“This isn’t supposed to be talk therapy. I came here for medication.”
“Yes, but in order for me to prescribe, I need to know about you and your problem.”
This exchange occurred 20 minutes into an interview with a 17-year-old patient. She suffered from school phobia and feelings of detachment. Her therapist was a social worker – a colleague who thought that the patient was a candidate for psychoactive medication. In the patient’s mind, my role was to write a prescription.
My practice has changed, and so has the focus of psychiatry. No longer am I a medical doctor specializing in treating mental illness. I am a medication provider. Now I get calls from potential patients who need a psychopharmacologist. I’m concerned about the future of our specialty if we fail to address these trends now.
Medication as a single tool
We all learn about medicating psychiatric patients. After all, the details of treating and prescribing get covered in residency and fellowships. We continue the learning process by reading journals, and attending conferences and workshops. A medical education is a scientific exploration of human processes in health and diseases; prescribing competency is just part of the psychiatrist’s armamentarium. Only recently has prescribing become the defining role of the psychiatrist.
Devaluation of talk therapy
Talk is cheap. That phrase comes to mind when referring to talk therapy. We all talk, so how can that be healing and magical, compared to prescribing psychoactive medication, now the domain of psychiatrists (and, of course, our colleagues in primary care.) This underappreciation of the value of talk therapy by trained psychiatrists might explain why we seem to have ceded this important tool to other mental health professionals.
Finances also play a role. Medicare, Medicaid, and insurance companies reimburse a lower fee to nonmedical therapists. This means that when practitioners who are not psychiatrists deliver therapy, the companies don’t have to shell out as much money. Besides, reimbursement is low to begin with.
Of course, an out-of-network psychiatrist can charge her fee. But most patients prefer the option of a copay rather than paying out perhaps as much as $300 a session out of pocket and awaiting a potential, partial reimbursement.
Those of us in the field know that psychotherapy is oriented to the unique needs of a patient. But if medication accomplishes the same result, where is the need for us? The trouble is that one person’s depression is not another person’s depression; causes and results vary. Problems need formulation and solutions; they require ideas. There is surely a place for what Dr. Henry A. Nasrallah recently described as to how to treat depression in Current Psychiatry ( 2015;14:10-3 ). “Treating depression … involves … increasing neurotrophic factors, enhancing neurogenesis and gliogenesis, and restoring synaptic and dendritic health and cell survival in the hippocampus and frontal cortex,” he wrote.
But can we dismiss the psychological component because we embrace and pursue depression’s biology? Should we, as medical doctors, abandon psychotherapy?
Changes in practice
Often cited is an article by Dr. Ramin Mojtabai and Dr. Mark Olfson in the Archives of General Psychiatry (now JAMA Psychiatry) entitled “National Trends in Office-Based Psychiatrists” ( Arch. Gen. Psychiatry 2008;65:162-70 ). The authors attempted to lay out the changes in psychiatric practice by comparing numbers of psychiatrists who provide psychotherapy in 1996 with numbers in 2005. Psychotherapy sessions were defined as longer than 30 minutes and designated as such.
Dr. Mojtabai and Dr. Olfson found a decline from 17.1 % to 10.9%, based on a systematic random sample of patient visits to each psychiatrist and gleaned from the National Ambulatory Medical Center Survey . The authors observed a decrease in psychotherapy by psychiatrists and an increase in psychiatrists who identify as psychopharmacologists. This trend is likely continuing to the present.
Where this leaves psychiatry
Those of us seeing patients every day are poor at promoting ourselves. In light of these trends, a reconfiguration of psychiatric practice is needed. Why should we forgo psychotherapy and offer primarily or solely medication management? A focus on prescribing is a waste of our medical education and experience – and deprives the community of our broad expertise.
Advances in genomic pharmacology or precision medicine will allow patients to either give a blood specimen or get a cheek swab, and perhaps fill out a questionnaire to receive proper medication. Still others will have neuromodular methods of brain stimulation for mental illness. I worry that talk therapy will become the domain of non-MDs and that the pharmacology of mental disorders will become a subspecialty of neurology or internal medicine.
The American Psychiatric Association represents us, but those who work for the APA are primarily salaried, hospital-based administrators in academic positions, and are largely removed from the day-in day-out treatment of patients. We need to redefine the mission of psychiatry by creating a task force made up psychiatrists in practice. Without committed advocacy from a wide variety of psychiatrists, many of us will continue to be critically underutilized. Ultimately, the losers will be our patients.
Dr. Cohen is in private practice and is a clinical assistant professor of psychiatry at Weill Cornell Medical Center of New York-Presbyterian Hospital, and psychiatric consultant at the Hospital for Surgery in New York.
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