I have talked about a lot of issues concerning mental illness in these blogs, but I have not so far talked about talk therapy. It is the gorilla in the room where treating mental illness is under discussion. Studies show that for a mental illnesses such as mine, depression, the best prognosis combines talk therapy with medications. But that is not the treatment most patients get, if they even have access to treatment. Treating with medications has become dominant and the role of the psychiatrist is often reduced to simply writing prescriptions. Like so many trends in medicine, this appears to be driven by cost.
I had my first major depression in the late 1980’s when I actually saw a psychiatrist twice a week and talked. I was fortunate in having two medical insurance coverages, through my husband’s and my own employers. But there was still cost and I remember as I sat in her office crying my heart out into a stack of Kleenexes that I needed to get my money’s worth. So there was no holding back. I took medication also, at a dosage so high my hands trembled, but it was the ability to talk to an objective stranger and have her help me with her questions understand why I was sitting there and accept what had led to my depression and change my thought processes about it. I eventually went off the anti-depressants and stopped see the psychiatrist.
Over twenty years later when I suffered another major depression the landscape had changed. I now see a psychiatrist once a month, one to whom I can thankfully talk, but my major talk therapy has been with my analyst, who without a medical degree is less expensive than the psychiatrist. I quite frankly see no distinction. Neither unfortunately participates in Medicare so I bear the cost. I take anti-depressants but without the talk therapy I do not think I would be where I am today. The cost has been worth it as I have had much more to work through.
I have been thinking about my experiences after reading an article in the New York Times that was looking at the finances of several families who had volunteered the information for an article about the middle class. I was struck by the fact that one family said that if there were extra money available in their budget, which there was not, they would use it for counseling. I give up things to pay for my talk therapy, but I am still able to include it in my budget. What about those who can’t?
Likewise, I have always lived in or near a large urban area and so finding mental health professionals has been a matter of finding the right ones, but 65% of rural communities have no access to a psychiatrist. What about them?
As the technology has become available, there has been a growing trend to do telemental health. There are two basic models—video conferencing and collaborative care in which mental health professionals consult with primary care physicians and which may involve uploading of videotapes of providers and patients, answers to questionnaires and the patient’s history. The studies seem to show that it can be just as effective as face-to-face. (see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662387/) Can this alleviate some of the problems involving the cost and availability? I would like to think so although there will be mental health professionals and patients not comfortable with it and there is still cost as the technology and time of the professionals is not free. But hopefully moving forward costs will go down and as demographics change both professionals and patients will be more comfortable with it. A most encouraging sign is that this year for the first time Medicare will pay for telemental health. We are moving into a new age.