From the Los Angeles Times

Medication increasingly replaces psychotherapy, study finds

Fewer patients are undergoing in-depth treatment as antidepressants 
and other drugs are more widely used. The shift is attributed partly 
to insurance reimbursement policies.

By Denise Gellene
Los Angeles Times Staff Writer

August 5, 2008

Wider use of antidepressants and other prescription medications has 
reduced the role of psychotherapy, once the defining characteristic 
of psychiatric care, according to an analysis to be published Tuesday.

The percentage of patients who received psychotherapy fell to 28.9% 
in 2004-2005 from 44.4% in 1996-1997, the report in Archives of 
General Psychiatry said.

Researchers attributed the shift to insurance reimbursement policies 
that favor short medication visits compared with longer psychotherapy 
sessions, and the introduction of a new generation of psychotropic 
medications with fewer side effects.

Although not a surprise to many psychiatrists, the findings were 
expected to intensify a debate over the increased medicalization of 
psychiatric care, which in part reflects an emphasis on the biology 
of mental illness, as opposed to the processes of the mind.

Psychotherapy is an interpersonal intervention that may involve such 
things as behavior modification and group discussion. It is 
recommended -- with or without medication -- for major depression, 
post-traumatic stress disorder, bipolar disorder and other 
psychiatric illnesses.

Besides psychiatrists, a range of mental health professionals not 
covered in the report also conduct psychotherapy, including 
psychologists, social workers and marriage counselors.

The study was based on data drawn from the National Ambulatory 
Medical Care Survey, an anonymous survey of office-based physicians 
that tracks characteristics of patients and physicians, and records 
the diagnosis and treatment, during a typical week.

Researchers examined data on 14,108 psychiatric office visits during 
a 10-year period.

Psychiatrists who said they provided psychotherapy to all of their 
patients declined to 10.8% in 2004-2005 from 19.1% in 1996-1997, 
according to the report. Consistent with previous studies, 
researchers found that patients who paid out-of-pocket, generally the 
wealthiest patient group, were more likely to receive psychotherapy.

Financial incentives were weighted against psychotherapy, the report 
said. Reimbursement for a 45- to 50-minute outpatient psychotherapy 
session was 40.9% lower than reimbursement for three 15-minute 
medication management visits, the report said, citing a 2003 study. 
Anticipated changes in Medicare reimbursement are expected to bring 
payments into closer balance, experts said.

Also fueling the trend, according to the report, was the aggressive 
marketing of psychotropic medications to psychiatrists and patients. 
That push, for example, has helped make antidepressants one of the 
largest-selling classes of drugs.

Dr. Mark Olfson of the Columbia University Medical Center, a study 
author, said patient attitudes might also be hastening the shift. 
Taking a pill may look a lot easier to patients than psychotherapy, 
which is more time-consuming and may involve the regular 
participation of more than one family member.

The report found evidence of a cultural preference for psychotherapy 
in the Northeast, which Olfson said might be attributable to the 
influence of Yale University School of Medicine and the University of 
Pennsylvania School of Medicine, whose faculties are strong 
proponents of psychotherapy.

Because the study looked only at psychiatrists, it couldn't determine 
whether patients who needed psychotherapy were receiving it from 
other mental health providers or going without treatment, Olfson said.

Dr. William H. Sledge, interim chairman of the department of 
psychiatry at Yale, said the report was worrisome. Although training 
in psychotherapy is a standard part of psychiatric training, he said, 
that know-how is in danger of becoming lost.

"A group of practitioners is losing an important skill. It is like 
going to war with fewer weapons at your disposal," Sledge said.

Dr. Alan F. Schatzberg, chairman of the department of psychiatry at 
Stanford University School of Medicine and president-elect of the 
American Psychiatric Assn., said the trend was not necessarily bad. 
It could be seen as a natural evolution, similar to what is seen in 
other fields of medicine.

"Years ago, if someone had a herniated disk, they had a very 
complicated surgical procedure and were in traction for weeks," he 
said. "Fields change. What we don't want to do is decide treatment 
based on reimbursement."

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