Psychiatrists Lament Decline of Key Treatment Modality

Evidence of the efficacy of psychotherapy has increased dramatically in recent years even as the place of psychotherapy in the identity, practice, and training of psychiatrists is diminishing—a fact that was widely recognized and just as widely deplored during a workshop at APA's 2009 annual meeting in San Francisco in May.

It was a subject that brought out considerable passion as speakers and attendees alike insisted that psychiatry brings a unique set of skills to the biopsychosocial treatment of mental illness and that new evidence is showing that psychotherapy works not only on the mind but on the brain. At the same time, speakers acknowledged what some research evidence published last year and presented at the meeting seemed to show—that psychotherapy by psychiatrists is declining.

“There is growing evidence that psychotherapy is efficacious for a range of individual disorders and for complex comorbid disorders,” said Eric Plakun, M.D., chair of APA's Committee on Psychotherapy by Psychiatrists.“ We are also learning that psychotherapy is associated with brain change. Though medications seem to work from the bottom up, psychotherapy seems to work from the top down—from the cortex down to the molecular level. In at least one study, therapy responders could be distinguished from nonresponders by imaging studies.

“Yet there is also this evidence that psychotherapy is dwindling as part of the identity, skill set, and training of psychiatrists,” Plakun said. “I think we can raise an interesting question of whether psychotherapy by psychiatrists is an endangered species.”

Plakun said that the trend is frustratingly at odds with what would appear to be common sense. “Therapy by psychiatrists absolutely maximizes the integration of mind and body, and it certainly also maximizes the possibility of integrating prescribing of medications with psychotherapy.

'Loss to Our Patients'

“So the minimization of therapy, should it continue, is a loss to psychiatry, but above all, it's a loss to our patients,” Plakun said.“ Are we offering our patients all we can if we aren't thinking about biological treatments and psychosocial treatments, including psychotherapy?”

There was poignancy to the workshop in that the Committee on Psychotherapy by Psychiatrists was being “sunsetted”—it is one of a large number of committees and other components that are being terminated as part of an APA organizational restructuring to make APA more efficient (see Original article: Some Thoughts on Reorganization). The committee's charge will likely fall under the Council on Research and Quality Care.

Outgoing APA President Nada Stotland, M.D., who was trained analytically and has a practice devoted to psychotherapy, was a discussant at the workshop. She urged committee members and other members of APA to think about strategy going forward and to communicate ideas to leadership. “We have to think strategically and practically if we want a position that insurers should cover psychotherapy by psychiatrists,” Stotland said.

“We need to think about how exactly psychotherapy by psychiatrists is going to be carried forward and to demand some accountability around this. In no way will any of your leadership want to let that go away.”

The trend away from psychotherapy by psychiatrists, acknowledged by most speakers, appeared to be confirmed by research presented at the annual meeting by Ramin Mojtabai, M.D.

Mojtabai and Marc Olfson, M.D., analyzed data from the 1996-2005 cross-sectional National Ambulatory Medical Care Survey to examine trends in psychotherapy provision within nationally representative samples of visits to office-based psychiatrists. Statistical analyses examined the time trend, adjusting for patient, visit, and setting characteristics. Practice-level analyses examined time trends in the percentage of psychiatrists who provided psychotherapy to all, some, or none of their patients during a typical week.

They found that psychotherapy was provided in 5,597 of 14,108 visits sampled during the 10-year period. The percentage of visits involving psychotherapy declined from 44.4 percent in 1996-1997 to 28.9 percent in 2004-2005.

At the practice level, the decrease in providing psychotherapy corresponded with a decline in the number of psychiatrists who provided psychotherapy to all of their patients, from 19.1 percent in 1996-1997 to 10.8 percent in 2004-2005.

“This trend is attributable to a decrease in the number of psychiatrists specializing in psychotherapy and a corresponding increase in those specializing in pharmacotherapy—changes that were likely motivated by financial incentives and growth in psychopharmacological treatments in recent years,” Mojtabai said.

He is an associate professor of psychiatry at Johns Hopkins University Bloomberg School of Public Health.

Psychotherapy in a 'Med Check'?

Dissenting somewhat from the conventional wisdom was Glen Gabbard, M.D., a renowned leader in psychoanalysis and psychodynamic therapy. He questioned what he called “the myth of the med check,” saying it was not really possible to know what was happening between a therapist and patient during a visit that might be coded by the office assistant as a“ medication check” and insisted that a great deal of important psychotherapy may be going on during those visits.

“We make far too much of the distinction between psychotherapy and medication,” Gabbard said. “Patients don't make that distinction. They are going to see their doctor. They don't say, 'I'm in a med check, so I will only talk to you about the therapeutic effects of this medication. I think there is a lot of psychotherapy going on during so-called medication checks.”

Moreover, he insisted that the principles of psychodynamic psychotherapy are applicable in every area of psychiatric practice. “There is no type of psychiatric practice that exists in a realm where psychodynamic principles—transference, countertransference, resistance, the therapeutic alliance—are irrelevant. So one of the things that I think we need to emphasize as a major public relations effort about psychiatry is that we are the integrators par excellence.”

Gabbard agreed that psychiatry has “abdicated far too much ground to other mental health professions.” And he wondered if the economic forces that have tended to drive the trend away from psychotherapy by psychiatrists have served as a convenient out for patients and clinicians alike who would rather avoid the difficult terrain of psychotherapy.

“As we know, the unconscious will always be resisted, and most of us would rather ignore the parts of people that are filled with pain and terror and aggression and rage,” Gabbard said. “There is a powerful incentive for us to turn away from the demons that inhabit people. If we can get by on 10- or 15-minute med checks, maybe we won't have to look at that stuff.”

Difficult as it may be to do psychotherapy, it is also rewarding, Gabbard said. “I train my residents that while it is true you could make money doing 15-minute medication checks, when you get to be 45 or 50, you will feel like Sisyphus pushing the boulder up the mountain, and you will have a sense of existential despair about your work,” he said.

He said the satisfaction of doing psychotherapy and of getting to know people in depth “is worth taking a financial hit for.” And he added, “We as psychiatrists didn't go into this for the money. We have to keep track of why we like doing this, and it is because we get to know people in depth.” ▪