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3 fold preference for talk-therapy

Posted Sep 06 2013 6:59am

i_love_evidence_based_medicine_key_chains-r33ff90ead6aa425ea368e31ca9ee70e5_x7j3z_8byvr_512 I swear I don’t go looking for this stuff.

This post from the British Psychological Society just popped up in my feed reader:

A line was crossed in 2005 as anti-depressant medication became the most widely prescribed class of drug in the USA. …

“It is unclear why the shift toward pharmacologic and away from psychological treatment is occurring,” the researchers said, “although limited access to evidence-based psychological treatments certainly plays some role.”

Kathryn McHugh and her colleagues identified 34 relevant peer-reviewed studies up to August 2011 involving 90,483 people, in which the participants were asked to indicate a straight preference between psychotherapy or drugs. Half the studies involved patients awaiting treatment, the others involved participants who were asked to indicate their preference if they were diagnosed with a psychiatric disorder. The researchers had hoped to study preferences among patients with a diverse range of diagnoses but they were restricted by the available literature – 65 per cent studies pertained to depression with the remainder mostly involving anxiety disorders.

Overall, 75 per cent of participants stated a preference for psychotherapy over drugs. Stated differently, participants were three times as likely to state that they preferred psychological treatment rather than medication. The preference for therapy remained but was slightly lower (69 per cent) when focusing just on treatment-seeking patients, and when focusing only on studies that looked at depression (70 per cent). Desire for psychotherapy was stronger in studies that involved more women or younger participants.

The author’s noted that, given the evidence showing comparable efficacy for psychotherapy and medication in treating most forms of anxiety and depression, there is strong empirical support for greater use of talk-therapy.

UPDATE: Ross shared this APA post on the cost-effectiveness of talk-therapy:

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.”

Emerging research

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.”

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