Psychiatrists Shifting Away From Psychotherapy Role

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Monday, 11 August 2008 16:30

The Diagnostic and Statistical Manual of Mental Disorders (DSM)

The DSM is a guide to what the American Psychiatric Association (APA) terms mental disorders. It is the handbook desktop reference used most often for diagnostics in the US and abroad.

The DSM contains a listing of psychiatric disorders, diagnostic codes, information on the prevalence of each disorder, and diagnostic criteria. The DSM is non-theoretical and does not offer information on causes or treatments.

Mental health professionals use the DSM for a variety of purposes, such as clinical practice, research, and educational purposes. Clinicians also use the DMS-IV to classify patients for billing purposes. The government and many insurance carriers require a specific diagnosis in order to approve payment for treatment.

The DSM has the force of law in a variety of mental health related activities, such as commitment hearings, and is a principal resource used in the development of legislation.

The DSM has gone though five major revisions, with the most recent major update published in 1994.

The current version is a minor variant published in July 2000 that adds clarifying text (DSM-IV, Text Revision). The primary goal was to maintain the currency of the DSM-IV text with the empirical literature up to 1992.

Most of the changes were in the descriptive text, with some error correction and changed diagnostic codes to reflect updates to the ICD-9-CM coding system adopted by the U.S. Government. It is available from the the DSM-IV-TR web site.

DSM-V publication is planned for 2010/11. The APA Steering Commitee says it is open to suggestions and maintains a web page, DSM-V: The Future Manual.

The Structured Clinical Interview for DSM-IV (SCID) Axis I Disorders (SCID-I) is a semi-structured interview for making the major DSM-IV Axis I diagnoses. The SCID-II is a semi-structured interview for making DSM-IV Axis II: Personality Disorder diagnoses.

The official SCID site maintains a list of Frequently Asked Questions (FAQs).

New York, NY, USA. Despite the central role of psychotherapy in the practice of psychiatry throughout its history, a declining number of office-based psychiatrists appear provide psychotherapy to their patients. A new report attributes this trend to changing reimbursement policies that favor the management of new medications.

Various forms of psychotherapy, either alone or in combination with medications, are recommended for the treatment of bipolar disorder, major depression, post-traumatic stress disorder, and other conditions dascribed as psychiatric illnesses.

National Trends in Psychotherapy by Office-Based Psychiatrists. Ramin Mojtabai and Mark Olfson. Archives of General Psychiatry 65(8) 962-970.

The psychiatric profession is the principal sponsor of the Manual for Diagnosis of Mental Disorders (DSM-V). The impact of a small profession that acts as the gatekeeper for the wider community of care givers has yet been subjected to objective measurement. It is also unknown whether the psychiatric profession can sustain itself with minmal emphsis on its founding practice.

The authors of the new study write that "… despite the traditional prominence of psychotherapy in psychiatric practice and training, there are indications of a recent decline in the provision of psychotherapy by U.S. psychiatrists …", noting that visits tend to be brief and focused on "… medication management …" and the introduction of "… newer psychotropic medications with fewer adverse effects."

The study authors were Ramin Mojtabai, M.D., Ph.D., M.P.H., then of Beth Israel Medical Center and now of the Johns Hopkins Bloomberg School of Public Health (Baltimore) [N2], and Mark Olfson, M.D., M.P.H., of the Columbia University Medical Center and the New York State Psychiatric Institute (New York) [N3].

Mojtabai and Olfson analyzed trends in psychotherapy provision using data from national surveys of office-based psychiatrist visits from 1996 through 2005.

Over the 10-year period, psychotherapy was provided in 5,597 (34 percent) of 14,108 visits lasting longer than 30 minutes.
The percentage of visits involving psychotherapy declined from 44.4 percent in 1996-1997 to 28.9 percent in 2004-2005.
The number of psychiatrists who provided psychotherapy to all of their patients also declined over the same time period, from 19.1 percent to 10.8 percent.

"This decline coincided with changes in reimbursement, increases in managed care and growth in the prescription of medications," the authors write.

"Psychiatrists who provided psychotherapy to all of their patients relied more extensively on self-pay patients, had fewer managed-care visits and prescribed medications in fewer of their visits compared with psychiatrists who provided psychotherapy less often," the authors write.

"These trends highlight a gradual but important change in the content of outpatient psychiatric care in the United States and a continued shift toward medicalization of psychiatric practice," they conclude.

"A key challenge facing the future generation of psychiatrists will likely involve maintaining their professional role as integrators of the biological and psychosocial perspectives while working within the constraints of the strong market forces of third-party payers and managed care to implement advances in the diagnosis and treatment of mental disorders."

[N1] This study was supported in part by a grant from the Agency for Healthcare Research and Quality (AHRQ).

[N2] Dr. Ramin Mojtabai is affiliated with the Department of Psychiatry, Beth Israel Medical Center. Dr Mojtabai is now with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

Dr. Mojtabai has received research funding from AstraZeneca and Bristol-Myers Squibb pharmaceutical companies and consultant fees from Bristol-Myers Squibb.

[N3] Dr. Mark Olfson is affiliated with the College of Physicians and Surgeons, Columbia University Medical Center, and the New York State Psychiatric Institute, New York.

Dr. Olfson has received research funding from Bristol-Myers Squibb, Eli Lilly, and Jansen pharmaceutical companies and has worked as a paid consultant to Pfizer and McNeil Pharmaceuticals.

National Trends in Psychotherapy by Office-Based Psychiatrists. Ramin Mojtabai and Mark Olfson. Archives of General Psychiatry 65(8) 962-970.

Abstract

Context. In addition to prescribing medications, providing psychotherapy has long been a defining characteristic of the practice of clinical psychiatry. However, there are indications that the role of psychiatrists in providing psychotherapy may have diminished in recent years.

Objective. To examine recent national trends in the provision of psychotherapy by office-based psychiatrists.

Design. Data from the 1996 through 2005 cross-sectional National Ambulatory Medical Care Survey were analyzed to examine trends in psychotherapy provision within nationally representative samples of visits to office-based psychiatrists. Multivariate analyses examined the time trend, adjusting for patient, visit, and setting characteristics. Practice-level analyses examined time trends in the percentage of psychiatrists who provided psychotherapy to all, some, or none of their patients during a typical week.

Setting. Office-based psychiatry practices in the United States.

Participants. Patients with psychiatric diagnoses visiting outpatient psychiatrists.

Main Outcome Measure. Provision of psychotherapy in visits longer than 30 minutes.

Results. Psychotherapy was provided in 5597 of 14 108 visits (34.0% [weighted]) sampled during a 10-year period. The percentage of visits involving psychotherapy declined from 44.4% in 1996-1997 to 28.9% in 2004-2005 (P < .001). This decline coincided with changes in reimbursement, increases in managed care, and growth in the prescription of medications. At the practice level, the decrease in providing psychotherapy corresponded with a decline in the number of psychiatrists who provided psychotherapy to all of their patients from 19.1% in 1996-1997 to 10.8% in 2004-2005 (P = .001). Psychiatrists who provided psychotherapy to all of their patients relied more extensively on self-pay patients, had fewer managed-care visits, and prescribed medications in fewer of their visits compared with psychiatrists who provided psychotherapy less often.

Conclusions. There has been a recent significant decline in the provision of psychotherapy by psychiatrists in the United States. This trend is attributable to a decrease in the number of psychiatrists specializing in psychotherapy and a corresponding increase in those specializing in pharmacotherapy—changes that were likely motivated by financial incentives and growth in psychopharmacological treatments in recent years.

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TS-Si is dedicated to the acceptance, medical treatment, and legal protection of individuals correcting the misalignment of their brains and their anatomical sex, while supporting their transition into society as hormonally reconstituted and surgically corrected citizens.

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Last Updated on Monday, 11 August 2008 18:08

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