Medication Rapidly Replacing Psychotherapy Due to Insurance Reimbursement

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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Filed In Category: Medications

Tagged as: Anxiety Disorder, Medications, Mental Health Professionals, Panic Disorder, Psychiatrist, PTSD - Post Traumatic Stress Disorder, SAD - Social Phobia, Specific Phobias