Publication | Talk Therapy by US Psychiatrists Declined by Half Since 1990s

For decades, psychiatrists routinely used both psychotherapy (talk therapy) and medications to treat patients. This is hardly the case anymore, according to a new study led by INCITE graduate fellow Daniel Tadmon.

The switch from talk therapy to medication management has swept psychiatric practices. Researchers analyzing 21 years of data across the U.S found that between 1996 and 2016 the percentage of psychiatrist visits involving psychotherapy had declined by half—dropping to only 21.6 percent of patient visits. By the mid-2010s, over half of U.S. psychiatrists no longer practiced any psychotherapy at all, and that number has likely fallen more since.

The study, published Dec. 8 in the American Journal of Psychiatry, finds that the decline in psychiatrists’ provision of psychotherapy did not affect all patient groups equally. Older, white patients in the Northeast and the West who pay for treatment out of pocket were impacted less by these declines and still retained access to a small class of psychiatrists who saw fewer patients, saw them more often, and were more likely to provide them with psychotherapy. For other patient groups—and in particular for younger, rural, Black or Hispanic patients and those relying on public insurance to pay for care—receiving talk therapy from their psychiatrists has become exceedingly rare.

While declines in American psychiatrists’ practice of psychotherapy were first observed in the 1980s and tracked up to the mid-2000s, little was known about the phenomenon in the period since. “We knew psychiatrists are providing less therapy than before, but we were surprised by the magnitude of the drop and its persistence. Almost all patient groups were impacted, though some much more than others,” said Tadmon.

The declines for some patients were particularly large. Whereas in the mid 1990s, patients diagnosed with a personality disorder would receive psychotherapy from their psychiatrists in 68 percent of visits, this declined to only 17 percent by the mid 2010s. For patients diagnosed with dysthymia (a persistent, less severe form of depression) psychotherapy provision declined from 65 percent to 30 percent. By the 2010s, 53 percent of psychiatrists no longer provided psychotherapy to any of their patients.

One of the main drivers of these trends, the study suggests, is economic. Insurance companies are incentivized for psychotherapy to be provided by counselors, social workers, and other mental health professionals who are compensated at lower rates compared to psychiatrists. From psychiatrists’ own perspective, too, psychotherapy is less financially worthwhile. In the time span of a single psychotherapy session, psychiatrists can have multiple, shorter, medication management visits. “For many psychiatrists, this helps pay their soaring medical school debt,” Tadmon said.

The decline in psychotherapy administered by psychiatrists is worsened by a severe national shortage in psychiatric services. In places with poor access to care and where providers are overwhelmed by demand, psychiatrists are particularly unlikely to practice psychotherapy. By focusing on medication management and leaving talk therapy to other providers, psychiatrists working in lower access areas might feel they can reach more patients in need. These trends are likely to only have been accelerated by the COVID-19 pandemic, which significantly increased the demand for mental health services.

Psychiatrists have long prided themselves on their mastery of both psychological and pharmacological treatment approaches, addressing “both the mental and physical aspects of psychological problems” according to the American Psychiatric Association’s website. Current official psychiatric guidelines instruct providers to treat many common disorders with a combination of psychotherapy and medications.

Yet, according to senior study author Mark Olfson, professor of psychiatry, medicine, and law and professor of epidemiology at Columbia, the trends reported in the study indicate that in practice, psychiatry is breaking away from psychotherapy—a modality of treatment that used to be emblematic of it. “In response to powerful economic incentives, U.S. psychiatrists have become increasingly focused on medication management,” Olfson said. “This transformation risks leaving unaddressed difficulties that their patients’ have in their personal relationships, families, and work roles.”