A front page article in today’s New York Times (3/6/11) was all about the changes that psychiatry has undergone over the past couple of decades. The article profiled Dr. Donald Levin of Doylestown, PA and focused on the fact that, like many of the 48,000 psychiatrists in this country, Dr. Levin no longer performs “talk therapy” or psychotherapy. Instead, largely because of how much insurance will pay, he prescribes medication. Psychotherapy, when it is part of the patient’s treatment plan at all, is provided by some other mental health professional, such as a psychologist, social worker, or other trained mental health counselor.
I could relate to much in Dr. Levin’s story. Like him, I trained at a time when psychotherapy was still the mainstay of treatment for most patients, especially those with depression and anxiety. Medications were often viewed as a “short cut” or a “crutch”. Then, only a year after I finished my residency, Prozac came out and changed everything.
It’s not that Prozac was any more effective than the antidepressants we already had. No studies have ever shown Prozac (or it many cousins) to work any better than the older antidepressants. It’s just that the newer drugs are a lot safer and easier to take. Eventually, primary care doctors learned how to recognize depression earlier, and because the newer drugs were so much safer and easier to prescribe, they began treating patients who would previously have been referred to a psychiatrist.
Thus began a transformation of the practice of psychiatry. Primary care doctors began to prescribe medications for most “garden variety” depressed patients, leaving the more seriously ill patients for the psychiatric specialists. When managed care arrived and insurance companies started paying less and less for psychotherapy, psychiatrists began focusing more and more on the medication part of treatment.
In the mid 1980s, I would typically see a patient for 50 minutes at each visit. Most of that time was devoted to exploring the patient’s thoughts and feelings while trying to understand the root cause of their problem. I would try to reserve enough time at the end of the session to review their medications and make sure they were working and not causing too many side effects. Two decades later, it was very different. After the initial diagnostic evaluation, I would see most of my patients for brief, 15 minute check-ups every couple of months. Like Dr. Levin, I would often have to remind my patients that I was not their therapist when they would start to talk about their various relationship problems and other woes. “We need to stay focused on your medications”, I would say.
I missed the psychotherapy part of my practice. After all, I had spent years trying to develop my skills as a therapist. Medications are certainly important. Without them, many patients would not even be able to benefit from psychotherapy. But when it reached the point where I was seeing as many as 30 patients a day for brief medication check-ups, it began to feel shallow and unrewarding. That’s when TMS began to usher in another transformation of the practice of psychiatry.
When I became one of the first TMS providers in late 2008, my practice of TMS was not too different than the rest of my practice. I would perform the first couple of treatments but would then hand things over to a trained nurse technician. It soon became clear, however, that when someone comes for a treatment every day for several weeks, something special starts to happen. As the magnet clicks away, patients start to talk about their thoughts and feelings. It was then that I realized that TMS offers a unique opportunity to combine the time honored practice of psychotherapy with the most advanced, cutting edge treatment.
So when I opened my own TMS practice, I decided to make the most of this opportunity. By doing most, if not all, of the treatments myself, I now have the opportunity to know my patients in a way I haven’t done for many years. Rather than just focusing on medications and their side effects, I now have the opportunity to know my patients as people, to understand their life stories, and once again use the psychotherapeutic skills that I had set aside for so many years.
This is just one example of how TMS is transforming the practice of psychiatry. TMS is the most advanced form of treatment for depression, yet for me it has brought things full circle.
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