Monday, March 7, 2011

The Value of Talk

I have a New York Times widget on my smartphone. It allows me to amuse myself in the excessive amount of time I spend on public transportation, by reading the most e-mailed articles. At the top of today's list this morning was Talk Doesn't Pay, So Psychiatry Turns Instead to Drug Therapy. I have undergraduate and graduate degrees in psychology, and I work in social services, so this article should clearly appeal to me. Except all it did was annoy me.

The article implies that the troubled patients come in seeking help and are unjustly sent away with nothing. "Hold it. I'm not your therapist. I could adjust your medications, but I don't think that's appropriate." What's wrong with that? Talk to your therapist, that's what he or she is there for. Oh, you don't have a therapist? "So Dr. Levin sent the man away with a referral to a less costly therapist and a personal crisis unexplored and unresolved." Okay, so call the referral. Is this the first time you've ever asked someone to help you with something and been told that someone else was better suited to help you and therefore you should get your help from them?

"Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so they can often afford to charge less — is the reason that talk therapy is priced at a lower rate." There's so much wrong with this sentence I don't even know where to start. Maybe I'm projecting the condescension on the phrase "do not attend medical school," but I doubt it. Medical school is hard, doctors learn mountains of valuable information in medical school. But nothing about medical school is training anyone to be a competent therapist. You know what is? Psychology degrees. Social work school. Supervision in jobs and internships doing therapy. And the cost of medical school has nothing to do with reimbursement rates. The only thing it has anything to do with is the value that insurance companies and society put on medication management. The price of those degrees depends on whether your institution is public or private and whether you have assistantship funding (in the case of psychologists, for PhD vs. PsyD, both of which are psychologists).

Two years of an MSW at a private school will cost you about $68,000 (based on NYU, but it's all pretty similar), while four years of medical school at a private school will cost you about $185,000 (based both on NYU, and what tells me is the AMA's statement of the average). According to a fairly generous average pay for social workers is $45,000, while this NYTimes article claims $190,000 for psychiatrists. Soo... a little math. The education cost difference is about $117,000, social workers' favor. The pay difference is about $145,000, psychiatrists' favor. Even throwing in a generous bit for lost wages in two extra years of school and student loan interest, I give it about two years to pay off. I guess the other 38 years of your career are just a bonus. I don't have time to look up the costs and payscales for PsyDs and PhDs, but trust me that the math won't look that different. And once you throw in the public vs. private divide this whole paragraph will be pointless anyways.

"Dr. Levin has found the transition [from talk therapy psychiatry to medication management psychiatry] difficult." Okay, I understand. Your career changed mid-life. You're doing something different than what you anticipated spending your career doing. That can be disappointing. It must be very depressing to sit in your cushy office with "matching leather chairs, and African masks and a moose head on the wall." Also, "the median annual compensation for psychiatrists was about $191,000" and I can pretty much bet that an experienced psychiatrist in New York City makes a hell of a lot more than that. So forgive me for being a bit doubtful when the psychiatrists moan that taking a pay cut to do talk therapy "was no longer economically viable." You're making a choice. That's a fine choice, and I don't have a problem with it. But just own it, you want the higher paycheck, you take the medication management career.

"Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, but fewer than half of depressed patients now get such therapy compared with the vast majority 20 years ago." This is not because psychiatrists do not do talk therapy. This is because marginally effective psychiatric medication with not completely debilitating side effects now exists and because people want a quick fix and because insurance companies limit access to social workers and psychologists. Twenty years ago lengthy Freudian psychoanalysis was all we had to offer depressed patients, so that's what they got. Yes, Prozac, widely accepted as the first SSRI (though it was not quite, technically), was approved by the FDA in December 1987. Nostalgia for that era in mental health is like nostalgia for HIV/AIDS treatment of the early 90's.

I mean, it's an interesting story of this man's life, but it says so little about the actual state of mental health treatment and what it does say it says poorly. Really, New York Times? I expect better.


  1. So, I didn't read the article (disclaimer!). And I agree with most of your points re: psychology vs. psychiatry. In that I see this more as a division of specialized labor -- MD more specifically trained for diagnosis and medication management, PhD/PsyD more specifically trained for counseling etc. Each specialty does what their training is most suited for. That being said, your economic analysis is somewhat flawed. In addition to 2 extra years of medical school, there are 4-7 years of residency and fellowship depending on what area of psychiatry you plan to practice. There are also malpractice insurance costs. And other costs related to private practice. Incidentally, psychiatrists are trained in counseling and other talk therapy modalities, but during residency, not medical school. That doctor probably does very competent talk therapy -- but he chooses not too. Agree that he is making a personal (not gov't or insurance company mandated choice as implied by the article).

  2. Ha, pretty much the first thing I said to Carrie after I read this was "you know your sister's gonna have a lot to say about that paragraph, right?" ;)

  3. No return comment though...

  4. Jen - Sorry, wasn't in the mood for blogging the end of this week. I definitely think the article was primarily about his personal experience of a changing career, because psychiatry has evolved in the last 30 years. And I don't disagree with specialized labor or undervalue the time and effort that MDs put into their education.

    And yes, my economic assessment was simplified. But even during residency and fellowship the psychiatrists are being paid either more or similarly to the PhDs/PsyDs/MSWs. And those other types have to pay a lot of costs related to private practice too, if that's how they're practicing.

    And yes, that particular doctor probably does do competent talk therapy (of a psychoanalytical school anyways), but I suspect that new psychiatrists are not learning that in their residencies and fellowships because their mentors are no longer doing it.

    My annoyance of the article was not regarding this doctor's experience, but regarding the overall assumption that being an MD is better in the treatment of mental health than other degrees.

  5. You came back :). The psych residents I have the most contact with are triple boarders (peds, psych, child psych) and they are definitely being trained in talk therapy, and not just (at all??) psychoanalysis. They have continuity counseling patients, family therapy sessions, and supervision just like the SW's do. They also spent considerable time in the partial hospitalization program which has a strong psych multidisciplinary component (ie MD, psyD, phD, RN, MSW). So at least SOME psychiatrists are being strongly trained in counseling and continue to use it in their practice. All that being said, there is a significant deficit in pediatric mental health care from all types of practitioners, especially inpatient beds. And of course I agree with you -- being an MD does not apriori make you better in the treatment of mental health.