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Unread February 25th, 2005, 10:16 PM
James Pretzer James Pretzer is offline
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Default Is CBT cost-effective?

A recent question on the ACT listserv got me thinking about the cost-effectiveness of CBT and I did a quick literature search on that topic. It turns out that quite a few cost-effectiveness studies have been published (and I'm sure I missed some, this was just a quick look).

In looking at cost-effectiveness studies it is important to notice which costs are considered and who bears those costs. For example, in the first study listed below (Antonuccio, et al., 1997) CBT compares favorably overall with an antidepressant. However, if an insurance company bears the cost of psychotherapy while the patient bears the cost of prescription medication, CBT is more expensive to the insurance company than medication because the insurance company doesn't pay the cost of the medication.

Anyway, here are summaries or abstracts of the studies I found:

Antonuccio, D.O., Thomas, M., & Danton, W.G. (1997). A cost-effectiveness analysis of cognitive behavior therapy and fluoxetine (Prozac) in the treatment of depression. Behavior Therapy, 28, 187-210.

Depression affects at least 11 million Americans per year and costs the U.S. economy an estimated 44 billion dollars annually. Comprehensive review of the existing scientific evidence suggests that psychotherapy, particularly cognitive behavior therapy (CBT), is at least as effective as medication in the treatment of depression, even if severe (Antonuccio, Danton, & DeNelsky, 1995). These conclusions hold for both vegetative and social adjustment symptoms, especially when patient-related measures are used and long-term follow-up is considered. In addition, several well-controlled studies with long-term follow-up (Evans, et al., 1992; Shea, et al., 1992; Simons, Murphy, Levine, & Wetzel, 1986) suggest that CBT may be more effective than drug treatment at preventing relapse. The relative effectiveness of psychotherapy for depression, particularly CBT, has been reinforced by meta-analyses reported in both psychiatry (Hollon, Shelton, & Loosen, 1991; Wexler .& Cicchetti, 1992) and psychology journals (Dobson, 1989; Robinson, Berman, & Neimeyer, 1990; Steinbrueck, Maxwell, & Howard, 1983). In the era of managed care, it is not enough to be effective; treatments must be cost-effective. This paper considers the outcome studies as the basis for a cost-effectiveness comparison of drugs and psychotherapy in the treatment of unipolar depression. The analysis shows that over a 2-year period, fluoxetine alone may result in 33% higher costs than individual CBT treatment and the combination treatment may result in 23% higher costs than CBT alone. Supplemental analysis shows that group CBT may only result in a 2% ($596) cost savings as compared to individual treatment.

Von Korff, M., Katon, W., Bush, T., Lin, E. H. B., Simon, G. E., Saunders, K., Ludman, E., Walker, E. & Unutzer, J. (1998). Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression. Psychosomatic Medicine, 60, 143-149.

ABSTRACT: Estimated treatment costs, cost-offset effects, and cost-effectiveness of collaborative care (CC) of depressive illness in primary care in 2 randomized controlled trials. In the 1st trial, with 217 depressed patients, psychiatrists provided enhanced management of pharmacotherapy and brief psychoeducational interventions to enhance adherence. In the 2nd trial, with 153 depressed patients, CC was implemented through brief cognitive-behavioral therapy and enhanced patient education. Consulting psychologists provided brief psychotherapy supplemented by educational materials and enhanced pharmacotherapy management. CC increased the costs of treating depression largely because of the extra visits required to provide the interventions. There was a modest cost offset due to reduced use of specialty mental health services among CC patients, but costs of ambulatory medical care serviced did not differ significantly between the intervention and control groups. Among Ss with major depression there was a modest increase in cost-effectiveness. The cost per patient successfully treated was lower for CC than for usual care patients. For patients with minor depression, CC was morecostly and not more cost-effective than usual care.

Otto, M. W., Pollack, M. H., & Maki, K. M. (2000). Empirically-supported treatment for panic disorder: Costs, benefits, and stepped care. Journal of Consulting and Clinical Psychology, 68, 556-563.

Abstract -Treatment outcome findings suggest that cognitive-behavioral therapy (CBT) and pharmacotherapy offer similar short-term treatment gains for panic disorder and that CBT may afford more optimal maintenance of treatment gains without the need for ongoing treatment. However, efficacy is not the only consideration for patients, and because of limited health care resources, evaluation of the cost-benefit ratio of these treatments is important. In this article, the authors review estimates of the relative efficacy, acceptability, tolerability, and costs of these treatments; empirically examine the costs and outcome of cognitive-behavioral and pharmacologic interventions as they are delivered in an outpatient clinic specializing in these treatments; and comment on how these data inform a stepped care model of treatment. Analysis of the "services" data indicated that CBT was at least equal to pharmacotherapy in terms of pretreatment severity and acute treatment outcome and that CBT is an especially cost-effective treatment option.

Koran, Lorrin M.; Agras, W. Stewart; Rossiter, Elise M.; Arnow, Bruce; et al (1995). Comparing the cost effectiveness of psychiatric treatments: Bulimia nervosa. Psychiatry Research. 58(1), 13-21.

Abstract Compared the cost effectiveness (CE) of 5 treatments for bulimia nervosa: 15-wks of cognitive behavioral therapy (CB) followed by 3 monthly sessions, 16 wks (Med-sub-16) and 24 wks (Med-sub-24) of desipramine, and CB combined with desipramine for those durations (Combo-sub-16 and Combo-sub-24). 71 female patients (18-65 yrs old) were given the treatment and an assessor without knowledge of the Ss' treatment determined the frequencies of binge eating through interviews. Effectiveness and costs were assessed before starting the treatment and after the Ss had completed the treatment. Results of this post hoc analysis show that treatment's CE varied according to when evaluation is done and how effectiveness and cost are defined. At 32 wks, Med-sub-16 appeared the most cost effective treatment, and Combo-sub-16 the least. At 1 yr, Med-sub-24 appeared the most cost effective treatment and Combo-sub-16 the least.

Hudson, A., Jauernig, R., Wilken, P. & Radler, G. (1995). Behavioural treatment of challenging behaviour: A cost-benefit analysis of a service delivery model. Behaviour Change. 12(4), 216-226.

Abstract In 1990, 13 behavior intervention support teams (BISTs) were established in Victoria, Australia to assist agencies providing support to persons with an intellectual disability who exhibited challenging behavior. This paper reports on a cost-benefit analysis of interventions conducted by 8 of these teams during the period 1991-1993. The cost-benefit analysis comprised 3 major components: an assessment of the average cost of BIST interventions, an assessment of the average benefit of the interventions, and a comparison of the costs and benefits. It was found that the existence of a severe challenging behavior resulted in an additional cost to the service system of an average $40,510 per annum. In contrast, the cost of a single intensive intervention conducted by a BIST was $5,725. Even allowing for substantial margins for error in the analysis, it is concluded that BIST interventions are cost effective.

Milgrom, J., Walter, P. & Green, S. (1994). Cost savings following psychological intervention in a hospital setting: The need for Australian-based research. Australian Psychologist. 29(3),194-200.

Abstract Examines the role of psychologists within the Australian health industry in providing cost-effective preventive services, and reports on a pilot study. It is argued that, in the face of escalating health costs and increasing evidence of the interrelationship between psychological/behavioral factors and physical illness, psychological services can play a major role in involving patients in their own health care, thus reducing medical costs. In an uncontrolled pilot study in a large general hospital, 10 patients were referred from a medical outpatient clinic to a clinical psychologist for short-term cognitive-behavioral therapy. Results show that psychological intervention led to dramatic savings, supporting the cost-effectiveness of psychological intervention in a hospital setting.


Williamson, D. A., Thaw, J. M. & Varnado-Sullivan, P. J. (2001). Cost-effectiveness analysis of a hospital-based cognitive-behavioral treatment program for eating disorders. Behavior Therapy. 32(3), 459-477.

Abstract This outcomes-management study evaluated the cost-effectiveness of a hospital-based cognitive-behavioral treatment program for eating disorders. The study found that by using a systematic, decision-tree approach to treatment, adult patients with severe eating disorders could be treated effectively by initiating treatment in a partial day hospital program, with less cost than when treatment was initiated at an inpatient level of care. The average cost saving of this approach was $9,645 per case. The rate of recovery for the entire sample was 63% at 12-mo follow-up and did not differ as a function of initial level of care. Patients who were treated with a shorter duration of illness and at an older age of onset had the best response to treatment. A longer duration of illness was associated with higher levels of eating disorder symptoms and higher levels of depression, which suggests that the early intervention may be more effective because treatment can begin at a lower level of psychopathology.


Thomas, V. J., Gruen, R. & Shu, S. (2001). Cognitive-behavioral therapy for the management of sickle cell disease pain: Identification and assessment of costs. Ethnicity & Health. 6(1), 59-67.

Abstract A previous study concluded that cognitive-behaviour therapy (CBT) appears to be immediately effective for the management of SCD pain in terms of reducing psychological distress pain as well as improving coping. The present study investigated the economic validity of using CBT in the management of sickle cell disease (SCD) pain. The costs of management of SCD were evaluated using a societal viewpoint. This approach included health and social services as well as costs privately borne by informal carers, but it did not include the economic loss due to patients' foregone earnings. Cost profiles were constructed for each of 82 patient Ss (aged 15-35 yrs), taking account of cost-generating events 12 mo before and 12 mo after CBT. The hypothesis of the present study, stating that CBT is economically efficient, was confirmed. However, analysis of longitudinal data suggests that CBT is most cost-effective during the first 6 mo after the intervention. The present findings suggest the need for CBT to be integrated into the normal package of care available for all patients with SCD. The clinical implication is that CBT should be routinely offered to patients on a 6-monthly basis.


Bower, P., Byford, S., Sibbald, B., Ward, E., King, M., Lloyd, M., Gabbay, M. (2000). Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. II: Cost effectiveness. British Medical Journal. 321(7273), 1389-1392,

Abstract Compared the cost effectiveness of general practitioner care and 2 general practice-based psychological therapies for depressed patients. A prospective, randomised controlled trial was conducted with 464 patients presenting with depression or mixed anxiety and depression who received usual general practitioner care or up to 12 sessions of non-directive counselling or cognitive-behaviour therapy provided by therapists. The main outcome measures were Beck depression inventory scores, EuroQol measure of health related quality of life, direct treatment and non-treatment costs, and cost of lost production. At 4 months, both non-directive counselling and cognitive-behaviour therapy reduced depressive symptoms to a significantly greater extent than usual general practitioner care. There was no significant difference in outcome between treatments at 12 months. There were no significant differences in direct costs, production losses, or societal costs between the 3 treatments at either 4 or 12 months. Within the constraints of available power, the data suggest that both brief psychological therapies may be significantly more cost effective than usual care in the short term, as benefit was gained with no significant difference in cost. http://www.bmj.com/cgi/content/full/321/7273/1389.


McCrone, P., Ridsdale, L., Darbishire, L. & Seed, P. (2004). Cost-effectiveness of cognitive behavioural therapy, graded exercise and usual care for patients with chronic fatigue in primary care. Psychological Medicine. 34(6), 991-999.

Abstract Background: Chronic fatigue is a common condition, frequently presenting in primary care. The aim of this study was to compare the cost-effectiveness of cognitive behavioural therapy (CBT) and graded exercise therapy (GET), and to compare therapy with usual care plus a self-help booklet (BUC). Method: Patients drawn from general practices in South East England were randomized to CBT or GET. The therapy groups were then compared to a group receiving BUC recruited after the randomized phase. The main outcome measure was clinically significant improvements in fatigue. Cost-effectiveness was assessed using the net-benefit approach and cost-effectiveness acceptability curves. Results: Costs were available for 132 patients, and cost-effectiveness results for 130. Costs were dominated by informal care. There were no significant outcome or cost differences between the therapy groups. The combined therapy group had significantly better outcomes than the standard care group, and costs that were on average £149 higher (a non-significant difference). Therapy would have an 81.9% chance of being cost-effective if society were willing to attach a value of around £500 to each four-point improvement in fatigue. Conclusion: The cost-effectiveness of cognitive behavioural therapy and graded exercise was similar unless higher values were placed on outcomes, in which case CBT showed improved cost-effectiveness. The cost of providing therapy is higher than usual GP care plus a self-help booklet, but the outcome is better. The strength of this evidence is limited by the use of a non-randomized comparison. The cost-effectiveness of therapy depends on how much society values reductions in fatigue.


Heuzenroeder, L.,Donnelly, M., Haby, M. M., Mihalopoulos, C., Rossell, R., Carter, R., Andrews, G. & Vos, T. (2004). Cost-effectiveness of psychological and pharmacological interventions for generalized anxiety disorder and panic disorder. Australian & New Zealand Journal of Psychiatry. 38(8), 602-612.

Abstract Objective: To assess from a health sector perspective the incremental cost-effectiveness of interventions for generalized anxiety disorder (cognitive behavioural therapy [CBT] and serotonin and noradrenaline reuptake inhibitors [SNRIs]) and panic disorder (CBT, selective serotonin reuptake inhibitors [SSRIs] and tricyclic antidepressants [TCAs]). Method: The health benefit is measured as a reduction in disability-adjusted life years (DALYs), based on effect size calculations from meta-analyses of randomised controlled trials. An assessment on second stage filters ('equity', 'strength of evidence', 'feasibility' and 'acceptability to stakeholders') is also undertaken to incorporate additional factors that impact on resource allocation decisions. Costs and benefits are calculated for a period of one year for the eligible population (prevalent cases of generalized anxiety disorder/panic disorder identified in the National Survey of Mental Health and Well-being, extrapolated to the Australian population in the year 2000 for those aged 18 years and older). Simulation modelling techniques are used to present 95% uncertainty intervals (UI) around the incremental cost-effectiveness ratios (ICERs). Results: Compared to current practice, CBT by a psychologist on a public salary is the most cost-effective intervention for both generalized anxiety disorder (A$6900/DALY saved; 95% UI A$4000 to A$12000) and panic disorder (A$6800/DALY saved; 95% UI A$2900 to A$15 000). Cognitive behavioural therapy results in a greater total health benefit than the drug interventions for both anxiety disorders, although equity and feasibility concerns for CBT interventions are also greater. Conclusions: Cognitive behavioural therapy is the most effective and cost-effective intervention for generalized anxiety disorder and panic disorder. However, its implementation would require policy change to enable more widespread access to a sufficient number of trained therapists for the treatment of anxiety disorders.


Haby, M. M., Tonge, B., Littlefield, L., Carter, R. & Vos, T. (2004). Cost-effectiveness of cognitive behavioural therapy and selective serotonin reuptake inhibitors for major depression in children and adolescents. Australian & New Zealand Journal of Psychiatry. 38(8), Aug 2004, 579-591.

Abstract Objective: To assess from a health sector perspective the incremental cost-effectiveness of cognitive behavioural therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) for the treatment of major depressive disorder (MOD) in children and adolescents, compared to 'current practice'. Method: The health benefit is measured as a reduction in disability-adjusted life years (DALYs), based on effect size calculations from meta-analysis of randomised controlled trials. An assessment on second stage filter criteria ('equity'; 'strength of evidence', 'feasibility' and 'acceptability to stakeholders') is also undertaken to incorporate additional factors that impact on resource allocation decisions. Costs and benefits are tracked for the duration of a new episode of MOD arising in eligible children (age 6-17 years) in the Australian population in the year 2000. Simulation-modelling techniques are used to present a 95% uncertainty interval (UI) around the cost-effectiveness ratios. Results: Compared to current practice, CBT by public psychologists is the most cost-effective intervention for MOD in children and adolescents at A$9000 per DALY saved (95% UI A$3900 to A$24 000). SSRIs and CBT by other providers are less cost-effective but likely to be less than A$50 000 per DALY saved (> 80% chance). CBT is more effective than SSRIs in children and adolescents, resulting in a greater total health benefit (DALYs saved) than could be achieved with SSRIs. Issues that require attention for the CBT intervention include equity concerns, ensuring an adequate workforce, funding arrangements and acceptability to various stakeholders. Conclusions: Cognitive behavioural therapy provided by a public psychologist is the most effective and cost-effective option for the first-line treatment of MOD in children and adolescents. However, this option is not currently accessible by all patients and will require change in policy to allow more widespread uptake. It will also require 'start-up' costs and attention to ensuring an adequate workforce.


Roberge, P., Marchand, A.,Reinharz, D.,Marchand, L. & Cloutier, K. (2004). Évaluation économique de la thérapie cognitivo-comportementale des troubles anxieux. Canadian Psychology. 45(3), 202-218.

Abstract This literature review examines the results of cost-effectiveness studies of cognitive-behaviour therapies published up to June 2003. Cost offsets likely to be derived from effective treatment of anxiety problems are also examined. A summary of results suggests the following: 1) cognitive-behaviour therapy is cost-effective compared to drug therapy for the treatment of panic disorder and social phobia; 2) group treatments and short courses as well as new technologies are promising alternatives to conventional therapy; 3) the existence of cost offsets for anxiety disorders has yet to be ascertained. Research approaches are suggested to cover significant shortcomings in the methodologies of studies conducted to date.


McCrone, P., Knapp, M.,Proudfoot, J., Ryden, C., Cavanagh, K., Shapiro, D. A., Ilson, S.,Gray, J., A.; Goldberg, D., Mann, A., Marks, I., Everitt, B., & Tylee, A. (2004). Cost-effectiveness of computerised cognitive-behavioural therapy for anxiety and depression in primary care: Randomised controlled trial. British Journal of Psychiatry. 185(1), 55-62.

Abstract Background Cognitive-behavioural therapy (CBT) is effective for treating anxiety and depression in primary care, but there is a shortage of therapists. Computer-delivered treatment may be a viable alternative. Aims To assess the cost-effectiveness of computer-delivered CBT. Method A sample of people with depression or anxiety were randomised to usual care (n=128) or computer-delivered CBT (n=146). Costs were available for 123 and 138 participants, respectively. Costs and depression scores were combined using the net benefit approach. Results Service costs were £40 (90% CI -£28 to £148) higher over 8 months for computer-delivered CBT. Lost-employment costs were £407 (90% CI £196 to £586) less for this group. Valuing a 1-unit improvement on the Beck Depression Inventory at £40, there is an 81% chance that computer-delivered CBT is cost-effective, and it revealed a highly competitive cost per quality-adjusted life year. Conclusions Computer-delivered CBT has a high probability of being cost-effective, even if a modest value is placed on unit improvements in depression.


Wells, K. B (1999). The design of Partners in Care: Evaluating the cost-effectiveness of improving care for depression in primary care. Social Psychiatry & Psychiatric Epidemiology. 34(1), 20-29.

Abstract Examined the cost-effectiveness of antidepressant and/or psychotherapy treatments and of quality improvement for depression in primary care, managed care practices. Six managed care organizations in Los Angeles, (Calif.), San Antonio (Tex.), San Luis Valley (Colo.), Twin Cities (Minn.), and Columbia (Md.) participated. Primary care clinics were randomized to 1 of 2 quality improvement interventions or care as usual. Interventions included patient and provider education, nurse-assisted patient assessment, and resources to support appropriate medication management or access to cognitive behavioral therapy. Patients with depressive symptoms regardless of comorbidities were eligible. Over 27,000 primary care patients visiting the practices of 181 primary care clinicians were screened for depression, 14% were potentially eligible, and 1,356 enrolled into the 2-yr longitudinal study. Enrollees were similar to eligibles, but usual care clinic patients tended to be less severely depressed than intervention clinic patients, partly due to clinic staff enthusiasm. Results show that studying treatment effects and quality improvement in nonacademic settings is feasible, but requires relaxation of design features of experiments that protect internal validity.


Wolfe, B. L. & Meyers, R. J (1999). Cost-effective alcohol treatment: The community reinforcement approach. Cognitive & Behavioral Practice. 6(2), 105-109.

Abstract Introduces the Community Reinforcement Approach (CRA), one treatment modality which is well-supported by the literature. CRA is a cost-effective behavioral and social-learning-based treatment protocol. Its menu-driven approach to substance abuse also integrates several other cost-effective treatments to make a comprehensive package for the clinician. An overview of CRA is provided with the objective of helping the clinician increase his or her cost-effectiveness with alcohol abusing and dependent clients.


Otto, M. W. (1999). Psychological interventions in the age of managed care: A commentary on medical cost offsets. Clinical Psychology: Science & Practice. 6(2), 239-241.

Abstract Provides a commentary on the J. A. Chiles et al (1999) meta-analytic review of the medical cost-offset literature. Emphasis is placed on the impact of managed care on their findings and on the field. Under conditions of closely monitored and/or restricted care, cost offsets may be more difficult to achieve. Moreover, recent research indicates that specialty care for mental health may be more costly than management by primary care physicians. However, specialty care is associated with more optimal outcomes and greater cost-effectiveness. Attention to the value of care (cost-effectiveness) will help ensure that psychological interventions compete well in current fiscal environments.


Kuipers, E., Fowler, D., Garety, P., Chisholm, D., Freeman, D., Dunn, G., Bebbington, P. & Hadley, C. (1998). London-East Anglia randomised controlled trial of cognitive-behavioural therapy for psychosis: III. Follow-up and economic evaluation at 18 months. British Journal of Psychiatry. 173, 61-68.

Abstract A randomized controlled trial of cognitive-behavioral therapy (CBT) for people with medication-resistant psychosis showed improvements in overall symptomatology after 9 mo of treatment; good outcome was strongly predicted by a measure of cognitive flexibility concerning delusions. The present paper presents a follow-up evaluation 18 mo after baseline. 47 (78%) of the participants (aged 18-65 yrs) were available and were reassessed on all the original outcome measures (see Part I; E. Kuipers et al, 1997). An economic evaluation was also completed. Those in the CBT treatment group showed a significant and continuing improvement in Brief Psychiatric Rating Scale scores, whereas the control group did not change from baseline. Delusional distress and the frequency of hallucinations were also significantly reduced in the CBT group. The costs of CBT appear to have been offset by reductions in service utilization and associated costs during follow-up. Improvement in overall symptoms was maintained in the CBT group 18 mo after baseline and 9 mo after intensive therapy was completed. CBT may be a specific and cost-effective intervention in medication resistant psychosis.


Byford, S., Knapp, M., Greenshields, J., Ukoumunne, O. C., Jones, V., Thompson, S.,Tyrer, P., Schmidt, U. & Davidson, K. (2003). Cost-effectiveness of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: a decision-making approach.Psychological Medicine. 33(6), 977-986.

Abstract Deliberate self-harm can be costly, in terms of treatment and subsequent suicide. Any intervention that reduces episodes of self-harm might therefore have a major impact on the costs incurred by service providers and the productivity losses due to illness or premature death. Four hundred and eighty patients with a history of recurrent deliberate self-harm were randomized to manual-assisted cognitive behaviour therapy (MACT) or treatment as usual. Economic data were collected from patients at baseline, 6 and 12 months, and these data were complete for 397 patients. Incremental cost-effectiveness was explored using the primary outcome measure, proportion of patients having a repeat episode of deliberate self-harm, and quality of life. The uncertainty surrounding costs and effects was represented using cost-effectiveness acceptability curves. Differences in total cost per patient were statistically significant at 6 months in favour of MACT, but these differences did not remain significant at 12 months. Nevertheless, exploration of the uncertainty surrounding these estimates suggests there is > 90 % probability that MACT is a more cost-effective strategy for reducing the recurrence of deliberate self-harm in this population over 1 year than treatment as usual.

Attanasio, V., Andrasik, F. & Blanchard, E. B. (1987). Cognitive therapy and relaxation training in muscle contraction headache: Efficacy and cost-effectiveness. Headache. 27(5), 254-260.

Abstract Examined the efficacy of adding a cognitive therapy component to traditional relaxation training and the feasibility and cost-effectiveness of administering these treatments in a largely self-administered format for headache patients. 25 20-59 yr old muscle contraction headache sufferers were assigned to 1 of 3 treatment conditions that provided either relaxation training alone or relaxation training in combination with cognitive therapy. At 1-mo posttreatment, Ss in all 3 conditions exhibited significant decreases in headache activity, with no significant differences between the groups. Results suggest that largely self-administered treatments can result in significant improvements in headache, while substantially reducing the total amount of therapist contact.


Von Korff, M., Katon, W., Bush, T., Lin, E. H. B., Simon, G. E., Saunders, K., Ludman, E., Walker, E. & Unutzer, J. (1998). Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression. Psychosomatic Medicine. 60(2), 143-149.

Abstract Estimated treatment costs, cost-offset effects, and cost-effectiveness of collaborative care (CC) of depressive illness in primary care in 2 randomized controlled trials. In the 1st trial, with 217 depressed patients, psychiatrists provided enhanced management of pharmacotherapy and brief psychoeducational interventions to enhance adherence. In the 2nd trial, with 153 depressed patients, CC was implemented through brief cognitive-behavioral therapy and enhanced patient education. Consulting psychologists provided brief psychotherapy supplemented by educational materials and enhanced pharmacotherapy management. CC increased the costs of treating depression largely because of the extra visits required to provide the interventions. There was a modest cost offset due to reduced use of specialty mental health services among CC patients, but costs of ambulatory medical care serviced did not differ significantly between the intervention and control groups. Among Ss with major depression there was a modest increase in cost-effectiveness. The cost per patient successfully treated was lower for CC than for usual care patients. For patients with minor depression, CC was more costly and not more cost-effective than usual care.

Scott, J., Palmer, S., Paykel, E., Teasdale, J. & Hayhurst, H. (2003). Use of cognitive therapy for relapse prevention in chronic depression: Cost-effectiveness study. British Journal of Psychiatry. 182(3), 221-227.

Abstract Examined the cost-effectiveness of using cognitive therapy for relapse prevention in chronic depression. 158 outpatients (aged 21-65 yrs) with partially remitted major depression underwent antidepressant drug therapy and clinical management, with or without cognitive therapy. Relapse rates and health care resource use were measured prospectively during a 17-mo period. Results show that cumulative relapse rates in cognitive therapy Ss were 29%; for those Ss not undergoing cognitive therapy, the relapse rate was 47%. The incremental cost incurred by cognitive therapy Ss was significantly lower than the overall mean costs of cognitive therapy. The incremental cost-effectiveness ratio ranged from 4,328 to 5,027 British pounds per additional relapse prevented. Findings suggest that adjunctive cognitive therapy is more costly but more effective than intensive clinical treatment alone for individuals with depressive symptoms that are resistant to standard treatment.


Hiller, W., Fichter, M. M. & Rief, W. (2003). A controlled treatment study of somatoform disorders including analysis of healthcare utilization and cost-effectiveness. Journal of Psychosomatic Research. 54(4), 369-380.

Abstract Prospectively evaluated the effects of cognitive-behavioral treatment (CBT) on mental health status and healthcare utilization in patients with somatoform disorders (SFD) of a specialized tertiary care center. According to DSM-IV interviews, 54 patients had somatization disorder (SD), 51 abridged somatization syndrome (SSI-8) and 67 other defined SFD. A clinical non-SFD comparison group consisted of 123 patients. Treatment effects were controlled against the waiting list. Cost calculations for the 2-yr periods before and after treatment were based on medical and billing records from health insurance companies. The SFD patients improved significantly with respect to physical symptom distress, health anxieties, dysfunctional beliefs towards body and health, depression and psychosocial functioning. Their outpatient plus inpatient charges during the 2 years prior to treatment were about 2.2-fold higher than for average patients of the health system. At the 2-yr follow-up, we found treatment-related cost offset of -24.5% for outpatient and -36.7% for inpatient care. Indirect socioeconomic costs due to days lost from work decreased by 35.3%. Per patient savings of -63.9% were found in a subgroup of somatizing high utilizers.

Gould, R. A., Buckminster, S., Pollack, M. H., Otto, M. W. & Yap, L. (1997). Cognitive-behavioral and pharmacological treatment for social phobia: A meta-analysis. Clinical Psychology: Science & Practice. 4(4), 291-306.

Abstract Conducted a meta-analysis using 24 available controlled treatment outcome studies of cognitive-behavioral and pharmacological treatments for social phobia.1079 Ss were included. The mean social anxiety effect size for cognitive-behavioral treatments was .74 and for pharmacological treatments was .62. Both were significantly different from zero and the difference between them was not significant. Among cognitive-behavioral treatments, exposure-interventions yielded the largest effect size (ES) whether alone (ES = .89) or combined with cognitive restructuring (ES = .80). Selective serotonin reuptake inhibitors (ES = 1.89) and benzodiazepines (ES = .72) yielded the largest effect sizes for pharmacotherapy. According to cost projections, group cognitive-behavioral treatment offered the most cost-effective intervention.


Hunsley, J. (2003). Cost effectiveness and medical cost-offset considerations in psychological service provision. Canadian Psychology. 44(1), Feb 2003, 61-73.

Abstract Suggests that empirical evidence has demonstrated that psychological interventions can effectively treat a wide range of child and adult health problems. The focus of this review is on costing issues associated with psychological interventions, including cost-effectiveness and cost offset (i.e., a reduction in health care costs attributable to effective intervention). Recent evidence has demonstrated that psychological interventions can be more cost-effective than optimal drug treatment. For example, although having comparable effectiveness, cognitive-behavioral treatments for panic disorder and for depression have been estimated to cost approximately one-third less than pharmacological treatment. Further, a recent meta-analysis of 91 research studies published between 1967 and 1997 found that average health care cost savings due to psychological intervention were in the range of 20-30% across studies, and 90% of the studies reported evidence of a medical cost offset. In conclusion, the evidence indicates that psychological treatments (1) can be cost-effective forms of treatment and (2) have the potential to reduce health care costs, as successfully treated patients typically reduce their utilization of other health care services.


Jerrell, J. M. (1996). Toward cost-effective care for persons with dual diagnoses. Journal of Mental Health Administration. 23(3), 329-337.

Abstract Compared three specialized intervention approaches (i.e., twelve-step recovery model, behavioral skills model, and intensive case management) for treating persons with co-occurring severe mental illness and substance abuse. 132 clients were interviewed every 6 mo after program admission. Results show that standard mental health care augmented by the behavioral skills intervention was more effective than the other 2 approaches across indicators of psychosocial adjustment, psychiatric and substance abuse symptoms, and mental health service costs. These findings reinforce the need to address mental health and substance disorders concomitantly; to provide skill-building interventions as the primary ingredient of active treatment to address various instrumental, coping, and social skill deficits that clients with dual diagnoses have; and to monitor the effectiveness of the services and client progress every 6 mo on multiple adjustment and symptomatology dimensions.


Severens, J. L.; Prins, I. B.; van der Wilt, G. J.; van der Meer, J. W. M.; Bleijenberg, G. (2004). Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome. QJM: An International Journal of Medicine. 97(3), 153-161.

Abstract Background: There is some evidence that cognitive behaviour therapy (CBT) is efficacious in chronic fatigue syndrome (CFS), but little data on its cost-effectiveness. Design: Prospective economic analysis alongside a randomized clinical trial. Methods: CFS patients were randomly assigned to CBT, guided support groups (SG), or the 'natural course' (NC, no protocol-based interventions). Patients were treated for 8 months and followed-up for another 6 months. Costs per patient showing clinically significant improvement, based on the CIS fatigue scale, and costs per quality-adjusted life year, were determined for a time period of 14 months. Results: Data were available for 171 patients at 8 months and for 128 at 14 months. At 8 and 14 months, the percentages of improved patients were 31% and 27% for CBT, 9% and 11% for SG, and 12% and 20% for NC. Mean QALYs gained at 14 months were, for CBT, SG and NC, respectively, 0.0737, -0.0018 and 0.0458. CBT and SG mean treatment costs were  1490 and  424. Other medical costs for CBT, SG, and NC, respectively, were  324,  623 and  412 for the first period, and  232,  561 and  378 for the second period. Non-medical costs for these periods for CBT, SG and NC were  262,  550,  427 and  226,  439,  287, respectively. Productivity costs were considerable, but not significantly different between groups. Discussion: CBT was less costly and more effective than SG. Compared to NC, the baseline incremental cost-effectiveness of CBT was  20516 per CFS patient showing clinically significant improvement, and  21 375 per QALY. The bootstrap ratios showed considerable uncertainty regarding the results. Future research should focus on productivity costs, and follow patients prospectively over a longer period.
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