The Difference Between Psychiatry and Psychology: Prescriptive Rites
By Brendan Sowers
Medical advancements have permeated the recent decades, having great impact in the evolution of both mental and physical health care. Discoveries have shifted the focus from dealing with mental illnesses as psychological orders to a more medical model. A major debate dealing with the prescription privileges of psychologists has risen from this shift. Several factors have encouraged some psychologists to push for prescription rights. Many large industrial drug companies are pouring money into sponsoring psychologists to do research with a strong psychopharmacology emphasis. New antidepressants, such as SSRIs, have been developed, and they are much safer and more reliable that past prescription drugs. The adverse effects are more favorable, and general practitioners (GPs), non-psychiatrists, are more likely to prescribe these drugs as a means of dealing with mental disorders. Only physicians have unlimited, independent prescription privileges in the United States (Lavoie). However, slowly, professions such as dentists, optometrists, and podiatrists have obtained limited prescription privileges (“Prescriptions by Psychologists”). Now, psychologists are also pushing for prescription privileges pertaining to their profession. However, a push for psychologists to obtain prescription rights at this point in time is unnecessary and not recommended.
Psychologists are, quite simply, just not qualified to prescribe medication. On even some basic levels psychologists lack the science background that is given to other prescribing professions. Psychologists have not been able to adequately demonstrate their competence in prescribing medication, and this can prove to be a hazard to patients. Also, there is no confirmation on the societal need for prescribing psychologists. A lack of consensus on the issue causes debate within the field of psychology itself. About half as many psychologists would want prescription rights as there are psychologists who oppose these rights (Caccavale). They are divided on several issues, including the moral implications and the views of where the field of psychology should be heading in the future. Will people still be talked through their problems or will medicine solve everything? This disagreement brings about the question of whether or not it is even a desirable change. The ability to prescribe would have impact on the graduate and post graduate training, possibly weakening and diluting the psychological training required to be a successful therapist.
Those who support the obtainment of prescription rights for psychologists do not do so without any warrant. Some psychologists argue that with proper training, they can offer superior quality mental health care. In the Journal of Clinical Psychology, John Caccavale stated that he believes that “the more supportable and honest argument for patient safety is for the prescriber and the treater to be one in the same person—an appropriately trained prescribing psychologist, who would combine behavioral interventions with the appropriate use of psychotropic medications.” Some argue that they will be able to better meet the health needs of the country. The mental health burden of industrialized nations is extensive, and many people have a diagnosable disorder. Disorders, when left untreated, can create much bigger problems within the person and people around them. Such people become can become quite unproductive.
Also there is a shortage of access to mental health care is rural areas (Norfleet). Sometimes people have to wait as long as six months to obtain treatment from a professional and in that amount of time the problem can often escalate to stages that require more extensive treatment. Some doctoral level psychologists have a fear of being replaced with people of lesser education who can perform nearly the same job for less pay (Lavoie). Caccavale complains about the lowering of the standard to a Masters degree, and the competition between the Masters degrees and the doctoral degrees. With the current oversupply of doctoral level psychologists, many think that the ability to prescribe would help circumvent the professionals who conduct psychotherapy.
This line of thinking has been put into practice on a very small scale in the states of New Mexico and Louisiana. There a program has been developed in which psychologists can obtain limited prescription rights after specific training. This program has been approved by APA’s Committee for Advancement of Professional Practice (CAPP) and the APA College of Professional Psychology. In order to even undergo the training, Psychologists have to meet certain requirements. They must have a doctoral degree in psychology, a current valid state license as a psychologist, and at least five years of experience as a health service provider psychologist. With those requirements met, a psychologist can then undergo 450 hours of training classes. That is followed by eighty hours of supervised work. Then 400 hours of work with at least 100 different patients with mental disorders must be completed, all the while receiving two hours of weekly supervision. After passing a certification exam, the psychologist is granted a two year license to prescribe under supervision of a physician. After those two years, the psychologist can finally apply to prescribe independently (Lavoie).
However, even with such a program in place, few psychologists graduate from it. Even so, some physicians, who go through many more years of training in the sciences in order to prescribe, would argue that the training is not sufficient enough for psychologists to provide proper prescription. What it can do is provide better communication with the GPs. This is important because there is a slowly declining number of psychiatrists (Lavoie), and GPs end up making most of the prescriptions of psychoactive medication to patients (Norfleet). Communication between psychologists and GPs will help reduce the amount of misdiagnosed and inappropriately medicated patients. Programs such as this are said to improve the shortage of access in rural areas. However, that has yet to be proven (Lavoie). Most psychologists generally live in the same areas as physicians and psychiatrists do, and of the ones who do complete the training, there no evidence that they would move to rural areas.
Having professionals without the ability to prescribe could be a good thing for the patients. Mental disorders are not always best dealt with using medication. Professionals who can pull away from medication are necessary, lest the entire mental health care system be overrun with prescriptions.
One issue not always brought up is who will bear the financial burden of such programs. There would be a very large cost to universities and professional school programs. The training described earlier would be approximately two years. That two year delay turns many away from the program and creates a hole in earning potential. Two years of work is a large amount of both income and tax cost. There is no proof as to whether or not the government would even support the investment. This brings into question the feasibility of psychologists being able to prescribe on a large scale. The American Psychiatric Association has repeatedly stated its firm opposition. Also, surveys show that most GPs are not in favor of psychologists having prescription rights, and they would not refer their patients to those psychologists (Lavoie).
Being able to prescribe is not necessarily as effective as some would believe it to be. Psychologists will still have to refer to physicians for co-morbid medical conditions, which is when there are more disorders or diseases than the disorder of interest. Often this refers to both a mental disorder and a substance abuse. Co-morbid medical conditions compromise of approximately fifty percent of patients. Psychologists will also have to do the same for the adverse affects of the medication (DeLeon). This is hardly effective for time or cost. Adding in the factor that training and licensing is a huge cost in both money and time, psychologists would be greatly encouraged to increase their fees. There aren’t too many benefits to the patient with the psychologists’ ability to prescribe. Most of the benefits are for the psychologist.
Generally, the possibility that psychologists could prescribe both safely and effectively with the proper training is accepted, and the DoD project which produced ten psychologists capable of prescribing showed this. However, those ten were trained under very close supervision of psychiatrists in a military facility. The patients were limited in age, all between eighteen and sixty five. Patients have also all received full medical evaluations before hand. Also, most cases were considered to be minor disorders (Lavoie). The number of psychologists, ten, and the situation in which the cases were being handled create little proof and usable data for supporting subscription rights for psychologists. Medical doctors worry as to whether the psychologists would know enough to even be aware of the gaps in their knowledge and be able to properly refer patients to more knowledgeable professionals.
Physicians undergo extensive training lasting from nine to twelve years in order to prescribe safely and effectively to their patients. Psychologists have no need to be able to prescribe as well. For many disorders, psychological treatment as it is now is less expensive and may also be more effective and longer lasting. Psychologists shouldn’t push for the ability to prescribe, but they should push for better communication with physicians. With better communication, and possibly a small amount of training on both sides to help improve that communication, both professions can do what they are good at to the greater benefit of the patient.
Caccavale, J. (2002). Opposition to prescriptive authority: Is this a case of the tail wagging the dog? Journal of Clinical Psychology, 58(6; 6), 623-633. http://proxy.foley.gonzaga.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=pbh&AN=6976990&site=ehost-live
DeLeon, P. H., Folen, R. A., Jennings, F. L., Willis, D. J., & Wright, R. H. (1991). The case for prescription privileges: A logical evolution of professional practice. Journal of Clinical Child Psychology, 20(3; 3), 254. http://proxy.foley.gonzaga.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=pbh&AN=6395077&site=ehost-live
Lavoie, K. (2003). Reply: Should psychologists be granted prescription privileges? A review of the prescription privilege debate for psychiatrists. Canadian Journal of Psychiatry, 48(7; 7), 497. http://proxy.foley.gonzaga.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=pbh&AN=10649097&site=ehost-live
Lavoie, K. L., & Barone, S. (2006). Prescription privileges for psychologists: A comprehensive review and critical analysis of current issues and controversies. CNS Drugs, 20(1; 1), 51-66. http://proxy.foley.gonzaga.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=pbh&AN=19362400&site=ehost-live
Litman, L. C. (2003). Re: Should psychologists be granted prescription privileges? A review of the prescription privilege debate for psychiatrists. Canadian Journal of Psychiatry, 48(7; 7), 496. http://proxy.foley.gonzaga.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=pbh&AN=10649096&site=ehost-live
Norfleet, M. A. (2002). Responding to society's needs: Prescription privileges for psychologists. Journal of Clinical Psychology, 58(6; 6), 599-610. http://proxy.foley.gonzaga.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=pbh&AN=6976987&site=ehost-live
Prescriptions by psychologists.(1996). Harvard Mental Health Letter, 13(4; 4), 8. http://proxy.foley.gonzaga.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=pbh&AN=9610171540&site=ehost-live
Walker, K. (2002). An ethical dilemma: Clinical psychologists prescribing psychotropic medications. Issues in Mental Health Nursing, 23(1; 1), 17-29. http://proxy.foley.gonzaga.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=pbh&AN=6347076&site=ehost-live