From the Los Angeles Times
Medication increasingly replaces psychotherapy, study
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
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
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
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
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
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
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."