To the Editor: Contributors to the Patient Safety Forum in the December issue debated the contentious question of psychologist prescribing (1). In the hope that your readersare interested not only in the views of the two "warring factions" but also inthose of patients, I am writing to offer my observations as a consumer of psychiatric services for more than 30 years.
A majority of prescriptions for antidepressants and anxiolytics are currently written by internists and general practitioners. These physicians are poorly trained to make initial psychiatric diagnoses and have little time for follow-up assessments. Few can remain current with the deluge of new research information pertaining to the myriad conditions theyencounter on adaily basis, such as congestive heart failure, diabetes, dyslipidemia, and autoimmune diseases. Swamped by new information,internists and general practitioners are understandably susceptible to marketing messages from sales representatives hawking the latest minor modification to an antidepressant that is being touted as "an important clinical breakthrough."
Fortunately, serious errors in prescribing are nearly impossible in view of the fact that the similarities between the leading drugs to treat depression and anxiety disorders vastly exceed their relatively trivial differences. Indeed, the most serious treatment errors made by internists and general practitioners in this area areapt to be overlooking the value of psychotherapy or selecting a new branded drug when a generic would do. The homogeneity among these classes of drugs also enormously simplifies prescribing for psychologists. Furthermore, because psychologists are unlikely to be high-volume prescribers, they would attract fewer visits from sales representatives offering "information" and drug samples that may improperly influence treatment selection.
Dr. Scully makes the point that "many nonpsychiatric illnesses cause or worsen psychiatric symptoms … [including] endocrine disorders, diabetes, malignancies, heart disease, and infections." The implication is that psychologists would likely overlook these problems. I have been treated by six psychiatrists during my years of experiencing depression and anxiety, and none has yet suggested that drug therapy be preceded by a battery of tests to detect any occult illness. These psychiatrists were all board certified; two were from the National Institute of Mental Health, and one was the former medical director of a large psychiatric hospital. Clearly, precious little in the way of medical triaging is being offered in psychiatrists' offices—most likely because it simply is not necessary.
Until there are meaningful clinical differences between drugs used to treat the most common psychiatric disorders, or an accurate way to predict patients' responses to the drugs, psychologists who are well trained in basic psychopharmacology are likely to offer pharmacologic care of equal or higher quality than that offered by general practitioners and internists. Indeed, psychologists' awareness of the added scrutiny that their treatment selections may attract is apt to foster a far more circumspect approach to prescribing—and a willingness to make referrals to specialists—than prevails in the current system.
It is time that professionals set aside their claims about who "cares more" about patients' welfare and instead allow progress in clinical care to supersede petty turf battles.
Mr. Ensign, who lives in Shirley, Massachusetts, was formerly a public health advisor at the U.S. Food and Drug Administration. He is currently employed as an independent pharmaceutical market analyst.