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 about.com tells me is the AMA's statement of the average). According to payscale.com 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.