Monday, December 13, 2010

Prescribing Psychotherapy: Today's Grand Rounds at Johns Hopkins



Today, I heard Dr. Meg Chisholm give Grand Rounds at Johns Hopkins Hospital on "Prescribing Psychotherapy." Coming at it from an obviously pro-psychiatrist-as-psychotherapist bias, Dr. Chisholm discussed the financial forces that encourage psychiatrists to have "med check only" practices. She mentioned Daniel Carlat's book, Unhinged, and even showed a picture of it --she gave it a thumbs up. Meg quoted someone as saying that psychiatrists are a precious resource and should only be doing time-efficient psychopharmacology and presumably cranking through those patients as fast as possible. She showed bar graphs that illustrate how fewer shrinks are doing psychotherapy and fewer patients are getting it. In terms of cost, it's not clear that split therapy is cheaper, and psychiatrist-for-meds/psychologist-for-therapy is actually more expensive than one-stop shrinking. She made the excellent point that while we know that a combination of therapy and meds works best for some conditions, we don't know if people do better if they have therapy with a psychiatrist or split therapy with two mental health professionals, and we really need outcome studies. Finally, she talked about what role, if any, psychotherapy training should have in the education of psychiatrists during residency.

There was a portrait of one of our mentors, the late Dr. Jerome Frank, a pioneer in psychotherapy researcher at Hopkins. Meg showed a photo from his younger days, but I chose one of Dr. Frank as I remember him (see above). There was the requisite cartoon of a psychoanalyst, and a picture of the fictional Dr. Paul Weston (Gabriel Byrne) over his In Treatment couch. Ah, but Meg has it wrong--- she's never watched the show yet her research revealed that Paul is a psychiatrist who prescribes medicine, but Paul is a psychologist with training in psychoanalysis. No prescription pad and we never see him actually practice psychoanalysis.

A psychologist in the audience made the point that the experience of doing split therapy is very different when done with different psychiatrists, and that it's a totally different event with a primary care doctor.

My thoughts? I had a few.

-- I don't like the implication that psychiatrists "should" practice a certain uniform way. "Should" every psychiatrist have to do psychotherapy even if they hate listening to the same patients? "Should" every psychiatrist see four patients per hour even if they would much rather practice psychotherapy? Doctors should do what they do best and like best, and it's fine if some docs do psychotherapy and some docs don't. Would we dictate that doctors in shortage fields shouldn't be allowed to hold administrative positions, do research that could be done by Ph.D's, take maternity leave, pursue hobbies, or have blogs?

--There's more to psychotherapy than just psychotherapy. Seeing patients often and for in-depth sessions allows for a more careful use of medications. In clinic settings where patients are seen infrequently and everyone's expectations are for 20 minute visits every 90 days, it's very difficult to address the question of whether a stable patient might do better on a different medication regimen. The risk of stopping a medication is often riskier than just continuing with the status quo. The question "Are you the best you can be?" doesn't get addressed and major changes in medications usually happen during periods of crisis or hospitalization.

--Psychotherapy continues to be an integral part of psychiatric treatment and residents should be required to learn to do psychotherapy even if they never plan to do it again. Without seeing patients through the process, a psychiatrist can't really appreciate the benefits or limitations, and the while we might like to think that psychotherapy is something one "prescribes" just like bactrim or synthroid or insulin, we all know that some people feel more helped
by therapy than others and the importance of the interpersonal rapport is not something one can generically dictate.
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Really good Grand Rounds.

Related Post: The Psychiatrist as Therapist