Thursday, September 14, 2006

Increasing Prescribing by Psychologists: Progress or Just Flatulence?

Well, here’s some good news if you are an enterprising psychologist: An article in the latest Journal of Clinical Psychology advocates that psychologists should not just be satisfied with the honor of prescribing psychotropic meds. The constant advocacy of the American Psychological Association has, of course, set the psychotropic train in motion by convincing legislatures in New Mexico, Louisiana, and Guam to allow psychologists psychotropic prescription privileges under varied degrees of supervision. That can of worms is beyond the scope of this latest article, which states that psychologists should carve out a bigger slice of market share through wider prescription privileges. All for the patients’ sake, of course.

The authors discuss the success of their mainly behavioral weight management program, which indeed sounds somewhat encouraging. They mention that, however, pharmacological treatments (they emphasize orlistat/Xenical), are effective in enhancing weight loss and then keeping the weight off, though they provide little data to back this assertion. My relatively brief review of trials on orlistat indicated that the effects are often relatively small relative to placebo In fact, a meta-analysis found that “for patients taking orlistat, weight loss was 2.2 kg greater than those on placebo at 4 years."

Oh, and let’s not forget the side effects, which I’ll quote from the authors: “oily spotting, flatus with discharge, fecal urgency, and oily stool.” Let’s face it: part of the joy of losing weight is that one becomes more appealing to members of the opposite (and in some cases the same) sex. When one is feeling joyous about losing 65 pounds, and is on a hot date, yet is emitting discharge-laden flatulence, this likely eliminates the romance of the evening rather quickly.

I’ll gladly agree when the authors say “Psychology practice is necessarily altered as one begins to prescribe medicine (p. 1217).” Take a look over at psychiatry over the last 40 years and see how well that worked out…

“Prescribing psychologists have additional responsibilities in physical health care management. The patient encounter involves areas of physical health status not usually covered in the general psychology appointment. Conducting a review of systems, inquiring about common side effects, and collecting biological markers (blood pressure, fasting glucose, lipid profile, etc.) are required parts of a standard patient encounter. To do this requires an adequate understanding of physical processes and the terminology needed to appropriately manage and document the patient status in ways not normally used in the mental health arena (p.1217).” Yep, more training, indeed. Like the kind you could get if you trained as a nurse practitioner or a physician.

“Any physical conditions that psychologists treat currently, such as nicotine dependence, sleep disorders, and chronic pain, are opportunities for psychologists to prescribe. Bupropion sustained-release, nicotine patches, nonbenzodiazepine hypnotics, selective serotonin reuptake inhibitors (SSRIs), non-steroidal anti-inflammatory drugs and other pain medications are all agents that psychologists, with proper training and experience, can prescribe safely and effectively (p. 1218).”

My take: Great economic opportunity for psychologists. However, the outcomes for patients are likely to be compromised as we become focused on treating more patients in less time. How will we develop relationships with patients and deliver the psychotherapeutic interventions that we know are as effective in the short term and generally more effective in the long-term than medications? Never underestimate the corrupting power of cash. Never.

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