Drugging America

In the December issue of the American Journal of Psychiatry, an article on "National Trends in Outpatient Psychotherapy" and an accompanying editorial on "The Changing Face of U.S. Mental Health Care" document a sea change in our mental health system.

The findings were drawn from in-person interviews from the Medical Expenditure Panel Survey in 1998 (22,000) and 2007 (29,000). The percentage of Americans who received one or more psychotherapy visits was stable at slightly over three percent. Approximately one-third made one or two visits, and only one in ten made more than 20. The estimated number of Americans receiving mental health treatment increased from 16 to 23 million, but the increase was almost entirely in use of medication. In 1998 44 percent received psychiatric medication without any psychotherapy. In 2007 the percentage increased to 57. The mean number of psychotherapy visits dropped from 9.67 to 7.92. Although total health expenditures increased by 88 percent during the study period, expenditure for psychotherapy declined by a third, from $10.9 billion to $7.2 billion.

The data do not allow comparison of outcomes in 1998 to 2007. But I'd take odds that a quality of care assessment would suggest that we're currently using too much medication and too little psychotherapy. The shift away from psychotherapy and to more use of medication is based on financial incentives and drug company marketing, not evidence about effectiveness.

Sadly, we mental health professionals contributed to the problem by not managing psychotherapy utilization ourselves. The managed behavioral healthcare organizations ("carve outs") that manage the coverage for more than 170 million filled that vacuum. During my training and early career in the 1960s and 1970s, psychotherapy was "prescribed" in larger "doses" than necessary for the outcomes being sought. Now the pendulum has swung the other way, and it is underprescribed.

In my practice at the Harvard Community Health Plan HMO we were expected to take new referrals on a regular basis, but it was left to us as to how we managed our practice panels. Shortly after I joined the practice in 1975 I divided my schedule into 30 minute blocks. When I wanted more time with a patient I put two blocks together. By working with my patients to create the most efficient psychotherapeutic approaches that worked for them, I was able to handle psychopharmacology and psychotherapy as a combined practice.

Alas, with the current anti-psychotherapeutic swing of the pendulum, this kind of balanced practice is much less common in the world of insurance-financed treatment. Don't expect the situation to change until medical groups take charge of managing their own resource use, as is envisioned for accountable care organizations. The day when clinicians could say "trust me to use resources prudently without being accountable" is long gone.

(Links to some of the clinical articles I wrote on managed care psychiatric practice can be found here, here, and here. I apologize for the fact that the journals haven't made the full articles available on line.)