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See Inside December 2008/January 2009

Psychiatric Drugs Replacing Talk Therapy

As drugs move in, talk therapy moves out

In the 1960s, the heyday of psychoanalysis, psychiatrists often saw their patients five days a week. But the number of psychiatrists today who focus on talk therapy is dwindling, according to a recent study that analyzed trends in psychiatry offices across the U.S. The study’s authors determined that between 1996 and 2005 the percentage of psychiatry office visits involving psychotherapy decreased from about 44.4 percent—already a significant decline from the 1980s—to 28.9 percent.

One of the main causes for this 35 percent reduction in psychotherapy, the study’s authors say, is the increasing availability of psychiatric medications with few adverse effects. As patient demand for these medications has increased over the years, they argue, many psychiatrists have had their hands full managing patients’ prescriptions, leaving the talk therapy—if it happens at all—to nonmedical therapists, such as psychologists and social workers. The authors suggest that insurance companies may encourage this arrangement by reimbursing less for psychotherapy sessions and more for medication management sessions, which tend to be shorter.

All these changes, the authors point out, have left psychiatrists wondering what their place is in the mental health field. “I think what these data show is a profession in transition,” says Mark Olfson, a psychiatrist and public health researcher at Columbia University and co-author of the study. “The role of the psychiatrist is changing, and the impact of that on patient outcomes is really an open question.”

Historically, psychiatrists have managed all aspects of patients’ care, and many psychiatrists who trained heavily in psychoanalytical techniques contend that such an all-­inclusive care model works best for patients. Others favor a split-care model, preferring to handle the medical side of patient care and delegating psychotherapy to nonmedical professionals. “We find there are really two kinds of psychiatrists now,” says Ramin Mojtabai, the study’s other author and a researcher at Johns Hopkins University’s Bloomberg School of Public Health.

It is not yet clear whether one care model benefits patients more than the other does, although some studies indicate, at least for disorders such as depression, that a combination of both psychotherapy and medication works better than either treatment alone. So psychiatrists who want to be involved in their patients’ psychotherapy need to make some changes to keep treatment financially feasible for patients, Olfson says. Many psychiatrists have started forming group practices with psychologists, which allows them to play a role in their patients’ therapy with fewer reimbursement issues from insurance companies.

Both patients and clinicians stand to gain from an office environment that integrates the biomedical perspective of psychiatrists with the more behavioral perspective of psychologists, says Mojtabai, who holds degrees in both disciplines. “Psychologists and psychiatrists look at problems somewhat differently and can work well together to help the patient,” he notes.

Note: This article was originally printed with the title, "Psychiatry in Flux".

This article was originally published with the title "Psychiatry in Flux."

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