Cost Concerns Likely Driving Drop in Psychotherapy Use

Benjamin Druss, M.D., M.P.H., wrote in an accompanying editorial that the findings “point to a major shift in mental health services delivery away from psychotherapy and toward psychopharmacology.” The result of that shift may be a decline in the range of treatment options available to patients.

“Many patients prefer psychotherapy as a first-line treatment, and some of the most successful trials of collaborative approaches to care improvement have given patients a choice between psychotherapy and pharmacological treatments,” Druss wrote.

He also pointed out that there are a number of likely causes for the trend away from psychotherapy, including more generous compensation to physicians for medication management compared with psychotherapy, an aggressive marketing infrastructure among pharmaceutical companies that has no counterpart for psychotherapy, and a lack of consensus among mental health professionals on the most effective types of psychotherapy for various psychiatric illnesses. Additionally, “Stigma, or a belief that these treatments are not effective, could keep patients from seeking out psychotherapy even in the face of broadened insurance coverage,” Druss wrote.

The findings indicate that both public and private health insurance providers “are still far more oriented to the delivery of medications and procedures than to cognitive and psychosocial treatments,” Druss wrote about the relative cost of multiple psychotherapy sessions compared with that of medications, many of which are available in low-cost generic formulations.

That preference by insurers led to reduced average payments for psychotherapy visits over the 10 years, which may have created “financial disincentives to providing psychotherapy,” according to the authors' analysis of the survey results. As insurance payments per psychotherapy visit declined—from $122.80 to $94.59, as did total national psychotherapy expenditures ($10.94 billion compared with $7.17 billion)—the mean number of annual psychotherapy visits per psychotherapy patient declined from 9.7 to 7.9.

Those decreases in psychotherapy use came despite a general lack of evidence that psychopharmacology alone is more efficacious and therefore more cost-effective than the use of psychotherapy alone or in combination with medications, they wrote.

The trend toward the use of more psychotropics and less psychotherapy might change in the coming years, according to Druss, through the ongoing implementation of the new federal health reform and mental health parity laws. Specifically, the health care reform law enacted last March may reduce financial barriers to psychotherapy through the creation of new health insurance marketplaces and expanded Medicaid eligibility, both of which will cover some forms of mental health care.

Additionally, the insurance parity law, which went into effect for plan years beginning on or after July 1, 2010, prohibits differences in coverage between mental disorders and other medical illnesses, noted Druss. It also prohibits “nonquantitative” mechanisms, such as prior authorization and utilization review, that have long been barriers to receiving psychotherapy.

The conclusions of the analysis were limited by a variety of factors including the surveys' use of household informants, who could be unaware of some mental health care received by other household members. Additionally, the surveys were vulnerable to memory failures and omissions stemming from lingering public stigma toward psychiatric conditions.

“National Trends in Outpatient Psychotherapy” is posted at <http://ajp.psychiatryonline.org/cgi/reprint/167/12/1456>. “The Changing Face of U.S. Mental Health Care” is posted at <http://ajp.psychiatryonline.org/cgi/content/full/167/12/1419>.