Moving Forward While Standing Still: A Case of Mental Health Advocacy Evolving in the Time of COVID-19.

There have been shifts over time in the value placed on long-term psychotherapeutic modalities even though they can be life-saving. For example, the province of Ontario in Canada has been dealing with a government proposal put forward in 2019 to limit the length of psychotherapy treatment. In response, stakeholders from numerous groups came together to advocate for the importance of continuing unrestricted access to long-term psychotherapy. Approaches to this advocacy then had to unexpectedly adapt to the Coronavirus Disease 2019 (COVID-19) pandemic that came to the forefront in 2020 and will continue to develop in response to this changing landscape.

Clinical Necessity Guidelines for Psychotherapy, Insurance Medical Necessity and Utilization Review Protocols, and Mental Health Parity.

The founding members of the Coalition for Psychotherapy Parity present Clinical Necessity Guidelines for Psychotherapy, Insurance Medical Necessity and Utilization Review Protocols, and Mental Health Parity. These guidelines support access to psychotherapy as prescribed by the clinician without arbitrary limitations on duration or frequency. The authors of the guidelines first review the evidence that psychotherapy is effective, cost-effective, and often provides a cost-offset in decreased overall medical expenses, morbidity, mortality, and disability. They highlight the disparity between clinicians' knowledge of generally accepted standards of care for mental health and substance use disorders and the much more limited "crisis stabilization" focus of many insurance companies. The clinical trials that health insurers cite as justification for authorizing only brief treatment for all patients involve highly selected, atypical populations that are not representative of the general population of patients in need of mental health care, who typically have complex conditions and chronic, recurring symptoms requiring ongoing availability of treatment. The standard for other medical conditions reimbursed by insurance is continuation of effective treatment until meaningful recovery, which is therefore the standard required by the Mental Health Parity and Addiction Equity Act for mental health care. However, insurance companies frequently evade the legal requirement to cover treatment of mental illness at parity with other medical conditions. They do this by applying inaccurate proprietary definitions of medical necessity and imposing utilization review procedures much more restrictively for mental health treatment than for other medical care to block access to ongoing care, thus containing insurance company costs in the short term without consideration of the adverse sequelae of undertreated illness (eg, increased costs of other medical services and increased morbidity, mortality, and costs to society in increased disability). The authors of the guidelines conclude that, given appropriate medical necessity guidelines at parity with other medical care, consistent with provider expertise and a broad range of psychotherapy research, there would be no need or place for utilization review protocols. Individuals and psychotherapy organizations are invited to visit the website psychotherapyparity.org to sign on to the guidelines to indicate agreement and support.

The Place for Psychodynamic Therapy and Obstacles to Its Provision.

Psychodynamic treatment provides benefits for patients with personality disorders, chronic depressive and anxiety disorders, and chronic complex disorders, and its intensity and duration have independent positive effects. Obstacles to its provision include a bias privileging brief treatments, especially cognitive behavior therapy, seen as a gold standard of treatment, despite difficulties with the design of, and ability to generalize from, its supporting research and the diagnostic nosology of the illnesses studied. Another obstacle lies in insurance company protocols that violate the mandate for mental health parity and focus on conserving insurers' costs rather than the provision of optimum treatment to patients.

The cost-effectiveness of psychotherapy for the major psychiatric diagnoses.

Psychotherapy is an effective and often highly cost-effective medical intervention for many serious psychiatric conditions. Psychotherapy can also lead to savings in other medical and societal costs. It is at times the firstline and most important treatment and at other times augments the efficacy of psychotropic medication. Many patients are in need of more prolonged and intensive psychotherapy, including those with personality disorders and those with chronic complex psychiatric conditions often with severe anxiety and depression. Many patients with serious and complex psychiatric illness have experienced severe early life trauma in an atmosphere in which family members or caretakers themselves have serious psychiatric disorders. Children and adolescents with learning disabilities and those with severe psychiatric disorders can also require more than brief treatment. Other diagnostic groups for whom psychotherapy is effective and cost-effective include patients with schizophrenia, anxiety disorders (including posttraumatic stress disorder), depression, and substance abuse. In addition, psychotherapy for the medically ill with concomitant psychiatric illness often lowers medical costs, improves recovery from medical illness, and at times even prolongs life compared to similar patients not given psychotherapy. While "cost-effective" treatments can yield savings in healthcare costs, disability claims, and other societal costs, "cost-effective" by no means translates to "cheap" but instead describes treatments that are clinically effective and provided at a cost that is considered reasonable given the benefit they provide, even if the treatments increase direct expenses. In the current insurance climate in which Mental Health Parity is the law, insurers nonetheless often use their own non-research and non-clinically based medical necessity guidelines to subvert it and limit access to appropriate psychotherapeutic treatments. Many patients, especially those who need extended and intensive psychotherapy, are at risk of receiving substandard care due to inadequate insurance reimbursement. These patients remain vulnerable to residual illness and the concomitant sequelae in lost productivity, dysfunctional interpersonal and family relationships, comorbidity including increased medical and surgical services, and increased mortality.

The mental health needs of military service members and veterans.

The prevalence in active duty military service members of 30-day DSM-IV psychiatric disorders, including posttraumatic stress disorders and major depressive disorder, is greater than among sociodemographically-matched civilians. Only 23-40% of returning military who met strict criteria for any mental health problem in 2004 had received professional help in the past year. One-fourth of Regular Army soldiers meet criteria for a 30-day DSM-IV mental disorder, two-thirds of whom report a pre-enlistment age of onset. Both pre- and post-enlistment age of onset are predictors of severe role impairment which was reported by 12.8% of respondents. In addition, three-fifths of those with severe role impairment had at least one psychiatric diagnosis. The number of deployments, especially three or more, is positively correlated with all disorders, especially major depressive disorder, bipolar disorder, generalized anxiety disorder, posttraumatic stress disorder, and intermittent explosive disorder. Patients with posttraumatic stress disorder and major depressive disorder frequently have comorbidity with other psychiatric diagnoses and an increased death rate from homicide, injury, and cardiovascular disease, and are at increased risk of medical illness, smoking and substance abuse, decreased employment and work productivity, marital and family dysfunction and homelessness. Active duty suicides have increased from a rate lower than among civilians to one exceeding that in civilians in 2008. Suicides among veterans climbed to 22 per day in 2010 with male veterans having twice the risk of dying from suicide as their civilian counterparts. Associated extremely high costs of psychiatric illness in decreased productivity and increased morbidity and mortality can be ameliorated with appropriate treatment which is not yet fully available to veterans in need. In addition, Veterans Administration/Department of Defense treatment guidelines to date do not recognize the need for intensive and extended psychotherapies for chronic complex psychiatric conditions including personality disorders and chronic anxiety and depressive disorders. It has been suggested that treatment should be available for all military service member mental illness regardless of whether or not it predates military service, a goal which remains distant.

Obstacles to early career psychiatrists practicing psychotherapy.

Though psychiatric residents are expected to be competent psychotherapists on graduation, further growth in skill and versatility requires continued experience in their ongoing career. Maturity as a psychotherapist is essential because a psychiatrist is the only mental health provider who, as a physician, can assume full responsibility for biopsychosocial patient care and roles as supervisor, consultant, and team leader. Graduating residents face an environment in which surveys show a steady and alarming decline in practice of psychotherapy by psychiatrists, along with a decline in job satisfaction. High educational debts, practice structures, intrusive management, and reimbursement policies that devalue psychotherapy discourage early career psychiatrists from a practice style that enables providing it. For the early-career psychiatrist there is thus the serious risk of being unable to develop a critical mass of experience or a secure identity as a psychiatric psychotherapist. Implementation of parity laws and the Affordable Care Act (ACA) will affect the situation in unpredictable ways that call for vigilance and active response. Additional service and administrative demands may result from the ACA, creating ethical dilemmas about meeting urgent patient needs versus biopsychosocial standards of care. The authors recommend 1) vigorous advocacy for better payment levels for psychotherapy and freedom from disruptive management; 2) aggressive action against violations of the parity act, 3) active preparation of psychiatric residents for dealing with career choices and the environment for providing psychotherapy in their practice, and 4) post-graduate training in psychotherapy through supervision/consultation, continuing education courses, computer instruction, and distance learning.

Workplace effectiveness and psychotherapy for mental, substance abuse, and subsyndromal conditions.

While it is known that psychiatric illness and subclinical psychiatric illness can be very disabling, their impact on workers' productivity has been little appreciated or appropriately addressed. Complex variables are involved in fashioning an appropriate policy to ameliorate the impact of mental illness on productivity including the identification of effective treatments and potential negative effects of controlling patients' access to them. The cost-effectiveness of such treatments is considered from the differing perspectives and goals of the various stakeholders involved, including employers, insurers, and workers with psychiatric illness. Depression in workers leads to significant absenteeism, "presenteeism" (diminished capacity due to illness while still present at work), and significantly increased medical expenses in addition to the costs of psychiatric care. In addition to the specific usefulness of psychotropic medication, there are a variety of studies on the cost-effectiveness of different psychotherapeutic treatments that improve health and productivity in psychiatrically ill workers. Research indicates the usefulness of approaches including employee assistance programs, specialized cognitive-behavioral treatments, and brief and longer term psychodynamic interventions. It is clear that substance abuse disorders and especially depression and subsyndromal depression have a profound negative effect on work productivity and increases in medical visits and expenses. The current system of mental health care suffers from ignorance of the negative effects of psychiatric illness in workers, from a lack of subtle awareness of which treatments are most appropriate for which diagnoses and from the reluctance by payers to invest in them. Access to evidence-based appropriate treatment can improve the negative impact on productivity as well as workers' health. This article considers these issues and argues for a role of psychotherapy in the treatment of mental illness and substance abuse from the perspective of worker productivity.