EDITORIAL
Defining the Unique Scope of Psychiatric Practice in 2015 W. Vaughn McCall, MD, MS
T
he practice of modern psychiatry in the United States shows substantial overlap with the practices of physicians in primary care and with those of nonphysician mental health providers. Some of this overlap has resulted out of the necessity to compensate for a general shortage of psychiatrists in the United States. As a result, primary care physicians, nurse practitioners, advanced practice nurses, and physician assistants in primary care write the lion’s share of antidepressant prescriptions in the United States.1 The ascendency of selective serotonin reuptake inhibitors, which are nonlethal in monotherapy overdose, has furthered the ease and comfort level of antidepressant prescribing in primary care. In parallel, primary care physicians prescribe more than 50% of all sleeping pill prescriptions2 and even 20% of atypical antipsychotics.3 In parallel, most psychotherapy is provided by psychologists, not psychiatrists. Even so, among physicians, primary care doctors account for 20% of the psychotherapy in the United States.4 Psychoanalysis, arguably requiring the most demanding training of all the psychotherapies, was conceived by a physician, but many psychoanalytic institutes admit psychologists, social workers, nurses, and laypersons. If antidepressant medications, hypnotics, atypical antipsychotics, and psychotherapy are now routinely handled by nonpsychiatrists, what professional activities remain that are uniquely psychiatric? The most fundamental, unique psychiatric activity is the understanding and diagnosis of disease at the interface of mind and body. The psychiatrist is best poised to identify physical illness as the origin of psychological symptoms and conversely the manifestations of mental illness on somatic function. Whereas the primary care doctor may have a superior understanding of physical illness, the capable psychiatrist is usually familiar with a broader range of mental illnesses. The psychologist may be the equal of the psychiatrist in the scope of mental illness diagnosis but does not have the same education in the appreciation of somatic mimics of psychopathology. Similarly, while the presumed criterion standard for Diagnostic and Statistical Manual of Mental Disorders diagnosis is a structured clinical interview that can be administered by any trained clinician, psychiatrists are trained to develop a more nuanced formulation that takes into account a biopsychosocial perspective. Beyond diagnosis, there is a handful of therapeutics that is best managed by psychiatrists. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), especially when used in full therapeutic doses, should be managed by psychiatrists, for the very reason that there are safer alternatives— selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors—and therefore expert justification is required to explain the utilization of a TCA or MAOI when safer alternatives are available. The use of MAOIs or full-dose TCAs requires a definitive confirmation of the diagnosis of severe depression and the failure of safer alternatives.5,6 Similarly, the use of lithium in the management of bipolar disorder is best handled by a psychiatrist. Expert, accurate diagnosis of bipolar disorder or another lithium-responsive condition is needed to justify exposure to the short- and long-term adverse effects of lithium, and prior experience with lithium is necessary for the assessment and management of lithium adverse effects.7 The metabolic adverse effects of atypical antipsychotics are sufficiently problematic that their use is best justified after an expert diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, or treatment-resistant depression.8 This is particularly true for treatment-resistant schizophrenia when clozapine is under consideration, as clozapine is associated with a significant risk for agranulocytosis.9 Therapeutic brain stimulation therapies, such as electroconvulsive therapy (ECT), also should be given by psychiatrists, based on (1) the need for expert diagnosis of basic mental disorders, (2) familiarity with more unusual psychopathologic syndromes such as catatonia and neuroleptic malignant syndrome, (3) determination of treatment-resistance, (4) expertise in the conduct of the ECT procedure and management of related adverse effects, (5) and so on.10 An audit of ECT in Sweden revealed that most ECT in that country is provided by nurses or nonmedical attendants, but the authors did not approve of this practice.11 In summary, the last-quarter century has seen a diffusion of some traditional psychiatric roles and the adoption of many traditional psychiatric treatments by primary care providers and psychologists. From the Department of Psychiatry and Health Behavior, Georgia Regents University, Augusta, GA. Received for publication February 5, 2015; accepted February 5, 2015. Reprints: W. Vaughn McCall, MD, MS, Department of Psychiatry and Health Behavior, the Medical College of Georgia, Georgia Regents University, Augusta, GA (e‐mail: [email protected]). The author has no conflict of interest or financial disclosures to report. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/YCT.0000000000000233
Journal of ECT • Volume 31, Number 4, December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ectjournal.com
203
Journal of ECT • Volume 31, Number 4, December 2015
Editorial
Still, there are some core activities that remain mostly unique to the practice of psychiatrists. We propose that these include, but are not limited to, the following: • diagnostic acumen at the boundary of mental health and physical health, • prescription of TCAs and MAOIs, • prescription of lithium, • prescription of atypical antipsychotics, especially clozapine, and • provision of all forms of psychotherapeutic brain stimulation, especially ECT.
Others may disagree with this list, or even the basic premise of such a list, but we feel that defining a unique scope of practice for psychiatrists has value for several reasons. First, outlining a unique scope of practice for psychiatrists helps define the value of psychiatry to the patients we serve and to the payers of these services. Second, delineating the unique scope of psychiatry should help psychiatric training programs set priorities for training in the skills that are particular to the field and that cannot be easily substituted by a different discipline. In particular, the psychiatrist’s expertise at the mind-body interface speaks to the importance of training in consultation-liaison practice. These comments should not be construed as reflecting a “standard of care” or “best practices” and instead describe the present state of who provides various mental health services. There will be instances for which providers other than psychiatrist may prescribe a therapeutic from the list above, for example, neurologists who prescribe lithium for cluster headaches or primary care providers or advanced practice nurses who practice in a setting that is at great distances from a psychiatric consultant.
204
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REFERENCES 1. Cascade E, Kalali AHU. Antidepressant prescribing by specialty and treatment of premenstrual dysphoric disorder. Psychiatry. 2008;5:14–15. 2. McCall WV, Fleischer AB Jr, Feldman SR. Diagnostic codes associated with hypnotic medications during outpatient physician-patient encounters in the United States from 1990–1998. Sleep. 2002;25:221–223. 3. Using atypical antipsychotics in primary care. Prim Care Companion J Clin Psychiatry. 2002;4:233–241. 4. Himelhoch S, Ehrenreich M. Psychotherapy by primary care providers: results of a national sample. Psychosomatics. 2007;48:325–330. 5. MacGillivray S, Arroll B, Hatcher S, et al. Efficacy and tolerability of selective serotonin reuptake inhibitors compared with tricyclic antidepressants in depression treated in primary care: systematic review and meta-analysis. BMJ. 2003;326:1014. 6. Shulman K, Herrmann N, Walker S. Current place of monoamine oxidase inhibitors in the treatment of depression. CNS Drugs. 2013;27:789–797. 7. Dols A, Sienaert P, van Gerven H, et al. The prevalence and management of side effects of lithium and anticonvulsants as mood stabilizers in bipolar patients from a clinical perspective: a review. Int Clin Psychopharmacol. 2013;28:287–296. 8. Riordan H, Antonini P, Murphy M. Atypical antipsychotics and metabolic syndrome in patients with schizophrenia: risk factors, monitoring, and healthcare implications. Am Health Drug Benefits. 2011;4:292–302. 9. Warnez S, Alessi-Severini S. Clozapine: a review of clinical practice guidelines and prescribing trends. BMC Psychiatry. 2014;7:102. 10. Lisanby S. Electroconvulsive therapy for depression. N Engl J Med. 2007; 357:1939–1945. 11. Nordanskog P, Hulten M, Landen M, et al. Electroconvulsive therapy in Sweden 2013: data from the national quality register for ECT. J ECT. 2015. In press.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Defining the Unique Scope of Psychiatric Practice in 2015 W. Vaughn McCall, MD, MS
T
he practice of modern psychiatry in the United States shows substantial overlap with the practices of physicians in primary care and with those of nonphysician mental health providers. Some of this overlap has resulted out of the necessity to compensate for a general shortage of psychiatrists in the United States. As a result, primary care physicians, nurse practitioners, advanced practice nurses, and physician assistants in primary care write the lion’s share of antidepressant prescriptions in the United States.1 The ascendency of selective serotonin reuptake inhibitors, which are nonlethal in monotherapy overdose, has furthered the ease and comfort level of antidepressant prescribing in primary care. In parallel, primary care physicians prescribe more than 50% of all sleeping pill prescriptions2 and even 20% of atypical antipsychotics.3 In parallel, most psychotherapy is provided by psychologists, not psychiatrists. Even so, among physicians, primary care doctors account for 20% of the psychotherapy in the United States.4 Psychoanalysis, arguably requiring the most demanding training of all the psychotherapies, was conceived by a physician, but many psychoanalytic institutes admit psychologists, social workers, nurses, and laypersons. If antidepressant medications, hypnotics, atypical antipsychotics, and psychotherapy are now routinely handled by nonpsychiatrists, what professional activities remain that are uniquely psychiatric? The most fundamental, unique psychiatric activity is the understanding and diagnosis of disease at the interface of mind and body. The psychiatrist is best poised to identify physical illness as the origin of psychological symptoms and conversely the manifestations of mental illness on somatic function. Whereas the primary care doctor may have a superior understanding of physical illness, the capable psychiatrist is usually familiar with a broader range of mental illnesses. The psychologist may be the equal of the psychiatrist in the scope of mental illness diagnosis but does not have the same education in the appreciation of somatic mimics of psychopathology. Similarly, while the presumed criterion standard for Diagnostic and Statistical Manual of Mental Disorders diagnosis is a structured clinical interview that can be administered by any trained clinician, psychiatrists are trained to develop a more nuanced formulation that takes into account a biopsychosocial perspective. Beyond diagnosis, there is a handful of therapeutics that is best managed by psychiatrists. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), especially when used in full therapeutic doses, should be managed by psychiatrists, for the very reason that there are safer alternatives— selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors—and therefore expert justification is required to explain the utilization of a TCA or MAOI when safer alternatives are available. The use of MAOIs or full-dose TCAs requires a definitive confirmation of the diagnosis of severe depression and the failure of safer alternatives.5,6 Similarly, the use of lithium in the management of bipolar disorder is best handled by a psychiatrist. Expert, accurate diagnosis of bipolar disorder or another lithium-responsive condition is needed to justify exposure to the short- and long-term adverse effects of lithium, and prior experience with lithium is necessary for the assessment and management of lithium adverse effects.7 The metabolic adverse effects of atypical antipsychotics are sufficiently problematic that their use is best justified after an expert diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, or treatment-resistant depression.8 This is particularly true for treatment-resistant schizophrenia when clozapine is under consideration, as clozapine is associated with a significant risk for agranulocytosis.9 Therapeutic brain stimulation therapies, such as electroconvulsive therapy (ECT), also should be given by psychiatrists, based on (1) the need for expert diagnosis of basic mental disorders, (2) familiarity with more unusual psychopathologic syndromes such as catatonia and neuroleptic malignant syndrome, (3) determination of treatment-resistance, (4) expertise in the conduct of the ECT procedure and management of related adverse effects, (5) and so on.10 An audit of ECT in Sweden revealed that most ECT in that country is provided by nurses or nonmedical attendants, but the authors did not approve of this practice.11 In summary, the last-quarter century has seen a diffusion of some traditional psychiatric roles and the adoption of many traditional psychiatric treatments by primary care providers and psychologists. From the Department of Psychiatry and Health Behavior, Georgia Regents University, Augusta, GA. Received for publication February 5, 2015; accepted February 5, 2015. Reprints: W. Vaughn McCall, MD, MS, Department of Psychiatry and Health Behavior, the Medical College of Georgia, Georgia Regents University, Augusta, GA (e‐mail: [email protected]). The author has no conflict of interest or financial disclosures to report. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/YCT.0000000000000233
Journal of ECT • Volume 31, Number 4, December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ectjournal.com
203
Journal of ECT • Volume 31, Number 4, December 2015
Editorial
Still, there are some core activities that remain mostly unique to the practice of psychiatrists. We propose that these include, but are not limited to, the following: • diagnostic acumen at the boundary of mental health and physical health, • prescription of TCAs and MAOIs, • prescription of lithium, • prescription of atypical antipsychotics, especially clozapine, and • provision of all forms of psychotherapeutic brain stimulation, especially ECT.
Others may disagree with this list, or even the basic premise of such a list, but we feel that defining a unique scope of practice for psychiatrists has value for several reasons. First, outlining a unique scope of practice for psychiatrists helps define the value of psychiatry to the patients we serve and to the payers of these services. Second, delineating the unique scope of psychiatry should help psychiatric training programs set priorities for training in the skills that are particular to the field and that cannot be easily substituted by a different discipline. In particular, the psychiatrist’s expertise at the mind-body interface speaks to the importance of training in consultation-liaison practice. These comments should not be construed as reflecting a “standard of care” or “best practices” and instead describe the present state of who provides various mental health services. There will be instances for which providers other than psychiatrist may prescribe a therapeutic from the list above, for example, neurologists who prescribe lithium for cluster headaches or primary care providers or advanced practice nurses who practice in a setting that is at great distances from a psychiatric consultant.
204
www.ectjournal.com
REFERENCES 1. Cascade E, Kalali AHU. Antidepressant prescribing by specialty and treatment of premenstrual dysphoric disorder. Psychiatry. 2008;5:14–15. 2. McCall WV, Fleischer AB Jr, Feldman SR. Diagnostic codes associated with hypnotic medications during outpatient physician-patient encounters in the United States from 1990–1998. Sleep. 2002;25:221–223. 3. Using atypical antipsychotics in primary care. Prim Care Companion J Clin Psychiatry. 2002;4:233–241. 4. Himelhoch S, Ehrenreich M. Psychotherapy by primary care providers: results of a national sample. Psychosomatics. 2007;48:325–330. 5. MacGillivray S, Arroll B, Hatcher S, et al. Efficacy and tolerability of selective serotonin reuptake inhibitors compared with tricyclic antidepressants in depression treated in primary care: systematic review and meta-analysis. BMJ. 2003;326:1014. 6. Shulman K, Herrmann N, Walker S. Current place of monoamine oxidase inhibitors in the treatment of depression. CNS Drugs. 2013;27:789–797. 7. Dols A, Sienaert P, van Gerven H, et al. The prevalence and management of side effects of lithium and anticonvulsants as mood stabilizers in bipolar patients from a clinical perspective: a review. Int Clin Psychopharmacol. 2013;28:287–296. 8. Riordan H, Antonini P, Murphy M. Atypical antipsychotics and metabolic syndrome in patients with schizophrenia: risk factors, monitoring, and healthcare implications. Am Health Drug Benefits. 2011;4:292–302. 9. Warnez S, Alessi-Severini S. Clozapine: a review of clinical practice guidelines and prescribing trends. BMC Psychiatry. 2014;7:102. 10. Lisanby S. Electroconvulsive therapy for depression. N Engl J Med. 2007; 357:1939–1945. 11. Nordanskog P, Hulten M, Landen M, et al. Electroconvulsive therapy in Sweden 2013: data from the national quality register for ECT. J ECT. 2015. In press.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
