Valuing Psychotherapy

A recent study published in the August issue of the Archives of General Psychiatry report that between 1996 and 2005 the rate of people reporting they have used antidepressants increased by 75%. During the same time period there was a 35% decrease in the use of psychotherapy. It was reported that only 32% of people taking antidepressants saw a psychologist or social worker.

While this study only looked at people taking antidepressant medications and did not look at people who were in therapy who were not taking antidepressants, the numbers are troubling. It has been shown repeatedly that if you are depressed and want to feel better quicker, using both antidepressants and psychotherapy is the most effective treatment.

What  might account for this drop in the use of psychotherapy? Some suggest that out-of-pocket costs to patients are a barrier. A co-pay for medication might be as low as $10 a month while insurance coverage for psychotherapy might have a deductible of $500 or even more than $2000 before coverage begins. It is also suggested that comparatively low insurance reimbursement by insurance companies to psychotherapists has lead to declining use of psychotherapy. This second factor is likely complicated: low reimbursement rates move more psychotherapists to cancel contracts with insurance companies. This increases the fee to patients because they would then have to pay the entire cost of their treatment rather than a portion.

While the article did not discuss this, my guess is that individuals with HMOs are probably the least likely to be in psychotherapy: traditionally these plans have are the most restrictive (small lists of therapists from which to choose, many of those therapists are not taking new patients, session limits, etc.). I'm anticipating some, but not all, of this inequity will change once the mental health parity law goes into full effect (see, here, here, or here).

What does depression cost? The National Institute of Mental Health has estimated that the annual cost of depressive illnesses in the United States was about $27 billion dollars. $17 billion of that figure represents time lost from work. An MIT study in 1990 found the depression costs the nation $43.7 billion. This later figure puts the costs of depression on par with illnesses such as HIV/AIDS, cancer, and coronary heart disease.

Despite these figures, it seems that society as a whole--as well as individuals--are not willing to spend money on psychotherapy.

• Significant investment. Depending on geographic region and the training of the psychotherapist, a therapy appointment can cost anywhere between $80 and $200+. 
• No quick fixes. While  many people feel better after just a few short sessions, enduring change can take more time. Medication offers the allure of a quick fix, though in reality antidepressants can take three of four weeks to take effect.
• Mysterious. Therapists spend most of their time in private one-on-one conversations. Most people are left to Hollywood or talk shows to learn about psychotherapy. 
• Not a cookbook. With the increase of cognitive behavioral therapies, many develop the notion that psychotherapy is a technology/commodity that one can learn from a workbook. While this is a whole lot less mysterious, it cookbook approaches really don't help teach the value of the investment in psychotherapy. Why spend money for therapy when you can get the book from the library?

Psychotherapy represents an important investment in health, wellness, life, and society. How do we get the news out there? I've got two really important ideas:

• Psychotherapists need to get out of the office and into the streets. We need to talk about what we do, be comfortable in talking about the value of what we do, and find more ways to offer our knowledge and skills to society.
• Clients, when comfortable, need to talk with those they care about and tell them how they have found psychotherapy valuable. 

For more, try reading, here, here, here, or here.