Should psychologists be allowed to prescribe?
10. The proposed training requires treating a minimum of 75 patients over 2 years. A typical third-year psychiatric resident sees 75 patients every month. Each first- and second-year resident works up and treats >600 inpatients in <1 year
11. At the end of the practicum, applicants must demonstrate competency in 9 milestones, but competency is not defined. In contrast, psychiatric residency programs have mandates from the Accreditation Council for Graduate Medical Education requiring that residents be graded every 6 months on 23 milestones, with specific anchor points provided
12. Only 25% of the practicum occurs on psychiatric inpatient wards or outpatient clinics. One wonders where the patients who need psychopharmacology would be
13. Supervision is inadequate. There is no requirement for supervision by psychiatrists, whose training and experience make them qualified psychopharmacologists
14. There is no guidance on the frequency or intensity of supervision. In psychiatry, residents are supervised with each patient encounter over 4 years. Should psychologists without medical training be held to a lesser standard?
15. There are no specifications of continuing medical education, ongoing supervision, or outcomes
16. The potential dangers of psychotropics are not emphasized. For example:
• permanent or life-threatening adverse effects, such as tardive dyskinesia or agranulocytosis
• addiction potential, such as with stimulants or benzodiazepines
• potentially fatal drug interactions with monoamine oxidase inhibitors and meperidine or serotonin syndrome, or cardiac arrests with overdoses of tricyclic antidepressants
17. Many medications require ongoing monitoring. Some involve physical examination (extrapyramidal side effects, metabolic syndrome) or laboratory tests (lithium, carbamazepine, clozapine, valproate, renal and hepatic functions, metabolic profile for all antipsychotics). Failure to monitor may lead to fatal outcomes. Some medications are considered unsafe during pregnancy or breast-feeding.
Psychologists do a great service for patients with mental illness by providing evidence-based psychotherapies, such as cognitive-behavioral, dialectical-behavioral, interpersonal, and behavioral therapy. They complement what psychiatrists and nurse practitioners do with pharmacotherapy. Many patients with mild or moderate psychiatric disorders improve significantly with psychotherapy without the use of psychotropics. Psychologists should focus on what they were trained to do because they can benefit numerous patients. That is much better than trying to become prescribers and practice mediocre psychopharmacology without the requisite medical training. Patients with mental illness deserve no less.
Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri
