Dismayed by managed care's thrust toward squeezing psychotherapy out of the scope of practice of child and adolescent psychiatrists, the Assembly in its May 1997 meeting requested the development of a new task force, the Task Force on Psychotherapy. "Psychotherapy is such an important issue," says Larry Stone, M.D., President, "the Executive Committee responded within twenty-four hours to the Assembly's request."

The Task Force is chaired by Rachel Ritvo, M.D., who articulated the concerns of many Academy members at the Assembly meeting in San Diego. "Providing psychotherapy is a part of the core identity of child and adolescent psychiatrists, and should be a primary focus of the Academy's efforts to protect the profession from managed care organizations that hope to save money by making psychotherapy the purview of Master's level therapists," she said. "While medication evaluation and management are obviously valuable services," she added, "child and adolescent psychiatrists can and should do more."

Dr. Ritvo's sentiments were echoed by the Chair of the standing Psychotherapy Committee, Eva Sperling, M.D., who is also a member of the new group. "The psychopathology of children and adolescents is much more subject to developmental and family influences, and requires more specialized psychotherapeutic intervention, than is the case with adults," she wrote, with William Swift, M.D., in a recent letter to Virginia Anthony, Executive Director, requesting the formation of the Task Force. Mandate of the Task Force The mandate of the new Task Force is spans both service delivery and training.

Specifically, the Task Force is charged with: Determining the value of psychotherapy in the marketplace, and its place in residency training, in the profession of child and adolescent psychiatry; and Recommending a plan of action regarding the fostering the optimal participation of child and adolescent psychiatrists in the provision of psychotherapy in all healthcare settings, including training programs. Task Force members are reviewing the current status of psychotherapy in training, practice, and research, and assessing how financial and service delivery systems affect the provision of psychotherapy by child and adolescent psychiatrists.

Since the Task Force's efforts focus solely on child and adolescent psychiatry, they compliment the activities of the American Psychiatric Association's Commission on Psychotherapy by Psychiatrists, which addresses similar issues in adult psychiatry.

Psychotherapy Works
What makes the decrease in psychotherapy services by child and adolescent psychiatrists especially egregious, Dr. Ritvo says, is that there is growing documentation that psychotherapy is a safe, effective treatment. A sampling of only a few studies, for example, finds that:

• At the end of psychotherapy, the average treated patient is better off than 80% of untreated patients (1);
• Family therapy reduces the relapse rate in patients with schizophrenia to the same extent (50%) as antipsychotic medication (2);
• Results of the NIMH Treatment of Depression Research Program showed that short-term treatments were inadequate for most patients. In particular, work-impaired and perfectionistic patients require a longer course of psychotherapy for recovery (3,4,5);
• The expansion of psychotherapy coverage for the U.S. military dependents by CHAMPUS resulted in a net savings of $200 million over three years through reductions in psychiatric hospitalization. For every $1 spent of psychotherapy, $4 were saved (6);
• Even when psychiatric care is free, only 4.3% of the population uses outpatient psychotherapy, and the average length of treatment is 11 sessions (7);
• In addition to the scientific evidence, popular sources cite the effectiveness of psychotherapy. A Consumer Reports survey of 2,900 readers who received psychotherapy, for example, showed that longer length of treatment was associated with better outcomes, and worse outcomes were linked to insurance or managed care plans that artificially limited the frequency and length of the psychotherapy (8).

Many have argued that it is too expensive for child and adolescent psychiatrists to provide psychotherapy. "The idea that it's cheaper or more efficient to split treatment, with a child and adolescent psychiatrist providing medications, and a psychologist or social worker providing psychotherapy, is quickly being worn away by the evidence," Dr. Ritvo says. A report by two researchers at the Department of Psychiatry, State University of New York, Syracuse, found that compared with the cost of a psychiatrist providing both therapy and medication, which averaged $1008 [for 10 visits], split treatment cost $1168 with a psychologist, and $999 with a social worker (9). "Splitting treatment with a psychologist turns out to be far more expensive, and with a social worker, only $9 less, than comprehensive treatment with a child and adolescent psychiatrist," Dr. Ritvo says.

Training Issues Covered
Under the pressure of reducing costs in an increasingly competitive milieu, a number of major training programs are reducing what many consider already inadequate time and training devoted to the skills and techniques of psychotherapy. In fact, trainees themselves are increasingly voicing concern about being ill-prepared in this fundamental skill. "We must advocate for and protect training in psychotherapy," Ritvo says. "Experience with child psychotherapies of more than one year's duration in our residencies is crucial, both for understanding how psychotherapy works, and importantly, for allowing our trainees to see the interplay of psychotherapy and child development."

Member Feedback Sought
"Psychotherapy is an issue that touches the practice of every Academy member, regardless of their practice setting or philosophy," Ritvo adds. "This Task Force won't fly without the input of members, who are out there in the trenches and who know what is needed." Members can comment to Dr. Ritvo in care of the Clinical Affairs Department, clinical@aacap.org or 1.800.333.7636.

References

(1) Lambert MJ & Bergin AE: The effectiveness of psychotherapy. In Handbook of Psychotherapy & behavior Change, 4th ed. Bergman A & Garfield S (eds). New York: Wiley, 1994, pp. 141-150.
(2) Hogarty GE et al.: The environmental-personal indicators in the course of schizophrenia (EPICS) Research Group: Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of schizophrenia. II: two-year effects of a controlled study on relapse and adjustment. Arch Gen Psychiatry 48:340-347, 1991.
(3) Blatt S et al: Impact of perfectionism and need for approval on the brief treatment of depression: the National Institute of Mental Health Treatment of Depression Collaborative Research Program revisited. J Consul Clin Psychol 63: 125-132, 1995.
(4) Elkin, I: The NIMH Treatment of Depression Collaborative Research Program: Where we began and where we are. In Handbook of Psychotherapy & Behavior Change, 4th ed. Bergman A & Garfield S (eds). New York: Wiley, 1994.
(5) Mintz J et al.: Treatment of depression and the functional capacity to work. Arch Gen Psychiatry 49:761-768, 1992.
(6) Zients A: Presentation to the Mental Health Work Group, White House Task Force for National Health Care Reform, April 23, 1993.
(7) Manning WG Jr et al." How cost sharing affects the use of ambulatory mental health services. Journal of the American Medical Association, 256-1930-1934, 1986.
(8) Consumer Reports. Mental Health: Does therapy help? November, 1995, pp. 734-739. (9) Mantosh JD. Cost of Care by a psychiatrist versus split treatment. Presentation NR295, American Psychiatric Association Annual Meeting, 1997. ###

Reprinted from AACAP News, September-October 1997