I had the good fortune of training with John Greist, MD at the University of Wisconsin in the 1980s. Interestingly, many people have the opinion that Dr. Greist is firmly in the camp of biomedical psychiatry. He and his long time colleague James Jefferson, MD regularly give Door County symposia on the medical treatment of mood and anxiety disorders. They are highly regarded for their scholarship and teaching ability. If you haven't listened closely enough over the years, you might miss the fact that Dr. Greist has consistently pointed out the superiority of psychotherapy for various conditions and that computerized versions of the same psychotherapy perform as well as seeing a therapist.
At a recent MPS meeting, Dr. Greist gave a presentation on computerized therapy. He made a compelling argument for computerized psychotherapy based on a recent meta-analysis of effectiveness and a comparison of the cost effectiveness of developing moderately effective drugs compared to very cost effective and potentially more effective computerized psychotherapies. He was an innovator in the field publishing some of the original research and designing some of the original software. At this meeting he made a strong argument that the software is inexpensive, potentially as effective and more consistent than human therapists and for many conditions more effective than medication.
If there was any market value in the existing mental health field, Dr. Greist's concept would be disruptive. It would potentially change the way that treatment is provided, especially treatment of anxiety and mood disorders. Think about the way that treatment of these disorders is currently delivered. Twenty percent of the adult population is at annual risk. About 40 percent of that group seeks treatment primarily through primary care clinics. Very few people see psychiatrists and very few people need to. The standard of care for almost everyone else is taking a medication prescribed by a primary care clinic. Many people are treated with benzodiazepines and sedative hypnotic medications that have no efficacy in anxiety or depression and they continue these medications on a chronic basis. If psychotherapy is available it is two or three sessions of crisis intervention or supportive psychotherapy rather than research proven therapy for a specific disorder.
The lack of availability of psychotherapy in the health care system is another direct result of managed care and rationing. Managing most of the anxiety and depression with medications and brief visits is ideal for the bean counters. Outpatient clinics become an assembly line of 15 minute "med checks". The only reality is a medication and whether that medication works and is tolerated. An occasional manager may insist that the clinic double book patients to compensate for missed appointments or extra appointments to generate more revenue.
I noticed today in an effort to send an e-mail to my internist that his primary care clinic offers e-mail consults on treating anxiety and depression for $40. That is about what most psychiatrists get paid for a face-to face consultation. I wonder if the $40 fee includes a description of the psychotherapies that might work better than medication?
Enter computerized psychotherapy. Instead of waiting to get into a clinic that is based solely on medications, a person with anxiety and or depression accesses an Internet Clinic and proceeds through a number of self-guided and computerized cognitive behavioral therapy options. There are options for preferences, combination therapies, and inadequate response to computerized therapy. There is no need to travel to a clinic and there is no waiting. The therapy is available on demand and for free. The cost of treating thousands of patients is trivial, basically limited to staff to maintain the web site, collect treatment data, analyze outcomes, and modify the software as necessary.
All of this has been a known possibility for about two decades. Why isn't it happening? Why is mental health treatment limited to medications when psychotherapy, even by a machine is superior in many cases? Over those two decades we have seen unprecedented rationing of mental health services. We have seen what used to be clinical decisions turned into business decisions. The end result has not only been lower quality clinical care but a complete lack of innovation. It is time for the pendulum to swing back in the right direction.
George Dawson, MD, DFAPA
Cuijpers P, Craske MG, McEvoy P, Titov N (2010) Computer Therapy for the Anxiety and Depressive Disorders Is Effective, Acceptable and Practical Health Care: A Meta-Analysis. PLoS ONE 5(10): e13196. doi:10.1371/journal.pone.0013196