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The Carlat Psychiatry Blog doc just sided with the over zealous psychologists...
I also feel IM, peds, and FM need to rotate through psych.
You'd never think of trying to manage someone's diabetes without at least trying to help them lose weight...
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The article is also written as if psychiatrists don't do psychotherapy. Several do
The article is also written as if psychiatrists don't do psychotherapy. Several do, and several programs are strong in their psychotherapy training.
I also believe the collaboration model is far better than independant prescribing, as it would fit in well with some of Carlat's points.
Because the economics don't make sense, and psychiatrists are able to practice psychotherapy even if they have little to no training in it. Whether or not that is ethical.....that's not my call.And countering Carlat's argument, why not then encourage more and better psychotherapy among psychiatrists, and more collaboration with psychologists?
psychiatrists are able to practice psychotherapy even if they have little to no training in it.
as he appears to relentlessly claim that psychotropics basically don't work,
I agree with you here, nancysinatra, but I'm with masterofmonkeys that it's pretty criminal that you can become board certified in Family Practice without doing a single rotation in Psychiatry, given that FP probably ends up treating more depression and anxiety than Psychiatry does. I think an outpatient rotation in a clinic-type environment should be a must.Having IM, peds and FM rotate through inpatient psychiatry like a psych intern would expose them to very sick psychotic patients, borderlines, manic patients, people with delusional disorder, etc--but that's not what they're treating in the real world.
I've heard this before. Out of curiosity, what exactly is the ACGME training guideline? Is there an hour requirement? Not disputing your point, I'm just not clear how much psychotherapy training is actually prescribed by the ACGME.BTW: by ACGME training guidelines, psychiatrists are required to have training in psychotherapy, though with the current industry guidelines, several may be out of practice with it.
Interesting stuff. According to the Psychiatry Program Requirements listed by the ACGME here, there are no specific psychotherapy requirements.
I agree with you here, nancysinatra, but I'm with masterofmonkeys that it's pretty criminal that you can become board certified in Family Practice without doing a single rotation in Psychiatry, given that FP probably ends up treating more depression and anxiety than Psychiatry does. I think an outpatient rotation in a clinic-type environment should be a must.
IV.A.5.a).(5).(c).(i) evaluation and treatment of ongoing
individual psychotherapy patients, some of
whom should be seen weekly under
supervision;
It seems clear that Carlat's near obsession with the profession's ties to the pharmaceutical industry have come full circle to the point of, in a sort of sad and ironic twist, ceding psychiatry to "collaboration" and "getting everyone in the same room" to paraphrase. This, in my eyes, is code for de-medicalizing psychiatry - something to which I'm vehemently opposed.
I had read his material less and less as he appears to relentlessly claim that psychotropics basically don't work, and the cynicism toward new developments in the psychopharmacology field were too much to take and frankly, became a drag. Now, I have even less reason to read it. I'll likely stop altogether at this point, as I've been finding it less useful.
I don't think his point is to side with psychologists. I think it is to point out that psychiatry is losing its identity and meaningful role in the mental health world by focusing more and more on psychopharmacology and ignoring matters of the mind, which are inseparable from mental health and illness.
The other day, I went back and reread the CATIE paper, which revealed among other things that antipsychotic compliance was a fair bit worse than we had typically speculated. About a quarter of subjects in the trial withdrew due to side effects, but a greater proportion withdrew due to "patient choice," which is pretty ambiguous. I can't help wondering more about this group. Assuming they weren't experiencing significant side effects, what could have been done to keep them in the trial? I think the answer lies somewhere in psychotherapy and the therapeutic relationship. Unfortunately, this seems to be paid short shrift, lip service, by many (not all) in the profession.
However, this stuff is the bread and butter of psychology. Setting aside Carlat's assumption that psychologist prescribing will pose no safety threat, his assertion that psychiatry would do well to reemphasize the importance of the mind, psychotherapy, the doctor-patient relationship, etc. in practice seems reasonable to me.
We are already well placed to offer the 'full package' but many of us aren't dong it. What Carlat is saying (I think) is that prescriptive rights for PhDs may force us to compete, which ultimately will get us back on track.
Two responses to your post:
(1) I don't think psychotherapy would help much with compliance.
......
From what you say in your post, you are undergoing some psychodynamically-based, insight-oriented therapy. This is one of many psychotherapies. No single type of therapy fits all situations. Therapies such as motivational interviewing and life skills training are useful in addressing issues such as med compliance.
While I agree with you that if someone is floridly psychotic that medication is the only thing that will work until they are stabilized, but short of that there are definitely more options. OPD correctly differentiated on the type of talk therapy. In many cases your "severely ill" are in the most need of some type of talk therapy intervention. I've seen it often in the ED, though the agitated pts. just get shipped off/out, particularly when they start to add up.I do CBT in 20% of my patients. In real life, the majority of patients prefer medicine over listening and talking an hour every week. All my CBTs patients are mildly ill and can probably be seen by LICSWs or PHd/PsyD. The rest came to me so severely ill that only medicines could help. And yes, even ECT and/or TMS.
I think it is to point out that psychiatry is losing its identity and meaningful role in the mental health world by focusing more and more on psychopharmacology and ignoring matters of the mind, which are inseparable from mental health and illness.
I'm glad my post helped get a good discussion going. My understanding is that the Oregon law requires psychologists to have completed a standard PhD or PsyD program (usually 5 to 7 years), then complete an APA accredited masters in psychopharmacology (two years) and then complete an 18 month residency, with a series of requiremens including inpatient work, outpatient work, work with specific diagnostic groups, etc....While I saw that point in his article, I doubt even Carlat, if he thoroughly examined the Oregon bill would've agreed there was enough training provided in it to the psychologist-prescribers.
My understanding is that the Oregon law requires psychologists to have completed a standard PhD or PsyD program (usually 5 to 7 years), then complete an APA accredited masters in psychopharmacology (two years) and then complete an 18 month residency, with a series of requiremens including inpatient work, outpatient work, work with specific diagnostic groups, etc....
Psychologists first obtained prescriptive privileges in the military through the Department of Defense demonstration project, and since then have been awarded privileges in both New Mexico (2002) and Louisiana (2004). The lengths of the training programs vary, though they are typically two year programs incorporating both didactics and a clinical practicum. Many have charged that these two year mini-programs cannot possible produce safe prescribers. But the evidence contradicts this position. There have been no adverse events reported in any of the programs operating thus far.
Is this enough to become a safe prescriber of a limited formulary of psychiatric meds? Probably so.
Thus, the scare tactics employed by my well-intentioned psychiatric colleagues have always been unconvincing. They typically involve a hypothetical patient who gets Stevens Johson Syndrome and an equally hypothetical bumbling medical psychologists who fails to recognize it. One can spin all kinds of other similar nightmare scenarios, but they are fictional.
What's the experimental set up for determining something like this, other than unleashing them and looking at outcomes?
At any rate, my main interest is not in winning prescription privileges for psychologists, but rather in reforming psychiatric training.
What has become painfully obvious to me over my years of practicing and writing is that most of the medical school curriculum is not relevant to what I do on a day to day basis. Screening for medical conditions, recognizing potential drug drug interactions, knowing when to order Li levels and thyroid levels, etc..., do not require 4 years of medical school
I had another patient with normal pressure hydrocephalus, but everyone was labelling her as psychotic.
I've worked in many different inpatient units, and I well remember that during residency there is a culture of the resident wanting to keep up his or her medical skills and aggressively pursue diagnosis and treatment of neurological and medical diseases. After residency, most inpatient units function very differently. Admission physical exams are often done by internal medicine as a consult. If there is a hint of medical problem, the attending requests a consult to properly diagnose the condition and start treatment.The NPH case is a good example. The way I learned NPH in medical school was that you expected the triad of gait changes, dementia and urinary incontinence. However if I'm not mistaken you can actually see NPH without actual incontinence, and just with urgency. So some NPH patients are going to be mistriaged to psych, it would seem like.
After residency, most inpatient units function very differently. Admission physical exams are often done by internal medicine as a consult. If there is a hint of medical problem, the attending requests a consult to properly diagnose the condition and start treatment.
Delighted to have you contributing, Dr. Carlat--I've been an admirer for some time--which makes it all the more surprising to read the apparent inconsistency in the paragraph above--am I to understand that although you see a psychologist as fully qualifiable to prescribe psychotropics such as valproate, lithium, and clozapine, you would not trust a physician-psychiatrist to manage a statin or hypertension meds?....Beyond that, in outpatient settings, practices vary widely. Some "go-getter" psychiatrists see themselves as primary care doctors, and check blood pressures, check lipid levels aggressively and institute statin treatment. Unless the psychiatrist is double-boarded in medicine and psych, I find this practice worrisome. Medicine is getting more and more complicated and I would not want my child being treated medically by a psychiatrist.
....
I've worked in many different inpatient units, and I well remember that during residency there is a culture of the resident wanting to keep up his or her medical skills and aggressively pursue diagnosis and treatment of neurological and medical diseases. After residency, most inpatient units function very differently. Admission physical exams are often done by internal medicine as a consult. If there is a hint of medical problem, the attending requests a consult to properly diagnose the condition and start treatment.
Beyond that, in outpatient settings, practices vary widely. Some "go-getter" psychiatrists see themselves as primary care doctors, and check blood pressures, check lipid levels aggressively and institute statin treatment. Unless the psychiatrist is double-boarded in medicine and psych, I find this practice worrisome. Medicine is getting more and more complicated and I would not want my child being treated medically by a psychiatrist.
Nonetheless, I see a continued role for medical school for an increasingly narrowly defined role, that might be termed a Neuropsychiatrist. In the current issue of Psychiatric Times, Ron Pies in fact argues that psychiatry and neurology should be merged. That would be fine with me, but it will then absolutely require us to create another profession. I don't even know what you'd call it. Maybe doctors of mental health, or medical psychologists, or pharmacopsychotherapists--the point is that these are people who are experts at understanding psychological symptoms, and treating these symptoms with all the tools available--medication and therapy.
The proposal is not to take neurologists out of medical school, but to have neurology and psychiatry merge. A Neuropsychiatrist would indeed go through the standard medical training--the 2 years of didactics, all the clinical rotations--and then do a 3 or 4 year neuropsychiatry residency. Neuropsychiatrists would be experts at a variety of neuropsychiatric diagnostic procedures and would presumably know how to treat the full range of neurological and psychiatric diseases, primarily through biological modalities.I think the idea of neurology and psychiatry merging is very interesting--but how could neurology get by without medicine training?
Well, let's not mix up terms here. I don't believe a psychologist should prescribe anything without proper psychopharm training. So, no, I do not consider a psychologist fully qualified to prescribe anything. However, after a two year masters in psychopharm and a year or two of residency, I would consider a medical psychologist qualified to prescribe from a formulary of psychotropics. Whether that formulary includes depakote and clozapine depends on how good I believe the training is.am I to understand that although you see a psychologist as fully qualifiable to prescribe psychotropics such as valproate, lithium, and clozapine, you would not trust a physician-psychiatrist to manage a statin or hypertension meds?
I see your point--but I disagree, because in each of the specialties you mention, the core function entails an understanding of pathophysiology of a biological disease entity. Orthopedic surgeons must learn pathophysiology of bones and joints in order to treat patients. Physiatrists, the physiology of muscles. Ophthomologists, the physiology of the eye and brain. Radiology, the pathophysiology of just about every disease. Psychiatry is the only medical specialty lacking an understanding of the pathophysiology of the diseases it treats, and therefore the only specialty for whom medical school is inappropriate.Hi Dr Carlat,
1) It seems I could replace "psychiatry" with "orthopedic surgery," "physiatry," "ophthalmology," "radiology," etc, change a few other words, and make the same arguments with ease: That a good portion of the work done in many (if not most) non-IM subspecialties has nothing to do with large chunks of what we endure in medical school.
All the power to them. These would be the doctors who would end up going into neuropsychiatry, and there will certainly always be a place for them.
You're right that all specialties use psychotherapy though they may not label it such. "Neuropsychiatrists" would use plenty, and might call it alliance building, or advice giving, or supportive therapy, etc.... These are also the techniques typically used by those psychiatrists who consider themselves to be primarily psychopharmacologists.What about those that intend to keep using their medical knowledge and knowledge of psychotherapy?
There is almost always a place for psychotherapy, even in non-psychiatric medical fields. Creating a new field with the goal of steering a physician away from the psychotherapeutic, and more to the physiological could encourage even less emphasis on psychotherapy.
Yes, I support the bill. I believe that the training required is sufficient, especially with the 18 month residency and the requirement of ongoing collaboration with physicians.As for my previous posts, I don't feel you addressed some of the issues. I understand that you don't have a problem with psychologists prescribing, and I don't either under the right conditions. A specific issue, however, is the Oregon bill...
Do you support that bill? Your op-ed didn't specifically say you supported it, though within the context of the entire article, it seems you do.
(c) Has completed, in no less than 12 months and no more than
24 months, an integrated, supervised clinical experience of at
least 250 hours, including differential diagnosis and applied
pharmacological management of patients congruent with the
specialty role sought;
SECTION 7. (1) The Oregon Medical Board, with the concurrence of the State Board of
Psychologist Examiners, shall adopt rules requiring a prescribing psychologist to maintain
an ongoing collaboration with the health care professional who oversees a patient's medical
care to ensure that:
(a) Necessary medical examinations are conducted;
(b) The prescribed drug is appropriate for the patient's medical condition; and
(c) The prescribing psychologist and the health care professional discuss, in a timely
manner, any significant changes in the patient's medical or psychological condition.
(2) The prescribing psychologist and the health care professional shall each document the
collaboration under subsection (1) of this section in the clinical records of the patient.
I'm excited about this thread, as it has some legitimate discourse rather than defensiveness and I'm pleased that Dr. Carlat is actually willing, as a psychiatrist, to take a stand on the issue for other practicioners prescribing.
So I'm not going to lose sleep over it personally.
I totally agree that my argument sounds silly at face value. But I'm driving at an issue that (I think) is a profound problem for psychiatry. One of the arguments I commonly hear against psychologists prescribing, or in favor of the idea that medical school is essential for prescribing, is some variation of: "writing out a prescription is, in fact, practicing medicine."To say that psychiatry should be separate from other fields simply because we don't understand why our medicine works, but only that it works in many cases, is in my opinion (and with all due respect) a silly argument.
There are hundreds of examples of medical doctors doing things that either a) in hindsight was stupid (like bloodletting), or b) in hindsight we now know why they work and have refined the techniques further.
Whopper--I think you're right about medical psychologists actually not representing a huge turf threat. I've heard through the grapevine that in Louisiana, it is a non-issue because there is so much business to go around.In fact, this was the only point brought up by the previous defenders of psychologist prescribers that I felt had some merit. There will be several psychiatrists who will fight this as a turf-war, though I'm not in that crowd, and everytime I asked for some data, I was not provided with any, and only accused of fighting a turf war.
In the few areas where it was approved, the numbers of psychologist prescribers have been small (which actually just points out that if there truly weren't any adverse outcomes, a small sample size is not much data to back it's safety), and I suspect those prescribers wouldn't even give out some of the hard-core meds I'd be worried about such as Depakote or Clozaril.