Scopeofpractice Issues Psychiatrists Versus Psychologists

Today, physicians across all specialties are forced to share certain duties with competing non-MD mid-level health care providers. Managed care and its push for cost containment, however, have hit psychiatry unusually hard. Medical students considering a career in psychiatry often wonder about competition from other mental health professionals, such as clinical psychologists, social workers, and nurse practitioners. Many of these professionals can perform psychotherapy. In some states, particularly rural ones, nurse practitioners are often the first-line health providers evaluating and treating psychiatric patients.

In particular, the issue of psychologists being allowed to prescribe psychiatric drugs is currently a matter of hot debate. Clinical psychologists do not have the education or experience to use powerful drugs in treating mental disease. Yet, in 2002, New Mexico made national headlines when legislators passed a law granting prescription-writing authority to psychologists. It became the first state to do so. In this case, psychologists argued that large rural areas of the state do not have enough psychiatrists for prescribing psychoactive medications. They have won a battle lost in other states. In the past decade, about 15 state legislatures rejected similar bills after considering the data and risks of placing potent drugs into the hands of people without medical education.

Nearly all psychiatrists (and many psychologists) agree that this ill-advised decision in New Mexico has significant potential to harm patients with mental illness. Because only those with the proper education should practice medicine, the medical community seriously questions whether psychologists can prescribe effectively and safely. Clinical psychologists, who hold masters or doctoral degrees, are trained only in psychotherapeutic principles to treat mental disorders. The New Mexico law grants prescription-writing privileges only to psychologists who take a crash course on psychopharmacology under physician supervision and pass a certification examination. But no quick workshop in drug prescribing, especially when reportedly designed and administered by psychologists, can substitute for the knowledge and skills earned from medical school, postgraduate training, and rigorous clinical experience.

Psychiatrists have extensive training in differential diagnosis, complex psy-chopharmacology, and the ability to evaluate whether symptoms are related to drugs or new medical problems. Whether or not they prescribe medication, psychiatrists, with their comprehensive understanding of both mind and body, always bring medical evaluation into their interactions with patients, even in psychotherapy sessions. As one academic psychiatrist observed,

As we increasingly understand how the rest of medicine can affect behavior, you must have a strong medical background in order to provide the best care. For instance, I had a patient who was seen by a psychologist who called him 'profoundly depressed with extremely latent speech.' When I saw him, I was able to immediately see that he was actually aphasic, and obtained a CT scan which showed a large brain mass. When you don't have a wide base of medical training, you miss things. This is not just about a power struggle between the psychiatrists and psychologists; it's just about good patient care.

The first psychologists to train under the new law in New Mexico will finish their academic and practical preparation by the end of 2003. Will this mark the beginning of a fundamental change in how mental illness is treated in the United

States? It is too soon to tell. Health insurance priorities have already shifted toward drug treatment over psychotherapy. If more states adopted such legislation, it might lead to more patients on psychiatric medications and less insurance reimbursement for psychiatrists' fees. Currently, no other similar bills in state legislatures have passed the introductory phase.

Regardless of the outcome, the current debate should not discourage medical students who are interested in psychiatry. Most psychiatrists worry about the quality of patient care under the new law—not their jobs. They are not threatened in any way by competition from mental health professionals. Remember, for the past several decades, primary care physicians and other nonpsychiatrists have written the majority of prescriptions for psychoactive medications. "We will still be the specialists in the field, seeing the most challenging—and interesting— psychiatric cases," stated a psychiatrist in private practice. The special education and medical experience of psychiatrists make them uniquely qualified to provide both psychotherapy and medication management.

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