What or Who Is a Psychopharmacologist?

By Jerry M. Wiener, M.D.

Last week the mother of a patient called to ask whether I would provide a prescription for an antidepressant until she could make an appointment with a "psychopharmacologist" to whom she had been referred by a nonlicensed counselor. About the same time, I read an article by Andrew Solomon in the January 12 issue of the New Yorker in which he described (in dramatic and graphic detail) his struggle with depression, during which his psychoanalyst referred him to a "psychopharmacologist."

These two anecdotes reminded me of how often I hear a psychiatrist referred to as a "psychopharmacologist," as if that was a subspecialty designation. This term is being used by families and patients, other physicians, and frequently by nonphysicians such as psychologists and social workers. But perhaps more significant is that some psychiatrists are designating themselves as "psychopharmacologists."

Is this more evidence of managed care's influence on the identity and practice of psychiatry through its policy that lower-paid non-physicians provide psychotherapy, and psychiatrists are limited to prescribing medications? If so, are psychiatrists too willingly accepting this role and thus allowing external bottom-line forces to reshape the definition of their specialty? Or does this designation represent a significant and growing internal redefinition, splitting off mind from brain, much as some advocacy groups and some leading researchers have promoted?

These questions do not deny that as in every profession there are those who by virtue of training and experience are recognized as experts in one or another aspect of practice and are referred to or consulted in complex or difficult cases. This is the case in psychiatry for both psychotherapy and psychopharmacology, but in other specialties does not give rise to a splitting of the fundamental and core body of skills and knowledge.

In psychiatry, however, this is precisely the implication, since "psychopharmacologist" is a self-designation that carries with it one or more of the following messages:

1. I am an expert in choosing and prescribing medications, but other psychiatrists are not.



2. I prescribe drugs but I do not provide psychotherapy, either because I consider the latter irrelevant and not "scientifically" proved to be effective or I consider it less important and thus adequately provided by a nonpsychiatrist with less training.



3. I am trained in and knowledgeable about medications but not about psychotherapy. (This message needs to be measured against the requirement that residency programs provide training in short-term and long-term psychotherapies and that the certifying exams for psychiatrists are supposed to examine specifically for competence in providing psychotherapy as well as psychopharmacology.)



4. As a "psychopharmacologist" I can receive referrals from psychologists and social workers, et al., and not have to consider, as some data would suggest, that a patient is either more efficiently and effectively treated by one clinician when an integrated combined therapy is indicated. (The argument is made that no data support that combined therapy provided by one person is superior in outcome to therapy provided by two persons for the same diagnosis, but even absent such data, is it not more consistent with common sense and clinical experience that integrated treatment by one professional is preferable to splitting the therapy?)



5. I understand that in the world of managed care and reduced payment for psychotherapy, it is more economically advantageous for me to be a "psychopharmacologist" even if I know that communication between me and the so-called "therapist" will be minimal at best and thus does not constitute optimal treatment.



6. People in other disciplines are as well or better trained than I in providing psychotherapy so it is more efficient and economic that they do so (this rationale falls short when the referral is from another physician) and that I practice as a "psychopharmacologist."

These may not constitute a complete list of the possible implications, but the public does have a right to expect that any psychiatrist who has completed an accredited residency and been certified by the American Board of Psychiatry and Neurology is knowledgeable and skilled in providing appropriate psychotherapy and is prepared to recognize when both medication and psychotherapy are indicated and best provided by a single clinician able to integrate and evaluate the full range of treatments.

At the same time, this is not to ignore at least two caveats-first, that there are trained and certified psychiatrists who have limited their practice to psychotherapy and who have not maintained their skills in psychopharmacology and should work collaboratively with another psychiatrist in managing medication, and second, there are circumstances where a psychiatrist and nonpsychiatrist work closely together, ideally in the same setting, and are able to maintain a clinically meaningful collaboration in the treatment and management of the patient, particularly when an important therapeutic alliance with the nonphysician therapist precedes the referral. Some might add an additional exception within psychoanalysis, which advises against medication management by the analyst because it intrudes into the transference, but this has never been empirically tested and experientially has little if any demonstrated basis.

I previously have proposed that the specialty of psychiatry and the identity of the psychiatrist are inextricably linked to the biopsychosocial model, which proposes that brain and mind cannot be divided off from each other, and that expertise in psychotherapy is as essential as expertise in the biological aspects of mental illness. Ensuring this level of competence in both the neurosciences and psychosocial sciences is the combined responsibility of residency programs, certifying exams, continuing education, our professional organizations, and of course each individual psychiatrist.