Fourth: Laboratory ordering and monitoring. Ordering laboratory data during follow-up of a patient receiving a psychotropic drug is necessary to monitor serum concentrations and ensure a therapeutic range, or to check for serious adverse effects on various organ systems that could be affected by many psychiatric drugs (CNS, cardiovascular, gastrointestinal, sexual, endocrine, pulmonary, hepatic, renal, dermatologic, ophthalmologic, etc.).
Conclusion: Medical training is required.
Fifth: General medical treatment. Many patients might require combination drug therapy because of inadequate response to monotherapy. Clinicians must know what is rational and evidence-based polypharmacy and what is irrational, dangerous, or absurd polypharmacy.9 When possible, parsimonious pharmacotherapy should be employed to minimize the number of medications prescribed.10 A patient could experience severe drug–drug reactions that could lead to cardiopulmonary crises. The clinician must be able to examine, intervene, and manage the patient’s medical distress until help arrives.
Conclusion: Medical training is required.
Sixth: Pregnancy. Knowledge about the pharmacotherapeutic aspects of pregnant women with mental illness is critical. Full knowledge about what can or should not be prescribed during pregnancy (ie, avoiding teratogenic agents) is vital for physicians treating women with psychiatric illness who become pregnant.
Conclusion: Medical training is required.
Although I am against prescriptive privileges for psychologists, I want to emphasize how much I appreciate and respect what psychologists do for patients with mental illness. Their psychotherapy skills often are honed beyond those of psychiatrists who, by necessity, focus on medical diagnosis and pharmacotherapeutic management. Combination of pharmacotherapy and psychotherapy has been demonstrated to be superior to medications alone. In the 25 years since psychologists have been eagerly pursuing prescriptive privileges, neuroscience research has revealed the neurobiologic effects of psychotherapy. Many studies have shown that evidence-based psychotherapy can induce the same structural and functional brain changes as medications11,12 and can influence biomarkers that accompany psychiatric disorders just as medications do.13
Psychologists should reconsider the many potential hazards of prescription drugs compared with the relative safety and efficacy of psychotherapy. They should focus on their qualifications and main strength, which is psychotherapy, and collaborate with psychiatrists and nurse practitioners on a biopsychosocial approach to mental illness. They also should realize how physically ill most psychiatric patients are and the complex medical management they need for their myriad comorbidities.
Just as I began this editorial with an anecdote, I will end with an illustrative one as well. As an academic professor for the past 3 decades who has trained and supervised numerous psychiatric residents, I once closely supervised a former PhD psychologist who decided to become a psychiatrist by going to medical school, followed by a 4-year psychiatric residency. I asked her to compare her experience and functioning as a psychologist with her current work as a fourth-year psychiatric resident. Her response was enlightening: She said the 2 professions are vastly different in their knowledge base and in terms of how they conceptualize mental illness from a psychological vs medical model. As for prescribing medications, she added that even after 8 years of extensive medical training as a physician and a psychiatrist, she feels there is still much to learn about psychopharmacology to ensure not only efficacy but also safety, because a majority of psychiatric patients have ≥1 coexisting medical conditions and substance use as well. Based on her own experience as a psychologist who became a psychiatric physician, she was completely opposed to prescriptive privileges for psychologists unless they go to medical school and become eligible to prescribe safely.
This former resident is now a successful academic psychiatrist who continues to hone her psychopharmacology skills. State legislators should listen to professionals like her before they pass a law giving prescriptive authority to psychologists without having to go through the rigors of 28,000 hours of training in the 8 years of medical school and psychiatric residency. Legislators should also understand that like psychologists, social work counselors have hardly any medical training, yet they have never sought prescriptive privileges. That’s clearly rational and wise.