THE BLOG
07/16/2014 02:55 pm ET Updated Sep 15, 2014

Psychologists Prescribing Medication Is a Bad Idea

The state of Illinois has now joined the states of New Mexico and Louisiana in allowing clinical psychologists the right to prescribe psychotropic medications. This new privilege comes with the requirement that psychologists take extra training to become familiar with the basics of the chemistry of the brain and how medications act to produce their affects. Ostensibly, this training gives them all the knowledge they need to determine the need for medication, prescribe them, and monitor their effects. However, the mere prescription of medication is only a part of what a psychiatrist does in the successful treatment of mentally ill patients. Giving psychologists the privilege of prescribing medications and pretending that this can obviate the need for more psychiatrists is a foolish idea.

Ironically, it is psychologists themselves who have so successfully educated the public to the fact that mild and moderate mental illnesses generally don't require treatment with medications. Perhaps the best example is major depression. The well-known work of psychologist, Irving Kirsch, suggests that antidepressants are no better than placebo in mild to moderate depression. Indeed, their benefits are suspect even in severe forms of the illness.

Nor can it be assumed that adding an antidepressant to psychotherapy would make all the difference for a lot of patients. There is some evidence that combining medication with psychotherapy can be useful in some patients. However, several studies have found the benefits of combined to be equivocal.

The psychiatric literature itself notes that a significant number of patients, from 30 to 50 percent, who suffer depression do not respond to a single antidepressant. This improves only slightly after several more antidepressants are tried. It is when depression is severe, antidepressants fail, and the addition of psychotherapy provides no further relief, that the full range of knowledge of skills of the psychiatrist is so critical.

Quite justifiably, psychologists have prided themselves in their holistic approach to patients. They recognize that each individual has thoughts, feelings, and ways of seeing the world. People are social and spiritual beings. Often, mistaken ideas about the world and themselves get people into psychological trouble. Psychologists have a great deal to offer their patients in exploring these problems. However, while having similar appreciation of the complexity of human beings, psychiatrists are also trained to understand the enormous complexities and interactions of the brain and the body. Psychiatrists understand that various deficiencies and abnormalities in the body can contribute to mental illness, and that the correction of these problems are often necessary to achieve remission from psychiatric illness.

In some cases, the correction of low thyroid levels, or the augmentation of an antidepressant with the form of thyroid hormone called T3 can bring remission from depression. Vitamin B12 deficiencies are surprisingly common, particularly among the elderly. These deficiencies can be due to diet, or may be the result of stomach conditions or medications. Until the deficiency is corrected, a person with depression is unlikely to improve. In some individuals, the vitamin folic acid is not metabolized properly, and the addition of the Methyl-folate form of the vitamin helps restore emotional stability. In many cases it is necessary to augment antidepressants with biological treatments or secondary medications. These measures require medical management and cannot be performed by psychologist, including those who have had some extra training in how drugs work.

There are also a wide variety of medical conditions that can mimic or exacerbate major depression, including autoimmune disorders, neurological disorders, malignancies, infections, heavy metal poisoning, liver diseases, blood disorders, adverse effects of non-psychiatric medications, and many others. It is often the psychiatrist who recognizes that what was assumed to be a psychiatric illness is in fact an untreated medical problem. It is very unlikely that a psychologist, even one with extra training, would diagnose these problems.

Psychiatrists are often criticized for a reductionist approach to mental illness. We are accused of "throwing pills" while ignoring the social, cognitive and spiritual aspects of our patients. However, the use of medications by psychologists with only rudimentary understanding of physiology, pathophysiology, and pharmacology is another form of reductionism that should be soundly criticized.

Simply stated, psychologists do not need medications to treat the majority of the patients they see, whereas a simple medication will not be enough for many if not most of those who don't respond to psychotherapy. The shortage of psychiatrists and the lack of access to competent mental health care is a serious problem, particularly in rural areas of America. However, the solution to the shortage is to train more psychiatrists and make practice in underserved areas more attractive. It serves no purpose to dilute the practice of psychiatry with ill-prepared surrogates.