Sigmund Who? Psychiatrists Writing More Scrips
11 CommentsBy Ed Silverman // August 5th, 2008 // 7:56 am
Roll over, Freud, and tell Woody Allen the news. Today’s psychiatrists are writing more prescriptions in favor of good, old-fashioned psychotherapy. And this shift from the couch to the prescription pad apparently reflects financial incentives from managed care and a greater number of available meds, according to a study in the Archives of General Psychiatry.
The researchers analyzed data from national surveys of office-based psychiatrist visits from 1996 through 2005, and found a significant drop in the number of office-based psychiatrists providing psychotherapy. Just 29 percent of office-based visits to psychiatrists involved psychotherapy in 2004 and 2005, down from 44 percent in 1996 and 1997. The decline coincided with changes in reimbursement, increases in managed care, and growth in the prescription of medications.
Visits provided under managed care tended not to include psychotherapy, according to the study, even though various forms of psychotherapy, either alone or in combination with medications, are recommended to treat depression, post-traumatic stress disorder, bipolar disorder and other psychiatric illnesses.
“Psychiatrists get more for three, 15-minute medication management visits than for one 45-minute psychotherapy visit,” Ramin Mojtabai of Johns Hopkins University in Baltimore and one of the researchers, tells Reuters. But there is hope for a well-heeled few. “If you have some hard feelings about your childhood and you live in New York and have a lot of money, you can still find psychiatrists who provide long-term psychotherapy.”
truthman30
Well, it’s easier to medicate than to go through the long process of finding the root of the problem isn’t it? ..
That way the psychiatrist get to see more patients and that means more money in their pocket ..
Psychiatrists operate a production line with peoples brains..
Quite disgusting really..
Even if people did prefer talk therapy, most psychiatrists charge a small fortune for an hour of it..
People should ditch psychiatry and find a listening ear from a friend or family member, would save money and save themselves from dubious psychiatric drugs…
Justice in Michigan
We talked about this trend in a recent thread. I don’t have numbers, but my impression is that it started earlier, also correlated with what insurance would reimburse. I’d take it back at least to the eighties.
I’d also say that it is less important that psychiatrists personally do therapy than that _someone_ does it in the right instances. But clinical psych and social work must also function within very limited ocverage in most instances.
JGeorge
Like Justice in Michigan said, it’s likely that psychologists and social workers are doing more therapy and consulting with psychiatrists if meds are needed. My sister, who is a licensed clinical social worker, works in a detox facility doing group therapy. If the client has medical problems or she thinks a psychiatric consultation is needed, the clinic works with a psychiatrist who provides those services. It actually works pretty well, and I think it saves the clinic overall a lot of money as they don’t need to hire more than 1 psychiatrist.
Bernard Carroll
Psychiatrists respond to incentives just like everybody else. Their brains are wired the same way. In the 1970s the provincial government of Quebec introduced new payment guidelines for psychiatry. Supportive psychotherapy was reimbursed at $45 per hour while psychoanalytic psychotherapy was reimbursed at $65 per hour. When I asked the local psychiatrists to explain how the government knew the difference they fell about laughing and told me all it required was to document one analytic interpretation per session. With one administrative stroke the government wiped out the practice of supportive psychotherapy in Quebec!
Michael D. Miller, MD
But you’re not sufficiently recognizing the greater understanding of the biological/genetic basis for many mental illnesses. That is the basis for the availability of new and better medicines to treat conditions like depression, bipolar disorder and schizophrenia. Psychiatrists (like any physician) would be delinquent if they did not use these new medicines for their patients. And since there are more medicines, then they will be used more.
There is certainly also a role for “talk” therapies, and if the financial incentives are out-of-whack, then that’s something that should be examined. But last time I looked, psychiatrists were towards the bottom of the physician income scale. Also, many psychiatrists don’t take insurance so they don’t need all the billing and support staff costs. If they shift to doing more medication management, will they need to change the infrastructure and staffing of their office to accommodate labs, blood draws and other equipment for physical examinations that may be required with some of the new medicines?
Laurie
“If they shift to doing more medication management, will they need to change the infrastructure and staffing of their office to accommodate labs, blood draws and other equipment for physical examinations that may be required with some of the new medicines?”
They are prescribing these meds now as “medication management” without having those things available now. Go sit in a psychiatrists office…q15 minute visits. No therapy going on there.
If you want therapy find a Psychologist, if you want a drug go to a Psychiatrist.
truthman30
But you’re not sufficiently recognizing the greater understanding of the biological/genetic basis for many mental illnesses. That is the basis for the availability of new and better medicines to treat conditions like depression, bipolar disorder and schizophrenia. Psychiatrists (like any physician) would be delinquent if they did not use these new medicines for their patients. And since there are more medicines, then they will be used more.
you gotta be kidding Justice right?
Even with studies that are done on the brains of the mentally ill such as genetic markers for schitzophrenia etc , who is to say that it’s not the drugs which have caused these changes in brain matter? ..
How are we to know?
How many studies have been done on those who have never taken drugs for their “mental illness”? Where’s the evidence and research?
Justice in Michigan
T’man - I’m wondering why you are addressing the above comment to me. The quote came from Michael Miller, M.D..
Adirondack
Sigh. The poor doctor must use these new drugs which he alleges are “better” while ignoring the thousands of people who have died from them. And as for the bother of drawing blood to get glucose levels and other bothersome “medical” procedures, think of all the people who didn’t get glucose measured who are now dead or have diabetes….I know it’s a bother, doc, but there is next to zero corroboration between psycs. and regular docs, especially in Medicaid. At the very least, you could buy a scale and keep track of your patients’ weight.
truthman30
T’man - I’m wondering why you are addressing the above comment to me. The quote came from Michael Miller, M.D..
My apologies Justice …
Mistake on my part..
M Helm, MD
Dr. Miller,
Is your post, particularly the first paragraph meant to be ironic, or to be taken at face value? Irony does not translate here.
For those who may not know, the biochemical model of psychiatric conditions is far from worked out - if it has any validity at all. The medications used for anxiety and depression - the most common problems in industrialized countries - often(typically/possibly even best case) are no more effective than non-medication treatments alone. For younger patients, the idea of medication only management is not endorsed by any professional society at this point. This is a big hole in a purely neurochemical theory of “mental illness” as I see it.
There is precious little literature providing information on comparative effectiveness of treatments (med v. non-med or med v. med) for “mental illness.” When comparative studies are found, very often the differences measured are intended to “stack the deck” in favor of a newer agent over an older one, or the measurements are on parameters which may not have clinical importance.
For serious conditions such as schizophrenia, clozapine - an older agent with very serious potential side effects - is ikely to be the most effective treatment available to address the parameters of the disorder most often consider pathologic. Comparing newer agents to perphenazine (another older agent with potentially fewer life-threatening complications than cloazapine) revealed that the older drug was at least as good, and likely produced fewer untoward side effects than the newer agents. Last I checked, Litium - with its faults - was still the gold standard medication treatment for bipolar disorders.
In other words, the idea that newer is better is not established. Newer is however, more expensive.
More isn’t necessarily better either.
Psychiatrists would not be delinquent if they chose to employ well-established, effective and safe treatments for their patients, even if that meant that they elected to use only medications that had been on the market for more than 5 or 10 years.
Psychiatrists and other phsycians would, of course, be delinquent if they relied on medications only when other adjunct treatments should be used. Additionally, they would be delinquent if they used medications (with no proven benefits, but known and unknown risks) to treat symptoms of a condition which was not accurately diagnosed. I would also argue that psychiatrists and other providers would be delinquent if they failed to obtain informed consent outlining specifically the diagnosis/diagnoses under consideration, all treatment approaches, the quality (or lack) of evidence-support for the treatment recommended, and the known and likely theoretical risks and benefits.
Still, though psychiatrists (and pediatricians) don’t make the same money as orthopedic surgeons, they aren’t impoverished. They certainly do better than clinical psychologists, licensed psychological counsellors, clinical social workers, etc. I know a few who do quite well with relationships with psychiatric hospitals, residential treatment facilities and community mental health centers while delegating much of the work to “mid-level providers.”
Certainly monitoring labs do not require a changes in office structure. There are plenty of commercial labs who will do the work, and send the results directly to the physician. A psychiatric office can operate with minimal overhead, especially relative to other medical specialties.
Of course I’m not a psychiatrist, so many would argue that I don’t know what I’m talking about. Some will also likely argue that I’m advocating the use of unsafe/inappropriate medications, though in fact, I’m not. I do advocate responsible treatment consistent with treatment guidelines/practice parameters and the most current, best avaialable evidence.
As for financial incentives being “out-of-whack.” That’s nothing but true. I believe in the golden rule of healthcare - “He who has the gold makes the rules.” There is a logical follow-up to this: “You get what you pay for.”
Until the people who actually purchase mental health services - that would mostly be us, the taxpayers - determine that medication management is not as valuable as providing/coordinating more comprehensive services, this is what we get.
I’m not very happy with it. Are you?