Delivering mental health care in a more rational fashion

Consider the following two clinical scenarios:

1. William, a 62 year-old accountant, has been feeling “depressed” since his divorce 5 years ago.  His practice, he says, is “falling apart,” as he has lost several high-profile clients and he believes it’s “too late” for his business to recover.  His adult son and daughter admire him greatly, but his ex-wife denigrates him and does everything she can to keep their children from seeing him.  William spends most of his days at his elderly parents’ house, a two-hour drive away, where he sleeps in the room (and bed) he occupied in his childhood.

William has been seeing Dr Moore every 1-2 weeks for the last 2 years.  Dr Moore has tried to support William’s ill-fated attempts to build up his practice, spend more time with his children, and engage in more productive activities, including dating and other social endeavors.  But William persistently complains that it’s “of no use,” he’ll “never meet anyone,” and his practice is “doomed to fail.”  At times, Dr Moore has feared that William may in fact attempt suicide, although to this point no attempt has been made.

2. Claudia is a 68 year-old Medicare recipient with a history of major depression, asthma, diabetes, peripheral neuropathy, chronic renal failure, low back pain, and—for the last year—unexplained urinary incontinence.  She sees Dr Smith approximately every four weeks.  In each visit (which typically lasts about 20 minutes), Dr Smith must manage all of Claudia’s complaints and concerns, and while Dr Smith has made referrals to the appropriate medical specialists, Claudia’s condition has not improved.  In fact, Claudia now worries that she’s a “burden” on everyone else, especially her family, and “just wants to die.”  She and her daughter ask Dr Smith to “do something” to help.

Each of these scenarios is an actual case from my practice (with details changed to maintain anonymity).  Both William and Claudia are in emotional distress, and a case could be made for a trial of a psychiatric medication in each of them.

The problem, however, lies in the fact that only one of these “doctors” is a medical doctor: in this case, Dr Smith.  As a result, despite whatever experience or insight Dr Moore may have in the diagnosis of mental illness, he’s forbidden from prescribing a drug to treat it.

I recently gave a presentation to a Continuing Education program sponsored by the California School of Professional Psychology.  My audience was a group of “prescribing psychologists”—licensed psychologists who have taken over 500 hours of psychopharmacology course work in addition to the years to obtain their psychology PhDs.  By virtue of their core training, these psychologists do not see patients as “diseases” or as targets for drugs.  Although they do receive training in psychiatric diagnosis (and use the same DSM as psychiatrists), neuroanatomy, and testing/assessment, their interventions are decidedly not biological.  Most of them see psychotherapy as a primary intervention, and, more importantly, they are well versed in determining when and how medications can be introduced as a complement to the work done in therapy.  Most states, however (including my own, California) do not permit psychologists to obtain prescribing privileges, resulting in a division of labor that ultimately affects patient care.

Let’s return to the scenarios: in scenario “A,” Dr Moore could not prescribe William any medication, although he followed William through two brief antidepressant trials prescribed by William’s primary care physician (with whom, incidentally, Dr Moore never spoke).  When Dr Moore referred William to me, I was happy to see him but didn’t want to see myself as just a “prescriber.”  Thus, I had two long phone conversations with Dr Moore to hear his assessment, and decided to prescribe one of the drugs that he recommended.  William still sees both Dr Moore and me.  It’s arguably a waste of time (and money), since each visit is followed by a telephone call to Dr Moore to make sure I’m on the right track.

Claudia’s case was a very different story.  Because Claudia complained of being a “burden” and “wanting to die”—complaints also found in major depression—Dr Smith, her primary care physician, decided to prescribe an antidepressant.  He prescribed Celexa, and about one month later, when it had had no obvious effect, he gave Claudia some samples of Abilify, an antipsychotic sometimes used for augmentation of antidepressants.  (In fact, Dr Smith told Claudia to take Abilify three times daily, with the admonishment “if you want to stop crying, you need to take this Abilify three times a day, but if you stop taking it, you’ll start crying again.”)  Like it or not, this counts as “mental health care” for lots of patients.

Some would argue that the only ones qualified to prescribe medications are medical doctors.  They would claim that Dr Moore, a psychologist, might have crossed a professional boundary by “suggesting” an antidepressant for William, while Dr Smith, a physician, has the full ability to assess interactions among medications and to manage complex polypharmacy, even without consulting a psychiatrist.  In reality, however, Dr Smith’s “training” in psychotropic drugs most likely came from a drug rep (and his use of samples was a telltale sign), not from advanced training in psychopharmacology.  When one considers that the majority of psychotropic medication is prescribed by non-psychiatrists like Dr Smith, it’s fairly safe to say that much use of psychiatric drugs is motivated by drug ads, free samples, and “educational dinners” by “key opinion leaders,” and provided without much follow-up.

Furthermore, Dr Smith’s training in mental health most likely pales in comparison to that of Dr Moore.  Psychologists like Dr Moore have five or more years of postgraduate training, 3000 or more hours of clinical supervision, research experience, and have passed a national licensing exam.  But they’re forbidden from using medications that have been FDA-approved for precisely the conditions that they are extraordinarily well-equipped to evaluate, diagnose, and treat.

A satisfactory alternative would be an integrated behavioral health/primary care clinic in which professionals like Dr Moore can consult with a psychiatrist (or another “psychiatric prescriber”) to prescribe.  This arrangement has been shown to work in many settings.  It also allows for proper follow-up and limits the number of prescribers.  Indeed, pharmaceutical companies salivate at the prospect of more people with prescribing authority—it directly expands the market for their drugs—but the fact is that most of them simply don’t work as well as advertised and cause unwanted side effects.  (More about that in a future post.)

The bottom line is that there are ways of delivering mental health care in a more rational fashion, by people who know what they’re doing. As it currently stands, however, anyone with an MD (or DO, or NP) can prescribe a drug, even if others may possess greater experience or knowledge, or provide higher-quality care.  As an MD, I’m technically licensed to perform surgery, but trust me, you don’t want me to remove your appendix.  By the same token, overworked primary care docs whose idea of treating depression is handing out Pristiq samples every few months are probably not the best ones to treat depression in the medically ill.  But they do, and maybe it’s time for that to change.

Steve Balt is a psychiatrist who blogs at Thought Broadcast.

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  • Annie Bradford

    I am a clinical psychologist and my 8 years of graduate and postgraduate training included supervised practice as well as formal coursework in psychopathology, psychological assessment, evidence based psychological interventions, neuroanatomy, research design, statistics (5 courses), social and personality development, cognition, and health care systems outcomes. I am comfortable discussing with my physician colleagues the evidence base for various psychotropic medications and their implications for treatment. A solid foundation of psychopharmacology knowledge is helpful – essential, really – for seeing the full picture of the people I treat. However, I have no desire for prescribing privileges. None.

    My reasons fall into two basic categories. First, I am not confident that 500 hours of additional training would adequately prepare me to assume complete responsibility, start to finish, for managing all of the possible outcomes associated with drug treatments, including side effects, interactions with other drugs or disease processes, symptoms resulting from sudden withdrawals, etc. For instance, would I be truly capable of ordering, interpreting, and acting upon labs, EKGs, and other relevant tests? (That other prescribing providers may not consistently do these things either is irrelevant to me.) And what curricula would training directors need to cut to make sure that all of this quasi-medical training and experience is available to the next generation of psychologists?

    Second, I see what the expanding role of psychopharmacology has done to the profession of psychiatry, and I shudder to consider how market forces might encroach upon psychology’s rich tradition of research and practice of behavioral, cognitive, and interpersonal psychotherapies. Psychologists have been played an dominant role in the development and dissemination of effective non-pharmacologic treatments for borderline personality disorder, obsessive-compulsive disorder, major depressive disorder, generalized anxiety disorder, panic disorder, and posttraumatic stress disorder, among others. Already there are too few psychologists who are well equipped to provide these most effective intervention strategies. We stand to lose even more as a science and a profession by shifting our focus away from the basic tools of learning, cognition, emotion, perception, and behavior.

    Integrated primary care models potentially offer the best of both worlds: better access to psychological therapies and mental health expertise, and reliable access to medical knowledge from clinicians who already prescribe the majority of psychotropic medications. An added bonus is that integrated primary care opens up new options for people who would benefit from a range of mental health treatments but who would never set foot in a mental health clinic or therapy office. It can also expand the range of choices for people who need support to change behaviors such as smoking, overeating, and poor stress management. Finally, integrated care would most likely facilitate patients’ access to more intensive or long-term mental health treatment, if indicated. Although we have a lot to figure out before integrated care becomes widely adopted, I believe it is the better solution to the “division of labor” problem and the one with the greatest potential for public health impact.

  • DavidBehar

    Steve: No offense, but you are mistaken many times over in your article.

    1) I will be filing an FDA Citizen’s Petition to place sertraline 25 mg over the counter. Not only should family docs prescribe these medications, but patients should have unfettered access to them on their own. Pharmacists and psychologists should be able to give psychotropic advice to patients for psychiatric first aid, as they might for a cut or a cold. What we do in is not brain surgery. It is as easy as any decision making gets in all of medicine.

    2) You forgot to make a disclosure, that your proposal will increase the income of psychiatrists like us, and that your criticism of family doctors is in bad faith, phony propaganda to preserve our turf.

    3) You did not learn psychiatry in med school, nor in residency, but after 10,000 hours seeing patients. Anyone can do that and get as good as we are.

    4) My daughter was in a med school graduating class of 250 this Summer. One student chose psychiatry. This fraction is catastrophic if repeated elsewhere. There will be no choice but to have patients do self help, and to enlist other specialists. What we do is an essential utility service, and the consequences of making it unattainable are quite harsh. There are 30,000 suicides, and paranoid schizophrenics kill 2000 people a year. The economic costs of under-treated mental illness are huge.

  • azmd

    A two-tier system of care for patients with psychiatric and psychological issues is being suggested by this piece. On one tier, affluent patients who can afford to pay cash can see board-certified psychiatrists such as Dr. Balt who have been through thousands of hours of medical training and do not accept insurance in their private practices.

    On another tier reside patients who must utilize their insurance for payment; presumably Dr. Balt believes that prescribing psychologists who have completed a 500 hour crash course in psychopharmacology are sufficiently qualified to meet the needs of those patients, thereby alleviating the shortage of psychiatric providers that has been created by the rush into cash-only private practice.

    I suppose it’s probably too much to expect that psychiatrists will be able to organize well enough to overcome the third-party payor issues that have resulted in such miserable reimbursement for psychiatric care that most psychiatrists who can do so, no longer accept insurance. Therefore, it is probably inevitable that there will be pressure to water down care further by certifying more types of mid-level prescribers, including prescribing psychologists.

    However, it seems incredible that we cannot organize at least well enough to work with our psychologist colleagues to develop a cost-effective integrated model of care that could leverage all of our strengths in a complementary fashion to provide high-quality care for our patients. In my current workplace, psychologists are an essential part of the treatment team. They provide testing and further diagnostic clarification for complicated patients and behavioral management plans for patients whose treatment requires a behavioral approach. Psychiatrists get to order medications, coordinate care for medical issues, manage emergencies and take night call. Everyone respects everyone else’s contribution, and no one wants to do the others’ job. What makes it so difficult to replicate this model in outpatient practice?

  • aShrink

    Dr. Balt’s skills at writing seem to exceed those he has at reason. I am unsure why a trained (and I guess board certified) psychiatrist appears to detest what he was trained to do. Dr Balt seems to belittle his own profession, it’s practice, and the ability needed to accomplish it. I don’t know anything about Dr. Balt, but if i were an analyst I would encourage him to explore with his own therapist (should he have one) why he resents his chosen profession so intensely. He might also do well wondering whether his anti-pharmacological pontification and adoration of spoken word therapy is adversely affecting the care he delivers to his patients.

    I agree with other commenters that psychologists are very skilled and largely have excellent training. But they are not medical doctors. What if “William” had hypothyroidism or a complication from another medication? how would 500 hours of psychopharmacological training prepare one to help diagnose that?

    What if Claudia’s case was better explained by normopressure hydrocephalus? Or perhaps hemorrhagic strokes? is this included in 500 hours of training? Dr Smith may not value the training he has, but others do.

    Finally, providing samples to patients has nothing to do with the inferred ‘benefit’ from a drug company. Samples are (by most) provided to help the patient financially. The ‘educational talks’ do include a dinner at a non-extravagant restaurant and only include FDA-regulated information. Perhaps Dr. Balt should learn a bit more about this.

  • AshleyCoopland

    Primary care MDs have too long had a monopoly on health care. They have little or no training in mental disorders, amongst a lot of other subjects.
    Well-trained psychologists ( and other so-called physician extenders) should have ability to prescribe psychiatric drugs.
    I know many primary care MDs who have neither the time nor the ability to manage such patients; any patient who is beyond the expertise of a clinical psychologist should be sent to a psychiatrist.

  • Dinah

    I seem to be missing something here. I was a psychology major in college, and to get into medical school I had to take: a year of each of the following: calculus, physics, chemistry, organic chemistry, and biology. Granted, I don’t think I used the calculus for anything, but these were difficult and they weeded out people who weren’t reasonably diligent, hard-working, smart, and with good memories. (It didn’t screen for social skills). I know it’s equally difficult to get into a PhD program in clinical psychology, but that requires being smart, diligent, and hard working. It doesn’t necessarily require strong basic science skills.

    Okay so medical school, first year: gross anatomy with human dissection, physiology, histology, biochemistry, neuroanatomy, embryology, intro to psychiatry. Second year: pharmacology, pathology,microbiology, immunology, physical diagnosis. Third year: clinical rotations in internal medicine, psychiatry, pediatrics, neurology, surgery. Fourth year was a lot of electives: I did a psychiatry rotation away, a psychiatry research rotation away, primary care rotation on the Navajo reservation, cardiology, and a subinternship in a burn unit. I may have forgotten some courses or rotations.

    Internship was a year I try to forget, but it was before the days of hour limits on interns, I seem to remember time on an AIDS unit, an ICU, CCU, kidney transplant unit, Emergency Room, and a lot of medicine– talking to patients, examining patients, standing on rounds with those older and wiser, writing orders. (I did a straight medicine internship, no psychiatry).

    Then there were 3 years of psychiatry residency, inpatient, outpatient, a few months of child, a variety of subspecialty services, during most of which the care is assumed by the resident with supervision.

    Okay, so I can treat your psychiatric illness, or you can see a psychologist, who is very smart, knows many things I don’t (you don’t want me doing your neuropsych testing), has a wonderful handle on psychiatric diagnosis and abnormal psychology, but when it comes to medical training, there were those 500 hours. That’s how long, 12 weeks maybe?

    I don’t know what to say about the training primary care docs get in psychiatry. Given that they prescribe most psychotropic medications, it’s probably not enough, but they do know the medical aspects and they do a lot of psych. I think a more rationale approach would be to provide much more psychiatry training in residency to primary care and internal medicine folks, and more psych cme after. And I think there is probably a lot of variation between doctors, there are docs out there that are board certified in both.

    • Homeless

      So how does calculus, physics…delivering babies, surgery make you better at therapy?

      You sound overtrained and when I am paying out of pocket, I don’t want to pay the extra for skills I don’t need in my treatment.

      • azmd

        If you read the original post to which we are all responding, it is not talking about doctors doing therapy, it’s talking about psychologists prescribing psychiatric medications. The point is that it’s important to have medical training if you’re going to prescribe medications. Psychologists do not have medical training, and doing a 500 hour crash course is not the equivalent. No one is disputing their ability or training to do therapy, however.

  • drjoekosterich

    Mental health care does need to be about more than drugs. Primary care physicians (and I am one) must take some of the blame. But pressure from patients seeking a pill to “fix” their relationship breakdown or finances adds to this. As do insurance systems which favour pills over talking.
    And the key problem is that much which is “diagnosed” as a mental health problem is actually a life problem without a medical solution

  • f. lusu

    i believe that Dr.Bolt was being very generous when he said, ‘but the fact is that most of them don’t work as well as advertised and cause unwanted side effects’..
    the MedpageToday article published on Dec. 06,2012 ‘Talk Therapy Boosts Response To Anti depressants’- –
    “still the evidence is that only about a third of people respond effectively to those antidepressants,and by effectively,we mean about a 50% or better reduction of symptoms” Jeffery Janata PhD , division chief, psychology UH Case Medical Center-
    and what part of the 50% is placebo?
    my wish is that every psychiatrist experience the misery of depression and then pile on a 4 week trial of every antidepressant and anti psychotic drug available,which is what many “non-responders” endure- and maybe triumph over. a psychologist sees exactly what the medication is doing for and doing to his client. if ‘dr. smith’ is so overworked that a 6 minute appointment involves some advice and some samples, then working with the psychologist might be a much safer option and better care from someone who can sit with them for 50 minutes to assess how they are responding to a medication and work closely with ‘dr. smith’ to keep the patient physically and emotionally healthy.

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