Psychologists Prescribing Antidepressants?

Here's another question from a visitor:

Your views on psychologists' obtaining the right to administer antidepressant.

I don't have any problem with this. If psychologists, or anyone else, were to have prescribing privileges, I do think there should be an educational program with a licensing exam, with continuing education requirements for maintaining licensure, etc., to ensure that the prescribers are up-to-date and knowledgable about the medications and risks, etc. At that point, it could be up to an informed patient to decide whether to trust and accept a prescription from a psychologist. As far as I'm concerned, this is a fair balance between regulation and individual rights in a freedom-oriented society.

I think some psychiatrists' opposition to psychologist prescribing has a lot to do with wanting to hold on to more influence, authority, power, or perhaps a greater sense of importance or exclusivity. There may be elements of narcissism and insecurity which underlie this position. It reminds me of the history of modern medical opposition to midwifery.

While many patients need complicated regimes of medication, may have complex comorbid medical problems, and may therefore require a highly specialized expert in psychopharmacology to prescribe for them (actually, the level of expertise in this area among psychiatrists is very inconsistent), the majority of patients who might benefit from antidepressants require a very simple regimen. Such a regimen does not require many years of advanced education to competently administer. It seems a waste of time and health-care expense for those individuals to have to seek out an MD for their prescriptions.

Furthermore, many antidepressant prescriptions are currently written by a gp who may have only seen the patient for a few minutes--if psychologists were prescribing, this would most likely be in the context of knowing the patient very well, with hour-long appointments, and offering very good follow-up care.

There are risks associated with prescription antidepressants, and there are bound to be patients who run into problems after being prescribed antidepressants from a psychologist. But I am doubtful that these risks would be higher than if antidepressants were only available from an MD, particularly if prescribing privileges required passing a licensing exam, etc.

Future of personalized antidepressants

Another question from a visitor:

Advances in psychiatrist medications: Holsboer has recently elaborated on the future of personalized antidepressants designed using genotype and biomarkers. Where do you think psychiatry is headed, in terms of ideology, but also medications and treatments?

Here's the reference:
http://www.ncbi.nlm.nih.gov/pubmed/18628772

It's an interesting and important subject. In current practice, it can be hard to find medications or other types of therapy which are helpful. It would relieve a great deal of suffering much more quickly to have some way of determining, in advance, which particular treatment for psychiatric illnesses might help best.

Also, the article emphasizes the need to search for treatments outside of the current pharmacological paradigms; we probably have enough medication choices affecting serotonin uptake, etc. It will probably be important to search for pharmacological treatments which affect other systems in the brain.

I don't feel very well-informed about the cutting edge of this science (translating genetic research into pharmacological treatments), but I can see this being a huge advance in the coming decades.

Are Psychiatrists Professionals, Friends, or Healers?

Another question from a visitor:

Are psychiatrists professionals, friends, or healers? I personally believe that healing occurs in a time and place beyond professional rules and regulations. Even friendships can be healing. I wonder if professionalization of medicine is antithetical to a healing process that is dependent on...deep human connection.

This is a good question, one I've often thought about.

The standard of practice in psychiatry, and in other areas of medicine, is for the therapeutic relationship to be "well-boundaried." Mind you, this seems like an obvious truth; furthermore, any healthy friendship also needs to be "well-boundaried." Many unhealthy friendships or family dynamics are problematic due to unhealthy or absent boundaries. But in psychiatry, there are formal legal and professionally-mandated restrictions around the type of relationships permitted between therapist and patient, or between therapists and former patients. In general, I would say the rule is that any interaction between psychiatrist and patient (or between psychiatrist and former patient) needs to be considered a "therapeutic action," or at least an attempt to be a "therapeutic action," and if this interaction cannot be justified as such, it would be considered outside a healthy boundary. These rules protect patients from unethical practioners.

But I do consider any type of healthy human interaction to be a manifestation of a type of friendship. And I consider it a healthy way to live, to consider that all of one's interactions in the world are "friendship-building" activities. To experience the very personal relationship of psychotherapy as strictly bereft of "friendship" seems wrong to me.

Different individuals will have different needs or wishes in this regard. For many people, they prefer to interact with a psychiatrist or other professional in a polite but formal and distant way. Many people would not want to have a friendship with their psychiatrist or physician.

For many others, closeness and trust in a therapy relationship is extremely important to nurture.

One thing I strongly feel to be true is that the therapy relationship needs to be a setting in which growth of healthy relationships outside of the therapy relationship can be encouraged.

I am reminded of some of the psychiatric theory from the previous century about "object relations." This theory generally considers that relationships become "internalized" as abstract mental models, during the course of development. Relationships with parents during early childhood become the first internalized models. Recent evidence establishes that early peer relationships are extremely important in psychological development, perhaps having an equal or larger effect than parental relationships in many cases. Included in these internalized relationships are a sense of "other," a sense of "self," and a sense of expected dynamics between "self" and "other." Future relationships then develop which tend to be in synchrony, or in a type of resonance, with the internalized models. If these internalized models are disturbed by unhealthy relationships, absent or neglectful caregivers, abuse, environmental adversity, or inherent neuropsychiatric symptoms (such as innate tendencies to be anxious, irritable, depressed, etc.), then future relationships are likely also to be disturbed. This leads to a vicious cycle of unhealthy relationships and escalating symptoms.

In a therapeutic relationship, I think this "object relations" idea is important. The therapeutic relationship should aim to be one in which previous vicious cycles are not allowed to repeat. Over time, if the therapeutic relationship is healthy, it could perhaps become "internalized" as well, hopefully as a model of comfort, stability, nurturance, respect, trust, and healthy boundaries. In this way, I think the role of therapist is a bit more like the role of a parent, in that there is an element of friendship, a strong expectation of nurturance, a benevolent "paternalism" to some degree (some desire this element more or less than others), but also the observation that the "parent" becomes less and less necessary for meeting personal needs as the relationship develops over time.

There can sometimes be experiences of very great personal need. The experience of therapy can partially meet this need. The boundaries of the therapy can feel tremendously frustrating for a patient if this need is only partially met. Yet I feel that part of the growth experience in therapy can be to come to terms with this frustration, i.e. that the therapist is a positive, caring figure, but also that the therapist is limited and unable to meet any need completely or perfectly. If the therapy is to be truly effective or "healing," then the more complete or "perfect" satisfaction of needs eventually could occur outside of the therapy, during daily life.

Here's a light-hearted poem about this theme. It's by Hal Sirowitz, from the collection My Therapist Said.

BETTER THAN A FRIEND
You shouldn't tell everyone that you're
in therapy, my therapist said. Some people
might think you're crazy. If
someone asks why you go to the city
at the same time each week, you should
just tell him that you have an appointment
with a friend, which is not really a lie,
because I'm your friend. But I'm also
so much more. You can insult me, & I'll
never get mad. I'll just say that you're
transferring again. I'll never leave you,
but you can leave me. One day you'll
tell me that you don't need to see me anymore,
& instead of being mad, I'll be happy,
because that'll mean you're cured. But
I wouldn't advise you to do that
in the near future. You still have problems.

* I like this poem but it's okay with me if you tell people you're in therapy!
**Thank you to the reader who found the author's name & info for me.

Political Involvement of Psychiatrists

Here's another excellent question from a visitor to the site:

Political involvement of psychiatrists: We live in a "therapeutic culture". [There] are changing sociocultural norms for what is considered normal and acceptable. Are--and should--psychiatrists be aware of the sociological and political changes occurring as a result of the millions taking antidepressants or receiving psychotherapy? Should psychiatrists take a more active role in managing forces that influence communities, given the positive therapeutic effects of unconditional positive regard, hope, trust, interpersonal connection, and belonging (some of the common factors)?

Psychiatrists as a group are extremely heterogeneous, in terms of personality style, intellectual background, and political beliefs. Those who involve themselves in administration or politics may do so in a loving attempt to help their community, but may also do so due to a need to have more influence, control, money, or self-aggrandizement (to be fair, I suppose most people would be motivated by all of these factors, to some degree). There are a lot of big egos in psychiatry, just like everywhere else.

I've often thought of the ideal role of psychiatrist (politically) as some kind of monastic figure ("Jedi-like", if I could indulge in a popular culture metaphor): serenely outside the political machine, possessing wisdom but healthily setting aside the need to exert power or control at all. This type of paradigm is in conflict with the competitive and ambitious world of politics or administration.

I do agree that we all need to be more active in informing ourselves about political concerns, and attempting to help not only individuals, but also groups, communities, or nations. And psychiatry as an organized group most definitely needs to be aware of large-scale social effects of treatments such as psychotherapy and medications.

In very dark and troubled times, or in dark and troubled parts of the world, very bad things can happen politically. The institution of psychiatry has sometimes been involved in these events. At other times, psychiatrists or therapists are themselves persecuted. It is a luxury to live in a peaceful and free nation, and we need to be vigilant to maintain social and political freedom.
Here are a few articles about this:
http://www.atypon-link.com/GPI/doi/pdf/10.1521/prev.88.2.295.17677 (an essay about psychiatry in Nazi Germany)
http://www.nybooks.com/articles/16082 (an 2003 excerpt published in the New York Review of Books about psychiatry in China)

Neurology & Psychiatry

Here's another question from a visitor to the site:

"Neurology and Psychiatry: ...I continue to read the scientific literature and I find it somewhat arbitrary how different fields are divided up. What do you think of joining psychiatry and neurology?"

The field of "neuropsychiatry" is extremely interesting. At UBC there is a specialized ward devoted to helping patients who suffer from a combination of neurological diseases (such as epilepsy, head injuries, etc.) and psychiatric illnesses. Some "neuropsychiatrists" have completed specialty training in both neurology and psychiatry. At UBC a particular focus in neuropsychiatry has been the treatment of severe somatization and conversion disorders: these are psychiatric illnesses which present with severe physical or neurological symptoms (such as paralysis, blindness, or seizures). In conversion disorders, symptoms such as paralysis, blindness, or seizures, are not caused by neurologic problems such as stroke or epilepsy, but by severe, complicated depression in most cases. Treatment of the underlying psychiatric illness causes the neurological symptoms to disappear.

So, neurology and psychiatry do have an intersection in current practice. However, many neurologists may not be predisposed to dealing with psychiatric problems, or may not be willing to offer the type of regular follow-up which I believe is a healthy standard of care in psychiatry (unfortunately, the same could be said of some psychiatrists). Conversely, most psychiatrists would be uncomfortable dealing with acute or esoteric neurological problems.

So, in practice, while neurology and psychiatry have an overlap, the areas outside of the overlap are sufficiently large for the specialties to exist separately.