Wednesday, May 14, 2014

Psychiatrists Doing Psychotherapy: added value? or waste of resources?

I always come away from my annual professional meetings (American Academy of Psychoanalysis and Dynamic Psychiatry and American Psychiatric Association) with new information and ideas. This year I've heard about and thought about collaborations with primary care, the connection between inflammation and depression, and detailed exercise prescriptions as a treatment for depression. However, the big thing I'm taking away from this year's meetings is a question that has been floating around both meetings in various sessions I've attended. What do I, as a psychiatrist who provides psychotherapy, bring to the table that is unique and valuable?

Many psychiatrists don't provide psychotherapy anymore; they prescribe medication and monitor side effects and leave the psychotherapy to counsellors, psychologists and social workers. It's more economical that way. A psychiatrist can see a patient for medication management in about fifteen minutes, which means that psychiatrist can bill for four patients an hour. When you have loans to pay off and bills to pay, or an office manager and a nurse to pay, that is a pretty big difference in income. It also means you are helping four patients an hour instead of one, which given the scarcity of mental health resources is not a negligible factor.

When I was interviewing for jobs a few years ago most of the groups I spoke to weren't interested in my psychotherapy skills. I would explain that I have a special interest and extra training in psychotherapy and ask if I could continue to offer it to patients. The reactions to that question ranged from "No, we wouldn't want you to do that." to "That's strange, but you can have a few psychotherapy patients if you want. But not more than one or two and you won't make as much money." It was discouraging, to say the least, and it was a big factor in my choosing my current job which offers me the freedom to continue to practice psychotherapy.

My impression after talking to my colleagues is that they have had similar experiences, although often without finding a congenial job opportunity. Among those who do continue to practice psychotherapy there is a sense of defensiveness and anxiety to their practice. There is a sense of something being lost or taken away and a determination to hang on to it. I resonate with this. I value my psychotherapy work. It interests me and challenges me in a way that medication prescriptions just don't. I worry that at some point someone will tell me that my work isn't economically valuable or viable and pressure me to stop.

The value of psychotherapy as a treatment is, I believe, indisputable. I can locate dozens if not hundreds of studies that demonstrate both efficacy and cost-effectiveness of psychotherapy as a treatment for mental illness. The question I am asking is what is the added value of me, as a psychiatrist, providing psychotherapy? When it means that I see fewer patients for my organization, making my care per patient more expensive and causing me to be available to fewer people, what is the value that I am adding?

It's not a comfortable question to ask. My hope (or perhaps my bias) is that I do add value. I believe that by understanding health in a deep as well as a broad way that I can give more to patients. I can recognize signs of medical illnesses that require evaluation and care and I know how to get patients access to those treatments, and I can do this better for patients I know well. I can discuss health management and maintenance in detail as part of behavioral psychotherapy. I understand the medical system and the impacts of chronic and severe illnesses on a person's body and on their life. I can move fluidly between medications for illness and psychotherapy for illness, allowing me to prescribe medication in a way that is right for each patient. My goal is to prescribe the right medications in the right doses at the right times for the right duration for the right patient so that my patients experience the most benefit for the least side effect and cost burden. Conducting psychotherapy concurrently helps me do that because I know my patients well. I believe that the healing relationship created by psychotherapy helps my patients accept, tolerate and benefit from medication. I am able to talk about what daily medication means to my patients and why they might hate taking it. I am able to work collaboratively because my patients trust that they can speak the truth to me. I also believe that the extensive and demanding training I have completed gives me a higher level of expertise that benefits the patients I see. I believe my patients are more likely to get better and stay better because I am offering more comprehensive care.

Those are just my beliefs, though. I can't prove them, and I obviously have some motivations for them. I don't know if anyone has looked at these questions in order to generate objective evidence about this question; I'm doing a search of the medical literature to find out. So far I haven't found much except opinion, but I'll keep looking. In the meantime, I wonder what other people think? People who don't have the same biases I have?