Book Review

Efficacy and Cost-Effectiveness of Psychotherapy

N Engl J Med 1999; 341:1088-1089September 30, 1999

Article

Efficacy and Cost-Effectiveness of Psychotherapy
(Clinical Practice.) Edited by David Spiegel. 199 pp. Washington, D.C., American Psychiatric Press, 1999. $28.50. ISBN: 0-88048-769-0

The past decade has seen a startling drop in the provision of insurance benefits for psychiatric care. Whereas the real value of employer-provided insurance for general medical treatment decreased 7.2 percent from 1988 to 1997, benefits for the treatment of psychiatric disorders fell by a dramatic 54 percent during that time. It is likely that a substantial part of this decline is accounted for by reluctance on the part of insurers, health maintenance organizations, and managed-care companies to provide benefits for psychotherapeutic treatment, which was once the mainstay of psychiatric care. Insurers and managed-care companies routinely refuse to authorize payment for medium-term and long-term psychotherapy and often resist requests to pay for even the short-term models they are said to favor.

Although the motives underlying this behavior are undoubtedly complex, the disfavored position of psychotherapy in the “playbook” of contemporary managed-care organizations is often attributed to the absence of data concerning its efficacy and cost effectiveness as compared with other approaches. These are precisely the issues addressed in this book, edited by Stanford psychiatrist David Spiegel, a leading researcher on psychotherapy. One concludes from this effort that psychotherapists — many of whom have failed to appreciate the value of rigorously designed trials demonstrating the efficacy of their work — have begun to realize the importance of having such data and are starting to make up for lost time.

Any appraisal of the efficacy of psychotherapy must begin by recognizing that all psychotherapists do not work in identical ways. The once-dominant individual psychodynamic approach has been joined by behavioral, cognitive–behavioral, interpersonal, group, and other techniques, many of which are more susceptible to the systematic implementation and measurement of outcome that are critical for meaningful assessment. Even within each of these general schools of therapy, approaches have been differentiated to address the needs of particular patient populations.

Thus, some of the most impressive data on the efficacy of psychotherapeutic treatment come from studies of cognitive–behavioral therapies for post-traumatic stress disorder, reviewed here in an excellent chapter by Foa and Jaycox. Given the absence of truly effective medications for post-traumatic stress disorder, it seems clear that psychotherapy is the treatment of choice. Similarly impressive results have been shown with dialectical behavior therapy, a variant of cognitive–behavioral therapy that was developed by Marsha Linehan for use in patients with the notoriously difficult to treat borderline personality disorder. Indeed, as Gabbard and Lazar note in their review of treatments for this condition, long-term psychodynamic psychotherapy has also been shown to be an effective intervention, although several years of treatment may be required before substantial results appear.

Spiegel himself has demonstrated just how powerful a tool psychotherapy can be with patients who are medically ill. In his research, women with metastatic breast cancer who were randomly assigned to group psychotherapy had an average survival time that was twice as long as in a control group. Similar effects have been found in a trial by Fawzy and colleagues in patients with malignant melanoma. The mechanisms of these potent effects of mind on body are just beginning to be discerned.

Data on efficacy, of course, are only half of what the title of the book promises. Unfortunately, data on cost effectiveness remain harder to come by. There is no question that psychiatric disorders have a huge economic impact that can be mitigated substantially by appropriate treatment. A number of chapters in this book recount the cost savings that can be produced by effective psychotherapeutic care. But the term “cost effectiveness” has an inherently comparative aspect. When we ask whether a treatment is cost effective, the appropriate retort is, “Compared with what?” Rigorous comparisons of the costs and benefits of psychotherapy as compared with other approaches to treatment are exceedingly rare, and they are not particularly well documented here.

The future of research on the efficacy and cost effectiveness of psychotherapy can be discerned from this book as well. As specific psychotherapeutic techniques are applied to discrete diagnostic groups, it will become easier to measure their effect and thereby to provide data about their efficacy. Even in the incomplete survey of the applications of psychotherapy offered in this book, it is clear that good data on efficacy are lacking in many areas. Testing of cost effectiveness can occur only after efficacy has been demonstrated and would involve comparative trials of psychotherapeutic and other approaches to treatment. This is the prescription for reversing current biases against psychotherapeutic interventions. Despite the economic disincentives that now exist for the practice of psychotherapy, it is heartening that so much creativity continues to be applied to the field.

Paul S. Appelbaum, M.D.
University of Massachusetts Medical School, Worcester, MA 01655