National Trends in Psychotherapy by Office-Based Psychiatrists

CONTEXT: In addition to prescribing medications, providing psychotherapy has long been a defining characteristic of the practice of clinical psychiatry. However, there are indications that the role of psychiatrists in providing psychotherapy may have diminished in recent years. OBJECTIVE: To examine recent national trends in the provision of psychotherapy by office-based psychiatrists. DESIGN: Data from the 1996 through 2005 cross-sectional National Ambulatory Medical Care Survey were analyzed to examine trends in psychotherapy provision within nationally representative samples of visits to office-based psychiatrists. Multivariate analyses examined the time trend, adjusting for patient, visit, and setting characteristics. Practice-level analyses examined time trends in the percentage of psychiatrists who provided psychotherapy to all, some, or none of their patients during a typical week. SETTING: Office-based psychiatry practices in the United States. PARTICIPANTS: Patients with psychiatric diagnoses visiting outpatient psychiatrists. MAIN OUTCOME MEASURE: Provision of psychotherapy in visits longer than 30 minutes. RESULTS: Psychotherapy was provided in 5597 of 14,108 visits (34.0% weighted) sampled during a 10-year period. The percentage of visits involving psychotherapy declined from 44.4% in 1996-1997 to 28.9% in 2004-2005 (P < .001). This decline coincided with changes in reimbursement, increases in managed care, and growth in the prescription of medications. At the practice level, the decrease in providing psychotherapy corresponded with a decline in the number of psychiatrists who provided psychotherapy to all of their patients from 19.1% in 1996-1997 to 10.8% in 2004-2005 (P = .001). Psychiatrists who provided psychotherapy to all of their patients relied more extensively on self-pay patients, had fewer managed-care visits, and prescribed medications in fewer of their visits compared with psychiatrists who provided psychotherapy less often. CONCLUSIONS: There has been a recent significant decline in the provision of psychotherapy by psychiatrists in the United States. This trend is attributable to a decrease in the number of psychiatrists specializing in psychotherapy and a corresponding increase in those specializing in pharmacotherapy--changes that were likely motivated by financial incentives and growth in psychopharmacological treatments in recent years.