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Rocky Mountain News (CO)
December 10, 1995
Author: ELLEN JOAN POLLOCK, THE WALL STREET JOURNAL
Psychotherapists are complaining about a growing drug problem among their patients. Marge Wertlieb, a Dix Hills, N.Y., psychotherapist, said she detected signs of heavy drug use in a troubled 10-year-old boy she saw this year. “He looked like someone on heroin,” Wertlieb said. “This child was clearly not in this world. I couldn’t treat the child while he was in that state.” The boy’s pill-popping wasn’t his idea but that of a psychiatrist working for a managed-care company. And his 30-milligram dose of the antidepressant Prozac was higher than what adults usually receive.
Wertlieb suggested that the boy stop taking medication long enough for her to talk with him in an undrugged state – and that both mother and son participate in psychotherapy. But, encouraged by the managed-care doctor, the mother decided to stick with the drugs. Managed-care companies, with their mandate to cut costs, make no bones about their preference for treating mental-health problems with drugs. Not only do they limit coverage for psychotherapy, but also they often pay psychiatrists more per hour to supervise drug treatment than to provide counseling. The pay premium has an “enormous influence” on how therapists practice, says Chicago psychiatrist John Gottlieb.
Cost pressures involved
In an age of extraordinary medical breakthroughs in treating such illnesses as depression and schizophrenia, the tilt toward drug therapy could offer great benefits to patients. But many psychiatrists, including some who strongly favor the use of medication, say they fear that much of the opportunity is being squandered as the managed-care industry overuses or misapplies the drugs. In some instances, they say, drugs alone are offered instead of the more expensive combination of drugs and psychotherapy, which many practitioners consider more effective. In other situations, older drugs with potentially troubling side effects are prescribed instead of the newer, safer – but pricier – drugs such as Prozac.
Patients often aren’t told that even the doctor’s choice of medication is affected by cost pressures. The new approach toward drugs reflects how profoundly managed-care plans have transformed the mental-health field. These employee-insurance plans tightly regulate the type and amount of mental-health care a patient receives and steer work to clinicians who will go along with the approach. The plans thus can save employers as much as 30% in treatment costs.
Managed-care officials also argue that their approach reflects the best of modern medicine by providing effective treatment to patients who wouldn’t have responded as well to psychotherapy. As Ian Shaffer, chief medical officer of Value Behavioral Health Inc. in Falls Church, Va., puts it, the goal is to ”get as many (patients) as better as you can as fast as you can.” Executives at managed-care firms such as Value also note that psychotherapists have financial and even emotional incentives to favor months or even years of talk therapy, which can cost the patient as much as $100 a session. “Will somebody please show me the literature where hurting longer is a good thing?” Dr. Shaffer asks.
Studies support psychotherapy’s role
Recent research, though, suggests that, even in the age of wonder drugs, psychotherapy still may have a significant role to play. Brain-imaging studies, which show that some mental illnesses are associated with chemical changes in the brain, strongly support the use of drug treatment. But the same research also shows that psychological upheavals affect brain chemistry, a strong clue that psychotherapy can be useful as well, says Joseph Coyle, chairman of the consolidated Department of Psychiatry at Harvard Medical School.
Patient evaluations suggest that this may be so. In one study of 128 patients recovering from acute depression, only 8% of those treated with both psychotherapy and the drug Imipramine suffered a recurrence over a three-year period. Of the patients using Imipramine alone, almost 18% had relapses, according to a 1994 paper by Myrna Weissman of Columbia University’s College of Physicians and Surgeons. Even many patients with illnesses that have long been treated with medication seem to benefit from psychotherapy. Relapse rates for people with schizophrenia and manic depression drop significantly when they receive psychotherapy along with their medication, says Frederick Goodwin, a former head of the National Institute of Mental Health and now a professor at George Washington University Medical Center.
Under the circumstances, says Barry Ostrow, a Raleigh, N.C., psychiatrist, prescribing drugs alone is “not any different than giving a diabetic insulin and forgetting about diet and an exercise regime.” Still, when patients or their doctors seek to combine psychotherapy and drugs, they are often second-guessed by the managed-care firms and health- maintenance organizations that determine whether the treatment will be covered by insurance.
Girl’s family pays $900 a week
The mother of a 15-year-old California girl who has attempted suicide more than once is battling with MCC Behavioral Care, of Eden Prairie, Minn., to get coverage for intensive psychotherapy for her daughter. The mother, speaking on condition of anonymity, says an MCC psychiatrist told her that the girl’s illness was extremely serious and that she should take the drug Zoloft. At one point, when the girl’s parents asked about individual therapy, the doctor replied, ” ‘The drugs are her therapy,’ ” the mother says.
Sandy Weimer, vice president of MCC, a unit of Cigna Corp., Philadelphia, declines to comment, citing patient confidentiality. But in a letter to the parents, he said that troubled families frequently “externalize the problems and become frustrated with care givers.” The girl now attends a special school and is seeing a psychiatrist paid for by her parents, at a cost to the family of $900 a week. “All of a sudden I realize I have no insurance. It’s on paper but you can’t use it,” says the mother, who is a teacher.
Pressure from managed-care firms to choose drugs over therapy ranges from subtle to explicit, says Gottlieb. Sometimes, he says, he is encouraged by a managed-care company to “find some symptom that responds to medication.” Often, he and his colleagues are given only one session to evaluate a patient for medication. Followups are limited to periodic 10- to 20-minute “med- checks” to review dosages. “Psychiatrists are cut off from doing any other assessing,” Gottlieb says.
Med-checks pay especially well. In the Chicago area, for instance, Merit Behavioral Care Corp., formerly known as Medco Behavioral Health Care Corp., generally pays psychiatrists $35 for a 15-minute med-check and $90 for 45 to 50 minutes of therapy. This sort of differential makes managing patients’ medication more lucrative to the practitioner than talk therapy, even when such therapy is covered by a health plan.
More drugs prescribed for children
The managed-care firms’ enthusiasm for drug treatment extends to both adults and children, even though little research has been done on the effects of drugs on the very young. For years, Ritalin, a stimulant, has been prescribed to children suffering from attention-deficit disorder. With the advent of managed care, therapists say, Ritalin use has risen. Prozac and older antidepressants also are being prescribed more and more often, child- health care specialists say.
“There’s often great pressure from the managed-care company to place a young child on medication, whether or not that’s my clinical judgment,” says Donald Rosenblitt, the medical director of a special Cary, N.C., nursery school that incorporates psychotherapy into its curriculum. “They are often not sympathetic to the fact that emotional problems in young children take a long time to work out and untangle with the family and that change often is slow.”
Record Number: 9503060078