Followup to Previous Post on Psychotherapy

An editorial aside. Like most professional organizations, but not all, the psychotherapy groups have pursued policies that limit the number of new psychotherapists entering the field. The physician (MD) psychiatrists resisted licensing psychologists for years, claiming that only they had the expertise to do psychotherapy and psychologists were to be relegated to laboratory studies. Eventually the psychologists lobbied the legislatures and got themselves licensed. Then it was the social workers and marriage and family therapists who wanted in on the game. They were well-trained and could do a fine job of psychotherapy, but the psychologists were the biggest barrier, lobbying the legislature to defeat the MFTs and social workers. Eventually both of these groups were licensed. Most recently, those who had extensive training, and a masters degree in counseling tried to become licensed. It took years and was accomplished over the strong lobbying effort of the American Association of Marriage and Family Therapists who blatantly opposed this because it would generate more competition. (This was the first time that any group was at least somewhat honest about their agenda. Though even this time it was done in the name of protecting the public consumer.)

Why license psychotherapists? The argument is that there are people who call themselves counselors and therapists and life coaches who are not competent to deal with emotional and mental dysfunction. But the hidden agenda is that the health insurance industry most often uses state licensing as the door to payment for services. The more people are licensed, the more financially competitive the field. This isn’t to say that there are not incompetent individuals who should not be doing psychotherapy. Of course there are. But an amazingly large proportion of those have licenses.

The result of all this shenanigans is that we have too few psychotherapists. And those we do have are congregated in the large and affluent areas, like New York City, Chicago, Dallas, San Francisco, Los Angeles, Phoenix. 

I have many friends who are trying to start psychotherapy practices in the SF Bay Area. And they are struggling to make ends meet. My suggestion–though I would miss their proximate friendship–is to move to Oroville or Delano or Porterville.

Here’s another from Science Digest

Depression Treatment Rates Increase Over Past Decade, but Psychotherapy Declines

ScienceDaily (Dec. 6, 2010) — The rate of depression treatment increased between 1998 and 2007 but at a slower rate than during the previous decade, and the percentage of patients treated with psychotherapy continued to decline, according to a report in the December issue of Archives of General Psychiatry, one of the JAMA/Archives journals.

“Depression is a leading cause of disability, lost productivity and health care expenditure,” the authors write as background information in the article. During the 1990s, the rate of depression treatment increased substantially, from 0.73 percent in 1987 to 2.33 percent in 1997. Among those who were treated, the use of antidepressant medications increased from 37.3 percent to 74.5 percent, and the use of psychotherapy decreased from 71.1 percent to 60.2 percent. These trends have been attributed to the introduction and promotion of selective serotonin reuptake inhibitors (SSRIs) and other newer antidepressants, publication of practice guidelines to diagnose and treat depression and the development of screening tools for primary care.

However, several factors — including the proliferation of managed behavioral care organizations, the changes in benefits among private mental health insurance plans and concerns about the safety of antidepressants in young people — may have impeded the growth of depression care in the most recent decade. Steven C. Marcus, Ph.D., of Philadelphia Veterans Affairs Medical Center and the University of Pennsylvania, Philadelphia, and Mark Olfson, M.D., M.P.H., of Columbia University and the New York State Psychiatric Institute, New York, assessed national trends in outpatient treatment of depression between 1998 and 2007 using two nationally representative surveys.

Between 1998 (when 22,935 participants were surveyed) and 2007 (when 29,370 individuals participated), the rate of outpatient depression treatment increased from 2.37 per 100 people to 2.88 per 100 people. The percentage of treated patients who used antidepressants did not change significantly — from 73.8 percent to 75.3 percent. Of those, the percentage receiving tricyclic antidepressants or SSRIs declined and the percentage receiving newer antidepressants increased.

Of treated patients, the percentage receiving psychotherapy declined from 53.6 percent to 43.1 percent between 1998 and 2007. “Of those who received psychotherapy, the average number of psychotherapy visits and expenditures for these visits also significantly decreased,” the authors write. “There was also a significant decline in the mean [average] number of outpatient depression care visits per treated person.”

It is unclear whether the decline in psychotherapy use is due to patient preferences or other factors, including scarcity of psychotherapists, the authors note. “A review of the literature concerning treatment preferences, however, revealed that most patients with depression prefer psychotherapy or counseling over antidepressant medications,” they write. “However, although third-party coverage of antidepressants and other psychotropic medications is typically generous, significant limits commonly exist on coverage of psychotherapy services.”

“As national health care reform unfolds, it will be important to develop clinical policies that promote access to effective treatments for depression,” they conclude. “Health care reform will extend coverage to an estimated 32 million uninsured Americans. Meeting the mental health care needs of these individuals, who currently have a low rate of depression treatment, will post a formidable challenge to general medical and mental health educators and practitioners.”


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