Is Your Psychiatrist Only Good For One Thing?
September 3, 2008 by Alicia Sparks, Mental Health Notes
Filed under Diseases & Conditions
And by “one thing” I mean prescribing medication.
Aside from the cost of mental health care, one of the biggest patient complaints I’ve heard since beginning Mental Health Notes and becoming involved with NAMI is the way in which appointments with psychiatrists seem to go these days.
It’s become the norm for a patient to take a half or whole day off work to sit in a waiting room for an hour or more only to see a psychiatrist for a few minutes in order to discuss whether or not a particular medication is working, grab a new or adjusted prescription, and leave in time for another patient to take the seat before the butt warmth has had time to cool.
When did psychiatrists decide it was okay to cut their services in half? Why are psychiatrists now merely tending to “medication management” (i.e. doling out drugs and monitoring their success) and leaving the “dirty work” to psychologists, social workers, and other non-doctor mental health professionals?
Read on.
From the Reuters article Move over Freud: Psychiatrists embrace pill power:
The shift to briefer visits for medication management, reported in the Archives of General Psychiatry, appears to be linked to better psychiatric drugs and pressure from managed care companies, which offer richer financial incentives for brief office visits.
“Psychiatrists get more for three, 15-minute medication management visits than for one 45 minute psychotherapy visit,” said Dr. Ramin Mojtabai of Johns Hopkins University in Baltimore and formerly of Beth Israel Medical Center in New York, where he did the research.
Up for a nice greedy round of money-grubbing, anyone?
Dr. Mojtabai also states that treatment from psychologists and social workers is most likely “short-term cognitive behavioral therapy” rather than the “analysis psychiatrists have traditionally offered.”
Of course, not everyone has dollar signs in their eyes.
While Dr. Mojtabai admits seeing a psychiatrist strictly for medication management and a psychologist or social worker for actual therapy “might not be as efficient” (as what? having a psychiatrist who actually knows more about you than what dosage of Zoloft you’re currently taking? and didn’t he just say the treatment from psychologists and social workers was different from what we can get from the analysis of a psychiatrist?), Dr. Eric Plakun, leader of an American Psychiatric Association committee on psychotherapy, notes that a shift in focus from psychotherapy to the biology of mental illness accounts for some of our psychiatrists’ current unwillingness to do more than drag out the prescription pad.
Plakun said in a telephone interview it is not clear if patients are getting therapy from other providers, or not at all.
“Either way, I’m worried about our patients,” he said. “Patients need the best help we can give them.”
For Plakun, that means offering a range of services, including psychotherapy, and not just medication. “If all you have is a hammer, everything looks like a nail,” he said.
Yes, everything does indeed start to look like a nail. If the only skills today’s psychiatrists are coming out of school with (or are willing to use) are the skills to properly medicate someone, does that mean more people than actually necessary are being medicated?
What about you? How would you describe your trips to the psychiatrist’s couch office? How happy are you with the various members of your mental illness management team?
Image: SXC
The alternative to what you are describing is to see an Advanced Practice Psyciatric nurse who does it all –medications and therapy. However, unfortunately the trend is toward short term solution focused therapy. As for the brief time with psyciatrists–it is not unlike seeing your primary care physician who diagnoses a problem and then gives an RX.
Your post raises good questions. I see the issue slightly differently, in that I perceive a fine-tuning of responsibilities as opposed to a loss or abdication of responsibilities from the psychiatrists. Medical school/the training and expertise required to manage medication is significant and specialized. And therapy–which also requires training & experience–requires a totally different skill set. It seems appropriate to me to utilize different providers for these very different treatments.
I’m a therapist myself, and wanted to mention that managing a practice based on what insurance companies pay can be very challenging. Insurance reimbursement is already so low that keeping the books in the black *requires* that a provider pay attention to the bottom line. Perhaps it looks like money grubbing from an outside perspective, but from the inside, it just looks like the constant, necessary scramble to stay out of debt.
Thanks to both of you (DC and Katie) for chiming in.
@ DC – The article I quoted in the post led me to believe that while they are few and far between, there are actually still some psychiatrists out there who provide both therapy services and medication management (I don’t think I know of any personally, though!) I do think it’s a bit different from a primary care physician, and for a couple of reasons. One, it’s usually easier to diagnosis a physical problem (and in a much shorter time period) than a mental problem (unlike with a mental health condition, a doctor doesn’t really need to “observe” the symptoms of a physical illness for a longer period of time in order to diagnose the illness). Two, once a physical health diagnosis is made and the patient is taking medication, there really isn’t any reason to have lengthier doctor’s appointments because tests will accurately determine whether or not the medication is working (whereas, with a mental health problem, there really aren’t many, if any, “accurate tests,” and talking with the patient, listening to the patient, and observing the patient is necessary to determine if the medicine is doing it’s job, the dosage needs to be changed, or a new medicine altogether is necessary).
@ Katie – Yes, I imagine balancing a practice and the insurance aspects can be very challenging, and frustrating for everyone involved (except maybe the insurance companies, ha). It’s a shame that adequate health care (of any sort, mental or physical) so largely depends on insurance companies.
To both of you: So often, people are misdiagnosed, taking medication that isn’t appropriate for their symptoms, etc. Do you think some (not all, but some) of this blame falls on the “trip” from the therapists office to the psychiatrists office? Do you think it’s “OK” for psychiatrists to prescribe medication based solely on the reports they get from the patient’s therapist (I’ve known a few to do this), or do you think the psychiatrist should be holding “sessions” of their own as well to determine what’s going on?
An excellent book that looks at this issue from the point of view of how psychiatrist training has changed in the past decade or so is “Of Two Minds”.
@ MM – Thanks for the recommendation