Psychiatrist Jay M. Pomerantz, MD, knows first hand the pressure to prescribe drugs for his patients rather than psychotherapy. Even though he's a firm believer in psychotherapy, his dealings with managed-care companies sometimes leave him feeling like nothing more than a medication manager. In fact, one managed-care company even tried to keep him from continuing to see a patient after Pomerantz refused to put him on antidepressants.
"Psychotherapy is rationed and medicine unrationed," says Pomerantz, a private practitioner in Longmeadow, Mass., and a lecturer in psychiatry at Harvard University Medical School. "That lop-sidedness changes prescribing patterns. Whether you think about it or not, you're pushed to prescribe."
New research suggests that the managed-care industry's emphasis on medication may be misguided. That research supports what psychologists have long believed: Focused psychotherapy--problem-oriented approaches like cognitive therapy, cognitive-behavioral therapy and interpersonal therapy--performs just as well as medication for a list of conditions that includes depression, panic disorders and eating disorders. What's more, focused psychotherapy's ability to produce lasting effects and prevent relapses makes it an economically, as well as clinically, viable alternative to medication.
"If I were running a large insurance company or health-maintenance organization, I'd be quite concerned that maybe I'm just pushing up my medication costs by pushing down psychotherapy costs," says Pomerantz.
A quick fix?
The behavioral health management companies that now dominate the field have a good reason to prefer medication to psychotherapy: They don't have to pay for patients' pills.
Managed-care companies typically "carve out" the mental health portion of patients' medical care, assigning that responsibility to specialized behavioral health companies. These companies, however, cover only the cost of providing patients with access to mental health providers and facilities. Responsibility for paying prescription drug costs lies with the original managed-care companies. Since behavioral health companies must squeeze psychotherapy costs out of tight budgets, says Pomerantz, it's not surprising that they favor general practitioners over psychotherapists and psychopharmacological solutions over psychotherapeutic ones. By doing so, he explains, they shift costs back to the managed-care companies themselves.
Even more importantly, says Pomerantz, behavioral health carve-outs typically have a short-term perspective when they consider their bottom lines. While medication gets doled out over long stretches of time, psychotherapy is typically provided in short but intensive periods. Because health plans' budgets focus on expenses in a given year, medication has an obvious short-term advantage no matter what the eventual long-term cost.
Although conditions such as schizophrenia and manic depression clearly warrant medication, he adds, behavioral health companies are pushing patients toward medication even when psychotherapy or a combination of psychotherapy and medication would be best for them.
"In a recent survey, almost 90 percent of patients who visit psychiatrists are taking psychotropic medications," says C. Henry Engleka, assistant executive director for marketing in APA's Practice Directorate. "Instead of medication being used as an adjunct to psychotherapy, the opposite is generally true in most managed-care practices now."
That's too bad, says Pomerantz, because over the long run psychotherapy is often more effective, and thus cheaper, for many conditions. Although psychotherapy requires more of an upfront investment, he explains, it pays off by getting the job done and preventing relapses. By contrast, patients on medication often relapse once their medication stops and may require a lifetime of expensive pills. In a column in Drug Benefit Trends, Pomerantz cites several studies from the ever-increasing literature on this topic to prove his point:
- In a randomized, controlled trial, researchers assigned 75 outpatients with recurrent major depression to three groups: acute and maintenance treatment with antidepressants, acute and maintenance cognitive therapy and acute antidepressants followed by maintenance cognitive therapy. Cognitive therapy proved as effective as medication in both the acute and maintenance phases, with a trend favoring cognitive therapy's long-term efficacy (British Journal of Psychiatry, 1997, Vol. 171, p. 328-334).
- In another study, researchers randomly assigned 40 patients who had been successfully treated with medication for recurrent major depression to two groups: clinical management or cognitive-behavioral therapy. Over 20 weeks, antidepressants were tapered off and then discontinued in both groups. Two years later, only 25 percent of the patients who received cognitive-behavioral therapy had relapsed compared with 80 percent of the other group [Archives of General Psychiatry, 1998, Vol. 55(9), p. 816-820].
- In a meta-analysis of studies published between 1974 and 1994, researchers compared controlled trials of cognitive-behavioral therapy and pharmacological treatment for patients with panic disorder. While both treatments worked in the short run, the results were more positive and longer lasting for cognitive-behavioral therapy (Clinical Psychology Review, 1995, Vol. 15, p. 819-844).
There are plenty of other studies with similar results, says psychologist Steven D. Hollon, PhD, of Vanderbilt University, citing the work of psychologists like David H. Barlow, PhD, on panic disorders and G. Terence Wilson, PhD, on bulimia. Hollon's own research on depression has also found that people who receive focused psychotherapy stay better longer than people who just receive medication.
If the insurance industry would only listen to this research, says Hollon, the implications could be far-reaching.
"Just do the math," he says, noting that pharmacotherapists may keep depressed patients on expensive antidepressants for the rest of their lives. "If you can get with four months of psychotherapy the same benefits you get from a year and a half to two years of continuous medication, you begin to break even after about a year's time even though it's more expensive upfront to provide psychotherapy. If the benefits extend over a half decade or decade, your savings really start piling up. But managed-care folks don't think that way."
They also don't consider the troublesome side effects that often accompany medication use, says David O. Antonuccio, PhD, a professor of psychiatry at the University of Nevada School of Medicine and staff psychologist at the Veterans Administration Medical Center in Reno. Who, he asks, can put a price on a patient's inability to have sex as a result of taking an antidepressant?
In a cost-effectiveness analysis of cognitive-behavioral therapy, Prozac and combination therapy, Antonuccio took into account other, often overlooked factors such as lost productivity, wages, taxes and community service during treatment (Behavior Therapy, 1997, Vol. 28, p. 187-210). He concluded that providing Prozac alone would cost an estimated 33 percent more than cognitive-behavioral therapy over a two-year period and that providing combination therapy would cost an estimated 23 percent more.
For Antonuccio and other psychologists, however, the issue is less about costs and more about underlying philosophies.
"Consider the analogy of giving a hungry man food or teaching him how to fish," he says. "Psychotherapy, particularly problem-focused, skill-oriented treatment, is a way of teaching people skills they can use to prevent, reduce and delay depression and other problems."
Rebecca A. Clay is a writer in Washington, D.C.
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