Remind Me Why Managed Care Companies Don't Offer Computerized Psychotherapy?

One of my mentors in residency enlightened me to the advantages of computerized psychotherapy.  That was in the days of the IBM AT PC or about 35 years ago.  I had an updated conversation with him about this 4 years ago after he gave a presentation that examined the more recent literature.  That literature had not only taken off, but there were more widespread applications.  Many of those applications were on a large scale using standard psychotherapeutic approaches.  Some of the research addressed the issue of patient acceptance and found that it was generally acceptable and more convenient for patients.

Interestingly, these innovations in computerized psychotherapy occur at a time when healthcare companies in the USA are implementing psychopharmacology on a large scale with minimal input from psychiatrists.  The collaborative care model for depression consists of patient in primary care settings rating depression with a standardized rating scale and generally being put on an antidepressant.  There is much wrong with this model, not the least of which is the fact that a rating scale is not a diagnosis and it probably leads to broader exposure to antidepressants medications.  It is nonetheless heavily promoted as an acceptable approach to the treatment of depression.

In the meantime, large organizations like the National Health Service in the United Kingdom have computerized psychotherapy services for the treatment of depression, generalized anxiety, and panic disorder.  The evidence base for these services is provided by the National Institute and Care Excellence (NICE).  According to the NICE guidelines for depression, computerized cognitive behavioral therapy is recommended as  "step 2 services for people with subthreshold, mild and moderate common mental health disorders".  In the US there are no similar resources and the treatment of depression as identified by screening techniques resembles a model of active monitoring and pharmacology with the widespread use of antidepressants.  Psychotherapy within health care systems in the US is sporadic and when it does occur seems to be based on a model of crisis counseling rather than any research model of the psychotherapeutic treatment of a specific disorder.  A main driver of that delivery system is the very low expense of modern generic antidepressants.  Some of these medications coast as little as $4/ month and are available at another discount if 90 day supplies are ordered.

A recent review of NSDUH data looked at medication utilization for the treatment of mental illnesses and found that the overall prescription rates had increased substantially across different generations of outpatients.  According to the authors there was a increase in prescription of psychiatric medications for all adults of about 28% between 2008 and 2013.  Of course the bulk of that medication is not prescribed by psychiatrists.  That paper also referenced a meta-analysis of patient preference for psychotherapy (2).  That study has significant methodological limitations and typical clinical constraints are probably not well represented.  In clinical practice, severely ill patients with psychiatric disorders or addictions are typically seen in intensive setting where psychotherapy is available and in many cases necessary like DBT or GPM.  The patient's I see list lack of rapport with the therapist, lack of direction in therapy, excessive self disclosure on the part of the therapist, cost, and inconvenience as being the main limiting factors for psychotherapy.  Most if not all of these constraints disappear with a computerized approach.

That brings me to a good example that I mentioned in a recent post on mindfulness based approaches to psychotherapy (3).  In the article I referenced, the Headspace web site was mentioned as a mindfulness based approach to psychotherapy.  The site offers 10 - 10 minute sessions and a more extensive selection of sessions at a reasonable cost after that.  As I completed the first 10 sessions, the advantages were immediately obvious.  The therapy model is obvious and there are standardized metaphors as examples.  The therapy is consistently delivered in the comfort of your own home and on your own schedule.  The site can be used by any psychiatrist or psychotherapist to augment outpatient treatment.  The site is valuable to trainees who are attempting to learn and deliver these mindfulness interventions on their own.  The site is cost effective - you can keep repeating the initial 10 sessions for free as much as you want or purchase additional sessions with different content.  A lifetime subscription to the web site is available for what might be the out-of-pocket cost of two psychoanalytic/psychodynamic sessions.

Every time I have been on the web site there are about 40,000 users logged in to the site.

Every managed care and health care company has a massive investment in IT to support their electronic health record and other clinic services.  Offering computerized psychotherapy would be a minor addition to those services.

Remind me again why managed care companies are not offering this option for depression, anxiety, and insomnia?    

And remind me why this is not the first step before prescription medication, especially in primary care settings?



George Dawson, MD, DFAPA



References:

1:  Han B, Compton WM, Mojtabai R, Colpe L, Hughes A. Trends in Receipt of Mental Health Treatments Among Adults in the United States, 2008-2013. J Clin Psychiatry. 2016 Oct;77(10):1365-1371. doi: 10.4088/JCP.15m09982. PubMed PMID: 27486895.

2: McHugh RK, Whitton SW, Peckham AD, Welge JA, Otto MW. Patient preference for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review. J Clin Psychiatry. 2013 Jun;74(6):595-602. doi: 10.4088/JCP.12r07757. Review. PubMed PMID: 23842011; PubMed Central PMCID: PMC4156137.

3:  Smallwood J, Mrazek MD, Schooler JW. Medicine for the wandering mind: mindwandering in medical practice. Med Educ. 2011 Nov;45(11):1072-80. doi:
10.1111/j.1365-2923.2011.04074.x. PubMed PMID: 21988623. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2923.2011.04074.x/full

Within the body of that article the web site called Headspace ( https://www.headspace.com/ ) for mindfulness training is referenced.

Disclosure:

I have no conflict-of-interest in mentioning the Headspace site.  I am not endorsing it and they do not endorse me.  I have no financial interest in the site.  I am listing it here as a resource for mindfulness based approaches because I think it is useful and it was recommended in the literature by a psychologist who I consider to be an expert in this field.

Fantasy Foundation For The Preservation of Psychiatry

Psychiatry is on the ropes.  The content of this blog illustrates the prevalent biases against the field that all eventually trickle down to less resources to work with and managed care companies rationing those meager resources in order to make money.  One of my favorite fantasies lately is to think about what I would do to save psychiatry if I ran a foundation with significant resources.  I have thought about it long enough and hard enough to come up with a number of guideposts:

1.  Save the teachers - probably the most beleaguered people in the field these days are the teachers of psychiatrists.  There are a lot of bloggers out there complaining about the "ivory tower" academics who just don't know how life is on the front lines.  The usual gripe is that they make too much money or are in some kind of shady consulting deal.  How dare they dictate to the rest of us how to practice?  That has not been my experience, and I have probably taught as much to medical students and residents as the next guy.  I see people trying to make a living and teach at the same time.  I see people needing to meet absurd "productivity" expectations and teach at the same time.  Teaching in generally is not counted as "productivity" in a managed care environment.  I see people who give up their ability to type up more patient notes at noon so that they can give a lecture to mostly disinterested medical students or fatigued residents.  They end up typing those notes at night on what is supposed to be their own time.

When I ask myself what would help them the most it comes like a flash - free high quality graphics for PowerPoints.  I have a parallel blog with some ideas, but there is nothing like great graphics that are free to use and save your faculty hours of sleep trying to come up with their own and not violate somebody's copyright.  You would think that professional organizations, like the American Psychiatric Association (APA) would support this idea.  Like everybody else, they produce downloadable PowerPoint slides for their major journals.  If you read the small print, you are supposed to go to the CopyRight Clearance Center and pay a fee.  I paid a fee of $45 for a lecture to a class of 12 and $85 to lecture a class of 42.  That was to project the slide and include it in my PowerPoint for the day.  I currently give about 32 lectures a year.  Considering the reimbursement I get for the lecture, it is not a commercial presentation, and I have been paying lots of money to the APA for about 30 years - you would think I could get a break.  As the head a a great foundation, I would purchase the rights to several good resources like Blumenthal's Neuroanatomy Through Clinical Cases or Atlas' MRI of the Brain and Spine and make them freely available to any instructors of psychiatrists.

2.  Free neuroscience conferences - there need to be much better basic science courses to bring clinical psychiatrists up to speed on the latest neuroscience and how it applies to the field.  Typical conferences are centered around some clinical activity that most of us are doing anyway.  Do we really need to hear more about something that we are doing everyday?  Something that we know everything about including the usual limitations?  Why not expand back into a consciousness based discipline looking at innovative ways to conceptualize problems and solutions.  Neuroscience is critical to that and there are several very articulate voices in the area.  I would plan a conference every years that was free to psychiatrists for 2 - 4 days of neuroscience.  There is a lot of neuroscience out there and I would ask some of the top journals like Nature, Science, Neuron, Biological Psychiatry, and Molecular Psychiatry to submit a program of Neuroscience for psychiatrists.  I would award the grant competitively to the best submitted program.

3.  Free computerized psychotherapy and an affiliated institute of psychotherapy using computers - I previously posted about John Griest's work in computerized psychotherapy and its effectiveness.  The whole point of the post was to emphasize a significant source of non-medication based treatment that is essentially not limited by manpower requirements.  There are several groups who have implemented this already, but to my knowledge none of them are major U.S. health care organizations or managed acre companies.  The commonest managed care approach is to give everyone a non specific depression rating scale, call that a quality marker, and then put as many people on antidepressants as soon as possible.  There is enough IT available that a foundation could take the lead in this area, develop the programs, and accept referrals from psychiatrists across the country for specific types of computerized psychotherapy.   

4.  Free clinical workgroups -  I have posted on the University of Wisconsin Memory Clinics collaborative clinical network across the state that focuses on maintaining a high level of expertise in all of the cooperating clinics for the diagnosis and treatment of Alzheimer's Disease and other dementias.  There is no reason that model cannot be extended to Depression, Bipolar Disorder, Post Traumatic Stress Disorder, or Attention Deficit Hyperactivity Disorder.  When people talk about collaborative care, they are usually talking about a managed care model that marginalizes psychiatrists.  A recent post suggested that some of the promoters of the managed care model have challenged naysayers to come up with an alternative.  I am a naysayer to anything that resembles managed care and the UW model is definitely a competing model that emphasizes psychiatrists at the top of their game in diagnosing and treating mental disorders.  That would be my priority over a managed care model that is so watered down, you don't even need a psychiatrist on the premises.

5.  An independent certification process - The American Board of Medical Specialties (ABMS) has a chokehold on all board certification processes with the exception of the American Board of Addiction Medicine (ABAM).  ABAM has their own certification and recertification process.  The current controversy involves the recertification process and whether it should be a standard blind exam with no learning aspects and a review of patients in a physicians practice or not.  I have posted some details about this to show how highly politicized it has become.  There is really no good evidence that recertification beyond the usual CME requirements is needed.  Although the American Board of Psychiatry and Neurology (ABPN) and the APA has gone along with ABMS ideas, most members find the process onerous and not conducive to learning, especially when they are in a labor intensive work environment that allows little time for study.  Any professional organization should be innovative enough to come up with an ideal process that would keep members up to speed professionally while not intruding on their limited time.  My foundation would develop a recertification system based on the APA's Focus journal an develop a process that would allow members to study on their own time and recertify by taking the Focus examinations.  It should eventually be possible to incorporate modules from the ongoing neuroscience seminars and what is learned in the computerized psychotherapy lab as study modules.

Using these innovations and hopefully more, my foundation would seek to improve the technical expertise of all psychiatrists, highlighting what is possible for the future and bring every clinician out of the current misery of political overegulation and managed care overproduction.  The whole idea that we currently have a professional organization and a specialty board that are not protective of psychiatrists is one thing.  The idea that they are actually doing things that are counterproductive to the ongoing professional education of psychiatrists and increasing burnout by creating a more stressfull practice environment is another.

My fantasy foundation would hope to reverse those trends.

George Dawson, MD, DFAPA

Preference for Psychotherapy or General Dislike of Medication?

I haven't see the study mentioned in many places yet, but there was a meta-analysis of patient preference for psychological versus pharmacological treatment of psychiatric disorders in the Journal of Clinical Psychiatry.  It contained all of the usual buzzwords about evidence based medicine and why this is a hot topic to study because of the possible cost savings and potential for better outcomes if preferences were matched to actual treatments.  Interestingly, in the same month a more high tech approach to matching depressed patients with pharmacotherapy versus psychotherapy came out in JAMA Psychiatry where the independent variable was a brain imaging result rather than patient preference.

The authors here looked at a final sample of 34 studies out of 644 studies that were screened.  They end up with a chart of effect sizes with confidence intervals for each of the 34 studies.  There were a total of 90,483 participants but 78,753 were included in one study.  All of the studies are of depression and anxiety.  They had tried to include studies on schizophrenia and bipolar disorder and found that they were not published.  The authors conclude that their meta-analysis was valid and that there was a consistent preference for psychological treatment in the treatment seeking and non-treatment seeking or recruited patients.  From this the authors suggest that patient prefernce should trump other considerations if the efficacy of both treatments are equivalent.  They question why medication related treatments have increased and psychological therapies have dimished over the past decade.  They suggest that the patients who prefer medication related therapies are non adherent.

In their discussion of the limitations of the study they find there was not enough data to compare combination therapy as a choice, they excluded non-published studies and therefore included potential publication bias, and they were not able to address the question about why psychological treatments were preferred over medication based therapies by a factor of 3:1.

These and other important questions have already been answered on this blog, but don't expect to see any publications on this anytime soon.  Managed care has taken the very evidence based treatments that these authors emphasize and stood them on their head.  I have written many times about the diagnosis of depression using rating scales and the preferred treatment of antidepressants.  If you are using a primary care physician follow up code and a PHQ-9 score result to diagnose depression in ten minutes and treat all of these patients with a generic antidepressant ($4/month) - there is no psychotherapy that compares to that low cost.

All psychiatrists who are actively looking for psychotherapists to treat anxiety and depression encounter the problems of a lack of qualified therapists and more specifically a lack of therapist time in managed care systems.  Managed care systems especially those that are actively managed to reduce outpatient mental health treatment has reduced available therapy in many systems to 2 or 3 sessions of crisis management and essentially limited or eliminated additional services like psychological testing that some therapists require to do their work.  It is no accident that patients seeking psychological therapy can't get it.  It is a conscious business decision.

The second problem is the lack of availability to research proven psychotherapies.  Any psychiatrist doing patient evaluations will hear the story that therapy sessions are often very non-specific, lack goals, and often result in the patient losing faith in the process and stopping the therapy.  Being seen in a psychological therapy is no assurance of a good outcome.  Many patients who are provided with excellent research proven therapy are frustrated with the time commitment and stop because of the cost or number of sessions.  Psychotherapy may look a lot better on paper than the reality of the relationship with the therapist and the logistics of getting to and paying for the sessions.

What can be done to improve the situation right now?  The decision to take a medication for any reason is never a casual one.  Taking that medication reliably is even more significant.  Non medication alternatives and combination therapies to reduce exposure to medications should be available in every clinic.  Instead of screening everyone for a medication on day one, non-medication alternatives should be presented at that time.  There are innovative non-medication therapies such as computer delivered psychotherapy for depression, anxiety and obsessive compulsive disorder.  No clinic appointments.  The therapy is delivered online or by phone any time of the day or night.  With the appropriate implementation, these therapies could be offered as first line treatment to massive numbers of patients.  The human cost is so low they could essentially be made available across an entire health plan for free.  There is no reason why networks of therapy clinics cannot be linked to primary care clinics who see the majority of patients with depression and anxiety.  Any medication alternative can be discussed if the psychotherapy or non-medication intervention works.

From a research perspective if only 34 of 644 studies were suitable for inclusion in a meta-analysis, the problem is clearly not being studied very well.  I think it is important to ascertain patient preference for psychological, combination, pharmacological and other (eg. lifestyle change) therapies in all registered clinical trials.  In clinical practice, it is all part of informed consent for treatment.  I think it is the universal experience of physicians that most people prefer to not take medications.  The negative treatment of psychiatry and  psychiatric medications in the press create an understandable bias against psychiatric medications relative to others as a potential source  of the described phenomenon.   There is some evidence that the advertising of these medications is different and potentially stigmatizing.  We also need better design of clinical trials.  If therapies are in fact equivalent, they need to be tested in actual clinical populations where psychiatrists work.  That includes severely ill patients with comorbidity, patients who are acutely agitated and suicidal, women and children and adolescents.  Much of the discussion of equivalent therapies is based on extrapolation from populations of people who are mildly depressed and in some cases who have enrolled in a number of studies.

This study highlights the current weaknesses in studying how people actually receive psychiatric treatment and how to best approach that from a research perspective.  It points out that we need much better research designs and better patient selection in order to answer even basic questions about the treatment process.  It should be apparent that a research design that is not adequate to describe clinical practice is not a commentary on clinical practice.

George Dawson, MD, DFAPA

McHugh RK, Whitton SW, Peckham AD, Welge JA, Otto MW.  Patient preference of psychological vs pharmacological treatment of psychiatric disorders: a meta-analytic review.  J Clin Psychiatry 2013; 74:6: 595-602.

Revolutionizing the Treatment of Anxiety and Depression

In a word - computers.

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

Andrews G, 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