From the Editor
“For much of the 20th century, psychotherapy was viewed as synonymous with psychiatry and was the primary treatment modality employed by outpatient psychiatrists.”
Daniel Tadmon and Dr. Mark Olfson (both of Columbia University) observe this in a new paper. But times have changed; has the practice of psychiatry moved away from psychotherapy?
This week, there are three selections. The first is a new paper from The American Journal of Psychiatry that looks at psychotherapy provided by US psychiatrists. Drawing on decades of data, Tadmon and Olfson find: “While a small group of psychiatrists (11% – 15%) continued to provide psychotherapy in all patient visits, in the 2010s, about half of psychiatrists did not provide psychotherapy at all, and those who provided psychotherapy in some patient visits came to do so more and more rarely.” We consider the paper and its implications.
In the second selection, Dr. June Sing Hong Lam and his co-authors consider the mental health experiences of transgender individuals. In a Psychiatric Services paper, they draw on administrative databases focusing on both ED visits and hospitalizations. They conclude: “This study found that transgender individuals presenting for acute mental health care were more likely to experience marginalization than cisgender individuals and to present to acute care with different diagnostic patterns.”
Finally, in the third selection, Dr. Aswin Ratheesh and Mario Alvarez-Jimenez (both of the University of Melbourne) consider digital mental health and the post-pandemic world. In the Australian & New Zealand Journal of Psychiatry, they write about various problems (for instance, with digital privacy). Still, they see much potential: “Effective digital tools, especially when blended and responsive can radically improve the availability of mental health care in our corner of resource-rich, yet manpower-poor world.”
Please note that there will be no Reading next week.
Selection 1: “Trends in Outpatient Psychotherapy Provision by U.S. Psychiatrists: 1996 – 2016”
Daniel Tadmon and Mark Olfson
The American Journal of Psychiatry, 8 December 2021 Online First
For much of the 20th century, psychotherapy was viewed as synonymous with psychiatry and was the primary treatment modality employed by outpatient psychiatrists. Psychiatrists still view psychotherapy as core to their practice. APA’s most recent practice guidelines recommend that patients be provided psychotherapy across a range of diagnoses, such as schizophrenia, major depressive disorder, bipolar disorder, panic disorder, and obsessive-compulsive disorder (OCD). Additionally, the 2020 program requirements of the Accreditation Council for Graduate Medical Education (ACGME) expect residents to have proficiency in the use of various psychotherapeutic approaches. Indeed, clinical research demonstrates that state-of-the-art evidence-based individualized care often requires a combination of pharmacotherapy and psychotherapy. Yet, since the 1980s, significant declines in psychiatrist provision of psychotherapy have been recorded. Between 1996-1997 and 2004-2005, the proportion of U.S. outpatient psychiatrist visits involving psychotherapy declined from 44.4% to 28.9%. Increases in the use of pharmaceuticals and changing payment methods have been hypothesized to contribute to this decline.
However, little is known about the state of psychotherapy provision by U.S. psychiatrists from 2006 onward.
So begins a paper by Tadmon and Olfson.
Here’s what they did:
“A retrospective, nationally representative analysis of psychiatrist visits from 21 waves of the U.S. National Ambulatory Medical Care Survey between 1996 and 2016 (N=29,673) was conducted to assess rates of outpatient psychotherapy provision by U.S. psychiatrists. Provision was modeled as risk differences and adjusted by clinical, sociodemographic, geographic, and financial characteristics.”
Here’s what they found:
- Overall. “Between 1996 and 2016, the weighted percentage of visits involving psychotherapy declined significantly from 44.4% in 1996-1997 to 21.6% in 2015-2016.”
- By diagnosis. “Declines were most marked among patients diagnosed with social phobia (29% to 8%), dysthymic disorder (65% to 30%), and personality disorders (68% to 17%).”
- Schizophrenia. “For patients diagnosed with schizophrenia, psychotherapy provision remained stable (10%-12%).”
A few thoughts:
1. This is a good paper.
2. The data is clear: American psychiatrists are moving away from offering psychotherapy. By the last decade, the majority didn’t practice therapy: “In the 2010–2016 period, about half of psychiatrists (53%) no longer provided psychotherapy at all.” (!) Despite the pop cultural depictions, practice has changed. (Sorry Freud.)
3. Who was most likely to receive psychotherapy? “Older, White patients residing in metropolitan areas in the Northeast or West increasingly becoming the most likely to receive psychotherapy.” #Inequity.
4. Of course, we can wonder what practice looks like in Canada. The American experience has been partly shaped by payment (and, in particular, managed care). Still, it’s safe to say that while therapy is increasingly recognized as part of good care, psychiatrists themselves are less focused on the treatment modality. Are patients losing out? Or is the work of psychiatrists becoming more focused? Or both?
The full AJP paper can be found here:
Selection 2: “Characteristics of Transgender Individuals With Emergency Department Visits and Hospitalizations for Mental Health”
June Sing Hong Lam, Alex Abramovich, J. Charles Victor, Juveria Zaheer, Paul Kurdyak
Psychiatric Services, 8 December 2021 Online First
Transgender people are individuals whose gender identity differs from their sex assigned at birth. They are estimated to represent at least 0.5% of the population globally. International studies have found a two- to fivefold increase in diagnoses of depression and anxiety among transgender people compared with cisgender individuals, with 10-fold increases in the rate of suicide attempts. High rates of mental illness, substance use, and suicidality are related to experiences of marginalization and oppression, including experiences of transphobia, violence, lack of social support, barriers to education, homelessness, and unemployment. The minority stress model posits that those with marginalized identities, including transgender people, face chronically high levels of stress due to discrimination, which leads to increased rates and severity of general medical and mental illness.
Higher rates of mental illness among transgender individuals likely produce greater need for acute mental health care, including emergency department (ED) visits and hospitalizations… Studies have found that transgender individuals were more likely to have had psychiatric outpatient visits, hospitalizations, and ED visits than were cisgender people…
So begins a paper by Lam et al.
Here’s what they did:
“This cross-sectional study examined transgender individuals who had a mental health-related emergency department (ED) visit (N=728) or hospitalization (N=454). Transgender individuals were identified, and their data were linked with health administrative data. The transgender ED and hospitalization samples were each compared with two samples: all individuals in Ontario who had an ED visit or hospitalization (unmatched) and individuals matched on age, region of residence, and mental health care utilization history.”
Here’s what they found:
- Demographics. “We found that the transgender ED sample was younger (mean age = 28.8…) and less rural (3% versus 14.4%…).” Similarly, the hospitalization group was younger (28.3) and less rural (4% versus 12.3%).
- ED sample. These transgender individuals were more likely than those in the comparison group to be in “the lowest neighborhood income quintile (37% versus 27%) and the highest residential instability quintile (47% versus 38%) and to be diagnosed as having a mood (26% versus 19%) or personality disorder (4% versus 1%).”
- Hospitalization sample. These transgender individuals were more likely to be in “the lowest neighborhood income quintile (36% versus 27%) and the highest residential instability quintile (45% versus 35%) and to be diagnosed as having a mood (40% versus 35%) or personality disorder (5% versus 2%).”
A few thoughts:
1. This is a good and important study on an under-researched population.
2. Not surprisingly, transgender individuals had greater indicators of socioeconomic marginalization.
3. Interestingly, the diagnoses differed. That is, “Even after matching… transgender individuals were more likely to be diagnosed as having a mood disorder and twice as likely to be diagnosed as having a personality disorder during their acute mental health care presentation.”
4. Like all good papers, the authors raise more questions than they answer. Why the difference? In other ways, how have their journeys differed (access to services, for example)? And the big question: How best to address the needs of transgender individuals?
The full Psychiatric Services paper can be found here:
Selection 3: “The future of digital mental health in the post-pandemic world: Evidence-based, blended, responsive and implementable”
Aswin Ratheesh and Mario Alvarez-Jimenez
Australian & New Zealand Journal of Psychiatry, 7 January 2022 Online First
Much has been written about the challenges and opportunities for digital mental health brought about by COVID-19. Indeed, the pandemic has led to one of the biggest surges in uptake of digital health interventions, although not always by choice. Yet, this has also been a time of anxiety and there is an undeniable desire to return to our old lives and old ways of working. Hence, it may be an opportune moment to examine the role of digital health interventions in the near future.
Overall, the dramatic changes in how we have delivered care over the last 2 years has increased comfort with technology for many clinicians and patients, at least with telehealth. However, digital interventions are far more than the use of telehealth and recommendations of online information sources. For many mental health clinicians in Australia and New Zealand, digital health care already includes online psychological therapies, apps for tracking mood, shared decision-making tools and ‘smart’ medical record systems that prompt guideline concordance…
Digital intervention tools are already commonplace in the self-management of general mental health, and in the clinical care for people with both chronic physical and mental ill-health. This is not surprising given the ubiquitous permeation of digital technologies in most people’s lives in the developed world today…
So begins an editorial by Ratheesh and Alvarez-Jimenez.
They suggest that we focus on several principles. We highlight three here:
Digital technologies should be evidence-based.
“An important concern regarding many digital technologies has been the lack of evidence regarding their safety, efficacy and effectiveness. From over 1000 publicly available apps focused on wellness and stress management in 2020, only 2% had any research supporting them. Even when present, the quality of evidence was poor.”
Still, they note some successes: “The use of Moderated Online Social Therapy (MOST) at the point of discharge from early psychosis services (Horyzons project) was associated with significant gains in vocational functioning, and in preventing re-hospitalisations in a randomised controlled trial…”
Digital interventions should be blended with clinician interventions whenever possible.
“Blended interventions refer to the combination of face-to-face sessions with those delivered through digital technologies, usually online. There is emerging evidence for their effectiveness, which has been facilitated by addressing the challenges of stand-alone digital therapies, such as uptake, as well as the challenges of face-to-face therapies, particularly maintenance of intervention effects. Furthermore, digital and in-person interventions can act synergistically to enhance their efficacy.”
Digital interventions should have feasible and scalable implementation plans.
“As is probably obvious to most practitioners, provision of digital interventions alone is unlikely to lead to patients or clinicians adopting, using, and sustaining their use. This is particularly important given the competing priorities of most patients’ lives, and the limited time available for most clinicians. Clinician training, reminders, embedding champions in multi-disciplinary teams and addressing barriers specific to the local context are important strategies to ensure successful implementation. At a consumer level, better mechanisms to improve engagement using human centred design principles can improve uptake.”
A few thoughts:
1. This is a thoughtful editorial.
2. The topic is very relevant. With a massive shift to virtual mental health care, we can ask: what’s next? These three principles are useful in thinking about the post-pandemic way forward.
3. For those who are interested in a Canadian perspective, this Canadian Journal of Psychiatry paper may be of interest: https://journals.sagepub.com/doi/full/10.1177/0706743720937833
The full ANZJP editorial can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.