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.
