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Psychotherapy in Psychiatry

Fighting Alternative Facts

Plakun, Eric M. MD; VILLELA, RENATA M. MD, FRCPC

Journal of Psychiatric Practice: November 2019 - Volume 25 - Issue 6 - p 466–469
doi: 10.1097/PRA.0000000000000422
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In the Canadian province of Ontario, the Ministry of Health and Long-Term Care is proposing to impose arbitrary limits on access to psychotherapy provided by physicians. This column presents and debunks 3 myths associated with this ill-conceived proposal: (1) that long-term psychotherapy costs the health care system too much money, making it necessary for the government to curb this spending; (2) that long-term psychotherapy is a non–evidence-based treatment being needlessly spent on the worried well; and (3) that we need to focus on quick treatments, not long ones.

VILLELA: Private practice, Thornhill, Ontario, Canada, President, Ontario District Branch of the American Psychiatric Association, and President-Elect & Psychotherapy Initiative Lead, Ontario Psychiatric Association, Toronto, ON

PLAKUN: Medical Director and Chief Executive Officer, Austen Riggs Center, Stockbridge, MA, and Founder, American Psychiatric Association Psychotherapy Caucus, Washington, DC

The authors declare no conflicts of interest.

Please send correspondence to: Renata M. Villela, MD, FRCPC, 412-300 John Street, Thornhill, ON, Canada L3T 5W4 (e-mail: renata.villela@mail.utoronto.ca).

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Introduction to Guest Column Eric M. Plakun, MD,Psychotherapy Section Editor

Many of us in the United States look to Canada with admiration for its guaranteed access to health care, including mental health care, as a basic right provided to all Canadians by the province in which they reside. One of the most forward-thinking provinces has been Ontario through its Ontario Health Insurance Plan (OHIP). Ontario psychiatrists are reimbursed to diagnose and treat patients with far less scrutiny than is the case under managed care in the United States.

Sadly, one of the reasons for our admiration may be changing. The Ontario Ministry of Health, citing a shortage of Canadian psychiatrists and offering American managed care as a model, is proposing to limit OHIP funding of any psychotherapy to roughly 24 sessions a year, regardless of diagnosis, comorbidity, previous treatment response, or suicide risk, and despite the lack of evidence that “one-size-fits-all” limits to treatment work. Meanwhile, in the United States, a series of “top down” (ie, legislative) and “bottom up” (ie, judicial) actions show signs of beginning to tame the Wild West of managed care that expanded dramatically in the 1990s.

These top down actions in the United States include passage of the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA or mental health parity law), which requires that, if mental health and substance use disorder benefits are offered in an insurance plan, barriers to access cannot be substantially more stringent than those to access other medical-surgical benefits. The 2014 “Final Rules” of the MHPAEA also specify that the law applies not just to inpatient and outpatient treatment, but also explicitly to so-called intermediate levels of care—intensive outpatient programs (IOPs), partial hospital programs (PHPs), and residential treatment centers.

The 2011 Affordable Care Act (ACA) reaffirmed the mental health parity law and made mental health and substance use disorder treatment essential benefits of ACA plans. This made it substantially harder for insurance entities to bypass the mental health parity law by simply omitting coverage for mental health and substance use disorder treatment from insurance plans. The ACA also requires that insurance entities disclose previously secret criteria used to deny requested services.

Currently, the 2019 Mental Health Parity Compliance Act, a bipartisan bill in the Senate and House authored by Senator Chris Murphy, D-CT, would require insurance entities to reveal their compliance with the terms of the mental health parity law. The power of this top down action comes from the way sunlight is the best disinfectant. What businesses or individuals will want to purchase insurance plans that fall short of legal requirements?

However, these top down actions are not the whole story. They are substantially strengthened by bottom up actions in the form of class action lawsuits against insurance entities. The best known of these is probably the landmark case of Wit v. United Behavior Health/Optum (UBH/Optum). In his scathing 106-page verdict last March in the liability phase of this federal class action tried in the Ninth District in California, Judge Joseph Spero faulted UBH/Optum for focusing its criteria for access to outpatient, intensive outpatient, and residential treatment on the limited goal of crisis stabilization, followed by the end of treatment once a crisis subsides, rather than on treatment that recognizes the complexity and chronicity of most mental disorders, addresses underlying issues and comorbid disorders, and is focused beyond crisis stabilization toward achieving true recovery. Among other elements of his verdict, Judge Spero faulted UBH/Optum for arbitrary limits to the duration of treatment rather than individualizing length of treatment based on patients’ clinical needs.

Taken together, these top down and bottom up actions in the United States are beginning to put limits on how managed care deals with mental heath needs. These laws and legal precedents are steps toward achieving true mental health parity because they establish that, in mental health and substance use disorder treatment, as in the rest of medicine and surgery, the goal of treatment is more than mere crisis stabilization.

Ironically, just as the generally accepted standards of good clinical care show signs of prevailing in the United States, the Canadian province of Ontario has set a course toward imposing the kind of arbitrary and ill-conceived limits on treatment that are being found to be inconsistent with generally accepted clinical standards of care in the United States—not to mention inconsistent with achievement of mental health parity in Canada.

In this month’s guest column, Renata Villela presents and debunks 3 of the myths on which the Ontario Ministry of Health bases its arbitrary and ill-conceived plans. We wish her and her Canadian colleagues the best in their efforts to thwart this proposal, which would adversely impact Canadian citizens in need of mental health and substance use disorder treatment.

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Psychotherapy in Psychiatry: Fighting Alternative Facts

Guest Columnist, Renata M. Villela, MD, FRCPC

In Ontario, it can feel like psychiatrists offering long-term psychotherapy are becoming an endangered species. Currently, Ontarians can see psychiatrists for psychotherapy via the universal health care system without any restrictions on the length of the treatment course. The government is proposing, however, that psychotherapy be limited to about 24 hours per patient per year for a given psychiatrist, alleging a lack of evidence for long-term psychotherapy.1 The stigma against psychiatry within the house of medicine remains strong and has further infected psychiatry as a reductionistic split between short-term and long-term treatments.

As myths concerning long-term psychotherapy have become increasingly pervasive,2 this column will highlight the key points to keep in mind when answering those who try to discredit this important treatment and when educating colleagues who may have decreasing access to comprehensive psychotherapy training.

Myth 1:Long-term psychotherapy costs the health care system too much money, making it necessary for the government to curb this spending.

Facts:It is important to remember that having a cost-effective treatment does not mean that it is cheap.3Long-term psychodynamic psychotherapy has been shown to be very cost effective by decreasing mental illness costs in public and private health care settings.4The use of long-term psychotherapy specifically provides savings in areas such as decreased absences from work and lower medical costs, including those relating to hospitalization.5Indeed, psychotherapy for those with depression has been proven to be effective and to provide good value for money, even though it is not necessarily publicly funded across Canada.6Seventy-five percent of patients prefer psychotherapy to medication,5and it roughly doubles the response rate when added to medication.6Asking people to first fail to respond to abbreviated care before getting access to treatment of greater frequency/duration can be devastating as they are made to feel untreatable.7Fast food medicine, in which people with lived experience of mental illness are being moved through the system as quickly and as cheaply as possible, devalues the end users and their health care team.8Clinical judgment and not arbitrary limits should determine the frequency and the duration of psychotherapy.5

Myth 2:Long-term psychotherapy is a non–evidence-based treatment being needlessly spent on the worried well.

Facts:Psychotherapy is not being overused by those who do not need it.3Long-term therapy can be an effective treatment for a broad range of mental illness experiences.4These complex experiences can include personality disorders, eating disorders, substance use disorders, somatization, and/or chronic forms of anxiety and depression.2,5,7In severe cases, depression can result in suicide, which is the second most common cause of death among those 15 to 29 years of age; suicide results in the death of around 800 000 people, irrespective of age, each year.9Changes at the level of the brain can occur following long-term psychodynamic psychotherapy, which has been correlated with symptomatic relief.8Furthermore, long-term psychotherapy has large effects for decreasing symptoms and for improving disorders of moderate severity, both at the end of the therapy and afterwards.5Long-term psychodynamic psychotherapy has consistently been shown to have comparable outcomes to cognitive-behavioral therapy and to medication, with long-term psychodynamic psychotherapy offering sustained improvement following the conclusion of treatment.8Dose-effect data suggest that short-term therapy is insufficient for complex mental disorders, a finding that has been supported by the results of meta-analyses.10Short-term therapies are easier to incorporate into quick study designs, making them more likely to appear in published randomized controlled trials.8Remember that it is difficult to demonstrate actual efficacy when therapies are constructed to suit idealized conditions rather than addressing the intricate interplay of real world factors necessary for a truly empirically informed treatment.11Up to two-thirds of patients seeking treatment can be excluded when a one-size-fits-all model of hypothesis testing becomes the focus.11The scientific literature, therefore, does support the efficacy of psychodynamic psychotherapy, with similar effects as those therapies that are more traditionally designated as being “evidence-based.”2

Myth 3:We need to focus on quick treatments, not long ones.

Facts:Over 25 years ago, findings from the National Institute of Mental Health Treatment of Depression Collaborative Research Program had already revealed that 16 weeks of different forms of short-term treatment were insufficient for most patients to have a full recovery and maintain remission of symptoms.12Yet detractors continue to suggest otherwise, even after the literature confirmed that patients in ambulatory settings typically require roughly a year of psychotherapy to achieve recovery at a level of 75%.13Furthermore, the benefits of short-term, manualized treatments can be brief, with an expansive review revealing that 50% of patients were looking for treatment again within 6 to 12 months.5Focusing on end of treatment evaluations or short-term follow-up can result in a later therapeutic benefit being missed.14It is also important to consider that nonpsychodynamic therapies may be effective partly because high-level practitioners are incorporating therapeutic strategies that are at the heart of psychodynamic psychotherapy.2

When fake news and cherry-picked data are at one’s fingertips, sharing the information presented above could help to stem the tide of misinformation and, ultimately, prevent the extinction of a life-saving treatment.

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REFERENCES

1. Doidge N. In Ontario, a battle for the soul of psychiatry. Toronto, ON: The Globe and Mail. April 6, 2019. Available at: www.theglobeandmail.com/opinion/article-in-ontario-a-battle-for-the-soul-of-psychiatry. Accessed June 3, 2019.
2. Shedler J. The efficacy of psychodynamic psychotherapy. Am Psychol. 2010;65:98–109.
3. Lazar S. Psychotherapy Is Worth It: A Comprehensive Review of Its Cost-Effectiveness. Arlington, VA: American Psychiatric Publishing; 2010:22.
4. de Maat S, de Jonghe F, Schoevers R, et al. The effectiveness of long-term psychoanalytic therapy: a systematic review of empirical studies. Harv Rev Psychiatry. 2009;17:1–23.
5. Lazar S. The place for psychodynamic therapy and obstacles to its provision. Psychiatr Clin North Am. 2018;41:193–205.
6. Dhalla I, Tepper J. Improving the quality of health care in Canada. CMAJ. 2018;190:E1162–E1167.
7. Lazar S, Bendat M, Gabbard G, et al. Clinical necessity guidelines for psychotherapy, insurance medical necessity and utilization review protocols, and mental health parity. J Psychiatr Pract. 2018;24:179–193.
8. Shapiro Y. Psychodynamic psychiatry in the 21st century: constructing a comprehensive science of experience. Psychodyn Psychiatry. 2018;46:49–79.
9. World Health Organization (WHO). Depression. Geneva, Switzerland: WHO. March 22, 2018. Available at: www.who.int/news-room/fact-sheets/detail/depression. Accessed August 12, 2019.
10. Leichsenring F, Abbass A, Luyten P, et al. The emerging evidence for long-term psychodynamic therapy. Psychodyn Psychiatry. 2013;41:361–384.
11. Westen D, Novotny C, Thompson-Brenner H. The empirical status of empirically supported psychotherapies: assumptions, findings, and reporting in controlled clinical trials. Psychol Bull. 2004;130:631–663.
12. Shea M, Elkin I, Imber S, et al. Course of depressive symptoms over follow-up: findings from the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Arch Gen Psychiatry. 1992;49:782–787.
13. Kopta S, Howard K, Lowry J, et al. Patterns of symptomatic recovery in psychotherapy. J Consult Clin Psychol. 1994;62:1009–1016.
14. Fonagy P, Rost F, Carlyle J, et al. Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: the Tavistock Adult Depression Study (TADS). World Psychiatry. 2015;14:312–321.
Keywords:

psychotherapy; Canada; United States; Ontario Health Insurance Plan; Mental Health Parity; costs; cost-effectiveness

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