精神科醫師不再提供心理治療


  August 6, 2008 — 根據一項長達10年的全國調查發現,美國在診間提供心理治療的精神科醫師數量逐漸減少中;由全國門診醫療調查(NAMCS)資料分析發現,看精神科門診進行心理治療的比例由1996年至1997年的44%降至2004年至2005年的29%。
  
  此研究的共同作者,過去服務於貝絲以色列女執事醫院,目前在馬里蘭州巴爾地摩約翰霍普金斯大學彭博公共衛生學院的Ramin Mojtabai博士向Medscape精神病學表示,2005年專門研究心理治療的精神科醫師比起1996年已經少很多了,而且對病患提供不同的心理治療。
  
  他注意到,在東北地區,精神科醫師傾向以個人經驗持續提供心理治療,其中大多是針對年紀大於25歲的白種人,且自費又多於健保,以及診斷較輕微的病患,例如輕鬱症或病態人格。
  
  他表示,無法預期去找出與心理治療的關聯性,一方面是保險、另一方面是地域的影響。
  
  Mojtabai博士與共同作者,哥倫比亞醫學中心與紐約州立精神病學院的Mark Olfson博士將此研究發表於8月號的一般精神學誌期刊。
  
  【經濟障礙因素】
  臨床治療指引建議精神方面疾病,例如重鬱症、創傷後症候群與雙極性疾病都可以用心理治療或搭配藥物治療。
  
  尚未有研究建議改變相關政策,美國的精神科醫師也因為抗精神病藥物有了新發展而減少提供心理治療。
  
  Mojtabai博士指出,一項最新的研究顯示,每45分鐘的心理治療,醫師的報酬還不如3次15分鐘的藥物門診開方,因此保險政策嵌入了精神科醫師提供心理治療的障礙;他補充道,現在抗精神病藥物已經比10年前的種類多更多了。
  
  有鑑於討論當代精神病學實踐、和訓練對於心理治療地位的改變,研究者審查了門診精神科醫師提供心理治療的趨勢。
  
  他們分析從1996年至2005年全國門診醫療調查(NAMCS)的抽樣資料,來看美國精神科醫師在一般典型工作日於門診所提供的治療。
  
  心理治療的定義要持續超過30分鐘;此調查包含人口統計的資料,例如付費方式、病患的精神診斷及治療模式(例如個人治療或團體治療)。
  
  研究者發現,在這10年間,病患有14,108人次看診,其中有5,597人次接受心理治療,但是有做心理治療的比例由44%下降至29%(P< .001)。
  
  【影響原因不明】
  在典型的工作日,此研究的756個開業醫師當中,有215個(佔其中的28.4%)在病人任一次看診時並未提供心理治療,其中92個(佔12.2%)在每次看診都有提供心理治療。
  
  進一步分析的結果顯示,病患接受心理治療的比例由1995-1996年的19.1%下降至2004-2005年的10.8%。
  
  Mojtabai博士表示,比起1996年時,在2005年,精神科醫師對於心理治療是越來越不感興趣;此外,因為心理治療太過耗費時間,病患對於藥物的需求多過於心理治療。
  
  然而,他補充道,就這樣下結論還言之過早。患者也許從其他提供者接受更多心理治療,譬如心理學家、社工師或其他治療師,而且這些資料並未顯示治療形式的改變是否對病患有正面、負面或中立的影響。
  
  Mojtabai 博士接受必治妥施貴寶公司及阿斯特捷利康公司的研究資金以及必治妥施貴寶公司的顧問費。Olfson博士接受禮來、必治妥施貴寶公司以及嬌生的研究資金,同時也在輝瑞及McNeil藥廠擔任顧問。此研究有部份資金補助來自於健康照護研究及品質專業行政部門。

Psychiatrists Shift Away From Providing Psychotherapy

By Marlene Busko
Medscape Medical News

August 6, 2008 — A declining number of office-based psychiatrists in the United States are providing psychotherapy, according to results from a national 10-year survey.

Analysis of data from the National Ambulatory Medical Care Survey (NAMCS) showed that the percentage of office visits to psychiatrists that involved psychotherapy provision dropped from 44% in 1996–1997 to 29% in 2004–2005.

"There were fewer psychiatrists who specialized in psychotherapy in 2005 than in 1996, and the psychiatrists who did provide psychotherapy for all of their patients had different profiles from other psychiatrists," study coauthor Ramin Mojtabai, MD, then from Beth Israel Medical Center and now from the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland, told Medscape Psychiatry.

Psychiatrists who continued to provide psychotherapy to all their patients tended to be in solo practices in the Northeast with patients who were older than age 25 years, white, self-paying rather than paying via insurance, and diagnosed with less severe illnesses, such as dysthymia or personality disorders, he noted.

"I did not expect to find this strong a relationship between provision of psychotherapy and either insurance on the 1 hand or region on the other hand," he said.

The study, by Dr. Mojtabai and coauthor Mark Olfson, MD, from Columbia University Medical Center and New York State Psychiatric Institute, in New York, is published in the August issue of the Archives of General Psychiatry.

Financial Disincentives

Practice guidelines recommend psychotherapy alone or with medications for psychiatric disorders such as major depression, posttraumatic stress disorder, and bipolar disorder.

Yet new research suggests changes in reimbursement policies and the introduction of newer psychotropic medications are contributing to a decline in the provision of psychotherapy by US psychiatrists.

"A recent study showed that for every 45 minutes of psychotherapy, physicians are reimbursed less than if they had three 15-minute medication management visits, so insurance policies have a built-in disincentive for psychiatrists to provide psychotherapy," said Dr. Mojtabai. He added there are many more types of antipsychotic medications available now than there were 10 years ago.

In light of these changes as well as the debate about the place of psychotherapy in contemporary psychiatry practice and training, the investigators examined trends in provision of psychotherapy by office-based psychiatrists.

They analyzed data from a 1996–2005 NAMCS survey of a national sample of US office-based psychiatrists, which is based on treatment offered in a typical week.

Psychotherapy visits were defined as those lasting longer than 30 minutes. The survey provided patient demographic information as well as data about payment type, psychiatric diagnosis, and office setting (such as solo or group practice).

The researchers found that psychotherapy was provided in 5597 of 14,108 visits during a 10-year period, but that the percentage of visits involving psychotherapy declined from 44% to 29% (P < .001).

Impact Unclear

In a typical week, 215 of the study's 756 practices (28.4%) did not provide psychotherapy during any visits, and 92 (12.2%) provided psychotherapy during all visits.

Further analysis showed a significant decrease in practices in which all patients received psychotherapy — from19.1% in 1995–1996 to 10.8% in 2004–2005.

It appears psychiatrists are less interested in specializing in psychotherapy in 2005 than in 1996, said Dr. Mojtabai. In addition, there may be greater patient demand for medication, since many perceive psychotherapy to be too time-consuming.

However, he added, it is premature to jump to conclusions. "Patients may be receiving more psychotherapy from other providers, such as psychologists, social workers, or other therapists, and these data do not reveal whether the changes in therapy modality have had a positive, negative, or neutral impact on patient outcomes."

Dr. Mojtabai has received research funding from Bristol-Myers Squibb and AstraZeneca and consultant fees from Bristol-Myers Squibb. Dr. Olfson has received research funding from Eli Lilly, Bristol-Myers Squibb, and Janssen and has worked as a paid consultant to Pfizer and McNeil Pharmaceuticals. This study was supported in part by a grant from the Agency for Healthcare Research and Quality.

Arch Gen Psychiatry. 2008;65:962-970. Abstract

    
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