We agree with Resnick (2002, this issue) that appropriately trained psychologists should be allowed to prescribe medication. In fact, most American psychologists would also agree (Sammons, Gorny, Allen, & Zinner, 2000).. However, there is an important issue that has emerged recently that Resnick did not address, which we would like to discuss in this comment, and that is the enormous influence of the pharmaceutical industry's marketing and promotion arm (Healy, 2002A). Wazana (2000) reported that the pharmaceutical companies spend more than $11 billion each year on marketing and promotions, $5 billion of which goes directly to sales representatives. [Furthermore, as Healy noted, one unintended consequence of the post-world war II policy that patients must obtain a prescription to purchase medications has been to dramatically reduce the number of people on whom these dollars are spent.] Wazana (2000) estimates that pharmaceutical industry's spends $8,000-13,000 per year, per physician.

     As folk singer-philosopher Bob Dylan so wisely observed, money doesn't talk, it swears. Pharmaceutical marketing money does have a profound impact on prescribing patterns of physicians. Based on an extensive review of 538 studies, 29 of which were included in the analysis, Wazana (2000) found that drug company-sponsored CME preferentially highlighted the sponsor's drugs, physicians who attended drug company-sponsored CME (including accepting funds for travel or accommodations) increased their prescription of the sponsor's drugs, and meetings with sales representatives of drug companies were associated with changes in prescribing practices including adding the companies medications to the hospital formulary.

     [But above and beyond these issues of influencing prescribing patterns, Healy (2002B) asserted that the drug companies, with the FDA playing a role analogous to that of Arthur Anderson in the Enron affair, subvert the science of pharmacology. If this allegation is true, it would most certainly call for reform on the broadest scale, addressing not only psychoactive drugs, but rather all drugs. These reforms would have to go beyond the management of conflicts of interests in the conduct of clinical trials (Morin, et al., 2002) to their outright regulation. ]

     Healy (2002B) goes further to assert that not only do drug companies subvert the science, but, as patents run out and the companies shift over to marketing new drugs, they "change the mindset of the clinician", getting them "to recognize depression where they had formerly recognized anxiety", in the case of the shift from benzodiazepine anxiolytics to the SSRI's.

     This scenario actually has some face validity, since over 80% of psychoactive drugs are prescribed by primary care physicians (DeLeon & Wiggins, 1996) who have minimal training in the diagnosis and treatment of mental illness, which does not augur well for their being able to conduct the first prerequisite for prescribing, namely making an accurate diagnosis. And the data suggests that they don't. Primary care physicians have been shown to miss the diagnosis of depression in women 30-50% of the time (McGrath, Keita, Strickland, & Russo, 1990). Moreover, the Agency for Heath Care Policy and Research noted that "depression is underdiagnosed and undertreated, especially by primary care and other nonpsychiatric practitioners, who are, paradoxically, the providers most likely to see these patients initially" (AHCPR, 1993, p. v).

     On the other hand, clinical psychologists obtain more training in the identification of mental disorders and illnesses than any other health care practitioner, including psychiatrists. It has been our strong and oft-stated conviction that fundamental differences in the training of psychologists and physicians will ineluctably alter the prescribing practices of psychologists. Psychologists' training is rooted in behaviorism and cognitive processes and not in the biologic/allopathic roots of medicine. This will, we believe, provide the profession with a unique understanding of the limits of pharmacotherapy and will provide partial insulation against the marketing efforts of pharmaceutical firms.

     The major argument for psychologists prescribing is that it would improve public health (DeLeon, Sammons & Sexton, 1995). Equally powerful is the continuity of care argument and the fact that outcome research has demonstrated that the most effective treatment for many mental health disorders is a combination of psychotherapy and medication (Sammons & Levant, 1999). Allowing appropriately trained psychologists to prescribe medication will result in increased continuity, integration, and quality of patient care. Patients who are treated by prescribing psychologists will need to see only one doctor for all of their mental health treatment and will be spared the expense, burden, and inefficiencies of seeing a psychiatrist or primary care physician solely for the purpose of receiving medications. There is also the argument of precedent. Many non-MD health professionals currently prescribe safely (e.g., osteopaths, podiatrists, dentists, advanced nurse practitioners, optometrists, physician assistants), and their services are highly beneficial to the public. Fortunately, the only thing as constant as organized medicine's warnings about impending disaster if one profession or another is granted prescription privileges, is the consistency with which state legislatures have batted away these arguments.

Reference

Agency for Health Care Policy and Research (1993). Depression in primary care: Volume 2. Treatment of major depression. Clinical practice guidline: Number 5. (AHCPR Pub. No. 93-0551). Washington, DC: U.S. Government Printing Office.

DeLeon, P. H., Sammons, M.T., & Sexton, J.L. (1995). Focusing on society's real needs: Responsibility and prescription privileges? American Psychologist, 50, 1022- 1032.

DeLeon, P. H., & Wiggins, J. (1996). Prescription privileges for psychologists. American Psychologist, 51, 225-229.

Healy, D (2002A). The Creation of Psyhcpharmacology. Cambridge, MA: Harvard University Press.

Healy, D. (2002B). Psychopharmacology 102 (…what they neglected to mention in psychopharmacology 101). The Clinical Psychologist (in press)

McGrath, E., Keita, G. P., Strickland, B. R., & Russo, N. (Eds.) (1990). Women and depression: Risk factors and treatment issues: Final report of the APA national task force on women and depression. Washington, DC: American Psychological Association.

Morin, K., Rakatansky, H., Riddick, F. A., Morse, L. J., O'Bannon, J. M., Goldrich, M. S., Ray, P., Weiss, M., Sade., R. M., & Spillman, M. A. (2002). Managing conflicts of interest in the conduct of clinical trials. Journal of the American Medical Association, 287, 20-26.

Sammons, M. T., Gorny, S., Allen, R., & Zinner, E. (2000). Prescriptive authority for psychologists: A consensus of support. Professional Psychology: Research and Practice, 31(6)

Sammons, M. T., & Levant, R. (1999). Combined psychosocial and pharmacological treatments: Introduction. Journal of Clinical Psychology in Medical Settings, 6, 1- 10. Wazana, A. (2000). Physicians and the pharmaceutical industry: Is a gift ever just a gift? Journal of the American Medical Association, 283, 373-380

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