Friday, March 11, 2011

Talk Doesn't Pay, So Psychiatry Turns To Drugs

Changes in insurance payments are driving the switch from couch to prescriptions.

DOYLESTOWN, Pa. Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help.

But the psychiatrist, Dr. Donald Levin, stopped him and said: "Hold it. I'm not your therapist. I could adjust your medications, but I don't think that's appropriate."

Like many of the nation's 48,000 psychiatrists, Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, popularized by Sigmund Freud. Instead, Levin prescribes medication, usually after a brief consultation with patients. So he sent the man away with a referral to a less costly therapist and a personal crisis unexplored and unresolved.

Medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations, but the new efficiencies can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry.

Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday.

Then, like many psychiatrists, Levin 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. Then, his goal was to help his patients become happy; now, it is just to keep them functional.

Levin has found the transition difficult. He now resists helping patients to manage their lives better. "I had to train myself not to get too interested in their problems," he said, "and not to get sidetracked trying to be a semi-therapist."

Brief consultations have become common in psychiatry, said Dr. Steven S. Sharfstein, a former president of the American Psychiatric Association and the president and chief executive of Sheppard Pratt Health System, Maryland's largest behavioral health system.

"It's a practice that's very reminiscent of primary care," he said. "They check up on people; they pull out the prescription pad; they order tests."

Levin's office, just above Dog Daze Canine Hair Designs in this suburb of Philadelphia, has no couch or daybed; Levin has neither the time nor the space for patients to lie down anymore.

"I miss the mystery and intrigue of psychotherapy," he said. "Now I feel like a good Volkswagen mechanic."

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1 comment:

Lindsay said...

Psychiatrists like other MDs should be Medicare providers. We are more than the body below the head! I feel many problems can be helped, even resolved, with talk therapy. It is my choice to talk, as it works! In my area I have found a psycholotist who will talk with me because I have Medicare-A plus a Medicare Supplement. If I didn't have the supplement I would pay the 40% that is not paid by Medicare without a supplemental plan. Oregon is a type of flag ship for many ideas and laws in that it is the first to have environmental bills that work, Oregon Health Plan for those unable to afford insurance, the disabled and poor. We had the first bottle bill. We have the best light-rail system in the country, and it keeps growing every year. There are many other examples. If we do not join the head to the body, many people will remain sick because everything we do is done first in our minds! I want to encourage every state to include the mind in health care as it just may be the most important organ in our bodies to help us get and stay well. We are not perfect, but we are now working on a type of single-payer health insurance plan for Oregon. It was kicked off at the state capitol yesterday. It will be interesting to follow how this evolves. We have a very progressive governor who is an M.D., and he designed our current health care program some years ago when he served two terms, for the aging, poor and disabled including veterans. Now he will be working with our Congress, a 50:50 split of Republicans and Democrats, and a Senate with more Democrats than Republicans. I believe Oregon will once more set the example of what can and should be done. I heard that the savings in overhead alone when one uses a type of Medicare for all as it is enough to offset any loss due to overhead. An expert stated that a doctor can save about $70,000 per year in overhead by this type of one for all insurance. That is very significant.