For Psychiatrists, Talk Therapy Falling by Wayside

TUESDAY Aug. 5, 2008 -- Fewer psychiatrists are providing psychotherapy to their patients during office visits.

The trend, noted by researchers publishing in the August issue of the Archives of General Psychiatry, appears to be due to fewer psychiatrists trained or specializing in psychotherapy and an increase in the number of drugs available, along with a reluctance by managed care to pay for psychotherapy.

"I was trained almost 30 years ago and received a lot of training in psychotherapy," said Dr. Christopher C. Colenda, a psychiatrist and the Jean and Thomas McMullin Dean of Medicine at Texas A&M Health Science Center College of Medicine. "Thanks to the advances of managed care, psychotherapy was basically devalued from the perspective of psychiatry. All that we were supposed to do was diagnose and consult for pharmacotherapy. A lot of the incentives for wanting to be in psychiatry were essentially removed by managed care."

Psychotherapy has long been a prominent feature of psychiatry, although recent evidence indicates this trend may be on the wane.

Indeed, using data on visits to psychiatrists' office between 1996 and 2005 from the National Ambulatory Care Survey, these authors confirmed that the proportion of visits to psychiatrists' offices that included psychotherapy dropped from 44.4 percent in 1996-1997 to 28.9 percent in 2004-2005.

There was also a decline in the number of psychiatrists providing psychotherapy to all of their patients, from 19.1 percent in the earlier period to 10.8 percent in the later period.

The decline coincided with changes in insurance reimbursement, the rise of managed care and a boom in the availability of different psychiatric medications.

Those psychiatrists who do still provide psychotherapy tend to have self-paying clients.

"They tend to rely more heavily on self-paying patients," confirmed study author Dr. Ramin Mojtabai, an associate professor of mental health at Johns Hopkins Bloomberg School of Public Health in Baltimore. Mojtabai was affiliated with Beth Israel Medical Center while completing the study.

"What's happened anecdotally is that some of the residents that I trained with have basically dropped out of insurance plans and are taking cash-only business where they can provide the comprehensive services [including psychotherapy]," Colenda added. "It's a clientele that's at a much higher economic level. If they're socially inclined, they end up volunteering at community mental health centers."

Those who do get psychotherapy tend to go to psychologists, social workers and other psychotherapists. "There is a trend for separate services," Mojtabai said.

And there may indeed be a decline in how well patients do. "We know that, for depression, the combination of psychotherapy and pharmacotherapy leads to better outcomes," Colenda said.

A second study in the same issue of the journal found, surprisingly, that although regular exercise is associated with less anxiety and depression, the exercise may not actually cause the improvement in well-being.

Instead, said researchers from UV Amsterdam University in the Netherlands, both exercise and mood may result from genetic factors.

The authors based their conclusions on an analysis of 5,592 twins, 1,357 additional siblings and 1,249 parents.

Among identical twin pairs, the twin who was more physically active did not have less anxiety and depression than the twin who exercised less.

More information

Visit the National Institute of Mental Health for more on how to treat depression and other conditions.

Posted: August 2008


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