Psychotherapy assumed a larger role in outpatient mental health care while psychiatric medication without psychotherapy became less common, according to a new study at Columbia University Mailman School of Public Health and Columbia University Irving Medical Center. The findings are published in the American Journal of Psychiatry.
"After years of American mental health care moving towards greater use of psychiatric medications, the pendulum has started swinging back towards psychotherapy," said Mark Olfson, MD, MPH, Columbia Mailman School professor of Epidemiology and Psychiatry.
Among adults receiving outpatient mental health care between 2018 and 2021, an increase occurred in use of only psychotherapy, from 11.5 percent in 2018 to 15.4 percent in 2021, respectively; while taking medication only declined from 68 percent to 62 percent. Increases also occurred in psychotherapy visits and total national psychotherapy expenditures ($31 billion to $51 billion) with a decrease in patients
receiving psychotherapy from psychiatrists from 41 percent to 34 percent. Psychiatric medications included antidepressants – the most common class of medications -- antipsychotics, stimulants or other ADHD medications, anxiolytics or hypnotics, and mood stabilizers obtained from pharmacies during the survey year.
Much of the change occurred between 2018 and 2019, which indicates that factors other than the COVID pandemic and the rise of telemental health care contributed to the shift in outpatient mental health treatment, according to Olfson. During the study period, a significant increase in the average number of visits occurred for patients with mild or moderate distress but not for patients with serious disturbances.
To investigate recent national trends in outpatient mental health care, the researchers analyzed data from four representative surveys of the U.S. household population, the 2018–2021 Medical Expenditure Panel Survey, focusing on adults with outpatient mental health visits (17,821)
including psychotherapy visits (6,415). They further presented data trends on mental health patients receiving psychotherapy only, those receiving medications, or a combination of the two.
"Psychiatrists provided psychotherapy to a decreasing percentage of all psychotherapy patients, which may have increased the need for psychiatrists to refer patients to and collaborate with non-physician psychotherapists," observed Olfson. "At the same time, social workers and counselors, but not psychologists, assumed a larger role in providing psychotherapy and there was an increase in the average number psychotherapy visits per patient. A decrease in the fraction of patients with just one or two psychotherapy visits further suggests there was a decline in early drop out. Americans are becoming more willing to seek out and stick with psychotherapy."
According to Olfson, psychotherapy by mental health counselors may increase further following a recent change in Medicare reimbursement policy that allows mental health counselors and licensed marital and family therapists to bill for psychotherapy.
Co-authors are Chandler McClellan and Samuel H. Zuvekas, Agency for Healthcare Research and Quality; Melanie Wall, Columbia Mailman School of Public Health and Columbia University Irving Medical Center; and Carlos Blanco, National Institute on Drug Abuse.
Columbia University Mailman School of Public Health
