Cost-Effectiveness and the Role of Psychodynamic Psychotherapies
Abstract
In our increasingly cost-conscious medical environment, research literature on studies investigating and documenting the cost-effectiveness of psychotherapy has grown substantially. Unfortunately, due to a combination of stigma and lack of knowledge of studies on efficacy and cost-effectiveness of treatment—and despite the Mental Health Parity and Addiction Equity Act—insurance companies continue to resist providing adequate coverage for mental health care, particularly psychotherapy. This article discusses evidence of the added value of psychodynamic therapies for patients with personality disorders, chronic anxiety and depression, and severe, chronic, and comorbid disorders.
Inadequate treatment for all psychiatric patients is a hidden multiplier of morbidity, disability, and overall health care expenses. Compared with patients without psychiatric illness, chronically anxious, depressed and comorbid psychiatric patients have increased medical expenses beyond the costs of their psychiatric care, more primary care visits, higher outpatient charges, and longer hospital stays. A high percentage of those with psychiatric illness are never even diagnosed, and most of those who are receive inadequate treatment.
Studies show that a number of psychotherapeutic approaches have efficacy for different diagnostic groups of psychiatric patients. Recent research demonstrates that psychodynamic psychotherapies have a particular role in the care of patients with chronic depression, anxiety, personality disorders, and chronic, complex, and comorbid disorders. While some psychiatric patients may improve with relatively brief treatment, patients with these disorders often require more intensive and/or extended psychotherapy. However, most insurance companies are unwilling to pay for treatments that allow them to achieve a recovery that would yield savings from decreased medical expenses and improved productivity. Insurance companies tend to favor the lower cost of medication, which, by itself, is often not the most cost-effective or definitive treatment over the course of a severe, chronic illness. In fact, psychotherapy often provides a higher effect size than medication alone, augments the effect of medication, has lower dropout rates than medication-only protocols, and lacks the side effects of medication treatments.
Patients with personality disorders, affecting at least 30 million Americans, are often chronically impaired, costly to society, and unemployed. They have more suicide attempts, interpersonal difficulties, criminal behavior, divorce, child abuse, and heavy use of mental and general health care.
Cognitive-behavioral therapies (CBT), psychodynamic, and other specialized treatments for personality disorders are all effective, leading to reduced symptomatology, improved functioning, and decreased hospitalization. However, patients with personality disorders and other chronic complex disorders often have deeply ingrained maladaptive thought processes and behaviors—leading to impaired interpersonal relationships that constitute a highly significant risk factor for increased mortality, exceeding the risks from smoking, alcoholism, obesity, and hypertension.
While CBT-based treatments improve symptoms, studies show that long-term psychodynamic treatments are significantly superior in improving maladaptive interpersonal relationships. And while dialectical behavior therapy and supportive psychotherapy are helpful in diminishing symptoms of patients with borderline personality disorder, they do not address their core pathology (unstable relationships, primitive defenses, identity disorder, and boredom). Psychodynamic psychotherapy treats this core pathology more effectively, leading to broader personality changes. Patients treated with psychodynamic psychotherapy also maintain therapeutic gains better and continue to improve after treatment ends—the ”sleeper effect.”
Depression is the most common diagnosis in primary care, with a lifetime prevalence of 20.8 percent in the United States. Yet primary care physicians miss the diagnosis 50 percent of the time. Depression’s costs to society include increased medical costs and suicide-related mortality costs. Impairment from depressive disorders is the greatest cause of global disability, according to the World Health Organization. The 20 percent of depressed patients who are treatment resistant have significantly greater health care costs, are twice as likely to be hospitalized both for depression and general medical problems, have 12 percent more outpatient visits, are prescribed 1.4 to 3 times more psychotropic medications, and incur over six times the mean total medical costs and 19 times greater total depression-related costs.
For patients with unipolar depression, an extended course of CBT, dynamic psychotherapy, or a more intensive psychoanalysis all improve symptoms. Both psychodynamic and psychoanalytic treatments yield greater improvement in interpersonal problems with the best overall improvement provided by psychoanalysis. Other depressed patients with character traits such as perfectionism, with dysfunctional social and interpersonal patterns, or with residual depressive symptoms after a relatively successful brief treatment are at risk for recurring depressive episodes. Psychodynamic treatments have greater efficacy with these traits.
Depressed patients with personality disorders have more treatment-resistant, persistent, and recurrent depression and more role limitations due to emotional problems, impaired social functioning, and general health perceptions than patients with major depressive disorder alone. Depressed patients who function the worst and take significantly longer to achieve remission are those with comorbid personality disorder. Borderline personality disorder emerges as a robust and independent predictor of chronicity (accounting for approximately 57 percent of persistent cases). It is also the strongest predictor of persistence of major depressive disorder, followed by schizoid and schizotypal personality disorder, any anxiety disorder (the strongest Axis I predictor), and dysthymic disorder. From a cost-effective perspective, patients with major depression and a comorbid personality disorder need treatment for both disorders to avoid recurrent and persistent depressive illness. For these patients, psychodynamic therapies are more likely to achieve improvement in core pathology and interpersonal functioning.
Psychodynamic psychotherapies have also been found to be effective for anxiety disorders, eating disorders, substance abuse, somatic symptoms, and marital discord. Furthermore, studies of patients with a variety of common DSM-4 Axis 1 and 2 diagnoses treated with either long-term psychodynamic psychotherapy or psychoanalysis demonstrate large effect sizes for symptom reduction, personality change, and improvement in moderate pathology. These improvements are measurable both at termination and at follow-up. In addition, both psychoanalysis and long-term psychodynamic psychotherapy lead to reduced work absenteeism and lowered hospitalization at seven-year follow-up.
In summary, in a climate in which each health care dollar counts, providers and insurance companies should recognize the cost-effectiveness of psychotherapy for many psychiatric patients and the specific advantages of psychodynamic therapies for those with personality disorders, chronic anxiety and depression, and severe, chronic, and comorbid disorders. ■
References:
1. Lazar SG, ed. Psychotherapy Is Worth It: A Comprehensive Review of Its Cost-Effectiveness. Arlington, VA: American Psychiatric Association Publishing; 2010.
2. Lazar SG and Yeomans FE, eds. Psychotherapy, The Affordable Care Act, and Mental Health Parity: Obstacles to Implementation. Psychodynamic Psychiatry. 2014; 42(3).
3. Melek S and Norris D. Chronic conditions and comorbid psychological disorders. Seattle: Milliman; 2008.
4. Wang PS, Berglund P, Olfson M, Pincus HA, Wells KB, Kessler RC. Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry. 2005; 62(6): 603-613.
5. Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Twelve-month use of mental health services in the United States: Results from the National Comorbidity Survey Replication. Archives of General Psychiatry. 2005;62(6): 629-640.
6. Levy KN, Ehrenthal JC, Yeomans FE, Caligor E. The efficacy of psychotherapy: Focus on psychodynamic psychotherapy as an example. PsychodynamicPsychiatry. 2014;42(3): 377-421.
7. Lenzenweger MF. Epidemiology of personality disorders. Psychiatric Clinics of North America.2008;31(3): 395-403.
8. Gabbard GO. Psychotherapy of personality disorders. The Journal of Psychotherapy Practice and Research. 2000;9(1): 1-6.
9. Pilkonis, PA, Neighbors BD, Corbitt EM. Personality disorders. NE Miller, KM Magruder, eds. Cost-effectiveness of psychotherapy. New York: Oxford University Press; 1999: 279-290.
10. Reich J, Yates W, Nduaguba M. Prevalence of DSM-III personality disorders in the community. Social Psychiatry and Psychiatric Epidemiology. 1989;24(1): 12-16.
11. Skodol AE, Gunderson JG, Shea MT, et al. The collaborative longitudinal personality disorders study (CLPS): Overview and implications. Journal of Personality Disorders. 2005; 19(5): 487-504.
12. Hadjipavlou G, Ogrodniczuk JS. Promising psychotherapies for personality disorders. Canadian Journal of Psychiatry. 2010; 55(4): 202-210.
13. Linehan MM, Armstrong HE, Suarez A, Allmon D, Heard HL. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry. 1991;48(12): 1060-1064.
14. Bateman AW. Treating borderline personality disorder in clinical practice. American Journal of Psychiatry. 2012; 169(6): 560-563. doi: 10.1176/appi.ajp.2012.12030341
15. Bateman A, Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. American Journal of Psychiatry. 2009; 166(12): 1355-364. doi:10.1176/appi.ajp.2009.09040539
16. McMain, S. F., Guimond, T., Streiner, D. L., Cardish, R. J., & Links, P. S. (2012). Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: Clinical outcomes and functioning over a 2-year follow-up. American Journal of Psychiatry, 169(6), 650-661.
17. Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: A meta-analytic review. PLoS Medicine. 2010;7: e1000316.
18. Huber D, Zimmermann J, Henrich G, Klug G. Comparison of cognitive-behaviour therapy with psychoanalytic and psychodynamic therapy for depressed patients: A three-year follow-up study. Zeitschrift Fur PsychosomatischeMedizin Und Psychotherapie. 2012;58(3): 299-316.
19. Levy KN, Ehrenthal JC, Yeomans FE, Caligor E. The efficacy of psychotherapy: Focus on psychodynamic psychotherapy as an example. Psychodynamic Psychiatry. 2014;42(3): 377-421.
20. Levy KN, Meehan KB, Kelly KM, et al. Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology. 2006;74(6): 1027-1040.
21. Leichsenring F, Rabung S. Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis. Journal of the American Medical Association. 2008; 300(13): 1551-1565.
22. Leichsenring F, Rabung S. Long-term psychodynamic psychotherapy in complex mental disorders: Update of a meta-analysis. British Journal of Psychiatry. 2011; 199(1):15-22.
23. Shedler J. The efficacy of psychodynamic psychotherapy. American Psychologist. 2010;65(2): 98-109.
24. van den Bosch L, Verheul R, Schippers GM, van den Brink W. Dialectical behavior therapy of borderline patients with and without substance use problems: Implementation and long-term effects. Addictive Behaviors. 2002; 27(6): 911-923.
25. Clarkin J, Levy K, Lenzenweger M, Kernberg O. Evaluating three treatments for borderline personality disorder: A multiwave study. American Journal of Psychiatry. 2007;164(6): 922-928.
26. Katon W, Sullivan MD. Depression and chronic medical illness. J Clin Psychiatry.1990;199(1): 15-22. Jun;51 Suppl:3-11; discussion 12-4.4.
27. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry. 2005;62(6): 593-602.
28. World Health Organization. Depression, fact sheet. 2016
29. Crown WH, Finkelstein S, Berndt ER et al. The impact of treatment-resistant depression on health care utilization and costs. J ClinPsychiatry. 2002;63:963-71.
30. Blatt SJ. The differential effect of psychotherapy and psychoanalysis with anaclitic and introjective patients: The Menninger Psychotherapy-Research Project revisited. Journal of the American Psychoanalytic Association. 1992:40(3): 691-724.
31. Blatt SJ, Quinlan DM, Pilkonis PA, Shea MT. Impact of perfectionism and need for approval on the brief treatment of depression: The National Institute of Mental Health Treatment of Depression Collaborative Research Program revisited. Journal of Consulting and Clinical Psychology. 1995; 63(1): 125-132.
32. Fava GA, Ruini C, Belaise C. The concept of recovery in major depression. Psychological Medicine. 2007;37(3): 307-318.
33. Skodol AE, Grilo CM, Keyes KM, Geier T, Grant BF, Hasin DS. Relationship of personality disorders to the course of major depressive disorder in a nationally representative sample. American Journal of Psychiatry. 2011;168(3): 257-264.
34. Grilo CM, Stout RL, Markowitz JC, et al. Personality disorders predict relapse after remission from an episode of major depressive disorder: A 6-year prospective study. Journal of Clinical Psychiatry. 2010;71(12): 1629-1635. doi: 10.4088/JCP.08m04200gre
35. De Maat S, Philipszoon F, Schoevers R, Dekker J, De Jonghe F. Costs and benefits of long-term psychoanalytic therapy: Changes in health care use and work impairment. Harvard Review of Psychiatry. 2007;15(6), 289-300.
36. De Maat S, de Jonghe F, Schoevers R, Dekker J. The effectiveness of long-term psychoanalytic therapy: A systematic review of empirical studies. Harvard Review of Psychiatry. 2009;17(1): 1-23.
37. Beutel ME, Rasting M, Stuhr U, Ruger B, Leuzinger-Bohleber M. Assessing the impact of psychoanalyses and long-term psychoanalytic therapies on health care utilization and costs. Psychotherapy Research. 2004;14(2): 146-160. doi:35.1093/ptr/kph014
38. Berghout CC, Zevalkink J, Hakkaart-van Roijen L. A cost-utility analysis of psychoanaysis versus psychoanalytic psychotherapy. International Journal of Technology Assessment in Health Care. 2010;26(1): 3-10. doi: 10.1017/s0266462309990791
39. Berghout CC, Zevalkink J, Hakkaart-Van Roijen, L. The effects of long-term psychoanalytic treatment on healthcare utilization and work impairment and their associated costs. Journal of Psychiatric Practice. 2010;16(4): 209-216. doi: 10.1097/01.pra.0000386907.99536.75
