Don’t Forget Psychotherapy

The article “Treatment Success Hinges on Unique Alliance of Psychiatrists, Patients” in the December 19, 2003, issue is a sad commentary on the contemporary role of the psychiatrist in treating mental disorders. The fact that one has to remind psychiatrists that the therapeutic relationship is important in treating patients along with medications is an indication that psychiatrists have all but abandoned their role as psychotherapists—as the sine qua non of the latter is the therapeutic alliance—in developing a relationship with the patient.

Unfortunately, this state of affairs has been fostered by attempts of HMOs to lower costs. Fifteen-minute medication monitoring sessions are reimbursed at half the rate of a 45-minute psychotherapy session by a physician. So limiting one’s practice to medication monitoring generates more income. Reimbursement for psychotherapy by nonmedical therapists is at a lower rate, thus encouraging so-called “combined therapy,” that is, when the psychiatrist does the medication for the therapist’s psychotherapy patient. However, it has been shown that combined therapy is actually less cost-effective, since when both therapy and medication are provided by a psychiatrist alone, treatment requires fewer sessions.

In addition, the training of psychiatrists usually includes more contact with inpatients and more intense study of their disorders, as well as the basic medical school experience and its emphasis on clinical skills. Apparently some psychiatry residency programs do not place very much emphasis on training in psychotherapy, which, in my opinion and experience, is the most interesting and rewarding aspect of psychiatric practice and often influences and accomplishes changes in patients that no medication can duplicate.