, that is exactly what you are promoting, whether you know it or not. Your speculations are being used by those advocationg prescription privileges for psychologists under precisely those training conditions. You may claim you were not aware of these specifics and cannot be held accountable for such an abomination, but you must bear responsibility for how your endorsement is being used.

I recommend you look into this and give some reflection on whether you want to be a part of this.

Actually, many psychologists have considerable science background both as undergraduates and in graduate level coursework.
Most psychologists have taken the GRE (general section as well as psychology section) prior to graduate school -- as rigorous as the MCAT, just testing different material.
Psychology graduate school requires prerequisites, and then states require a specific curriculum before licensure can be considered. And we must pass the EPPP, a national written examination.

And after licensed practice for two years, we can opt to take several more years of coursework, supervised practice in order to prescribe.

The current undergraduate requirements at my alma mater include:
Neuroscience, Drugs & Behavior, Hormones & Behavior, Clinical Neuroscience, Cognitive Psychology, Developmental Psychology, Social Psychology, Clinical Psychology, even possibly a semester long course in Depression -- what primary care doc, or even psychiatrist, gets that AS AN UNDERGRADUATE?

Then proceed to examine the state guidelines for licensure, which dictate minimum graduate level coursework necessary to even sit for the EPPP. I've excerpted Oregon's requirements below (with some added emphasis):

And then add a Post-Doctoral Master's in Psychopharmacology.

Yes, we don't have enough training.

But since 75% of psychotropic medications are prescribed by pediatricians, family practice, Ob/GYN and internists -- and I don't even mean "just" antidepressants -- I've seen primary care physicians prescribing antipsychotics. Really? Is that in their training? Does their training include "detailing" from pharmaceutical reps?

The requirements for basic licensure as a psychologist include:
(taken from the Oregon statute)
(b) Curriculum. The curriculum of the program must require applicant's successful completion of the following:

(A) 40 semester hours (60 quarter hours) of graduate courses identified by title and course content as psychology, that may include clinical, counseling, industrial/ organizational and school psychology, excluding thesis and practica;

(B) An original dissertation or equivalent that was psychological in nature that meets the requirement for an approved doctoral program.

(C) Three or more graduate semester hours (five or more graduate quarter hours) each in biological basis of behavior (including, but not limited to PHYSIOLOGICAL PSYCHOLOGY, comparative psychology, NEUROPSYCHOLOGY, PSYCHOPHARMACOLOGY, sensation and perception, BIOLOGICAL BASIS OF DEVELOPMENT); cognitive-affective basis of behavior (including, but not limited to learning, thinking, motivation, emotion, cognitive development); social basis of behavior (including, but not limited to social psychology, organization theory, community psychology, social development); individual differences (including, but not limited to human development, personality theory, psychopathology);

(D) At least one graduate course each in research design and methodology; statistics and psychometrics; and scientific and professional ethics.

Those training requirements are exactly those specified by APA's bills
Read what they are trying to get away with and not what you wish for
That's 20 semester hours of medical education through correspondence school. Total.
That is a shameful fraud. Dr. Carlat is responsible for encouraging this fraud even if he did not intend to.

I hope readers will consider the other side of this issue, and take a look at the editorial on Psychiatric Times' website:

http://www.psychiatrictimes.com/display/article/10168/1545667?CID=rss

Sincerely,

Ronald Pies MD
Editor in Chief
Psychiatric Times

When competence, safety and ethics are at the forefront then change is possible.

Please do not diminish the education and training that many have pursued regardless of the ability to write a prescription. The need for integrated health care is evident in every corner of our society. This may require the blurring of previous drawn lines of education and scope of practice. Although this particular step may cause some cognitive dissonance it is worthy of consideration.

The bill on the Governor's desk in Oregon will establish a new task force made up of physicians and psychologists who will determine what is adequate education and training for a psychologist to obtain competence in prescribing a limited formulary (to be determined).
The certificate to prescribe will be issued and monitored by the Oregon Medical Board (not the board of Psychology).

All prescribing by a psychologist must document full medical assessment by the person's primary care provider and there will be documentation of collaborative communication about the patient's physical health and medications prescribed by both providers throughout treatment.
Read the full bill at http://www.leg.state.or.us/10ss1/measpdf/sb1000.dir/sb1046.en.pdf

Also....
The post doctoral masters degrees are delivered by fully regionally and nationally accredited academic institutions/universities via live classes that simultaneously are offered via satellite or live video-streaming on the web with the ability for all students and professors to interact. This is similar to many major nursing programs and provides the opportunity for psychologists in active practices throughout the state to participate. Because the psychologist is in active practice they are integrating their learning from the first day of course work into a previously learned skill set and additionally have full phone and email access to their expert professors and colleagues.
The other requirement (that was taken out of the current bill in lieu of a new task force) required an additional 18 months of clinical training (after doctoral internship, residency and a minimum of two years of practice in a health care setting).
A national certified comprehensive examination was also required.

The graduate course work mentioned in the previous comment is for all psychologists. The bill in Oregon requires additional education and training. In the current post-doctoral masters of clinical psychopharmacolgy programs the psychologists spends a year ramping up their "medical/science" education with courses in
• Clinical Biochemistry
• Neurosciences, includes: - Neurochemistry - Neurophysiology - Neuroanatomy/Neuropathology
• Clinical Medicine/Pathophysiology
• Physical Assessment
The second year and a half is spent building upon that knowledge
• Pharmacology and Clinical Pharmacology
• Psychopharmacology includes: - Antidepressants - Anxiolytics - Antipsychotics - Mood Stabilizers and Drug/Drug Interactions
• Introduction to Molecular Nutrition & Its Place in Psychopharmacology
• Special Populations in Psychopharmacology includes: - Child/Adolescent Psychopharmacology - Gender Issues - Geriatric Psychopharmacology/Chronic Pain - PTSD/Borderline Personality/Chronic Medical Conditions - Ethnopsychopharmacology
• Chemical Dependence
• Pharmacotherapeutics includes: - Research Issues in Psychopharmacology - Professional, Ethical and Legal issues - Integrating Psychotherapy and Pharmacotherapy
• Case Seminar

Many times this conversation develops into a discussion of the training that psychiatrists and psychologists have. However, one should be aware that psychiatric nurse practitioners are now prescribing psychotropic medications. Psychiatrists seem to have no problems with this. I think when the training of "prescribing psychologists" and the training of psychiatric nurse practitioners is compared, it is eye opening and it makes it appear that much of the debate is more centered on guild issues and not on training.

I completely agree with Fraulien that this is primarily a guild issue and is about how to split up the patients and the money.

Not that there aren't some legitimate medical and safety issues as well. As a practicing psychiatrist, a small percentage of my patients, maybe 20% or so, genuinely are best treated by a psychiatrist because their medical issues are quite extensive and an understanding of these is helpful, mainly in terms of communicating with the primary care doctor. But the majority of my patients are medically healthy and can safely be treated by a non-MD prescriber, whether a nurse practitioner, a physician's assistant, or a medical psychologist.

If we had an unlimited supply of psychiatrists, there would be no issue here. But instead, there is a critical shortage across the nation. And my profession is refusing to seriously grapple with this problem.

Readers of this blog may want to read the pro/con editorials on the Psychiatric Times website. The links follow.

http://www.psychiatrictimes.com/display/article/10168/1548811
http://www.psychiatrictimes.com/display/article/10168/1549223

I agree with Dr. Carlat that at least 20 out of every 100 patients presenting to many psychiatrists have complex medical problems best treated by a psychiatrist--and Dr. Carlat and I know this, precisely because we have had the medical training to recognize this type of patient.

Will psychologists also be in that position of knowledge, when patients show up asking for medication? Will the affiliated primary care practitioner know, given that most patients are seen by PCPs for 10-12 minutes per visit, and there is no defined frequency of medical evaluation in the Oregon statute?

As Dr. Tom Hansen notes in his Psychiatric Times editorial, there are safer ways to address the shortage of psychiatrists in Oregon and other under-served states--ways that link PCPs with psychiatrists, rather than creating a new and largely untested class of medical practitioners called "prescribers". Surely, if we were addressing a shortage of surgeons, we would not be looking to create a new class of non-physician "cutters", would we?

Regards,
Ronald Pies MD

Yes, I agree with Fraulein as well. I think the main issue here is social. PAs and NPs can prescribe with much less training than what is outlined in the Oregon bill for psychologists. I have just entered a Psy.D. program and I took the full gamut of pre-med courses, including a senior/graduate level course in Biochemistry. I also have a M.S. in Biology. I am just as prepared as, if not better prepared than, any entering medical student to learn to prescribe. As far as exams, I took both the MCAT and the GRE, as have several other Psy.D. students who I have spoken with in my program. I think what it comes down to is some MDs do not want psychologists intruding on their territory. In addition, they may feel that all of those crazy and unnecessary "rights of passage" they go through have been a waste of time...in other words, "It's not fair!" Also, when an NP or PA prescribes, doesn't the psychiatrist collect the fee? I heard that somewhere....

Of course, psychologists can already prescribe given appropriate training. That training is called medical school. What is wanted is a shorter route to the prescription pad. This is a bad idea. Arguments about the lack of training among those currently prescribing are hardly convincing. The adequacy of the training of psychologists is not logically connected to the adequacy of the training of other providers. Why has the APA (and its shills) not spent millions over the past couple decades working towards better integration of psychologists with primary care? The more sensible route wold be to have people well trained in psychology working with people well trained in medicine.

I now currently work (as a psychologist) at a DOD army hospital and there is one psychologist licensed there to prescribe meds who works in primary care (in most federal institutions, it does not matter what state you are licensed in-- i.e. that is the case of this prescribing psychologist I am speaking of; he is licensed in a state that allows it, but is able to work at this federal institution in another state). Anyway, point is the primary care docs, etc. love this person as he has vast knowledge on both the best mental health treatments and psychpharm (the MDs/ NPs in this primary care setting routinely turn to him for advice regarding what pills to prescribe). He has a long waiting list for patients… I don't know, proof is in the pudding... right? The only resistance came several years ago when psychiatry tried to block the credentialing which didn’t work (a little worried psychiatry, huh?)… Also, in terms of psychiatrists there about 10 to the 50 psychologists at this hospital. I am not turning this into some sort of psychiatry vs. psychology debate—but many NPs, PAs, and GPs turn to the psychologists for help with behavioral health treatment. Psychiatry is dying (I am seeing it first hand), psychologists will have to get presepction privileges eventually—it’s only a matter of time!