November 1st, 2010

Talk therapy on the decline, study says

Talk therapy is on the decline, while more Americans with mental health conditions are being treated with drugs alone, according to a new study.

The results, reported in the American Journal of Psychiatry, are based on data from government health surveys conducted in 1998 and 2007. The percentage of Americans who said they’d had at least one psychotherapy session in the past year remained just over three percent in 1998 (3.37) and 2007 (3.18). However, those being treated with drugs alone rose from 44.1 to 57.4 percent in that span; combined treatments (drugs and psychotherapy) declined from 40 to 32.1 percent; and the use of psychotherapy alone dipped from 15.9 to 10.5 percent. Spending specifically for psychotherapy declined from $11 billion to $7 billion.

The study indicated that more people are seeking outpatient help, just not for psychotherapy.

Mark Olfson, M.D., MPH, professor of clinical psychiatry at Columbia University/New York State Psychiatric Institute and one of the study’s authors, says the trend toward greater access to mental health services represents a positive development.

“Epidemiological studies consistently indicate that large numbers of people with psychiatric disorders do not receive any treatment for their symptoms. Narrowing this gap represents progress,” Olfson says. “At the same time, there are some reasons for concern. For several conditions, psychotherapy combined with psychotropic medications tends to be superior to either treatment alone. The benefits of psychotherapy may also be more enduring than those of medications which disappear after the medication is stopped.

“Growth in medication-only regimens, especially for conditions such as bipolar, depressive, and anxiety disorders suggests that many patients who might benefit from psychotherapy are not receiving it” according to Olfson.

Olfson says it is difficult to know the extent to which the shift toward medication-only treatment is being driven by patients, physicians or both. “I suspect that many factors are involved including an increase in drug promotion directed at physicians and the general public, growth in the role of primary care physicians in prescribing psychotropic medications, reimbursement factors that tilt toward medications, increasing public acceptance of a biological basis of mental health problems and more favorable views of psychotropic medications,” he says.

Primary care physicians account for a majority of psychotropic prescriptions, like antidepressants and the quality of psychological assessment, psychotropic medication management and clinical monitoring is highly variable, Olfson says. “In my view, much more needs to be done to provide mental health training and support to primary care physicians to help them appropriately manage the common anxiety and mood disorders and train them in referral to mental health specialists as necessary.”

Jeff Matranga, Ph.D., ABPP, Board Certified in Clinical Health Psychology, M.S. in Clinical Psychopharmacology at Health Psych Maine, says the fact that PCPs (including nurse practitioners) account for 70-80 percent of psychotropic prescriptions is a reality of our healthcare system. With a shortage of psychiatrists, there are no signs of this turning around, he says. “It falls to the PCPs as the major prescribers of psychotropics, though they are very interested in assistance, including from psychologists who know something about psychopharmacology.”

“Psychologists with psychopharmacology expertise on top of empirically-based therapy knowledge are in a unique position to contribute to their patients, their primary care collaborators and the health care system in general,” he says.

Primary care providers are under enormous time pressure and writing a prescription can be efficient, Matranga says. Nevertheless, “The family practice physicians and residents that I work with seem to be more aware of the limits of medications.” ”

And let’s be balanced – medications are helpful for some people and situations,” he says. “Although they have been oversold, that does not mean they are worthless.” Matranga is an advocate of prescription privileges for psychologists (RxP), which he says should not to be confused with pro-medication. “RxP is all about responsible, evidence-based choices between therapy, medications, a combination and also how to get people off medications.”

Matranga notes that cognitive behavior therapy (CBT) alone, and combined treatments, are more effective in treating many conditions. “I don’t believe there is any good data indicating that a meds-only approach is more effective.”

But it is in the area of relapse rates where CBT comes out as more effective. He cites data that indicates that on average, there is a 70 percent relapse rate in a year for depression treated with meds only; but if treated with CBT, that rate drops to 30 percent. “Longer term, when you factor in relapse, it is much cheaper for society to include a form of psychotherapy that teaches a person behavioral activation, active coping skills, etc.,” he says.

By Pamela Berard

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