How did our field come to curb its enthusiasm for psychotherapy? In discussing this complex issue, reimbursement rates are first and foremost on most psychiatrists' minds. Yes, it is true that we are being reimbursed less for a potentially more effective long-term treatment. What is also true, however, is that if treatment is divided between a psychiatrist who is prescribing medication and a nonpsychiatrist who is providing therapy, no third party will reimburse for the time spent communicating between the two. Moreover, preliminary data suggest that treatment may end up being more expensive.1 In addition, in the absence of reimbursement, communication may fall by the wayside to the patient's detriment. Now that doctoral psychologists also are feeling some of the same financial pressures, some are considering gaining prescribing privileges.
Aside from the philosophical issue, what is certain to happen from a financial perspective is that insurance companies will pay psychologists less to see patients for medication management and therapy, shifting important therapeutic work to therapists with less experience and training and potentially diluting the efficacy of psychotherapy. As we seem to go down this slippery path, do we really want to dilute the efficacy of psychotherapy if we have any hope of convincing health care organizations that they should reimburse more for psychotherapeutic treatment?Efficacy of drugs and psychotherapy
Consider the placebo response rate for children in depression studies. Placebo is often as effective as active medications in the acute treatment of children and adolescents with depression.2-4 Fluoxetine(Drug information on fluoxetine) is currently the only SSRI that has consistently shown efficacy for depression in children and adolescents and, therefore, is the only FDA-approved medication for depression in this age group. Instead of being disheartened that the medications do not seem significantly more efficacious than placebo, shouldn't we be asking why placebo works so well?
Furthermore, consider the long-term effects of therapy and medication. Analyses of studies for depression suggest that medication can produce more significant improvement early in treatment. The results of the NIMH-sponsored Treatment for Adolescents With Depression Study confirmed that, with remission rates of 23% (fluoxetine), 16% (CBT), and 17% (placebo). More important, however, was that the superior form of treatment was the combination of CBT-fluoxetine (37% remission). In addition, other study results suggest that in the long term, psychotherapy can surpass medication efficacy.5,6 I am constantly telling patients and residents, "Therapy builds skills that you can keep utilizing, which taking a pill can not duplicate."
There is also an illusion of mastery, at times, in prescribing medication. For residents and psychiatrists, the professional pressure to know what to do and how to "fix" a patient is quite ingrained in our medical training. Residents most often only watch faculty when they are prescribing medication, even if the faculty has an active psychotherapy caseload. Medical training is still an apprenticeship, but the adage "see one, do one, teach one" is difficult to arrange for the practice of teaching psychotherapy.
In addition, prescribing medication can appear to be (and in some cases actually is) easier than psychotherapy. With the well-documented shortage of child and adolescent psychiatrists and long wait lists to see providers compounded with financial concerns, the pressure to do more in less time is enormous for practitioners as well as for health care systems that treat children. Therefore, thinking largely in the biological domain of neurotransmitters, receptors, and brain activity can focus a clinician's thinking to the point that the rich psychosocial aspect of the formulation can be lost.
For example, I recall an instance at the American Academy of Child and Adolescent Psychiatry's national meeting last year in San Diego, when the controversial subject of preschool and prepubertal bipolar disorder was examined during a clinical symposium. What was striking to me (besides the accuracy of the diagnosis of mania in a 4-year-old) was that the researchers were planning on using parent-interactional therapy to treat preschool-aged children with bipolar disorder. Treat a serious brain disorder such as bipolar with therapy? For once I was in agreement—yes, let's consider nonpharmacological management for serious problematic behaviors, especially in children so young.
I don't wish to minimize the obvious distress many families go through with these young children, but to label a child as having bipolar disorder, given our current state of scientific knowledge, leads most psychiatrists firmly down the path of psychotropic medication.
During the same symposium, another researcher discussed the possibility of using medication preemptivelyfor adolescents in whom bipolar disorder has not been diagnosed, if they have subdromal depressive symptoms and a first-degree relative with the disorder. When I asked if any of the researcher's treatment arms included a psychotherapy or psychoeducational component, I was told that perhaps other researchers would conduct such a study. "Where is the majority of the enthusiasm focused in our field today?" I thought. My only answer was "in pharmaceuticals."Using a comprehensive approach
In conclusion, to clarify why I, a child psychiatrist, use psychotherapy, I would say adamantly that it is because I have this extensive medical training with which I can approach the problem from all directions in a unique manner. Questions about medications and symptoms often lead to fruitful psychotherapeutic moments that we may miss, even when multiple treatment providers are collaborating perfectly. My therapeutic skills and the relationships they engender definitely bring me more professional satisfaction than being seen as "the prescribing doctor."
I struggle, as I believe many clinicians do, with the pressure to help frantic patients and their families, while also doing no harm in the face of limited resources and lacking scientific evidence. In the end, I would rather treat fewer patients, providing the medications and therapy modalities when clinically indicated.
Certainly there will be patients and families for whom perhaps only one modality is necessary, or another treatment provider is necessary, but as specialists, I believe we should treat the most complex cases in the most comprehensive manner available, despite long hours, poor reimbursement rates, and occasional difficult countertransference moments. I know that I would not trade this approach for anything.