The Decline of Psychotherapy

Although several studies indicate that psychotherapy (alone or in combination with medications) can help psychiatric patients reach recovery faster and stay well longer, a declining number of office-based psychiatrists are providing psychotherapy to their patients.

Analyzing data from the National Ambulatory Medical Care Survey from 1996 through 2005, researchers Ramin Mojtabai, MD, PhD, MPH, of the Johns Hopkins Bloomberg School of Public Health in Baltimore, and Mark Olfson, MD, MPH, of Columbia University Medical Center, recently identified trends related to the provision of psychotherapy in the Archives of General Psychiatry.¹

“The decline in the number of psychiatrists who provide psychotherapy for all their patients was marked during the past 10 years or so,” Mojtabai said, adding that in earlier studies, “the downward trend was not that dramatic.”

The number of psychiatrists who provided psychotherapy to all of their patients declined from 19.1% in 1996-1997 to 10.8% in 2004-2005. From 1996 through 2005 psychotherapy was provided in 5597 of 14,108 office visits to psychiatrists lasting longer than 30 minutes, but the percentage of visits involving psychotherapy declined from 44.4% in 1996-1997 to 28.9% in 2005-2006.

Several predictors were associated with a greater likelihood of receiving psychotherapy.

Patients who pay out-of-pocket are more likely to get psychotherapy from psychiatrists than those who have private insurance, said Mojtabai. Patients with personality disorder or dysthymia are more likely to receive psychotherapy from their psychiatrists, whereas patients with schizophrenia are less likely.

Regional differences also were apparent, Mojtabai told Psychiatric Times. Patients in the Northeast (46.4%) are more likely to receive psychotherapy from their psychiatrists than those in the South ( 23%).

Among patients less likely to receive psychotherapy from psychiatrists are those who are black, Hispanic, or younger than 25 years andthose who have public insurance such as Medicaid.

The trends identified in the analysis “highlight a gradual but important change in the content of outpatient psychiatric care in the United States and a continued shift toward medi-calization of psychiatric practice,” Mojtabai and Olfson wrote. “Much of this change can be explained by shifts in financing of outpatient mental health care and increasing prescription of medications.”

The magnitude of financial dis-incentives for provision of psycho-therapy was highlighted by a Practice Research Network study that documented that third-party reimbursement for a single 45- to 50-minute outpatient psychotherapy session is 40.9% less than reimbursement for three 15-minute medication management visits. Visits provided under managed care tended not to include psychotherapy.

Examining a typical week for 756 office-based practices, the researchers found that 59% of psychiatrists provided psychotherapy for some but not all patients, 12.2% provided psycho-therapy during all visits, and 28.4% did not provide psychotherapy during any patient visits.

Such trends, they warned, have implications for the identity of psychiatry as a profession:

We found that psychiatrists who strongly favor psychotherapy tend to prescribe medications for only slightly more than half of their patients, and a growing number of psychiatrists who prescribe medications for the large majority of patients appear to shun delivery of formal psychotherapy altogether. A key challenge facing future psychiatrists will likely involve maintaining their professional role as integrators of the biological and psychosocial perspectives.

Meeting the challenge

Psychiatry has known about the decline in psychotherapy practiced by psychiatrists for more than a decade, said Eric Plakun, MD, who is chair of the American Psychiatric Association’s (APA’s) Committee on Psycho-therapy by Psychiatrists. That is why in 1996, he said, APA established the committee he chairs. The committee’s charge is to represent the importance of psychotherapy as part of the identity, skill set, and training of psychiatrists.

Plakun also added that the Accreditation Council for Graduate Medical Education through its Residency Review Committee for psychiatry has established clear requirements for psychotherapy.

Current program requirements state that psychiatry residents should develop competence in applying supportive, psychodynamic and cognitive-behavioral psychotherapies to both brief and long-term individual practice as well as ensure exposure to family, couples, group, and other individual evidence-based psychotherapies. Competence in the concurrent use of medications and psychotherapy is another requirement.

Speculating on why fewer psychiatrists are using psychotherapy, Plakun said it could be a result of the shift away from the earlier emphasis on psychoanalysis to biological psychiatry, the growth in effective pharmacological treatments, the emergence of managed care, and the “quite possibly erroneous belief” that payers could save money by adopting the split-care model, in which psychologists and others provide the psychotherapy.

“Two studies cited in our paper suggest that split care may be less cost-effective compared to integrated care,” said Mojtabai. “But the issue hasn’t been studied fully,” and more research also is needed to compare the effectiveness of split care versus integrated care.

Plakun declares, “It is extremely powerful to have a psychiatrist who can do both the psychotherapy and the prescribing because it really allows the meaning of medications to come into the work.”

He described a patient who would not take medications the way he had prescribed them-she either overdosed or refused to take them at all.

“Finally through the process of therapy,” Plakun said, “we were able to have a conversation in which she said to me, ‘you have to understand that the way I was abused as a child had to do with forced oral rape, and I’m not letting you be in charge of what goes down my throat.’”

Plakun and the patient built a different kind of working alliance around the use of medications.

Surveys planned

Plakun noted that the APA’s Committee on Psychotherapy is developing 2 surveys-1 for practicing psychiatrists and 1 for residents-to gather more definitive information about factors involved in psychotherapy’s decline. He expects the survey of psychiatrists to be finalized and sent to participants in APA’s Practice Research Network within the next 6 months. It will ask about the extent of the psychiatrist’s practice of psycho-therapy as well as possible obstacles (eg, financial disincentives or inadequate training).

The survey of residents (with 5 questions about the adequacy of their training and supervision in psycho-therapy) is part of a larger survey to be disseminated by the Committee on Residents and Fellows, Plakun said.

The psychotherapy committee also is proposing a component workshop on the topic for next May’s APA Annual Meeting in San Francisco.

Training

Both Mojtabai and Plakun suggested improvements in psychotherapy training for residents.

Rather than just developing competence in different modalities, future psychiatrists should have a better sense of which disorders are more responsive to psychotherapy. This knowledge will be particularly beneficial when making referrals for psychotherapy, Mojtabai said. Because other mental health professionals will probably provide the bulk of psychotherapy, he added, psychiatrists should learn how to better communicate with those professionals over issues needing exploration in therapy.

Plakun recommended that psychotherapy be taught in a way that eliminates the warfare between proponents of specific psychotherapeutic approaches such as cognitive-behavioral therapy and psychodynamic therapy. He proposed the Y-model for teaching psychotherapy competencies, which was developed by members of the Committee on Psychotherapy and is available at the Web site of Austen Riggs Center, where he is director of admissions and professional relations (www.austenriggs.org/continuing_education/ymodel).

The model begins with common psychotherapeutic skills a psychiatrist needs, regardless of a particular psychotherapy approach, including negotiating a therapeutic alliance, understanding limits and boundaries, and prescribing medications as part of therapy. The model then compares and contrasts schools of therapy on the basis of their underlying theoretical assumptions, with technique following from theory.

Growing evidence

There is growing evidence that various therapies provide effective treatment for numerous psychiatric disorders, according to Mojtabai and Plakun.

Behavioral treatments have been shown to be more effective than medications in the treatment of obsessive-compulsive disorder, Mojtabai said, and we have very good evidence that psychotherapy is as effective as medications for treating major depression.

Plakun added that psychotherapy has been shown to be an effective treatmentassociated with changes in the brain, as documented on imaging studies.

Results of major NIMH-funded studies also indicate the effectiveness of psychotherapy. The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), for example, found that adults who received up to 30 sessions of family-focused therapy, cognitive-behavioral therapy, or interpersonal therapy plus medications recovered more rapidly from depressive episodes than participants who received only 3 psychoeducational sessions in addition to medication.

“It really is a loss to our patients if they aren’t getting psychotherapy,” Plakun said. “Moreover, psychiatrists are in a unique position to provide psychotherapy because they really have the medical training that allows them to integrate medication and therapy, mind, and body.”

References:

Reference

1. Mojtabai R, Olfson M. National trends in psycho-therapy by office-based psychiatrists. Arch Gen Psychiatry. 2008;65:962-970.