What We Want; What We Need; and What We Can Get

Just about every day I see patients in the general hospital in a crisis, often after suicide attempts. When I ask them if they’ve been to a psychotherapist, some of them say “yes” and that it’s not been helpful. Some of them indicate that therapy, in their experience anyway, was not much more than verbal hand-holding.

They can tell me what they want, which is almost always relief from their suffering. Many of them were looking for release from their suffering–the permanent kind of release that some think they want, but not really.

They got plenty of pills from their psychiatrists or even their primary care doctors, who think they know what their patients need. Pills often aren’t very helpful and they frequently try to die by overdosing on them. Do most people want medication? It turns out that a recent meta-analysis reveals that most patients want psychotherapy, not medication [1]. Whether or not they have access to evidence-based psychotherapy rather than verbal hand-holding is a different story.

If most patients want psychological treatments, why don’t more of them get it? I thought that the U.S. was the place where most people who want psychotherapy have access to it. It turns out that’s not true, either, according to a paper recently published in the American Journal of Psychiatry [2].  In fact, psychotherapy is more likely to be promoted in other countries, like Haiti, Brazil, Pakistan–the U.S., not so much. The author points out that psychological treatments are just as likely to alter the brain (as well as the mind) as medication. If we can’t get psychotherapy in America, how do underdeveloped countries make it available?

piggybankWho is deciding what we want, what we need, and what we can get? It probably has something to do with money.

1. McHugh, R. K., S. W. Whitton, et al. (2013). “Patient preference for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review.” J Clin Psychiatry 74(6): 595-602.

OBJECTIVE: Evidence-based practice involves the consideration of efficacy and effectiveness, clinical expertise, and patient preference in treatment selection. However, patient preference for psychiatric treatment has been understudied. The aim of this meta-analytic review was to provide an estimate of the proportion of patients preferring psychological treatment relative to medication for psychiatric disorders. DATA SOURCES: A literature search was conducted using PubMed, PsycINFO, and the Cochrane Collaboration library through August 2011 for studies written in English that assessed adult patient preferences for the treatment of psychiatric disorders. The following search terms and subject headings were used in combination: patient preference, consumer preference, therapeutics, psychotherapy, drug therapy, mental disorders, depression, anxiety, insomnia, bipolar disorder, schizophrenia, substance-related disorder, eating disorder, and personality disorder. In addition, the reference sections of identified articles were examined to locate any additional articles not captured by this search. STUDY SELECTION: Studies that assessed preferred type of treatment and included at least 1 psychological treatment and 1 pharmacologic treatment were included. Of the 644 articles identified, 34 met criteria for inclusion. DATA EXTRACTION: Authors extracted relevant data including the proportion of participants reporting preference for psychological or pharmacologic treatment. RESULTS: The proportion of adult patients preferring psychological treatment was 0.75 (95% CI, 0.69-0.80), which was significantly higher than equivalent preference (ie, higher than 0.50; P < .001). Sensitivity analyses suggested that younger patients (P = .05) and women (P < .01) were significantly more likely to choose psychological treatment. A preference for psychological treatment was consistently evident in both treatment-seeking and unselected (ie, non-treatment-seeking) samples (P < .001 for both) but was somewhat stronger for unselected samples. CONCLUSIONS: Aggregation of patient preferences across diverse settings yielded a significant 3-fold preference for psychological treatment. Given evidence for enhanced outcomes among those receiving their preferred psychiatric treatment and the trends for decreasing utilization of psychotherapy, strategies to maximize the linkage of patients to preferred care are needed.

2. Weissman, M. M. (2013). “Psychotherapy: a paradox.” Am J Psychiatry 170(7): 712-715.

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