Wednesday, April 7, 2010

Governor Kulongoski has a Decision to Make


Governor Ted Kulongoski of Oregon finds himself in the unenviable position of deciding the fate of two professions. And he has to do it either today or tomorrow.

Yes, I hyperbolize...a little. Senate Bill 1046 would not actually hand psychologists prescription pads. Instead, the bill would allow the Oregon Medical Board to issue prescriptive privileges to psychologists who are properly trained. Before any privileges are handed out, however, a task force of psychiatrists and psychologists would have to hammer out final guidelines, including exactly how much training is required, what kind of collaboration with physicians is needed, and which medications psychologists would be allowed to prescribe.

The Governor has put this bill on a list of measures that he is "threatening" to veto. Apparently, this is his invitation to all the stakeholders to whip themselves up into even more of a frenzy in their efforts to lobby him. My wild guess is that Kulongoski was initially in favor of the bill, but as crunch time arrived and he got more and more of an earful from Oregon physicians worried about loss of income, he began to reconsider. These last few days will serve as a quick straw poll to find out how much political damage he might do to himself if he were to sign the bill.

Personally, I support the bill because I believe it requires enough medical training to produce safe prescribers. At least two Oregon psychiatrists support the overall concept of psychologists prescribing, including Jim Phelps, who wrote this editorial in favor of the bill in Psychiatric Times, and Joseph Arpaia, who has commented on this blog. Both Dr. Phelps and Dr. Arpaia are joining with me in forming a multi-disciplinary study group to develop a list of principles for appropriate training of psychologists interested in prescribing. If anybody else wants to join, please e-mail me directly at drcarlat@comcast.net. I suspect there are many more open minded psychiatrists out there who are afraid of "coming out" on this issue because they fear the wrath of colleagues.

Although I have been asked to actively lobby for this bill, I've declined, for various reasons, not the least of which is financial. I get most of my income from psychiatrists subscribing to my newsletters. The more political I become on this issue, the more I fear subscription cancellations.


But more nobly, I think there is a far more important underlying issue than this particular bill. There is a critical shortage of psychiatric prescribers in the U.S. The most recent estimates by the University of North Carolina Scheps Center, published in a series of article in
Psychiatric Services, documented a shortage of prescribers in 96% of U.S. counties, and estimated that only 50% of the needs of psychiatric patients are currently being met. We must offer more realistic solutions than telepsychiatry, increasing residency slots (which we can barely fill with qualified applicants as it is), and phone call consultation with primary care doctors.

Rather than lobbying for specific bills, I want to get psychiatrists and psychologists together to jointly come up with a position paper on best practices for training, supervising, and monitoring prescribing psychologists. This could then serve as a blueprint for prescription legislation in other states (and in Oregon, which will surely pass another version of this bill next year if the current one is vetoed.)

39 comments:

Sara said...

"a critical shortage of psychiatric prescribers in the U.S.?" Hmm, I have to take that with a huge grain of salt. Absolutely everyone I know is either taking a psych med or being urged to take one. They aren't having any problem getting someone to prescribe them something either. Since deciding what pill to prescribe is highly subjective or dictated by current marketing practices and since more often than not the meds cause harm rather than benefit at least over the long term and even over the short term in some cases (sorry, but I truly believe this), I can't really support increasing the ranks of prescribers. The education that existing prescribers really need is about the drugs' toxicity to the body and brain and I don't see that being put at the top of the agenda with further educational requirements anytime soon.

Debra said...

This bill, and this issue risk linking psychiatry AND psychology to prescribing medication in the public's minds.
Like... psychiatry AND psychology=medication.
At a time when we should be PULLING BACK AT LEAST A LITTLE from this equation.
A fair amount of "harm" has already been done on this issue. Why make it worse ?

SteveM said...

Dan,

I can't speak to the clinical trade offs of the Oregon initiative because I'm not a clinician. But I really applaud your efforts for two process reasons:

1) You are actually doing something rather than merely recycling the same issues and moving food around the plate. (Platitudes and wishful thinking drive me nuts.)

2) You acknowledge at least implicitly that Pareto optimality in real life is an illusion. And The Perfect is the enemy of The Good Enough.

Psychiatry needs more intelligent, take action pragmatists like yourself. Good luck with that...

Daniel Carlat, M.D. said...

Sara and Debra-

I certainly hear your concerns. If you believe that people are already over-medicated you might believe that giving another profession prescriptive privileges is crazy. But as it turns out, anecdotal information is that the prescribing psychologists in New Mexico and Louisiana have adopted a much more conservative prescribing style--therapy first, pills second. Many of their patients come to them on a long list of meds and their expertise is getting them down to one or two, by using psychotherapies that help with the symptoms.

So paradoxically, expanding prescriptive privileges to psychologists will almost certainly reduce the per-patient number of prescriptions while allowing those who really need an SSRI, eg., to get it.

Sara said...

Thanks for the response, Dr. Carlat, and I do agree that having one person in charge of someone's care is important. If this passes I truly hope this works out the way you envision.

moviedoc said...

You justify allowing psychologists to prescribe based on the idea that this will address all those under-served counties, but I don't hear anything that would require these psychologists to practice in under-served areas. I believe 1) prescribing psychologists will stay in the same over-served areas, and 2) the psychologists who choose to prescribe will be the ones who have failed at what they set out to do in the first place.

Joel Hassman, MD said...

Professional Suicide.

That is what you and like minded colleagues are colluding to do.

I just don't get you anymore. What did your mentors teach you in medical school and residency? To just give in to people who crave the skills we painstakingly learned that do separate us from other disciplines that did not make the sacrifices we voluntarily agreed to make when accepting that medical school matriculation?

It is so disappointing to read people who you think really are making the effort to take a stand and reset the boundaries that have been so ridiculously twisted instead just cave. And I don't care if you don't agree, because I know in my heart that giving in when the going is tough just sells out our colleagues who stand by the oath and committment.

You know, my wife read your last post about this issue and genuinely said to me, "what is his problem!?" She knows that I once was a subscriber to your newsletter and really valued your writings and efforts. I think after this latest escapade of well intentions just ending up as fodder for the quick fix crowd is finally getting her to realize what I am so upset about.

This is not what I envisioned. And Obamacare is the final nail of the coffin that buries psychiatry.

The antipsychiatry crowd must be cheering in their little happy place. And then they can turn their attention to psychology.

If you remember, look me up in 2014. I sincerely doubt I will still be practicing psychiatry. The question is, will it be because I had no choice but to leave as the field is lost, or this legislation will just push it out the door?

And to think I pulled out your Psychiatry Interview book this week as a reference for the latest locums I am doing.

Well, good luck in your pursuits. Even if you do not put this comment in the thread, I hope you keep it for prosperity. Maybe you can show it to me in 4 years and tell me how wrong I was.

Or, maybe not.

Anonymous said...

I am a psychologist at a major academic medical center and I agree with moviedoc and Dr. Hassman. I believe that if you want to prescribe meds, then go to medical school. There is nothing to stop a PhD in Clinical Psychology from going to medical school, and then he or she will be a MD/PhD and have the mental health world as his or her oyster! I also believe we have too much prescribing going on for mental health issues-- I mean My God you don't have to be a psychiatrist to prescribe. Studies indicate that most of the psychotropics prescribed are by non-psychiatric MD's anyway. Psychologists should stick to what they (we) are trained to do -- psychological and neuropsychological testing and psychotherapy. A lot of education and training goes into developing those skills. We don't need prescribing curricula in a PhD program!

Joseph Arpaia, MD said...

Dr. Hassman and the Anonymous commenter after him: Do you not realize that psychologists ALREADY have the right to prescribe in several states and that they are only going to increase that number?

The question facing us is not "Will psychologists gain prescribing rights?" as that question has already been answered in the affirmative.

The question facing us is "Will those who have the most expertise and training on prescribing psychotropics have input into the processes by which psychologists gain prescribing privileges or will they stay aloof and allow others with much less training to make all the decisions?"

Anonymous said...

"The antipsychiatry crowd must be cheering in their little happy place. And then they can turn their attention to psychology."

Dr. Hassman, as someone who has cheered alot of your posts, why are comments like this necessary? All this is doing is being inflammatory instead of contributing to the discussion.

As I said to Dr. Carlat, when I felt he made an unfair similar comment, you all don't like it when your profession is unfairly stereotyped. So why is it ok for you to engage in similar type behavior?

As an FYI, as one who has been critical of psychiatry (but who is not antipsychiatry), I am not cheering this at all. I greatly fear that if psychologists are given drug prescription privileges, their profession will eventually look like psychiatry meaning that there will be very little therapy and mostly med checks. It won't happen overnight but that is what will occur in my opinion.

That means less options for people who are looking for alternative mental treatments to meds. As a result, I greatly fear people won't get the help they need which would be a tragedy.

AA

Debra said...

Since I'm looking at the mother country with a telescope, I can say..
That it looks like people are ALREADY pulling back from the ALL medication "solutions" to what many of us have decided to call "mental illness"...
This is good news.
I can't say that I endorse "pragmatic" solutions to any problem, though.
Because "pragmatic" solutions are JUST NOT UTOPIC enough for ME. The uh, EXTREMES DO have their purpose. And, to be pragmatic about this.. we are NOT going to make them go away just because we want them to.
It takes...ALL kinds to make a world. Let's try remembering this, right ?
And, food for thought :
Are the psychologists who are RESPONSIBLY prescribing, and taking over care doing so... BECAUSE THEY ARE PSYCHOLOGISTS, or because TIMES THEY ARE A CHANGING ?
Hard to tell, in my book.

Daniel Carlat, M.D. said...

Debra,

Please limit your use of all caps in comments, because they are the typographical equivalent of SHOUTING and don't serve to further rational discussion.

Thanks,

The Management

Asslete said...

I am not an apologist for psychiatry. I do see the value of meds and my interventions on a daily basis with true Bipolar and Psychotic folks.

But I gotta agree with Sara. I don't think we have a critical shortage of psychiatric prescribers. We have a critical overage of psychiatric med use.

In my past life, I had access to a database of 60 million covered lives. I ran an analysis on antidepressant prescriptions in 2009. There were some segments (perimenopausal women) where antidepressant use approached 50%.

If 50% of a population requires psych meds, then arguably, insanity is the new norm...and perhaps we should be medicating those of us who are blissfully content off meds.

Joseph Arpaia, MD said...

The issue of too much prescribing is not really relevant to the question of psychologist prescribing as there is no evidence that this will increase prescribing.

The forces driving excessive prescribing are several, but from my perspective two are:
a) the reimbursement rate per hour for med checks is absurdly greater than that for doing therapy. This is but an instance of the excessive reimbursement for "procedures" under the current system.
b) direct-to-consumer advertising and disease mongering have convinced millions who are simply struggling a bit with life that they are ill and need treatment. This puts an excessive burden on the health care system and too many providers fill their practices with the "worried well".
c) swamped primary care doctors treat the multitudes with the treatments recommended by the drug-company reps as they do not have the time to really provide effective treatment.

These systemic issues are not going to be touched by the issue of prescribing psychologists and wasting our energy in that conflict will only reduce our effectiveness in changing the system as a whole.

Dr John said...

I have very mixed feelings about this and have no desire for more people prescribing psych meds but have some hope psychologists will not fall into the same hole everyone else has. I can see no reason why they could not be trained to prescribe but does anyone buy into the idea they will not bow to the same market forces that have caused the rest of the medical practitioners to pollute the US with psychotropics as Asslete points out? If so how can this be prevented?

Joel Hassman, MD said...

How can this process be prevented?

Our illustrious representatives in Congress should have re-examined what ERISA allowed insurance companies to do to psychiatry specifically, medicine in general, and done what was the right thing to do and take them out, what, about 15 years ago. Maybe striking the insurance industry from that protective legislation would have created more accountability on them, and they wouldn't have chipped away our professional responsibilities, as they did with a sledgehammer.

There was a psychologist/lawyer who wrote awesome columns detailing exactly this in Psychiatric Times in the mid 90's (sorry I don't have his name, I am doing temp work 2 hours away from my home to review files). And of course, no one listened, no one took a stand, no one thought about it and just let the system screw us.

And now I have to watch my back as my own colleagues are embracing the adage "if you can't beat em, join em!"

Dr Arpaia, do you realize that the next profession to pursue this will be social work, and with the logic you and your colleagues embrace and sell so easily will validate it?

Just be honest with those of us who really like practicing psychiatry the way we were trained at accredited and responsible programs, what are you falling back on for income WHEN you can't provide the majority of your yearly earnings as doctors? Because between issues like this, Obamination-care, and the ongoing devaluing of psychotherapy as a legitimate intervention for mental health care, what will be left for a psychiatrist to offer as a provider?

Are you so certain you are right that you do not have to entertain this as a possible scenario?

Ronald Pies MD said...

Here is the headline from the Oregonian, folks:

Kulongoski vetoes bills on prescriptions

http://www.oregonlive.com/politics/
index.ssf/2010/04/kulongoski_vetoes_bills_on_pre.html

"Oregon psychologists won't be prescribing drugs anytime soon.

Medical groups and even some psychologists opposed the bill.
Kulongoski said such a change "requires more safeguards, further
study and greater public input." "

Amen to that! For more on all this, we have a number of comments and discussions on the Psychiatric Times website.

But rather than gloat, psychiatrists need to realize that this issue will come up over and over, each year, in one state or another. We need to do much more to educate the public and our representatives on the important differences between psychiatric physicians and psychologists.

We psychiatrists also need to put our own house in order, and work to ensure that psychotropic medication is prescribed for the right reasons, in the right way, at the right time--and only after thorough evaluation and consideration of non- pharmacological options.

We also need to explain to the general public and our psychologist colleagues why separating "prescribing" from the art and science of general medicine is like trying to separate bone from muscle, using a paring knife: you can't do it without injury to the patient.


Ronald Pies MD

moviedoc said...

Dr. Arpaia says, "This is but an instance of the excessive reimbursement for "procedures" under the current system."

If psychotherapy is not a procedure, then something is wrong. Medication management is definitely NOT a procedure.

All this "too much psychotherapy" vs. "too much medication" should embarrass all professions involved. Patients should get the treatment that works for them, and the patient should have a say in it. No patient should have to sit through psychotherapy just because the psychiatrist or psychologist requires it.

Joseph Arpaia, MD said...

Moviedoc:

By "prodecure" I meant CPT code. Psychotherapy has a couple of CPT codes 90804-9 for instance. The "med check" is a procedure, 90862.

The fact that health professionals are reimbursed based on procedures is, in my opinion, at the root of the dysfunction in our system.

If a doctor spends time talking to patients to help them change their lifestyle the reimbursement is far less then if they ignore the lifestyle issues and then treat the complications of that.

Even if a doctor is willing to take the hit in income by using the lifestyle change approach, their employer won't tolerate that and will schedule them with far too many patients for them to do that. Going into solo practice will avoid that issue, but it is simply not an option for most doctors. Here is a link to an article which describes this problem, http://content.healthaffairs.org/cgi/content/full/29/4/732?etoc

Joseph Arpaia, MD said...

Wow, here today's post from Hooked on the same reimbursement issue:
http://brodyhooked.blogspot.com/2010/04/whats-driving-overuse-of-complex-spinal.html

Anonymous said...

I think the fact that psychologist are even thinking that they can behave like physicians is a direct consequence of terrible standard of care being provided by psychiatrist. We as psychiatrist have really stopped practicing medicine and have become prescribers which makes psychologists think that they can write prescriptions too.
Its time for psychiatry as a profession to wake up and start behaving like physicians instead of becoming prescribing agents.Our jobs go much beyond scripts but how many of us truly know about all the medical illnesses or medications our patient are on.How many of us bother to find out exactly what birth control our female patients are on and so on, how can we see 40 patients in one day?
We have set a bad example of what psychiatry is and we need to fix it or our profession will be obselete soon.
We must take back what is ours.

moviedoc said...

Dr. Arapaia: I'll admit everything we can get reimbursed for (which is not to say everything we should get reimbursed for) has a procedure (CPT) code. My point is that psychotherapy is like a surgical procedure. The psychotherapist DOES the treatment. Medication management on the other hand involves assessment and prescription of a treatment. Your point about relative reimbursement is well taken, but now comes the hard part: How much can we as a society afford to pay for psychotherapy, especially given the myth that everyone can use a little, and given that un-managed (as in in managed care) it can go on indefinitely, often with little to show for it. And those 40 patients Anonymous says some of us "see" per day. If that gets knocked down to 7 patients per day where will we get treatment for the other 33?

Ronald Pies MD said...

As readers of this website may already know, Gov. Kulongoski has vetoed the bill in question, raising some of the same concerns about it that many of us in the profession did. I expect that some new version of the bill will again come up for more debate in Oregon, over the coming year.

This should not be the time for gloating or recriminations, however. It is a time for psychiatrists and psychologists to work together constructively, in order to increase access to good, comprehensive, mental health care. It is also a time for physicians (both general and psychiatric) to “buff up” their medical and psychopharmacological skills and training, so that what we provide is a model for responsible care–not an easy “target” for others to seize upon, in order to expand their practice into the realm of medical care.

As a consultant in psychopharmacology for almost three decades, I know that physicians have a long way to go, in achieving a level of excellence in prescribing psychotropics. We all do! But the best way for psychiatrists, PCPs, and psychologists to advance the health care of our patients is to respect the training and expertise of each specialty–and, most important, to advocate for wider access to mental health care in general.

A more detailed blog on this topic will appear shortly on the Psychiatric Times website.

Sincerely,
Ronald Pies MD

moviedoc said...

Dr. Carlat: Dr. Pies has invited us to read more at the Psychiatric Times Web site. It seems obvious that the site, its publisher, and indeed I assume Dr. Pies, exist off the largess of advertisements for big pharma. How do you square this with your own stance? Your dilemma seems to be censorship vs becoming part of the pharma ad machine.

sadnessaddicted said...

Firstly, one should consider that the average prescribing pschiatrist makes $170,000 per year (I'm not sure if this includes drug company baksheesh) and the average psychologist makes $90,000 year. This is due to insurance company reimbursements. It looks to me that Psychologists want to make more money. Why do we need more people prescribing these medications. These meds are over prescribed already. We need more study of the medications. We need psychologists to protect us from the pharmacological assault of psychiatrists.

Prescribing psychiatrists should be referrals from therapists and should not deliver primary mental health care because they are not objective.

A non-prescribing therapist psychiatrist or psychologist should set the treatment plan and there should be a time frame for the medication to prove its effectiveness on the patient.

Mental health will simply become pharmacological.

If we are going to do this we should just make these drugs over the counter meds. That will satisfy big Pharma. Just like addictive cigarettes, any one over 18 can buy their addictive meds at their local CVS.

http://sadnessaddiction.blogspot.com/

SteveM said...

Re: Dr. Pies.

I am agnostic about the policy actually. Because I’m not a clinician. But if inchoate were a crime, Dr. Pies would be doing hard time. I need a logic machete to hack through this morass.

Re: I know that physicians have a long way to go, in achieving a level of excellence in prescribing psychotropics. We all do!

"We all" is well, you physicians. How can you apportion blame where there is no responsibility?

Re: "It is also a time for physicians (both general and psychiatric) to "buff up" their medical and psychopharmacological skills and training..."

If you guys aren't already "buffed up", that's scary.

Re: "But the best way for psychiatrists, PCPs, and psychologists to advance the health care of our patients is to respect the training and expertise of each specialty–and, most important, to advocate for wider access to mental health care in general."

The ol’ Mom and Apple Pie sleight of hand and everything is copacetic. If training is broken, (see Dr. Pies’ comments above), then respecting it without comment leads to, well, more broken training.

I don’t get it...

Anonymous said...

I think Sadness has a great point. Big Pharma with their swarthy surrogate "academic" psychiatrists have been making the case that SSRI's and what not are "safe" and "side effect free." Let's be real-- SSRI safety and no side effects was the campaign to market these drugs over the "old" antidepressants like imipramine. If all the marketing is true, maybe all SSRI's should be over the counter!

Anonymous said...

I think justice would be served if legislation is promulgated to see if psychiatrists should have psychotherapy privileges. I can't see any State approving those privileges given psychiatric residency curriculum!

Ronald Pies MD said...

Although it is my policy not to respond to anonymous critics, I do feel compelled to say something regarding Psychiatric Times and the issue of "Big Pharma", conflicts of interest, etc. It should be evident to anyone with a scintilla of economic savvy that a larger "prescriber" pool means more business for Big Pharma, which means more revenues for journals that rely mainly on pharmaceutical advertising (rather than charge a subscription fee). Psychiatric Times falls into that category.

If such a journal, or its editors, wanted to make lots of money, they would clearly and vigorously champion the idea of "psychologist prescribers." So would many authors intent on selling more of their psychopharmacology texts. (One psychologist wrote to tell me she had used my psychopharmacology Handbook in her "masters level" degree program, in preparation for "prescribing").

In fact, if economic self-interest were the chief factor in play, journals with Big Pharma advertising would probably be advocating "prescribing privileges" for social workers, pastoral counselors, and perhaps
for really empathic sociologists, as well. (It is probably just a matter of time, isn't it...?).

By the way, my own position against "prescribing privileges" (i.e., practicing medicine) for psychologists was formulated at least 20 years ago, when I was working primarily for the State of Massachusetts, in a clinic that served some of the sickest and poorest patients in the state. The psychiatrists who worked there did not see much "largess" coming their way.

My 1991 article on the subject may be found in:

Pies R: The "deep structure" of clinical medicine and prescribing privileges for psychologists. J Clin Psychiatry 52:4-8, 1991.

Ronald Pies MD

moviedoc said...

No need to be so defensive Dr. Pies. If you'll read my comment again, I think you can see that I directed a sincere question at Dr. Carlat, not a criticism at anyone. I'm not quite ready to jump on the "satan pharma" bandwagon myself, and I see nothing wrong with you or your publication taking ad money. Conflict of interest is at the essence of fee for service medicine, probably more so than in your work for PT. Interesting point about the financial incentives involved in the question of whether to support psychologist prescribing. I'm not sure I'm ready to believe your stance proves there is no financial motive at work, but I certainly won't dismiss the idea either.

Ronald Pies MD said...

To readers of this site: I apologize if my last comment appeared to be "defensive." I did feel that the reputation of the paper I edit was being besmirched--evidently, I was mistaken. Perhaps I was a bit "primed" for a defensive response, having read one earlier remark, asking whether "psychiatrists should have psychotherapy privileges"(Please imagine the sound of my hair being pulled out!).

I suppose I'm just not cut out for reading anonymous criticisms of this sort on the internet. Where I trained, people took personal responsibility for their comments, especially criticisms; and were willing to expose their "paper trail" to the scrutiny of others. Similarly, all comments on the Psychiatric Times website must include full names, posted publicly.

I'm now working on a piece for Psychiatric Times tentatively entitled: "The Psychiatrist: Once a Physician, Always a Physician." Perhaps I'll be better able to express my feelings about all this in that venue. We will also be publishing a piece on the very extensive and robust training in psychotherapy, provided at Upstate Medical University, in Syracuse, N.Y.

For now, I think I'll say thanks to Dr. Carlat for the discussion, and sign off.

R. Pies MD

sadnessaddicted said...

The prescriber and the therapist need to be independent. There needs to be a treatment plan with tangible behavioral goals. If medication is added to the treatment plan the medication should be started with a target of stopping the medication.

I would see a psychologist instead of a psychiatrist because he could not prescribe and if I were to chose medication we would make an informed decision to seek out an objective psychiatrist and my therapist would maintain an objective baseline of my progress.

I have seen too many people flounder on medication whose psychiatrists see them once ever 90 days for 30 minutes and modify the medications. Brain chemistry Russian roulette is a better term for this type of treatment. This legislation will promote more of this.

Then we have the GP's who share the simplistic ideological belief in the serotonin deficiency model of the early 1970's with Oprah and the general public. The GP's prescribe these potent unpredictable medications like Cymbalta and Effexor like they are antibiotics. OMG.

We need a smaller smarter more supervised group of prescribers working with much better studies. The drug studies need to continue after FDA approval.

Anonymous said...

This is for sadnessaddicted. First I agree that psychologists should not have prescribing privileges. However, that's about where you and I share common ground.

I'm a psychiatrist. You quote the average salary of a "prescribing psychiatrist." I'm not sure what that label means, but I'm sure it's an aspersion. The average psychiatrist graduates from college, spends four years in medical school and another four years (at minimum) in a residency program earning a pittance. Most come out of medical school with a huge debt load. Yes, the average salary of a practicing psychiatrist is about $170K.

Compare that with the average salary of other physician specialists (eg, radiology, dermatology, opthalmology) whose residenies are no longer nor more difficult than a psychiatric residency program. Their average salary is about $400K. Psychiatrists (and other primary care physicians) are not practicing medicine to make money. They do fine, but in general they make no more than mid-management executives in corporate America, and believe me, their lives are far more stressful and the stakes much higher.

You obviously see the pharmaceutical industry as the evil empire and psychiatrists as its puppets. Your view about the state of the science of psychopharmacology is woefully inaccurate, but I am not posting here to change your view about this, simply to point out some facts.

Why is it that we don't hear any raging against oncologists who prescribe medicines for incurable illnesses (sometimes to prolong a life for a few months at most), whose toxicity and side effects make any psychotropic drug look relatively benign? Where is the raging against rheumatologists who prescribe medications for the pain of incurable diseases like lupus and rheumatoid arthritis, whose side effects can wipe out immune systems and lead to death?

Psychiatrists prescribe medicines because they can, and because there are not yet any reliable markers to determine which patients will respond favorably and which won't. Just like oncologists and rheumatologists they attempt to relieve suffering and prolong life in often severely debilitating and incurable illnesses. Psychotherapy has its place in the treatment armamentarian, but it can sometimes only go so far in. Do you not want patients to get every available treatmeent option which may produce a favorable outcome?

You obviously have very deep resentments against psychiatry and against the pharmaceutical industry. I am thankful that we have an industry that has brought new drugs to market. Lives have been saved, suffering relieved, and quality of life improved. We have a long, long way to go in understanding the science of mental illness and in developing effective treatments, both pharmacologic and non-pharmacologic. In the meantime we try our best to help--that's why we went to medical school and chose this profession.

Psychiatry these days is often an impossible profession. Almost always thankless. Your posts are certainly demonstrative of the lack of understanding and respect for the profession.

Dr John said...

anonymous: I think it is very easy to see why there is not the same universal castigation of other specialties. Pathology is much easier to define in most and not so contentious. Regardless, there are many examples of very reasonable and appropriate critiques in other areas such as cardiovascular medicine(cholesterol drugs and stents) and pain mang.(over prescribing of opiods,Cox 2 inhibitors). These are just limited examples.You are right however that no field is so open to obvious criticism or has such a large cheering section of detractors. People are distrusting of psychiatry for many reasons as you can see from reading the posts on this blog.Personal values play a much larger role on how individuals might conceptualize the meaning of an emotional problem and what should be done about it as compared to a tumor. This is why people speak out so strongly against it or so loudly when they feel they have been harmed by it.The risks people should endure in the face of Tx are not so clear as when one is facing a glioblastoma.I agree psychiatry is an impossible profession. I think because of the conceptual issues involved in the entire paradigm this is not likely to change. You state "Lives have been saved" secondary to new TX. Can you provide me some specific references to support this?

sadnessaddicted said...

My friend the anonymous psychiatrist, rest assured I am not cast aspersions, only trying to set a system of checks and balances. Too many people are prescribed these drugs too often who should not take them by people who don't understand them. Seriously, if psychiatrists actually spent enough time with their patients to diagnose them they would be making far less than $170,000 per year due to the disparity of insurance disbursements for managing patients with medications versus therapy.

My estimate is that 70 - 80% of the people prescribed Effexor and Cymbalta qualify as medically unsupervised.

The state of psychotropic drugs today is primitive, where cancer surgery was in the 1960's.

The general public and most of the medical profession hold a dogmatic belief that the absence of happiness can be explained by a very simply serotonin deficiency model. According to this belief, the absence of happiness is as simple as problem to solve by adding more serotonin as adding insulin is to remitting diabetic symptoms. Anyone who has read the science and followed depression and anxiety patients knows this is not true. The brain physiology and the absence of happiness take together or separately are much more complex than that.

I empathize about your income. The insurance companies and big pharma have you locked in an ethical dilemma. But like the absence of happiness, there is no pill that will fix that problem and it is up to psychiatrists themselves to solve both problem.

Prescribing potent SSRIs and SNRIs to patients who are seen for 30 minutes every 90 days is awful medicine. It is done too often.

12% of the women in this country are on some form of antidepressant medication. This is a bubble as big and ready to burst as the high risk mortgage backed securities market was in 2008.

moviedoc said...

"Prescribing potent SSRIs and SNRIs to patients who are seen for 30 minutes every 90 days is awful medicine. It is done too often." Very true. Many patients are sufficiently stable that yearly visits are adequate, but what on earth would we talk about for 30 minutes? As little as five minutes often suffices, and the need for visits every 90 days just feeds the malpractice monster. (Some expert witness and some judge will somehow conclude that whatever bad thing happened was surely caused by not enough visits, whether they were indicated or not. Too much psychotherapy can be a problem too: firing the psychotherapist should be the goal of treatment from the outset.

Anonymous psychiatrist: We don't just prescribe meds because we CAN. We do it because they work, they're well tolerated, and because our patients choose that modality.

Correctly done psychotherapy works too, and it probably is undervalued. Let's hope our patients continue to have a choice: either or both.

Thomas said...

As a clinician, I am stunned by the irresponsibility of statements such as:

"Many patients are sufficiently stable that yearly visits are adequate"

10mg fluoxetine a yearly visit might be suitable but 375mg venlafaxine definitely not. Let's be clear.

"but what on earth would we talk about for 30 minutes? As little as five minutes often suffices[?]

Hmmmm I don't know how to respond to this. What could a clinically useful 5 minute dialogue consist of?

"firing the psychotherapist should be the goal of treatment from the outset."

Independence of both the psychotherapist and medication should be the goal.

Sadness may have evoked MovieDoc's antagonism due to her two earlier posts and he really may not feel this way. He may at the same time synically be agreeing Dr. Arpaia's point that the health networks will force the doctor's towards medication dominated therapy.

Thomas Rueben
Stuttgart, Germany

Anonymous said...

firing the psychotherapist should be the goal of treatment from the outset.

Hey moviedoc: Firing the psychiatrist should also be the first goal of treatment! But the problem is, as research has demonstrated, that firing the shrink leads to relapse and intolerable side effects; firing the psychologist results in long standing treatment gains as least as regards to depression! Do the research!

moviedoc said...

Anon: Did you mean to say firing the psychologist results in long standing treatment gains? My point is that endless psychotherapy where the patient incorporates the psychotherapist as a significant other has negative effects. I believe that applies when the psychiatrist does the psychotherapy, too. Stopping the medication is not always a goal. Some patients will benefit from some drugs lifelong. Analogy from the general medical world: insulin for diabetes. Treatment gains from psychotherapy can also occur after termination.