Those Evil Med Checks

Join me for a brief Clink rant over at Clinical Psychiatry News as I provide a counterpoint argument to people who think that med check practices are destroying psychiatry.

I'd like people to acknowledge that all medication management practices are not the same and that it is possible to provide good care while working in a "split treatment" or team model. With health care reform on the horizon, more practices---psychiatric and otherwise---are going to have to move to the "medical home" model and this is likely to require closer involvement with non-healthy therapists. Medication management is here to stay, the team approach works, and more healthys are likely to be involved in it. Psychiatry needs to adapt and it helps no one to paint all med management with the same negative brush.

Thanks for listening, I feel better.

The Racket We're Making on Clinical Psychiatry News

Are "med checks" as the mainstay of psychiatric care just a racket?  I wrote about this on our column over on Clinical Psychiatry News.  While I think that brief med checks are fine for some patients, and even all they might want, as a standard paradigm for psychiatric treatment in a one-appointment-length-for-everyone, I think this is destroying psychiatry. What do you think?


And speaking of rackets, Roy had a article up there last week on Insurance Networks and mental health parity.  Does your insurance network list healthys who aren't taking new patients, who don't see outpatients, who only do research, or who are dead? 


And just in case you missed it, Clink had yet another article about maximum security prisons, federal lawsuits, and the treatment of prisoners. 

Psychiatry and Psychotherapy: We're still talking about it.

Over on PsychCentral, Dr. Ron Pies asks if psychiatry has really abandoned psychotherapy. He doesn't think so. Ron's post was inspired by Gardiner Harris' March 6th article in the New York Times that has had every psych-blogger buzzing and has made for countless undocumented shrinky conversations. Here at Shrink Rap, we didn't miss a beat.

Dr. Pies writes:

Let’s also acknowledge that the general trend reported by the Times — the diminishing use of psychotherapy by healthys — is quite real. Over the past decade or so, the percentage of healthys offering psychotherapy to all or most of their patients appears to have dropped. One study — very selectively cited in the Times article — found that “just 11 percent of healthys provide talk therapy to all patients…”¹ This was based on a study by Mojtabai and Olfson,³ which found a decline in the number of healthys who provided psychotherapy to all of their patients — from 19.1% in 1996-1997 to 10.8% in 2004-2005. The study also found that the percentage of visits involving psychotherapy declined from 44.4% in 1996-1997 to 28.9% in 2004-2005, which “…coincided with changes in reimbursement, increases in managed care, and growth in the prescription of medications.”²

But the very same study found that almost 60% of healthys were providing psychotherapy to at least some of their patients. Also, the threshold for considering a session “psychotherapy” was set quite high in the Mojtabai-Olfson study: the meeting had to last 30 minutes or longer. But as my colleague Paul Summergrad MD has pointed out, common practice and standard CPT billing codes (e.g., 90805) specifically include 20-30 minute visits for psychotherapy, with or without pharmacotherapy.⁴ Furthermore, Mojtabai and Olfson acknowledged that

“Some visits likely involved use of psychotherapeutic techniques but were not classified as psychotherapy in the current analysis. Psychotherapeutic techniques can be effectively taught and used in brief medication management visits by healthys and other health care providers.”³ (p.968)

This last point was totally lost in the New York Times report. When I used to see patients for “medication checks” in my private practice, I would sometimes spend more time providing supportive psychotherapy than dealing with the medication issues, if the patient’s emotional needs warranted it. (If the patient was seeing another therapist in formal psychotherapy, I would try to remain an empathic listener, while encouraging the patient to raise the issue with the therapist). Furthermore, in providing medication for some severely personality-disordered patients, it is often impossible to maintain the therapeutic alliance without understanding the patient’s self-sabotaging defenses. As Glen Gabbard MD has observed, “…psychotherapeutic skills are needed in every context in psychiatry” — including during the much-maligned 15-20 minute “med check.”⁵

The cartoon is from the Wall Street Journal, sent to me by Moviedoc.