Outpatient psychiatric care in the United States saw a significant shift
from psychotherapy to psychotropic medications from 1996 to 2005, according to
a study published in the August Archives of General
Based on the National Ambulatory Medical Care Survey (NAMCS), 28.9 percent
of office-based visits to psychiatrists involved psychotherapy in 2004-2005, a
significant decrease from 44.4 percent of office-based psychiatric visits in
Only 10.8 percent of the psychiatrists in the sample provided psychotherapy
to all of their patients in 2004-2005, about half the rate in 1996-1997 (19.1
On average, more than a quarter (28.4 percent) of the sampled psychiatric
practices provided no psychotherapy during a typical week in 2004-2005.
A total of 5,597 visits to office-based psychiatrists in the overall NAMCS
database were included in the analyses. The NAMCS is an annual survey of
outpatient visits to physicians throughout the country. It collects
information on these visits from a random sample of physicians or their staff
during a randomly selected one-week period. The survey is conducted by the
National Center for Health Statistics, a division of the Centers for Disease
Control and Prevention.
The study was conducted by Ramin Mojtabai, M.D., Ph.D., an associate
professor of mental health at Johns Hopkins University School of Public
Health, and Mark Olfson, M.D., M.P.H., a professor of psychiatry at Columbia
University College of Physicians and Surgeons and a researcher at the New York
State Psychiatric Institute. The study was supported in part by a grant from
the federal Agency for Healthcare Research and Quality.
Psychiatrists who saw more self-pay patients and conducted fewer visits
covered by managed care provided more psychotherapy. In addition, the number
of medications prescribed at a practice was inversely related to the amount of
The reason for decreased use of psychotherapy, the authors believed, lies
primarily in the financial incentives in favor of medication treatment over
psychotherapy in recent years. They cited data from a previous study showing
third-party reimbursement for one 45-minute outpatient psychotherapy session
to be substantially less than three 15-minute medication-management visits.
The increasing number of new psychotropic medications on the market also
contributed to the trend, said the researchers.
"The trend [of decreasing psychotherapy by psychiatrists] is not at
all a surprise, but the study is useful for giving us actual numbers,"
Eric Plakun, M.D., director of admissions and professional relations at the
Austen Riggs Center in Stockbridge, Mass., told Psychiatric News.
Plakun agreed with the study authors that financial disincentives for
providing psychotherapy are among the main reasons for its declining use, but
suggested that the shift in the training of psychiatrists is also a
significant factor. "The field of psychiatry has moved toward more
pharmacological treatment and other approaches like [electroconvulsive
therapy]. It reflects changes in who the teachers are and who is selected into
psychiatric residencies," he explained. Preceptors and mentors
specializing in psychotherapy are rare in many programs.
As chair of APA's Committee on Psychotherapy by Psychiatrists, Plakun
noted that the committee has been addressing the decline in psychotherapy use
and training for more than a decade and helped establish the Accreditation
Council for Graduate Medical Education's requirements for psychotherapy
training in psychiatry residency programs.
If psychiatry is walking away from psychotherapy, this direction has"
implications for the identity of psychiatry as a profession," the
authors wrote. Although some strongly believe psychotherapy is an important
and integral part of a psychiatrist's arsenal, they noted, "a
growing group of psychiatrists ... appear to shun delivery of formal
psychotherapy all together."
The study does not show whether patients were getting less psychotherapy
overall or simply getting it from other mental health clinicians. However,
Plakun noted that psychiatrists are in the best position to integrate both
psychotherapy and medication management, especially for patients who are more
severely ill. He pointed out that a substantial proportion of patients have
disappointing or no response to multiple courses of medications, and many have
comorbid conditions that require a full arsenal of treatments from
psychiatrists who are skilled in delivering all of them.
Large clinical trials on mental illnesses such as depression and bipolar
disorder have demonstrated the superior efficacy of combining psychotherapy
and medications over either treatment alone (Psychiatric News,
November 2 and May 4, 2007). The higher cost of providing both treatments,
however, often makes the combination treatment difficult for patients to
"We need to ask ourselves what the future role of psychiatrists
is," said Plakun. He believes that psychiatrists will become the
ultimate specialists to diagnose and treat the more severely ill and
difficult-to-treat patients. To treat these patients effectively,"
psychiatrists need the competency to integrate medications and
psychotherapy," he said.
An abstract of "National Trends in Psychotherapy by
Office-Based Psychiatrists" is posted at<archpsyc.ama-assn.org/cgi/content/abstract/65/8/962>.▪