Two articles in the news this week point to a glaring contradiction in current mental health policy.
First, as referenced by Philip Dawdy and Reuters, noting a study in the Archives of General Psychiatry noting the dramatic decline in numbers of psychiatrists who practice psychotherapy --
The percentage of visits involving psychotherapy declined from 44.4% in 1996-1997 to 28.9% in 2004-2005 (P < .001). This decline coincided with changes in reimbursement, increases in managed care, and growth in the prescription of medications. 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% in 1996-1997 to 10.8% in 2004-2005 (P = .001). Psychiatrists who provided psychotherapy to all of their patients relied more extensively on self-pay patients, had fewer managed-care visits, and prescribed medications in fewer of their visits compared with psychiatrists who provided psychotherapy less often.
Conclusions There has been a recent significant decline in the provision of psychotherapy by psychiatrists in the United States. 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.
As I have noted before, a psychiatrist can earn at least 57% more in a medication only practice than he or she can providing psychotherapy. So certainly money is a primary driving force here. But also implicated are the turf issues I have written about before, because prescribing is pretty much limited to psychiatrists though a few clinical psychologists do so as well. Limiting the turf to a single group also helps feed the coffers and even more so when it also serves the interests of the drug companies -- more sales -- and the insurance companies -- fewer visits.
Now I think it is not such a bad thing that fewer psychiatrists practice psychotherapy these days. Because decreasing numbers of them have received much if any training in therapy, most significantly less than that of clinical psychologists and clinical social workers. And actually, because fee schedules and reimbursement rates tend to be based on degree category and not skill level, leaving therapy to or favoring its provision by psychiatrists drives the cost up and out of reach of many. The real problem here s that it reflects the extent to which the notion that all mental illness and emotional difficulties are medical illnesses, biologically based, has permeated the system, which now favors psychopharmacology above all else. The question that was not answered is what percentage of these prescribing only psychiatrists also urge if not expect patients they prescribe for to also be in therapy? I know of a few but not many, certainly not enough.
In an AP article discussing the same study we find the following:
"The study did not survey visits to psychologists or other mental health counselors who are not medical doctors, but who also practice talk therapy.
Psychotherapy uses verbal methods to get patients to explore their emotional life, thoughts or behavior. The goal is to ease symptoms, sometimes through getting the patient to change behavior or mental habits.
Its benefits can be seen in brain imaging studies, said Dr. Eric Plakun, who leads an American Psychiatric Association committee working to restore interest in psychotherapy by psychiatrists.
"The couch is far from dead," Plakun said. "The couch turns out to be an effective 21st century treatment."
Talk therapy can be done by psychiatrists less expensively than split treatment, where a patient sees a doctor for pills and a counselor for talk therapy, Plakun said, citing two prior studies.
It also works better than drugs for some patients, such as those with chronic major depression and a history of childhood trauma, he said.
Accreditation requirements for psychiatric residency programs are putting more emphasis on talk therapy, Plakun said. That may slow the decline of the couch.
The new study doesn't answer an important question: whether other professionals are picking up the slack, said psychologist David Mohr of Northwestern University's Feinberg School of Medicine. Psychologists and social workers provide counseling but most cannot prescribe drugs, so it's possible that for patients who require both talk and pills, some coordination in care may be lost, Mohr said."
Better but still with the assumption that therapy provided by psychiatrists is better than that by other mental health professionals because of the presumption that medication is almost always required. Says who? Does it not matter that these meds, mostly SSRIs are being shown to be far less effective than the ads would have us believe? This reminds me of my ex-husband's grandfather who used to tell him that he would pay his way through medical school so he could become a *real* doctor, this despite the fact that he was and is a successful clinical psychologists. It seems that there is a belief that *real* doctors are the best choice and the rest of us are just not quite up to the same level, even those of us who are also doctors but not M.D.s
Couple this with this opinion piece which appeared at the same time:
"What Americans are experiencing economically is clearly not "all in our heads," or, as former U.S. Sen. Phil Gramm, a John McCain adviser, recently put it, a "mental recession." But the increasing difficulty of the struggle to make ends meet and avoid homelessness is taking a correspondingly harsh toll on the mental health of our citizens...
...Increasingly, low-cost or free mental health services are being offered by nonprofit organizations like Atlanta-based Metropolitan Counseling Services. I became involved with MCS in part because I believe MCS and organizations like it can play a critical role in a community's efforts to recover from economic difficulties by addressing the mental health impact of such hardship. Indeed, counseling or psychotherapy can help one transcend despair and rebuild that healthy sense of perspective and self-esteem that is the foundation for effective planning and action in all spheres of life."
In my own community, the local paper recently suggested that it might be good to develop groups for citizens facing hardship this winter to give them a place to vent, to share and to get the relief that comes from talking with others in the same group. But community mental health centers have seen drastic cut-backs in their budgets and they have turned increasingly to revenue producing psychopharm treatment over therapy. In fact many clinics now offer case management and medication but no therapy. So, in the face of times that increase the demand and the need for therapy and counseling, what we see is money, insurance and turf making it ever ore difficult to get what is needed.