Despite a trend that started as early as the late 1980s, Gardiner Harris writing in The New York Times yesterday seems to bemoan the fact that most psychiatrists don’t practice psychotherapy any longer.

Perhaps Harris should have interviewed Dr. Danny Carlat, who nearly a year ago wrote about his experiences as a modern psychiatrist (in the The New York Times Magazine, no less). Psychiatrists nowadays are generally poorly trained in psychotherapy, so they spend most of their time prescribing psychiatric medications. (Dr. Carlat’s book, Unhinged is well worth the read for further background about modern psychiatry.)

So I wasn’t sure why I was reading this in the “Money and Policy” section of the Times. Surely it’s not news that psychiatry is no longer practicing much psychotherapy — and hasn’t been doing so for decades. What’s the story here?

It appears to really just be a lifestyle piece about Dr. Levin, a practicing psychiatrist who has had to switch gears mid-career from a psychiatrist who was doing a fair amount of psychotherapy earlier in his career, to one who does nothing but medication prescriptions.

Dr. Levin no longer sees patients for 45-minute sessions to do psychotherapy:

Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

I think this is a perfect example of a false dichotomy on the part of the writer. Of course a person who is “functional” because he or she is stable on their medications can also be “happy and fulfilled.” The role of the psychiatrist has not been diminished — it has simply changed. Do we look down upon a family doctor because all they do is pretty much the same thing — try and address the person’s presenting complaints, usually with a prescription? Why the negative take on this important job?

The switch from talk therapy to medications has swept psychiatric practices and hospitals, leaving many older psychiatrists feeling unhappy and inadequate. A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since. Psychiatric hospitals that once offered patients months of talk therapy now discharge them within days with only pills.

I guess it’s just a lament for “the good ‘ole days,” when psychiatry was the primary clinical mental health profession and didn’t have to share its professional space with clinical psychologists (or clinical social workers). Nowadays, of course, most psychotherapy is performed by either clinical psychologists — who get far more training and practical experience in psychotherapy than medical doctors do — marriage and family therapists or clinical social workers.

There is a tiny discussion of the economics of psychiatry and mental health care in general, buried in the middle of the article. Here’s a snippet of it:

Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so they can often afford to charge less — is the reason that talk therapy is priced at a lower rate.

Wow, great research there. In fact, many psychologists nowadays come out of their graduate school training in as much debt as psychiatrists — as much as $150,000. While those are the extreme outliers, many psychologists are graduating with 6-digit debt figures, and will be hard pressed to repay that debt making $110 – $120/hour (the typical psychotherapy session fee charged by a psychologist).

A great deal of the article is focused on how over-worked and underpaid (for their training) psychiatrists can be — even when they switch to an all-meds practice.

I have news for Harris — that’s all of mental health care. I suspect most professionals today who practice psychotherapy don’t feel like they’re “doing well.” Sure, there are exceptions; for instance, anyone who can afford to move exclusively to an all-cash business are usually doing quite well (e.g., they accept no insurance). And once therapists figure out their business model (few psychology graduate programs offer any courses in business or marketing still!), 10 or 20 years down the road after graduating, they can begin to breathe a little easier.

But most clinical mental health professionals are living a very middle-class, middle-of-the-road lifestyle. The first decade after school is often the most difficult — debts are due, but salaries start out too low to even keep one’s head above water.

So while I do indeed feel for psychiatrists who have had to make these kinds of mid-career changes in how they practice their profession, they are not alone. The healthcare system in the U.S. remains broken, and every mental health profession — not just psychiatry — is feeling the pain.

Read the full article: Talk Doesn’t Pay, So Psychiatry Turns to Drug Therapy –