A recent study out of Philadelphia and published in the American Journal of Psychiatry found a general trend toward the use of psychiatric medication without psychotherapy. The authors of the study note that this is not particularly good news for patients, as research tells us that people do best when treated with a combination of medication and psychotherapy.
The specific data: The percentage of persons using outpatient psychotherapy was 3.37% in 1998 and 3.18% in 2007. Among individuals receiving outpatient mental health care, use of only psychotherapy (15.9% and 10.5% in 1998 and 2007, respectively) as well as psychotherapy and psychotropic medication together (40.0% and 32.1%) declined while use of only psychotropic medication increased (44.1% and 57.4%). Declines occurred in annual psychotherapy visits per psychotherapy patient (mean values, 9.7 and 7.9), mean expenditure per psychotherapy visit ($122.80 and $94.59), and total national psychotherapy expenditures ($10.94 and $7.17 billion).
At first blush the numbers are not all that dramatic. For example, the percentage of persons using psychotherapydropping from 3.37% to 3.18% is not a huge issue. But the numbers become more significant when you look only at the people receiving mental health care. In that group, the percentage treated with psychotherapy alone dropped by over a third (another way to phrase that outcome is that a greater percentage of people who get help for mental illness use medication). I believe that the numbers reflect a larger, insidious pattern of discouraging psychotherapy by insurers, and of dismissal of psychotherapy by patients as not useful. This belief is supported by the other data– that even those who recieve psychotherapy are having less of it, the data showing fewer visits by such patients. And despite the well-known increases in health care expenditures over the past ten years, money spent on psychotherapy has actually dropped over the past ten years– dramatically.
This article is only the tip of the iceberg. People generally think of psychotherapy as an hour-long session with a therapist. But psychotherapy can take many forms. A psychiatrist can provide ‘supportive psychotherapy’ during a 30-minute medication check with a patient. Internists and family practice physicians commonly provide such supportive psychotherapy as part of a wellness check or any doctor visit. Supportive psychotherapy generally attempts to do exactly as the title suggests; to support the person as he/she faces challenges in life. It is easy to feel alone in today’s world, despite (or because of?) all of the electronic means of communication. A supportive word or a calm voice can be a Godsend during times of emotional upheaval.
The primary reason for the movement away from psychotherapy is likely financial considerations. Psychotherapy is labor-intensive and relatively inefficient. On the other hand, efficiency determinations depend on the outcome measures that are used. If nobody is getting better from medication alone– and a recent study in JAMA showed exactly that fact, that medication is not all that effective for mild depression–then psychotherapy deserves a place in modern psychiatry, no matter how few patients can be ‘cranked out!’
I have written about the nature of my practice a number of times. I see at most two patients per hour, and more and more, I am providing longer psychotherapy sessions for people who have not done well historically using medication alone. I hear stories that are simply shocking– and disappointing. I’ve had patients tell me that they have not seen a psychiatrist for an appointment lasting longer than 10 minutes! I recently saw a person with side effects from haloperidol, an old antipsychotic medication; she could not sit in place for more than a few minutes before rising to her feet and pacing, apologizing for feeling so ‘restless.’ I explained the relatively common side effect to her called ‘akathesia’, and put her on a new medication without that side effect; she now sits comfortably through her 30-minute appointments. I wonder if her past psychiatrist saw the side effect as a blessing– as a chance to move her from his office more quickly! More likely, though, he never even made the diagnosis; the patient said that she never sat in his office long enough for the symptoms to cause her trouble!
I cannot speak for other practices, but I see a huge benefit for patients in having a psychiatrist who ‘gets’ them; someone who can provide insight into their feelings and behaviors, who can help them know that their feelings are not unique from the human experience; someone who helps them realize that they ‘matter.’ These are much more important parts of treatment than the benefit of an SSRI in most cases. I hope that insurance companies realize that the goal is not to ‘medicate’ patients, but to help people and ease suffering. I myself have decided to leave insurance companies behind for now, until they get things figure out. They want psychiatrists to push people through, one after the other– and that, most of the time, is pure folly.
Sometimes I envy scientists and physicians from 100 years ago who took credit for the easy discoveries, sometimes even attaching their names to them. The Bernoulli Principle, for example, describes how the pressure of an inviscid material decreases as the flow of the material increases, and why the disgusting shower drape in cheap motels is pulled toward the person in the shower. I’m sure that I noticed that effect when I was about six years old, and had it not been already figured out, I know I would have come up with it eventually! But the days of simply thinking real, real, hard and coming up with a ‘discovery’ are long gone.
Or are they? I have a good one, I think… and with the right presentation and help from readers I might become famous. Or not. Either way, it’s worth a shot…. So I’d like to introduce Junig’s Warm Coat Theory of Psychotropic Prescribing. (I know—the title needs work)
Back when I was an anesthesiologist, surgeons sometimes used the phrase ‘better is the enemy of good.’ The point was that in some surgeries the best approach was to remove the infected or diseased tissue, stop the bleeding, close up ASAP and get the patient back to the ICU. Spending another 4 hours picking at the tissue to make everything pretty risked a drop in the patient’s body temperature, a decrease in clotting and immune function, and an increased stress response, all in turn increasing the odds of a bad surgical outcome. I have to give credit where credit is due, and note that the warm coat theory is similar in some ways to the ‘enemy of good’ phrase that I have heard recited over the years. In fact, it is entirely possible that the unconscious parts of my mind stole the phrase and adapted it to psychiatry. If that is the case, I’m sorry for the actions of my unconscious—and I plead ignorance to the entire affair!
When prescribing medication for psychiatric conditions– for example ADD or anxiety– the patient might note positive effects initially but then at some point ask ‘maybe I’d do better with a higher dose—should we try a little more?’ With any medication for any condition, there is a balance between positive effects of the medication and risks or side effects from the medication. Serotonin medications work well for depression and anxiety, but as their doses are increased they will eventually cause sexual side effects. At still higher doses they may cause drowsiness or nausea. The positive effects of a medication go up with dose, but the side effects increase as well. The goal for the patient and physician is to find the proper balance is between positive effects and negative side effects. If the patient has no interest in sex (and doesn’t WANT an interest in sex), sexual side effects should not limit the dose. Nausea or sedation on the other hand may be barriers to dose increases. Different people have different concerns about risks and side effects, and different people have different needs for higher doses of medication. These differences, by the way, are why I maintain that psychiatrists should spend more time with patients than they do—but that’s another topic for another day.
A warm coat in Wisconsin
When us Wisconsin folks go outside in January, we take a look at the Weather Channel and dress accordingly. But we don’t dress for 14 degrees F; we dress for ‘pretty darn cold.’ If I’m going to a Packer game, I’ll put on my long-johns (too much information?), jeans, and the snow-suit from Fleet Farm (that changed my life when I finally bought it, after suffering a few football seasons without it). I’ll also wear a stocking cap and maybe even a face mask, and of course a thick pair of gloves. At some point during the game, if the drunken guys squeezed in way-too-close on each side of me take off their shirts so their body heat radiates toward me and warms me up, I’ll take off my face mask and maybe my cap. By the end of the game I might even have my own shirt off if the sun is out. Of course the guys next to me might have enough of the game at some point and spend the rest of the game at the bar, just as the sun disappears behind a thick layer of clouds. Then I’ll put the heavy stuff back on, and maybe rub my hands together or do some jumping around to raise my body heat. If I get cold enough, I’ll go inside and warm up for a few possessions. The point is that I don’t bring along a spring jacket to change into when I’m warm, and I don’t bring extra coats for when I’m cold. Instead I change my activity, my location, or make minor adjustments to my wardrobe.
According to the warm coat approach, I suggest that patients think of their psychiatric medications in a way similar to how I think of dressing for a Packer game in January. At the time the person wonders about a higher dose, he/she is getting a good response from the medication, usually with a low amount of side effects. At this point, ‘better’ may be the enemy of ‘good.’ The person is essentially wearing a warm coat in January. There is no need to run home and pick up a few more coats; the better action is to change behavior to fine-tune the degree of symptom relief. If the target symptoms are attention problems and the current dose of stimulant has taken the person 85% of the way, the correct action is to adjust behavior. Find a quiet location for studying. Get enough sleep. Come up with reminders and plan ahead, to avoid time crunches that interfere with performance. These are better approaches than increasing the dose of stimulant, which might raise blood pressure or lead to addictive problems. If the target symptoms are anxiety-related, work on positive self-talk and try to gain insight into why the anxiety is there in the first place. Learn to relax using deep breaths or by taking a walk to get away from the stressful environment.
The medication should be like a warm coat in January; a way to make symptoms ‘good.’ Use behavioral or therapeutic interventions– approaches that don’t increase risks or side effects– to make things ‘better.’
If Junig’s Warm Coat Approach becomes big, some day you’ll be telling your grandchildren about the day you first read it, before anyone was talking about it. They’ll look up at you with big eyes and say ‘Wow!’
Or not. Either way, I for one think the idea has legs!
A couple months ago the Governor of Oregon, Ted Kulongoski, vetoed a bill that would have allowed psychologists to prescribe medication after completing two years of additional education. To date only two states, New Mexico and Louisiana, have granted prescribing authority to psychologists despite significant lobbying by psychologists over the past few years.
Proponents of prescribing authority for psychologists point to the shortage of psychiatrists, claiming that granting prescribing power to psychologists would alleviate that shortage and allow greater access to mental health care for patients in need. They also cite studies that (so far) have not found negative consequences from the granting of such prescribing authority.
I have written a number of times about the problems with the field of psychiatry. For example I believe that psychiatrists make a mistake when they leave the mind behind, thinking that the symptoms of depression, anxiety, and other disorders can be understood using only the ‘hard sciences’ of physiology, chemistry, and anatomy. But ‘hard science’ is where the field is going; those without a firm grip on neuroscience blindly follow the leaders on a professional snipe hunt, taking it on faith that there will be answers at the end of their journey. While much of the training for my PhD in Neuroscience is out of date, I have enough background to know that there is no ‘there’ there. Understanding the metabolic pathway for paroxetine for specific individuals is NOT going to have profound effects on mental health care.
Many of the patients who I see tell me horror stories about their prior encounters with psychiatrists. They talk about appointments lasting several minutes. They talk about being prescribed medications without any explanation of why they are to take them, what side effects to expect, or what other options are available besides the medications. Many times they do not even remember their psychiatrist’s name! All of these issues come down to one thing: time. People want more time to explain themselves, more time to hear the options that are available, and more time to learn whether they are ‘normal.’
In a way, I am saying that psychiatrists need to emulate… psychologists. I find it a bit ironic that psychologists are striving to get the very power that is pulling psychiatrists AWAY from patients! It will be interesting to see if the psychologists who gain prescribing authority move toward the psychiatry model of the ‘med check’ appointment!
Psychiatrists do not fret over the issue of prescribing authority for psychologists. Many of them work for health systems on a salary, and if anything they would prefer a lighter load. So what if a few patients disappear?! Besides, most psychiatric medications are already prescribed by non-psychiatrists, i.e. family care docs or nurse practitioners. But I think that such nonchalance is a mistake. I assume that third party payers are looking forward to the day when the initials ‘M.D.’ no longer command a higher fee schedule than N.P. or even Ph.D. And I doubt that any leveling of fees will do as much to elevate the fees of non-M.D. practitioners as it will to lower those of M.D. psychiatrists. There have clearly been efforts to make everyone the same in the eyes of healthcare consumers. Those efforts are fine and dandy for the person who DIDN’T spend eight years accumulating debt!
If physicians are ever forced into a position of having to justify their higher fees, they have placed themselves in a bad position in the battle for PR. If everything else is even close to equal, patients will choose the practitioner who provides TIME over the 7-minute appointment with someone ‘more educated.’ Already, I hear patients talk about ‘Dr. Steve’ or ‘Dr. Betty’ in reference to their APNPs, any difference in training compared to ‘Dr. Thompson’ totally lost on them.
For the sake of the profession, I hope that psychiatrists learn one thing: slow down.
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Click here to get the mp3 file
Or use our player to listen now:Send questions for the show to drj@fdlpsychiatry.com