Is psychiatry trending toward drug therapy rather than psychotherapy?

[itsallgood123]

Current first year medical student here interested in becoming a psychiatrist. I have found articles similar to the one below suggesting psych is becoming more drug based than patient based over the last years or so...which disappoints me somewhat. Are the majority of psych docs still having 50 mn-1hr psychotherapy appointments (my preference) or has it become more so like the 15 mn/drug refill case as suggested by the article (I am aware this was written in 2011).

Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy

Many thanks

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[jaymon]

It's more medication management these days. Very few people in my area do psychotherapy. It's mostly therapists and psychologists who do it.

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[wolfvgang22]

This does not mean you cannot do some psychotherapy, however.
This has been discussed a lot here before, as a quick search of this forum will reveal. Not much has changed.

 

[Shikima]

Pills before skills.

 

[smalltownpsych]

Pills before skills.

🤣

Current first year medical student here interested in becoming a psychiatrist. I have found articles similar to the one below suggesting psych is becoming more drug based than patient based over the last years or so...which disappoints me somewhat. Are the majority of psych docs still having 50 mn-1hr psychotherapy appointments (my preference) or has it become more so like the 15 mn/drug refill case as suggested by the article (I am aware this was written in 2011).

Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy

Many thanks

Although it might be true on the surface that the delivery of psychotherapy is going to be done by such as myself, the reality is that if a psychiatrist doesn't have solid therapeutic skills and ability to conceptualize cases, then they will end up throwing pills at patients with Cluster B type personality problems, addiction problems, and psycho-social problems and getting other things thrown back at them. Seen it happen first hand in the locked units.

 

[Shikima]

🤣

Although it might be true on the surface that the delivery of psychotherapy is going to be done by such as myself, the reality is that if a psychiatrist doesn't have solid therapeutic skills and ability to conceptualize cases, then they will end up throwing pills at patients with Cluster B type personality problems, addiction problems, and psycho-social problems and getting other things thrown back at them. Seen it happen first hand in the locked units.

Now, there may be of some benefit from using SSRI/SNRIs in reasonable dosages for these 3 groups and it would lend support towards neuroplasticity while working through psychotherapy. But pushing to maximums in hopes to suppress any and all emotions? Well, we're not Vulcan but wish for people to live long and prosper.

 

[PistolPete]

Lots of private practice psychiatrists do combined meds and therapy, smaller portion do meds only or therapy only.

 

[J ROD]

generally, pills pay bills! And talk is cheap......unless you do straight cash homey. Then, let the good times roll!

 

[Information Underload]

I see patients in either 20-minute or 40-minute appointments with therapy, and I think this works quite well. For patients who need therapy, they get the 40-minute appointments. For those who might benefit less from it (read: my grumpy ADHD kids, kiddos with ASD, relatively stable patients, patients on a tight budget), they get the 20-minute appointments. It's not the same as seeing a patient for an hour every week, but it is just about as financially feasible for me to see patients this way as opposed to taking 20-minute med appointments for every patient. The 90833 code has really made it much easier to do psychotherapy as a psychiatrist.

It is true that I only have a handful of patients who I continue to see who aren't on medication, as they are likely best served by regular therapy appointments.

 

[hamstergang]

I have found articles similar to the one below suggesting psych is becoming more drug based than patient based

This is a rather false dichotomy you've set up. Just because I prescribe meds and don't deliver any real psychotherapy doesn't mean my work isn't patient based. I still need to understand my patients well in order to effectively use medications and know when to.

Also, my current job is a salaried position working with kids with 90-120 minute intakes and 30 minute follow ups.

 

[birchswing]

I wouldn't say that's a trend over the last "few" years. More like the last 50 years.

 

[Shikima]

enh... 30ish years.

 

[nitemagi]

enh... 30ish years.

Since the 80s, aka "the decade of the brain." I blame my old chairman.

But pendulums swing both ways.

 

[splik]

Since the 80s, aka "the decade of the brain." I blame my old chairman.

But pendulums swing both ways.

actually the 90s was the decade of the brain but yes it's all be going downhill since the 80s heralded by DSM-III, competition from other mental health professionals, the neokrapelinian turn, prozac, and the rise of managed care.

 

[nitemagi]

actually the 90s was the decade of the brain...

You're right.

 

[smalltownpsych]

Now, there may be of some benefit from using SSRI/SNRIs in reasonable dosages for these 3 groups and it would lend support towards neuroplasticity while working through psychotherapy. But pushing to maximums in hopes to suppress any and all emotions? Well, we're not Vulcan but wish for people to live long and prosper.

It is surprising how many patients really do wish or even think that it is possible to have no emotions. Especially if they have a trauma history, then many of the people with addiction just want to feel good all the time and if they don't, then they need their meds adjusted.

Also, just wanted to add that I didn't mean to imply that medications can't be useful with those patients, just that these are the types of patients that if you neglect or miss the interpersonal or psychological, then you will be less effective.

 

[Shikima]

It is surprising how many patients really do wish or even think that it is possible to have no emotions. Especially if they have a trauma history, then many of the people with addiction just want to feel good all the time and if they don't, then they need their meds adjusted.

Also, just wanted to add that I didn't mean to imply that medications can't be useful with those patients, just that these are the types of patients that if you neglect or miss the interpersonal or psychological, then you will be less effective.

"I want to feel good" "I want to be happy" "I want the pain to stop"

All synonymous for Vulcan-like control of emotions. When did we get so afraid of emotions and when did we learn to be incredibly reactive to emotions that others have?

 

[HarryMTieboutMD]

actually the 90s was the decade of the brain but yes it's all be going downhill since the 80s heralded by DSM-III, competition from other mental health professionals, the neokrapelinian turn, prozac, and the rise of managed care.

Because American psychiatry was in such an awesome state before then, right? Also, managed care has been a disaster for medicine as a whole

 

[smalltownpsych]

"I want to feel good" "I want to be happy" "I want the pain to stop"

All synonymous for Vulcan-like control of emotions. When did we get so afraid of emotions and when did we learn to be incredibly reactive to emotions that others have?

Ever since the development of the pre-frontal cortex and the sense of control over all that cause and effect reasoning provides? 😉

 

[Jules A]

"I want to feel good" "I want to be happy" "I want the pain to stop"

All synonymous for Vulcan-like control of emotions. When did we get so afraid of emotions and when did we learn to be incredibly reactive to emotions that others have?

In my outpatient endeavours I'm frequently fired for attempting to reduce polypharmacy and encouraging patients to slowly learn to tolerate and value discomfort and their emotions. Fortunately affective dysregulation in my office doesn't disarm or move me to continue what I know is an unsafe, unnecessary medication regimen.

The patients who stick with me and their skilled therapists show marked improvement in function and a reduction in medications. There are many patients I have taken off the borderline cocktail, which in this area includes Effexor, Wellbutrin, Seroquel, Buspar, Vistaril or a benzo and for what anecdotally seems to be a disproportionate number of young, attractive females a stimulant also, and eventually stabilized them on an antidepressant along with DBT, TF-CBT or whatever modality their therapist deemed appropriate. Its not initially pretty or quick but it works and is worth the effort in my opinion.

 

[WisNeuro]

In my outpatient endeavours I'm frequently fired for attempting to reduce polypharmacy and encouraging patients to slowly learn to tolerate and value discomfort and their emotions. Fortunately affective dysregulation in my office doesn't disarm or move me to continue what I know is an unsafe, unnecessary medication regimen.

The patients who stick with me and their skilled therapists show marked improvement in function and a reduction in medications. There are many patients I have taken off the borderline cocktail, which in this area includes Effexor, Wellbutrin, Seroquel, Buspar, Vistaril or a benzo and for what anecdotally seems to be a disproportionate number of young, attractive females a stimulant also, and eventually stabilized them on an antidepressant along with DBT, TF-CBT or whatever modality their therapist deemed appropriate. Its not initially pretty or quick but it works and is worth the effort in my opinion.

Will you come and work in my clinic? We need more of this.

 

[Shikima]

In my outpatient endeavours I'm frequently fired for attempting to reduce polypharmacy and encouraging patients to slowly learn to tolerate and value discomfort and their emotions. Fortunately affective dysregulation in my office doesn't disarm or move me to continue what I know is an unsafe, unnecessary medication regimen.

The patients who stick with me and their skilled therapists show marked improvement in function and a reduction in medications. There are many patients I have taken off the borderline cocktail, which in this area includes Effexor, Wellbutrin, Seroquel, Buspar, Vistaril or a benzo and for what anecdotally seems to be a disproportionate number of young, attractive females a stimulant also, and eventually stabilized them on an antidepressant along with DBT, TF-CBT or whatever modality their therapist deemed appropriate. Its not initially pretty or quick but it works and is worth the effort in my opinion.

Fired out of a cannon and into the sun?

Or just by management and/or patients?

 

[Jules A]

Fired out of a cannon and into the sun?

Or just by management and/or patients?

Lol, actually just fired by patients although out of a cannon into the sun would be a respite some days. I worked one OP job early in my career where the LCSW who ran the clinic encouraged me to continue horrendous regimens because patient's complained so I resigned and have subsequently only worked where there is no presure to retain clients who aren't interested in a safe and appropriate care.

Full disclosure with regard to cleaning up meds I have had two, out of hundreds, of the SUD and BiPad variety who actually got manic but we saw it coming, it confirmed the diagnosis and they were stabilized on an appropriate regimen which was still 1/2 the meds they came to me on.

 

[Nasrudin]

I think. This question from an M-1 is more damning of us than we're letting on. To the lay public. Ourselves. Our patients.

But. At the same time it sets the stage... just as I would like it... The unrewarded, long way around. For the right reasons. Against a tide of enlightened, rational, symptom-checking, imbeciles. Wherein, I get to do what I want--being a therapist who uses medications--and distinguish myself as a natural cause of moving in the opposite direction of the herd.

OP. This option is available to you as well.

There are mentors playing the relic role of teaching therapist in the institutions. You can take 10 therapy cases instead of 2. You can read the seminal works of psychology. We're shrinks. We're not pounding out 80 hour weeks in the hospital. You'll have time and energy to focus on learning if you want. There are mentors waiting to transmit knowledge to a motivated mentee with a serious intent to learn to be a therapist.

You just need a program that has them. Or a city where there are resources in the community.

There are a variety of ways.

As for rubber hitting road in the work place. I think the opportunities are there if that's what's important to you. You just have to think creatively. Entrepreneurially. And keep a ready supply of politely phrased F@ck you's to dish out to anyone who doesn't think that the patient encounter is real. And that it matters. And that it's quality... is where it's at.

I plan on taking the best public job I can get that will allow me to carve this out. Maybe that means I make less money from them. And then I'm going to open my own practice. And put it down just as I like it.

Because. I am. A therapist. And I use medications. In other words I'm a real psychiatrist.

The bureaucrats will have to deal with it. My employers will have to deal with it. I'll try to be efficient enough to justify my weight. But I realize that, that's not going to happen everywhere. They'll have to be a lean outfit to afford a real shrink. If they want a med manager they can have it. In someone else.

I think realized recently. That it's going to be all or nothing for me. And I'll just have to hang my shingle on the outcome. Because if I do what an MBA would have me do...I'll hate the work. And I just can't do that.

So. I think it's possible.

But I'm not even sure, if you meant all of what the question means to me. so... anyway.

 

[SeniorWrangler]

Lol.