More Patients Receiving Psychotherapy Without Medication, Study Finds

White House Releases Budget Proposal; APA Continues to Monitor Process Today, the White House released its FY 2026 partial budget proposal that calls for $163 billion in cuts to federal spending in the next fiscal year. This includes a $1 billion proposed reduction in SAMHSA’s budget. This proposal lays out broad priorities and requests Congress to enact certain spending levels but does not spell out specific program reductions. APA is closely monitoring the budget process and will be working with appropriators in Congress to prevent cuts to these vital programs.

Between 2018 and 2021, the proportion of adults receiving outpatient mental health care that was solely psychotherapy rose, while the proportion of those taking only psychotropic medications declined, according to a study published yesterday in the American Journal of Psychiatry.

“Psychotherapy has long been viewed as a core clinical activity of mental health specialists,” wrote Mark Olfson, M.D., M.P.H., of the Columbia University Mailman School of Public Health and colleagues. “Between 1998 and 2007, however, there was a significant decline in the percentage of adult mental health outpatients in the United States who received psychotherapy either with or without psychotropic medications.”

Olfson and colleagues calculated national outpatient mental health care trends using data from the Medical Expenditure Panel Survey from 2018 to 2021, which included information on 17,821 outpatient mental health visits, including 6,415 psychotherapy visits. The data also included information on participants’ mental health conditions, such as depression, schizophrenia, and other disorders.

The estimated number of adults who received any outpatient mental health care increased from 11.2% in 2018 to 12.4% in 2021. Among this group:

• The percentage of patients who received psychotherapy without medications rose significantly from 11.5% in 2018 to 15.4% in 2021.
• The percentage of patients who received medications without psychotherapy dropped significantly from 67.6% in 2018 to 62.1% in 2021.
• The percentage of patients who received both medications and psychotherapy remained relatively stable (20.8% in 2018 and 22.5% in 2021).

There was a particularly notable rise in the use of psychotherapy only among patients treated for schizophrenia or related disorders—rising from 1.3% in 2018 to 16.6% in 2021; this rise was balanced by a significant drop in the percentage of patients treated with both psychotherapy and medications.

Olfson and colleagues noted that the largest single-year increase in the use of psychotherapy occurred between 2018 and 2019, so factors unrelated to the COVID-19 pandemic and the rise of telemedicine contributed to this trend.

The authors also found interesting changes in which health professionals were providing psychotherapy.

“Psychiatrists provided psychotherapy to a decreasing percentage of all psychotherapy patients, which may have increased the need for psychiatrists to refer patients to and collaborate with non-physician psychotherapists,” Olfson said in a news release. “At the same time, social workers and counselors, but not psychologists, assumed a larger role in providing psychotherapy.”

Olfson said this shift in providers may increase further following a recent change in Medicare reimbursement policy that allows mental health counselors and licensed marital and family therapists to bill for psychotherapy.

For related information, see the Psychiatric News article “Wither, Psychotherapy?”

(Image: Getty Images/iStock/Jacob Wackerhausen)

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Reduced Clozapine Monitoring During COVID Did Not Result in More Neutropenia or Discontinuation

Patients using clozapine for at least a year were not more likely to experience severe neutropenia or to discontinue the medication during the COVID-19 pandemic, when laboratory monitoring became less frequent, according to a report in Psychiatric Services.

Early in the pandemic, the Food and Drug Administration (FDA) removed penalties against health care professionals who were unable to meet the stringent laboratory monitoring requirements for clozapine. Then, in May 2020, an expert workgroup released a consensus statement suggesting that the frequency of monitoring could be reduced from every month to every three months for patients on continuous clozapine treatment for at least one year and no history of neutropenia.

(The FDA recently eliminated their requirements for clozapine prescribing but still recommend that clinicians monitor neutrophil levels according to prescribing information.)

Allison L. Little, Pharm.D., of the Corporal Michael J. Crescenz Department of Veterans Affairs (VA) Medical Center in Philadelphia, and colleagues analyzed data on 2,106 patients in the Veterans Health Administration who had been using clozapine for at least 12 months prior to March 2020; the study period was from March 1, 2020, to July 31, 2021. Clozapine discontinuation was determined to have occurred if the most recent clozapine prescription was coded as “discontinued” and no active prescriptions were listed in the medical record.

Little and colleagues also classified patients according to neutropenia status, with severe neutropenia defined as an absolute neutrophil count (ANC) of less than 500/μL. They further classified patients according to the length of their longest interval between laboratory monitoring: less than 30 days, 31 to 55 days, 56 to 90 days, 91 to 179 days, and greater than180 days.

On average, the longest ANC monitoring gap was 87.8 days, consistent with the consensus statement. No patients discontinued clozapine because of severe neutropenia. In fact, only one patient developed severe neutropenia, and after cessation and careful monitoring, that patient began a new trial of clozapine.

Moreover, the researchers found that longer intervals between ANC monitoring did not increase the rate of clozapine discontinuation. Overall, clozapine discontinuation for any reason occurred in 96 patients.

“More studies are needed to confirm the noninferiority of extended-interval laboratory monitoring for patients receiving clozapine,” the researchers wrote, but added that mental health providers should “consider these results to help bolster prescribing of this highly effective yet underutilized treatment option.”

For related information, see the Psychiatric News article “FDA Has Ended the Clozapine REMS. What Happens Now?”

(Image: Getty Images/iStock/Bacsica)

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