The New York Times has run a piece about a historic turnabout in psychiatry: Most psychiatrists in the US do not offer talk therapy of any sort to their patients, but only medication. This will not come as news to most who are close to psychiatry or clinical psychology, but it is interesting that the main driving force behind this change is not an important shift in theory or evidence but, rather, simply cost.

Of the psychiatrist featured in the article, Donald Levin of Pennsylvania, the article says:

Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday. Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names.

Some psychiatrists, especially older ones, have found this dramatic transition difficult. It is primarily medical insurance companies, ever keen to cut costs, that have forced the change. Psychiatrists, of all people, are now saying to their patients, “I’m not your therapist,” as they usher their patients out the door after a few minutes with a prescription in their hands. Levin expands on the new mantra: “I’m not here to help you figure out how to get along with your boss, what you do that’s self-defeating, and what alternative choices you have.”

For some patients, of course, medication will improve their immediate condition. For patients, however, who have authentic personal problems that they need to work through verbally with a specialist of some sort, psychiatrists are no longer the relevant group. Such patients are routinely referred to psychologists, who do not have prescription privileges (with a few of minor exceptions) and, so, continue to offer traditional talk-therapy in a wide range of theoretical perspectives. (A number of studies have found cognitive-behavioral therapy to be as effective as drug therapy for some common psychological conditions.)  But psychologists’ services are often not covered by medical insurance and so are beyond the means of many patients.

The pressure does not come entirely from the insurance companies, however. Many psychiatrists are themselves eager to earn as much income as their colleagues in more lucrative medical specializations. Dr. Levin concedes this in the article. His wife, a former social worker and talk-therapist, now runs the business end of Levin’s practice. She says, about not allowing patients to pick the initial times for their appointments:

This is about volume…and if we spend two minutes extra or five minutes extra with every one of 40 patients a day, that means we’re here two hours longer every day. And we just can’t do it.

Levin’s son, Matthew, who is also training to become a psychiatrist, is far from oblivious to the risks inherent in this new approach to the profession. He says: “I’m concerned that I may be put in a position where I’d be forced to sacrifice patient care to make a living, and I’m hoping to avoid that.”