What's killing psychiatry?

Part 3

by Lisa Birk

The idea of managed care evolved in response to a crisis: in the mental health field, as in all health care fields, costs skyrocketed in the '70s and '80s. Doctors could charge whatever they wanted, and did. Patients could receive services indefinitely, or as long as their insurance company paid the bills. Psychiatrists had a financial incentive to prolong treatment.

Managed care reversed that. The financial benefit now lies in reducing the time spent in treatment. And though the details vary from one health care company to another, the principles do not. Health care companies control costs by means of two mechanisms: a gatekeeper and "capitation."

The gatekeeper, often not a trained therapist -- or even familiar with the tenets of therapy -- is a bureaucrat who approves, reduces, or denies a doctor's treatment plan. Capitation is a limit, or cap, on the amount of money allotted per patient per year. If the cost of a patient's annual treatment falls short of the cap, the company makes money. If it exceeds the cap, the company loses money. The equation is simple: less care means more profit.

The managed care system was designed to stabilize costs, and on that front it has succeeded. Nationwide, health care inflation, once in the double digits, was down to just 3 percent in 1996, according to the National Alliance for the Mentally Ill.

Locally, too, costs are down. Massachusetts hired a managed care company to run Medicaid mental-health care in 1992. The Medicaid mental-health budget is down 22 percent. The state anticipates an additional 15 percent decrease in the next few years. Private sector costs have followed a similar pattern.

What has allowed those savings, in part, has been a new generation of drugs based on advances in the understanding of brain chemistry. While business concerns were altering the way mental health treatment was financed, science was altering the way it could be administered.

The new drugs -- more effective than their predecessors, with fewer side effects -- were truly revolutionary. They were cheaper than talk therapy (a year of Prozac runs about $1000, whereas talk therapy with a psychiatrist costs several thousand more), and they could ameliorate symptoms very effectively. Depressed? Take Prozac. Anxious? Take Xanax. Schizophrenic? Take Clozaril.

The new drugs, to be sure, have spawned some miraculous stories. Dr. Joseph Coyle, chairman of the Consolidated Department of Psychiatry at Harvard Medical School, tells of one patient, a man from a lower-middle-class background who was the first in his family to go to college. His second year in medical school, he developed schizophrenia.

"We tried everything," says Coyle. "High-dose Haldol, low-dose Haldol, everything, but he just sat in his room. He was not alive for eight years. After Clozaril came out, we tried him on that. He woke up! Last I heard, he was finishing his Ph.D."

But Clozaril, like most drugs, has limitations. Roughly one-half to two-thirds of patients respond poorly. And even for those who do respond Lazarus-like, there are other issues. What does it mean to have a lifelong mental illness? How does the illness affect future possibilities in love and work? Studies show that the best outcomes for patients on medication are for those who also get talk therapy, who get help adjusting to their new self.

A 1992 National Institute of Mental Health study of depression and relapse showed that those who fared best received medication and talk therapy. Eighteen months after a 16-week treatment program, those treated exclusively with medication relapsed at a rate of 50 percent, while those who also received talk therapy had a 33 percent relapse rate. Still high, but significantly lower than the drugs-only approach.

The authors' conclusions? Talk therapy matters. And 16 weeks is not enough treatment for those with major depression. This at a time when many managed care companies permit just 20 appointments per year, and often authorize no more than eight. Is managed care costing more than it saves? A study designed to test that hypothesis would be massive and expensive. The answer is not yet known.

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Lisa Birk is a freelance writer living in Cambridge.