Psychologists and Prescribing Privileges
I found multiple issues to be challenged in a disappointing article by Dr. Field (“Psychologists Gain a Foothold in the Battle for Prescribing Privileges,” P&T, June 2005).
If physicians are the “guardians against inappropriate and harmful use” of pharmacotherapy, then Dr. Field has chosen to ignore the Institute of Medicine and a host of other studies. Diagnosis, which is the keystone of appropriate therapy, might be representative of the statistics in bipolar disease: 20% of patients receive the correct diagnosis, 30% are diagnosed as having unipolar depression and 50% are misdiagnosed entirely. It takes 10.4 years to diagnose Bipolar II Disorder.
No, the psychologists are not nearly as assertive as optometrists were in obtaining diagnostic, and then therapeutic, prescriptive privileges decades ago. The same rhetoric was used then—just substitute “psychologists” for “optometrists.” A cursory literature search failed to reveal any disasters from this action.
Dr. Field does not report any follow-up from the U.S. Department of Defense on the performance and experience with the psychologists previously trained.
Now to the critical issue: education and training. The average non-psychiatric physician receives two to four hours of psychopharmacology education in predoctoral pharmacology. No psychopharmacology training is found in the essentials for postdoctoral training programs. Dr. Field omits any description of the course content of the two-year American Psychological Association program or those of degree-granting accredited colleges or universities.
The bottom line is that we are now licensing physicians with far less education and training than the proposed process for prescriptive privileges for psychologists.
J.J. Rodos, DO, DSc
Clinical Professor of Behavioral Medicine, Midwestern University Adjunct Professor of Social Medicine, Ohio University canada pharmacy mall
In questioning the prescribing skills of physicians, Dr. Rodos correctly notes that their diagnostic acumen is far from perfect, especially regarding psychiatric conditions. He is also correct that physicians who are not psychiatrists generally receive very little formal training in psychopharmacology and that the training required for prescribing psychologists under both the New Mexico and Louisiana laws may be more extensive.
However, concerns over psychologist prescribing do not focus solely on knowledge of psychoactive medications. They also involve psychologists’ broader familiarity with the physiological effects of medications. This bears on their ability to spot nonbehavioral side effects and drug interactions and to identify physiological conditions that could underlie behavioral symptoms. Opponents of psychologist prescribing contend that clinical proficiency in these regards requires more extensive medical training.
These concerns, however, do not necessarily mean that psychologist prescribing is unsafe. Dr. Rodos asks about follow-up on the limited psychologist-prescribing program that the military initiated in the 1990s. An evaluation by the General Accounting Office in 1999 concluded that the quality of care rendered by the 10 psychologists in that experiment was generally good. Implementation of the programs in New Mexico and Louisiana will further help to inform the debate. However, in light of the possible risks and limited experience to date, programs such as these should be conducted with caution until there is enough outcomes data to provide broader reassurance.
Robert I. Field, JD, MPH, PhD
Director, Graduate Program in Health Policy Associate Professor of Health Policy University of the Sciences in Philadelphia Philadelphia, Pennsylvania