You Are Always on My Mind

From the Editor

No, for a change, I’m not talking about the inundation from the 24-hour-a-day news. I’m thinking about psychotherapy and want to discuss 2 related things. The October issue of the American Journal of Psychiatry published 2 articles of major importance for those interested in strengthening the evidence base for psychotherapy.^1,2 Over the past 5 decades, for a variety of reasons, the training in and availability of psychodynamically focused psychotherapy has been diminishing. Since the publication of the Institute of Medicine’s report on evidence-based medicine, the pace of the decline has increased. Why?

In large part the decline has occurred in association with several factors related to cognitive behavioral therapy (CBT) and psychoanalysis. The first is that a large cadre of CBT faculty expertise became available in training programs to broaden the reach of teaching that modality, and at the same time psychoanalysts were leaving academia. The second factor is that the more standardized clinical approach embodied in CBT practice made outcomes research for CBT much more easily done than for psychodynamic psychotherapy research. A further factor was significant resistance from psychoanalysts-of which I’m one, so I can say this-to engage in modern outcomes research. I bemoaned this some years ago in an article I published in the Journal of the American Psychoanalytic Association,³ which not surprisingly to me, had little impact.

For many years, Dr. Barbara Milrod has been on the forefront of attempts to rectify the imbalance of clinical outcomes research in psychodynamic therapy compared with CBT. In her current article, she highlights the difficulties in doing a good meta-analysis, especially one that deals with psychotherapy treatment outcomes.¹ These include ensuring not only similar diagnostic criteria and inclusion of patients across studies, but also more important for psychotherapy research, ensuring that clinical interventions are comparable within a study and across studies. Lack of such uniformity across studies has impaired high-quality meta-analytic studies analyses in many areas, but especially in psychotherapy.

It was, therefore, reassuring that her assessment of the Steinert meta-analysis was that it met a very high standard. Thus, Steinert and colleagues’ finding of essential equivalence between CBT and psychodynamic therapy was satisfying to me and many other psychodynamically inclined therapists-and was important for patient care. Milrod cites several other important studies that demonstrated positive outcomes for psychodynamic therapy, and there have been a number of others in recent years, mostly focusing on depression treatment.

The importance of the Steinert study is that it looked across diagnoses and used high inclusion standards for individual research reports. Yes, the sample sizes in the studies are small and the number of studies that could be included is small because so few met the high standard for inclusion in the meta-analysis, but this is an important contribution. And maybe this and similar reports to come will help slow the decline in the training of the next generation of clinicians in psychodynamic therapy.

The reality is that other individual studies such as the Driessen⁴ study that compared CBT and psychodynamic therapy show equivalence of outcome in depression treatment. But their finding that only about 25% of patients improved with either treatment, and the fact that no one else has thus far found any formula to help a clinician determine which treatment will be more likely to succeed in any one patient, means there is still a long way to go to convince payers in the US to more appropriately reimburse for psychotherapy treatment.

The slow advances in psychotherapy research, contrasted with decades of clinician experience that support clinical improvement with such treatment, pertain directly to my second topic. Over the summer, The New York Times reported on a major shift in support for psychotherapy as an essential clinical intervention.⁵ Unfortunately for our patients, at least for now, this didn’t come from the US but from the UK. Their National Health Service has embarked on what the Times called “the world’s most ambitious effort to treat depression, anxiety, and other common mental illnesses.”

And how are they doing this? By essentially making unlimited psychotherapy available free of charge at clinics throughout England when the patient’s clinical condition indicates it is a necessary treatment. The goal is to eventually expand this throughout the entire UK. And, the report notes, there was widespread publicity about the initiative, including a video from Princes Harry and William talking about their own struggles after the death of their mother, Princess Diana, as well as comments from Princess Kate. The clinical head of mental health for the National Health Service is quoted as saying that the project-and its attendant publicity-has already led to a reduction in stigma among Millennials.

The program’s origins go back just over a decade, when it started on a smaller scale. Of course, the first comment we’d hear from insurers and the government about this in the US is that we can’t afford it. But given that the World Bank’s analysis of the global economic burden of all diseases will have depression at the top of the list within a few years, the predictable costs of not providing adequate treatment for all of the most common psychiatric disorders are unimaginably high-not to mention the personal and societal costs, which are much harder to quantify.

Not surprisingly, the English program has been inundated with demand, although therapy is only generally available after an appropriate clinical evaluation. Their 1-month wait time for a therapy appointment has been a cause of great concern, but they should look at the situation in the US. We don’t have very good data on wait times here because we have such a decentralized system and can’t gather it. But I think in nearly every location in the US, the wait time to begin therapy is undoubtedly much longer. I do know that yesterday I evaluated about 10 patients in our clinic and thought at least half of them would benefit from immediate therapy. Of course, they will wait much, much longer than a month to begin.

There is little chance that such an important initiative would even be seriously considered on such a grand scale in the US in the foreseeable future. Aside from the usual stigma-related discrimination against psychiatric treatments, the inability to project the cost of this type of program is a major impediment. But the experiment in the UK is gathering clinical tracking data and will at some point have direct cost data, so a cost/benefit analysis will eventually be available. I’m pretty optimistic the data will show this type of program is worth the effort not only on economic, but also on quality-of-life measures. However, much more important is that with all the therapists practicing in the US today, demand already exceeds capacity. So who would deliver all that new care?

References:

1. Milrod B. The evolution of meta-analysis in psychotherapy research. Am J Psychiatry. 2017;174:913-914.

2. Steinert C, Munder T, Rabung S, et al. Psychodynamic therapy: as efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. Am J Psychiatry. 2017;174:943-953.

3. Tasman A. Beyond the single case study: it’s time to do our homework. J Am Psychoanalytic Assoc. 1997;46:669-672.

4. Driessen E, Van HL, Don FJ, et al. The efficacy of cognitive behavioral therapy and psychodynamic therapy in outpatient treatment of major depression: a randomized clinical trial. Am J Psychiatry. 2013;170:1041-1050.

5. Carey B. England’s mental health experiment: no-cost talk therapy. New York Times. July 24, 2017. https://www.nytimes.com/2017/07/24/health/england-mental-health-treatment-therapy.html. Accessed October 6, 2017.