Ari Zaretsky is chief of the department of psychiatry and vice-president of education at Sunnybrook Health Sciences Centre
Recent discussion about proposals to limit the individual frequency of psychotherapy sessions in Ontario has activated a lot of strong emotion, particularly from psychiatrists who devote part or all of their practice to the provision of psychotherapy. Norman Doidge’s piece in The Globe and Mail was a cri-de-coeur and a lamentation of what he perceived as a hopelessly misguided strategy by the government of Ontario to improve access to psychiatric care and induce psychiatrists to see more severely ill psychiatric patients who require a higher intensity of care.
Not every psychiatrist who values psychotherapy shares this perspective. At Sunnybrook Health Sciences Centre’s Hurvitz Brain Sciences Program, where I work, there is special expertise in providing comprehensive treatment for patients with complex mood and anxiety disorders across the lifespan. Most of my colleagues utilize some form of psychotherapy and strive to integrate psychotherapy into every interaction that we have with patients and their families. In this emotionally fraught debate, more nuanced perspective, based on a population health lens, is required.
Although cost savings from eliminating psychoanalysis and intensive long-term psychotherapy would be small in the scheme of the entire Ontario mental health budget, it is still important to choose wisely and emphasize value for money spent. There is no evidence that four to five sessions a week for five to seven years is significantly superior than weekly psychotherapy. With the $23,000-$30,000 a year saved from reducing four to five sessions a week to one session a week, the Ministry of Health could afford to invest in psychotherapy delivered by social workers and other regulated allied health practitioners. For every four psychoanalyses that are replaced with weekly therapy, one social worker could be employed to deliver psychotherapy for 40 patients for one whole year.
A recent, well-designed German research study published in January, 2019, in the Canadian Journal of Psychiatry involved chronically depressed patients on stable medication regimens. Some of these patients were randomly allocated to cognitive behavioural therapy (CBT) or to psychoanalytic therapy and some were deliberately assigned to either of these two treatments based on the patient’s personal preference. Although most psychotherapies overlap and depend on common factors such as empathy, support and the therapeutic alliance, CBT is generally a time-limited model of psychotherapy that emphasizes skill acquisition and problem-solving in the “here and now,” whereas psychoanalytic psychotherapy emphasizes insight into patterns of behaviour that stem from the past. After a long course of treatment and follow-up, the authors found that both treatments delivered exactly the same degree of improvement in depression, regardless of whether the patients were arbitrarily assigned to their treatment modality (CBT or psychoanalytic psychotherapy) or simply chose their treatment based on personal preference. Even more striking was that CBT was as effective as psychoanalytic psychotherapy but was actually much faster and more cost effective.
An average of 57 sessions of CBT over the course of approximately one year delivered the exact same clinical outcome as 234 sessions of psychoanalytic psychotherapy delivered over four years. The implications of this study are huge. Previous biases by many psychotherapists about CBT being too superficial in order to effectively address chronic and complex “real world” problems are debunked by this study. Patients with complex problems do indeed need longer-term treatments; however, they likely do not require the same intensity of treatment that traditional psychotherapists have assumed to be the “optimum dose.” Although a drastic and arbitrary government limit of 24 sessions a year is not advisable, generally limiting psychotherapy to no more than once a week will permit some reallocation of resources to enhance access for more Ontario patients.
We also need to be much more innovative and bold and learn from Britain and Australia by investing much more in empirically supported and scaleable forms of psychotherapy delivered by well-trained social workers and other regulated health professionals. Although psychiatrists do have some special advantages when they integrate psychotherapy and pharmacotherapy treatment together, they do not have a monopoly on delivering effective psychotherapy. Some of the best psychotherapists that I have ever sent patients to were social workers and psychologists, not physicians.
One of the tragedies of psychiatry and medicine in general is that we fail to provide innovative health-care delivery solutions ourselves and instead wait for government to make these decisions for us. Psychiatrists need to integrate a population health lens to our work. If we do not do so soon in Ontario, we risk losing our autonomy and our ability to both shape and lead the delivery of high-quality mental-health care in this province.