Psychiatrists are engaging in less psychotherapy than they once did and may be more likely to specialize in drug therapy, according to a report in the August issue of the Archives of General Psychiatry. The trend may be explained by several factors including financial incentives to focus on other aspects of care, fewer psychiatrists being trained in -- or specializing in -- psychotherapy, and the wider range of medications now available to clinicians.

In the Archives study, researchers analyzed data from 1996 through 2005 on a nationally representative sample of over 14,000 visits to office-based psychiatrists. They found overall that psychiatrists were offering at least 30 minutes of psychotherapy at 34 percent of the visits within the course of a normal week. But the percentage decreased from 44.4 percent in 1996-1997 to 28.9 percent in 2004-2005, according to the research.

George Grossberg, MD, a professor of geriatric psychiatry at Saint Louis University School of Medicine, said he, too, has noticed a trend toward "the re-medicalization" of psychiatry.

This process is not surprising to Grossberg, particularly given a system ruled by third party payer involvement. Many are reluctant to pay for psychotherapy. "Several years ago, I predicted more medical management, differential diagnosis and treatment planning," on the part of psychiatrists, Grossberg said. "Psychiatrists will still be doing some psychotherapy but mostly supportive, directed therapy as part of a comprehensive plan which involves pharmacotherapy and working with the other healthcare professionals involved in the patient's care."

Researchers in the Archives study found that psychiatrists were more likely to offer psychotherapy to patients who were self-pay than those with managed care visits. The study concludes that psychiatrists face "a key challenge" in balancing "biological and psychosocial perspectives while working within the constraints of the strong market forces of third-party payers and managed care."

Training is an issue

Experts here say training plays a role as well. "As psychiatrists are more and more biologically-based, the amount of psychotherapy training in many places is very little," said Randi Mozenter, Ph.D., a clinical psychologist who is board certified in psychopharmacology and in practice at Barnes-Jewish Hospital. "Often for a resident physician to get trained, they have to really seek it out."

And while psychotherapy has long had a significant role within the context of psychiatry, more recently it is being conducted by psychologists, social workers and other psychotherapists rather than psychiatrists. "A patient could have severe anxiety and really need both cognitive therapy and medication but oftentimes, such a patient can't get both from one provider," Mozenter said.

Only a few states allow prescriptions from health care providers other than physicians and mid-level providers such as nurse practitioners. Missouri is not one of those states. "We are not permitted to prescribe," Mozenter said. "We are medical managers; we manage, consult and collaborate."

Less money, less time

Economics are at play for psychiatrists who have only so much time for psychotherapy. "If you're getting reimbursed less and less and need to continually increase the number of patients seen to earn the same amount each year, you don't have a great amount of time to spend on an individual," Mozenter said.

With acknowledgement that medication is, in many cases, an appropriate plan of action, Grossberg advised on his standards of best practice. "An ideal psychiatrist makes decisions about whether a patient even needs medication, or if they can do better with cognitive-behavioral therapy." He cited a recent case from his own practice in which a patient presented with severe obsessive-compulsive disorder, a condition notoriously difficult to treat with medication. The patient was referred directly to the department's new psychotherapist, a leading expert in cognitive-behavioral therapy nationally.

Many clinicians know that for many mental illnesses including depression, the combination of psycho- and pharmacotherapy usually works much better than either alone.

Another concern raised is that of the medical workforce waning in general, with psychiatrists possibly becoming even more endangered. "The number of psychiatrists in this country is inadequate in terms of providing even all the [non-psychotherapy] services," Mozenter said. "Many areas of the country are grossly underserved as it is."