A cover story by Gardiner Harris in Sunday’s New York Times spotlights the changes in modern psychiatry, from extensive, psychotherapy-based interaction to brief, medication-oriented “psychopharm” practice. The shift has transpired over the last decade or longer; it was brilliantly described in T.R. Luhrmann’s 2000 book Of Two Minds, and has been explored ad nauseum in the psychiatric literature, countless blogs (including this one), and previously in the New York Times itself.
The article shares nothing new, particularly to anyone who has paid any attention to the rapid evolution of the psychiatric profession over the last ten years (or who has been a patient over the same period). While the article does a nice job of detailing the effect this shift has had on Donald Levin, the psychiatrist profiled in the article, I believe it’s equally important to consider the effect it has had on patients, which, in my opinion, is significant.
First, I should point out that I have been fortunate to work in a variety of psychiatric settings. I worked for years in a long-term residential setting, which afforded me the opportunity to engage with patients about much more than just transient symptoms culminating in a quick med adjustment. I have also chosen to combine psychotherapy with medication management in my current practice (which is financially feasible—at least for now).
However, I have also worked in a psychiatric hospital setting, as well as a busy community mental health center. Both have responded to the rapid changes in the health care reimbursement system by requiring shorter visits, more rushed appointments, and an emphasis on medications—because that’s what the system will pay for. This is clearly the direction of modern psychiatry, as demonstrated in the Times article.
My concern is that when a patient comes to a clinic knowing that he’ll only have 10 or 15 minutes with a doctor, the significance of his complaints gets minimized. He is led to believe that his personal struggles—which may in reality be substantial—only deserve a few minutes of the doctor’s time, or can be cured with a pill. To be sure, it is common practice to refer patients to therapists when significant lifestyle or psychosocial issues may underlie their suffering (and if they’re lucky, insurance might pay for it), but when this happens, the visit with the doctor is even more rushed.
I could make an argument here for greater reimbursement for psychiatrists doing therapy, or even for prescribing privileges for psychologists (who provide the more comprehensive psychotherapy). But what’s shocking to me is that patients often seem to be okay with this hurried, fragmented, disconnected care.
Quoting from the article (emphasis mine):
[The patient] said she likes Dr. Levin and feels that he listens to her.
Dr. Levin expressed some astonishment that his patients admire him as much as they do.
“The sad thing is that I’m very important to them, but I barely know them,” he said. “I feel shame about that, but that’s probably because I was trained in a different era.”
It is sad. I’ve received the same sort of praise and positive feedback from a surprising number of patients, even when I feel that I’ve just barely scratched the surface of their distress (and might have even forgotten their names since their last visit!), and believe that I’m simply pacifying them with a prescription. At times, calling myself a “psychiatrist” seems unfair, because I feel instead like a prescription dispenser with a medical school diploma on the wall.
And yet people tell me that they like me, just as they like Dr. Levin. They believe I’m really helping them by listening to them for a few minutes, nodding my head, and giving a pill. Are the pills really that effective? (Here I think the answer is clearly no, because treatment failures are widespread in psychiatry, and many are even starting to question the studies that got these drugs approved in the first place.) Or do my words—as brief as they may be—really have such healing power?
I’ve written about the placebo effect, which can be defined as either the ability of a substance to exert a much more potent effect than what would be anticipated, or as a person’s innate ability to heal oneself. Perhaps what we’re seeing at work here is a different type of placebo effect—namely, the patient’s unconscious acceptance of this new way of doing things (i.e., spending less time trying to understand the origins of one’s suffering, and the belief that a pill will suffice) and, consequently, the efficacy of this type of ultra-rapid intervention, which goes against everything we were trained to do as psychiatrists and therapists.
In an era where a person’s deepest thoughts can be shared in a 140-character “tweet” or in a few lines on Facebook (and Charlie Sheen can be diagnosed in a five-minute Good Morning America interview), perhaps it’s not surprising that many Americans believe that depression, anxiety, mood swings, impulsivity, compulsions, addictions, eating disorders, personality disorders, and the rest of the gamut of human suffering can be treated in 12-minute office visits four months apart.
Either that, or health insurance and pharmaceutical companies have done a damn good job in training us that we’re much less complicated than we thought we were.
Thought Broadcast 
As a practicing psychiatrist I strongly agree with the need to know our patients better ……and that usually means spending more time with them;
But the bottom line is : how do you feel about working with 20-30 patients and letting hundreds more with the following options: get medications from a PCP who usually has less time and training than you do; have psychologists with NO medical training prescribing medications or put your patients on a waiting list so they can see the master in a few months?
It’s great to complain about the changes Psychiatry has been going through,but the better course would be to figure out how we can train more Psychiatrist so they can practice in an ideal setting,spending as much time as is needed and getting reimbursed for that time;
Or maybe realize that it’s better to go towards a model that can integrate different specialists strengths and weaknesses…..
Do that many more people need meds than when I started my practice 20 years ago? I’m particularly referencing the 4000% increase in the use of atypicals in children and adolescents.
I, too, was shocked by the positive patient response in the New York Times… then I read Gianna’s post on the subject. An independent search of his patient reviews online yields different results… harder to find rave reviews there! Much more common are feelings dissatisfaction, betrayal, anger, etc. He gets called a “pill pusher,” “insensitive,” and sundry other things.
The positive patient response is simply the one response (of many) the NYT reporter chose to represent. Sends a very specific message doesn’t it?
But I think the most shocking thing in the entire article was the quote from Dr. Levin’s son, studying to be a child psychiatrist… “I’m concerned that I may be put in a position where I’d be forced to sacrifice patient care to make a living, and I’m hoping to avoid that.”
Sounds like he’s open to the possibility… My God.
***
Great to hear your perspective on this. Keep up the good work!
Alt… Thanks for your comment. Trying to think about this whole issue from a patient’s perspective has brought up many conflicting views, but also (in a bigger sense) calls into question what we’re really called upon to do in psychiatry.
As I gather my thoughts here in the next day or two, I plan to write more about this side of the story. Stay tuned…
Looking forward to it!
When a psychiatrist combines meds and psychotherapy you get one brand of psychotherapy, not necessarily the one the patient needs, and a marginally qualified pspychopharmacotherapist. I call it sporkiatry. Here’s what it can look like:
http://behavenetopinion.blogspot.com/2011/01/sporkiatrist-tries-to-do-psychotherapy.html
Sure it has advantages sometimes, but drugs alone sometimes do work, and contrary to the myth everyone does not need psychotherapy, and it should not be forced on them just because the sporkiatrist gets a kick out of it.
moviedoc, I have watched the video of the sporkiatrist and found it amusing. Perhaps many psychs clamoring to be paid more to combine psychotherapy and medication management would conduct themselves in a similar fashion. Clearly, treatment should not be fragmented if a psychiatrist can function competently in both roles. I can and have for almost 25 years. My concern is that psychiatrists who have been trained in the past decade or two might very well practice in a fashion akin to the farcical spork doc, if they were expected to do both. I agree with Steve’s point that primary care providers who are willing and inclined toward treating mental illness for less reimbursement, will quickly supplant those psychiatrists who consider themselves psychopharmacology experts with an arrogance that resembles the spork shrink. As one of my astute psychotherapy attendings told me at the start of my residency…”You can learn all you need to know about the DSM and prescribing psychotropics in your first 6 months, but you’ll spend the rest of your career learning how to be a good therapist.”
[…] Type 1 processes more frequently than we should. Many psychiatrists, particularly those seeing a large volume of patients for short periods of time, often see patterns earlier than is warranted, and rush to diagnoses without fully considering all […]
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