As long-time readers of World of Psychology know, there’s no easy fix to the convoluted, second-class mental health care system in the United States. People with mental disorders — like depression, anxiety, ADHD or bipolar disorder — are shunted away from the mainstream healthcare system into a patchwork quilt of “care” that varies greatly depending upon where you live, what kind of insurance you have (if you have any), and whether you want to pay cash for treatment instead of using your insurance.
It shouldn’t be this way. It shouldn’t be so hard to find a good treatment provider. It shouldn’t be so complicated to get integrated care from a single practice.
Why is it so hard to get good mental health treatment in the U.S.?
A lot of hype has gone around tiny wins in the past year — the gains of the Affordable Care Act, a few million thrown at states by the federal government that does little to make up for the loss of hundreds of millions over the past decade. Any chance to trumpet these tiny gains clouds the larger picture though — for most Americans, mental health treatment is still difficult to access.
And it’s no wonder. The country has suffered from too few psychiatrists for decades (going all the way back into the 1950s). The reason is twofold — psychiatry is a medical specialty (requiring nearly a decade’s worth of education), and the lowest paying one available. That hasn’t changed much in 50 years.
What has changed is the cost of medical school tuition. As education costs skyrocket, it becomes economically unviable to most to attend medical school in the U.S. and come out making a psychiatrist’s salary. The math simply doesn’t work. So until education costs come under control, we’ll continue to have too few psychiatrists in the U.S.
Unfortunately, in an article in The American Prospect, Amelia Thomson-DeVeaux points the finger at big bad pharma. She also focuses nearly solely on medication and psychiatrists — completely ignoring (except for one passing mention) of psychotherapy. You know, that same psychotherapy treatment that is often more effective than medications in the treatment of nearly any mental disorder.
Coaxing more psychiatrists out of medical schools will be no easy task. Students who want a high-paying job generally don’t turn to psychiatry; the median income for a psychiatrist is hundreds of thousands of dollars less than the salary for a surgeon or anesthesiologist.
But money isn’t the only reason why med students are turning up their nose at the specialty. Beginning with Sigmund Freud, psychiatrists used to emphasize talk therapy. The rise of big pharma changed all that. Insurance companies pay twice as much for a medication consultation than for a traditional therapy session. Now, many psychiatrists spend their days scribbling cocktails of anti-depressants and anti-anxiety medicines on prescription pads during 15-minute consultations.
What Amelia fails to mention is that medication appointments have always been shorter than psychotherapy appointments. A psychiatrist can do 2 or 3 medication appointments in one hour, whereas they can only do one psychotherapy appointment. As the New York Times noted in this 2011 article, “A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.”
Who, in their right mind, wouldn’t choose $150/hour over the $90/hour?1 Especially when you have those high medical school bills to pay back.
It doesn’t take a rocket scientist to see that prescribing medication is more lucrative than prescribing — or actually doing — psychotherapy for psychiatrists. This has less to do with “big pharma” and a lot more to do with the perverse insurance system in the U.S. that’s been designed by insurance companies to reward medication treatment over psychotherapy treatment.
Why? Probably because insurance companies are under the delusional belief that medication treatment is more cost-effective than psychotherapy treatment. I say “delusional,” because there’s a wealth of evidence in the literature to demonstrate how, for most disorders and most patients, this is actually the opposite of the truth.
Psychiatry is Not the Problem
However, I’d argue that the shortage of psychiatrists isn’t the biggest problem in getting good mental health treatment in America. It’s a symptom of the larger problem — the lack of integrated care.
Your physical and mental health are one and the same. Your body is impacted by what’s going on in your mind, and your mind (and mood) is directly impacted by what your body is doing. This isn’t new news, and it’s well accepted by the vast majority of researchers and practitioners in the field.
Separating them out into two separate treatment systems is a relic of a bygone era. It’s an arbitrary separation that no longer serves any purpose — and in fact, likely hurts people more by limiting access to care while providing uneven service.
One thing that’s needed is integrated, holistic care by a treatment team.2 Who all work together in the same practice and office, treating a reasonable total population that allows the entire treatment team to be aware of each patient’s circumstances and needs. This would be one huge step forward in getting better mental health care in our country.
Mental health treatment in America can be fixed. But it won’t be through the sad band-aid approach to care that passes for “treatment” today.
Read the full article: The ACA Can't Fix Our Mental Health Crisis
- This is my primary argument against extending prescription privileges to psychologists — they’ll follow in psychiatrists footsteps in forgoing psychotherapy and instead embracing the more lucrative medication-only appointments. [↩]
- It might be composed of a physician, a mental health professional (such as a psychologist or psychiatrist), and a physician’s assistant or nurse, as well as a nutritionist or dietician, social worker, and probably another specialist or two in there. [↩]