Mental health care in the United States has changed over the last decade. Mark Olfson and Steven C. Marcus (3) analyzed data between 1998 and 2007 to describe those changes, with a special emphasis on psychotherapy. Several things have not changed— the overall percentage of persons using psychotherapy, who is most likely to receive psychotherapy (female, white, single, well educated, and unemployed), and the fraction of psychotherapy provided by psychologists or social workers. Several other things have changed, some dramatically: 1) the number of individuals receiving any mental health services (a 44% increase), 2) the percentage receiving psychotherapy alone without medication (a 34% decrease), 3) the percentage receiving medication alone (a 30% increase), 4) the mean number of visits per psychotherapy patient (an 18% decrease), and 5) expenditure per psychotherapy visit (a 23% decrease).
The economic data are striking when viewed on a national basis. During this period, expenditures for outpatient medical care, adjusted for inflation, increased 64%. Expenditures for outpatient mental health care increased 4%. However, this almost constant figure is composed of two radically disparate components: psychotherapy decreased 35% while nonpsychotherapy mental health services increased 98%. This means that expenditures for nonpsychotherapy outpatient mental health care increased at a greater rate than did costs for general medical care, while psychotherapy expenses decreased significantly.
In summary, individuals are receiving psychotherapy from the same provider mix with the same socioeconomic biases as in the past, but many more individuals receive nonpsychotherapy mental health services. The number of visits per psychotherapy patient, the cost per visit, and the percentage of mental health expenditures devoted to psychotherapy have all decreased significantly.
Olfson and Marcus have mapped dramatic changes in outpatient mental health care. Their study does not extend to causes, but they note a more than tripling of the number of individuals covered by managed care during this period. The most critical question remains unanswered: Has the cost-benefit ratio of mental health expenditures increased or decreased?