At a time when improved therapies are leading more people to be
treated for depression, mental health care advocates say doctors and health
insurance companies are pushing pills instead of counseling for emotional
illnesses, sometimes at the expense of the consumer.
Critics of managed care say that as a result of health care companies'
efforts to cut costs, patients routinely face obstacles while seeking
psychotherapy. Some give up trying -- with dire consequences.
"The for-profit managed care companies can only make a profit by rationing
(mental health) care," said Dr. David Byrom, president of the National
Coalition of Mental Health Professionals and Consumers.
Byrom said health insurance companies use ambiguous terminology in handling
mental health referrals, provide outdated lists of therapist networks and
severely restrict the number of sessions.
"It's unethical," Byrom said. "The result is increased anxiety in the
consumer at a time of stress. It's probably had some impact on people not even
following through."
LAWS GO ONLY SO FAR
Legislation has been passed to ensure that insurance consumers have similar
access to mental health care as they do to medical care, but Byrom said the
new rules have gone only so far, and the consumer is often left to fend for
himself.
"You really need people working out their own individual and marital
problems (in therapy) sufficient to return to a better level of functioning,"
Byrom said. "Instead, managed care's approach seems to be, 'Take 12 steps and
call me in the morning,' " referring to the Alcoholics Anonymous approach to
recovery. Many HMOs, he said, are referring patients to community groups such
as AA, which don't cost the company a dime.
Ann, a 55-year-old secretary from Oakland who asked that her full name not
be used, said she decided to pay a therapist out of pocket after failing to
get a referral for individual therapy for depression through her insurance
company, Kaiser Permanente.
Kaiser sent her to a psychiatrist who put her on Prozac and suggested that
she attend group therapy, neither of which, she said, helped her with the
insomnia, anger and depression she was suffering from a childhood trauma.
"It seemed like the psychiatrist's primary job was dispensing Prozac," Ann
said. "There was no mention of psychotherapy. I was sent to a group and
listened to other women's horror stories. It was really of no help."
BENEFITS OF TALK THERAPY
Since she began seeing her current therapist, she said, her anger has begun
to subside, and her mood has improved.
"I'm not sure if I would be here if it weren't for therapy," Ann said.
Research shows that a combination of psychotherapy and medication work best
to treat severe depression. But many psychologists have become increasingly
concerned with the trend toward prescribing medication as the primary means of
treating depression and other emotional problems.
Part of the reason for the increasing use of anti-depressants such as
Prozac, Paxil and Zoloft is that the medications have milder side effects than
their predecessors, said Dr. Charles Faltz, director of professional affairs
for the California Psychological Association.
"The drug companies reap the profits from sales of medication, and
consumers want them," Faltz said. "They're asking physicians for these
medications, and in many cases they work. Still, for the health insurance
companies, controlling utilization seems to be more their focus than
maintaining quality.
"We really believe that there is good data to get back to a combination of
psychotherapy and medication. It produces a better result in the long run, at
a lower cost. Also, catching the patient at the earliest possible stage of the
disorder, you can help them get better and be on their way."
DEFENDING MANAGED CARE
A spokesman for Managed Health Network, the company that contracts to
handle behavioral health for Health Net (one of the largest insurance
providers in California), said its member surveys continue to come back
positive when it comes to evaluating mental health services.
Dr. Alan Savitz, a psychiatrist and corporate medical director for the
network, said new mental health parity laws have required that insurance
companies provide extended access to psychotherapy for major depressive
episodes. Somebody diagnosed with bipolar disorder, panic attacks, childhood
trauma or other severe disorders could have 50 to 100 talk therapy sessions
per year, depending on the situation, he said.
But coverage for most psychotherapy is under tight controls requiring
referrals, a specific plan and time limits, which Savitz said studies have
shown to be most effective.
"Indeterminate talk therapy -- the Woody-Allen-character approach to
therapy -- may be effective for self-actualization, but not for the treatment
of depression," Savitz said.
"We're certainly not limiting access. Every patient who calls and wants to
see a therapist sees a therapist in our network. Patient satisfaction is quite
high."
Arletta Cortright, a 49-year-old stay-at-home mom from Fairfield, said she
benefited greatly from Kaiser Permanente's mental health coverage when she
suffered a severe bout of depression after losing her father and best friend
to heart failure.
She witnessed her father die on a road trip to San Diego for her parents'
50th wedding anniversary in 1996.
Then in January 2002, her best friend, with whom she attended church, died
at age 49.
"It really threw me for a loop," Cortright said. "She was the same age as
me. She left two children and a husband. It was a shock to the church
community. She was the type of friend you could depend on for child care or to
help out with a favor on a moment's notice."
Cortright noticed she was having chest pains. "I was getting panicky. I had
a feeling like I was going to die."
After Kaiser doctors did all the physical tests and they came up clear,
Cortright's primary-care doctor referred her to a psychiatrist, who met with
her weekly and suggested that she try an antidepressant.
"I've seen a big difference," she said, adding that she continues to see
her therapist once a month. Her doctor has also used eye movement therapy, in
which Cortright is trained to substitute a positive memory for the painful
flashbacks of her father dying.
Herbert Klein, publisher of Psychotherapy Finances, a newsletter geared to
therapists, said you get what your employer pays for. Companies negotiate with
insurance companies, sometimes down to the number of therapy sessions that
employees are allowed.
"The whole system is pushing prescription medication," Klein said. "The
system is under financial stress, and as a result companies are ratcheting
down care."
E-mail Christopher Heredia at cheredia@sfchronicle.com.
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