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Psychiatric Practice: A March from the Brainless to the Mindless?

When fewer psychiatrists provide psychotherapy, what is the effect on the patient — and on the field of psychiatry?

Psychotherapy has long been considered an essential component of the psychiatrist’s work and is one of the cornerstones of the biopsychosocial model from the 1980s. Many experts still adhere to this model, which emphasizes that psychiatry was the specialty that could best integrate all relevant dimensions of illness. This report of data from a national survey of representative outpatient medical practices from 1996 to 2005 suggests that the psychosocial and biological components of psychiatry are increasingly split.

The investigators surveyed 14,108 visits to psychiatrists involving a psychiatric diagnosis. The percentage of visits with at least 30 minutes of psychotherapy decreased significantly over 10 years from 44% to 29%. For patients with private insurance, the decline was significant (from 50% to 25%), but not for those in publicly funded programs, where the initial percentage was low (Medicare, from 32% to 21%; Medicaid, from 22% to 13%). The percentage was highest among self-paying patients and did not change significantly (from 55% to 59%). In HMOs, the percentage of visits with psychotherapy decreased significantly to a remarkable degree (from 23% to 5%). Overall, the reduction in psychotherapy provided by psychiatrists was attributable to changes in payment sources and increased prescription of medications.

Comment: Third-party reimbursement to psychiatrists is 41% less for one 45-minute psychotherapy session than for three 15-minute "med checks." This model is based on the completely unsupported belief and self-fulfilling prophecy that it is cheaper to split than to combine psychotherapy and medication prescription: Today, psychiatrists in insurance plans cannot afford to provide psychotherapy. Given the pressure to see large numbers of patients briefly and the minimal reimbursement for non–patient-contact activity, true coordination of pharmacologic and psychosocial therapies is rare. This situation, combined with the vigorous marketing of medications to patients and practitioners, is altering psychiatric practice and, perhaps, the psychiatrist’s professional identity. Meanwhile, as psychotherapy becomes less relevant to the actual practice of most psychiatrists, it is evolving into a theoretical topic in residency education.

Scientific practitioners would not defend the older practice of using whatever unstructured and unvalidated approach felt right. However, it is unrealistic to expect that components of care provided by different clinicians will somehow be integrated by the patient, especially since many of the target symptoms for medications overlap those for psychotherapy. Practicing psychiatrists might want to resist this trend before psychiatric practice becomes so technologically driven that it becomes one of the least holistic of specialties.

— Steven Dubovsky, MD

Published in Journal Watch Psychiatry September 15, 2008

Citation(s):

Mojtabai R and Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry 2008 Aug; 65:962.

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