March 29, 2001 -- A depressed patient goes to a psychologist for psychotherapy and is told he might benefit from Prozac as well. "Can you give me some, doc?" the patient asks. "Sorry, I'm not a medical doctor," the psychologist says, and sends the patient across town to a psychiatrist -- or, more likely, to a primary care doctor -- to receive a prescription.
The scenario illustrates a curious and typical feature of the American mental health care system and raises a question some professionals and policymakers are asking: Why shouldn't psychologists prescribe medicine?
This week a bill was introduced into the Illinois State Legislature that would grant that right to psychologists who have undergone special training. Psychologists in the state say they could be trained to prescribe Prozac -- and other, often dangerous drugs for various psychiatric illnesses -- just as safely as any psychiatrist with a medical degree.
And they claim they can fill a gaping need for services left by what they say is a nationwide shortage of psychiatrists.
"This is a public health issue," says Marlin Hoover, PhD, president-elect of the Illinois Psychological Association. "We know of many people out there who don't receive any services at all. Our primary purpose is to serve underserved populations."
If passed, the bill would overturn a century-old tradition in which the prescribing of medicine has been almost exclusively the province of people with medical degrees. Psychologists, who receive extensive training in thought and psychological processes and who often treat patients with psychotherapy, have never been allowed to prescribe medicine.
Illinois is not the first state in which psychologists have attempted to gain the right to prescribe through legislation. California, Tennessee, New Mexico, and Hawaii, among other states, have all entertained legislation that would extend prescribing to psychologists.
A pilot program of the U.S. Department of Defense to train military psychologists to prescribe was initiated in the late 1980s and has since produced 10 psychologists who have prescribed for members of the service and their families. The program reduced the time patients had to wait for treatment and increased the number of patients who could be treated.
"As psychologists, our biggest concern is to contribute to the mental health of our patients," Hoover says. "We wouldn't want to prescribe drugs unless it could be done safely."
But in Illinois, as elsewhere, the legislation is hotly contested by psychiatrists who say that extending prescribing privileges to people who have not been through medical school is dangerous to patients.
"It is absurd to suggest that someone without a medical education and knowledge of the entire body can safely prescribe and monitor the effects of psychiatric medications," Paul S. Appelbaum, MD, tells WebMD. He is a professor and chair of psychiatry at the University of Massachusetts Medical School in Worcester and president-elect of the American Psychiatric Association.
"This is a great misinformation campaign that has been launched by psychologists who want to skip medical training and obtain instead a second-class MD license by legislative means -- without regard to safety," Maria T. Lymberis, MD, clinical professor of psychiatry at the UCLA School of Medicine tells WebMD. "It would be a tragedy to allow psychologists to prescribe without first going through medical school."
The special curriculum for prescribing psychologists would consist of a minimum of 300 hours of classroom training in various things -- like how the body functions, what problems arise in disease states, and how medications work. It would also require the candidate to treat at least 100 patients under supervision and to undergo oral and written exams.
Hoover says the curriculum is the equivalent of 10 graduate courses and amounts to a master's degree on top of their doctorate training.
But psychiatrists say it's not enough.
"[Medications] affect many organs in the body, and one has to have advanced understanding of those effects," says psychiatrist Jay Scully, MD, chair of the department of neuropsychiatry and behavioral sciences at the University of South Carolina School of Medicine in Columbia. "That's why people go to medical school."
"They are attempting to offer in a number of weeks the kind of clinical training in disease processes that physicians gain over 8 years," Sidney Weissman, MD, tells WebMD.
Weissman, who is a representative of the Illinois Psychiatric Association, testified against the bill this week during hearings in Springfield, Ill.
He cites as an example a patient he treated in intensive psychotherapy for many years. For no apparent reason, the patient -- after much progress -- suddenly experienced a serious depression. Upon questioning, Weissman learned the patient had started a new medication for high blood pressure --a 'beta-blocker' known to cause depression.
"I told her she had to call her internist and get on another [blood pressure medicine]," Weissman says. "That was on a Friday. By Monday, her depression was lifting. The fact that I could apply a medical sense -- not only a psychological sense -- and ask a different set of questions, allowed me to conclude that there was a different process going on."
But some psychologists who were themselves dubious about prescribing have become advocates of the bill.
"In my own practice I began to see a shortage in my network of psychiatrists I could refer patients to for medication," says Nancy Molitor, PhD, president of the Illinois Psychological Association and assistant professor of psychology and behavioral sciences at Northwestern University Medical School in Chicago.
Meanwhile, she says, primary care physicians are often too busy to keep up with the demand.
"Many of the primary care doctors are good at putting patients on antidepressants, but if the patient doesn't respond the doctor will call me up and ask me if they should bump up the dose," Molitor tells WebMD. "They are asking me for advice, so I am having to become more informed by necessity."
Psychiatrists acknowledge that primary care doctors need better training in managing mental health conditions, but they say the solution is not to allow lesser-trained professionals to prescribe.
The claims of patient safety and public health, cited by both sides, are difficult to disengage from the more parochial economic concerns of the two professions.
Although psychologists claim that psychiatrists are professionally threatened by the effort, psychiatrists counter that the move to gain prescribing privileges is similarly a matter of professional self-interest: With more and more patients receiving psychotherapy from social workers or other less expensive professionals, and with the prescribing of medications still in the hands of the medical profession, psychologists are being squeezed in the middle.
"Psychologists are the odd person out," says Weissman. "One of the things they are trying to do is add another trick to their practice."
The fate of the Illinois legislation is uncertain. Hoover says the psychologists received a "good hearing" from legislators. Weissman tells WebMD he believes the bill has little chance of passing in a state that has always respected the integrity of the medical profession.
Between the competing claims of the two professions, the voice of the patient in need of services may be harder to hear. And the conflict between psychiatry and psychology may reflect a larger failure on the part of a mental health care system to provide coordinated mental health care by appropriately trained professionals.
For another perspective on this debate, read Short on Shrinks.