Managed care drives U.S. psychiatrists to abandon psychotherapy

A declining number of office-based psychiatrists appear to be providing psychotherapy to their patients, according to a report in the August issue of Archives of General Psychiatry.

Psychotherapy has been part of the practice of psychiatry for generations. Various forms of psychotherapy, either alone or in combination with medications, are recommended for the treatment of anxiety disorders, major depression, bipolar disorder and other psychiatric illnesses. "Yet, despite the traditional prominence of psychotherapy in psychiatric practice and training, there are indications of a recent decline in the provision of psychotherapy by U.S. psychiatrists - a trend attributed to reimbursement policies favoring brief medication management visits rather than psychotherapy and the introduction of newer psychotropic medications with fewer adverse effects," the authors write.

Ramin Mojtabai, MD, PhD, MPH, then of Beth Israel Medical Center and now of the Johns Hopkins Bloomberg School of Public Health, Baltimore, and Mark Olfson, MD, MPH, of the Columbia University Medical Center and New York State Psychiatric Institute, New York, analyzed trends in psychotherapy provision using data from national surveys of office-based psychiatrist visits from 1996 through 2005.

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 authors 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. "Psychiatrists who provided psychotherapy to all of their patients relied more extensively on self-pay patients, had fewer managed-care visits and prescribed medications in fewer of their visits compared with psychiatrists who provided psychotherapy less often," the authors write.

"Psychiatrists get more for three, 15-minute medication management visits than for one 45 minute psychotherapy visit," Mojtabai explained.

"These trends highlight a gradual but important change in the content of outpatient psychiatric care in the United States and a continued shift toward medicalization of psychiatric practice," they conclude. "A key challenge facing the future generation of psychiatrists will likely involve maintaining their professional role as integrators of the biological and psychosocial perspectives while working within the constraints of the strong market forces of third-party payers and managed care to implement advances in the diagnosis and treatment of mental disorders."

The study was supported in part by a grant from the Agency for Healthcare Research and Quality.

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Mojtabai R, Olfson M. National Trends in Psychotherapy by Office-Based Psychiatrists. Arch Gen Psychiatry. 2008;65(8): 962-970.   [Abstract]

Update - August 8, 2008

In response to the study and the resulting media attention the American Psychiatric Association has released the following statement:

APA Highlights Importance of Psychotherapy in Treatment Plans

Arlington, VA – Psychotherapy remains a major component in the treatment of mental illness, the American Psychiatric Association stated today. Many mental health problems can be resolved with psychotherapy alone, and psychotherapy is often a crucial component in the success of treatment with medication.

A recently released study in the Archives of General Psychiatry entitled “National Trends in Psychotherapy by Office-Based Psychiatrists” showed a decline in psychotherapy practiced by psychiatrists due to insurance policies that favor shorter office visits. The study also found there is growing evidence that various therapies provide effective treatment for a range of disorders.

“The best result for many patients is often a combination of psychotherapy and medication,” said APA President Nada Stotland, M.D., M.P.H. “It is most unfortunate that so many health insurance plans will only pay psychiatrists to prescribe medication; this deprives patients of the integrated care that psychiatrists are trained to provide and decreases patients' chances of achieving the full recovery they deserve.”

Organized psychiatry is already aware of and responding to the shifts in the practice of psychotherapy. The APA established the Commission [now Committee] on Psychotherapy by Psychiatrists in 1996 out of recognition that therapy was dwindling as part of the skill set and training of psychiatrists. Psychotherapy is a required element in psychiatric specialty training, and the accreditation council established that psychiatry residency curricula must include training to a level of competence in three schools of therapy.

Eric Plakun, M.D., chair of the APA Committee on Psychotherapy by Psychiatrists, noted that talk therapy can be done by psychiatrists less expensively than split treatment, where a patient sees a doctor for medication and a counselor for talk therapy.

“Therapy provided by medically trained psychiatrists offers the maximum integration of mind and body to our patients,” said Dr. Plakun.

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