Sunday, September 07, 2008

HEALTH: Psychiatrists Are Prescribing More Pills, Less Therapy

(previously published here at

With Sigmund Freud and HBO's popular series "In Treatment" featuring a psychiatrist and his patients, it seems a safe bet that paying someone to analyze your life is still a strong option.

However, a new report published in the Archives of General Psychiatry this Monday reveals that fewer psychiatrists are providing psychotherapy to patients during office visits, instead prescribing drug therapy - medication - at increasing rates.

According to the researchers, the trend appears to be linked to there being fewer trained psychiatrists, the marketing of improved psychiatric drugs and pressure from managed care companies that offer incentives for prescribing drugs over giving the more expensive psychotherapy.

"Psychiatrists get [paid] more for three 15-minute medication management visits than for one 45-minute psychotherapy visit," said Dr. Ramin Mojtabal, who co-led the research at Beth Israel Medical Center in New York, and who now works at Johns Hopkins Bloomberg School of Public Health in Baltimore.

"I was trained almost 30 years ago and received a lot of training in psychotherapy," said Dr. Christopher C. Colenda, a psychiatrist and Dean of Medicine at Texas A&M Health Science Center College of Medicine. "Thanks to the advances of managed care, psychotherapy was basically devalued from the perspective of psychiatry. ... A lot of the incentives for wanting to be in psychiatry were essentially removed by managed care."

The study examined data from the National Ambulatory Care Survey on visits to psychiatrists' offices for a 10-year period between 1996 and 2005, finding that the proportion of visits over 30 minutes long dropped from 44 percent in 1996-1997 to 28.9 percent in 2004-2005. Overall, out of 14,108 visits, only 34 percent provided psychotherapy to patients.

The number of psychiatrists who provided psychotherapy to all patients also fell, from 19.1 percent to 10.8 percent during the same 10-year period. Those who chose to continue psychotherapy had more patients who paid out-of-pocket for treatment than other doctors who gave less talk therapy.

For patients who require a combination of talk therapy and drug therapy, the trend towards medication-only can result in spotty treatment, in which the patient receives psychotherapy from a psychologist and drugs from a psychiatrist or general practitioner.

Physicians differ in their opinions over whether this is a problem.

"Whether it has any impact on the outcome of the disorder, we don't really know," said Dr. Mojtabal to Reuters. "I don't think necessarily that it is harmful. It might not be as efficient."

However, Dr. Eric Plakun, who leads an American Psychiatric Association committee working to restore interest in psychotherapy by psychiatrists, told Reuters that a shift away from psychotherapy began about 10 years ago when medical schools began to focus more on the biology of mental illness than on its psychology and behavior. "Either way, I'm worried about our patients [who] need the best help we can give them."

So is this the end of psychotherapy? Perhaps not, as it is effective and less expensive, and if you look deeper, there are signs that the use of talk therapy will continue and is, in fact, on the rise.

Since its benefits are well documented via behavior changes, emotional and mental habits, as well as through brain imaging studies, whether alone or combined with drug therapy, "the couch is far from dead," Dr. Plakun said. "The couch turns out to be an effective 21st century treatment."

Accreditation requirements for psychiatric residency programs are also putting more emphasis on talk therapy, so future medical professionals have the appropriate background to keep it alive.

Various forms are the recommended form of treatment for depression, post-traumatic stress disorder, bipolar disorder and other psychiatric illnesses.

In addition, visits to psychologists, social workers and other mental health counselors, who also provide talk therapy but are not medical doctors - and thus cannot prescribe drugs - were not included in this research.

Heather J. Chin can be reached at

©The Evening Bulletin 2008

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