How Will Psychologists Practicing Medicine Affect Psychiatry?

One of the most regrettable events of the past several years has been the success of psychologists in New Mexico and Louisiana in enhancing their scope of practice to include the prescribing of psychotropic drugs. The practice of medicine by nonphysicians in many jurisdictions around the country includes optometrists, podiatrists, anesthetists, and advance-practice nurses (who in several states are entitled to prescribe psychotropic drugs). This issue is correctly perceived as a patient safety and quality issue as we may be regressing to a pre-Flexnarian era in which many nonmedical professionals have expanded their licensure to include prescribing drugs.

Just last month, the efforts of psychologists in Hawaii to achieve prescribing privileges from the state were thwarted by the extraordinary efforts of the Hawaii Psychiatric Medical Association with considerable help from our APA (see page 1). Enough concern was raised about the quality and safety issues of poorly trained non-M.D.s prescribing to vulnerable patients that the issue has been referred to an independent body for study and review. The legislature in Hawaii remains very concerned about the access issue, especially in rural areas, and the Hawaii Psychiatric Medical Association has been asked to come up with some solutions to this problem.

As we remain vigilant about the serious safety concerns we have, we must respond to the access questions in a persuasive and timely manner. In this column, however, I would like to address a different concern: the potential impact of psychologist prescribing on psychiatric practice.

While safety and quality are paramount in our continuing battle with nonphysicians who want to practice medicine, as I have traveled around the country, many psychiatrists have expressed deep concern about whether the addition of psychologists in the marketplace for prescribing antidepressant, mood-stabilizing, antipsychotic, and antianxiety agents will radically alter the prospects for the practice of psychiatry. Psychiatrists who have spent thousands of hours in medical school and residency training now see psychologists with less than 5 percent of this training treading on their hard-earned licensure and economic entitlements. In recent years with the struggle over reimbursement that psychiatrists have had with managed care, this is an insult added to injury in terms of psychiatric identity and a potential threat to our livelihood.

But let's be quite clear about the terrain of prescriptions. Most of the prescribing of psychotropic medications has been dominated by general physicians who do the bulk of prescribing, estimated at more than 75 percent of all prescriptions for psychiatric medications in the U.S. Will the addition of some psychologists to the entitlement of prescribing have a dramatic effect on the prospects of psychiatric practice?

Although it is too early to know what the impact will be in New Mexico and Louisiana, I believe there is little reason to panic. How many psychologists will actually become eligible to prescribe if they could? My guess is that number will be small, and those who do will have a small impact on psychiatrists' practices. Only a minority of psychologists are interested in expanding their practice in this way. Many psychologists have expressed what I believe is their legitimate concern about what the impact of prescribing will be on their identity as psychologists and have, in addition, expressed concern about the risks, including malpractice, of inadequately trained psychologists in their arena. The epidemiology of serious psychiatric disorders is such that even with an influx of psychologists into the practice of medicine, the large number of complicated patients with psychiatric and comorbid medical problems will continue to retain the major role for psychiatrists in caring for our patients for many years to come. The fact is that even with general physician prescribing, when it comes to our patients, especially those with complicated Axis I and Axis II disorders, only psychiatrists have the training, time, and commitment for the expert evaluation, diagnosis, and treatment of these conditions.

Of greater concern for psychiatry is the domination of treatment of mental illness by psychopharmacologic means and the attrition of psychotherapeutic and psychosocial approaches in our practice. Psychopharmacology ascendance in practice has been driven by managed care protocols, which deemphasize the psychotherapeutic skills of psychiatrists and puts a premium on very short-term hospital care, medication management, and reevaluation of diagnosis and treatment. Psychiatrists are often being prohibited from providing psychotherapy. The absence of adequate psychotherapy residency training for many psychiatrists reinforces this regrettable trend. In the decade 1987-1997, Olfson and colleagues found a substantial increase in the proportion of individuals with depression receiving medications and a substantial decline in the use of psychotherapy. In a more recent study by West and colleagues published in Psychiatric Services' “Economic Grand Rounds,” the financial incentives for psychiatrists to provide psychopharmacologic treatments in contrast to psychotherapy showed a clear economic advantage to provide medication with brief follow-up visits and a clear financial disincentive to provide psychotherapy. Psychiatrists earn more than $100 less an hour for providing one 45- to 50-minute session of psychotherapy versus providing three medication management visits in the same time.

Many psychotherapies are evidence based. Most studies show the combination of psychopharmacologic treatment with psychotherapy has better outcomes than does psychopharmacology alone. Too often, what's recommended by managed care is “split treatment,” which is medication management by psychiatrists and psychotherapy by others. Many patients would do best with the combination of treatments provided by the same therapist, a well-trained physician-therapist.

So, in the struggle against psychologists prescribing (and we must continue that struggle), we need to keep our eye on the real access issues. This includes the future of evidence-based treatments that are nonpharmacologic and the importance of keeping patient safety and quality first in what we do.▪