November 20, 2013

Are Patients Getting the Mental Health Care That They Want?

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R. Kathryn McHugh, PhD

McLean Hospital, Belmont, Massachusetts, and Harvard Medical School, Boston, Massachusetts


In the past decade or so, US mental health care trends indicated increases in the use of medication and decreases in the use of psychotherapy.1 These trends are puzzling when considering that, for many of the most common psychiatric disorders—such as anxiety disorders,2 depression,3 and insomnia4—psychotherapy is as effective as (and, in some cases, more effective than) medication. Both evidence-based psychotherapies (such as cognitive-behavioral therapy) and medications (particularly generic formulations) are also highly cost-effective.

In a recent study,5 colleagues and I found that these trends are also inconsistent with patient preferences for the treatment of depression and anxiety. Our meta-analysis found that people prefer psychotherapy over medication for depression and anxiety at a level of 3 to 1. Matching people to their preferred treatment not only is beneficial from a patient-centered care perspective but also appears to improve treatment outcomes. Those who receive their preferred type of care both stay in treatment longer and do better.6

Our study cannot answer the question of why this discrepancy between preference and treatment receipt exists. However, the availability of services almost certainly contributes to this issue. Psychiatric medication can be managed outside of specialty mental health care settings (such as primary care), which makes it far more accessible than evidence-based psychotherapies. Low insurance reimbursement rates for psychotherapy sessions may also serve as a disincentive for offering these services. Although the results of our study certainly suggest that many people prefer medication, our results also suggest that enhancing access to evidence-based psychotherapies may increase the likelihood that patients receive their preferred type of care.

Efforts have been made to increase the number of evidence-based psychotherapy providers available. For example, the Veterans Health Administration has trained large numbers of clinicians in recent years to improve access to evidence-based psychotherapies for veterans with posttraumatic stress disorder as well as other psychiatric disorders. However, access to psychotherapy in the US and internationally continues to be poor, with far fewer trained providers than can meet the demand or need for these services.

If connecting patients to their preferred care can enhance the likelihood of success, greater attention to making options available and to providing patients with information about their options may improve outcomes. The majority of those with psychiatric disorders do not receive any mental health care. Even fewer receive evidence-based care. The field has made enormous improvements in the development of evidence-based treatments for a number of psychiatric disorders. Although continued efforts to improve care and to develop novel treatments are clearly needed, the primary challenge to the field at this time is enhancing treatment access and choice for those in need.

Financial disclosure:Dr McHugh had no relevant personal financial relationships to report.


1. Olfson M, Marcus SC. National patterns in antidepressant medication treatment. Arch Gen Psychiatry. 2009;66(8):848–856. PubMed

2. Roshanaei-Moghaddam B, Pauly MC, Atkins DC, et al. Relative effects of CBT and pharmacotherapy in depression versus anxiety: Is medication somewhat better for depression, and CBT somewhat better for anxiety? Depress Anxiety. 2011;28(7):560–567. PubMed

3. Cuijpers P, Berking M, Andersson G, et al. A meta-analysis of cognitive-behavioral therapy for adult depression, alone and in comparison with other treatments. Can J Psychiatry. 2013;58(7):376–385. PubMed

4. Stepanski EJ. Hypnotics should not be considered for the initial treatment of chronic insomnia. J Clin Sleep Med. 2005;1(2):125–128. Correction in: J Clin Sleep Med. 2005;1(3):235. PubMed

5. McHugh RK, Whitton SW, Peckham AD, et al. Patient preference for psychological vs pharmacologic treatment of psychiatric disorders: A meta-analytic review. J Clin Psychiatry. 2013;74(6):595–602. Abstract

6. Mergl R, Henkel V, Allgaier AK, et al. Are treatment preferences relevant in response to serotonergic antidepressants and cognitive-behavioral therapy in depressed primary care patients? Results from a randomized controlled trial including a patients’ choice arm. Psychother Psychosom 2011;80(1):39–47. PubMed

Category: Anxiety , Depression , Insomnia , Mental Illness , PTSD
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10 thoughts on “Are Patients Getting the Mental Health Care That They Want?

  1. Correct observation. Availability and quick response are the two main points in favour of increased med use. This particular trend is more common in underdeveloped countries, for the same reason. Thanks.
  2. The study cited is a good beginning but I think more sophisticated one is needed to see how many subjects who say they prefer psychotherapy over medications actually continue psychotherapy week after week after week.
  3. It is my observation that pharmacotherapy has been seen as a “quick fix” by both the practioner and the clients because it is being promoted as such. This is the case in spite of the fact that many medications for the treatment for depression may take six to eight weeks to reach maximum benefit levels and that psychotherapies may provide benefits sooner than that. It is my observation that the pharmacotherapies have been”oversold” in this regard.
  4. Beyond the immediate benefits to those who prefer psychotherapy including avoidance of drug-drug interactions & side effects of drugs in general are the long term benefits.
    When psychotherapy is effective its benefits persist whereas med benefits often fade once medications are stopped. But given that insurance coverage so often changes from company to company one year to the next, insurance companies derive no long term benefit.
    Where there a universal single payer system, psychotherapy’s benefits for many patients with a wide variety of conditions would be better known, better reimbursed and far more widely available.
    Tom Rusk MD
    Maine, US
  5. Basically, it is a matter of three things:

    1) Simple easy work for the doctor, and easy reimbursement for the simple work.
    2) Simple easy answers for the patients, (even if they don’t work that well for many issues)
    3) Insurance companies prefer simple easy payments for (endless) band aids, not reparative surgery, even if the latter costs less in the long run.

    Now that said I am all for a major focus on meds for conditions like schizophrenia or the cases of (real) Bipolar Disorder. Beyond that the Medical Reductionism of the past two plus decades has been the holocaust of real mental health treatment.

  6. In my opinion both are necessary. The reasoning behind this is simple. A disturbing thought disturbs biochemistry of the individual experienced as disturbance in emotions. Medication can restore or neutralize this to some extent giving temporary relief. The persisting disturbed thoughts the causative agent has to be dealt with for which therapy is needed. This is the most crucial aspect where lots of confusion exists. The insurance companies are not able to credit it appropriately. A busy clinician goes for pills. The therapy takes the back seat. S.Krishnamoorti.M.D.
  7. I think we should go back to Psychoanalysis- 3Xa week for 2Hrs on the couch. Remember how popular it was and effective while half a million truly mentally ill were confined to State Institutions. How was it possible to sell it?
  8. In the developing countries, most of the Psychiatrists do not prefer psychotherapy for following reasons 1) It is time consuming 2) They are skeptic about its efficacy, and thus do not feel safe to charge huge amounts for the sessions (Which is mandatory/deserved for the effort put) for the fear that patients may question about its utility 3) They are more well trained in pharmacotherapy than psychotherapy 4) they do not want to lose the patients by referring the patients to a well trained psychotherapist 5) there is scarcity of well trained psychotherapists. So, often they resort to brief, eclectic or CBT in combination with psychotherapy and balance these two, in accordance with the patients’ wishes. Psychodynamic and Psychoanalytic therapies are rarely done

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