Psychiatrists shift away from providing 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, one of the JAMA/Archives journals.

Psychotherapy has been part of the practice of psychiatry for generations, the authors write as background information in the article. Various forms of psychotherapy, either alone or in combination with medications, are recommended for the treatment of major depression, post-traumatic stress disorder, 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 favouring brief medication management visits rather than psychotherapy and the introduction of newer psychotropic medications with fewer adverse effects,” the authors write.

Ramin Mojtabai, M.D., Ph.D., M.P.H., then of Beth Israel Medical Center and now of the Johns Hopkins Bloomberg School of Public Health, Baltimore, and Mark Olfson, M.D., M.P.H., of Columbia University Medical Center and New York State Psychiatric Institute, New York, analysed 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.

“These trends highlight a gradual but important change in the content of outpatient psychiatric care in the United States and a continued shift toward medicalisation 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.”

(Source: Archives of General Psychiatry: Columbia University Medical Center: August 2008)