A Missed Opportunity
A Missed Opportunity
Gardiner Harris’s1 recent article in The New York Times was, at best, a missed opportunity to look at the changing patterns of outpatient care by psychiatrists. Centered around a single psychiatrist in Pennsylvania whose practice is limited to diagnostic and medication management visits, Harris paints a picture of psychiatric outpatient care driven primarily by the distorted financial reimbursements built into our health care insurance system. Harris1 cites, with obvious concern, a 2005 federal survey that found that “just 11% of psychiatrists provided talk therapy to all patients.”
How accurate is this picture, and what explains the changing patterns of psychiatric practice? First, the survey that Harris cites—the National Ambulatory Medical Care Survey—provides data that contradict the impressions in Harris’s article. As analyzed by Mojtabai and Olfson,2 psychotherapy visits to psychiatrists—defined as visits of longer than 30 minutes—occurred in 28.9% of visits in 2004 - 2005 compared with 44.4% of visits in 1996 - 1997. As they themselves noted, the authors used a “restrictive definition of psychotherapy that may have misclassified some visits.”2 Indeed, common practice and standard Current Procedural Terminology (CPT) codes specifically include 30-minute visits for psychotherapy, with or without pharmacotherapy—visits they excluded in their analysis.
Even with the restrictive definition in the Mojtabai and Olfson study, 59% of psychiatrists in the sample provided some psychotherapy, although with regional variation. More important, there was significant variance in provision of 45-minute (or longer) psychotherapy visits, based on diagnosis: patients with schizophrenia were least likely to receive more intensive forms of psychotherapy, and patients with dysthymia and personality disorders were most likely, even after controlling for multiple other variables. These data suggest that the provision of more intensive psychotherapy by psychiatrists is highly sensitive to evidence-based studies and perhaps to circumstances in which well-documented pharmacotherapies are less available. If payment were the sole or primary determinant of care, it is unlikely that this more granular and specific provision of psychotherapy would be present.
In addition to his mischaracterization of the Mojtabai and Olfson study, Harris ignores contrary data. Thus, Reif and colleagues3 looked at types of outpatient visits to a private national managed behavioral health plan. Based on their analysis of these 2004 data, more than 67% of visits to psychiatrists involved either medication management and psychotherapy, or psychotherapy alone. This was despite the fact that the visits occurred in the type of insurance setting that has generally been viewed as least hospitable and remunerative to psychiatric practice.
So in what ways was the Harris piece a missed opportunity? First, one would not know, on the basis of the article, that psychiatry has been rapidly increasing the quality of its evidence base and the specificity of its treatments—verbal, behavioral, and psychopharmacological. Indeed, the growth in the use of pharmacotherapeutic agents—imperfect though they are, according to the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) and Sequenced Treatment Alternatives to Relieve Depression (STAR*D) efficacy studies—has been driven not merely by financial or marketing considerations, but by the efforts of generations of psychiatric researchers to find more effective treatments for fearsome and profoundly disabling illnesses.
Second, Harris fails to note that it has been psychiatric clinicians and researchers, as well as colleagues in psychology and other disciplines, who have argued for the use of combined treatments. These include forms of psychotherapy, such as cognitive-behavioral therapy, that can be provided outside the framework of hour-long visits.