Over the last five years, the concept of evidence-based treatment in psychiatry has steadily taken hold, despite concerns about cookbook medicine and the marginalization of treatments that have yet to be adequately researched. The body of scientific evidence continues to grow, and residency programs are increasingly including training in the use of evidence-based approaches. However, a number of obstacles remain to the widespread adoption of evidence-based treatment in private clinical settings.
A low percentage of psychiatrists use evidence-based treatment, Ranga Krishnan, M.B., Ch.B., chairperson of Duke University's department of psychiatry and behavioral sciences, told Psychiatric Times. It has not been part of the core of training programs in general. By contrast, fields such as cardiology and oncology have developed a lot of data and include evidence-based approaches as part and parcel of curriculum and training.
Somewhere along the line, people made the assumption that the level and quality of data is not as good in mental health as in other fields, but that's not true, Krishnan said. The application of that data, however, has not been systematically pushed. But the field is moving in the right direction, he said. Systematic evidence-based approaches are being developed that clearly delineate levels of evidence to support treatment recommendations.
At this point, evidence-based practices are percolating into psychiatry and the mental health field relatively quickly. The annual meetings of the American Psychiatric Association have had a growing number of sessions with evidence-based in their titles, said Krishnan, who this year chaired a session titled "Evidence-Based Medicine: The Next Generation" and spoke on "How to Make Judgments Under Uncertainty."
The APA uses periodic surveys of its members to determine the degree to which psychiatrists are following treatment guidelines, which are developed by leaders in the field based on the best evidence available. The survey by leaders in the field includes basic questions such as whether physicians are using the expected medications for a given diagnosis.
"We try to get some sense of the degree to which recommendations that exist in the practice guidelines are in fact being followed in routine clinical practice," Darrel Regier, M.D., M.P.H., told PT. Regier is executive director of the APA's American Psychiatric Institute for Research and Education.
The most recent survey found clear ethnic and racial differences in terms of which patients receive atypical antipsychotics. Basically, some minority populations were less likely to get the newer drugs and more likely to get older ones that carry a higher risk of neurotoxicity and metabolic syndromes such as diabetes, he said. The survey also found a much lower level of overall compliance with guideline-recommended psychosocial treatments for schizophrenia and other severe mental disorders, including any kind of psychotherapy or supportive family therapy.
Payment mechanisms certainly play a role in whether evidence-based practices are widely adopted, Regier said. For instance, he explained, "The reimbursement rates now for psychopharmacologic treatment are an order of magnitude larger than what you would get for psychotherapy."
The amount a psychiatrist gets paid for four 15-minute medication-management sessions results in a substantially higher income than does an hour of psychotherapy. For instance, a medication visit might pay $45, while a one-hour visit combining medication management with psychotherapy might pay slightly more than $100.
"What happens then is that because of some of the financial incentives, there often is not the adherence to guidelines that you would like," Regier said.
"That pattern is encouraged by the managed care companies," he said. On one hand, managed care is trying to subsidize treatment at the highest level of competence. Because only psychiatrists can prescribe drugs, managed care tries to funnel them into medication management and turns to psychologists, social workers and other less expensive professionals for psychotherapy.
However, even in the absence of payment issues, making sure that patients get treatment such as family skills training and psychosocial support services can be challenging for a psychiatrist in private practice, he said. Without direct contact with a range of specialists in social work, nursing and psychology, it becomes much harder to refer patients to those resources, he said.
There's also an educational issue, according to Regier. Knowing the effectiveness of a given treatment is important, but if psychiatrists do not have good information on the cost benefits for services that are not immediately available within their practice, they are less likely to go the extra mile to make sure that their patients get the full range of services they need. Even then, while those additional services might help the patient, they represent little more than an additional cost to the payor.
"That's one of the major problems with our system," Regier said. "The payor is not necessarily the one who gets the benefit from optimal care. The payor sometimes gets the benefit from minimal care."