Sunday, June 26, 2011

Understanding the Research on Psychotherapy Trends-- a Discussion with Dr. Ramin Mojtabai






For whatever reason, it bothers me when media says that psychiatrists don't do psychotherapy, and lately, it happens a lot.  What am I, chopped liver?
They quote a study by Mojtabai and Olfson in the Archives of General Psychiatry, and say, "Only 10.8% of psychiatrists see all of their patients for psychotherapy."  Is that really true?  Is it really relevant?  I tried to read the article and I wanted to understand how the study was done so I could think about it myself, but I didn't understand how the research was done-- Roy thought it was based on CPT codes, then he said it wasn't.  So why not go to the source?  I asked Dr. Mojtabai if he would have lunch with me and tell me how the study was conducted.

If that got you curious, please read about it on over on Shrink Rap News!  You're welcome to comment there if you're physician, or to surf back here and tell us what you think.  Ramin says he's interested in what people think, and he's been very kind about humoring me, both over lunch and in the many subsequent emails over the details.

28 comments:

Sarebear said...

Whenever I see it say that there's a percentage that do it for ALL patients, that always makes me thing, well what about those who do it for 90% of their patients, or for 60%, etc?

I seem to remember you quoting a similar statistic awhile ago, that was specific about it being for ALL a psychiatrist's patients.

It was obvious to me that that would exclude many people's practices; what if someone comes to YOU, Dinah, and has been having therapy with a psychologist that they really like, for years? I doubt that you'd force psychotherapy on them by you since they are happy with their current provider.

Anyway, I'm happy to see the data dissected and see that it doesn't mean what it first looks like on quick glance.

I too wish they'd put out there that the 70.whatever percent of psychiatrists use psychotherapy for SOME of their patients at least, if not all (for the practices included in that that came back with "all" even though it was a very random sampling).

Sara

jesse said...

Fewer psychiatrists are doing psychotherapy and that psychotherapy is for a shorter period of time. But there is one major point that was not mentioned: How frequent are the sessions? If a psychiatrist sees most patients weekly or every other week, and also does psychotherapy for those patients, that is a very different thing from seeing most patients at every other month intervals and doing psychotherapy for them. The word - psychotherapy - is the same but the thing is very different.

So psychotherapy by psychiatrists is going down. Philosophy Follows Funding.

Shrink2B said...
This comment has been removed by the author.
Shrink2B said...

While psychotherapy may be diminishing, I think it is more important to note how it is changing. Much can be done in less than 30 minutes, especially with an established patient.
This study concerning ALL patients is like asking a D.O. whether they perform OMT on ALL patients...or even a surgeon of he performs surgery on ALL patients.
Isn't that the point of the physician - to determine when treatment is indicated? ALL psychiatrist can't spend over 30 minutes with ALL patients giving them ALL psychotherapy. That sounds eerily like cookbook medicine.

Discover and Recover said...

10 percent?

Hardly a return to the Moral Era, it appears.

Two therapists who are making some news out there... helping people fully recover from "schizophrenia" are Ron Unger,LCSW and Danile Mackler, LCSW.

I hope psychiatry follows their lead.

Duane

Discover and Recover said...

typo

Daniel Mackler, LCSW

rob lindeman said...

How on earth can you do effective psychotherapy once per week per patient?

wv = solead. The epic journey of a white fish.

Dinah said...

Sarebear:
The issue of split therapy is a complicated one and one that I don't deal with a lot. In the clinic, I see patients with their therapists and we have a shared chart. At least the communication flows well, but I feel like the patients there have been 'trained' over time to keep it to symptoms and medications and I'm often trying to coax people to talk.
In private practice, I don't see patients who have another therapist-- it's just confusing for me and requires more coordination than I want to do, especially if the referral is from a completely random therapist I don't know. I tell people they should talk to their therapist and get names of psychiatrists they are used to working with, or I give them the number for a group where I used to work where the psychiatrists will see patients in therapy with others. There are a lot of psychiatrists here, so I don't feel obligated to treat people because there is no where else to go.

Jesse-- this study was chock full of data--there were figures of how many times patients had been seen before the index time period, but I had enough trouble figuring out where 10.8% came from so I didn't even try to sort out what that meant. Perhaps when Ramin surfs over, he can help clarify this, but it was a different aspect to the study.

I actually wondered if the study Over-estimated psychotherapy. Because of CPT codes, psychiatrists think of anything more than 25 minutes as being "therapy" so a doc could have checked off Yes Therapy, and 50 minutes, but perhaps the patient is only seen every 4-6 months.

Shrink2B: No, we really don't want all psychiatrists seeing all patients for psychotherapy. I believe it should be an option for those who want to pay for it, for those whose conditions have been resistant to other treatments, and for those psychiatrists who want to practice it. But it's not feasible, necessary, or recommended that all of the patients all of the time be seen for regular sessions.

Rob: Was there a question there?

jesse said...

I was confused by methodology and numbers. What S2B was saying I think, is that the Always box would not be checked by someone who did 98% of something. Who does anything 100%? And the next category down might not fit either. And if you see a patient four times per year for a half hour each, is that "therapy"? A practice could be filled by those patients and the statistics would be misleading.

Dinah said...

Jesse, and maybe Shrink2B:
oh,no--surf over to the CPN post at
http://www.clinicalpsychiatrynews.com/views/shrink-rap-news/blog/108-a-look-behind-the-report-on-psychotherapy-trends/3089db42ea.html

No one checked off "all" or "most" or any numbers.

Docs (all kinds) filled out forms for a one week period and the forms asked "Did you order or prescribe psychotherapy" and "How many minutes did you see the patient for". The researchers then looked at the data for the psychiatrists. If the box was checked for psychotherapy and the minutes was above 30, then it was called a therapy session. There was a random sample of forms taken from each psychiatrist== an average of 19, so if all 19 of those patients the doc saw had both psychotherapy AND >30 minutes, then he saw ALL of his patients for therapy. If there were another 50 patients that week and they weren't all seen for therapy, that data was missed.

jesse said...

"Did you order or prescribe psychotherapy?" I have never ordered or prescribed it. I just do it. Speaking of it as being ordered or prescribed is already a huge change in perception.

Dinah said...

Oops, from my CPN post:
To get to the statistic of 10.8%, the researchers looked at the responses to two questions on the form. In the area for “Non-Medication Treatment” there was an option to check “psychotherapy” under “List all ordered or provided at this visit.” (The bolding is on the form, it is not my intention to add emphasis). The second item they looked at was “Time spent with Provider” to be listed in minutes.

Mojtabai and Olfson did a simple cut to define “psychotherapy” for the purpose of this study. If the box for psychotherapy was checked and the time spent with the physician was more than 30 minutes, it was deemed to be psychotherapy. The authors were attempting to capture a traditional psychotherapy session.

These forms were given to all physicians (I think they excluded anesthesiologists and maybe radiologists and pathologists)...so another doctor might have "prescribed" (recommended ? psychotherapy). Mojtabai and Olfson only looked at the shrink's data.

Anonymous said...

Do you folks think there is an advantage to seeing a psychiatrist for therapy rather than a counselor? I have had disatrous results with medications, and there are no more options to try (really, I have been trying for 15 years and had workups from many docs) and there is no question it's bipolar because when I was younger, it was the classic form of it. I do all that eating right and exercising and using a light box stuff. Might there be an advantage to having a psychiatrist who does therapy for a case like this? I like my therapist, but she is at a loss too, other than use my light box and coping skills.

If there is NOT an advantage to a psychiatrist over a therapist, why would psychiatrists do it at all, other than to understand the profound meaning of having mental illness (in other words, for the benefit of the doctor, but not so much the patient)?

Dinah said...

Anon: Yes.

jesse said...

If you live somewhere where there are psychiatrists who also do therapy, it might be a real advantage. This is because the medical part of bipolar is so profound it is hard to separate it, and a psychiatrist will likely be more tuned in to the medical part than a non-medical therapist. Sometimes non-medical therapists miss the extent that personality traits are functions of illness. The mind and the body are not separate things! So from what you are saying it would be worth a consult with one if available.

That said, therapy is a very hard thing to do well, and takes a lot of training. There are near infinite variables. So, in general, while there are advantages to being a physician, for situations other than bipolar or other serious mental illnesses, the quality of the therapist (psychologist, LCSW, and so on) may be much more important than whether the person has an M.D.

rob lindeman said...

Here's the answer: you can't accomplish effective psychotherapy in even one hour per week. Perhaps it can be done, with appropriate individuals (good insight, willingness to take control of one's life) with three hours per week over an extended period.

Re: the necessity of being a doctor: All the M.D. gets us is monopoly rights to prescribe drugs. This is about protection of the franchise, not about special access to the mystery of medicine. In the age of the internet, everybody has access to all the information one could possibly need to make an informed decision about any drug he might take. To suggest otherwise imputes powers in the we docs that we just ain't got.

wv = ablor. Devotee of Dr. Keith

jesse said...

Rob Lindeman wrote (this was in my email but the post never appeared on the blog):

"Here's the answer: you can't [italicized] accomplish effective psychotherapy in even one hour per week. Perhaps it can be done, with appropriate individuals (good insight, willingness to take control of one's life) with three hours per week over an extended period.

Re: the necessity of being a doctor: All the M.D. gets us is monopoly rights to prescribe drugs. This is about protection of the franchise, not about special access to the mystery of medicine. In the age of the internet, everybody has access to all the information one could possibly need to make an informed decision about any drug he might take. To suggest otherwise imputes powers in the we docs that we just ain't got."

Rob, your first assertion is near astounding. "You can't accomplish effective psychotherapy in even one hour per week. Perhaps...with three hours per week..."

Where in the world did you get that? Almost very word in that sentence needs to be qualified and explained. You can speak ex cathedra if you wish, but it just don't make it so.

rob lindeman said...

I guess that means you believe effective psychotherapy can be achieved once per week.

Re: ex cathedra. I recently learned that when Lord Acton said "Power corrupts, absolute power corrupts absolutely", he was referring to the doctrine of papal infallibility, i.e., the doctrine that states that when the Pope speaks ex cathedra on matters of doctrine, by definition he cannot err.

Unlike the pope, I don't speak ex cathedra, I only dispense opinions.

wv = grighole. Archaic swearword, never really caught on.

Dinah said...

Rob sent me a link to an article by Danny Carlat on KevinMD on the dilemma psychiatrists face whether to provide meds vs. therapy:
http://www.kevinmd.com/blog/2011/06/decision-point-psychiatrists-faced-psychotherapy.html#comment-172726

It recaps the NYTimes article by Gardiner Harris, but doesn't say anything new.

Rob--- Three times a week therapy? I've never done that. The only people I know who do are the psychoanalysts and they a very small fraction of today's psychiatrists-- training is too long and expensive, people don't want to commit to & pay for that quantity of treatment, and there are effective treatments available that don't require the investment of time or money. In my career to date, I have had 3 patients who had previously been in analysis (I could be forgetting some).

People seem to have effective therapy coming once a week, and often less.

The study in question, however, would capture the same patients repeatedly in surveys, so there is nothing that says that some of the psychiatrists queried were not psychoanalysts. Even psychoanalysts generally do not see most of their patients for psychoanalysis. You need to be very rich with a lot of free time to afford it.

rob lindeman said...

"...there are effective treatments available that don't require the investment of time or money [i.e. for analysis]"

If only this were true of anything in life, psychotherapy included!

rob lindeman said...

...not that more expensive is better, certainly not in pediatrics, just that some things, psychotherapy included, can't be bought cheap.

Is analysis really dead? In Freud's day analysis was the only game in town, wasn't it? (insane asylums excepted)

jesse said...

Rob, could you please explain where you got the idea that psychotherapy (a vague and unspecific term) could not be effective (what does that mean?) unless a patient is in it three times per week for years (why years, and for what conditions?)? For William, he needs to explain what he means by "basic care" for a 20 minute visit (which is obvious), but you don't explain the vast generalizations you deliver (ex cathedra - they may be opinions but they seem unquestionable) without doubt.

When I was in my residency all but one resident in my year were in analysis, but now few residents are. That is perhaps unfortunate, but long term analytically-oriented psychotherapy is not that common anymore in psychiatry. This does not mean that the psychotherapy practiced by all the analysts and analytically-trained psychiatrists (and social workers and psychologists) is without value. It is extremely valuable to patients, even when done in a short-term crisis oriented manner.

Perhaps discussions on psychotherapy could be a part of Shrink Rap. I hope so.

Dinah said...

Jesse-- on the sidebar there are topics, "psychotherapy" links to 78 posts.

Rob: here's a clinkshrink story:
http://psychiatrist-blog.blogspot.com/2010/06/cab-driver-story.html

Anonymous said...

Rob is pulling everyone's chain. It's what he does.

RH

Anonymous said...

I have to say that the most helpful intervention I got was learning some practical skills like meditation and distracting myself when I start to ruminate over my problems, assertiveness training, things like that. Therapists don't seem to teach that. I learned it from classes my county put on, or inpatient, but not in therapy. I never was asked about my spending habits or other problems that go with mania, not by a psychiatrist, not by a therapist.

Anyhow, a lot of that therapy stuff is kind of abstract and flowery, and imo, practical interventions are never offered except by my social worker type folks who don't have a fancy degree.

I am not putting down the other therapy, i am pointing out that practical interventions, like how to breathe to calm yourself down, are not taught in therapy, in my experience. And I have seen a lot of doctors and therapists over the years.

rob lindeman said...

Thanks, Dinah,

The cab driver story reminds my of a routine I saw Tracey Ullman do once. She plays an Australian pro golfer (complete with the flawless accent) who visits a therapist. Ullman asks the therapist exactly two questions (one of which was about foreplay), declares that she feels much better, gets up and leaves.

The sketch was funny because it was absurd. The cab driver story was only absurd.

Wv - werenest. The home you left

jesse said...

Anon above wrote: "learning some practical skills like meditation and distracting myself when I start to ruminate over my problems, assertiveness training, things like that."

Earlier today I spoke with a new patient about just these things. Your point is well taken, though. The problem is that there are so many ways to approach therapy that no one is skilled or even knowledgeable about all of them. wWe all have our areas of expertise. The therapist who is expert in meditation and breathing techniques is likely not expert in some other things, or even does not even know when they would be helpful.

What comes first is an evaluation from someone with enough breadth of experience and knowledge that he does not quickly put the patient into a box. Symptom does not easily translate into diagnosis, nor into treatment methods.

So one of the more important things in looking for a good psychiatrist, or therapist, or psychologist, etc, is that he have enough experience and openmindedness to reevaluate his own conclusions frequently and reverse his positions if necessary. Close mindedness is never a good thing.

Discover and Recover said...

What about bias on the part of a psychiatrist?

In other words, if someone has been taught though a medical model, it would seem they would see their patient's suffering as a 'medical condition' versus a 'human condition'.... or at least more prone to do so.

More importantly, they might see the root cause of suffering as a 'lifelong, incurable illness' versus issues that can be overcome.

I wonder about the bias that comes from seeing a psychiatrist versus other kind of therapist or counselor.

As far as reponses back to others, I think I'll just read what others have to say.

Duane