PSYCHOLOGISTS' CLAIMS VS. REAL FACTS
Claim: There is a large number of underserved mentally
ill individuals, many of whom need medication.
Fact: This is correct. But this bill does not provide the
answer. In fact psychologists are not the health professionals who treat
the underserved.
- Psychiatrists treat the poorer, sicker patients (1)
- Psychologists treat a larger proportion of white, employed, insured,
highly educated, wealthy and less impaired people than do psychiatrists
(1)
- The patients are underserved primarily because of lack of insurance
coverage and lack of funds to pay for their own care.
Claim: There is a shortage of psychiatrists, and no shortage
of psychologists. Psychologists are available. "24 counties have 5
or fewer psychiatrists, and patients must turn to other health care providers
with little or no training in mental health. If psychologists could prescribe
this problem would be drastically reduced." (Quoted from the psychologists'
own materials).
Fact: The truth or fiction of this statement is a non-sequitur
with respect to this bill. However, the information below refutes the claim.
Further, any shortage in rural California can be addressed in other ways
which deliver medical services by physicians to those with biological brain
diseases, not by non-medically-trained behavioralists. Further:
- The numbers the psychologists used are inaccurate. They use a source
which is out of date, and counts only a little over half of California's
psychiatrists. County lines are artificial boundaries, and do not take
into account the psychiatrists who "circuit ride" in less populous
areas of the state. Research the California Psychiatric Association has
done to obtain actual numbers through county sources reveal that Alpine
County is the only county lacking direct psychiatric coverage, and it has
only 1200 people, 14 patients, and no psychologists, either. All other
counties have psychiatric coverage, whereas many do not have psychologists.
See the attached summary of a study conducted by the California Psychiatric
Association in 1996.
In anticipation of a hearing in December, 1997, CPA obtained a more current
list from the Board of Psychology in July of 1997. It revealed that little
had changed. As of November, 1997:
- 4 counties have no psychologists, although San Benito now had one,
Glenn now has none;
- 3 counties have one psychologist;
- 5 counties have 2 psychologists;
- 3 counties have only 3 psychologists, resulting in 16 counties with
3 or fewer psychologists, and 13 with 2 or fewer; and
- 18 counties have 5 or fewer psychologists.
- 21 of the 24 counties noted by the psychologists as having less
that 5 psychiatrists have less than 75,000 people, 16 have less than 50,000
people, 12 have fewer than 30,000 people, and only one has more than
137,000 people. The need for psychiatrists in rural California is being
met by alternative methods of access to adequately trained psychiatrist
physicians, such as telemedicine; non-discriminatory health care coverage
by both managed care companies and Medi-Cal; the recruitment efforts that
have been undertaken by our association in cooperation with the counties;
and circuit riding. Additionally, U.C. hospitals are developing a telemedicine
hotline, where consultations for primary care physicians with psychiatrists
would be available 24 hours per day.
- Psychologists are generally located in the same geographic areas as
psychiatrists, so the existence of additional psychologists is irrelevant.
(4) It is interesting that the psychologists give no distribution on
psychologists, only psychiatrists. The reason is that there are fewer
psychologists in many rural areas. See the attached.
- The number of psychiatric residents increased by about 24% from 1982-83
to 1989-90, and has held steady at about 6,100 per year since that date.
In 1997, the percentage of medical school graduates choosing residencies
in psychiatry increased by 3.13 % (3), (7).
- The nation's medical schools are responding to the increasing emphasis
on family practice by creating combined 5-year residencies in family practice
and psychiatry. In 1996, 7 of these combined programs were approved,
including ones at U.C. Davis and U.C. San Diego (5).
- Only 60% of the members of the American Psychological Association identify
themselves as health service providers. (6)
Claim: Most brain medications are prescribed by non-psychiatrist
physicians, who receive little training in mental health.
Fact: The argument confuses the training of physicians
and behavioralists. Psychiatrists and other physicians are trained to
diagnose and treat human illness, which includes the brain and the rest
of the body and the use and side effects of medication in treating those
illnesses. Psychologists are trained in human behavior. Medications
are used to treat body chemistry and are biologically based. Physicians
are also trained to find a biological disorder of one part of the body masking
itself in another part of the body, including the brain. Medicine and
behavioral studies are distinct and different. They can and must interface,
but neither is the other.
Most of these brain medications prescribed by primary care physicians
are benzodiazapines (tranquilizers) or anti-depressants used for patients
with milder symptoms and not severe brain disorders. Family physicians usually
refer patients to psychiatrists for lithium, antipsychotics, and the other
medications used for the more severe brain disorders.(1) This is the standard
practice in today's managed care environment. Further, the non psychiatrist
M.D.s are still M.D.s, not behavioral counselors. The medications are used
for biological brain disorders, not "mental" behavioral issues.
Claim: Psychologists cost less
Fact: The cost per visit for psychiatrists and psychologists
is nearly the same. (2)
Claim: Non-psychiatric physicians do not tend to refer
to mental health specialists for care of mental health patients.
Fact: The article cited in footnote (1) notes that patients'
utilization of services tend to be distributed about equally between general
practitioners, psychiatrists, psychologists, and "other health professionals."
The distribution of outpatient visits generally breaks down as follows:
- psychiatrists treat the bulk of the severe brain disorders, such as
schizophrenia, bipolar disorder, and severe depression;
- general physicians treat the bulk of substance abuse and adjustment
disorders;
- psychologists treat the bulk of anxiety disorders, "isolated symptoms"
and "other symptoms;"
- "other health providers" treat the bulk of childhood disorders
and mental retardation. (1)
Claim: Psychologists are increasingly practicing in settings
where the seriously mentally ill are treated, where patients need medications.
Fact: Those settings are called hospitals, and psychiatrists
are clearly available there.
Claim: Many non-physicians, nurse practitioners, physician
assistants, dentists, & podiatrists, have authority to write prescriptions.
Fact: Nurse practitioners and physicians' assistants have
substantial training in the medical model and are authorized to dispense
limited kinds of medications, under the supervision of a physician- they
do not practice independently of a physician, as this bill would allow psychologists
to do. They generally dispense birth control pills, antibiotics, decongestants,
and topical skin medications-not brain medications. Podiatrists and
dentists are trained in the medical model, having a 4-year program in their
specialty, which includes substantial training in anatomy & physiology,
and are limited to the foot and the mouth, respectively.
Claim: Studies have shown that non-MD providers can safely
and satisfactorily prescribe medications without the supervision of a physician.
Fact: What studies?
Claim: The Department of Defense Demonstration Project
showed that this training works. "The DOD permits military psychologists
who have completed the required training to prescribe medications for patients."
(Quoted from psychologists' materials)
Fact: In the DOD project, the participants
were licensed psychologists who then received 3 or more years of training,
one year full time in the classroom, one year clinical and one year proctorship.
The program was audited by the U.S. Government Accounting Office, and in
an April 1, 1997 report, the GAO recommended that the program be discontinued,
pointing out that, although when the project was begun, it was expected
the psychologists would be allowed to practice independently, it is doubtful
any of them ever will be authorized to practice other than under the close
supervision of a psychiatrist. Some proposals would allow independent
practice by psychologists after less than the equivalent of 0.3 years of
medical school course work, plus 800 hours supervised practice, compared
to psychiatrists' and other physicians' 4000 or more hours of course work
in medical school, including at least 72 hours of supervised clinical practice,
and 10,000 to 12,000 of supervised practice in residency, more than a 13
to 1 differential. Does California really want to allow this experiment,
and is it worth the money and risk?
Claim: With an average of 7.2 years of study, psychologists
are the most highly-trained mental health professionals.
Fact: The average may be 7.2 years, but the full-time equivalent
is 5 years, 4 years of graduate school and one year of clinical work. Apparently
the psychologists have concluded that psychiatrists are not "mental
health professionals" since they have to have 8 years of full-time
study (4 years medical school, 4 years residency).
(1) Study reported in the American Journal of Psychiatry,
153:10, October, 1996.
(2) Study reported in Open Minds, Volume 2, Issue 2, May,
1989.
(3) American Psychiatric Association annual censuses of
residents.
(4) Geographic Access to Psychiatrists' Services: A county-Level
Analysis, Lewin / ICF, prepared by the American Psychiatric Association,
January, 1989.
(5) Psychiatric News, January 17, 1997
(6) summary of the Report of the Ad Hoc Task Force on Psychopharmacology
of the American Psychological Association, Smyer, M. et. al., Professional
Psychology: Research and Practice, Vol. 24, No. 4, page 400, 1993.
(7) Psychiatric News, Volume XXXII, Number 8, April 18,
1997, page 1.
March 3, 1998
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