Medication Rapidly Replacing Psychotherapy Due to Insurance Reimbursement

– Posted in: Medications

Do you treat your mental health issue with medication only?

If you do, you are part of a growing trend among mental health care providers.

This shift to the sole use of medication to treat mental health problems is detailed in a study released this month in the Archives of General Psychology. The authors find that market forces, primarily insurance reimbursements, are forcing psychiatrists to limit their time with patients to 15-minute medication maintenance visits rather than also providing psychotherapy.

The percentage of patients who received both medication and psychotherapy from their psychiatrists fell to 28.9 percent in 2004-05, from 44.4 percent in 1996-97. 

The findings are expected to intensify a debate over the increased medicalization of psychiatric care. The debate is about the shifting emphasis on the biology of mental illness, as opposed to the processes of the mind addressed in psychotherapy. This debate is seen in the mental health stances of the two Presidential candidates. McCain’s plan emphasizes the use of medications over psychotherapy, while Obama’s seeks a balance between the two.

Integrated Psychiatry and Psychotherapy is not being received by those that need it

Psychotherapy is recommended as a front-line defense — with or without medication — in many types of mental illnesses, including Panic Disorder, Post Traumatic Stress Disorder, Social Phobia, Generalized Anxiety Disorder, and Specific Phobias

Diagnosis is squeezed into 15 minutes

Often, and especially in the diagnostic stage of treatment, more time is required to get at the roots of the patient’s problems before prescribing medication. Traditionally, psychiatrists were able to spend the time necessary to get a good diagnosis, but now they are being forced to shorten this diagnostic time to 15 minutes.

The wide range of mental health care professionals besides psychiatrists are not covered in the report, so it is not reported how this trend is affecting them. Yet from other studies, it is known that insurance companies and managed health care plans favor shorter and less-intensive mental health treatments. They also favor using lower-paid counselors over more highly-paid psychotherapists. It is widely known that most insurance companies’ reimbursements for medical and mental health services are not at parity, with mental health receiving far less coverage.

Many patients are unable to afford both a psychiatrist and a therapist, and have to make do with medication alone.

Dr. Mark Olfson of Columbia University Medical Center, a study author, said patient attitudes might also be hastening the shift. Taking a pill may look a lot easier to patients than psychotherapy, which is more time-consuming and may involve the regular participation of family members.

Insurance company reimbursements are fueling the shift to medications alone

Only those who pay out of pocket receive psychotherapy

Financial incentives for psychiatrists are weighted against psychotherapy. Reimbursement for a 45- or 50-minute psychotherapy session is 40.9 percent lower than that for 3, 15-minute medication management visits. Only those who pay out of pocket, generally the wealthiest patient group, are more likely to receive psychotherapy. The authors write,

Psychiatrists who provided psychotherapy to all of their patients relied more extensively on self-pay patients, had fewer managed-care visits and prescribed medications in fewer of their visits compared with psychiatrists who provided psychotherapy less often.

Also pushing the trend along is the aggressive marketing of psychotropic medications to psychiatrists and patients. This push has helped make antidepressants one of the largest-selling classes of drugs.

“We don’t want to decide treatment based on reimbursement.”

Dr. Alan F. Schatzberg, chairman of the department of psychiatry at Stanford University School of Medicine and president-elect of the American Psychiatric Association, said the trend was not necessarily bad. It could be seen as a natural evolution, similar to what is seen in other fields of medicine. Though he added, 

What we don’t want to do is decide treatment based on reimbursement.

Psychiatrists are losing an important skill

The authors of the report write,

[D]espite the traditional prominence of psychotherapy in psychiatric practice and training, there are indications of a recent decline in the provision of psychotherapy by U.S. psychiatrists — a trend attributed to reimbursement policies favoring brief medication management visits rather than psychotherapy and the introduction of newer psychotropic medications with fewer adverse effects.

Going to war with fewer weapons

Dr. William H. Sledge, interim chairman of the department of psychiatry at Yale, said the report was worrisome. Although training in psychotherapy is a standard part of psychiatric training, he said, the know-how is in danger of becoming lost. He continues, 

A group of practitioners is losing an important skill. It is like going to war with fewer weapons at your disposal.

The authors conclude,

These trends highlight a gradual but important change in the content of outpatient psychiatric care in the United States and a continued shift toward medicalization of psychiatric practice. A key challenge facing the future generation of psychiatrists will likely involve maintaining their professional role as integrators of the biological and psychosocial perspectives while working within the constraints of the strong market forces of third-party payers and managed care to implement advances in the diagnosis and treatment of mental disorders.

What do you think?

The American public likes its pills, and regards them as silver bullets that cure all ills. And the drug companies play to this with advertisements blanketing the airwaves and print media. The insurance companies encourage the shift to medication only as a way to keep their costs low and make more money. 

I am uneasy over the long-term viability of mental health care should this trend continue. Rather than enable the patient to feel better, get better and stay better, the moneyed interests are encouraging the treatment of mere symptoms with drugs, creating a whole class of people who are dependent on their wares to function in their daily lives.

  • If you take medications only, do you feel the need for a therapist?
  • Are you taking drugs only because you can’t afford a therapist?
  • Do you think my opinions are valid, or are they sound like conspiracy theories?

As always, your comments are welcome!

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Resources used in this post:

Gellene, Denise. (2008, August 5). Medication increasingly replaces psychotherapy, study finds. Retrieved August 5, 2008 from Los Angeles Times Web site: http://www.latimes.com/news/science/la-sci-shrink5-2008aug05,0,7966688.story

Mojtabai, Ramin; Olfson, Mark. (2008, August). National Trends in Psychotherapy by Office-Based Psychiatrists. Retrieved August 20, 2008 from Archives of General Psychiatry Web site: http://archpsyc.ama-assn.org/cgi/content/abstract/65/8/962

Science Daily. (2008, August 11). Psychiatrists Shift Away from Providing Psychotherapy. Retrieved August 17, 2008 from Science Daily Web site: http://www.sciencedaily.com/releases/2008/08/080804165316.htm

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33 Comments… add one
omayerume emomine August 21, 2008, 5:14 am

thank u

Mike August 21, 2008, 5:25 pm

You’re quite welcome, omayerume!

This subject is something I feel quite strongly about. Americans just want to take a pill and have it all go away, like a headache. It doesn’t work that way. But the insurers and drug companies want you to think so, because it makes them profits!

Grrrrrrr!

Dawn Pugh August 22, 2008, 3:55 am

Hi Mike,
Did you know that, allegedly:
In the late 1970’s there was a decline in the marketing of tranquillisers and the big drug companies made great effort to remedy this.
One particular way was to distribute to 1000’s of GP’s a book, called ‘Recognising the depressed patient’ (Frank Ayd) At the same time they were promoting a drug for the diagnosis of depression.
Giving many patients a label of depression, something to hang onto and hide behind without really understanding what depression actually was. Writing prescriptions for medication like handing out smarties.
With this evidence in mind it could appear that the drug companies were ‘peddling’ the idea of depression. Exploiting the general public to line their huge bottomless pockets.
Did the diagnosis and treatment arrive at the same time?
Many thanks
Dawn Pugh
http://www.dawnpugh.com/2008/05/02/define-drug-dealers/

Mike August 22, 2008, 9:33 am

Dawn,
I was not aware of this, but it is in keeping with the amount of “education” the drug companies provide to American doctors, the number of free meals, and the numbers of free seminars they offer.

My brother is a doctor and he is bombarded by this all the time. He can hardly go to a conference or seminar that is not sponsored, at least in part, by the drug companies. The drug reps are forever dumping free pens, desk widgets and samples on him. The drug companies are obviously spending a lot of money, and it’s not for philanthropic purposes.

Of course, in the US, the drug companies do provide a great deal of money for basic research, which is to their credit. I do not know how many strings are attached to this money. It would be a good subject for me to research.

Again, thank you for your comment!

Eric August 24, 2008, 6:31 pm

Magic pills! I need my magic pills!

I went to a psychiatrist once to see what it was like, and my health insurance paid for most of it. He talked to me for a few minutes, then gave me a big brown paper bag full of Zoloft samples. After that I realized that the field of psychiatry was turning into a money laundering operation for the companies.

Mike August 24, 2008, 8:21 pm

Eric, thank you for your comment!

I had the good fortune of having a top-notch psychiatrist when I was going through the worst of my mental illness problems. He did more than dispense drugs, but really listened to what I had to say. Needless to say, he was always behind on his schedule!

I once asked him if I could do psychotherapy with him as well, and he replied simply, “You couldn’t afford it.” It was then that it sank in that his hands were tied by the insurance companies — they wouldn’t pay for the kind of therapeutic help that he was able to offer! I didn’t blame him; he was already doing much more than required for his patients, and he, too, had a family to take care of.

I feel that the psychiatrists are being backed into a corner on this. They are becoming mere drug dispensers, and I know for a fact that the majority of them don’t like it at all.

The problem is not the psychiatrists, but the drug and insurance companies that are medicalizing the whole of mental health care. They are the ones pushing pills instead of getting at the root causes of mental illness through psychotherapy — and all for the almighty dollar!

Mizanur Rahman August 6, 2009, 7:01 am

Thank you for your valuable information .

kevin
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August 10, 2009, 2:00 am

hahah… “Psychiatrists are losing an important skill”

This is it? Hopefully it`s just proverb
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drsmith September 6, 2009, 9:45 pm

very appreciate for your valuable information about health issues
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zuphel September 9, 2009, 6:23 am

“Great info about mental health. ”

Sometimes it depends to the person itself if he or she likes the medication or psychotherapy. They themselves can observe which one is effective.

Zuphel (a.k.a. brandonraynor.co.uk)

Mike - Water Filters Shop September 10, 2009, 1:08 pm

Too much “pill popping” which quite often just relieves symptoms and doesn’t actually attemp to deal with the cause of the problem. There maybe isn’t always a “cure” but it shouldn’t stop us looking for the root cause and a possible solution.
.-= Mike – Water Filters Shop´s last undefined ..If you register your site for free at =-.

hyoung January 4, 2010, 1:18 am

Isn’t true that psychiatrist rate is 100$ per hour?! wow. a great fortune. all i need is a glass of wine everyday before I go to sleep. :-)
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Kim (Have Younger Skin) Hartley February 6, 2010, 8:53 am

Kim Hartley Leading skin care specialist Everything you need to know about your skin and hair says…This is CRAZY! How can someone just go ahead and prescribe medication before truly knowing what the underlying cause is? And why would you even consider doing this. Isn’t that the point of seeing a psychiatrist so they can figure out what the problem is, then treat? Too much pill popping going on for a quick fix!
Regards
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at home colon cleanse February 8, 2010, 4:35 pm

Better living through medication. It’s unfortunate that drugging people is seen as a better way to dealing with problems.
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L HPV F February 17, 2010, 1:38 pm

I think medication is rapily replacing REALITY! We are inundated with advertisements for pills that are supposed to treat everything from bad breath to depression. I know some medications are very helpful but do we need so many? How many of these pills could be replaced by simple diet changes and a little bit of exercise? What’s worse is that some of the side-effects of the pills are worse than what they are supposedly helping you with!

I completely agree with your post Mike. Especially this section: “The American public likes its pills, and regards them as silver bullets that cure all ills. And the drug companies play to this with advertisements blanketing the airwaves and print media. The insurance companies encourage the shift to medication only as a way to keep their costs low and make more money. “

Your blog is always a good read. Keep up the good work!
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Resveratrol Health Benefits Site February 25, 2010, 10:47 am

What isn’t clear in your article is whether the patient benefits from medication rather than psychiatric help. Is it a natural progression because medication works better than psychotherapy?

Veto Corleone April 14, 2010, 4:38 am

Better living through medication. It’s unfortunate that drugging people
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June 9, 2010, 4:32 am

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Angelica July 29, 2010, 8:56 am

Medication is very important to treat this kind of diseases but the
therapy is a long time process that can not be skipped, is in some cases more important than the medication itself.

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Jessica Allen September 16, 2010, 6:47 am

It is so true what you have said.

We live in a growing culture now of “put a plaster on it”, and that can’t be the best way to go.

You have pointed out some very important points here, so well done for your informative article

Constipation relief October 15, 2010, 12:58 pm

I think It’s just the nature of human beings to want to be able to take a pill and problems vanish, I know I fall into this trap occasionally. I think working on thinking is the best route.
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Karen, RN February 6, 2011, 1:53 am

The article is incorrect in that diagnostic visits are done in 15 minutes. First time appointments are at least 45 minutes and more often an 1.5 hours to establish what is known as a working diagnosis. Re-evaluation visits are at least 30minutes while medication management visits are 15-20 minutes.

I cannot tell you the number of times I have heard a client receiving psychotropic medications express how much of a difference the medication has made in their life. Current peer reviewed journal articles have shown that a combination of both medication and therapy are more effective than either alone.

That being said, most psychiatrists do not do therapy as therapy is better provided by a psychologist whose educational background specializes in both therapy and psychological testing; while a physicians training specializes in the pathology and medicinal treatment of mental disorders. But, explaining the differences and the value of both and why things are done as they are is not as interesting as telling people that psychiatrists care about nothing more than making money and so then focus on prescribing meds instead of therapy…psychiatrists usually do not do therapy, psychologists do.

Shauna Ekstrom February 27, 2011, 4:06 am

Great Post. It seems to me that the drug companies are always pushing the doctors to prescribe there drugs and the doctors are ignoring the real problem of mental health. I found your article very informative and helpful please continue give us more content on your site. Shauna at Nutritional Cleansing
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