Psychotherapy Use is Declining: How Does That Make You Feel?
I shadowed a psychiatrist, Dr. D, about a year ago. I didn’t know how it was going to work. Trust between patient and psychiatrist seemed central to the whole practice of psychotherapy. I was worried that, even as a ‘shadow’ lurking in the corner, I would breach the insulated environment that likely required multiple sessions to create.
It turns out I didn’t have to worry about this because Dr. D was doing consults that day—which were far from intimate, compared to the psychotherapy sessions I expected to see. It involved us going from bed to bed, as Dr. D asked each patient with a history of psychiatric issues general questions about their mental health. As the day of consults went on, I started to wonder whether or not psychotherapy was as relevant as it used to be. Perhaps the image of a patient lying down on a couch and sharing their feelings with a note-taking psychiatrist was more outdated than I thought. Dr. D confirmed my suspicions. He explained to me that many of today’s psychiatrists do not utilize psychotherapy as a dominant form of treatment. Instead, in addition to performing consults, a modern psychiatrist relies more heavily on prescribing psychotropic medications like Zoloft, an antidepressant, or Chlorpromazine, an antipsychotic.
The numbers support the trend Dr. D described. According to a 2010 study in the American Journal of Psychiatry, from 1998 to 2007 the number of patients in outpatient mental health facilities receiving only psychotherapy fell from 15.9 percent to 10.5 percent, while the number of patients receiving only medication rose from 44.1 percent to 57.4 percent.
There are a number of reasons for this shift from psychotherapy to medication. Dr. D explained a couple. For one, psychiatrists just don’t have the time for long psychotherapy sessions. Psychiatrists employed by hospitals are required to see a long list of patients each day. It’s more practical to prescribe medication during shorter sessions and then refer patients to a psychologist if therapy is needed. There are still many psychiatrists in private practices who center their approach around psychotherapy. But, as Dr.D explained, they don’t earn as much money because they aren’t able to see as many patients when conducting long therapy sessions.
Dr. D provided a number of physician-focused reasons for the shift in psychiatric care. But, a Clinical Psychology Review study conducted by Brown University professors, Brandon Gaudiano and Ivan Miller, offers a large-scale explanation: the shift to psychotropic drugs mirrors the medical community’s trend towards evidence-based medicine. Psychotropic drugs are evidence-based treatments—they enter the marketplace after their safety and efficacy is validated through extensive, empirically-driven research in increasingly prestigious, well-funded labs. With so much money going towards biomedical research, the evidence base for psychotropic drugs has grown tremendously, according to Gaudiano and Miller. On top of that, greater biomedical research on psychiatric disorders has shown that they aren’t purely a dysfunction in behavior. Rather, countless studies have shown that the underlying effect of disorders is altered brain chemistry—which psychotropic drugs can directly improve. So, because we now understand psychiatric disorders as biological dysfunction and psychotropic drugs are proven—by a large number of sources—to better neurological symptoms, the use of medication is preferred.
Unlike psychotropic medication, psychotherapies—such as cognitive behavioral therapy and mindfulness—don’t have quite the ample evidence base. Much fewer studies indicate that psychotherapy meets the scientific standards that psychotropic drugs do. Instead, there’s “a proliferation of non-supported psychotherapies out there,” according to Gaudiano. Psychotherapy doesn’t necessarily affect brain chemistry as directly as psychotropic drugs do and, without an established set of standards, it’s unclear how exactly psychotherapy improves symptoms. It’s much easier for practitioners to express some kind of personal bias during psychotherapy treatment, which runs counter to the optimization of decision-making that evidence-based treatments prize. In today’s medical world where a premium is placed on adherence to scientific standards, unstandardized psychotherapies simply don’t fit.
Although psychotherapy has a small evidence base compared to that of psychotropic drugs, studies that evaluate patients’ treatment preference show that it’s still a valuable form of treatment—valuable enough that it’s declined use is concerning. A literature review in General Hospital Psychiatry found that a majority of patients from all other available studies preferred psychotherapy to antidepressants. Psychotherapy may be preferred because it addresses components of psychiatric disorders that psychotropic treatments don’t. Some common psychiatric disorders, including depression or PTSD, may be the result of early childhood trauma. Psychotherapy treatments that delve deep into the patient’s past, such as psychodynamic psychotherapy, may allow them to work through specific issues more effectively than a pill—in fact, a PNAS study of 681 depressed patients showed just that. Medications may also fail to address the culturally unique stigmas that worsen psychiatric disorders. For example, Islamophobia contributes to and worsens symptoms of Muslims’ PTSD. Certainly, psychotropic drugs would alleviate PTSD symptoms, but they don’t necessarily resolve the root social causes and influences, while culturally competent psychotherapy can.
Psychotropic medications work. That’s close to undeniable, which is why they’re so widely used. But, even though psychotherapies aren’t as standardized as drugs, patients recognize their effectiveness. Dr. D acknowledged as much. In an ideal world, he said, psychotherapy and medication should be used together. A combination of the two makes perfect sense—drugs affect the biological components of disorders, while therapy addresses the social, cultural, and behavioral. But, according to the American Journal of Psychiatry mentioned earlier, the percentage of depressed patients receiving both psychotherapy and medication has fallen from 40 percent to 32.1 percent. If this trend continues, psychotherapy will become a very small part of psychiatric treatment, possibly obsolete. Insurance coverage for psychotherapy is diminishing, funding for psychotherapy studies is paltry, and pharmaceutical companies spend billions of dollars on advertising to promote medications—the future of psychotherapy is bleak. And, considering how important psychotherapy can be in treating psychiatric disorders, that doesn’t make me feel good.
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