Evidence-Based Mental Health Treatments: Lost in Translation

Earlier this month I attended a conference sponsored by the MacArthur Foundation spotlighting the intersection of mental health and public policy. In introductory comments for the event, Howard Goldman, Professor of Psychiatry at the University of Maryland School of Medicine and director the MacArthur Foundation’s Network on Mental Health Policy Research, called mental illness “an overlooked crisis.” He’s right. But contrary to what you might expect, it’s not just the public which overlooks mental health. Medical practitioners are often slow to adopt well-researched, proven mental health interventions—because they’re rarely profitable.

This is bad news for America, because mental illness is a big problem. Goldman noted that 38 percent of Americans who receive Social Security Disability Insurance have a mental disorder, as do more than 200,000 adults in prison and 30 percent of the nation’s homeless.

But mental illness isn’t just an issue for the have-nots. Jon Fanton, Ph.D., President of the MacArthur Foundation, addressed the conference after Goldman and offered some compelling numbers on the fiscal impact of poor mental health. Every year, said Fanton, mental illness amounts to $80 billion in indirect costs (lost productivity due to illness, premature death, and losses for incarcerated individuals and for individuals providing family care) and another $99 billion in the direct cost of providing care. Fully half of children with mental illnesses drop out of school.

For these reasons, said Fanton, the “interests of those in trouble are not in contrast to the interests of society and or the rest of us”—though “we tend to think…[that] the opposite is actually true.” In the end, mental health is a very public concern.

Given this fact, you’d think that health care practitioners would make it a priority to provide effective mental health treatment. But a 2005 study from the National Institutes of Mental Health (NIMH) and Harvard found that only one-third of mental health therapies received by patients meet minimal standards for adequacy as established in national guidelines. That means that when we know what works—and even draw up guidelines to define best practices—relatively few providers follow the rules. Why is it so hard to translate knowledge into practice?

Three academics—Robert Drake, M.D. and Jonathan Skinner, Ph.D from Dartmouth Medical School, along with Goldman—wrote an issue brief for the conference that looked at his very question. Their conclusion? It’s all about the money.

According to the authors, most effective mental health treatment regimes are not purely medication-based but also involve psychosocial intervention—that is, a program of cognitive and behavioral measures such as patient education, psychotherapy, and peer support. Unlike medication, which changes body chemistry, psychosocial treatments are focused on changing the way patients view themselves and their relationship to others and their environment.

By way of example, consider cognitive-behavioral therapy (CBT), a particularly well-researched kind of psychosocial intervention. The University of Michigan Depression Center (UMDC) offers an overview of how CBT would be applied to someone suffering from clinical depression:

“The first [component of CBT,] cognitive restructuring, involves collaboration between the patient and the therapist to identify and modify habitual errors in thinking that are associated with depression. Depressed patients often experience distorted thoughts about themselves (e.g. I am stupid), their environment (e.g. My life is terrible) and their future (e.g. There is no sense in going forward, nothing will work out for me). Information from the patient's current experience, past history, and future prospects is used to counter these distorted thoughts.

“In addition to self-critical thoughts, patients with depression typically cut back on activities that have the potential to be enjoyable to them, because they anticipate that such activities will not be worth their effort. Unfortunately this usually results in a vicious cycle, wherein depressed mood leads to less activity, which in turn results in further depressed mood, etc.

“The second component of CBT, behavioral activation, seeks to remedy this downward spiral by negotiating gradual increases in potentially rewarding activities with the patient. When patients are depressed, problems in daily living often seem insurmountable. In the final process, the CBT therapist provides instruction and guidance in specific strategies for solving problems (e.g. breaking problems down into small steps).”

Given CBT’s focus on self-esteem, perspective, and encouragement, it might come off as somewhat touchy-feely to the outside observer—but in fact it’s proven to be quite effective.

The UMDC notes that 75 percent of patients who undergo CBT show significant improvements. A 2000 NEJM study showed that the most effective depression treatment for adults is a combination of CBT and medication, which produced a response or remission in 73 percent of patients involved (versus 48 percent for CBT or antidepressants alone). A NIMH-funded study from earlier this month paints an even more flattering picture of CBT, showing that of 242 depressive teens, 74 percent who received medication-only treatment sustained improvement over 36 weeks, compared to 89 percent who received both medication and CBT—and a whopping 97 percent of those who only received CBT treatment.

CBT is clearly an important component of effective interventions for depressed patients—yet, relative to purely medicinal treatments, it’s proven unpopular. A 2002 JAMA study found that between 1987 and 1997 the proportion of patients who used antidepressant medication climbed by 38 points, while the proportion who received cognitive therapy dropped by nine points. Even as a greater share of patients received treatment in the form of prescription drugs, fewer received alternative interventions.

Even  though the FDA issued a warning about prescribing antidepressants to children in 2004—causing a dip in prescription rates—psychosocial treatments haven’t seen a boost. A 2007 study from the American Journal of Psychiatry found that, even though the proportion of diagnosed kids who went without antidepressants has increased “to three times the rate predicted by the pre-advisory trend” since the FDA warning, there is “no evidence of a significant increase in use of treatment alternatives” including psychosocial programs.

Why can’t psychosocial treatments seem to catch a break? “Unlike new medications, where the marketing of new practices is supported and encouraged by patents,” notes Drake et al. in their issue brief, “psychosocial treatments are not patented and therefore lack the economic incentives to promote them widely. Because it is difficult to market, doctors are less exposed to best practice strategies and consumers are often unaware of other strategies for treatment.”

Speaking about this issue in person during a panel at the conference, Drake didn’t mince words, noting that “no one makes a profit off psychosocial interventions, so they are used less often.” Moreover, a treatment like CBT is not quick and easy: it’s sequential, collaborative, and personalized. In short, it’s messy, labor intensive—and thus hard to sell. As one audience member pointed out during a Q & A session, “I haven’t seen any media that says ‘ask your doctor about peer supports…’”

Drake went on to note that, due in part to complexity of such interventions, less than 5 percent of people with a serious mental illness get access to evidence-based treatment—much of which includes interventions other than drugs.

No doubt much of the remaining 95 percent get prescription drugs. Lots of prescription drugs. “The products that are producing a profit for companies tend to be oversold,” said Drake before the audience. “This just gets worse and worse now that we have DTC [direct-to-consumer advertising], and now that the [prescription drug] industry has figured out that [it] can have very strong effects on doctors and other prescribers through a variety of [marketing] techniques.”

We now know that the drug industry spends more on advertising and marketing than it does on research and development; but there is only a limited number of dollars in the treatment pool, which means that the more medication is aggressively peddled, the “less money [we are able to put] in[to] other effective services.” The din of Big Pharma’s marketing often drowns out other voices—and other treatment options. 

Perhaps the worst part of all this is that the money that goes into medications is often wasted. It often funds drugs that, as Drake noted, are so poorly researched that “we find out years later that they are not as effective” as their manufacturers claim.

Here on Health Beat we’ve pointed out how drug companies distort statistics to make their products seem more effective than they really are, or how once-sacred assumptions—like the notion that everyone with high cholesterol should be on statins--—are in fact untrue.  In many cases the risks may outweigh the benefits. 

Unfortunately, similar tales of over-marketing exist in the mental health sphere. In their issue brief, Drake and his co-authors call attention to the case of second generation schizophrenia drugs (such as Zyprexa, Seroquel, and Risperdal), which target a different set of chemical receivers than traditional medications and which “were aggressively marketed in the early 2000s.”

“Prices for these medications were ten times those of the first-generation drugs—a key reason behind more aggressive marketing and sales,” the authors point out. “Consequently, expenditures for these second-generation medications in the United States rose to $2.6 billion in 2003, accounting for 71 percent of users and 93 percent of total expenditures for antipsychotics.”

But over the past few years, multiple “longer-term, well controlled studies found that the new second-generation antipsychotic medications are no more effective than the older antipsychotics.” Perhaps even more strikingly, a 2000 study in the Journal of Clinical Psychiatry found that CBT was just as effective as these newer schizophrenia drugs. In other words, billions of dollars were spent for nothing.

Thus the problem isn’t only that psychosocial interventions don’t get a lot of attention; it’s also that the medications that do get the attention—and the money—are often profoundly ineffective. Precious resources are sucked away from proven treatments and funneled to ineffective drugs.

It would be wrong to say that, were drug companies to become less aggressive, practitioners would leap at the chance to implement psychosocial interventions. The truth is that programs like CBT are labor-intensive and the overhead is expensive. Speaking at the conference, Drake noted that “well-researched interventions that are highly effective [tend to be] grossly under-utilized because they involve some start-up funds and reorganization.”

This is an easy point to understand. Research that proves a new drug is effective can garner a quick—albeit sometimes expensive—response from providers: prescribe the drug. But translating research on the efficacy of CBT into practice might require an organizational overhaul additional staffing, or the development of new therapy programs. These are not burdens that health care organizations are eager to take up.

In the end however, Drake notes that interventions with high up-front costs will actually save money “across years and over problems” by improving our aggregate mental health and reducing that gargantuan price tag of direct and indirect costs.

Yet like so much else in our health care system, the dynamics surrounding mental health treatments favor short-term profits over long-term solutions. And so “best practices” aren’t practiced.

Comments

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[Daniel Carlat, M.D.]

Overall, I do agree with the gist of your article here, but there are some fairly major factual errors which detract from the credibility of the posting. Marilyn Mann already mentioned the misuse of the 97% figure for teens sustaining improvement in the TADs study. Later in the post, you say: "Perhaps even more strikingly, a 2000 study in the Journal of Clinical Psychiatry found that CBT was just as effective as these newer schizophrenia drugs. In other words, billions of dollars were spent for nothing." In actuality, this study compared CBT with antidepressants, not with antipsychotics. CBT has, in some studies, been shown as effective as drugs for mild to moderate depression, but it has never been shown to be as effective as antipsychotics for schizophrenia.

[Marilyn]

The study of depressed teens was the Treatment of Adolescents with Depression Study (TADS). The teens were randomized to 1 of 3 treatments for 36 weeks -- Prozac, CBT, or both. By week 12, the combination group achieved the highest rate of sustained response (71%), compared to the Prozac-only group (68%) and the CBT-only group (42%). Of the teens who reached a sustained positive response by week 12, the following percentages maintained improvement through week 36: 89% of the combination group, 74% of the Prozac-only group, and 97% of the CBT-only group. The 97% for the CBT-only group is very good, but remember that is 97% of the kids who had responded by week 12, which was only 42%.

Marilyn Mann

[John Grohol]

Thanks for a great -- and timely -- entry. This isn't like to change any time soon, but it's good that at least people are noticing the problem....

[Chris Johnson]

And sorry about spelling your name wrong, Niko

[Chris Johnson]

Excellent. Nikko and Maggie, you two are rapidly turning your blog into the most thoughtful, best informed one in the health policy blogosphere.

[Beth W.]

Yes, you are correct, mental illness is an overlooked crisis, not only by the general public but also by the Medical practitioners. You have well exposed this problem in your Article. Thanks!
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Beth W.
Universal Health Care & Medical Tourism

Is it possible to create universal health through medical tourism? Or does it just create a brain drain that benefits wealthy travelers? Maybe it's too soon to tell.
http://www.healism.com/