April 24, 2010


Mind Over Meds (DANIEL CARLAT, 4/19/10, NY Times Magazine)

The newer generation of psychiatrists, who graduated in the 1980s and afterward, trained in programs that were increasingly skeptical of therapy and that emphasized a focus on medications. M.G.H. was by far the most influential of these modern programs. Graduates of the M.G.H. program and its sister program at nearby McLean Hospital have fanned out throughout the country, becoming chairmen of departments and leaders of the National Institute of Mental Health.

A result is that psychiatry has been transformed from a profession in which we talk to people and help them understand their problems into one in which we diagnose disorders and medicate them. This trend was most recently documented by Ramin Mojtabai and Mark Olfson, two psychiatric epidemiologists who found that the percentage of visits to psychiatrists that included psychotherapy dropped to 29 percent in 2004-5 from 44 percent in 1996-97. And the percentage of psychiatrists who provided psychotherapy at every patient visit decreased to 11 percent from 19 percent.

While it is tempting to blame only the biologically oriented psychiatrists for this shift, that would be simplistic. Other forces are at work as well. Insurance companies typically encourage short medication visits by paying nearly as much for a 20-minute medication visit as for 50 minutes of therapy. And patients themselves vote with their feet by frequently choosing to see psychopharmacologists rather than therapists. Weekly therapy takes time and is arduous work. If a daily pill can cure depression and anxiety just as reliably, why not choose this option?

In fact, during my 15-to-20-minute medication visits with patients, I was often gratified by the effectiveness of the medications I prescribed. For perhaps a quarter of them, medications worked so well as to be nearly miraculous. But over time I realized that the majority of patients need more. One young woman I saw was referred to me by a nurse practitioner for treatment of depression that had not responded to several past antidepressants. She was struggling to raise two young children and was worried that she was doing a poor job of it. Her husband worked full time and was rarely available to help. She cried throughout our initial interview. I started her on Effexor and referred her to a social-worker colleague. She improved initially, but over the years since, her symptoms have waxed and waned. When she reports a worsening of her anxiety or depression, my first instinct is to do one of three things — switch medications, increase her dosage or add another.

Posted by Orrin Judd at April 24, 2010 6:38 AM
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