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Part 3: Prescription process

Who can prescribe psychiatric medications?

There are four groups of people who can prescribe psychiatric medications: (1) psychiatrists, (2) primary care doctors or any physician with a valid medical license, (3) physician's assistants (PAs), and (4) nurse practitioners (NPs) (Note: Most states do not allow psychologists to prescribe medications, but there are exceptions, e.g., Illinois, Louisiana, and New Mexico.). [1]

Psychiatric patient work flow

The flowchart below shows the internal process of how healthcare systems handle incoming patients. There are three processing points where psychiatric medications can be prescribed: (1) initial assessment, (2) in-patient assessment, and (3) out-patient assessment.

In-patient and out-patient assessments are typically done by psychiatric specialists, while initial assessments are often done by primary care or urgent care physicians. It is unknown how well primary care physicians are trained in psychiatric evaluations. A recent report shows that 80% of antidepressants were prescribed by non-psychiatric specialists without any accompanying psychiatric diagnosis. [2]

Psychiatric evaluation

Before prescribing medications, your doctor should perform a thorough psychiatric evaluation. According to the guidelines published by the American Psychiatric Association, evaluations are complex, time-consuming, and "involve a systematic consideration of the broad domains described in the guideline and vary in scope and intensity." [2] The domains described in the guideline are listed below, illustrating the complexity and resource-intensive nature of psychiatric assessment.

Reason for the evaluation
History of the present illness
Past psychiatric history
History of alcohol and other substance use
General medical history
Developmental, psychosocial, and sociocultural history
Occupational and military history
Legal history
Family history
Review of systems
Physical examination
Mental status examination

Functional assessment
Diagnostic tests
Information derived from the interview process

Use your doctor as your support system

People often talk about support systems. They are typically referring to friends and family members who stand behind and help them by understanding their special circumstances. Because your doctor is the one who understands the biomedical aspects of your health and may advise you to take medications and/or supplements, your doctor is a big part of your support system.

In order to maximize the value and minimize the risks of medications, work with your doctor to:

discuss options other than medications—for example, therapies or self-help,
set clear, reasonable expectations for outcomes and the risks of using medications, and
stay connected and informed of any changes or developments in the medications you take.

[1] Types of Mental Health Professionals. Mental Health America. Retrieved on May 13, 2016. Link

[2] Mojtabai R. Olfson M. Proportion Of Antidepressants Prescribed Without A Psychiatric Diagnosis Is Growing. Health Affairs. 2011;30(8):1434-1442. Link

[3] Practice Guideline for the Psychiatric Evaluation of Adults. Second Edition. American Psychiatric Association. June 2006. Link