Pills Pushed For Mentally Ill -- Psychiatrists' Talks Wane As Main Treatment

NEW YORK - Forget the couch. Take a pill and we'll talk - maybe - in the morning.

Advances in powerful new medications are conspiring with managed care to reshape the way psychiatry is practiced, bringing the biological side of treatment - as opposed to the behavioral aspect - to the fore.

"As we work to contain health-care costs, psychiatry is being driven more and more toward internal medicine," said Steven Hyman, the government's top scientist in mental health. "People who want to practice psychotherapy exclusively will have to increasingly rely on individuals who can pay out of pocket - and that's a shame."

What this means is that the rich will get therapy, and the poorer, or uninsured, will get drugs.

Mental-health experts have always maintained that depression or schizophrenia is every bit as "real" as a fractured ankle or the flu.

"For so long, mental illnesses have been separated out in health policy based upon the belief they were not medical and not real," said Laurie Flynn, executive director of the National Alliance for the Mentally Ill, the nation's premier group representing families of people with serious mental disorders.

"Science has demonstrated that they are just as real as heart disease or cancer," she said.

But society's perception of these illnesses has been hazier. Depressions have been romanticized as the price for creativity and genius, while schizophrenia and anxiety disorders have been

stigmatized as signs of poor upbringing, character flaws, even possession by evil spirits. Psychoanalysis was the stuff of movies, "soft" science.

Also, insurers grew suspicious that patients complaining of "mental illnesses" were suffering no more than behavioral problems, adolescent angst or midlife crises.

"Everything from acute schizophrenia, to feeling unhappy, to gambling addiction, to drug addiction," complained Mark Ugoretz, president of the ERISA Industry Committee, a trade group representing American big business, about the things people wanted their insurance to cover.

But with the arrival of powerful drugs like Prozac, "hard" science entered the picture. The drugs brought with them impressive credentials from other fields - this was not the stuff of Woody Allen neuroses anymore. Medical schools began concentrating on teaching students about medications, driven in part by the high cost of training them in psychotherapy.

Yet studies have shown therapy and medication produce the same physical changes in the brain. In one study at UCLA, researchers put one group of patients with obsessive compulsive disorder, an affliction where patients get obsessed with imaginary anxieties, on medication and another on a "talk" treatment called cognitive behavioral therapy.

The medication worked faster than the therapy and was therefore cheaper. Both produced the same measurable changes in people's brains. Both treatments were effective.

If medication and therapy are effective, which should doctors pick? A powerful player has entered the picture to provide the answer: managed care.

"In the short term, behavior therapy was more expensive," said Sanjaya Saxena, a UCLA scientist. "But in the long term, if you don't give patients behavior therapy, they have to stay on the medication for years."

"This is something," he said, "that insurance companies don't understand."

Across America, patients and doctors are saying managed care is firmly driving psychiatry toward drug treatment.

"What's the role of the psychiatrist?" asked Dr. William Glazer, associate clinical professor of psychiatry at Yale. "The role of the psychiatrist in some situations has been narrowed to supplying medications."

In fairness, managed care is putting an end to endless therapy and sharply reducing mental-health expenses from almost a fifth of health-care costs to maybe a tenth.

"Costs are managed to avoid the Woody Allen syndrome," Ugoretz said. "He's been in therapy for 33 years. He has the luxury of retaining an `emotional trainer.' That may be fine for Woody Allen, who's very wealthy, but the health-care system in America can't afford it."

Even more important, managed care's triage system has meant that patients with serious mental illness are much more likely now to get care. The trade-off is that patients who want to "explore issues" increasingly must pay for it themselves. If managed care pays for such therapy, it will only be for brief periods.

"You want to improve yourself and feel better about the choices you've made in your life, you'll see someone for a few visits but not for a year," said Dr. Douglas Berv, a psychiatrist in New Haven, Conn., who has seen his psychotherapy practice rapidly shrink even as his drug prescriptions have increased.

"The question is," he said, "are those really health-related issues?"

Managed-care companies, at least the ones who aren't just looking to their bottom lines, are beginning to consider such therapy as part of their drive toward patient wellness and prevention of disease.

"Some of them cover people getting in touch with issues," said Donald Fowls, medical director of Options Mental Health, a behavioral health-care company based in Norfolk, Va. "It can be a life-enhancement type of thing, like exercise."