Perhaps we’ve seen the rise and fall of psychotherapy treatment. At least when it comes to depression, the most common mental disorder diagnosed today.
The numbers don’t lie, according to multiple nationally-representative surveys conducted over the past two decades.
At the start of the 1990s, psychotherapy was the treatment of choice for depression, with 71.1 percent of depressed people saying they had been treated with psychotherapy. By 1997, with the newer SSRI antidepressants firmly taking hold in prescribers’ toolboxes, that number had dropped to 60.2 percent.
When the latest research when conducted, they found 53.6 percent of depressed people surveyed in 1998 were in psychotherapy. When they looked again in 2007, that number had dropped to a new all-time low — to only 43.1 percent.
In two decades, psychotherapy went from being the primary treatment employed for depression, to becoming a minority treatment. What happened?
As we wrote in the news article describing the most recent research, “It is unclear whether the decline in psychotherapy use is due to patient preferences or other factors, including scarcity of psychotherapists, the authors note.”
“A review of the literature concerning treatment preferences, however, revealed that most patients with depression prefer psychotherapy or counseling over antidepressant medications,” they wrote. “However, although third-party coverage of antidepressants and other psychotropic medications is typically generous, significant limits commonly exist on coverage of psychotherapy services.”
Traditionally, that’s been true. However, with the passage of the mental health parity law in 2008, insurance coverage must now be equal to what you receive for physical ailments. This suggests that for most people covered by health insurance, their mental health benefits should now support reimbursement for an unlimited number of outpatient psychotherapy visits each year (typically one a week).
Psychotherapy remains the treatment of choice for depression for many reasons — virtually no side effects, typically no long-term dependence, and treatment tends to be time-limited, even for severe clinical depression. Yes, it’s definitely not as easy as taking an antidepressant medication once a day. But for most people who try it, they appear to experience significant relief from their depressive symptoms within 12 to 16 weeks.
I can’t change a trend like this with a blog entry. But I can point out that you should really look at the effectiveness of the antidepressant you’re considering taking, as for many kinds of depression, an antidepressant may be no better than a sugar pill.
You have a choice when it comes to depression treatment. Just because your primary care doctor says, “Hey, why don’t we try you on this antidepressant and see how it goes,” doesn’t mean you should take his advice unquestioningly. Primary care doctors and GPs are not experts in mental health issues — they’re simply repeating what they’ve typically done in the past, because it’s the only thing they can do.
Instead, ask for a referral to a mental health professional if your GP has concerns you may be depressed. Or better yet, seek out such a professional to start with (you typically don’t need to see your family doctor any more for that initial referral). I don’t care if it’s a psychologist, psychiatrist or other mental health professional — I just know they’re going to better understand the depression treatment options available and hopefully present them in a more thoughtful light.
Read the full article: More Seek Out Depression Treatment, But Not Psychotherapy
26 comments
Interesting how treatment fluctuates over time! Thanks for the post.
I wonder if this is at all because more and more therapists are no longer accepting any health insurance, medicaid, or medicare (not that I suspect most did earlier.) The hassles are just too much and reimbursement is just too low. This prices most people out of psychotherapy. Even my generous insurance policy, will only pay half of the $150 cost of my therapy visits. Antidepressants? $25 for a 3 months supply. My mom’s health insurance, one of the best since she’s a government employee, won’t pay for anything, because the therapist is “out-of-network” (she doesn’t take any other insurance).
Although, I understand that therapists need to get fairly compensated for their years of studying and their current work and they have their own overhead, how many patients can really pay $75-200 a session? If they can, are they be willing? Especially when you really need several months of weekly treatment for psychotherapy to work. The only ones that seem to be willing to pay and/or deal with the hassles of finding a decent “in-network therapist,” ever increasing co-pays, and getting pre-approvals and so forth, are either 1) very opposed to medication or 2) still are very depressed even after being on antidepressants for awhile. Otherwise, $25 for a 90 day supply of meds sounds good.
However for insurance companies and the government who are footing the bill for the meds and other medical treatment, therapy is actually more cost-effective for most patients in the long-run. Older, generic antidepressants like Wellbutrin still cost hundreds a month (the quote I got was $388!) and the newer ones typically cost about the same as weekly therapy, if not more. Plus many patients are taking multiple antidepressants or add-on medications, for years at a time. And if the patient ends up being hospitalized because of inadequate depression treatment or a severe side effect of a medication, that’s thousands of dollars right there.
Therefore, 1) health insurance companies and medicare should compensate therapists based on the going rate in the area and the therapist’s education level.
2)co-pays or co-insurance should be the same for therapy as it is for medication. It should be $25 a month, instead of $25 a session
3)If insurance companies are unwilling to significantly raise their compensation, the federal government should step in and make up the difference
4)All therapists should be strongly encouraged to take some forms of insurance or medicare or medicaid. Or do sliding scale. Especially if compensation is increased, I don’t think it’s ethical to only treat the rich.
I believe in part the massive ad campaine plays a huge role. But I must go to three Doctors to get my medications, PCP will only do, thyroid and antibiotics, Pain management will only do pain medicine and if I’m at a hard place in my treatment with my psychlogist I can only get Shrink me’d from them. I have a PAD and am really iritated my Srinks who diregard it. I can not take antidepressants, but they refuse to beleive me, they even put down my psychologist saying she doesn’t know anything–she has watch me detereate when a shink lied to me about a drug and by the time I found out the drug was an antidepressant, I had end up in two differant psych hospitals lost friends. I had not been hospitalized for over a decade!The shinks resonse, it did not really couse any harm! For me it is psychotherapy all the way, never had one lie to me but a great many shrinks are brain washed into just being licensed pill pushers by the drug companies that have full access to their offices.
In my case, my coverage only allows 20 visits per year (and the copay goes way up every year) – not even close to once a week! There doesn’t seem to much parity to me. I have had more success with a combination of medication and therapy. I don’t know how I would have made it without either one.
two thoughts: 1)You note the decline in therapy as treatment for depression using statistics collected prior to 2007. Is there any data since the 2008 parity bill was passed?
2)”In two decades, psychotherapy went from being the primary treatment enjoyed for depression, to becoming a minority treatment.”
“enjoyed” really? Please tell me you meant to use the word “employed.” It has been my experience that therapy has been excruciatingly painful work. If I am supposed to be enjoying this I am doing something wrong!
Hi Karen,
1. Although the parity act was passed and signed into law in 2008, the rules that implement the act weren’t solidified until this year. I think insurers have until sometime in early 2011 to comply with the new rules. So we won’t likely see any significant impact of the parity law into 2011-2012 timeframe. Assuming people even become aware that their coverage for mental health issues has (usually) expanded.
2. Good catch! 🙂
It would have been more useful if you had read the actual provisions of the law. Here are two pertinent conditions from the government DOL site:
1. “Provides that employers retain discretion regarding the extent and scope of mental health benefits offered to workers and their families (including cost sharing, limits on numbers of visits or days of coverage, and requirements relating to medical necessity.”
2.Increased cost exemption. MHPA does not apply to a group health plan or group health insurance coverage if the application of the parity provisions results in an increase in the cost under the plan or coverage of at least one percent.
What do you think the response of the employers and the insurance companies is going to be, given these provisions?
Source: http://www.dol.gov/ebsa/newsroom/fsmhparity.html
Dave, unfortunately I think you missed this note at the very top of the page you reference:
That’s not the parity act of 2008 mentioned here.
I really appreciate the thoughtful response by LS.
I’ve been a practicing psychologist for over 25 years. Insurance reimbursement for psychotherapy has actually decreased since I started private practice in 1984. That’s not in “inflation adjusted” dollars but in actual dollars. One representative major insurer that paid $75 for one hour of therapy in 1985 now pays $65. I don’t believe there is any other profession – or occupation for that matter – that has seen their real wages fall to below what they were paid in 1985. My physician, plumber, and mechanic certainly don’t charge less than they did in 1985. Even McDonald’s pays more than they did then. No employer would even think to offer less than they paid 25 years ago. And no employee would accept it!
So, I have severely limited my private practice. I accept no insurance. I charge about 80% of the prevailing fee in my area and payment is expected at time of service. Patients are provided with receipts indicating procedure code and diagnosis and they may, if they wish, seek reimbursement from their insurers. I just won’t be a part of that process. Prospective patients are, of course, given this information prior to the first session so they may choose to go elsewhere if insurance coverage is the priority.
I see many fewer patients but no longer have the hassle of dealing with the insurance companies. Practicing this way allows me to concentrate on treatment and, not incidentally, to totally guarantee patient confidentiality. It is much less stressful and also much more rewarding professionally because I find that I am working with highly motivated patients. I didn’t become a psychologist to become wealthy. I would like to be compensated fairly for my education and experience. The current system does not do that.
The larger issue is systemic. The almost complete control of health care by the insurance companies. The domination of health care – including psychological health care – by Big Pharma and its multi-billion dollar advertising campaigns. The increasing tendency to medicalize and pathologize all difficult human behavior. The overselling by psychiatry and subsequent buy-in by the media and the public of the so called “chemical imbalance” theory of all psychological distress. The cultural desire for quick fixes with little effort or sacrifice. But those are subjects for another day!
Apologies if this is a repeat submission. Thanks for your understated 🙂 correction of my mistake. I would have done well to heed my own advice: “It would have been more useful if [I] had read the actual provisions of the law.” Following my own advice (assisted by you) I found out the following:
96 percent of U.S. small businesses (defined as 50 or less employees) would be exempt from these regulations. Specifically: “Small employer exemption—(1) In general. The requirements of this section do not apply to a group health plan (or health insurance issuer offering coverage in connection with a group health plan) for a plan year of a small employer. For purposes of this paragraph (f), the term small employer means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least two (or one in the case of an employer residing in a state that permits small groups to include a single individual) but not more than 50 employees on business days during the preceding calendar year.”
The 96% figure comes from U.S. Census figures. “We also looked at research the Small Business Administration compiles using data from the U.S. Census. Their research shows that the vast majority of businesses in the United States have fewer than 50 employees. In 2007, 5,814,584 firms had fewer than 50 employees, compared with a total just over 6,049,655 firms.” In other words, 96 percent of U.S. small businesses are specifically exempted from fines on employers who don’t insure their employees. http://politifact.com/truth-o-meter/statements/2010/oct/18/us-chamber-commerce/us-chamber-says-health-care-law-hammers-small-busi/
In terms of ALL businesses (over 50 employees) that fall under this law, the IIlustrative List of Nonquantitative Treatment, limitations include: Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective (also known as fail-first policies or step therapy protocols). In other words, unless a mentally ill patient (or advocate) can “prove” medication/short term (brief) therapy “is not effective,” psychotherapy will be an easily-refused modality for businesses covered by the April 5, 2010 expanded implementation of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.
In addition, if certain requirements are met, plans that incur increased costs above a certain threshold as a result of the application of the parity
requirements of both these laws can be exempt from the statutory parity requirements. Raising the threshold for qualification from one percent to two percent for the first year for which the plan is subject to MHPAEA qualifies ANY business for an exemption.
All additional resources: Federal Register / Vol. 75, No. 21 / Tuesday, February 2, 2010 / Rules and Regulations, found on this site: http://www.regulations.gov/search/Regs/home.html#documentDetail?R=0900006480a8935c
John-
Interesting post. In my Wash., D.C., psychotherapy practice in the last year or two, I’ve noticed a slight increase in anxiety disordered patients and a comparable decrease in depressed patients. (About 5-10% on either end.) When I speak to the primary care docs who refer to me they say they are seeing more anxiety-related complaints from their patients. Not entirely sure how to explain it but at least some of it has to do with the downturn in the economy; some clients are worried they may lose their job while others fear they may not be able to find something better.
Also, I do think that the constant advertising of antidepressants on television has played a role in some people relying solely on meds — and not turning to psychotherapy — to treat their depression.
I think health insurance companies cut off their nose to spite their face. While they realize that medications may be more expensive — especially newer ones, and because patients are on them longer — and frustrating to find an effective one, they also know most Americans are probably not up for making the difficult choice — pop a pill once a day, or go into psychotherapy once a week that requires your active hard work and participation.
Ray makes a lot of good points in his post about the economics of the situation. It is and always has been a systematic problem, one that is largely controlled by health insurers looking to ensure they make the most amount of money by providing the easiest, least expensive care.
And you don’t hear many patients complaining because they don’t seem to be as interested in psychotherapy as a treatment choice as taking an antidepressant medication.
Dave, if your point is that no employer is going to be covered by the new mental health parity law of 2008, I’m not sure why everyone worked so hard to pass it.
The small business exemption is a part of nearly any federal law passed, because it can be extremely costly to a small business to require them to meet the same standards as a company like IBM or Google.
Is the law perfect? Of course not. Does it cover every American? No, and no one ever made the claim it did. Is it a giant leap forward in mental health advocacy and helping to get health insurers to stop discriminating against mental disorders? I believe the answer is a resounding yes.
The mental health system in this country is a disgrace. Since the broken promises by the “deinstitutionalization” designers that they would make mental health treatment more compassionate and relaxed by opening community area centers, which never materialized, “bio-psychiatrists” became the only option for the uninsured and most of the insured people suffering from chronic depression and other mental illnesses. These “doctors” are well paid by pharmacological companies to use patients as lab rats by “evaluating” them every month during a 10-20 minute office visit during which they monitor how the prescription du jour is working. But because these “professionals” have no idea what the correlation is between the brain chemistry profile of their patients and their ailments, which should be the basis for prescribing psychiatric drugs, (as is done when treating every other organ in the human body) patients become guinea pigs that end up being doped or under-medicated time after time -many to the point of committing suicide. The sad truth is that for many of those who are “lucky†enough to be offered to get on the medication merry-go-round, they will be worse off going through a never-ending list of useless and highly toxic medications than believing that the only reason that they are still alive (even if not functional) is because they are strong enough to resist a practice that even PETA considers cruel and inhumane.
If the mental health community really wanted to “help” the mentally ill, they should start by studying what works in other countries, where psychiatrists and neurologists work hand in hand to diagnose from the most serious to the most basic mental health issues, and where psychologists and other talk-therapists do not impose a financial burden on those who are already suffering from the overwhelming stress of being marginalized by a society that for the most part deems mental illness as a character flaw.
Ray- This is probably better for YOU but what about 90-95%% of the population that you are effectively cutting off by only taking well-off clients? I understand being fairly compensated, but I still think that if you were lucky and/or resourceful enough to acquire a specialized skill set, you have an obligation to help the less fortunate as well. I know some therapists who get around this by offering sliding scale or allowing medicare or something like that. I know my insurance company reimburses therapy at $120 a session, so not all of them are that bad.
Diana-When you say “mentally ill” what do you mean? I thought we were just talking about Major depression treatment here. I don’t think anyone with Major Depression sees them self as “mentally ill.” In fact using that term at all is highly disrespectful. Many highly successful people, Brooke Shields, Winston Churchill, Abe Lincoln, Pro Athletes, etc have battled Major Depression and I don’t think anyone would call them “mentally ill. ”
Also, I’ve lived in 2 European countries and know many Canadians and Brits, and I can assure you that they also use antidepressants as well. Neurologists are useful in some cases, but the unfortunate thing is that we don’t have reliable, safe tests yet to measure brain activity down to the Neurons and brain structures where the defects associated with Major Depression probably are. Research needs to continue. Until then, medication will mostly be a guessing game. Lastly, although some patients can get better with just psychotherapy, a lot of patients do need medications, but I personally believe that should be an adjunct to treatment. Of course their our side effects and the system isn’t great, but if you had a serious, potentially debilitating disorder like Major Depression, would you want to wait until better diagnostic tools and treatments came out? Probably not.
John, that wasn’t my point. I am referring solely and specifically to psychotherapy, depression, and the Parity Act. The actual wording of the act allows for almost complete discretion on the part of insurers and companies to dictate “lower-cost therapies,” (a quoted term from the act) unless they can be proven to be ineffective, which is different from proving another approach is, or might be, more effective.
This almost certainly eliminates psychotherapy as a treatment modality. The declining percentages of people using psychotherapy to deal with depression is far less a matter of preference (unless preference is defined as the desire to pay for treatment out of pocket) than a response to existing and the now-amended mental health coverage.
As psychotherapy was the focal point of your post, I think it’s safe to say passage of this amended Parity Act won’t significantly change the trend lines you’ve described. Other areas of coverage WILL see significant advances.
Many good people fought very hard to combat an industry which had grown used to the cutting of delivery costs even as they posted record-setting profits year after year. Any changes would (and did) result in tremendous push-back. Even if the proposal had been to allow everything to stay exactly the same but limit policy increases to 10% per year, this industry still would have fought, tooth and nail to deny and limit coverage even as it raised premiums. That’s why “everyone (aside from insurance companies) worked so hard to pass it.”
First, I can’t say enough how I see now what the “manic type†behaviors and the unhealthy consequences on the users and the family (often leading other family members to be depressed or worse) seem to be in conjunction.
I still have yet to understand why SSRI’s are considered acceptable for depression with it’s “connection to suicide, irresponsible behaviors, kidney and liver hazards, and ‘discontinuation syndrome’â€. However, cocaine isn’t prescribed in equivalent quantities because of the irresponsible behavior, health hazards, and “withdraw syndromeâ€. Seems hypocritical.
I also don’t understand. My GP wouldn’t think of prescribing and/ or administering chemo therapy because he/ she knows nothing about treating cancer. BUT, they don’t hesitate at prescribing and treating psychological ailments that they have even less knowledge about. Why? I believe its because most often (except in cases of suicide) antidepressants don’t kill the body, they take the mind and the personality. Try explaining to a judge how the mother of your child is no longer remotely the person you married and decided to have a kid with.
Last point, we are a culture that has to have everything fast and cheap. Therapy takes hundreds of hours digging into your repressed past, confronting demons that are painful and embarrassing. Taking a little pill in the bottle to simply do away with those pesky “Super Ego†driven thoughts that cause so much anxiety is soo much easier.
As a psychotherapist I advocate psychotherapy, but I believe there is a real role for antidepressant medication. In my view whatever can be done to ease the pain of someone in the depths of clinical depression should be offered. What I really wonder about is what is being lumped together as depression. Many times I have worked with clients who have left a bad relationship or a horrible workplace and their depression remits and never returns. One way I like to think about it is: Is it depression or despair?
LS, I’ve spent most of my career working with less fortunate people in one way or another. I left full time private practice only because the trend was clear: work harder and longer hours with more responsibility and greater liability for less income. Again, is there any other profession forced to do that? I now work full time in a state run addictions clinic that accepts everyone. I have a very limited private practice and cannot afford to do sliding fee or accept ever decreasing insurance (by the way, I’ve never had an insurance company pay $120 for psychotherapy.)Interestingly, my patients are middle class, not well off, and have made the decision to invest in themselves and their well being rather than, as one of may patients said, a flat screen TV. I provide time limited, outcomes oriented, cognitive behavior therapy so the number of sessions is generally under 20, keeping the costs down. I’ve also observed that people with a financial stake in their treatment work very hard at it and, therefore, get more from the experience.
Some – and I emphasize only some – of the systemic issue I alluded to in my first post is about people taking responsibility and ownership. There are many people who say they cannot afford therapy but think nothing of buying the latest smart phone, clothes, TV, electronic gadget, or, as happens in my state, spending $300 per month on a daily pack of cigarettes. This is a cultural factor in health care, along with the desire for quick, easy fixes and an external solution to what is an internal problem.
I’m BiPolar and I prefer to see both a Pychiatrist and a Counselor. It really seems that just seeing a doctor to monitor your psychiatric drugs just isn’t adequate at all. Depression can take a toll on your whole life, at work, at home an in relationships. I find I often need help with damage control. However, even with good insurance sometimes seeing a counselor is still unaffordable. After paying co-pays for Pychiatrist visits and co-pays for any other medical concerns plus co-pays for drugs, it is often too much for my low income to add counseling.
I mostly have to consider what’s going to help me keep working and keep my work performance stable. Maybe I should have considered filing for disability. I wish there were counselors who could help you figure out how best to afford care for major psychological illnesses.
I live in Canada so what I say is unaffected by changes in the American system. Canada’s healthcare system is socialized in comparison to the U.S. Many (most?) forms of treatment are fully covered by government managed insurance systems. We still pay for drugs but inexpensive plans allow us to pay about 20% of the true cost. And, of course, the most disabled among us are given supports which include full coverage of drug costs. This is a system and so it has cracks to fall through. One of the largest is that to qualify for such plans, one mist manage reams of paperwork – one of the things people severely disabled with mental illnesses have troubles with. However, that said, it is a fairly good system. I have yet to meet anyone who truly needed help and was turned away. (Of course, if you’ve not in critical condition, wait times can be very long.)
Thanks to this system, I see an excellent psychiatrist for psychotherapy weekly and do not pay a cent. One would think that in such a system, patients who wanted psychotherapy could choose to have it and you could judge popularity without a price factor.
The problem is that, here, psychiatrists choose not to offer it. $ I want a psychiatrist who will monitor my medications, the list is long and my doctor will be able to recommend one who suits my particular needs. But to see a psychiatrist willing to talk to me… ? That is hard.
I have heard “I’m transforming my practice to only monitor meds” more times than I can count. This is a choice by the individual practitioner. And it is endemic. Why this choice is made, I’m not sure. Cynics will say that doctors earn more scheduling 4 15 min drug sessions than one 1 hr counselling session. Possibly this is true. However, I have seen a great number of health practitioners who are motivated by things other than money. I believe that these doctors are regularly making this choice because of burn-out. In this system, a psychotherapist cannot stack his client list with mostly “worried well” and keep open only a few slots for the truly ill.
In any case, in Canada, psychotherapyis becoming less and less common because psychiatrists are increasingly refusing to offer it. In my case, it took virtually Herculean efforts on my behalf to find a psychotherapist willing to accept a new patient. And these efforts were only undertaken because I had already spent 7 years taking every time-limited group program available in my (largish) city.
There are people here willing to do the work involved in therapy. All they need is the doctors willing to help them on the journey.
i have bipolar and am unemployed. i go to county mental health for meds. i am lucky to have a therapist who cares and is willing to see me for $20/$30 on revolving week for 60 minutes rather then her normal $125 for 50 minutes. i wouldn’t be in therapy if it weren’t for her flexibility and sacrifice but nobody else is that lucky. i started seeing her because the insurance i had made it so i could only get an appointment for a therapist every month and a half. i know i’m lucky.
why has it declined? because insurance is much more willing to throw pills at the problem and the resources for low income folks have been cut.
I participated in 7 yrs of psychotherapy with a psychotherapist, while being monitored by a psychiatrist, during the same period, for depression. I never felt the two worked together on my case.
For meds, I started with Celexa, then switched to Wellbutrin, Risperdol, Zoloft, then, Lexapro. Celexa’s effect was dramatic, but short lived. Wellbutrin caused hallucinations and Risperdol deadened my personality. Zoloft was barely effective with lethargic side effects. Lexapro was slightly more effective with less severe side effects.
Then, my psychotherapist changed offices after a period when I was unable to get transportation to his office. I lost out on the psychotherapy. I resumed the psychiatrist visit, because I could manage a ride four times a year.
However, it became apparent to me that I was a lab rat in a drug trial and my life problems were still tangled. I stopped refilling and taking the Lexapro this year to try to make it on my own.
The psychotherapy helped me get a handle on my depression better than the meds. Depression is not all about the chemical imbalance. There are people suffering depression in depressing circumstances. Talk therapy is critical to managing and overcoming depression’s hold on people like me. I am frightened by what I see as a trend to diagnosis and treat depression with pills only.
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