Psychologists Get Prescription Pads and Furor Erupts

Psychologists are adept at diagnosing and treating mental illness. But unlike psychiatrists, who are medically trained, they have never been able to prescribe drugs for their suffering patients. As of July 1, however, psychologists in one state, New Mexico, will be authorized to pull out the prescription pad. A new law will grant prescribing privileges to licensed, doctoral-level psychologists who have completed an additional training and certification program. And though the specifics of the plan remain to be worked out, the law is already the focus of a bitter national debate. Proponents argue that the law will provide greater access to quality care at lower cost. Opponents contend that psychology should remain distinct from its medical cousin and they worry that the legislation may place vulnerable patients in danger. Most vehement in their objections are the representatives of organized psychiatry. “Most of the patients we see as psychiatrists have many other medical problems,” said Dr. Richard K. Harding, president of the American Psychiatric Association. “They have hypertension, diabetes, migraine headaches. And the interactions of the medicines we give for these other conditions are often extremely difficult and scary.” NY Times

This is a very very bad idea, in my opinion both as a psychiatrist and a consumer advocate for my patients. First off, let’s remember that most members of the public have only a hazy notion of the difference betwen a psychologist and a psychiatrist. “Are you a medical doctor too?”, I’m constantly asked. This makes me suspect that the quality of the public debate on the New Mexico law was sorely lacking. Moreover, the law requires far less training and supervision of the prescribing psychologists than the pilot study on whose successful results it is predicated. In the time-honored tradition of not even knowing enough to know how little you know, one of the psychologists first trained to prescribe says that the amount of knowledge necessary to prescribe has been overrated. Eminent psychiatrist Joel Yeager comments, “People are going to learn psychopharmacology for dummies. They will learn how to pass tests but will not really have a decent immersion in this material because they won’t have the background for it.”

On the other hand, the argument (above) by the psychiatrist president of the American Psychiatric Association — that most psychiatrically ill patients who require medication are also medically ill and require someone skilled in avoiding drug interactions to prevent disaster — is no more than the typical scare-tactic spin of a professional lobbyist. Far more pertinent than drug interactions or recognizing covert medical illness is the ease with mind-body integration and the familiarity with the rhythm of prescribing, assessing, adjusting that psychiatrists have come by over years of medical training, as Dr Yeager’s comment suggests. And since more of healing, even psychopharmacological, than we ever acknowledge depends on the patient’s unconsciously entering into the shared premise of the healing (a.k.a. the placebo response), treatment success depends too on ineffable qualities of charisma and directiveness that are the unspoken subtext learned in medical training. Needless to say this cannot be galvanized in this shortcut correspondence school approach to getting psychologists up to speed to prescribe. Not to mention that, whereas medical training is a clinical field from the get-go, although there is “clinical psychology” psychology is an academic and research-oriented field — quite a different mindset, and selecting for quite a different personality.

I know this diatribe may offend psychologist FmH readers, but I don’t mean to suggest their ability is lesser — only different. The obvious twin dangers inherent in psychiatrists, MDs, responding in this debate are that they will be tarred with the usual brush of being seen as arrogant and that they will be seen as trying to protect their eroding market share — which is the usual approach of the APA and the reason I no longer belong to that ol’ dinosaur of a lobbying group. Instead, I’m trying to suggest there’s an argument from quality of care as well, a Hippocratic one (“first, do no harm”) if you will. If you see MDs only as overpriced functionaries whose sole distinction is that they have prescribing privileges, then of course it makes sense to try to develop lower-priced alternatives. But you get what you pay for. Caveat emptor, not that the consumer is going to have any say in the matter, or even necessarily know what they are missing, the way modern healthcare is going.

I already find that most of my poor, disenfranchised patients with major mental illnesses, on public assistance, get second-rate prescribing from the nurse practitioners who are allowed to write prescriptions in my state. And, yes, I know that will unleash another firestorm of reproach from any readers who are RNs or sympathetic to them. But, from more than a decade of consulting to, supervising, hiring (and firing), and treating patients referred from nurse clinical specialists, I am comfortable with my conclusion that their lack of global preparation and experience for prescribing results in a job less well done by most of them than most physicians in equivalent clinical roles. And the same will be true with the new law (even more, since psychologists have no experience treating medically very ill patients in general). Of course there are anecdotal exceptions, if you compare a particularly gifted non-MD prescriber with a particularly clumsy MD prescriber — there are NPs to whom I would send a family member for psychopharmacological treatment, and there are MDs I would not, needless to say — but public policy should be based on aggregates, not anecdotes. Okay, I’ve got my asbestos suit on, let the flamewar begin. Actually looking forward to thoughtful disagreement on this issue, so close to my heart and passion…