The psychologist who prescribes medication and the psychiatrist who didn’t go to medical school

The portrayal of these two types of mental health professional

Close your eyes. Now picture a psychologist. Who do you see?

Odds are it is a bearded man in a button up shirt sitting on a couch. As much as the visuals of that may have real world cred, the details surrounding the character often do not. For example, psychologists are well-trained professionals who play a crucial role in the treatment of mental illness, however they cannot prescribe medication (at least not in North America). They have a PhD in clinical psychology and they offer various types of ‘talk therapy’, exposure therapy (to treat phobias), play therapy (for children) and others. Often times we see them portrayed as cutting off the patient, telling them they are running out of time for the session and handing them a prescription. The goal of these visits is less about diagnosis and mainly about therapy. Therefore such an interaction would not typically occur.

Robin Williams portraying Sean, a psychologist

In actuality, most psychiatric conditions are treated by primary care providers (family physicians, internists or nurse practitioners). This is mainly because of the sheer volume of mental illness in North America, and the relative scarcity of psychiatrists. This relative shortage of psychiatrists is due in part to the 5 years of residency training they undertake after 4 years of medical school. Some sub-specialize and therefore spend an additional 1-2 years after residency to become a specific type of psychiatrist e.g. a child/adolescent psychiatrist.

On screen, when a character does see a psychiatrist, the interview is generally not an abstract discussion on a sofa. It is a clinical interview with pointed questions about establishing symptom patterns and assessing red flags (suicidal or homicidal ideation, psychosis, and others). Ultimately the goal of the visit is to establish the diagnosis and guide course of treatment. More often than not, psychiatric treatment consists of oral medication. In rare cases periodic injections and/or electroconvulsive therapy (ECT) are employed in the medical management of psychiatric illness.

Psychiatrists generally work in hospitals, but like psychologists, do have outpatient clinics where they see their patients. The visits with a psychiatrist are generally shorter in duration – guided by the differing goals the two professionals have. They also both share other commonalities; the commitment to patient confidentiality is the same. This is also portrayed in numerous ways on screen. More on this in a future article.

Additionally, both professionals regularly employ clinical questionnaires in their practice to aide in establishing a diagnosis or assessing symptom severity. The PHQ-9 questionnaire for major depressive disorder is an example of one commonly used in my office.

Although there are certainly similarities in these two professionals, there are important differences that need to be accurately portrayed on screen. For more information feel free to contact me: heydoc@reelmd.com

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