Talk therapy, or psychotherapy, is on a very sharp decline among psychiatrists in the USA, according to new research from Columbia University.

The USA’s psychiatrists are not engaging in talk therapy anywhere near as much as they used to do in the last decades, a new study reports. The findings point to the unequal effects this shift has had on different segments of the population and examine the causes for this shift.

The greatest drivers seem to be economic, the authors explain.

Pills over talking

“We knew psychiatrists were 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 Daniel Tadmon, a PhD candidate in the Department of Sociology at Columbia and the study’s lead author.

Traditionally, psychiatrists employ both psychotherapy and medication in their efforts to treat patients. According to the American Psychiatric Association’s website, this allows them to tackle “both the mental and physical aspects of psychological problems”. Official guidelines instruct psychiatrists to treat many common disorders using both avenues of treatment. And, for decades, this is exactly what they did.

But it’s not the reality on the ground any longer. The study analyzed 21 years of data recorded across the U.S., finding that, between 1996 and 2016, the percentage of psychiatrist visits that involved psychotherapy dropped by half, reaching only 21.6% (roughly 1 in 5) of all patient visits. By the mid-2010s, the paper reports, over half of the psychiatrists (53%) in the U.S. no longer practiced any psychotherapy at all.

Instead, they are prescribing medicine.

The effects of this shift impact various social groups to different extents, the authors add. Older patients in the Northeast and the West, who generally pay for treatment out of pocket, saw the least decline in psychotherapy sessions; however, for the most part, these services are provided by a smaller number of psychiatrists who take on fewer patients and see each one more often. Others, in particular younger patients, but also generally less-well-off groups such as Black or Hispanic patients or those relying on public insurance to cover the cost, virtually never get any psychotherapy.

Some classes of patients are feeling the lack of this type of treatment much more acutely than others, as some disorders benefit more from talk therapy. The authors cite the case of patients with personality disorders, who received psychotherapy in 68% of visits in the mid 1990s, which declined to around 17% by the mid 2010s. Patients with dysthymia, a persistent, less severe form of depression, also saw a decline from 65% to 30% over the same timeframe.

As for the causes, the study points to the health insurance system and rising student debt. Insurance companies are pushing for psychotherapy to be performed by counselors, social workers, and other mental health professionals, as they receive lower compensation than psychiatrists. On the other hand, psychotherapy is less viable for psychiatrists themselves; in the time needed for a single psychotherapy session, they can complete several medication management visits. According to Tadmn, this “helps pay their soaring medical school debt”.

This shift is more damaging against the backdrop of the pandemic, according to the authors. Demand for mental health services has skyrocketed due to the restrictions imposed by the COVID-19 pandemic. In areas of the country where demand far outstrips access to psychiatric services, psychiatrists are much more unlikely to practice talk therapy, the paper notes. By focusing on medication management, these psychiatrists might feel that they can help a greater number of patients.

“In response to powerful economic incentives, U.S. psychiatrists have become increasingly focused on medication management,” says senior study author Mark Olfson, a professor of psychiatry and medicine at Columbia University Vagelos College of Physicians and Surgeons. “This transformation risks leaving unaddressed difficulties that their patients have in their personal relationships, families, and work roles.”

The paper “Trends in Outpatient Psychotherapy Provision by U.S. Psychiatrists: 1996–2016” has been published in the American Journal of Psychiatry.