If you follow the news, you know it’s a bad time to be a psychiatrist. I’d say almost as bad as being a Catholic (especially during the sex scandal … holy Jesus).
Apparently they no longer really care about their patients. They are a bunch of greedy Mr. Krabs. They have abandoned psychotherapy, only to pass out samples of the latest drug so that they can get their free lunch from big Pharma. (My sister used to make them … they’re quite good!)
And then along comes one of my favorite psychiatrists, Ronald Pies, M.D., to set the story straight. In a World of Psychology post earlier this week, he dissects the front-page article in the March 6 issue of The New York Times.
Pies cites some statistics that, yes, indicate there is less psychotherapy today performed in psychiatric visits; however the same studies also maintain that almost 60 percent of psychiatrists are providing psychotherapy to at least some of their patients. And there are a few other complexities regarding the numbers that the Times failed to consider.
Like the window of time and the psychotherapeutic technique. Pies explains:
The threshold for considering a session “psychotherapy” was set quite high in the Mojtabai-Olfson study: the meeting had to last 30 minutes or longer. 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.4 Furthermore, Mojtabai and Olfson acknowledged that
“Some visits likely involved use of psychotherapeutic techniques but were not classified as psychotherapy in the current analysis. Psychotherapeutic techniques can be effectively taught and used in brief medication management visits by psychiatrists and other health care providers.”3 (p.968)
This last point was totally lost in the New York Times report. When I used to see patients for “medication checks” in my private practice, I would sometimes spend more time providing supportive psychotherapy than dealing with the medication issues, if the patient’s emotional needs warranted it…. Furthermore, in providing medication for some severely personality-disordered patients, it is often impossible to maintain the therapeutic alliance without understanding the patient’s self-sabotaging defenses. As Glen Gabbard MD has observed, “…psychotherapeutic skills are needed in every context in psychiatry” — including during the much-maligned 15-20 minute “med check.”5
Pies documents other statistics that show that many psychiatrists ARE committed to psychotherapy:
Moreover, other data, omitted from the Times article, contradict the impression that psychiatrists have given up on psychotherapy, or that most meetings with psychiatric patients are just 15 minutes long. For example, Reif et al (2010) found that, in a managed care psychiatric practice setting, two-thirds of claims involved medication management, and two-thirds involved psychotherapy — with an overlap of about 30%.6.
Here’s where I feel a little guilty, because in a blog post I recently published on the website Blisstree.com, I also complained about the 10 to 15 minute slot some psychiatrists have. I experienced it back when I was shopping for a head doctor like a nanny. However, I don’t blame the psychiatrists. I blame the insurance companies. In the blog post called “Mental Health Overmedicating Vs. Health Care,” I wrote:
Here’s the thing. Most good doctors don’t take insurance. They can’t. Because they can’t properly diagnose a person in 10 to 15 minutes. No one can.
On the contrary, my current doctor won’t accept a patient until he/she agrees to an initial assessment of two hours. Two hours. Can you imagine? Two hours to give a doctor your psychological history, family history, current symptoms – and an exhaustive reading of your non-verbal language as well – so that she can begin to paint the context or story around your illness that’s absolutely crucial in order to diagnose correctly. She keeps her patients accountable to things like diet, exercise, counseling, and meditation, and incorporates alternative therapies like omega-3 capsules into their recovery.
But no doctor who accepts health care insurance can pull that off. And that, I believe, is our biggest problem.
I also went on to explain that most people on Prozac and Zoloft these days don’t get their meds from psychiatrists but rather their primary care physicians, who definitely don’t do psychotherapy or have the time to delve into the psychological issues surrounding a person’s diagnosis.
I close that blog post with an excerpt from Judith Warner’s op-ed piece in The New York Times about a year ago, entitled “The Wrong Story About Depression,” that I think accurately articulates the bigger problem we have regarding mental health in this country:
Contrary to popular belief, there’s no evidence that most psychiatrists regularly prescribe pills straight off to people who can get better by reading about depression, exercising or doing nothing….That people have come to believe otherwise may be in part because most patients with depression are treated by general practitioners, not psychiatrists. Studies have shown that these primary care doctors don’t strenuously enough screen their patients for depression before prescribing drugs, or closely monitor their care afterward.
Inadequate treatment by nonspecialists is only a piece of the problem. In fact, most Americans with depression, rather than being overmedicated, are undertreated or not treated at all. This is the big picture of mental health care in America: not perfectly healthy people popping pills for no reason, but people with real illnesses lacking access to care; facing barriers like ignorance, stigma, and high prices; or finding care that is ineffective.
Kudos to Ron Pies and Judith Warner for filling out the black and white picture in the media with a few strokes of gray.