Posted by Phillipa on September 3, 2010, at 20:58:53 [reposted on September 4, 2010, at 9:24:08 | original URL]
Seems use of medications is up but types of theraphy down when both together yield better results. Phillipa
From Medscape Medical News
Outpatient Psychotherapy "Not Keeping Pace" With Increasing Use of Psychotropics
Deborah BrauserSeptember 3, 2010 Although the overall use of outpatient psychotherapy by the general population remained stable between the years 1998 and 2007, the levels decreased by more than 5% for those using outpatient mental care facilities, according to a new national trends survey.
In addition, use of psychotherapy and psychotropic medication together also decreased by almost 8% in this setting, whereas treatment with psychotropic medication alone increased by more than 13%.
"We found that for an increasing number of Americans, mental healthcare involves medications but not psychotherapy, and this trend is evident especially for depression and for bipolar, anxiety, and child disorders," Mark Olfson, MD, MPH, professor of clinical psychiatry at Columbia University in New York City, told Medscape Medical News.
"The absolute proportion of the population that is receiving psychotherapy is really very little changed over the last 10 or even 20 years. But it's contributing a smaller proportion of overall mental healthcare because it's not keeping pace with the big growth in the use of psychotropic medications," added Dr. Olfson.
He noted that "it's very important" for clinicians to be aware of psychiatric conditions where there's been a demonstrated advantage for combined treatment. "I think the current trend toward medication-only treatment puts some people at risk, especially those with more severe depression, by receiving less optimal care."
The study was published online August 4 in AJP in Advance.
A Paucity of Trends Data
Psychotherapy "is widely viewed as a core clinical activity of psychiatrists, psychologists, social workers, and other mental healthcare professionals," write the study authors.
However, past research has suggested that its use alone and combined with medications has diminished in recent years, possibly in part due to "a decrease in employer-sponsored health plans that cover outpatient psychotherapy," they add.
When Dr. Olfson and colleagues did a recent study (covered by Medscape in 2008) that focused specifically on psychiatrist visits, they found that the number of visits that included psychotherapy was decreasing.
"Within psychiatric practices, there is a growing and increasing emphasis on medication. Psychotherapy within psychiatry is playing a somewhat smaller role, which is something you can see in the declining amount of time psychiatrists are spending with each patient," he explained.
"That study got me wondering: if we opened it up more generally and looked across all kinds of mental health professionals, how has the role of psychotherapy changed in recent years?"
Citing a "paucity of information" on US trends after 1997, the investigators evaluated data from the 1998 (n = 22,953; 53% female) and 2007 (n = 29,370; 52% female) Medical Expenditure Panel Surveys, which were conducted to provide national representative estimates on the use and financing of healthcare services.
Focusing on the participants who had more than 1 outpatient psychotherapy visit within that year, the researchers looked at rates of any psychotherapy use, psychotherapy expenditures, and percentages of those treated with psychotherapy plus psychotropics or either treatment alone. Each respondent was also asked to specify whether care was provided by a mental health specialist or other healthcare provider.
Psychotherapy (or mental health counseling) was defined as "a treatment technique for certain forms of mental disorders relying principally on talk/conversation between the mental health professional and the patient."
The psychotropics used by the patients were divided into the following groups: antidepressants, antipsychotics, anxiolytics/hypnotics, stimulants, and mood stabilizers.
Significant Psychotropic Increases
Results showed that the overall percentage of outpatient psychotherapy use remained nearly the same for participants in both surveys at 3.37% in 1998 vs 3.18% in 2007.
However, a significant decrease occurred among adults in the 35- to 54-year age group (from 4.97% to 4.02%) and among those who were publicly insured (from 5.29% to 4.17%).
For the participants specifically receiving outpatient care at mental healthcare facilities, psychotherapy alone and with psychotropic medications decreased significantly, whereas use of psychotropic medication alone increased significantly.
Table. Outpatient Treatment Use at Mental Care Facilities
Treatment 1998, % 2007, % AOR (95% CI)
Psychotherapy only 15.9 10.5 0.66 (0.48 0.90)
Both together 40.0 32.1 0.73 (0.59 0.90)
Psychotropics only 44.1 57.4 1.63 (1.32 2.00)AOR = adjusted odds ratio; CI = confidence interval
When focusing specifically on psychiatric conditions, the investigators found that psychotherapy-only treatment decreased significantly for anxiety disorders and for mental healthrelated conditions, which included psychosocial circumstances, sleep disturbances, malaise and fatigue, and nervousness.
In addition, the combination treatment decreased significantly for bipolar disorders, whereas psychotropics alone increased significantly for depressive, bipolar, anxiety, childhood-onset disorders, and mental healthrelated conditions.
"In both years, antidepressants were the most commonly used class of psychotropic medication, followed by anxiolytics/hypnotics," add the study authors. Plus, "there was a significant increase in the proportion of psychotherapy patients who reported using antipsychotic medications and stimulants."
Finally, significant decreases occurred in annual psychotherapy visits per patient (from 9.7 to 7.9), mean expenditure per psychotherapy visit (from $122.80 to $94.59), and total national psychotherapy expenditures (from $10.94 to $7.17 billion).
"Several factors may have contributed to the shifting distribution of treatment modalities," write the researchers. "First, although the pharmaceutical industry spends billions of dollars each year promoting medications to physicians and the general public, there is no entity of comparable influence or visibility to advocate psychotherapy."
Other possible reasons cited include that no federal agency ensures the effectiveness of individual psychotherapies or psychotherapists as does the US Food and Drug Administration for medications; that psychotherapy typically comes from a mental health specialist, whereas psychotropics are often given by primary care physicians; and that psychotherapy typically demands a substantial time commitment.
The Stigma of Mental Illness
"I think this study highlights the problem of stigma for mental illness," Douglas Ziedonis, MD, MPH, professor and chair of the Department of Psychiatry at the University of Massachusetts Medical School and UMass Memorial Healthcare System in Worcester, told Medscape Medical News.
"Because of stigma, managed care has not supported these disorders in the same way it would cancer or other diseases," said Dr. Ziedonis, who was not involved with this study. "In cancer, if we know there's good evidence-based treatment available, it's provided in people's insurance, and the physicians and other treatment providers are supported and reimbursed."
"It's very clear that the evidence-based treatment literature for mental illnesses shows that the integration of psychosocial treatments with the appropriate use of medication is often the best. And in some cases people might benefit just from psychotherapy or behavioral therapy alone," he added. "This reduction in having psychotherapy be available or encouraged or supported, I do think, reflects on how things are reimbursed."
Dr. Ziedonis noted that 1 concern he had with the journal article was that it had little discussion on defining the types of psychotherapy used. "It could have been with individuals, couples, families, or groups. The format also could have been cognitive behavioral therapy, psychodynamic therapy, motivational interviewing, relapse prevention, and social skills training. There are a lot of really good evidence-based approaches that have developed in the last 10 years that are more specific than this general, vague psychotherapy concept."
He also pointed out that when prescribed, used, and monitored appropriately, medications can also be helpful. "The point of the article isn't to criticize medicines. The researchers are just, rightly I think, pointing out that some disorders are weighted to psychotherapy as the treatment that is going to better help people over time."
The study was funded by a grant from the Agency for Healthcare Research and Quality. The study authors report receiving research grants or support from Eli Lilly, Bristol-Myers Squibb, and McNeil Pharmaceuticals. Dr. Ziedonis had disclosed no relevant financial relationships.
AJP in Advance. Published online August 4.
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