Psychiatric Times Vol 14 No 10

Over the past decade, cost containment efforts have pushed psychotherapy patients away from psychiatrists and toward the offices of psychologists, therapists and other less expensive mental health workers. The availability of new drug treatments for psychiatric disorders has shifted many psychiatrists' practices away from a long-term therapeutic focus to that of short-term drug treatment. If psychiatry merely reacts to these economic and political forces, rather than managing them with a plan, the future of the field is highly uncertain.

What started out as a solitary quest for justice by a veteran Orange County, Calif., obstetrician who was terminated without cause from two HMO networks operated by Metropolitan Life Insurance, has now blossomed into a major policy debate that has physician groups lining up to plead their global causes to the Supreme Court. And though Louis Edgar Potvin, M.D., a former president of the Orange County Medical Association, never expected to become the standard bearer for the medical profession, the case has grown beyond a mere effort by one physician to restore his practice and life savings; it has become symbolic of the increasingly heated debate that has enveloped the delivery of health care.

The psychologists appear to believe that large numbers of untreated mentally ill would get better if their psychologists could prescribe medication for them, thereby making up for a resource-poor and underfunded mental health system. There is no lack of prescribers. Psychiatrists know that the biggest problem for the mentally ill isn't a lack of medication, it is the dearth of supportive services available to augment, among other treatments, the taking of medication. So why are psychologists fleeing the duties they have long been mandated to provide? The answer is simple: Money.

The Americans with Disabilities Act of 1990 (ADA) was to have ushered in a new age of equal opportunity for individuals suffering from physical and mental infirmities. But rather than providing "a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities," the ADA often becomes the legal battleground upon which individuals' rights clash with the economic interests of businesses that bear the brunt of the costs associated with equality.

All of the forces affecting and influencing my professional life thunder through my day like these footsteps on the bridge. So many times we hear that private practitioners are "dinosaurs" in today's managed health care environment. At times, I admit, I do feel like a hanger-on in some evolutionary cul-de-sac. Yet, as referrals keep coming in, I find myself feeling more and more fit to survive the Darwinian challenges facing psychiatry. Sharing daily life with colleagues I trust and respect better enables me to live with or ignore the "footsteps on the bridge," which in my more optimistic moments I imagine to be the sound of the real "dinosaurs" rumbling off into the mist.

Prior to training in psychiatry, my practice was in a rural primary care setting where I routinely collaborated closely with physician assistants and nurse practitioners. I see prescriptive privileges of one form or another for psychologists to be an inevitability. I watched a similar struggle for nurse practitioner prescriptive privileges in Oklahoma during my stint in primary care. My recommendations to physicians in California would be to endorse prescriptive privileges for other mental health professionals in the format of the "physician extender" model similar to the traditional physician assistant.

Proponents of SB 694 argue that the doctoral-level training undertaken by psychologists qualifies them to deal with mental illness more so than most physicians. More than 75% of mental health prescriptions are written by general practitioners who have limited training in treating mental illness. They say it makes good sense to set up a system in which psychologists who meet additional educational requirements would be given the authority to prescribe medication. Opponents contend that the training provided for in the bill is inadequate. Many feel that as time brings new and significantly more powerful drugs for the treatment of mental disorders to the market, the arguments against psychologists prescribing will increase.

The role of psychiatry in primary care is an area of rapid expansion and increasing significance. Given the fact that inadequate diagnosis and treatment of psychiatric disorders are major public health problems, it is essential to integrate psychiatrists into multidisciplinary primary care teams. Since primary care physicians are increasingly called upon to act as "gatekeepers" in managed care programs, they will have to meet the important and growing need for broader psychiatric diagnostic and referral skills.