Monday, October 13, 2008

A snap shot of my reality

Angst Is Rising, but Many Must Forgo Therapy


In the latest sign of the deepening economic crisis, more people are considering cutting back on their mental-health therapy, even as they become more stressed.

Across the country, psychiatrists and psychologists say they are seeing an increasing number of patients who are worried about paying for treatment. Some are reducing the amount of time they spend in therapy. Others are trying to negotiate a reduced fee. And, despite doctors' warnings that it can be detrimental, some patients are using tactics to make their medication last longer, such as taking half their dose.

"People are in a quandary," says Jaine Darwin, a psychologist who teaches at Harvard Medical School and has a private practice in Cambridge, Mass. "The economy is forcing them to decide, 'Do I give up my lifeline?'"

The developments come as Americans begin cutting back on a broad range of health care, ranging from preventive tests to prescription drugs. But studies show that in times of economic crisis, when people lose their jobs and insurance, they tend to reduce their mental-health care more readily than their general medical care, with consequences that can be dangerous. When the economy slides, suicides and psychiatric hospitalizations tend to go up, as people neglect to get treatment until it's too late.

More people are showing signs of psychological distress. In New York, some therapists are reporting an influx of clients from the beleaguered financial-services industry. And many doctors nationwide say that patients are talking more often of their concerns about losing jobs, homes and savings.

Lynne Brunello of Verona, N.J., has been struggling to keep paying for her daughter's eating-disorder treatments. Kristen, a 21-year-old college student, has been hospitalized twice in the past two years. She sees a psychologist twice a week and a psychiatrist and nutritionist once a month -- care that costs about $400 a week.

Ms. Brunello, a bookkeeper for a title company, estimates she and her husband have spent $80,000 on their daughter's care over the past couple of years. She says they have taken out a second mortgage on their home and have given up all luxuries, including vacations and evenings out.

Now, Kristen is worried about the future as the price of necessities such as gasoline and food have risen. "I have been thinking about sacrificing care, how it's going to have to happen if things keep going the way they are, because we can't keep paying $400 a week," she says.

Psychiatrists and psychologists are seeing patients of all types struggling to afford their care. At Massachusetts General Hospital in Boston, Mark Goldstein, chief of the division of adolescent and young adult medicine, says he's noticed some patients with eating disorders who may be trying to save money by calling to discuss their illnesses with him on the phone, rather than coming in for appointments.

Shorter Sessions

In New Rochelle, N.Y., Paul Greene, a psychologist who is a professor at Iona College and has a private practice, says he's seeing patients asking to cut back on the frequency of their visits. In Belmont, Mass., Carol Kauffman, a staff psychologist at Harvard-affiliated McLean Hospital, has allowed patients to schedule shorter therapy visits -- a half hour instead of an hour -- so they can pay half as much.

Help For Stressful Times

  • If you are suicidal or in crisis, call your therapist or a crisis hotline.
  • Do not reduce or stop taking your medication without your doctor's approval.
  • If you really can't afford your therapist's fee, ask for a reduced rate, based on what you can afford.
  • If your therapist cannot provide a reduced rate, ask for a referral.
  • A crisis hotline can help you find a therapist with a reduced feeor can steer you to community services.
  • Many pharmaceutical companies provide medications to people who cannot afford them, through their patient assistance programs.

Ankur Saraiya, a psychiatrist in Manhattan, says some of his patients are too embarrassed to talk about money, "so they will talk about the fact that they don't want to come in as often." He's offered to renegotiate his fee for people who no longer can afford it. "Many therapists have a dedication to their patients' well-being," he says.

April Jones, who lost her job as a paralegal last year, recently negotiated with both her therapist and her psychiatrist to continue treatment for her bipolar disorder at a rate she could afford. Ms. Jones, a single mother in Plattsmouth, Neb., had paid a $10 co-payment per session until her insurance ran out. After that, her out-of-pocket expenses jumped to $105 for her therapy appointments and $180 for her psychiatrist. She also had to pay for her medications out of pocket.

At first, Ms. Jones, 37, stopped seeing both medical professionals and even cut back on her medication, but her health quickly deteriorated. "I got depressed and lonely," she says. "I couldn't really do anything: The dishes and laundry piled up. I didn't have the energy to give attention to my kids."

Sliding Scale

She discussed her situation with her psychologist, who suggested she pay on a sliding scale, based on what she can afford. Her psychiatrist agreed to do the same. Now, she sees both her therapists less frequently, and pays just $5 for each session. She also applied to the patient assistance program at AstraZeneca PLC, and the pharmaceutical company now gives her her medication.

"It's degrading and embarrassing to have to ask for help," says Ms. Jones. But "it's definitely life or death," she says.

Experts say people with the most severe mental disorders will be the hardest hit if they encounter problems paying for treatment. "The 'worried well,' who do therapy for personal growth, will generally be OK," says Iona College's Dr. Greene. "The people who concern me are those for whom that therapy helps them to function and earn a living and be good parents."

Suicide and Recession

Research shows that suicides and psychiatric hospitalizations tend to peak at the lowest point of a recession, when unemployment is at its height. A smaller peak also occurs just prior to the economy falling into recession, when there is widespread uncertainty. "If you were to look at suicide graphically, it wouldn't be difficult to imagine that you would be seeing another economic indicator," says M. Harvey Brenner, a professor of public health at the University of North Texas Health Science Center, in Fort Worth, Texas, who has studied the relationship between recessions and mental health, primarily at Johns Hopkins University's Bloomberg School of Public Health.

Other research, most notably a Rand Corp. health-insurance study from the 1970s, has shown that when costs increase people are somewhat more likely to defer their mental-health care than their general medical care because they may see it as more discretionary. "You are more likely to forgo your therapy compared to your surgery or chemo," says Harold Pincus, vice chairman of the department of psychiatry at Columbia University and a senior scientist at Rand.

A big reason is insurance. If people lose their jobs, they lose their health insurance. But even people with insurance may have trouble affording mental-health treatment, since therapy can be expensive and is not often adequately covered by insurance companies. Meanwhile, government and nonprofit resources for mental-health treatment are strained, with more cuts likely on the way as the economy slows.

Legislation meant to address at least some of these problems finally made it into law -- more than a decade after it was introduced in Congress -- when it was tucked into the Bush administration's $700 billion financial rescue package and signed by the president last week. The law, known as the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, requires most employers and insurers to cover mental illnesses just like other medical conditions covered by their plans. But experts say it's too early to know how the legislation will actually affect individual consumers.

Mental-health experts have advice for people who are struggling to afford treatment. First off, people who are thinking of hurting themselves should not curtail or stop therapy. Psychiatrists also advise people not to cut back on their medication without the supervision of a doctor.

"If you are in treatment, the first thing to do is to have a very frank talk with your doctor and with yourself," says Nada Stotland, a psychiatrist with a private practice in Chicago who is president of the American Psychiatric Association. "For example, are you buying a $5 coffee every day?"

If you really cannot afford your treatment, Dr. Stotland suggests asking your doctor if you can renegotiate the fee. Many therapists will agree to do that. "Doctors have a right to earn a living, but they don't have a right to abandon someone if they are in the throes of a disease," she says. Experts say some people can reduce their therapy appointments safely, under the supervision of their doctor.

If your therapist cannot reduce your payments, he or she may be able to refer you to someone who has a sliding-scale fee structure. Local and national crisis hotlines, such as the National Suicide Prevention Lifeline (1-800-273-TALK) can provide referrals to therapists who accept reduced fees, and to local community resources.

Write to Elizabeth Bernstein at

Corrections and Amplifications:

M. Harvey Brenner is a professor of public health at the University of North Texas Health Science Center, in Fort Worth, Texas. This article incorrectly said he worked at the University of North Texas, in Denton, Texas.

1 comment:

NobleKnits said...

Hi! Here's a stress buster for you! I've tagged you on my blog - so it's you're turn to share 7 things (some random, some weird) about yourself. It's fun!