Wednesday, June 16, 2004

Antidepressant Rx: Careful Monitoring Needed

On WebMD, there is a decent article  with recommendations for monitoring antidepressant treatment, especially for children and adolescents.  While I agree with much of the article, there are a few things I disagree with:

Therapy helps people understand the roots of their depression, change negative thought patterns, and learn better coping skills, Fassler explains.

This notion -- that therapy helps people understand the roots of their depression -- is a common misunderstanding, in my view.  The statement implies that it is possible to know what the "roots" of the depression are.  Sometimes it is obvious; usually it is not obvious; and when it is not obvious, it probably is not possible to know what the roots are; at least with our current level of technology.  This is not to impugn the value of psychotherapy.  On the contrary, psychotherapy can be enormously beneficial.  I am skeptical, though, of any claim that we know how or why it works. 

As a philosophical aside, I think it is important to recognize therapy for what it is: an attempt to solve problems.  When first confronted with a problem, a natural response is to approach the problem by trying to figure out what caused the problem.  Sometimes that leads to a solution, but not always.  In fact, in the course of psychotherapy, it often is more helpful to understand what perpetuates  a problem, as opposed to what caused  it in the first place. 

Managed care companies now recognize the need for mental health treatment, Feinberg tells WebMD. "The number of visits may be limited, but I think managed care has done a good job in increasing access to treatment."

I don't know who this Feinberg is, or what planet he is on, but on Earth, managed care has been a disaster for mental health treatment.  (Actually, I do know who Feinberg  is, and he has a good reputation.)  The hospital I work for terminated its contact with Blue Care Network, because they kept imposing unrealistic limits on coverage for mental health treatment.  One of the clinics I work at refused to renew its contract with Care Choices, for similar reasons.  I personally refuse to do business with Health Alliance Plan, because they impose such ridiculous bureaucratic obstacles to everything.  Years ago, I worked at an eating disorders program.  We had to close the program because of tightening insurance restrictions.  To be fair, managed care is not the only culprit, but I really don't see how Dr. Feinberg can say what he said.  Apparently, he had second thoughts himself, because his next statement was:

However, there may be some difficulty getting coverage for a psychiatrist's care, he adds. Patients may have to pay out of pocket, or sign up for a preferred provider (PPO) plan, to get coverage for a psychiatrist's care.

This is followed by:

Access to treatment for clinical depression has improved in recent years, Feinberg tells WebMD. "If you need therapy, you will get therapy."

Another perplexing statement.  Most therapists won't accept Medicaid, because it literally does not even cover the overhead in most clinics.  Washtenaw County Community Mental Health rarely provides psychotherapy to clients.  Another vexing aspect to insurance coverage is that most plans will authorize only a certain number of sessions, AND the number they authorize has to be split between the therapist and the psychiatrist.  So the more the patient sees the therapist, the less they can see the psychiatrist.  One could argue that this rarely poses a problem for patients with uncomplicated problems.  But the patients with uncomplicated problems usually don't see a psychiatrist: they get their prescriptions from their primary care provider. 

The title of the article -- Antidepressant Rx: Careful Monitoring Needed -- is good advice.  Careful monitoring is needed, for sure.  But the very structure of modern health insurance either makes that impossible, for many people, or makes it so difficult as to be impractical. 

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