Psychopharmacology in psychiatric practice

Most psychiatrists use medicines routinely in their clinical work. This is based on a substantial body of research – randomised controlled trials synthesised in meta-analyses, systematic reviews, and practice guidelines – which together show that contemporary psychotropic medications are effective, acceptably safe when used carefully, and helpful in the management of many disorders. We assume it is not disputed that anyone prescribing should know the indications and contraindications of each drug and their effects, adverse effects and interactions. Expertise should include not just the practicalities of prescribing and the evidence on which it is based, but also knowledge of the essentials of drugs’ mechanisms of action and the relevant underlying science. After all, no one is expected to do psychotherapy without a sound grounding in the theory as well as in the practice.

In this context, the time is ripe for a review of the level of psychopharmacological knowledge and skills which psychiatrists have and which they should be expected to have. The Royal College of Psychiatrists has been largely silent on this matter. In the 58-page Roles and Responsibilities of the Consultant in General Adult Psychiatry, ² just two lines are devoted to psychopharmacology: ‘detailed knowledge and understanding of risks and benefits; wide experience of application of such treatments’. (It is also interesting that risks are highlighted before benefits.) There would seem to be considerable room for improvement in terms of using psychotropic drugs with maximal effectiveness and safety, ^{Reference Maidment, Lelliott and Paton3,Reference Procyshyn, Barr, Brickell and Honer4} including issues of excessive dosing and polypharmacy ^{Reference Paton, Barnes, Cavanagh, Taylor and Lelliott5} and inadequate monitoring. ^{Reference Barnes, Paton, Hancock, Cavanagh, Taylor and Lelliott6,Reference Collins, Barnes, Shingleton-Smith, Gerrett and Paton7} More difficult to measure, but also important, is the extent to which drug treatment is discussed with, and offered to, patients in line with National Institute for Health and Clinical Excellence (NICE) and other evidence-based guidelines. A further reason to advocate a greater and career-long emphasis on skills in psychopharmacology is that competence in this area is likely to become a key issue for appraisal and revalidation: drugs have the potential to cause serious harm, and drug treatment provides a number of objective and readily auditable indices. Demonstrable expertise should be expected not only in the adherence to treatment guidelines but, importantly, in competence in using drugs in more complex cases – including combinations and off-label uses – when guidelines do not exist or where deviation from them is indicated. ^{Reference Baldwin and Kosky8} Finally, the potential for medication-related litigation – for errors of omission and of commission - should not be overlooked.

Although medication plays a lesser role in some subspecialties and posts, patients and carers should be entitled to expect that all psychiatrists have up-to-date knowledge of and balanced views about the role of drugs. Equally, a focus on psychopharmacology in no way diminishes the contribution of psychological and social treatments, nor the importance of the relationship between psychiatrist and patient. Indeed, particular skills in this regard are needed to ensure informed consent and promote treatment adherence. ^{Reference Cowen9}

Psychopharmacology in psychiatric training

The foundation for psychopharmacological expertise among consultant psychiatrists is adequate teaching and exposure during training. The limited pharmacological knowledge of newly qualified doctors ^{Reference Likic and Maxwell10} highlights the need for this postgraduate education to be substantial and rigorous. The new core curriculum for psychiatry mentions psychopharmacology once in its 50 pages: ‘Show a clear understanding of physical treatments including pharmacotherapy, including pharmacological action, clinical indication, side-effects, drug interactions, toxicities, appropriate prescribing practices, and cost effectiveness; electro-convulsive therapy and light therapy’ (p. 29). ¹¹ We question whether this succinct statement, buried among over 200 other core competencies, is adequate for such a key area of clinical practice.

The crux of the matter is whether psychiatrists complete their training with sufficient clinical psychopharmacological competence. Anecdotally, we have our doubts, although we are not aware of good evidence. If there is a problem, it is not the fault of trainees: one manifestation of the lack of emphasis given to psychopharmacology is that the teaching provision is often limited or difficult to obtain. The only well-established, non-industry supported courses in the UK that we are aware of are those run by the British Association for Psychopharmacology, and they are oversubscribed and do not cover the whole syllabus. Most trainees presumably rely on the teaching provided by their local MRCPsych course (which may or may not be sufficient), independent learning, and following the practice of senior colleagues.

If psychopharmacology is to be an important component of what psychiatrists do, it requires a corresponding degree of prioritisation during training. The current situation appears to be unsatisfactory; at the very least, it merits review. This should include clarification as to where responsibilities lie for determining the psychopharmacological knowledge and skills expected, and for delivering the training – the latter applies to medical student teaching as well as to psychiatric trainees.

Psychiatry without psychopharmacology?

Some might disagree with the premise that psychopharmacology should be a core, prominent attribute of psychiatrists. The alternative position is tenable if one believes (for ideological or other reasons) that drug therapy has only a peripheral or limited part to play in mental healthcare, or if others are expected to do the prescribing.

One could advocate, for example, for the emergence of a small number of specialist psychopharmacologists who would provide a service for patients who require complex, unusual or potentially toxic drug regimens, or whose treatment is complicated by medical comorbidity. For all other patients, prescribing could be done algorithmically by their general practitioner, in liaison with mental health teams which would deliver psychological and social interventions. However, we view this option as undesirable. First, although not formally evaluated, the experience of an exclusively psychopharmacological role for psychiatrists in the US community mental health centres was unsatisfactory both for the clinicians and the centres; ^{Reference Talbott, Clark, Sharfstein and Klein12} similarly, utilising the psychiatrist as an available but otherwise disengaged psychopharmacology expert was not favoured by successful home-based treatment services. ^{Reference Wright, Catty, Watt and Burns13} Second, the ‘specialist psychopharmacologist’ scenario could have significant ramifications for the future of psychiatry. Elsewhere in medicine, prescribing is one of the defining characteristics of a doctor: ‘for most doctors, prescribing a medicine is the most significant action they will undertake in patient care’ (p. 24). ¹⁴ Clearly, it is not the sole one, nor in the era of nurse prescribing is it an exclusive one, nor in psychiatry does it have this therapeutic pre-eminence. But several of the other roles of a doctor taken for granted in other specialties, such as clinical leadership and working within an explicit medical model, are also contentious within psychiatry. ^{Reference Craddock, Kerr and Thapar1,Reference Shah and Mountain15,Reference Craddock, Antebi, Attenburrow, Bailey, Carson and Cowen16} The widespread shift towards the physical health of psychiatric patients (except in-patients) becoming de facto the responsibility of primary care removes another reason for all psychiatrists to be medically trained. Without psychopharmacology expertise as one of the central characteristics of our specialty, the case is further weakened. In turn, the number of psychiatrists required, and their perceived value and status – financial and otherwise – could be open to debate. This scenario might have been unthinkable in the past – although the issue has been raised in various guises over the years ^{Reference Kessel17–20} – but the National Health Service and other healthcare systems in years to come will have no such qualms. A similar conclusion, that ‘we are ripe for culling, to be replaced by fitter, cheaper health professionals’ was also recently reached – ironically, referring to medical psychotherapists. ^{Reference Denman21}