PSYCHOTHERAPY: TOO EXPENSIVE NOT TO PROVIDE
SUSAN MCNAIR MD, FRCPC
I have a patient in my practice that I have being seeing weekly for several months. Together we work through problems he has had in the past week, with coworkers or family members or with his mood. He is increasingly capable of seeing how these small weekly miseries relate to the abuse and neglect he endured as a child.
My job is to listen intently, and to shine light more directly on the pain of this – a yawning chasm that, for years, he saw as unrelated to his present difficulties. I bill OHIP, the Ontario Health Insurance Plan, for each hour that he spends in my office.
When he first presented, he indicated that he had seen several physicians for anxiety and depression-related complaints, as well as vague and undiagnosed physical problems which had each been thoroughly investigated with blood tests and x-rays. He had daily suicidal ideation of varying intensity. He had had 2 month-long hospital stays, tried 5 different antidepressant medications with variable effects and side effects, and had also had 2 courses of 12 sessions of cognitive-behavioural therapy which had been the most helpful interventions to date.
However, he still missed an average of one day a week of work, underachieved while at work due to anxiety, and had been on short-term disability 3 times in the past 5 years. Sometimes, to his embarrassment, his wife would also miss work to stay home with him, worried by how unsafe and unwell he seemed. “Defective”, he said, best captured how he felt about himself. He was planning to apply for a disability support pension, despite his high degree of educational attainment.
This patient (an example based on several patients I see) well demonstrates the high cost of mental illness. The economic impact of illness involves direct, indirect and human costs. Direct costs are those incurred to treat the illness and rehabilitate the patient. In this patient’s case, the cost of psychotherapy sessions are direct costs, as are his 2 previous hospitalizations, prescription medications, investigations for physical symptoms, and previous psychotherapy. Many studies would also include his income support from short term disability and the disability support pension as direct costs.
In 2011 in Canada direct costs of mental health care were estimated at $42.3 billion (1). Outpatient appointments for interventions such as psychotherapy account for only 8.5% of this total figure. Community services (27%) and income support (22.9%) dominate, with inpatient hospital care (16%) and prescription medication spending (15%) close behind (1).
Indirect costs, by contrast, refer to the various losses sustained in productivity due to illness. In this patient’s case, for instance, his missed work days, decreased productivity while at work, and his withdrawal from the labour market would all be reflected as indirect costs of mental illness. In addition, his wife’s loss of productivity as his caregiver would be reflected here as well. These costs are clearly more difficult to measure, but one established method is to estimate the hours of work participation lost and multiply this by hourly wages. Using this method, a 2012 study estimated that the Canadian economy may be losing almost $21 billion each year from lost productivity due to mental illness (2); an earlier 2006 study estimated lost caregiver productivity separately at almost $4 billion (3).
These are the figures that spell “emergency” most clearly to governments, as each productivity loss spells lower tax revenue and consequences for public finances.
Finally, human costs: the pain, distress and loss of enjoyment of life incurred by mental illness, which are at once the most difficult to estimate and the most clinically pressing. In economic terms, using a measure of disability-adjusted life years, this cost was estimated at $20.3 billion dollars in 2006 (3). In human terms, this means a tide of misery not expressible as a dollar figure. This is a mental health emergency for clinicians and, of course, for patients.
Professor Lord Richard Layard, a renowned economics professor and founder of the London School of Economics’ Centre for Economic Performance, spent most of his career tackling economic and GDP-impacting social issues in the UK such as unemployment and poverty. But in more recent years he has turned his attention to the problem of mental illness. He used his influence in academics and government to call for improved access to psychological therapies covered by that country’s National Health Service, under the aptly named “Improving Access to Psychological Therapies (IAPT)” initiative. His argument for this was accepted as sound economics: according to the calculations of the Centre for Economic Performance, a one-time expenditure of on average £750 for a course of psychotherapy (10 sessions of CBT at £75 a session) resulted in cost savings of £750 per month in decreased direct costs and recouped indirect costs. If government-funded psychotherapy resulted in just one month of improved function, he reasoned, this approach pays for itself (4).
Over the years since its initial rollout the IAPT has shown itself to be a cost-effective programme, although session costs were higher than expected (5) and functional recovery rates in the demonstration sites have been between 50 and 55%, with 5% returning to full employment from receiving sick benefits (6). Remarkably the programme is described as cost-effective despite the fact that a full 55% of the patients referred did not in fact complete a course of treatment – they did not attend an initial appointment, declined after 1 or 2 sessions, or dropped out (5). Perhaps this high drop-out rate is because the therapeutic alliance was not established early, or perhaps because CBT did not seem to address their problems.
As a national funding body the NHS has a responsibility to limit its funding to evidence-based treatments, and for decades CBT has led the way in the number and quality of available studies. However, in fact the policy nowhere indicates that this approach should be limited to CBT. Rather, the message is that effectivepsychotherapeutic treatments are economically sound additions to a publicly-funded healthcare system. Results offset spending.
Several months later, my patient still deals with anxiety and low mood. But he can’t recall the last time he missed a day of work because of it. His suicidal ideation is an occasional fleeting thought rather than a persistent daily grind. He has days when he enjoys himself and the life he has built. He is being groomed for a promotion at work and is now confident in promoting his ideas. The thought of a disability pension is far from his mind. His wife has also changed jobs –something she had not felt comfortable doing before. We are gradually, but definitively, preparing for his discharge.
Has this therapy been expensive for the province to provide?
Certainly it would have been prohibitive for the patient to afford out-of-pocket. But what savings have been made by 1) avoided hospital stays 2) an avoided disability pension 3) vastly decreased missed work days 4) more work productivity 5) increased caregiver productivity and income 6) decreased visits and investigations for physical symptoms related to anxiety and depression 7) decreased use of resources not ultimately helpful to him (ie. further CBT) 8) a promotion in keeping with his training and skills?
And what are the reduction in human costs and the improvement in quality of life worth? It has been argued that it is not economical for psychiatrists to provide longer-term psychotherapy, but until there is an effective publicly-funded psychotherapy strategy in Ontario, I will continue – it is too expensive not to provide.
Notes *The patient example provided is based on representative data from a psychotherapy clinic and do not identify any one patient.
1 1. Smetanin P et al., The Life and Economic Impact of Major Mental Illnesses in Canada, RiskAnalytica, Report commissioned by the Mental Health Commission of Canada, December 2011.
2 2. Conference Board of Canada, Mental Health Issues in the Labour Force: Reducing the Economic Impact on Canada, July 2012.
3 3. Lim K-L et al., How Much Should We Spend on Mental Health?, Institute of Health Economics, Alberta, September 2008.
4 4. The Centre for Economic Performance: Mental Health Group., The Depression Report: A New Deal for Depression and Anxiety Disorders, London School of Economics and Political Science, 2006.
5 5. Radhakrishnan, M., Cost of Improving Access to Psychological Therapies (IAPT) programme: An analysis of cost of session, treatment and recovery in selected Primary Care Trusts in the East of England region. Behaviour Research and Therapy, 2013, 51(37-45).
6 6. Clark, D., Improving access to psychological therapy: Initial evaluation of two UK demonstration sites. Behaviour Research and Therapy, 2009, 47(11), 910-920.