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FromDrug Benefit Trends®
Behavioral Health Matters Jay M. Pomerantz, MD [Drug Benefit Trends 12(11):2BH-3BH, 2000. © 2000 Cliggott Publishing Co., Division of SCP/Cliggott Communications, Inc.]
IntroductionThe current treatment paradigm enforced by managed behavioral health is short-term -- a few sessions to relieve symptoms and quick termination. This treatment model assumes that most emotional upset resolves quickly, especially with help. Patients may return for additional sessions if there is a recurrence of difficulty. The model further assumes that nonmedical therapists, available at a lower price than psychiatrists, should do the bulk of this work. Full psychiatric evaluation is reserved for those patients who do not improve with talk therapy. There may be urgent referral to psychiatrists for patients presenting an imminent threat of harm to self or others, or possibly requiring hospitalization (hallucinations, delusions, concurrent substance abuse, mania, and so forth).For some patients, this model works quite well, is cost-effective, and avoids the stigma of mental or emotional problems. "Counseling" is acceptable to "clients," whereas formal psychiatric treatment may imply the presence of serious problems or "mental illness." Even psychotropic medication can be added to the package, given the availability of relatively safe and efficacious SSRIs. The prescription most often comes from the patient's primary care physician. The problem with this ubiquitous conceptualization and treatment of behavioral health patients is that it mishandles many patients. Anyone who is chronically or intermittently ill will not receive proper care from a sequence of encounters with a variety of uncoordinated caregivers. Contrary to the claims of MCOs, case management usually adds just another player to the disorganized "treatment team." Since the focus continues to be short-term, who will get the treatment team back together again for the next go-around? Where does prevention and maintenance treatment fit into the short-term treatment algorithm? Before answering such questions, we should first define the extent of the problem. How many patients suffer from chronic or relapsing behavioral health syndromes? The count should include not just patients with schizophrenia or bipolar disorder but also those with major depression, dysthymia, panic disorder, obsessive-compulsive disorder (OCD), anorexia nervosa, bulimia, generalized anxiety disorder, social phobia, post-traumatic stress disorder (chronic), attention-deficit hyperactivity disorder, somatoform disorders, dissociative disorders, sexual and gender identity disorders, and all severe substance abuse and personality disorders. Actually, I have just listed most of the major diagnostic categories of DSM-IV (the diagnostic manual of the American Psychiatric Association). The major exception to the chronic and usually relapsing category is adjustment disorder, a frequent diagnosis, but one whose prevalence does not exceed the sum of all the other diagnostic categories. Could it be that the vast majority of what behavioral health providers treat are chronic or frequently relapsing conditions? Let us look at what the scientific literature shows about chronicity in 2 conditions arbitrarily chosen from the list: panic disorder and OCD.
Dr Pomerantz practices psychiatry in Longmeadow, Mass, and is a lecturer on psychiatry at Harvard Medical School in Boston. REPRINTED WITH PERMISSION
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