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Psychotherapy Is Worth It: A Comprehensive Review of Its Cost-Effectiveness
Reviewed by Jean E. Milofsky, M.D.
Am J Psychiatry 2011;168:102-103. doi:10.1176/appi.ajp.2010.10081133
View Author and Article Information
Denver, Colo.

Book review accepted for publication August 2010.

The author reports no financial relationships with commercial interests.

Accepted August , 2010.

Copyright © American Psychiatric Association

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Psychotherapy Is Worth It is an encyclopedic treasure trove for mental health professionals considering treatment options for patients with mental illness. Dr. Susan Lazar points out that treatment for mental illness has always been viewed as a "soft" service, with no clearly understood outcomes. Societal prejudice regarding the "worried well" indulging in psychotherapy beyond strict medical necessity colors the perception of mental health services.

Lazar gathers a group of distinguished authors to re-examine the uses of psychotherapy within the diagnostic categories traditionally served by psychiatry and in medically ill patients for whom psychotherapy can improve coping and quality of life.

In the introduction, co-authored with Drs. Gerald Adler and William H. Sledge, Lazar supports the argument that the disease burden of mental illnesses in both developed and developing countries is massive, resulting in direct and indirect costs to healthcare institutions and society. Chapters written by a variety of authors follow. Each author attempts to prove the cost effectiveness of psychotherapy as a single modality or in combination with other interventions.

Affective and anxiety disorders, schizophrenia and psychotic disorders, personality disorders, posttraumatic stress disorder (PTSD), and childhood mental illness are all addressed.

The volume would have been biased indeed if only those outcomes that support the title's thesis were included. Actually, the authors' conclusions range from enthusiasm to skepticism. In the chapter by Lazar and Offenkrantz, psychotherapy is not conclusively proved to be either cost effective or of long-term benefit for PTSD. Dr. Jules Bemporad proposes that the use of psychotherapy in treating children should be effective in returning them to a course of normal development, although the author acknowledges that there are no studies offering conclusive evidence.

In the depression literature (also reviewed by Lazar), the cohorts are larger and the evidence more robust. Even here, however, many studies conclude that psychotherapy is equal to medication or that therapy plus medication outperforms either treatment alone.

Along the way, there are compelling arguments that psychotherapy can be dosed, applied, and measured like other health interventions.

This volume is a marvelous reference for mental health professionals who are thinking through optimal treatment strategies. But it seems that Lazar and her colleagues want to go farther. The intended audience may ultimately be policy makers or healthcare executives looking for guidance in developing cost effective mental health programs with measurable outcomes. This group of authors argues for insurance coverage for psychotherapy to be at parity with other treatments in health insurance plans.

Over the past two decades, the mental health field has grown more slowly than the healthcare industry as a whole. The disease burden has increased exponentially. Yet we are still arguing about the value of mental health treatment! Our tentativeness is multifactorial, but it may stem largely from our poor understanding of the brain and behavior and our lack of standardized treatments for mental illness. There are treatment protocols for all other major disease states that likely vary only slightly from institution to institution. In contrast, the treatment for the same mental illness can vary in different settings. I am not sure that we can convince governmental and private agencies of the value of the treatments our profession offers when these treatments lack consensual definitions from system to system. In some ways, we have created our own problem.

In some institutions, behavioral health patients do not necessarily receive exactly the same treatment for the same illness. Choices, including the prescription of psychotherapy, often depend upon clinic culture, region, or individual practitioner preference. Eighty percent of mental health care is now delivered in primary care offices. Even in an integrated delivery system, there is no standard way of deciding when a patient belongs in a specialty clinic, where psychotherapy is common, versus primary care, where it is not. When we assert that our patients should receive mental health services at parity, we do not know whether we are asserting for them to receive treatment that is highly effective or not.

For parity to be meaningful, leaders in the field must eliminate less effective, less evidence-based treatments and help the healthcare industry decide on a standardized set of treatments, including psychotherapy where it is indicated, with proper outcome measures.

Lazar's volume, despite its comprehensiveness, does not direct us out of this maze. Cost effective services, as Lazar points out, are not "cheap" but may return the investment by offsetting other medical costs. My own perspective is that nonmedication interventions should be standardized, manualized, and often group-based if they are to be covered by health insurance. However, this volume, perhaps reflecting the state of our field, does not give us a definitive conclusion that any of our opinions are as yet sustained by evidence that will convince policy makers and health economists or even ourselves.

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