Monday, October 25, 2010


MANAGED CARE SHOCKER!   Imagine my surprise when I opened my mail and found a letter to me from AmeriChoice by UnitedHealthcare managed care insurance company telling me that psychiatrists were not referring enough of their depressed patients for psychotherapy (presumably to psychologists and social workers.  Nothing was said about psychiatrists doing the therapy themselves).

The letter went on to say that "evidenced-based medicine" has shown that the combination of antidepressants and psychotherapy is more effective than either alone.  This letter was almost as bizarre as another letter I had received not long ago from another managed care company telling me that Abilify or any other atypical antipsychotic medication is not the first choice in augmentation medicine for patients with major depression who do not respond to an antidepressant alone.  No sh*t, Sherlock!

The letter about psychotherapy, as well as the one about about misuse of certain brand-named drugs, is a sick joke coming from managed care, which joined forces with the pharmaceutical companies in the late nineties to try to destroy psychotherapy as we know it.  As I describe in my new book, managed care companies routinely paid psychiatrists a lot more for doing med checks than for doing psychotherapy. In response, psychiatrists stopped doing therapy for the most part, and they began to see medication as a cure all for everything and appropriate for everybody.

Then, mangled care companies started lying to their subscribers about how much psychotherapy was covered under their insurance plan.  In their reading materials, the companies might say that 20 sessions per year were covered, but then they would only certify 4 or 5 sessions as "medically necessary" and refuse to cover any more.  Therapists would then have to spend hours on the phone arguing with clerks about what treatments were medically necessary.  The clerks would try to intimidate the therapists.  Why, the therapist must not be very competent if he or she could not cure the patient in four or five sessions!

For the record, 20 sessions in most mainstream psychotherapy models is itself considered brief therapy, which is most appropriate for patients who are relatively high functioning, have at least some good relationships, and have a single, very well-circumscribed conflict to manage. Diagnositically, they would have only one disorder (no co-morbidity).  This type of case is today rather unusual because patients with anxiety or depression generally have behavioral and relationship issues as well.

In other words, brief psychotherapy works best for the so-called "YAVIS."  YAVIS means young, attractive, verbal, intelligent, and successful.  One might ask why such an individual would even need therapy in the first place.  And, of course, they tend to get better no matter what the therapist does.  For patients who are the most in need of psychotherapy - such as those with serious personality disorders, alcohol and drug abuse, and/or long term repetitive self destructive behavior - brief therapy accomplishes very litle.

After a while, mangled care insurance companies found out that it was not cost effective to hire clerks to argue with therapists, and they were also getting a bad name with employers who are the primary ones purchasing insurance.  I recall a managed care group losing a contract with Matel Toymakers in Southern California because they did not certify as medically necessary psychotherapy for patients who were referred for treatment by the company's own Employee Assistance Program (EAP)! 

So insurance companies quit that strategy and merely racheted down fees for ALL psychotherapists. 

This practice, they found, had a side effect that was just perfect for their ultimate bottom line. Suddenly, psychologists who never before had the slightest interest in prescribing psychiatric medication wanted prescribing privileges.  It was all an issue of money, and little else really. 

(The problem with psychologist prescribers, from this psychiatrist's point of view, is that psychiatric medications not only affect the brain, but may interact with all other organ systems, diseases, and non-psychiatric medications.  If you want to do it, IMO you should go to medical school.  Of four psychologists first trained in psychopharm by the Armed Services, two of them decided to do just that).

Instead of banding together to fight for their patients' needed access to psychotherapy, as well as for their own need to all get paid at rates comparable to other highly trained professionals, the American Psychiatric Association and the American Psychiatric Association got into a turf war over prescribing privileges.  I have come to believe that mangled care has devised a strategy to divide and conquer.  If they did, they were successful beyond their wildest dreams. 

And now they have the audacity to complain about psychiatrists and psychologists not working together, because it would actually save them money? This may seem self-serving coming from a physician, but it is true: Your friendly neighborhood health insurance carrier does not give a good God damn about their patients' mental health.                


  1. Abram Hoffer, M.D., Ph.D. had some interesting things to say about psychotherapy and the future of psychiatry -

    Insurance companies?
    Insurance companies?...

    Your friendly neighborhood psychiatrist knows nothing about mental health!

    Duane Sherry, M.S.

  2. My local neighborhood psychiatrists are not even friendly.

    Becky Murphy

  3. If you're trying to make psychotherapists look good and managed care look bad, I'm not sure invoking the YAVIS acronym is such a good choice. "YAVIS means young, attractive, verbal, intelligent, and successful." In the early '80's when I first heard it, it designated "patients" who psychotherapists, including psychiatrists who rarely prescribed anything but diazepam (Valium), preferred over those who really needed treatment but were more difficult and less interesting. In those days psychotherapists could still fill their practices with patients who probably were not mentally ill at all, sometimes several sessions per week, and paid very well by insurance, often for years and years, and generally for psychoanalytically based treatments.

    It was just this extravagance that motivated a psychiatrist at Four Winds psychiatric hospital to offer the first behavioral managed care program, I believe to the State of New York. This eventually became Preferred Health Care. And the rest is history.

    The YAVIS joke is really on greedy psychotherapists, not on managed care.

  4. Moviedoc-

    I know that the acronym was initially used, as you say, to make fun of psychoanalysts who catered to the rich and successful and avoided the tougher cases as "unanalysable."

    I find that the term is also useful to make fun of CBT therapists who overstate the results of their empirical studies, most of which exclude complicated patients as well.

    Managed care wants everyone to think that all patients are as easy to treat as a YAVIS and can be successfully treated ultra-brief therapy models. That is the point I was making here.