As the U.S. healthcare system lumbers towards change, in part induced by the Affordable Care Act and in part by advances in our understanding of what constitutes best practice, it is essential to examine the evidence underlying our assumptions about effective mental health service provision.
For many years, the holy grail of research into integrated care was the search for the “cost-offset”. Put very simply, funders and insurors were reluctant to invest assets in integrated care unless it could be proven that the additional cost of providing such care was recouped in the form of lower medical utilization, and therefore lower healthcare costs. Psychologists working in integrated care argued that these linear formulations were not likely to reveal the true benefits of integrated care. For one thing, benefits of integrated care were unlikely to be achieved in the short time windows that actuaries used to perform standard cost-benefit analyses. Particularly for patients with chronic mental or physical disorders, we argued that the financial gains resulting from integrating care would not be apparent in the short run.
The SAMHSA article that leads off our newsletter provides welcome confirmation that, although the calculus remains difficult, integrated care service delivery can indeed save patients and our healthcare system money. How much is uncertain, but savings to healthcare delivery systems appear to be significant. As the percentage of the U.S. GDP spent on healthcare steadily inches towards 20% (far higher, as you know, than in other industrialized nations), we must look at every opportunity to make not just mental healthcare, but all healthcare, more efficient.
Similarly, we have for many years searched for evidence that combining common psychological interventions with medication would yield improved patient outcomes, with an associated reduction in overall cost of care. While the Scientific American article included in our “myth busters” section does not directly address this, it does point to a well-known but still troubling phenomenon that is specifically correlated with a healthcare system that relies excessively on the prescription of medication for treatment of common mental conditions. This is the well-acknowledged fact that for many years the psychiatric literature has consistently overestimated the benefit of psychotropics while underreporting the adverse side effects associated with these medications. Publication bias (suppression of studies with negative results) is not unique to psychiatry; psychological research is culpable here as well. But industry funded drug trials have persistently slanted results in favor of prescribed medication, in spite of the existence of government-mandated clinical trials registries and other protective measures.
I have argued that these undoubtedly true observations should not lead us to reflexively eschew pharmacological treatments, but they should lead us to stop reflexively prescribing them, as researcher Joanna Moncrieff argues in the Scientific American piece. The data are clear that combined treatments for most mental disorders, including psychosis, yield superior outcomes to unimodal treatments. Effect sizes for both pharmacological treatments and psychological treatments are disappointingly small, and it is to me doubtful to the point of improbability that we will ever devise any single pill or psychotherapy that is more than modestly effective in managing disorders that are chronic, complex, and highly idiosyncratic. We have, I believe, long labored under a false assumption I have labeled the “DSM tautology”—simply put, just because we can define a disorder with greater specificity does not mean that our treatments for it have greater specificity.
Combined treatments work. They often reduce the pharmacological burden a patient has to bear, and they generally result in improved functioning. Clinicians have been aware of this common sense outcome for many years, but in the past it was difficult to prove, often because either we did not use the correct methodology or because studies that did not show the superiority of pharmacological interventions were dismissed. This has led to a situation where the de facto treatment in this country for most mental conditions is pharmacological, in spite of accumulating evidence that this strategy is suboptimal. Integrating psychological services into a healthcare delivery system where medications predominate can, I believe, lead to the implementation of more effective clinical interventions. And effective interventions not only result in improved health but, as the SAMHSA study shows us, saves money as well.