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Psychotherapy Is Worth ItReview - Psychotherapy Is Worth It
A Comprehensive Review of Its Cost-effectiveness
by Susan G. Lazar (Editor)
American Psychiatric Publishing, 2010
Review by Robert Cohen, Ph.D.
Apr 19th 2011 (Volume 15, Issue 16)

Study after study has demonstrated that psychotherapy effectively treats mental disorders.  In recent years, new therapies have been shown to be effective for often intractable problems such as schizophrenia, borderline personality disorder and post-traumatic stress disorder.  In some studies for depression and anxiety, psychotherapy alone has been shown to be just as effective as medication, with longer lasting effects.

Yet in outpatient mental health, the use of psychotherapy appears to be in decline. The American Journal of Psychiatry recently reported that between 1998 and 2007, the number of patients in outpatient mental health settings declined by 17 percent, while treatment with medication increased. During this period, there was also significant decline in the number of psychotherapy visits patients received when they did enter talk treatment. 

In spite of its success, psychotherapy is assumed to be too expensive to be covered fully by insurance benefits.  Opponents of the Mental Health Parity Act—the law passed in 2008 that forbids insurance companies from restricting benefits for mental illness unless similar limits are placed on general medical  benefits—argued that making therapy more freely available would result in massive cost overruns. It is widely believed that once patients have freer access to psychotherapy, they will become involved in long, expensive treatments.  

The authors of Psychotherapy is Worth It: A Comprehensive Review of its Cost Effectiveness  argue that the stigma attached to mental disorder leads both insurers and the general public to see patients with mental disorder as "weak willed and self-indulgent."  Susan Lazar, the editor of this volume, states in the introduction: "...[A] psychiatric population that is viewed as weak and self-indulgent may be expected not only to seek psychotherapy services needlessly but to never want to end them."

To counteract this impression, the book provides an extensive literature review showing that psychotherapy not only helps those suffering mental and emotional difficulties, but does so in way that may actually reduce general medical costs and indirect expenses such as lost wages and disability payments.   And the research indicates that patients generally do not use psychotherapy wastefully.

The book is organized in chapters written by different authors who each focus on a major psychiatric problem, such as schizophrenia, anxiety, depression, substance abuse, and childhood emotional distress. In addition, chapters focus on the use of psychotherapy in chronic medical conditions and the particular utility of longer term psychotherapies. Each chapter follows a similar structure: studies are culled from treatment efficacy literature using searches of the Medline database;  relevant research is described and analyzed; and each chapter ends with a chart that helpfully summarizes relevant research.  A case example of effective treatment is provided for each of the mental health problems studied.

The book is addressed to policy makers, benefits providers, and therapists. Given the complicated material presented and the challenges of producing a consistent work by multiple authors, the book maintains a consistent format and tone.

Some of the results will be eye-opening, especially for therapy practitioners who may not be aware of the full effects of their work.  A study involving employees of a major corporation  that provided generous outpatient psychotherapy benefits found that total health care expenses per employee declined by $9 per month, even though the cost of the therapy increased by a third.  Another study found that providing psychotherapy led to an average decrease in absenteeism from 10 to 3 days a year, reducing the yearly cost of missed work days by $1,054 per employee.  Converging studies by several investigators studying borderline personality disorder show that the cost of providing extended outpatient and partial hospital therapy for these patients is easily recouped in savings in hospitalization and other medical expenses.  These studies did not measure the likely additional savings in increased work productivity. 

Contemporary attitudes suggest that improvements in mental health are likely to be derived from new miracle drugs.  But an international study of treatment for schizophrenia –a disorder for which a number of new medications are generally seen as being far superior to older formulations—found that adding psychotherapy provides significantly better outcomes than switching from older to newer drugs.  

While this volume covers the extant literature on the cost-effectiveness of therapy, often there is not enough research of this sort for particular disorders, such as Post-Traumatic Stress disorder.  The book thus also reports studies demonstrating that psychotherapy is effective, even if no data is available on cost savings.The reasonable assumption is that since effective therapy has been shown to reduce costs in some studies, any study demonstrating the therapy works also adds to the evidence that therapy is cost effective.  But this is purely hypothetical and additional research showing that therapy is "worth it" using direct measures of cost-effectiveness is needed.

The authors are aware that valuing psychotherapy because it reduces other medical expenses—a major focus of studies reported here—is a double-edged sword.  Yes, the findings regarding cost savings are welcome, but why does psychotherapy need to be justified because it reduces other medical care expenses?  This emphasis perpetuates the stigma associated with mental health problems which are not considered "real illnesses," so that improvement might not be considered significant unless it accounts for changes in "physical health." Fortunately, more recent studies attempt to measure effectiveness not just in terms of cost offset, but in terms of the quality of life achieved. 

The studies described in this book raise questions not addressed by the authors.  A variety of therapies have been shown to be "worth it" in various studies.  Does this confirm the often debated contention that all well-conceived therapies are effective because of common factors that transcend particular theoretical approach or specific technique?  Or would differences be found cost-wise if different therapies were measured against each other (only a few such studies are reported in the book).  As competition for health care dollars continues to be competitive, we can assume answering this question will become even more urgent. 

In recent years, insurance companies have limited reimbursement to short-term, symptom-targeted treatments that cost less than longer-term, more intensive therapies.  This is in part because much of the most methodologically rigorous research has involved short term cognitive behavioral treatments, which are easier to study due to their length and narrow focus on discrete symptoms. But critics have argued that these studies do not represent therapy as it is practiced in the real world, where patients' difficulties go beyond discrete symptoms to include more pervasive and longstanding personality problems.

No doubt insurance providers—who often focus on the immediate bottom line, even when the research suggests spending more now will save money later—will attempt to pay for as little therapy as possible.  Already, insurance companies are working to find ways around the parity act by restricting benefits without violating the law.

The question for the future, then, may not be if psychotherapy is worth it, but whether changes in the health care system will make it possible for patients to get the best treatment available, even when it's more expensive in the short run.  Common sense, as is meticulously documented in this volume, suggests this should occur.  Experience suggests, however, that such an outcome is quite unlikely.



Mark Olfson and Steven C. Marcus, National Trends in Outpatient Psychotherapy Am J Psychiatry 2010 167: 1456-1463  Dec 2010

Russell  Adams and Avery Johnson," Law Prompts Some Health Plans to Cut Mental-Health Benefits," Wall Street Journal, Dec 28, 2010


© 2011 Robert Cohen


Robert Cohen, Ph.D. is associate professor of psychology at Madonna University in Livonia, Michigan, where he also is director of supervision and training for the Masters of Science in Clinical Psychology Program.   He is also an associate faculty member at the Michigan Psychoanalytic Institute. Dr. Cohen practices psychotherapy with adults, children and couples in Ann Arbor, Michigan.



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