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The Decline of Psychotherapy

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.

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