Since 1996, Fewer and Fewer Psychiatrists Practice Psychotherapy in the US

A retrospective review of psychiatrist visits in the United States between 1996 and 2016 found a decline in psychotherapy services affecting nearly all clinical categories. These findings were published in the American Journal of Psychiatry.

Data from the National Ambulatory Medical Care Survey (NAMCS) were assessed for trends in psychotherapy over time. Psychotherapy was defined as all treatments lasting ≥30 minutes involving intentional use of verbal techniques to explore or alter the emotional life of a patient and to foster symptom reduction or behavioral change.

Each year, 1,386 physicians were surveyed, representing 5.9% of psychiatrists in the US and 29,673 of the 26 million yearly psychiatry visits.

Psychotherapy has been declining yearly (risk difference [RD], -0.9%; 95% CI, -1.3% to -0.6%; P <.001). The proportion of psychiatry visits that used psychotherapy was 44.4% in 1996-1997 and 21.6% in 2015-2016.

The proportion of psychiatrists who said they provided no psychotherapy increased from 27% in 1996-2002 to 35% in 2003-2009 and 53% in 2010-2016. The proportion of psychiatrists who provided only psychotherapy remained constant over time (15% vs 11% vs 12%, respectively). Among those who practiced some psychotherapy, the proportion of visits where the psychiatrist provided psychotherapy decreased from 44% in 1996-2002 to 34% in 2010 and 2016.

Among physicians who offered only psychotherapy, more of their patients had dysthymic disorder (P <.001), personality disorders (P <.001), posttraumatic stress disorder (P =.005), obsessive compulsive disorder (P =.005), social phobia (P =.002), and other anxiety disorders (P =.002) and fewer had major depressive disorder (P =.04).

Stratified by demographics, geographic information, clinical characteristics, and financial features, psychotherapy decreased or was unchanged on the basis of most features. However, psychotherapy increased with age group (adjusted risk difference [aRD], range, 4.7-8.1; all P ≤.001), among patients with personality disorders (aRD, 17.7; P <.001), dysthymic disorder (aRD, 8.9; P <.001), posttraumatic stress disorder (aRD, 6.3; P =.01), obsessive-compulsive disorder (aRD, 6.2; P =.001), other anxiety disorders (aRD, 5.1; P =.02), and for patients who self-paid for psychiatry appointments (aRD, 16.1; P <.001).

After controlling for significant predictors, the decline in psychotherapy over time remained significant (aRD, -0.9%; 95% CI, -1.2% to -0.55%; P <.001), indicating additional significant factors were contributing to the observed trend.

Over time, income (aRD, 3.3%; 95% CI, 1.6%-5.1%; P <.001) and education (aRD, 5.8%; 95% CI, 4.1%-7.4%; P <.001) have become strong predictors for receiving psychotherapy.

This study was limited by the coding in the NAMCS database, which codes repeat visits as unique visits and by the overall decline in NAMCS response rate during the study period.

This study found that psychotherapy has declined in the US by >50% between 1996 and 2016. Since 2010, fewer than 50% of psychiatrists still practice psychotherapy at all. The decline in psychotherapy tended to affect younger individuals with less severe psychiatric illness and those who did not self-pay for care.

“These trends pose a challenge to psychiatrists’ unique role as integrators of biological and psychological dimensions of care, with important implications for the profession and for the delivery of US mental health care as a whole,” the authors said.

Reference

Tadmon D, Olfson M. Trends in outpatient psychotherapy provision by US psychiatrists: 1996–2016. Am J Psychiatry. 2021;appiajp202121040338. doi:10.1176/appi.ajp.2021.21040338