Managing the Impact of Prescribing Privileges on Psychological - - PowerPoint PPT Presentation

Managing the Impact of Prescribing Privileges on Psychological Practice

Daniel J. Carlat, M.D.

Affiliations/Disclosures

• Associate Clinical Professor of Psychiatry

Tufts University School of Medicine

• Publisher and Editor in Chief,

The Carlat Psychiatry Report (www.thecarlatreport.com)

• No financial relationships with

pharmaceutical companies

Outline

• My background and how I came to support

prescription privileges for psychologists

• General suggestions for how to be a good

integrative practitioner

• Specific clinical recommendations

How a nice Jewish boy turned into a turncoat psychiatrist and endorsed the RxP movement

How I ended up writing this book

Mnemonic for DSM Major Depression

SIGECAPS (4/8 + poor mood or anhedonia) Sleep Psychomotor Interest Suicidality Guilt Energy Concentration Appetite

DSM-5. Washington, DC: American Psychiatric Association; 2013.

Don’t be This Clinician

A Profession in Crisis

• A Shortage of Prescribers
• Psychiatric Treatment = Split Treatment
• Doubts about efficacy of

psychopharmacology

• Manipulation of doctors by drug

companies

• How do we fix psychiatry?

Responses to Unhinged

Responses to Unhinged

Integrative Treatment

• “Tranquilizers and psychotropic drugs

serve as a life jacket--they keep you afloat, but they do not show you the way back to shore."

Ingeborg Van Pelt, “Where Is the Hurt? How Do We Help?” Clinical Psychiatry News 37 (6) (2009):10

Trends in Psychotherapy by Psychiatrists

• 1997: 44% of psychiatric visits included

therapy; 19% provided therapy to all patients

• 2005: 29% of visits included therapy; 10%

provided therapy to all patients

• Mojtabai R and Olfson M, National Trends in Psychotherapy by Office-

Based Psychiatrists, Arch Gen Psychiatry. 2008;65(8):962-970

Combination vs. Meds only

• 1998

– Meds + Therapy: 40% of patients; – Meds only: 44% – Therapy only: 16%

• 2007

– Meds + Therapy: 32% of patients; – Meds only: 57% – Therapy only: 11%

• Olfson and Marcus, National Trends in Outpatient Psychotherapy, Am J

Psychiatry August 4 2010, AJP in Advance

Strategies to Enhance Integrative Treatment

• 1. Understand your patients’ expectations
• 2. Rapidly narrow down the diagnosis
• 3. Determine the most promising medication

possibilities

• 4. Determine the most promising therapy

techniques

• 5. Decide how to combine these

Rapid Diagnosis

• 1. Start with open ended questions
• 2. After 5 minutes, you should have 4

diagnostic hypotheses

• 3. Investigate hypotheses with screening

and probing questions

Diagnostic Mnemonic

Depressed Patients Sound Anxious, So Claim Psychiatrists

• 1. Depression and mood d/o’s
• 2. Psychosis
• 3. Substances
• 4. Anxiety
• 5. Somatic
• 6. Cognitive
• 7. Personality

Most Promising Meds

• 1. Depression…Bupropion, SSRIs, etc

Bipolar…Lithium, lamotrigine, atypicals

• 2. Psychosis…Low side effect atypicals
• 3. Substances…Naltrexone, acamprosate,

Suboxone

• 4. Anxiety…SSRIs/SNRIs, benzos
• 5. Somatic…Few choices
• 6. Cognitive…Aricept et al.
• 7. Personality…Few choices

Promising Psychotherapy Techniques

• 1. Cognitive Behavioral Therapy
• 2. Psychodynamic therapy
• 3. Dialectic behavioral therapy
• 4. Motivational interviewing
• 5. Psychoeducation
• 6. Family therapy
• 7. Misc: hypnosis, relaxation, pet therapy,

doll therapy, etc….

PTSD

• Meds: SSRIs, prazosin
• Therapy:

– Cognitive restructuring – Exposure – Imagery rehearsal

Anxiety Disorders

• Meds: Almost everything
• Therapy:

– Exposure hierarchy – Breathing retraining

Schizophrenia

• Meds: A range of antipsychotics
• Therapy:

– Hallucination coping – Attribution shifting – Compartmentalizing symptoms – Talking back to the voices – Enlist a support network

Substance Use Disorders

• Meds: Naltrexone, acamprosate,

Suboxone, Antabuse

• Therapy:

– Motivational interviewing – DBT – Encouraging 12 step program participation

Questions/Discussion

• To contact me:

Daniel.carlat@gmail.com

• Website:

www.thecarlatreport.com