A fifteen-minute med check, a ‘scrip for some Prozac, and you’re outta here, buddy!
You got other problems? Talk to your therapist!
If the front-page article in the March 6 New York Times1 can be believed — and who wouldn’t believe America’s “Paper of Record”? — this is essentially what the practice of American psychiatry has become. But how accurate was the Times’ portrait of outpatient psychiatry? How grounded was it in the best available research? And given the roughly 30,000 psychiatrists in the U.S., how clear a picture can we get by peering through the eyes of one beleaguered practitioner who believes that psychotherapy is no longer “economically viable”?
As an occasional contributor to the Times who has great respect for its journalistic integrity, I’m sorry to say that this story was a disservice both to the Times readership, and to the profession of psychiatry. Although the article may have been a well-intended expose of malign insurance company practices, it amounted to a jaundiced caricature of psychiatric care — accurate in some respects, but distorted in many others. Furthermore, by disparaging the role of psychiatric medications, the Times article reinforced the “mind-body” split that has bedeviled psychiatry for the past 50 years, as Tanya Luhrmann showed in her classic study, Of Two Minds: The Growing Disorder in American Psychiatry.
But before critiquing the Times article, let’s own up to some real problems associated with current psychiatric practice.
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I was treated by two different psychiatrists. Both acted *exactly* as the article describes–the visits were 15 minutes or less (including the first visit), and no therapy was provided beyond medication.
Jude, what CPT code did they use? Mine (about a half-dozen over 10 years) all used the CPT code for psychotherapy even though all they were doing was med checks.
I appreciate your balanced response to the New York Times article. It’s also good to hear about SUNY’s rigorous program.
Just two quick things I’d like to mention: The New York Times also did not mention psychiatrists who have chosen to operate outside the insurance provider list system. The ones whom I know do as much full session psychotherapy as they do medication management. They’ve made this choice because they want to be able to do therapy. Of course, a downside is that they are priced out of the market for many people; but at least one of the MDs I know uses the resulting as high or higher income for less hours worked to be able to do more pro bono and reduced fee work.
On the psychotherapy side, we’re also watching neuroscience enter therapists’ offices via the work of such paradigm shifting thinkers as Allan Schore and Daniel Siegel. Their work both enlightens therapists as to why what we’ve been doing works – and makes us more effective at it.
I very much appreciate Catherine Boyer’s point about working outside the insurance system (which was how my practice was set up, with the exception of Medicaid). I was free to work out an affordable fee with my patients, and I used to see some for sessions lasting over an hour. By the way, there is no justification for an initial (intake) session lasting 15 minutes! It is impossible to do a thorough evaluation of a new patient in less than 45-60 minutes, in my view.
Finally, just a note to readers: I will gladly respond to remarks and questions, provided the comment is “civil” and accompanied by the reader’s full name. Thanks to all for your understanding and interest!—Best regards, Ron Pies MD
Hi Dr. Pies,
I am heartened to read your excellent critique of that disturbing New York Times story about the practice of psychiatry. It desperately cried out for the balance you provide and I thank you for it, especially your stressing that psychotherapy and psychopharmacology are both necessary for effective emotional healing.
My experience with psychiatry and psychiatrists spans more than 51 years and about 15 different psychiatrists. All are completely different ~ they’re human, after all. As far as I’m concerned, talking therapy is the only way to really gain insight and ~ with or without medication ~ to heal. There are no insights in a pill bottle.
Essentially, I believe, psychotherapy involves healing oneself with guidance, a skilled, empathetic and intelligent listener, the judicious use of medication as a tool if needed, and a great deal of hard work. It takes time and patience. A good psychiatrist cares. That’s the bottom line.
I know. I’ve been seeing one psychiatrist for more than 20 years. He is truly, as you describe, a “doctor of the soul.” He is a university professor, and, like you, I’m sure he inspires his residents, to practice their profession with the values to which he subscribes. Not the values of the pathetic psychiatrist portrayed in The Times piece.
I know people who’ve had these experiences, but others, who have meaningful relationships with their psychiatrists and active psychotherapy sessions that last a minimum of 50 minutes.
I was so annoyed that The Times piece was discrediting the entire practice of psychiatry. Years ago, one of my psychiatrist’s was negligent in his monitoring of my Lithium levels, resulting in iatrogenic acute endstage kidney failure, dialysis and transplant. That doesn’t mean all psychiatrists are negligent or that Lithium is a bad drug. It is not. For some people, it’s very effective.
This portrait was more about one man’s sick values than about the contemporary practice of psychiatry.
Thank you for setting the record straight and offering an annotated insider’s perspective on the practice of psychiatry. Frankly, I wouldn’t be as well as I am right now, without my psychiatrist and my on going psychotherapy.
Sandy Naiman
I am a pharmaceutical rep selling an antidepressant. 99 percent of the psychiatristsmi call on are turnstiles. I don’t want to come off as derogatory, but my anecdotal evidence supersedes both billing analysis, which is often exaggerated, or study analysis, which relies on subjective analysis of one’s own practice. Not many psychs are willing to admit it, but they are medication managers who often prescribe off label and outside of FDA approved dosing ranges.
I noticed you took no responsibility in hawking drugs. How do Dr’s find out about these off use, uses of drugs…the big pharms.The fact you invade the Dr’s territory, use their time, leave samples, make it worth their time to listen to your high pressured sales tacktics, I’d say you are motivated by a self serving need to cover up your involvement.
I have worked with some very skilled psychiatrists and one thing I noticed is the incredible pressure they have to push medication along with the rewards and perks they get for prescribing certain brands. Then you have what I call “the babes” who come to the office to flirt and push their drug company’s products. If you are published or well known in your field then there are the requests to go and promote and speak about the “scientific” benefits of a particular drug at a Doctor’s banquet. The company pays you handsomely and takes care of all expenses. Sometimes you can do a couple of these a day and walk away smiling.
Somehow I feel a little cheated…
I can see many of my patients experience massive healing of core issues and traumas. Their life becomes healthy and whole and yet I don’t make as much as those who push chemicals. Don’t get me wrong, I believe in using medication within reason but the guys who can heal… I guess we don’t get credit…$$$$$
We are not as interesting…
Samuel Lopez De Victoria, Ph.D.
http://www.DrSam.tv
Once again, the NY Times published a portrayal of an extreme case/outlier, which once again, led to a widespread infiltration of critique articles on all the popular mental health blogs and pop psychology websites.
The 15 minute appointments just don’t work; they can prolong patients’ illnesses. Problem is, we often don’t realize this until after years of our lives have passed by while we were cognitively blunted and emotionally numbed by medications. Some will never know just how detrimental this popular mental health model can have on one’s well beings.
Luckily, I still had some decent years left by the time I found a psychiatrist-psychoanalyst. He seems to make a decent living and fulfilled with the psychotherapy services he offers. Rarely see a drug rep in his office either (all you have to do is put a sign on the door to keep them out).
Many thanks to fellow blogger Sandy Naiman for her supportive and illuminating comments! It is very refreshing to see balance and good-heartedness–and courage–in these surly times!
With regard to Dr. Lopez De Victoria: I believe that all of us in the helping professions strive to be “healers”, and I do not believe most psychiatrists are “pushing” medications. In fact, I believe most are committed to trying “talk therapy” first, in instances of mild-to-moderate illness. There are some cases of severe psychiatric illness, however–cases often referred to psychiatrists–in which early use of medication is both necessary and appropriate.Ideally, this should be in the context of concomitant psychotherapy, notwithstanding the market forces (and lack of insurance coverage) that often make this difficult.
Nonetheless, I agree that the field of psychiatry as a whole has often had too close a relationship with “Big Pharma” in recent years, and needs to become more independent and evidence-based in its use of medications.
Ronald Pies MD
As someone who had a schizophrenic father that I could never control and a schizophrenic grandmother, I feel psychiatry basically over medicated them both until my father would not take any medications at all and then self-medicated himself with drugs. My grandmother was a walking zombie. This is my perception from personal experience. Thank you.
No offense intended, but I completed resonated with the NY Times article. I understand that Dr. Pies is a renowned psychiatrist. But no doubt he works on the East coast, where psychiatry is more likely to retain some of its former grandeur. When I was in training, psychiatry often embodied the best of what people see in medicine– thoughtful counselor & advisor, expert diagnostician, and [lastly] prescriber of medications.
I practice rheumatology, in which many patients have significant psychiatric problems coupled with chronic pain and somatoform disorders. For years, I worked with psychiatrists who would help with diagnosing and managing the dynamic issues involved with these difficult patients. I feel a little ripped off when I refer patients for psychiatry consults these days. I can usually manage their meds, but I’d like a little help with difficult patients.
That being said, psychiatry isn’t that different for any other part of medicine–with declining reimbursement physicians are finding more profitable activities. I give more injections, spine surgeons do more fusions, psychiatrists do more medication management, etc. In case you haven’t noticed, many people who can avoid prolonged interactions with patients are doing so. Psychologists are doing fellowships in neuropsychology in order to do evaluations rather than therapy, etc. I’m hopeful that this general trend reverses itself someday, but I’m not hopeful. PS I do ask psychologists in our clinic for medication recommendations. I find that the level of intellect and thoughtfulness is much more important than the person’s specific area of training. Where I work, psychiatrists don’t take middle of the night phone calls unless its to authorize admission to the psych unit. The ER manages middle of the night medical problems.
I agree that the NY Times article over-simplified things, as there clearly are a number of psychiatrists who provide excellent clinical care.
That being said, I’m not certain that you and I agree 100% on what constitutes vigorous clinical training. For instance, the training the Ph.D’s in clinical psychology obtain extends across years of both didactic and practical experience.
More importantly, however, is the issue of what is taught. Specifically, the absence of psychodynamic psychotherapy in the training of psychiatrists is, based upon the data, not a source of weakness. Certainly there is some evidence that psychodynamic approaches are beneficial in some contexts, but recent efforts to proclaim that the treatment is equal to or superior to empirically supported treatments of other orientations (e.g., CBT for depression, DBT for borderline personality disorder, family-based treatment for adolescent anorexia) such as the highly publicized piece by Shedler (2010) have been refuted quite definitively through careful examination of the data. I would recommend the most recent issue of the American Psychologist in which a series of critiques of that piece were published as a resource on this front.
Psychiatry is a vital part of this nation’s mental health care system and I have referred clients in that direction repeatedly. That being said, the degree to which psychiatrists are trained in and subsequently practice evidence-based psychotherapy is problematic and a situation in need of remedy.
Mike Anestis
My psychiatrist is exactly like the NYT article described. That said, I live in a crappy city in Ohio so it may not be representative, and I also realize that this is anecdotal evidence. So maybe you’re right.
I have never once been to a psychiatrist (and I’ve been going on and off for twenty years) who did psychotherapy with me or anything else besides prescribe me drugs.
This is exactly what has happened to me with every psychiatrist I have taken myself or my son to. They generally will prescribe meds on the FIRST visit! Wow. And I’ve had one who spent only about 15 minutes with my son DISAGREE with a diagnosis made by a person who made the diagnosis over 6 appointments including observation sessions at home and school! Insulting. They do not listen.
I’d like to thank those who took the time to write comments, and I will respond more substantively to some concerns when I return from my current travels. In the mean time, I want to thank fellow blogger Therese Borchard for her important perspective. The link follows.
Best, Ron Pies MD
http://psychcentral.com/blog/archives/2011/04/07/psychiatrists-are-like-cat
holics-disliked-by-the-media/
Hi, Ron–
I borrowed this for Shrink Rap.
Dinah
I thank all those who contributed comments to this discussion, and thanks to Dinah for her “call out” to my article.
In particular, thanks to Dr. VandeWalle and Dr. Anestis for their observations of current psychiatric practice, and the comparative efficacy of different types of psychotherapy, respectively.
I agree with Dr.VandeWalle that virtually all medical and mental health specialists are being
“squeezed” by economic pressures, and that this is altering practice patterns–not for the
better, I fear, in many cases. I do find it disheartening that Dr. VandeWalle finds psychiatric consultation less helpful than in years past, though given the time pressures on psychiatrists, I am not entirely surprised. When I was doing psychopharmacology consults, some years ago, I often spent two or three hours preparing a report for the referring clinician, having spent 1-2 hours evaluating the patient. I can’t imagine that many psychiatrists nowadays would be able to justify such lavish expenditures of time. As for asking psychologists for recommendations on medication, I think that this is both understandable and–with all due respect to my psychologist friends and colleagues–only partly justifiable. Certainly, psychologists are in a very good position to help the physician decide whether psychotropic medication is warranted in a given case; but for reasons I have discussed elsewhere, I do not believe psychologists should be offering opinions on the indications or contraindications for specific psychiatric medications, any more than they should be offering recommendations on specific anti-inflammatory agents. But that is a topic that takes us far afield from my article on psychotherapy.
Dr. Anestis offers some important criticism of the evidence-base for psychodynamically-oriented
psychotherapy. I have looked over the abstracts, but not the entire articles, he references in
the American Psychologist. These papers critique the article by Shedler, which appeared to show
the efficacy of psychodynamic psychotherapy, compared with CBT and other approaches.
Interestingly, a recent German review (meta-analysis) of psychodynamic psychotherapy concluded that, “psychodynamic psychotherapy is superior to control conditions (treatment-as-usual or wait list) and, on the whole, as effective as already established treatments (e.g. cognitive-behavioral therapy) in specific psychiatric disorders. With regard to process research, central assumptions of psychodynamic psychotherapy were confirmed by empirical studies.” [Leichsenring F, Leibing E.
Psychol Psychother. 2007 Jun;80(Pt 2):217-28].
My personal bias, in truth, is toward the cognitive-behavioral therapies, such as Ellis’s REBT; however, I do believe that psychodynamic psychotherapy is a useful, validated form of treatment in certain instances,notwithstanding the methodological problems inherent in all meta-analyses of psychotherapy.
Stated a bit differently, I believe there are non-specific factors common to all psychotherapies
that render them effective, and I have yet to see randomized, controlled, head-to-head, prospective studies showing that one type of therapy is conclusively better than another. Absent such rigorous studies, I believe the proverbial jury is still out.
In the mean time, the general public should be assured that psychotherapy really does work–and that many psychiatrists(and other mental health professionals) still provide this vital form of treatment. The larger problem, alas, is that accessible and affordable psychotherapy is very hard to come by, given our present patch-work health care system. This must change if any of us in the mental health field are to help those most in need of our services. –Ron Pies MD
Dr. Pies -
Thanks for your thoughtful reply. Just a quick note:
The Leichsenring & Leibing (2007) study you mentioned was one of the studies utilized by Shedler in his review to arrive at his conclusions. In other words, my critique (and those of other comment authors) of Shedler’s conclusions took that article into consideration. More importantly though, Bhar and colleagues (including eminent psychologists Jim Coyne and Aaron Beck) published a reply to that piece in Psychotherapy and Psychosomatics (Bhar et al., 2010) that fairly conclusively discredited the conclusions of Leichsenring & Leibing, who unfortunately have published a number of highly flawed meta-analyses.
I agree that common factors are an important consideration and there are a number of researchers out there devoting their careers to studying those issues (e.g., Crits-Christoph, Tang, Siev). I also agree that evidence-based approaches such as CBT do not work for every client and that some individuals no doubt have benefited from psychodynamic psychotherapy. My issue is simply with folks who are publishing research based upon faulty data, who make claims inconsistent with their results (or the results of others) and nonetheless get substantial media attention. I think that kind of work ends up directing patients away from optimal care, as they have almost no way of knowing whether the mental health treatment they are receiving represents current best practices.
Anyway, thanks again for your thoughtful reply. Hope you’re doing well.
Mike Anestis
Thanks to Mike Anestis for clarifying the reference issue. I think we are largely in agreement, Mike, though I wish the field would move away from meta-analyses of psychotherapy to prospective, randomized, head-to-head comparisons of different approaches for specific disorders…hard to do, but more valid, I think, than many of the meta-analyses. –Best regards, Ron Pies
“….But as my colleague Paul Summergrad MD has pointed out, common practice and standard CPT billing codes (e.g., 90805) specifically include 20-30 minute visits for psychotherapy, with or without pharmacotherapy….”
If this is the statistical basis of this defense — and I believe it is — allow me to point out that every one of the half-dozen psychiatrists I’ve seen has billed for the higher-paying CPT code rather than lower-paying medication management, even though he or she never spent more than a half-hour with me (more often 15 minutes), and did nothing but med management.
It’s not that so many psychiatrists provide “some” psychotherapy with their pharmaceuticals, it’s that some many psychiatrists routinely commit insurance fraud. Hey, they all do it — it’s a standard of the profession.
So the truth is, psychiatry has sunk even lower than the NY Times article implied.
Psychiatrists are sometimes so eager to fill their day with an excessive number of patients that they over overbook their schedules. Insurance companies and government providers such as Medicaid and Medicare are often swindled when psychiatric facilities bill them for patient work which has not been completed or when the patient has been given unnecessary treatment. So a person with lesser income group how can he stay away from such problem as Psychotherapy Training is proving to be necessary requirement for a healthy world
I’m not a psychiatrist, and I’m aware that my dealings with psychiatrists is limited in the grand scheme of the profession. However, my opinions can only be formed based on the statistically irrelevant cross-section of the field that I have come into contact with. I accompany my mother to all of her quarterly med-check visits, and I can attest that writing prescriptions and monitoring side-effects is literally all they do for her. She is on a managed care plan that now only pays for medication, but even before this change happened in our state that’s all her psychiatrists ever did. She’s been on a coctail of different medications for two decades; in my own (layman) research, I’ve learned that the disorder affecting her most profoundly is BPD/ERD can be managed most effectively with DBT. She’s had this diagnosis for at least 15 years and this therapy has never been offered. No therapy has ever been offered. She’s been medicated and turned loose, hospitalized to stabilize her medication and then turned loose again. It’s not one single doctor or one small contingency of doctors, it is a systematic failure of the profession to properly care for my mother’s treatment. I can’t help but agree with the article’s assessment of the situation, and I can’t help but wonder, as an ethical human service professional myself, whether those doctors can sleep at night knowing they are herding cattle with chemical prods instead of treating patients with the view to improving their quality of life.
*I meant to say ‘statistically insignificant’. Obviously they are still relevant.