Are We Overprescribing Pills and Underprescribing Therapy?

It is well documented that when people seek help for mental health issues, the best results often come from a strategic blend of medication and psychotherapy. However, a recent study published in the Journal of Pediatrics (2015) found that fewer than half of the children diagnosed with attention-deficit hyperactivity (ADHD) had received this combined approach to treatment. The outcome of this study has left many in the mental health community asking why.

Clinical Guidelines

The American Academy of Pediatrics (AAP) recently set forth updated clinical guidelines for the treatment of ADHD in children and adolescents. Because the long-term effects of stimulant medication on preschool-aged children is not fully understood, the AAP recommends the use of behavior therapy in lieu of medication for children ages 4 and 5. The AAP further encourages professionals and parents to try medication only after behavior therapy proves ineffective. Additionally, for children and adolescents between the ages of 6 and 18, the AAP prefers that U.S. Food and Drug Administration-approved ADHD medications are administered alongside evidenced-based behavior therapy.

It is not just the AAP that endorses the combined use of pharmacotherapy and psychotherapy, and the benefits are not exclusive to ADHD. The American Psychological Association’s Practice Guidelines Regarding Psychologists’ Involvement in Pharmacological Issues also states that, whenever possible, mental health professionals should consider the incorporation of psychotherapy whenever medication is prescribed. The APA even suggests that a positive therapeutic relationship can enrich all interventions, including medication.

What the Research and Experts Say

In a recent article published in Scientific American (2015), developmental behavioral pediatrician Dr. Adiaha Spinks-Franklin explained that medication can address the biological component of mental health concerns, but therapy improves outcomes by teaching coping strategies, social skills, and self-management.

Hundreds of studies have found that psychotherapy can improve a person’s quality of life when experiencing a mental health issue. According to an article published in The Journal of Family Practice (2008), two studies determined that a combination of cognitive behavioral therapy (CBT) and antidepressants was a superior treatment when compared to CBT or medication alone.

Furthermore, according to a resolution published on the APA website in 2012, psychotherapy is not only useful for improving a person’s overall well-being but it’s a cost-effective treatment as well. Some research findings from the APA resolution on the effectiveness of psychotherapy are summarized below:

• Psychotherapy results can last longer than pharmacological treatment alone. For example, psychotherapy provides people who experience depression or anxiety with skills that can be used long after treatment concludes, allowing for continued improvement.
• Multiple meta-analyses of psychotherapy studies indicate that including psychotherapy as part of a person’s treatment regimen can reduce overall medical expenses.
• A large body of research highlights the efficacy of psychotherapy for use with various populations and problems.
• Recent research findings suggest that concurrent use of medication and psychotherapy is efficacious for the following issues: childhood anxiety, adolescent major depression, major depression as experienced by adults, and pediatric obsessive compulsion (OCD).

Given all of this evidence, one might think that psychotherapy utilization would be through the roof. Alas, this is not the case.

Psychotherapy Obstacles

According to an article in Monitor on Psychology (2011), between 1998 and 2007 the percentage of people using psychotherapy alone or in conjunction with medication dropped, while the percentage of those taking medication alone for treatment increased.

Psychotherapists have a hard time competing with pharmaceutical companies when it comes to marketing expenditure and therefore struggle to get the exposure necessary to highlight the relative benefits of psychotherapy.

So, what are some of the obstacles that perpetuate this medication-only or medication-first treatment model rather than a combined approach?

One major impediment is marketing. Sit in front of the television long enough and you will come across at least one commercial for medication. Some believe that this level of exposure has contributed to the high volume of people seeking medication-only treatment. Critics argue that these commercials prompt self-diagnosis and superfluous prescribing of psychiatric medications. In addition, psychotherapists have a hard time competing with pharmaceutical companies when it comes to marketing expenditure and therefore struggle to get the exposure necessary to highlight the relative benefits of psychotherapy.

Another barrier is insurance coverage. Many insurance companies make it seem like paying for pharmacological therapy is easier than paying for psychological interventions. However, according to a survey conducted by the APA, only 4% of Americans know about the Mental Health Parity and Addiction Equity Act of 2008. This legislation requires that insurance companies provide mental and behavioral health coverage that is equal to physical health coverage.

Two more obstacles that impact the implementation of psychotherapy are access and convenience. In some rural areas, psychotherapists are not as accessible as they might be in urban areas. Socioeconomic status can also impact access due to the cost and availability of transportation to clinics and other mental health care providers. In some cases, it can be easier for families to attend one monthly med check versus multiple psychotherapy appointments. In addition to access, convenience plays a role. Some professionals theorize that the convenience of popping a pill is more attractive than attending therapy sessions, even when therapy is clinically indicated. Similarly, some medical professionals might feel it is easier to write a prescription instead of making a referral to a mental health care provider.

New Guidelines that Advocate for Psychotherapy

In order to combat these obstacles, the APA is developing an updated set of clinical guidelines that will not only advocate for the efficacy of psychotherapy, but will also serve as a resource for practitioners. In addition to presenting people and policy makers with evidence-based treatment options, the guidelines will inform those interested in therapy about the types of therapy available for their specific mental health needs.

References:

1. Attention-Deficit Hyperactivity Disorder (ADHD). (n.d.). In Center for Disease Control and Prevention. Retrieved April 25, 2015, from http://www.cdc.gov/ncbddd/adhd/guidelines.html
2. Clay, R. A. (2012, September 24). Advocating for psychotherapy.Monitor on Psychology, 42(8). Retrieved April 26, 2015, from http://www.apa.org/monitor/2011/09/psychotherapy.aspx
3. Has Psychotherapy Taken a Back Seat to Medication? (2012, September 24). InAmerican Psychological Association. Retrieved April 26, 2015, from http://www.apa.org/news/press/releases/2012/09/psychotherapy.aspx
4. Haelle, T. (2015, April 20). Meds Trump Therapy Recommendation for Treating ADHD.Scientific American. Retrieved from http://www.scientificamerican.com/article/meds-trump-therapy-recommendation-for-treating-adhd/
5. Hickner, J. (2008, November). Treat depressed teens with medication and psychotherapy.Journal of Family Practice, 57(11).
6. Practice Guidelines Regarding Psychologists’ Involvement in Pharmacological Issues. (n.d.). InAmerican Psychological Association. Retrieved April 26, 2015, from http://www.apa.org/practice/guidelines/pharmacological-issues.aspx
7. Recognition of Psychotherapy Effectiveness. (2012). InAmerican Psychological Association. Retrieved April 26, 2015, from http://www.apa.org/about/policy/resolution-psychotherapy.aspx
8. Resources on the Mental Health Parity Law. (2012). InAmerican Psychological Association. Retrieved April 26, 2015, from http://www.apa.org/helpcenter/parity-law-resources.aspx

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