Outliers in psych pay

[ellorie]

Not necessarily true. For many conditions, psychotherapy can be as effective as medication (milder depression, some anxieties). For conditions like Borderline Personality Disorder, therapy is entirely where it's at - medication is more for some symptom management and comorbid conditions - therapy is really the only chance at changing the core pathology.

 

I would also argue that those depressive episodes that remit that quickly are probably a different beast from the kind of severe recurrent depression that a lot of people battle.

 

I think there are definitely differences in what works for different severities and types of depression.

[rmorelan]

I'll bite. I really don't know much about psych but what evidence is there that CBT or other talk therapies are more efficacious than time? I just read a meta-analysis that showed that something like 30% of major depressive episodes spontaneously remit within 30 days or something.

 

Perhaps psychiatry has turned to pharmaceuticals because it works much better than talk therapy.

 

and yet SSRIs often take longer than 30 days to reach effectiveness - 2 to 8 weeks say. Thus they are not particularly useful in many cases either - by the time you seek help, by the time you get medication and it starts to work you are past the 30 day window. CBT can be effective in around 2 to 8 weeks as well.

 

The problem, if you want to call it that, is that the field is split between clinical psychologists that do all the talk therapy, and MDs as psychiatrists that are the only ones allowed to administer prescriptions. It is cheaper to pay the salary for the clinical psychologists than an MD to do the same work and thus MDs don't as a rule do CBT and thus are really not even properly trained in talk therapy. There is a natural division as such, and anyone's treatment demands a integrated team approach - and that division is growing I think.

 

In the long run CBT is a very, very powerful treatment that is often as good or better than SSRIs without the possibility of drug side effects - which are very real with these drugs. It may also be the closest we have to directly targeting the underlying problem in the brain and correcting it - which no SSRI will ever do.

 

For more extreme forms of depression likely multi-modal therapy is required anyway - there is no point being half assed about it - throw everything you have at it. Correct any underlying social issues, use CBT or equivalent and drug therapy all of which is tailored to the particular patient.

[ellorie]

Many psychiatrists that I know are practicing talk therapy to some extent, especially in the community. I think a lot of it depends on what additional training you choose to seek out.

 

The big advantage is that OHIP pays for psychiatrists and not for psychologists. So if you are poor and need psychotherapy, you need to either get into a hospital program or find a psychiatrist doing it.

[spontaneouscombustion]

I think most of the younger psychiatrists are more open to talk therapy than the older, "decade of the brain" generation. The attendings I worked with (young guys) were really interested in analytic psychology and also led their own DBT groups.

 

Its not as lucrative, but they found it far more satisfying. They were making more than enough money as it was anyways.

[youngdad]

and yet SSRIs often take longer than 30 days to reach effectiveness - 2 to 8 weeks say. Thus they are not particularly useful in many cases either - by the time you seek help, by the time you get medication and it starts to work you are past the 30 day window. CBT can be effective in around 2 to 8 weeks as well.

 

The problem, if you want to call it that, is that the field is split between clinical psychologists that do all the talk therapy, and MDs as psychiatrists that are the only ones allowed to administer prescriptions. It is cheaper to pay the salary for the clinical psychologists than an MD to do the same work and thus MDs don't as a rule do CBT and thus are really not even properly trained in talk therapy. There is a natural division as such, and anyone's treatment demands a integrated team approach - and that division is growing I think.

 

In the long run CBT is a very, very powerful treatment that is often as good or better than SSRIs without the possibility of drug side effects - which are very real with these drugs. It may also be the closest we have to directly targeting the underlying problem in the brain and correcting it - which no SSRI will ever do.

 

For more extreme forms of depression likely multi-modal therapy is required anyway - there is no point being half assed about it - throw everything you have at it. Correct any underlying social issues, use CBT or equivalent and drug therapy all of which is tailored to the particular patient.

 

Nicely put.

I hope this discussion continues.

Therapy is so inaccessible right now. Patients often have to wait months to see a therapist and then they have to pay out of pocket because their fees are not covered. In therapy, the relationship between the patient and the therapist is paramount, but because there are so few, patients rarely have a choice who they see. Even worse is when improperly trained psychiatrists think they know how to do therapy. It can be hideous.

Here's an interesting conversation with some experts on where psychiatry is going.

http://www.npr.org/2012/10/22/163409863/psychiatrists-shift-focus-to-drugs-not-talk-therapy

[leviathan]

The thing is, I've heard psychologists/psychiatrists are no better than laypeople at treating depression with talk therapy. I wonder if that's really true, never looked at the evidence myself but was told this by a clinical psychologist once. Maybe people just need someone to talk to, more than a particular kind of person.

[BigM]

The thing is, I've heard psychologists/psychiatrists are no better than laypeople at treating depression with talk therapy. I wonder if that's really true, never looked at the evidence myself but was told this by a clinical psychologist once. Maybe people just need someone to talk to, more than a particular kind of person.

 

I'm sure that won't be a hard and fast rule. You need to keep in mind that most psychiatrists don't focus on psychotherapy and won't have as much experience as a clinical psychologist as that is the main focus of their training and for a large part what they get paid to do day-to-day. Psychiatry training is largely in dealing with mental illness and the biological and psychopharmacology aspects of managing mental illness. If you do have a psychiatrist who focuses on psychotherapy and devoted a great deal of energy to training their skills then they are likely to be damn good at it. This would also allow the psychotherapy and medications to be handled by one individual who knows the patient well. The reason that this doesn't happen often is because it takes a long time, you can't see as many patients and you make less money.

 

This situation is similar to a physiotherapist claiming that they are better at providing MSK rehabilitation that a family physician, they should be, its a huge portion of what they do as a group of practitioners.

[leviathan]

I think you misread my post. I was talking about clinical psychologists, who are arguably the best (or at least equivalent) at non-pharmaceutical therapy, being equivalent to anyone off the street.

[BigM]

I think you misread my post. I was talking about clinical psychologists, who are arguably the best (or at least equivalent) at non-pharmaceutical therapy, being equivalent to anyone off the street.

 

Yep, I misread. I would need to see a lot of strong data from the clinical psychologist to support that claim. Interestingly I have come across a few studies showing that computer-based CBT modules have similar results to traditional CBT. If this turns out to be a viable solution it could completely change the mental health landscape as reliable access to CBT would be game changing.

[ellorie]

Yep, I misread. I would need to see a lot of strong data from the clinical psychologist to support that claim. Interestingly I have come across a few studies showing that computer-based CBT modules have similar results to traditional CBT. If this turns out to be a viable solution it could completely change the mental health landscape as reliable access to CBT would be game changing.

 

It bothers me that CBT is being touted as the biggest thing in psychotherapy. It's good but it's not the right fit for everyone.

 

Not saying that that's what you are implying - just an observation from the psychiatry teaching that I have had.