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[the following is reprinted from the Houston Chronicle]
Managed care receives blame for overmedications
Therapists just use drugs to treat patients, some say By MARK SMITH
Copyright© 1997 Houston Chronicle
The emergence of managed mental health care is adding fuel to a long-simmering debate over the place of medication in psychiatric treatment.
Some psychiatrists charge that health maintenance organizations and other managed care plans pressure therapists to treat mental health problems with drugs alone rather than with psychotherapy, or a combination of drugs and psychotherapy.
They fear that patients, including children and teens, may be inappropriately medicated with multiple psychotropic drugs, without adequate oversight or follow-up care. Psychotropic drugs are those that alter the function of the mind, such as tranquilizers or antidepressants. Psychotherapy is traditional counseling, in which a clinician seeks to uncover and treat mental conditions through detailed conversations with a patient.
"Managed care companies tell us fairly often (that) if we don't start an antidepressant, they won't pay for a patient to stay a second day in the hospital," said Dr. Joe Woolston, a Yale professor of child psychiatry. "It is not unusual for me to see children on five or six psychotropic medications at the same time. There are thousands of kids all over the country on these drugs."
He said these combinations have not been studied enough to assess possible long-term health effects, especially on children and teen-agers who are still growing and developing. "No one has looked at what six medications can do in rats, let alone people,"
Woolston said. "Therapists are under increasing pressure to medicate in order to make things look better faster,"added Dr. Karen Shore, a psychologist and president of the National Coalition of Mental Health Professionals and Consumers.
Shore acknowledged that medication — including the multiple use of drugs known as "polypharmacy" — has a place in treating mental illness. "But in some instances," she said, "it just seems medication is used to make patients quieter, making everyone think things are OK."
Managed care officials responded that the debate about medication began years before the advent of managed care. They said managed care has become merely a scapegoat for other long-standing medical controversies. "Board certified psychiatrists are the ones writing the criteria for managed care companies," said David Redfield, chief operating officer of CORPHEALTH of Fort Worth, which handles managed mental health care along with various outpatient facilities and employee assistance programs. "Only state-licensed physicians may serve as the managed care reviewers to make a final medical decision."
The management of mental health benefits, he said, should be judged on clinical outcomes rather than the amount of therapy denied or granted.
"Managed care is not interested in getting less for people," said Dr. Ian Shaffer, chief medical officer of Value Behavioral Health Inc. of Falls Church, Va. "It is about accountability. ... The faster we can help them get better, the better we have all done our job."
But Redfield acknowledged that managed care companies recruit staff that conforms to their clinical philosophy. And managed care officials have said that many companies limit coverage for psychotherapy, often paying psychiatrists more to supervise drug treatment than to provide counseling. Pressure to choose drugs over therapy ranges from subtle to explicit, therapists said. Often, managed care reviewers — many of them social workers or nurses — walk a fine line. "They don't necessarily tell you to prescribe something in order to continue hospitalization, but it gets dangerously close to practicing medicine without a license," said Dr. Raymond F. Patterson, a vice chairperson on the Council on Psychiatry and Law of the American Psychiatric Association. "They'll suggest that if medication is not given, then perhaps continuous hospitalization is not needed."
"It's hard to resist (prescribing drugs) if a person needs to be in the hospital and acutely ill but the managed care company is pressuring,"said Dr. Stephen Pierrel, a Baylor College of Medicine professor of psychology. "My hope is people will resist."
Psychiatrists said they are often given only one session to evaluate a patient for medication. Follow-ups are limited to periodic 10- to 20-minute checks to review the dosages.
"All certain managed care companies want from me is to prescribe medication," said Dr. Milton Altschuler, a Houston psychiatrist. "It's intellectual prostitution to rationalize that, by giving medicine, the patients are at least gaining partial treatment," Altschuler said. "There is a problem if a doctor knows the child doesn't need the medication but gives him it to justify hospitalization."
Sometimes medicine is prescribed by nonspecialists. "Pediatricians and family practitioners are encouraged to prescribe psychotropic medication without the skills or time to do an adequate evaluation of the child," Woolston said. "They have increasing pressures not to refer to specialists."
Therapists also are troubled by their inability to monitor the effects of powerful psychotropic drugs on acutely ill patients.
"It takes 10 to 14 days to see the effects of psychotropic drugs," said Dr. Gary Miller, a Houston psychiatrist who served terms as commissioner of mental health and mental retardation for Georgia, New Hampshire and Texas.
Yet therapists fear that if they see patients too often or spend too much time with them, they may be removed from the panel of "preferred providers" that form the treatment network in some managed care programs. "On one hand you want to advocate for patients, but you don't want to be seen as a troublemaker," said Dr. Aaron Fink, a former president of the Houston Psychiatric Society. "You can get kicked off a panel of preferred providers."
Managed care companies send out "report cards" that encourage doctors to compare their use of therapy, hospital stays and medication with that of other providers in their network. Many doctors view this as intimidation. "There is a message that if you see any patient too much, you can be crossed off the patient provider list,"said Dr. David Kruzich, an El Paso psychiatrist. "They won't say you saw a patient too many times. They'll simply say: `Other people are more efficient.' "