Unlocking The Pill Bottles

By ANDREW PURVIS

Psychiatrists were once the power brokers of mental health care. With full medical-school training and M.D.s after their names, they controlled the prestigious institutes of Freudian psychoanalysis. They determined whether patients would be committed to mental hospitals. And they had the exclusive right to prescribe mind-altering medications. But in the past several years psychologists, who have Ph.D.s but no medical school on their resumes, have been chipping away at the psychiatrists' domain.

Now psychologists are poised to grab a share of perhaps the biggest professional prize: prescribing drugs. This fall a pair of psychologists at the Walter Reed Army Medical Center in Washington began selecting and dispensing medications to a handful of patients in an experiment to see if novice prescribers can do the job safely and effectively. The test marks the first time in the field of mental health that non-M.D.s have been permitted to prescribe medication. Last week the American Psychological Association showed its confidence that the experiment will be a success by appointing a study group to explore university curriculum changes that would teach psychology students the art of prescribing.

The push to give prescription privileges to psychologists has intensified tensions between the two groups of mental health professionals. Psychologists insist that the initiative is the only way to get valuable medications to all those who could benefit from them. Psychiatrists and many other doctors contend that granting such powers to people without adequate training is irresponsible and possibly dangerous. Says Dr. Carolyn Robinowitz, deputy medical director of the American Psychiatric Association: "We're talking about patients and their lives. I just hope people don't suffer serious complications for the sake of proving a point."

At the heart of the dispute is the groundbreaking experiment at Walter Reed. Two clinical psychologists who recently earned their Ph.D.s are beginning an on-the-job training course that could last up to two years. They will prescribe pills for a broad range of conditions, from hyperactivity to manic depression. At the end of the trial period, independent experts will evaluate the students' performance and make recommendations to Congress on whether the program should be expanded for general use. The initiative was proposed by Senator Daniel Inouye of Hawaii, whose administrative assistant, Patrick DeLeon, is an American Psychological Association board member. Ostensibly, the study aims to explore ways to deal with physician shortages in the armed services. But several state legislatures are watching the experiment to determine whether psychologists in their regions should have the right to prescribe.

Such an expansion of privileges would not be without precedent. Dentists and podiatrists have always prescribed some medications. And other non-M.D.s, including pharmacists, physician's assistants and nurse practitioners (registered nurses with some advanced training) have been granted at least limited privileges -- either for a restricted number of drugs or under close supervision by physicians -- in many states. Nurse practitioners can now prescribe in 34 states, up from 28 last year.

But psychologists are in a different league, many doctors maintain. In particular, says the A.P.A.'s Robinowitz, psychoactive medications are often more powerful than the drugs prescribed by other non-M.D.s. The tranquilizer Haldol, for example, acts not only on the brain but also on the cardiovascular system and the liver. Occasionally the medication can cause jaundice, severe skin problems and abrupt drops in blood pressure. Prescribers need to be able to spot problems wherever they may occur, not just those that show up in psychological disorders, says Robinowitz. There is also the danger of drug interactions. It is important to know not only which combinations of medications should be avoided but also how a particular drug might affect some pre-existing medical condition. Predicting and detecting such problems, argues Dr. John Tupper, president of the American Medical Association, "is not something one learns in a quickie course." Tupper and others believe that only full medical-school training could prepare psychologists to prescribe drugs safely. "There is no shortcut," he says.

The American Psychological Association contends that the medical establishment is overestimating the difficulty of selecting drugs. Bryant Welch, executive director of professional practice at the A.P.A., claims that doctors rely on such readily available manuals as the Physicians' Desk Reference and background materials provided by the drug companies when deciding what to prescribe. "Psychiatrists would have you believe that they go in and learn chemistry and biology and anatomy and from that they independently figure out what all the adverse reactions are going to be," says Welch. "I don't believe you'd find 5% of the medical community who use that scientific training." Welch argues that permitting psychologists to prescribe drugs would help make up for the serious shortages of qualified psychiatrists in the rural U.S. and many state hospitals.

Psychologists maintain that they are eager to prescribe because medication is an increasingly powerful tool for relieving mental illness. But some critics see an ulterior motive. They contend that what the two professions are really concerned about is profits. In fact, psychiatrists have reason to worry. From 1982 to 1987, according to one poll, the proportion of counseling visits handled by psychiatrists fell from 36% to 22%, while those by psychologists rose from 29% to 34%. This summer Washington loosened psychiatrists' grip on treatment of the elderly by permitting psychologists to receive reimbursements from Medicare. In addition, the California supreme court undercut psychiatrists' authority by allowing psychologists to admit patients to the state's hospitals.

Both psychiatrists and psychologists insist that their main concern lies not with their pocketbooks but with their patients' welfare. If that is true, then experiments like the one at Walter Reed will settle the debate over who should prescribe psychoactive drugs. But if power and profits are the real issues, the battle between the two sides could go on for a long time.