Perspectives on Practice

While medication is an appropriate part of a treatment plan for many mental health disorders, psychotherapy has been documented as the preferred treatment for many common psychological disorders. A growing body of literature demonstrates the efficacy of several forms of psychotherapy for these disorders.

Notwithstanding that evidence, however, some disturbing trends in mental health treatment patterns from 1998 to 2007 are reported in the U.S. government’s Medical Expenditure Panel Surveys.

While the percentage (3.37) of Americans who receive outpatient mental health care in 2007 is very similar to the proportion of those (3.18 percent) receiving such treatment in 1998, the pattern of that care has changed. Overall there has been a decrease in the use of psychotherapy only, a decrease in the use of psychotherapy in conjunction with medication and a big increase in the use of medication only.

In 2008, 57.4 percent of patients received medication only, indicating that compared with treatment patterns in 1997, approximately 30 percent fewer patients received psychological interventions. This trend was noted particularly among those with anxiety, depression and childhood-onset disorders.

For children being treated, 58.1 percent received medication alone and no other interventions! There has been a dramatic increase in prescribing psychotropic medications, including antipsychotics, to children and adolescents, even though research to support the safety and usefulness of some of these medications is lacking. Indeed, the U.S. Food and Drug Administration publicly concurred with a 2004 finding from controlled clinical trials that the use of nine common antidepressants increased the risk of suicidal thoughts and actions in pediatric patients.

Several reasons account for this shift in the focus of care for individuals with mental health disorders, beginning with the rise of the managed behavioral health-care industry in the 1990s. This burgeoning industry developed strategies to reduce the costs associated with the mental health and substance abuse benefits portion of both public and private health insurance plans. Over time, management of these benefits has resulted in controlling provider fees, strict limitations on episodes of inpatient care and reduction in the average number of outpatient visits per patient treated.

Interestingly, prescription drugs are not typically part of the costs managed by these carve-out plans. By 2006, the costs of psychotropic drugs accounted for 51 percent of mental health care spending. Per capita expenditure for psychotropic medications tripled from 1996 to 2006.

In addition to these market forces, other contributing factors have shaped our current mental health care delivery systems. One factor in particular has had a huge impact on the increasing reliance on psychotropic medications: aggressive marketing by the pharmaceutical houses, augmented by their ability since the late 1990s to advertise directly to consumers. Pharmaceutical companies constantly make information available to the public about the benefits of a variety of medications. In 2005, these companies spent $4.2 billion on direct-to-consumer advertising and a whopping $7.2 billion on promotion to physicians — nearly twice what they spent on research and development (A. Shaw, 2008). Don’t you love “If your antidepressant isn’t working … try Abilify!”? How about: “If your antidepressant isn’t working, try psychotherapy!”

Obviously, APA doesn’t have the resources to wage an ad campaign of our own. Instead, we need to bolster our current activities to inform the public about the evidence base for and benefits of psychotherapy and other psychological interventions. I invite your input on this crucial effort. Please send your thoughts and suggestions to me by e-mail.