Insight Matters
Spring 2005

EDITORIAL
The Big Difference. (Pass it on!)

Henry A. Nasrallah, M.D., Editor

A good chunk of the public regrettably cannot tell the difference between a psychiatrist and a psychologist. To many, both are simply "shrinks." Until that confusion is corrected, psychologists may continue to make gains in misleading the public [and legislators] that they can provide the same healthcare as psychiatrists. Our challenge is to make it very clear to the public that unlike psychologists, the core identity of psychiatrists is being physicians. The medical knowledge and skills acquired during four years of medical school training are the foundation for our four additional years of medical specialty training as psychiatrists. And that does not only include knowing how to select and prescribe medications, which has been the main focus of attention - it also includes the fundamental pretreatment phases of evaluation and diagnosis.

The DSM-IV criteria explicitly mandates that an underlying medical condition must be ruled out as the possible cause of the psychiatric symptoms before a primary psychiatric diagnosis can be made. If that is not done, then the entire process of treatment will be flawed. Thus, only physicians can truly make a valid differential diagnosis in a psychiatric patient using the standard psychiatric present illness, medical history, family history of psychiatric and medical disorders, review of systems, physical exam (including a neurological exam and mental status exam), then ordering the appropriate laboratory tests and procedures and interpreting their relevance to the psychiatric presentation. This integration is one of the critical skills that psychiatrists have to demonstrate to pass their oral boards. Psychologist's lack of medical training means that they cannot integrate the physical findings with the mental findings to formulate possible medical etiologies to the psychiatric presentation. I have seen patients who received psychotherapy for years from psychologists for mood and anxiety symptoms with no improvement and protracted suffering because their symptoms were due to an endocrine disease, neurologic disorder or iatrogenic etiology not recognized by their therapist. Only when they became suicidal, were they finally referred to a psychiatrist who revised both the diagnosis and treatment plan.

The proper and safe medical treatment of psychiatric disorders also requires the skills of a physician with psychiatric training. The underlying medical condition must be corrected or stabilized. The medications selected to improve the psychiatric disorder must not worsen co-existing medical disorders (cardiac, pulmonary, hepatic, renal, hematological, etc.) and must not have deleterious drug-drug interactions with other medications the patient is receiving (1,2). In fact, psychiatric physicians often identify iatrogenic psychopathology caused by non-psychiatric medications such as antihypertencives, steroids, cancer meds or GI meds. Only a psychiatric physician can integrate general medical knowledge with a specific psychiatric expertise to make, implement and monitor a comprehensive biopsychosocial treatment plan. The long-term maintenance phase of psychiatric treatment is fraught with medical pitfalls that only a psychiatric physician can anticipate, monitor and address. The metabolic, neurological, hormonal and cardiovascular adverse effects of atypical antipsychotic are a good example of the importance of medical knowledge in managing life-long psychopharmacological therapy in chronic psychiatric disorders.

Psychiatrists need to educate the public about these basic differences between two mental health professions that have a few overlapping skills but a great many differences the most profound of which are medical knowledge and skills that are glaringly absent in the training of psychologists. Once the public understands that only physicians can accurately diagnose and competently provide medical management of mental disorders, the efforts of the faction of psychologists who want to get a license to practice medicine via the political process, instead of going to medical school and residency training, will certainly fail. Psychologists can be highly skilled at providing psychiatric patients with various forms of psychotherapy, but not being physicians, they should "do no harm" and refer patients to psychiatrists for the medical management of psychiatric illness.

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