Blog | Monday, October 6, 2008

Is JAMA psychic?


Just two days after JAMA ran an article that found long-term psychotherapy works better than short-term for the complex mentally ill, Congress passed (and Pres. Bush signed) a bill that would effectively require many insurers to cover longer-term treatments.

So does JAMA have some sort of psychic on its payroll? (NEJM has already informed us there are psychic cats that can predict when people will die; perhaps JAMA has a psychic hedgehog that predicts the outcome of legislation?)

In all seriousness, this mental health parity legislation-- which was attached to a big bailout bill you may have heard about-- was a long time coming. To be clear, it doesn't tell insurers they must cover mental illness. It just says that if they already offer mental health coverage, it has to be equal to that of other medical coverage. In other words, treat schizophrenia like you would heart disease.

For years, mentally ill patients have paid higher copays and deductibles, and had lower visit limits, than people with other kinds of illness. This makes it difficult for internists to do anything with these patients other than write them a prescription, because doctors know that a referral to psychotherapy means a limited number of sessions-- if any at all. (An issue we addressed in a story about parity last year.)

Medication is useful, but research has shown the best approach for certain disorders, such as severe depression, is medication plus therapy. And the Oct. 1 JAMA study shows it can take quite a bit of that therapy to make a dent in complex disorders like depression and anxiety.

Specifically, the study found that patients who had at least one year or 50 sessions of psychodynamic psychotherapy were better off than 96% patients who had shorter durations of other therapies, including cognitive-behavioral and behavioral therapies. (Psychodynamic therapy focuses on the patient-therapist relationship-- not the same as the Freudian stuff.)

Study author Falk Leichsenring told the Washington Post that the ideal number of sessions varies by patient, but that most patients with acute distress will do well with 25, while those with chronic distress need about 50, and those with personality disorders need about 200.

Until the parity legislation, most insurance plans covered 20-30 sessions per year, at best.

So what do you think? Will you be more likely to refer your mentally ill patients to therapy, once this law kicks in on Jan. 1, 2010 (for most plans)?