As we reported earlier today, psychiatrists are doing less psychotherapy than they were a decade ago:
Over the 10-year period, psychotherapy was provided in 5,597 (34 percent) of 14,108 visits lasting longer than 30 minutes. The percentage of visits involving psychotherapy declined from 44.4 percent in 1996-1997 to 28.9 percent in 2004-2005.
“This decline coincided with changes in reimbursement, increases in managed care and growth in the prescription of medications,” the researchers write.
The number of psychiatrists who provided psychotherapy to all of their patients also declined over the same time period, from 19.1 percent to 10.8 percent.
This is not a surprising finding, given that psychiatry as a profession has enjoyed a general, progressive decline over the past 4 decades. At the start of the 1970s, over 11% of medical students chose psychiatry as their medical specialty. By 1980, that number had been cut by more than half, to under 5.5%. Nearly 14 years later, in 1994, only 3.2% of U.S. medical school graduates chose psychiatry. While the number has since risen to 4.2% in 2002, it’s still a far cry from the 1970s when one in every 10 doctors chose to become a psychiatrist (Newton & Grayson, 2003).
With fewer psychiatrists available, those who do go into practice in most areas of the country are in generally high demand. And the demand tends to be focused on what psychiatrists can do that virtually no other mental health professional can provide — prescription medications.
Coinciding with the great increase in the number of psychiatric medications prescribed over the past decade, psychiatrists have largely been unable to resist the pressure of market forces which reinforce their expertise with these medications over psychotherapy.
Combine that, too, with the vast quantity of master’s level therapists now available (and who enjoy the same insurance reimbursement rates as their medical counterparts for doing psychotherapy), as well as the continuing increase of clinical psychologists, and you can see why psychiatrists have less time to spend in talk therapy.
Sadly, I don’t think the situation is likely to change much in the upcoming years, as medical school students tend to rank psychiatry right up there with proctology. I also don’t think it hurts potential clients, however, as long as they are seen by an experienced psychotherapist in addition to a psychiatrist for their mental health concern.
References:
Mojtabai, R. & Olfson, M. (2008). National Trends in Psychotherapy by Office-Based Psychiatrists. Arch Gen Psychiatry, 65, 962 – 970.
Newton, D.A. & Grayson, M.S. (2003). Trends in Career Choice by US Medical School Graduates. JAMA, 290, 1179-1182.
8 comments
I think patients benefit most when they receive integrated care (psychotherapy and medication from the same person.) But this is more and more rare as you point out.
Those 15-minute medication checks don’t work so well for someone with a complex (or changing) condition. Or for someone who is not articulate, or doesn’t understand their disorder very well.
A factor you didn’t mention is that psychotherapy doesn’t seem to be taught as much to psychiatric residents as it used to be. Luhrmann’s book, “Of two minds: The growing divide in American psychiatry” explores this in more detail.
My psychiatrist pawned me off on a social worker for psychotherapy. At first, I was insulted, but I now believe I have a better rapport with her than I ever would have had with him as my psychotherapist. I think psychatrists that don’t do much therapy are out of touch with the skills it requires.
Wendy Aron, author of Hide & Seek: How I Laughed at Depression, Conquered My Fears and Found Happiness.
http://www.wendyaron.com
My wife – 5th year psychiatry resident – is involved with a teaching hospital that promotes and teaches psychodynamic psychotherapy as well as the short-term therapies. As I type this comment she’s co-facilitating a therapy group at her hospital.
Not all is lost… at least in Toronto, Canada.
I agree with previous posters that integrated care by one practitioner is preferable to the split between medication doc and therapist.
As a masters level social worker, I don’t believe that two years of graduate school and field work equips one to be a therapist the way three years in a psychodynamically oriented psychiatry residency does.
In short, I believe psychiatry and mental health care have suffered due to economic pressures, i.e.big pharma and competition for reimbursement.
>> I agree with previous posters that integrated care by one practitioner is preferable to the split between medication doc and therapist.
The psychiatrists I work with prefer to split the med/therapy roles. At first I was a skeptic, but now I support the dual roles.
>> I believe psychiatry and mental health care have suffered due to economic pressures, i.e.big pharma and competition for reimbursement.
Yeesh… you can dedicate a whole blog to this topic alone.
I think that while dual roles is fine, I think it would be best for patients, especially ones with more complex mental health needs, is these two professionals know and communicate with each other. This has only happened for me once, but I think it would help many people. Also, the psychiatrist should still have some clinical skills and I think they should at least be able to provide some brief interventions like CBT and problem solving. Unfortunately, I often feel uncomfortable talking to psychiatrists who think that psychotherapy isn’t there job anymore. And it’s important for patients to be able to communicate all they symptoms and side effects as well as other issues going on in their life to their psychiatrist.