Although most psychiatrists still consider psychotherapy as central to their practice, fewer of them are performing it. Indeed, for most of the 20th century, psychotherapy was synonymous with psychiatry and the main way that psychiatrists treated outpatients.

But since the 1980s, the decline in the number of psychiatrists performing psychotherapy has been especially steep. This phenomenon could be due to changes in remuneration or the increase in psychotropic utilization.

What can be learned from this downward trend?

 

By the numbers

Writing in the American Journal of Psychiatry, investigators shed light on the plummeting rates of psychiatrists practicing psychotherapy.

Tadmon D, Olfson M. Trends in outpatient psychotherapy provision by U.S. psychiatrists: 1996–2016. Am J Psychiatry. 2022;179(2):110–121.

 

Results from this retrospective study indicated that the provision of psychotherapy declined to approximately half of all psychiatrists not providing the service at all. Furthermore, only 11%–25% conducted psychotherapy at every visit. Unfortunately, those of lower socioeconomic states were least likely to benefit from psychotherapy.

A possible explanation for this discrepancy could be the lack of approved medications for personality disorders, whereas other psychiatric disorders boast a bevy of FDA-approved treatments.

 

Factors underlying the sliding numbers

There are likely many reasons why so few psychiatrists offer psychotherapy. In an exclusive interview with MDLinx, Mark Olfson, MD, MPH, of the Columbia University Department of Psychiatry, and co-author of the AJP study, said the main reason probably has to do with finances.

“Psychiatrists have fixed-income targets and … third-party reimbursement for psychotherapy … is considerably less than for medication management,” he said. “Unless psychiatrists have cash-paying patients who can afford rates that are competitive on an hourly basis with medication-management visits, there will be financial disincentives for psychiatrists to provide psychotherapy.”

Another factor is a decline in the number of practicing psychiatrists leading to a disproportionate shortage of psychiatrists practicing in rural areas, resulting in a shift toward the use of pharmacotherapy alone. Lower socioeconomic communities, rural areas, as well as geographic regions in the South and Midwest were especially prone.

An increasing number of psychiatrists also shifted toward private-pay patients and did not tap into the increased funding made available for psychotherapy via the Affordable Care Act and the Mental Health Parity and Addiction Equity Act.

Another issue is the paucity of psychotherapy training given during residency.

Many psychiatric residency programs offer only shallow training in evidence-based psychotherapies.

“Without rigorous didactic training and extensive expert supervision, many psychiatrists—especially younger psychiatrists who were trained in an era dominated by psychiatric pharmacotherapy—may not feel competent to provide psychotherapy to a range of patients," Olfson added.

Finally, as pointed out in an article published by the AAMC, a greater public awareness of mental health issues has encouraged more people to seek treatment.

Weiner S, Writer SS. Addressing the escalating psychiatrist shortage. AAMC. February 12, 2018.

As a result, the rise in mental health need has contributed to the shortage of psychiatrists, which may likely only worsen with time. The AAMC article highlighted data projecting that by 2025, demand for mental health treatment could outpace supply by between 6,090 and 15,600 psychiatrists.

 

 

Why offer psychotherapy?

The American Psychological Association (APA) recognized the general effectiveness of psychotherapy in a 2012 resolution, as highlighted by the following motion:

Recognition of psychotherapy effectiveness. American Psychological Association. August 2012.

 

“Psychotherapy (individual, group and couple/family) is a practice designed varyingly to provide symptom relief and personality change, reduce future symptomatic episodes, enhance quality of life, promote adaptive functioning in work/school and relationships, increase the likelihood of making healthy life choices, and offer other benefits established by the collaboration between client/patient and psychologist.”

The APA is in the process of developing clinical guidelines to address which types of psychotherapy are best for which conditions.

As Olfson noted, some conditions, such as severe adolescent and adult depression, respond best to a combination of psychotherapy and medication. In these cases, it can be helpful to keep psychotherapy in-house and performed by one specialist.

Unless psychiatrists and psychologists share caseloads and are co-located, it is quite difficult for them to coordinate the delivery of psychotherapy and medications.

“It is a time-consuming process that is challenging for patients and mental-health professionals alike. Having psychiatrists deliver the combination of psychotherapy and pharmacotherapy provides key advantages in terms of care coordination and integration,” Olfson said.

 

What the future holds

When asked what could be done to increase the number of psychiatrists offering psychotherapy, Olfson stressed that there is no one solution.

While it would be desirable to increase the number of psychiatrists who offer psychotherapy, this problem does not have an easy solution.

“Ideally, public and private insurers would recognize the value of having psychiatrists provide psychotherapy and psychiatrists, themselves, would become a bit more willing to accept somewhat lower fees for this work," Olfson concluded.