Psychologists and Prescription Privileges: A Conversation (Part One)

A psychiatrist discusses psychologist prescription privileges with his patient.

Posted Mar 30, 2010

The always controversial topic of whether psychologists should be allowed to prescribe medications is back on the public stage with a vengeance. Oregon just overwhelmingly passed legislation authorizing psychologists' prescription privileges after a 3 ½ year course of extra training after their PhD. Recently, I had a conversation with one of my patients about this issue. Here is Part One.

"Dr. Carlat," asked Linda. "I've always wondered--what is the difference between a psychiatrist and a psychologist?"

"The main difference," I said, leaning back in my leather chair, "is that psychiatrists can prescribe medications, while psychologists-with a few exceptions--cannot."

"So...that's the only difference?"

"No. Psychologists have much more training in doing talk therapy."

"So to become a psychiatrist, do you go to psychiatry school?"

"No-to be a psychiatrist you have go to four years of medical school first, then you do one year of general medical work in a hospital, and then you go to three years of something called psychiatric residency, which is an on the job training program."

"Wait a minute," asked Linda, almost jumping out of her Queen Anne chair. "You went to medical school?"

"Yup."

"You mean like where you cut open cadavers, do surgery, deliver babies, and do rectal exams?"

"Uh huh."

"But why would a psychiatrist have to learn all those things? You don't do physical exams or surgery, do you?"

"No I don't. And almost none of my colleagues do either. Mostly what we do is what I am doing right now-sit across from people and talk to them. And at the end of the conversation, I usually write out a prescription."

"So you have to go to five years of medical training just to write prescriptions?"

"Well...not really. In fact, there are hundreds of thousands of health care practitioners who can write prescriptions who never attended medical school, like nurse practitioners, optometrists, podiatrists, and nurse midwives."

"But how can they write prescriptions if they didn't go to medical school?"

"Because each profession has a training program that incorporates enough elements of medical school to allow them to prescribe safely."

"But what's the point? Why do we need all these other professionals? Why doesn't everybody just go to medical school?"

"Because for many years there has been a severe shortage of doctors in the U.S. If we required the full medical school training for everybody who did anything medical, patients would have to wait for months before they could get any type of treatment. So these other professions have created streamlined training allowing them to do certain specific medical tasks. And as long as they do only what they were trained to do, research has shown that they perform just as well as doctors, and in some cases even better, at least in terms of patient satisfaction."

"You, mean, like the nurse practitioner I see every time I have doctor's appointment? She's really nice, and always spends at least a half hour with me. With my doctor, it seems he's always in a huge rush."

"Right."

"So you said there are some cases where psychologists can prescribe. What do you mean?"

"Well, first, let's talk about how psychologists get trained. They start by going to five to seven years of graduate school in psychology, where they learn all about how to make psychiatric diagnoses, about neuropsychology and how the brain works, how to use different talk therapies to help people, and how to do research to show whether certain treatments actually work."

"And then they can prescribe?"

"No-before they can enroll in a prescription training program, they have to practice their craft for at least two years. That means seeing patients, doing therapy, and often learning quite a bit about psychiatric drugs, because so many of their patients are on such medications, as prescribed by a family doctor or a psychiatrist."

"So after that, they can prescribe?"

"No. After at least two years of clinical practice, they are eligible to enroll in a special master's degree in psychopharmacology. They learn about all the psychiatric drugs, how to prescribe them, which lab tests must be ordered before you start patients on them, how to make sure patients don't have a medical illness that mimics a mental disorder."

"Wow- what a marathon. After all those years of work, then can they prescribe medicine?"

"No, not yet. They still have to do a year or so of practical, on the job supervised training in prescribing."

"And then, finally, they can prescribe?!"

"Well, only if they happen to have offices in New Mexico, Louisiana, Guam, or if they are hired by a branch of the U.S. military. All of these entities allow qualified psychologists to prescribe."

"Wait a minute. It sounds like these prescribing psychologists would be the ideal people to treat mental disorders. They do therapy, they understand the brain, and they know how to prescribe brain medications. Why are they not allowed to prescribe everywhere in the U.S.?"

"Well, Linda, that's a very interesting story in itself, and we're unfortunately out of time today. Let me write you a refill and we can continue this next time."

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