In era of pills, fewer shrinks doing talk therapy

CHICAGO — Cartoons about the psychiatrist's couch were recently the subject of a museum exhibition. Now, the couch itself may be headed for a museum.

A new study finds a significant decline in psychotherapy practiced by U.S. psychiatrists.

The expanded use of pills and insurance policies that favor short office visits are among the reasons, said lead author Dr. Rain Mojtabai of Johns Hopkins Bloomberg School of Public Health in Baltimore.

"The 'couch,' or, more generally, long-term psychoanalytic psychotherapy, was for so long a hallmark of the practice of psychiatry. It no longer is," Mojtabai said.

Today's psychiatrists get reimbursed by insurance companies at a lower rate for a 45-minute psychotherapy visit than for three 15-minute medication visits, he said.

His study found that the percentage of patients' visits to psychiatrists for psychotherapy, or talk therapy, fell from an average of 44 percent over the 1996-1997 two-year period to an average of 29 percent for the years 2004-2005. The percentage of psychiatrists using psychotherapy with all their patients also dropped, from about 19 percent to 11 percent.

Psychiatrists who provided talk therapy to everyone had more patients who paid out of pocket compared to those doctors who provided talk therapy less often. And they prescribed fewer pills.

As talk therapy declined, TV ads contributed to an "aura of invincibility" around drugs for depression and anxiety, said Charles Barber, a lecturer in psychiatry at Yale University and author of "Comfortably Numb: How Psychiatry is Medicating a Nation."

"By contrast, there's almost no marketing for psychotherapy, which has comparable if not better outcomes," said Barber, who was not involved in the study.

The findings, published in Monday's Archives of General Psychiatry, are based on an annual survey of office visits to U.S. doctors. Of more than 246,000 visits sampled during the 10 years, more than 14,000 were to psychiatrists. The researchers analyzed those psychiatrist visits.

The study did not survey visits to psychologists or other mental health counselors who are not medical doctors, but who also practice talk therapy.

Psychotherapy uses verbal methods to get patients to explore their emotional life, thoughts or behavior. The goal is to ease symptoms, sometimes through getting the patient to change behavior or mental habits.

Its benefits can be seen in brain imaging studies, said Dr. Eric Plakun, who leads an American Psychiatric Association committee working to restore interest in psychotherapy by psychiatrists.

"The couch is far from dead," Plakun said. "The couch turns out to be an effective 21st century treatment."

Talk therapy can be done by psychiatrists less expensively than split treatment, where a patient sees a doctor for pills and a counselor for talk therapy, Plakun said, citing two prior studies.

It also works better than drugs for some patients, such as those with chronic major depression and a history of childhood trauma, he said.

Accreditation requirements for psychiatric residency programs are putting more emphasis on talk therapy, Plakun said. That may slow the decline of the couch.

The new study doesn't answer an important question: whether other professionals are picking up the slack, said psychologist David Mohr of Northwestern University's Feinberg School of Medicine. Psychologists and social workers provide counseling but most cannot prescribe drugs, so it's possible that for patients who require both talk and pills, some coordination in care may be lost, Mohr said.