Mr. Hogarty Replies

To the Editors: Drs. Dinakar and Sobel offer interesting survey results regarding the provision of psychotherapy to schizophrenic patients in a managed care program, but it is unclear what inferences they wish to have drawn. At first glance, it appears that only 17% of 1,036 schizophrenic patients enrolled in a partially capitated managed care plan either wanted individual psychotherapy or were judged by their treating physicians to need it. If the need or desire for psychotherapy is so circumscribed, do we and others waste our time and resources developing and testing more effective forms of psychotherapeutic intervention? Or is there a problem with the method used to estimate the need and desire for psychotherapy?

Asking physicians whether their schizophrenic patients need "psychotherapy"might well have implied insight-oriented, uncovering, investigative, or other psychoanalytically based approaches that might have led to a low rate of endorsement, at least among those who have read reports of the better-designed empirical studies of dynamic psychotherapy that were conducted over the past 30 years (1). Soliciting the schizophrenic patients' desire for psychotherapy might also predictably yield a similar response, when the majority of patients appear to have little or no insight into their illness (2).

But what would happen if both groups were asked their preference for a nonsomatic, disorder-relevant intervention that would 1) greatly reduce the risk for psychotic relapse and other poor outcomes, 2) teach patients about their unique prodromes and effective ways to manage them according to their clinical state and preference, 3) prepare patients to form and maintain important human relationships, and 4) increase the potential for vocational success and independent functioning (3, 4)? Whatever one might call this intervention (psychotherapy, psychosocial treatment, or mental health service), it is entirely possible that only 17% of patients or their psychiatrists would decline the invitation!

Further, what Drs. Dinakar and Sobel define as "psychotherapy"(symptom management, psychoeducation, and supportive therapy offered in the context of case management and medication monitoring), we have called "supportive therapy"in our studies. Our results suggest that significant symptom improvement and minor gains in social adjustment do occur during the first year of supportive therapy, but little or no continuing improvement is to be found in subsequent years. Personal therapy, on the other hand, significantly grows in efficacy with the passage of time (4). It is difficult to conclude that 83% of recovering schizophrenic patients would not need or desire such an intervention. While it is unlikely that personal therapy could be offered for $231 annually for each patient, it could prove to be cost-effective over time, once the savings from reduced inpatient use and increased social and vocational functioning entered the equation.