In a nationally representative sample of office-based psychiatrists, the percent- age of patient visits involving at least 30 minutes of psychotherapy dropped from 44% in 1996-1997 to 29% in 2004-2005. The percentage of psychiatrists who pro- vided psychotherapy at every patient visit decreased over the same time-frame from 19% to 11%. Patients on Medicaid and patients who saw psychiatrists working in group practices or HMO settings were significantly less likely to receive psychotherapy from a psychiatrist, while self-pay patients and patients in the Northeast were more likely to receive such treatment. Through a series of analyses, the authors concluded that changes in payment source and the prescription of medications were the variables that most likely explain the decrease in psychotherapy provided over time (Mojtabai R, Olfson M, Arch Gen Psychiatry. 2008;65:962-970).

TCPR's Take: It comes as no great surprise that psychiatrists are spending less of their time doing therapy, and more of their time prescribing medica- tions. The authors speculate that this trend reflects both the increase in medica- tion options and reimbursement policies that give a financial incentive to prescribe. Whether this is a "good" or "bad" trend is a matter of personal judgment. Presumably, patients' therapy needs are being met by psychologists, social workers, and clinical nurse specialists, although the study did not provide data relevant to this hypothe- sis. The real question is whether integrated treatment (in which a single clinician pre- scribes meds and does therapy) is any more effective than the more common split treatment model. We plan to review this literature in a future issue.