Sacramento Street Psychiatry

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Talk doesn't pay: Comments on the NY Times article

Can psychiatrists afford to do therapy?

I'd like to take this opportunity to comment on the article that appeared in today's New York Times: "Talk doesn't Pay, So Psychiatry Turns to Drug Therapy." Gardiner Harris writes about psychiatry's shift from talk therapy to drugs, and profiles psychiatrist Donald Levin of Doylestown, PA (a suburb of Philadelphia), who felt financially unable to maintain a psychotherapy practice, and therefore shifted to a high-volume, medication-only practice. It is clear that both the doctor and the journalist consider this a sad state of affairs. Dr. Levin is quoted as saying: "I'm good at it, but there's not a lot to master in medications. It's like ‘2001: A Space Odyssey,' where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I'm the ape with the bone now."

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That comparison is apt to rile my colleagues who are serious and careful psychopharmacologists. But Dr. Levin is right: Most medication management in psychiatry is tediously straightforward. Which is why it is mostly done by primary care doctors, not psychiatrists. In the U.S. most antidepressant and antianxiety prescriptions are written by non-psychiatrists. (And even antipsychotics lately, but this is a different and far more worrisome issue.) It seems to me that any self-respecting psychiatrist who limits his or her practice to psychopharmacology, i.e., medication management only, should add some value over a visit to a family doctor, internist, or pediatrician. Either the cases seen should be harder, e.g., "treatment resistant," or the doctor should offer something more nuanced and sophisticated, or more comprehensive. If so, such a psychiatrist will not be "the ape with the bone." Unfortunately, my experience suggests this is the exception, and that the shift to medication management has been borne of expediency and financial pressure in many cases, not an earnest scholarly focus on advanced psychiatric medication strategies. And for this reason, the critique that our field is increasingly populated by dumbed-down medication technicians is not the throwaway line it would otherwise be.

In saying this, I invite a rebuttal. If psychiatrists who give meds should add something over other med providers, what do psychiatrists who conduct therapy add over other therapists? The answer is a more comprehensive viewpoint, one that takes into account medical and bodily issues, drug interactions, and similar matters. And the option to prescribe medications when these are needed in addition. If we cannot add this value, we should not charge more than other therapists.

Since I have a mostly-psychotherapy practice myself, I took note of several points made in the article. Most glaring is a starkly misleading statistic. Gardiner cites a 2005 government survey showing that just 11 percent of psychiatrists "provided talk therapy to all patients." I'm not sure why that surprises anyone. I'm a huge advocate of psychotherapy, yet I don't recommend, much less provide, it for everyone. It's a treatment - it's expensive, it takes a lot of time, it's often uncomfortable. I only provide psychotherapy when I predict it will help, and when my patient agrees to it. While I believe it would be helpful for many patients I see, I nonetheless still treat a minority of patients with medication only. In my view, one of the best things about being a psychiatrist is that we have a variety of tools. While I find dynamic psychotherapy more intellectually interesting and humanly engaging than writing prescriptions, I'm glad I can do both. The 11 percent statistic is meaningless.

Another potential confusion in the article are the widely disparate fees cited, with little explanation. At one point Gardiner writes: "A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session." At least here in San Francisco, this is considerably less than either service is typically worth, even accounting for payment caps by health insurers. Not to mention that psychotherapy is traditionally 50 minutes, not 45. But then Gardiner writes about "a select group of [New York] psychiatrists [who] charge $600 or more per hour to treat investment bankers," and later notes that a nearby colleague of Dr. Levin charges "$200 for most [therapy] appointments." The truth in my experience is that no psychiatrist starves by being a psychotherapist, even though there is more competition from other disciplines and the overall income may be less. Talk does pay, just not quite as much. When psychiatrists complain about comparatively low psychotherapy income, it makes me wonder why they didn't become surgeons. Seriously, from what I gather surgery is very engaging, very satisfying, and very lucrative. It sounds much better than doing half-hearted, half-assed psychiatry just for the income boost.

As I wrote last year, dynamic psychotherapy is more than merely a treatment technique to place on a shelf alongside medications. It is a perspective that informs our understanding of patients even when we do not offer this specific therapy as treatment. Thinking about our patients dynamically can help us be better medication providers, better CBT (non-dynamic) therapists, better referrers to other professionals. Psychiatrists don't have to be psychotherapists all the time, but we do need to think psychotherapeutically all the time. The real tragedy highlighted by the NY Times article is not one man's devolution to an "ape with a bone," nor even a profession's. It is the loss of intellectual curiosity - of knowing there is a better way, yet choosing not to pursue it.

© 2011 Steven P Reidbord, MD.  All rights reserved.

Steven Reidbord, M.D., is a psychiatrist and psychiatric educator, and chairs the Continuing Medical Education Committee at California Pacific Medical Center.

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