Throughout my training in clinical psychology, I was taught that psychotherapy is for the mentally ill. I learned how to diagnose and treat people suffering from psychotic, personality, mood, and anxiety disorders, and those who were grappling with self-injury and suicidal thoughts.
I still draw heavily on my training when faced with patients in crisis, but this past year has made me realize that this narrow view may be costly and detrimental to mental health in general.
My office has been inundated with phone calls. Yes, the prevalence of mental disorders has increased substantially, and many inquiries have been from people with diagnosable conditions. But a sizable number of cases involved “adjustment disorders,” which are not mental illnesses. They are symptoms that occur in response to stressful life events.
I am delighted that my sessions with these people, all over Zoom, have been relatively inexpensive for them and have had good effects. In one instance, a middle-aged woman came in having experienced a single panic attack, thinking she was going “crazy.” Our 50-minute meeting focused on correcting her misconception, and she needed no further intervention. In another instance, I saw a young man who had started to feel significantly sad and lethargic for the first time. I helped him strategize ways to remain socially and physically active during quarantine, and he never slipped into clinical depression.
This is consistent with recent evidence suggesting that brief psychosocial interventions are highly effective for people with adjustment disorders.
Therefore, I envision a broader model for psychotherapy: People should be able to seek guidance from mental health professionals before they need a diagnosis. It should be the norm for all Americans to have an annual 50-minute psychotherapy well visit.
This approach is already practiced in many other areas of health care: It’s called prevention. The American Dental Association recommends that even individuals who aren’t at elevated risk of periodontal disease have dental well visits once or twice a year.
Preventive dentistry allows practitioners and patients to identify and deal with issues quickly and with minimal intervention. Cleaning teeth, checking gums for decay, and filling small cavities is better than waiting until it’s time for invasive and expensive procedures such as a root canal. Preventive psychotherapy could work in a similar way. It could help people recognize and cope with smaller emotional concerns, before the onset of depression, panic disorder, obsessive-compulsive disorder, or another mental health problem.
Patients could begin by completing self-report assessments (like the PHQ-9 for depression and GAD-7 for anxiety). These measures take just minutes to complete and help clinicians screen people for common mental health problems such as worry, social anxiety, panic, unwanted thoughts or obsessions, compulsive repetitive behaviors, alcohol/substance use, non-suicidal self-injury, and suicidal thoughts or activity.
With that information in hand, psychologists could also identify stressors in the patients’ lives such as finances, relationships, and work, and the patients could learn steps for dealing with them. For example, someone struggling with work-related stress could be trained to practice a two-minute mindfulness exercise each day. Someone in a strained relationship could be coached to raise their concerns in a loving manner with their partner, before issues become major impasses. People who feel sad, anxious, or worried could learn to recognize and accept their distress, so they don’t develop full-blown depressive or anxiety disorders.
I am not a politician, and I don’t work for a health insurance company, but from my vantage point, it seems that annual psychotherapy well visits could yield substantial cost savings in addition to their health benefits. The World Health Organization recommends early cancer screening not just because it’s humane and kind to save lives but because it cuts treatment costs. Routine screening for heart disease is even more financially beneficial, saving approximately $3,500 per patient and more for high-risk individuals.
Notably, neuropsychiatric disorders are the number one cause of disability in the United States, carrying $200 billion in direct costs and indeterminable indirect costs from lost productivity. In addition, total spending on mental health services is approximately $225 billion, which exceeds that for cancer care.
The most significant expense, however, is overutilization of the medical system, since many people with mental disorders present with physical complaints. Approximately 48 percent of all Medicaid dollars are spent on people with mental disorders, totaling $284 billion each year. This does not include sums spent by private insurers and corporations, or costs related to time taken off work.
Adding all those costs up, I estimate that if every American had an annual psychotherapy well visit at a cost of $90 per session, the program would pay for itself if it alleviated only 5 percent of the direct costs of medical illness in this country. And that’s even without factoring in the gains in productivity and reduced use of the medical system that could result. When President Joe Biden proposes enhancements to Obamacare, psychotherapy well visits should be an option for employers and states to include.
Beyond the economic and health benefits, psychotherapy well visits would help put an end to mental health stigma. Historically, mental distress has been a mark of disgrace and source of shame. For this reason, fewer than half of people with a diagnosable mental disorder receive professional help. Routine visits to a psychotherapist would normalize the mental health care.
I am not the first to advocate for annual mental health screenings. It has been suggested, for example, that primary care providers screen for depression during annual physical exams. But our society’s unprecedented openness to discussing mental health underscores the need for something more. Perhaps preventive psychotherapeutic care is finally within reach.
The isolation and trauma of the pandemic have taught us that managing our mental health is crucial. Do we really want to take the health of our teeth more seriously than the health of our minds?
David H. Rosmarin is an assistant professor of psychology at Harvard Medical School and founder of the Center for Anxiety in New York.