A graduating resident recently told me that a psychiatric group attempting to recruit him informed him that he would have 10 minutes for medication appointments and 30 minutes for new patient evaluations. He was horrified. (So was I.)
There can be little doubt in our current era that the brief “med check” is becoming standard practice in psychiatry. There are a number of implicit assumptions in this practice. One is that the optimal distribution of mental health services means restricting psychiatrists to brief medication management appointments and assigning psychotherapy to other practitioners. An even more extreme assumption is that medication management without psychotherapy is good psychiatric care. After all, many people currently seeing psychiatrists for medication appointments or for pharmacotherapy are not receiving psychotherapy.
Another rarely articulated assumption is that we can parse treatment into a psychological dimension and a biological dimension. We unwittingly convey to mental health consumers that “mind” and “brain” are separate and require different treatments. The irony of this distinction is hard to miss. Indeed, one of the assumptions inherent in the current emphasis on the brief med check is that psychiatry is not a biopsychosocial specialty in the spirit of Engel.
One of the perils of the med check approach is that the “person” may be lost in the process of treating the symptoms. Many years ago, Dr William Osler noted that “it is more important to know what kind of person has a disease than to know what kind of disease a person has.”
The current state of affairs also has dire implications for training. Psychiatric residents may not really know how to provide psychotherapy if their activities are confined to medication appointments while they are residents. The Residency Review Committee mandates at least 3 forms of psychotherapy, but supervision appointments and didactic seminars are not necessarily enforced by local residency training committees. Hence many psychiatrists are trained without any real “hands on” experience.
One of the major difficulties with the med checks is that economic factors may militate against delivering comprehensive psychiatric care. In most settings, a psychiatrist can make more money doing 4 or 5 med checks per hour than from seeing 1 patient for psychotherapy. But how much can one really accomplish in 10 or 15 minutes?
The message to a patient is one that is alarmingly reductive—namely, that mental life can be explained in terms of physiology, and our choices are fixed and determined by the laws of chemistry.
Patients are not likely to buy into the same conceptual model that treaters attempt to impose upon them. In other words, they don’t go to their doctor’s with the assumption that “brain” and “mind” are separate, and they don’t necessarily view psychotherapy and medication as separate entities. When they show up at their pharmacotherapy appointment, patients are not inclined to limit the content of the appointment to the side effects or therapeutic effects of the medication. A clinical example illustrates this point:
Ms A came to see me for a 30-minute medication appointment. She had recently started taking venlafaxine. I asked her how the medication was working, and she said that she had almost called me the previous day. I asked why she wanted to speak to me, and she responded, “I’m pregnant.” She went on to tell me that she had met her ex-husband for dinner. After dinner she got a bit tipsy, and they had sex. Now she had discovered that she was pregnant. She had already decided that it was a terrible mistake to meet her ex-husband for dinner, and after that night, she told him that she no longer wanted to see him. She then went on to say that her church did not believe in abortion, and she did not know what to do. I started to talk with her about the effects of medication on the developing fetus, and she told me that she hadn’t even started taking venlafaxine. It was clear that medication was not on her mind.
I explored with the patient her longstanding pattern of refusing to give up on men in her life, and how that frequently led to adverse consequences. She acknowledged the difficulty and felt that this time she had really grasped the unforeseen consequences of trying to make an impossible relationship work.
This patient was coming to see her doctor to talk about problems—regardless of whether they involved medication or psychological issues. Other patients who are in psychotherapy wish to bring up medication issues as part of the psychotherapy process.
Psychiatry has probably made far too much of a distinction between psychotherapy and pharmacotherapy in training and in practice. Psychotherapeutic skills are needed in every context in psychiatry because the same phenomena that emerge in psychotherapy—transference, resistance, countertransference, schema, automatic thoughts—appear in other contexts. All clinical work in psychotherapy depends on attending to the therapeutic relationship. In the NIMH Treatment of Depression Collaborative Research Program, the strength of the therapeutic alliance accounted for more variance in treatment outcome (21%) than the treatment method itself (1%).1
There are problems inherent in the continued division of mental health care delivery into psychiatrists providing pharmacotherapy and nonpsychiatrists providing psychotherapy. In some settings, the 2 treaters never meet and may never communicate. Moreover, third-party payers will not reimburse for communication outside of time spent with the patient, which discourages any type of collaborative effort. Also, with communication, the divided treatment setting creates a fertile field for splitting. If the patient complains about one treater to the other, the patient’s account may be taken at face value; the idealized treater may collude with the patient against the other treater, who has been devalued.
The issue of cost-effectiveness is often glibly dealt with, but the research on this subject is very limited at this point. At least 1 study suggests that it may be more cost-effective for 1 psychiatrist to see the patient than 2 separate providers.2 More research is needed, but in the meantime, let’s treat the whole patient.
There are a number of proposals that follow from these concerns:
1. Psychiatry residents need to be taught that psychotherapeutic principles apply in all settings where psychiatric treatment is delivered.
2. Psychotherapy is a biological treatment, and knowledge of neuroscience should be brought to bear in understanding the psychotherapeutic action of psychotherapy.
3. Psychiatry must retain a biopsychosocial perspective to treat the whole person.
4. More cost-effectiveness data must be collected to counteract assumptions about the nature and cost of treatment.
5. Strategies of psychotherapy must be developed that are based on specific therapeutic action in the brain in the same way that we prescribe medication.