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Survey shows
talk therapy on the decline
(November
2008 Issue)
By Nan Shnitzler
Psychotherapy has been supplanted by medication management during
office visits to psychiatrists, says an analysis published in the
August issue of the Archives of General Psychiatry. The principal
drivers are better psychiatric drugs and the financial incentives
to prescribe them.
Using data from the annual National Ambulatory Medical Care Survey
(NAMCS), authors Ramin Mojtabai M.D., Ph.D., M.P.H., and Mark Olfson,
M.D., M.P.H., found that from 1996 to 2005, office visits involving
psychotherapy declined from 44 to 29 percent. There was also a decline
in the number of psychiatrists who provide psychotherapy to all
their patients from 19 percent to 11 percent. These finding were
gleaned from 14,108 office visits sampled during the 10-year period.
Psychotherapy was provided in 5,597 of them.
The authors, both psychiatrists, wanted to know whether the trend
away from psychotherapy, noted in a similar study between 1985 and
1995, had continued into the next decade.
"Overall, there has been a gradual decline in the provision of
psychotherapy in the United States. Perhaps more important, psychotherapy
provision has not kept pace with the rapid growth in psychotropic
prescriptions," Olfson says. "As a result, each year a larger number
of Americans are receiving prescribed psychotropic medications without
receiving any psychotherapy."
That's not true at the Austen Riggs Center in Stockbridge, Mass.
where the psychiatrists are all therapists providing intensive psychodynamic
treatment, says Marilyn Charles, Ph.D.
"Psychiatrists come here because they have some belief in psychodynamic
therapy with medication as auxiliary to that, rather than the belief
in medication as leading edge," Charles says.
As for the rise in prescriptions, she says it's driven by a quick-fix
society and perpetuated by pharmaceutical companies.
"The amount the drug companies spend on relationships with doctors
is mind-boggling. I know practices that never have to buy themselves
lunch," Charles says. New Hampshire psychologist Sandy Rose, Ph.D.,
says unlike medical professionals, psychologists are trained to
rely less on drugs because they have a repertoire of behavioral
techniques at their disposal. For example, exposure therapy, used
to desensitize a phobic stimulus, works best when a certain level
of anxiety is present, which medication could dampen.
Rose also points out that when psychiatrists are disincentivized
to provide psychotherapy, patients are forced into a split model
of care with medication dispensed from a physician and therapy provided
from a psychologist or social worker. It's less satisfying for the
patient and more costly than an integrated model.
In fact, a 2003 Practice Research Network study documented that
one 45-minute psychotherapy session was reimbursed 41 percent less
than three 15-minute medication management visits.
New Hampshire psychologist Rick Berke, Ph.D., is unhappy about
what he calls the overuse of medications in psychiatry and doesn't
want psychologists to succumb to the same temptation. He uses his
psychiatric affiliations when meds are warranted, but relies on
them less and less in favor of relational psychotherapy and tools
that enhance the quality of the therapeutic alliance.
"The evidence suggests that setting up a therapeutic relationship
that works is the main reason people improve. And it's not dependent
on medication," Berke says.
Outcomes are not measured by NAMCS, an acknowledged limitation
of the study. At the moment, there is little evidence that psychotherapy
provided by psychiatrists is more effective that that provided
by other clinicians to justify the higher cost.
Mojtabai suggests that the next research step should gather longitudinal
data on the effect of treatment patterns on the quality of care.
Results could help pressure insurance companies for more generous
benefits.
"Insurance companies are more concerned about the cost for each
patient," Mojtabai says. "They don't have an incentive to look at
outcomes. That's a fact."
Charles has had success negotiating with managed care.
"Insurance companies vary and the people who work for them vary.
If we can articulate clearly enough our treatment protocol, we can
work with them to do things they might not be at first inclined
to do in terms of their ideas of how treatment should proceed,"
Charles says. "Sometimes you can work it out and sometimes you
can't."
With physicians and nurse practitioners prescribing psychiatric
medications and prescribing psychologists in Louisiana, New Mexico
and the U.S. military providing integrated care, psychiatry is
losing its uniqueness, says Gerald P. Koocher, Ph.D., ABPP, dean
of the School of Health Studies at Simmons College in Boston.
He predicts the demise of psychiatry in the coming decades and
warns psychologists, even as more states adopt prescribing privileges,
to maintain competence in the scientific underpinnings of assessment,
therapies and non-medical interventions that traditionally differentiate
psychology in the mental health canon.
The authors think psychiatry's demise is greatly exaggerated. They
say it's a profession in transition.
According to the National Board of Medical Examiners, the number
of residents matching to psychiatry has gradually increased from
979 in 2004 to 1,013 in 2008, Olfson says, but acknowledges that
the newer generation of psychiatrists is more interested in biological
theories and treatments.
It's a philosophical change, Mojtabai says. Hastening the transition,
psychotherapy-providing psychiatrists, whose patients pay out-of-pocket
or have better insurance, are dwindling.
"There are mandates for residency programs to teach psychotherapy,"
Mojtabai says. "But it's possible that uptake of this mandate is
not very enthusiastic."
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