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> Psychiatrists are mostly doing medication management because that’s where they’re most effective. I think it's money: insurance will shell a lot more $/hour

> Psychiatrists are mostly doing medication management because that’s where they’re most effective. I think it's money: insurance will shell a lot more $/hour if they do 15 minute medication appointments instead of hour therapy + medication appointments.

caturopath 6y ago
Integrating counselling and medical doctoring is a strange idea, and it's somewhat weird that it's even as much of a thing as it is. Drug-focused psychiatrists are certainly going to be a thing so long as med school is so costly and med schools conspire to keep the supply of doctors low.
- jacobr1 6y ago
  Increased secularization is also probably a factor. I presume going to your clergy for assistance was previously more common. I'm sure that kind of care had mixed effectiveness, but suspect it less available and norms are bit different for initiating that kind of conversation.
- munificent 6y ago
  > Integrating counselling and medical doctoring is a strange idea Why? It doesn't seem any different to me than surgery + physical therapy for a non-brain-oriented medical problem.
  - caturopath 6y ago
    Right, and a surgeon doesn't serve as your physical therapist just like the psychiatrist doesn't serve as your talk therapist. They're different roles, even though they're both addressing the same part of your health.
    - mapt 6y ago
      Under the US system, the surgeon has to press the patient to learn what operation they're going to perform, because the physical therapist / primary care doc / specialist doc isn't paid to communicate with the surgeon, but they're willing to guess the operation if the patient doesn't take great notes.
- thebean11 6y ago
  It's weird even when the medical doctor is trying to alleviate the same symptoms as the counselor? I think the way you put it simply sounds weird because a psychiatrist isn't the first doctor you think of. The concept isn't strange at all, especially considering the huge overlap in training.
klodolph 6y ago
Going to dissent here—we need psychiatrists doing medication management because there are so many medications today, and so many previously untreatable conditions which are treatable with modern medications. If we switched to one-stop therapy + meds, the psychiatrist shortage would be worse.
- leetcrew 6y ago
  the problem with this approach is there's not an obvious person to consult with to decide whether to start with therapy, medication, or both. I find that therapists tend to consider themselves unqualified to even suggest that their clients look into medication (or perhaps they are explicitly prohibited from doing so, idk). psychiatrists can either give you drugs or say no, but they tend to offer you something if there's at least a chance it could help.
  - jrumbut 6y ago
    The problems with this approach are probably even bigger than that, but given they're already stretched this thin and there are years long waiting lists for new patients it will probably be some time before we can really address the more nuanced issues of phychiatry.
  - klodolph 6y ago
    This comes back to what I mentioned earlier in the thread that it “requires a shocking amount of initiative on the part of the patient.” There are also easy and hard paths through the system. If you are motivated to get a diagnosis, you can talk to a psychologist or psychiatrist and get a diagnosis. You can look for a therapist who specializes in those issues. You can take this diagnosis to a psychiatrist and say “I have diagnosis X and symptoms Y.” If you go into the hospital with a broken leg, you can just check into the hospital and you will come out with a cast and an appointment to have it removed. If you have mental health issues, unless they are severe enough to require hospitalization, you are in charge of your own treatment.
novok 6y ago
Yes it is. Psychologists get paid about $120k/yr with the same amount of schooling and expense as an actual doctor. It's not as intense as med school is and their internships are normal hours instead of the official hazing ritual that is residency, but the expense is very high unless you get lucky and get a publicly funded PhD program, and then half of your education is research instead of therapy. Insurance defines the financial demand which determines the pay of psychologists and the amount hired.
- justinko 6y ago
  Recently, here in Denver, I could not find a psychiatrist that accepted insurance. And the minimum out-of-pocket hourly fee I came across was $250/hour. One was $450. The psyches that did accept insurance had wait times with March being the soonest. A stark, stark contrast to seeing a cardiologist, for example. The shortage of mental health professionals is real. Why do we not take mental health more seriously?
  - novok 6y ago
    A psychiatrist is a medical doctor who specialized in mental health meds. A psychologist can diagnose your with mental illnesses and help you via therapy and testing. Very different. A psychiatrist makes significantly more than a psychologist and needs to go to actual med school, do residency and so on. My pet theory as to why not is how it's less profitable usually than 15m doctor visits or large do-or-die surgeries and is more objective than once a week 1 hr therapy sessions, thus easier to make money as a professional from insurance providers. The mentally ill also have a harder time holding a job and so the ones that need it the most are often the ones most ignored for it, while the ones who need physical medicine the most are old and have retirements to suck out.

caturopath 6y ago

Integrating counselling and medical doctoring is a strange idea, and it's somewhat weird that it's even as much of a thing as it is. Drug-focused psychiatrists are certainly going to be a thing so long as med school is so costly and med schools conspire to keep the supply of doctors low.

jacobr1 6y ago
Increased secularization is also probably a factor. I presume going to your clergy for assistance was previously more common. I'm sure that kind of care had mixed effectiveness, but suspect it less available and norms are bit different for initiating that kind of conversation.
munificent 6y ago
> Integrating counselling and medical doctoring is a strange idea Why? It doesn't seem any different to me than surgery + physical therapy for a non-brain-oriented medical problem.
- caturopath 6y ago
  Right, and a surgeon doesn't serve as your physical therapist just like the psychiatrist doesn't serve as your talk therapist. They're different roles, even though they're both addressing the same part of your health.
  - mapt 6y ago
    Under the US system, the surgeon has to press the patient to learn what operation they're going to perform, because the physical therapist / primary care doc / specialist doc isn't paid to communicate with the surgeon, but they're willing to guess the operation if the patient doesn't take great notes.
thebean11 6y ago
It's weird even when the medical doctor is trying to alleviate the same symptoms as the counselor? I think the way you put it simply sounds weird because a psychiatrist isn't the first doctor you think of. The concept isn't strange at all, especially considering the huge overlap in training.

klodolph 6y ago

Going to dissent here—we need psychiatrists doing medication management because there are so many medications today, and so many previously untreatable conditions which are treatable with modern medications. If we switched to one-stop therapy + meds, the psychiatrist shortage would be worse.

leetcrew 6y ago
the problem with this approach is there's not an obvious person to consult with to decide whether to start with therapy, medication, or both. I find that therapists tend to consider themselves unqualified to even suggest that their clients look into medication (or perhaps they are explicitly prohibited from doing so, idk). psychiatrists can either give you drugs or say no, but they tend to offer you something if there's at least a chance it could help.
- jrumbut 6y ago
  The problems with this approach are probably even bigger than that, but given they're already stretched this thin and there are years long waiting lists for new patients it will probably be some time before we can really address the more nuanced issues of phychiatry.
- klodolph 6y ago
  This comes back to what I mentioned earlier in the thread that it “requires a shocking amount of initiative on the part of the patient.” There are also easy and hard paths through the system. If you are motivated to get a diagnosis, you can talk to a psychologist or psychiatrist and get a diagnosis. You can look for a therapist who specializes in those issues. You can take this diagnosis to a psychiatrist and say “I have diagnosis X and symptoms Y.” If you go into the hospital with a broken leg, you can just check into the hospital and you will come out with a cast and an appointment to have it removed. If you have mental health issues, unless they are severe enough to require hospitalization, you are in charge of your own treatment.

novok 6y ago

Yes it is. Psychologists get paid about $120k/yr with the same amount of schooling and expense as an actual doctor. It's not as intense as med school is and their internships are normal hours instead of the official hazing ritual that is residency, but the expense is very high unless you get lucky and get a publicly funded PhD program, and then half of your education is research instead of therapy. Insurance defines the financial demand which determines the pay of psychologists and the amount hired.

justinko 6y ago
Recently, here in Denver, I could not find a psychiatrist that accepted insurance. And the minimum out-of-pocket hourly fee I came across was $250/hour. One was $450. The psyches that did accept insurance had wait times with March being the soonest. A stark, stark contrast to seeing a cardiologist, for example. The shortage of mental health professionals is real. Why do we not take mental health more seriously?
- novok 6y ago
  A psychiatrist is a medical doctor who specialized in mental health meds. A psychologist can diagnose your with mental illnesses and help you via therapy and testing. Very different. A psychiatrist makes significantly more than a psychologist and needs to go to actual med school, do residency and so on. My pet theory as to why not is how it's less profitable usually than 15m doctor visits or large do-or-die surgeries and is more objective than once a week 1 hr therapy sessions, thus easier to make money as a professional from insurance providers. The mentally ill also have a harder time holding a job and so the ones that need it the most are often the ones most ignored for it, while the ones who need physical medicine the most are old and have retirements to suck out.