Until late in the last century, individuals who have mental illness usually consulted a psychiatrist for all their treatment. Trained as a physician, a psychiatrist would evaluate possible medical causes of psychiatric symptoms, such as hypothyroidism, anemia, and hyperglycemia.
The psychiatrist often conducted the admitting physical exam if the patient were admitted to a psychiatric facility. Next, the psychiatrist would consider indications for prescribing the limited number of available psychoactive medications. And he would initiate psychotherapy. At that time, the primary treatment provided by a psychiatrist was psychotherapy. This treatment model allowed the patient to be treated by one individual who was proficient in the necessary skills.
However, since the 1980s, the all-inclusive responsibilities of the psychiatrist have been divided. With increasing familiarity with psychotropic drugs, many primary care physicians are willing to prescribe them. In “split” treatment approaches, a therapist, such as a licensed counselor, social worker, psychologist, or life coach, provides “talk therapy” while the psychiatrist (or other physicians) prescribes medicine. Indeed, many psychiatrists avoid administering psychotherapy. A psychiatrist who advertises himself as a “psychopharmacologist” or “neuropsychiatrist” is proclaiming an interest primarily in prescribing.
A study analyzing over 20 years of data collected by the U.S. National Ambulatory Medical Care Survey (NAMCS) evaluated the employment of psychotherapy in outpatient psychiatric sessions. Psychotherapy was defined as “all treatments involving the intentional use of verbal techniques to explore or alter the patient’s emotional life to effect symptom reduction or behavior change” in a session of more than 30 minutes. The study revealed that psychotherapy practiced by psychiatrists decreased by more than half between 1996 and 2016.
Furthermore, since 2010, more than 50 percent of psychiatrists have provided no psychotherapy. Self-pay patients were more likely to receive psychotherapy. Patients under 25, Black or Hispanic, or on Medicare, Medicaid, or HMO coverage were less likely to receive psychotherapy. Diagnoses of schizophrenia or bipolar disorder were less likely to involve psychotherapy.
Psychiatrists offering psychotherapy more often saw patients with dysthymic disorder, anxiety disorders including social phobia, PTSD and obsessive-compulsive disorder, and personality disorders. Psychiatrists prescribed psychotropic drugs at a higher rate for patients receiving no psychotherapy.1
Market forces have greatly influenced this shift in psychiatric practice. Insurance reimbursement programs strongly incentivize brief “med checks” for psychiatrists and favor lower-reimbursed nonphysician providers for longer sessions. Increasing biomedical advances and the development of more psychotropic medicines have skewed emphasis to biological approaches to treatment.
Although the Accreditation Council for Graduate Medical Education requires psychiatric residents to gain proficiency in cognitive, psychodynamic, and support therapies, many training programs are deficient.2 Psychotherapy training encourages the trainee to openly and self-critically expose himself to a supervisor in describing his encounters with the patient. The residency program must also absorb the expense of hiring experienced faculty for supervision time. These requirements discourage the more demanding elements of teaching and learning psychotherapy. It is less demanding for the residents and their teachers to focus on reviewing biochemistry and dosage recommendations for medications from lectures and readings.
Are psychiatrists relevant if primary care physicians can prescribe medicines and nonphysician clinicians can provide therapy? “Split” treatment can be advantageous when the therapist has specialized training in a particular treatment. However, multiple providers are inconvenient, communication between professionals is limited, and all can be inefficient for the patient.
Integrated treatment by a psychiatrist who possesses knowledge of psychotropic drugs more specialized than a family doctor and experience with appropriate psychotherapy models can be the most proficient provider of mental health treatment. For this traditional model of psychiatry to persist and not be confined to the role of “pill pusher,” payer sources and training programs must recognize more fully the value of medical psychotherapy.
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