Feature

Turn on the television, and you'll probably see an ad advising you to ask your physician about a drug used to treat depression, heart disease or some other health problem, says APA President-elect Suzanne Bennett Johnson, PhD.

Those ads are just one part of the pharmaceutical industry's multi-pronged effort to sell its products. And as data show, marketing to people with mental health concerns—combined with other trends—is paying off for drug companies. The percentage of medication-only visits for mental health problems has been climbing over the last decade. According to government surveys, the percentage of outpatient mental health visits that

involve only medication and no psychotherapy jumped from 44 percent to 57 percent between 1998 and 2007.

"The pharmaceutical companies have spent millions and millions of dollars to promote their drugs," says Johnson. "Who's going to do that for psychotherapy?"

According to Johnson and other psychology leaders, the answer is psychologists themselves, individually and collectively.

At APA, governance members are developing a policy that will pull together evidence of psychotherapy's effectiveness for use as an advocacy tool. APA is also working to develop treatment guidelines that will serve as a vehicle for advocating with payers as well as a resource for practitioners. (See "Treatment guidelines are coming" in the October 2010 Monitor.)

In addition, APA and APA's Div. 29 (Psychotherapy) are engaged in a variety of public education and other projects to spread the word about just how effective psychotherapy is.

Psychotherapy in decline?

In a 2010 study in the American Journal of Psychiatry (Vol. 67, No. 12: 1456–1463), Mark Olfson, MD, and Steven C. Marcus, PhD, examined trends in outpatient psychotherapy in the United States. (See "Where has all the psychotherapy gone?" in the November 2010 Monitor.)

Drawing on data from the nationally representative Medical Expenditure Panel Surveys conducted by the federal Agency for Healthcare Research and Quality, the authors found that the percentage of the general population who used psychotherapy stayed the same between 1998 and 2007.

But over the same period, outpatient mental health care has changed. Over that decade, the use of psychotherapy on its own and in conjunction with medication has dropped, while medication-only visits have increased.

More than 57 percent of patients now receive medication without psychotherapy, up from 44 percent. The percentage who receive psychotherapy only has dropped from almost 16 percent to 10.5 percent, while the percentage who receive a combination has dropped from 40 percent to 32 percent.

Marketing isn't the only reason patients are turning more toward medication and less toward psychotherapy. Another critical factor is insurance coverage: Insurers will often pay for drugs but not for psychological interventions, says Johnson (see sidebar, next page). And prescribing medication is more convenient for physicians, nurses and others than providing psychotherapy, she adds.

"Most people who have problems see their primary-care physician," says Johnson. "From a primary-care provider's point of view, it's easier to write a prescription than try to find a provider who could offer other kinds of treatment."

Advocacy efforts

What's particularly alarming about the data is that psychotherapy isn't prescribed even in situations—such as mild to moderate depression or sleep disorders—where we know that psychotherapy and medication are equally effective or effective if done in combination, says Katherine C. Nordal, PhD, executive director of APA's Practice Directorate. "We have a society that wants a quick fix," she says.

To help counter that trend, APA is developing a series of treatment guidelines for the first time. Those guidelines aren't just for use by psychologists, Nordal emphasizes.

"The guidelines will allow us to present the evidence to policymakers, insurance companies and other payers who make decisions about what kind of treatment they're going to pay for," she says. "It will allow us to say, 'You know what? There's a huge evidence base for psychological interventions.'" The guidelines will also help to inform consumers about the kinds of treatments that work best for their problems, she adds.

In addition, the new guidelines will help correct the bias in existing guidelines, such as those created by the American Psychiatric Association, says Steven D. Hollon, PhD, who chairs the Advisory Steering Committee that will oversee APA's guideline development.

Take the current treatment guideline for depression, for instance. It's not a bad guideline, says Hollon, but it's a guideline designed for practicing psychiatrists and so emphasizes medication.

"It's like one of those maps of the United States done by New Yorkers: New York dominates three-quarters of the page, and the rest of the states are kind of off on the edge," he says. "The guideline has lots of coverage of pharmacological interventions, which are generally quite effective and quite safe. It has much briefer descriptions of psychotherapeutic approaches, which are generally comparably effective, are even safer and often have long-term enduring effects."

While the topics to be covered in the treatment guidelines are still undecided, Hollon predicts APA will produce one guideline per year.

Another effort that may soon bear fruit is a resolution highlighting psychotherapy's effectiveness that APA President Melba J.T. Vasquez, PhD, introduced at APA's Council of Representatives meeting in February 2010.

The resolution, which Vasquez and others are revising based on feedback from colleagues, summarizes studies and meta-analyses of psychotherapy with various groups, treatment types and other factors. (See sidebar for examples of studies that may be included in the resolution.) Vasquez hopes the council will approve it in 2012. APA staff and individual psychologists can then use the document to educate insurance companies, managed-care organizations and anyone else who makes policy decisions about psychotherapy, she says.

Meanwhile, APA's Mind/Body Health initiative continues to work to educate the public and promote the value of psychotherapy. Local and national outreach activities include APA's online Help Center, its annual Stress in America survey and a partnership with the YMCA of the USA. APA's Div. 29 is also busy advocating for psychotherapy, says Past President Jeffrey J. Magnavita, PhD. To help build the evidence base and draw attention to the area, the division's new Norine Johnson Psychotherapy Research Grant, for example, will award $20,000 to a psychologist conducting research on psychotherapy effectiveness. The first grant will be awarded this year.

The division will soon a launch a video series about psychotherapy on its website. Called "Psychotherapists Face to Face," the series consists of informal interviews of psychology's "heavy hitters" (see www.divisionofpsychotherapy.org/face-to-face). "When you hear these people talk, I think you'll find they're amazingly inspiring and strong advocates for psychotherapy," says Magnavita, who will conduct the interviews.

Also, through its Task Force on Psychologist-Psychotherapists, Div. 29 has created a literature review on psychotherapy effectiveness (available online).

What you can do

Individual psychologists can also help promote psychotherapy, say Magnavita and others. One important role is educating both the public and other health-care providers, says Magnavita, suggesting that psychologists offer to write columns in local newspapers.

"I'm not sure the word is out that psychotherapy is as effective as it is," he says. "I think there might be a lot of misunderstanding in the health profession outside of psychology about psychotherapy's efficacy and potency."

Supporting the development of treatment guidelines and other efforts by paying the practice assessment is another way to get involved, says Johnson. Working with state, provincial or territorial psychological associations to push for payment for psychotherapy and other priorities is also important, she says. Psychologists can also get active in the Practice Directorate's grassroots network, whose members use letters, face-to-face meetings and other ways of advocating for psychology's concerns in Congress. How you go about these advocacy efforts is critical, says Johnson, who recommends that psychologists partner with other groups. Don't just stick with other mental health practitioners, she emphasizes.

"That's a big mistake on our part," she says. "I think we would get a lot of support from other groups that are interested in physical disease." Since behavioral interventions can play a key role in treating such problems as pain, diabetes and heart disease, she says, these potential allies include physicians, nurses, physical therapists and others.

"If it's just psychologists doing it, it looks like the pharmaceutical industry," says Johnson, explaining that patients and others tend to be skeptical of one group pushing its preferred intervention. "If we partner with other groups, including patient groups, that's going to be much more convincing."


Rebecca A. Clay is a writer in Washington, D.C.

Highlighting psychology's effectiveness

Some of the studies that may be included in APA's Recognition of Psychotherapy Effectiveness Resolution include:

  • Barlow, D.H., Gorman, J.M., Shear, M.K., & Woods, S.W. (2000). Cognitive behavioral therapy, imipramine or their combination for panic disorder: A randomized controlled trial. Journal of the American Medical Association, 283: 2,259–2,536.

  • Hollon, S.D., Stewart, M.O., & Strunk, D. (2006). Enduring effects for cognitive behavior therapy in the treatment of depression and anxiety. Annual Review of Psychology, 57: 285–315.

  • Imel, Z.E., McKay, K.M., Malterer, M.B., & Wampold. B.E. (2008). A meta-analysis of psychotherapy and medication in unipolar depression and dysthymia. Journal of Affective Disorders, 110: 197–206.