Commentary: The Prescription Jihad

I was compelled to pen this piece after reading yet another opinion on the fierce psychologist-prescribing debate in the Feb. 3 issue of Psychiatric News.

Before I go any further, some disclosures are in order. I am a psychiatrist, employed by a community mental health center in Arkansas, in a 100% outpatient practice. I am one of four psychiatrists (three specializing in the treatment of adults and one in child psychiatry) employed by our center, and we serve a catchment area of seven counties with a combined population of approximately 200,000. Despite having trained in a traditionally psychoanalytic program at Baylor College of Medicine, I was always more comfortable with medication evaluations and with what today would be called the biological aspect of psychiatry. I do very little therapy per se, apart from supportive therapy, some crisis intervention and education. I do, therefore, have a vested interest in keeping prescribing privileges out of the hands of non-physicians.

Having said that, I find it more than a little amusing when I hear all kinds of high-minded arguments being bandied about over what is obviously an economic issue. To quote from the above-mentioned article by Jan Leard-Hansson, M.D., "To prescribe medication properly the physician must know the patient from head to toe We, as psychiatric physicians, must maintain a steadfast commitment to protecting and providing high-quality patient care."

Admirable sentiments indeed, but when was the last time Leard-Hansson, or any of us, did a rectal examination on a patient? Or auscultated their chest? Or palpated their lymph nodes or liver? Even my colleagues who work in hospital settings routinely defer physical examination to their internal medicine or family practice consultants. The simple truth of the matter is that sub-specialization, by definition, means that most of us lose some of the skills that we learned in medical school, primarily those that we do not use on a regular basis. I know that I would have a tough time picking up a murmur on a chest exam or appreciating a subtle physical finding. It is, therefore, more than a little disingenuous to claim that we, as psychiatrists, know our patients from head to toe. The day-to-day practice of our art demands, in fact, that we concentrate on certain areas and de-emphasize others, referring patients to others with more expertise when necessary. Surely, I find it easier to examine a routine blood report and pick up obvious abnormalities or interpret the results of a computed tomography or magnetic resonance imaging scan, but those are skills that can be learned with time.

Coming back to the main topic of non-physician prescribing, the arguments being put forward by both camps (i.e., physicians and non-physicians--mainly psychologists but soon to be joined, I am sure, by social workers and other clinical personnel) are similar. Each side accuses the other of being petty and money-grubbing, while claiming the moral high ground for themselves.

The Psychiatrists

Psychiatrists claim that the whole psychologist-prescribing effort was born of the drive toward managed care. Managed care organizations are increasingly driving down the rates of reimbursement for both therapy and psychological testing, while farming out therapy to ancillary (read "cheaper") clinical staff such as licensed certified and master's level social workers and associate counselors, or even counselors with only a bachelor's degree.

The managed care trend has also put psychologists in the uncomfortable position of feeling like a fifth wheel relegated to doing psychological and neuropsychological testing, which may also one day be delegated to even less costly technicians. Prescribing ability would ensure a more reliable income stream for psychologists. In addition, prescribing is much less labor intensive than therapy or testing.

The psychiatric community claims, with some justification, that this is uncomfortably similar to the top of a slippery slope. What is next? Prescribing privileges for social workers, marriage, family and child counselors, case managers, and mental health technicians? Where does it stop?

Psychiatrists argue that they oppose this effort purely for the sake of their patients and with the purest motives at heart. (I am exaggerating, of course, but you get the gist.) Psychiatrists are resistant to psychologist prescribing because non-physicians would have a greater risk of missing crucial side effects, drug interactions and co-existing medical conditions, thereby leading to increased morbidity and mortality. There is something to be said for this concern, but it requires a greater leap of faith. Have none of us psychiatrists ever had any patients with bad outcomes? Of course we have, but one learns and moves on and, presumably, non-physician prescribers could do the same.

The Psychologists

Psychologists, on the other hand, claim that managed care organizations are increasingly restricting access to psychiatrists, preferring that psychopharmacological management is done by primary care physicians.

Also, thanks to managed care, Medicare and the Health Care Financing Administration, recent graduates from psychiatric residency training programs are well-versed in medication evaluation and management but are increasingly unaware of, and uninterested in, therapy skills. This makes psychiatrists little more than "dispensers," diagnosing people through DSM-IV checklists and prescribing the recommended medications according to various algorithms--something that can be done by a simple computer program, and for much less cost than using human dispensers. The move away from trying to understand the inner lives of people and learning how their relationships, families and feelings impact their illness makes today's psychiatrists increasingly expendable and replaceable by family physicians who can do the necessary prescribing while also caring for day-to-day illnesses. Psychologists argue, with some justification, that psychiatrists are already obsolete or will be in short order.

Also, unlike oncological chemotherapy, invasive cardiology or neurosurgery, for example, psychopharmacology is hardly rocket science. There are a limited number of agents, with most belonging to two or three major classes with similar efficacy and side-effect profiles. The safety margins--especially for the newer agents--are wide, with even large overdoses rarely proving fatal. In addition, the proponents of the psychologist-prescribing effort point out that the recently discontinued U.S. Department of Defense program has demonstrated that non-physicians with appropriate training can be just as effective and safe as physicians.

However, psychologists argue that they want prescribing privileges not for the crass purpose of making more money, but because the result would be an increase in the availability of qualified psychopharmacologists in rural areas where the need is still great. This argument flies in the face of several recent papers that have pointed out that, traditionally, doctorate level psychologists tend to cluster in big cities usually in and around universities.

It is the psychologists and their supporters, some say, who are the noble warriors in this crusade, battling against those dastardly psychiatrists (again, I exaggerate, but you get the gist).

Conclusions

As can be seen, there are valid arguments from both sides, and both sides have a vested economic interest in the outcome, which is usually unacknowledged. From personal experience, I have spoken to a number of psychologists on this issue, none of whom were enthusiastic about prescribing. These are qualified, competent people who do therapy, psychological testing, disability evaluations and some administrative work and are well-satisfied with what is on their plate. Most of them were of the opinion that the added monetary benefits of prescribing were not worth the additional risks of making decisions about people's suicidality, proneness to violence and other issues of potential medicolegal consequence, such as the use of psychotropics in pregnancy. They were more than happy to defer such decisions to the physician.

An added disincentive is the attendant deluge of drug-seeking patients, such as those with ill-defined physical conditions (i.e., chronic back pain, fibromyalgia, chronic fatigue) or others with intractable personality disorders who demand benzodiazepines, pain medications and the like. I see a large proportion of such patients in my day-to-day practice, and they are usually the ones I dread.

There are others who are either on, or in the process of applying for, disability. There is, of course, no hope that any of them will ever improve, since substantial improvement would mean loss of benefits. It's like walking on a treadmill. No matter how long you walk, you stay in exactly the same place.

Of course, I practice in a rural area where there are generally more patients than qualified practitioners. The situation is likely different in larger cities where there may be a large number of practitioners and where competition for patients may be fierce.

On the other hand, I have at times wished that there were more of us, simply because the need appears so great. The number of people needing care, from nursing home patients to adults to schoolchildren, means that most of us are booked up to six weeks or more in advance, and at times some extra help would be welcome. Just as family practice doctors often have nurse practitioners or physician assistants who can prescribe under supervision, perhaps a similar system could be devised for non-psychiatric prescribers. The quality and knowledge base would likely vary widely, but in the long term, self-selection would eliminate those with obvious deficiencies.

I think prescribing privileges for non-physician personnel are inevitable at some point. If such practitioners would cost less than psychiatrists, you can be sure managed care will be the first to jump on the bandwagon. As psychiatrists, our choice is not between having or not having non-physicians prescribe psychotropics. Our challenge is to engage in this process in a way that is productive and non-confrontational. In the long term, as with managed care, we will gain more by being active and shaping the debate rather than being isolated behind the ramparts of our self-righteousness, firing off shots in the dark.