What are the qualifications required for a physician to be competent in diagnosing and treating children and adolescents with psychiatric problems?

    A physician must be fully-trained in general psychiatry and have 2 additional, post-doctoral years of formal training in a child and adolescent psychiatry training program that is approved by the Accreditation Council for Graduate Medical Education (ACGME), and recognized by the American Board of Psychiatry and Neurology, inc and by the American Board of Medical Specialties (ABMS). Click here for ACGME training requirements.

    General psychiatry training simply does not offer the years of special child and adolescent training and experience necessary to understand children and adolescents’ issues, family interactions, and their potential forensic issues.

Can psychiatrists without formal training in child and adolescent psychiatry diagnose and treat children and adolescents?

    A handful of psychiatrists have training in adolescent psychiatry, who are qualified to prevent, diagnose and treat mental disorders in adolescents (but not children), however these are rare exceptions (ACGME approved programs have only existed briefly in the past).

    The American Society for Adolescent Psychiatry (ASAP) provides Continuing Medical Education (CME) credits (approved by the ACGME) for physicians, primarily psychiatrists, and other mental health professionals, which improve their ability to recognize, diagnose and manage psychiatric conditions in adolescents and young adults. Psychiatrists may also receive certification through ASAP in adolescent psychiatry.

   

What is the difference between a psychiatrist and a psychologist?

    Even thought they are commonly confused in the media, the general public, and even by other professionals, they are very different in terms of their qualifications, training and scope of practice. One of the factors contributing to the confusion is that individuals trained in both disciplines are qualified to provide psychotherapy (talk therapy), and they both begin with “psy”.        

    Psychiatrists are physicians (Doctors in Medicine, or MDs), who have 4 additional post-doctoral years of  training in the prevention, diagnosis, assessment, and treatment of patients with mental disorders in the context of their biological, psychological and sociological configurations. Their training has to comply with the ACGME requirements in order to be eligible to be certified in General Psychiatry by the ABPN and the ABMS.

    Psychologists are not MDs, but rather Ph.D.s or Psy.D.s. They have doctoral training in psychology, and are qualified to administer psychological tests and to do psychotherapy.

Can psychiatrists and psychologists prescribe medications?

    The short answer is that only Doctors in Medicine, ie. psychiatrists, are adequately trained to prescribe medications (including psycho-pharmachological agents, also known as psychotropics).

    Traditionally, since Hippocratic times, only those trained in the art/science of Medicine have knowledge of the biological/physiological effects of medications in humans.

    Psychiatrists have the medical background and a comprehensive understanding (as comprehensive as the advancement of science allows us) of how chemical agents (including medications, non-biological substances, toxic agents, and drugs) interact with the human body. All medications affect multiple organs and systems in humans. The body absorbs, distributes, metabolizes and eliminates all medications.    

    Medications have specific target organs and work by modifying the cell or chemical function of the organ. In psychiatry the target cells are located in the brain. The brain is an exquisitely complex and sensitive organ (arguably the most complex organ in the body). The medications that psychiatrists prescribe work by manipulating the brain’s functioning (physiology).

    An important question  to consider is that, in the unfortunate situation in which a person (yourself, a family member or someone close to you) suffers from a psychiatric illness, derived from a problem in their brain’s functioning, which could be correctible with medications; who would you trust to be competent in evaluating the need for the medicine, recommending the medicine, and prescribing & monitoring the side effects of the medication? Who would you trust to provide pertinent information in order for you to make an informed decision to consent or refuse treatment?

    Although many psychologists are attempting to obtain legal rights (as other non-medical disciplines have) to prescribe medications, their training simply does not include the core medical knowledge to understand and to be competent to prescribe medications in general, much less psychiatric medications.

    The required knowledge derives from comprehensive knowledge in anatomy, physiology, pharmacology, biochemistry, histology, pathology, embryology (medications may affect fetal development), and experience in other medical disciplines which are also part of the core curriculum to be a Doctor in Medicine (ie. Internal Medicine, Family Medicine, Obstetrics and Gynecology, Pediatrics, Surgery, and others). In addition, psychiatrists undergo a rigorous immersion in clinical psycho-pharmachology (use of psychiatric medications) during the 4 years of post-doctoral training.  

    Non-medical disciplines lack this knowledge and clinical experience in using psychiatric and non-psychiatric medications. Most psychiatric medications have interactions with non-psychiatric medications (ie. cardiological, endocrinological, gastroenterological, neurological agents, etc. and antibiotics, contraceptives, blood-thinners, blood pressure medications, cholesterol and lipid correction medications, etc). Lack of this knowledge could cause a patient to have serious and/or permanent side effects, ie. Tardive Diskenesia, Neuroloptic Malignant Syndrome, Steven-Johnson’s syndrome, liver damage, kidney damage, heart arrhythmia (Torsades de Points, QTc prologations), metabolic and endocrinological alterations, etc, and even death.

    Even if legislation allows non-medical disciplines to prescribe medications, this does not mean that they have the training to be competent to do so.

    For more information on this issue please refer to the American Psychiatric Association (APA) website, and the multiple articles in the Psychiatric News.

What is a Forensic Psychiatrist?

    A forensic psychiatrist is a medical doctor with specialized expertise in psychiatric-legal issues. Since 1992 it became recognized by the ABMS as a medical specialty. Since then forensic psychiatrists must undergo post-doctoral training in a Forensic Psychiatry  Program to be eligible for board certification.  Before 1992 forensic psychiatrists was could be either formally trained or simply by developing the special skills and expertise needed, on their own. However, once recognized as a specialty, already practicing forensic psychiatrists who were able to demonstrate knowledge and ability in this field grandfathered into being recognized by the ABPN and ABMS. The first exam for board certification was administered in 1994.

    Forensic psychiatrists must fulfill the ABPN core competency requirements and at the end of the training are eligible to be board certified by the ABPN and  ABMS. To be eligible for training in forensic psychiatry, candidates must have successfully completed at least 4 years of post-doctoral training in an ACGME accredited program in general psychiatry.

    Some of the activities they are qualified to do include (but by no means limited to) court expert witness testimony; provide consultation to the Courts, attorneys, hospitals, ethical-legal committees, and other physicians; evaluate defendants for criminal responsibility, and a series of competencies (to stand trial, to refuse treatment, to enter a plea bargain, to waive Miranda Rights, to be executed, etc); evaluate plaintiffs and defendants in civil cases (i.e. medical malpractice claims, insurance disability claims, competencies to enter contracts, to get married, to  write a will, etc); and, in the case of those who have special expertise in children and adolescents may do evaluations of children/adolescents and their families (i.e. provide expert witness testimony in Child Custody cases, termination of parental rights, insurance disability, criminal responsibility, and competencies in this special population).

What is Forensic Psychiatry?

    It is a medical subspecialty that focuses on the overlapping  psychiatric issues with civil, criminal and administrative law. This subspecialty also focuses on the evaluation and treatment of individuals involved with the legal system, incarcerated in jails, prisons, and forensic psychiatry hospitals.

Is a forensic psychiatrist the same thing as a forensic psychologist?

    Please read above answer to question about how psychiatrists and psychologists are different. Similar answer applies when acting as forensic experts. They can each provide expert witness testimony, and diagnosis/treatment of forensic patients in accordance to their scope of practice.

     For instance, a psychiatrist can provide an expert opinion about the use of psychotropic medications, standard of care of psychiatric patients, and provide an opinion to a reasonable degree of medical certainty. Psychiatrists are physicians with specialty training in the prevention,  understanding, diagnosis, and treatment of mental disorders. These includes biological evaluations and treatments (such as interpreting laboratory tests, need for consultation with other medical disciplines, and prescribing medications), psychotherapy, and family & social issues.

    Doctoral-level (e.g., Ph.D., PSY.D.) psychologists are professionals who are competent as (non-medical) expert witnesses and clinicians in their own right, and may have expertise in topics not usually studied in detail by psychiatrists (such as psychological testing).

© M. Lopez-Leon, M.D. 2006-2008, All rights reserved.