The Combination of Drugs and Talk Therapy- Training Institute for Mental Health

This is a short piece I did for the newsletter for the Training Institute of Mental Health..

More and more, therapy is being drug based rather than talk based

Studies still show that a combination of the two is most effective for more people--however, as it usually does, it comes down to money-- health insurers would just rather pay for the drugs, period.

The Importance of Talk Therapy and its Combination

With Prescription Drugs

A radical change has come to the lives of medical psychiatrists and patients during recent years, as for medical insurance payments and other reasons, fewer and fewer pill prescribing psychiatrists offer anything more than rudimentary counseling to their patients.

An article in October 2011 in the New York Times focused on one psychiatrist in Philadelphia, ( a Dr. Levin) who now “ no longer gets involved with patients’ lives.”

The preponderance of all studies has shown that combination medical and talk therapy is often much more effective than either on its own, and the Training Institute now refers about 100 patients a year to psychiatrists who  mostly leave the talking to the therapists at TI…

Some people always liked just getting the pills and avoiding the stress involved in facing their feelings in talk therapy. However, as noted, this proved much less effective than when they also saw talk therapists.

For some people, doing yoga or other physical exercise is a substitute for talk therapy. There is not enough research available to tell how well this works out compared to talk therapy, but it seems to please many patients.

The Change in the Role of Medical Psychiatrists

The whole relationship between medical psychiatrists and patients has changed so much it leaves a lot of the doctors feeling uneasy…

To quote the NY Times article, interviewing Dr. Levin:

“I miss the mystery and intrigue of psychotherapy,” he said. “Now I feel like a good Volkswagen mechanic.”

“I’m good at it,” Dr. Levin went on, “but there’s not a lot to master in medications. It’s like ‘2001: A Space Odyssey,’ where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.”

The switch from talk therapy to medications has swept psychiatric practices and hospitals, leaving many older psychiatrists feeling unhappy and inadequate. A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since. Psychiatric hospitals that once offered patients months of talk therapy now discharge them within days with only pills.

Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, but fewer than half of depressed patients now get such therapy compared with the vast majority 20 years ago. Insurance company reimbursement rates and policies that discourage talk therapy are part of the reason. A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.

Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so they can often afford to charge less — is the reason that talk therapy is priced at a lower rate. There is no evidence that psychiatrists provide higher quality talk therapy than psychologists or social workers. “

The Training Institute’s referrals to medical psychiatrists cost about $100 ( much below market rates) with fewer follow ups and it seems to be working out fine, according to patients and therapists. ( NOTE to John McCaffrey: please elaborate more on how payment for medication prescription works).

Sigmund Freud, the father of modern psychiatry, himself referred to psychotherapy as “the talking cure.” While trained as a medical doctor, he didn’t use psychiatric medications, though some were being used then and continued to be for a long time

The use of “ psychometric medicine” has a long history….

Drugs used prior to 1950s included Opium, Bromides, Barbituates, Hysocne, Benzedrine, Amphetamine, Thyroxine and and sometimes sex hormones.

People were often institutionalized using only medicines like these…many of which are now no longer used or only rarely used. As noted, talking therapy was then brought in…but now the story has turned around again and institutions use less and less talking therapy, as noted
In the history of the development of psychiatrist, “heretic” psychiatrists like Sandor Ferenczi and Wilhelm Reich stressed either actual physical contact with patients ( impossible in today’s climate!), or, especially in Reich’s case, the use of special physical exercises and also sometimes the notorious “orgone box” which was supposed to capture energy and focus it on a patient.

Reich was more or less ostracized by the psychiatric community and eventually jailed for what the government felt were violations of the law ( apparently he may have even advised some people to use the orgone box as a treatment for cancer).

 “Wonder Drugs”

To skip way ahead, we can refer to the first really publicized popular “wonder drug,” Prozac….
Prozac is the registered trademarked name for fluoxetine hydrochloride and the world's most widely prescribed antidepressant to-date, the first product in a major new class of drugs for depression called selective serotonin re-uptake inhibitors. Prozac was first introduced to the US market in January 1988. It took two years for Prozac to gain its 'most prescribed' status.

Prozac works by increasing brain levels of serotonin, a neurotransmitter that is thought to influence sleep, appetite, aggression and mood. It was hailed as a “ wonder or miracle drug” and is still regarded as such by some people, though…

Other popular drugs have since been developed of course, and the sale of them has become an important part of the drug industry’s profits.

Conclusion

The Training Institute leaves the choice of medications to the consulting psychiatrists ( and the reactions of patients) and focuses on the “talking therapy” part of the program.

While there will always be new research developments for medications and probable “breakthroughs” ( as noted, Prozac is no longer considered by many as the panacea for treatment of depression as it once was) TI will continue to focus on Freud’s “talking cure” and its proven effectiveness.