Dalle ricerche emerge che la terapia psicodinamica è efficace in modo specifico per pazienti con disturbi di personalità, disturbi cronici d'ansia e depressivi e anche disturbi cronici complessi. Inoltre, la frequenza settimanale e la durata della terapia hanno effetti positivi indipendenti tra loro. Uno degli ostacoli alla diffusione della terapia psicodinamica è il fatto che vengono preferiti i trattamenti brevi, in particolar modo la terapia cognitivo-comportamentale (CBT), considerata spesso il gold standard (cioè la terapia migliore che ci sia) nonostante i problemi che sono stati rilevati nelle metodologie delle ricerche sperimentali, nella validità dei risultati in suo favore, nella generalizzabilità dei risultati e nei metodi diagnostici utilizzati. Un altro ostacolo all'erogazione della terapia psicodinamica risiede nei protocolli delle compagnie assicurative vigenti in molti Paesi, che guardano al contenimento dei costi anziché fornire ai pazienti un trattamento ottimale; negli Stati Uniti, ad esempio, tradiscono il mandato del Mental Health Parity Act, la legge che obbliga che i limiti massimi di copertura assicurativa per i disturbi mentali non seguano criteri diversi da quelli per i trattamenti ottimali dei problemi medici o chirurgici.

Psychotherapy, especially dynamic psychotherapy and psychoanalysis, has been poorly supported by insurance although the Mental Health Parity Act mandates benefits for mental health care at parity with other health care and The Affordable Care Act lists mental health care, including psychotherapy, as an Essential Health Benefit. Limiting insurance support for psychotherapy turns away very ill, especially poorer patients who forego treatment and incur increased medical costs and disability. Patients with personality disorders, chronic anxiety depression, chronic illness and comorbidity require extended, often intensive, psychotherapy for optimal recovery. Brief cognitive-behavioral therapy is seen as a “gold standard” and “most evidence-based” although its research protocols study subjects not typical of most patients and who achieve only short-lived improvements. Research finds psychodynamic therapies to be highly cost-effective, equal to other efficacious therapies in improving symptoms, and also superior in improving maladaptive interpersonal relationship patterns, a high-risk factor for mortality. Knowledgeable attorneys and expert witnesses were key to the 2019 successful class action lawsuit against United Behavioral Health for declining to cover research supported generally accepted standards for mental health care and for a subsequent California state law mandating sufficient insurance coverage. To defend it in legal and policy arenas, providers and advocates for psychodynamic psychotherapy should familiarize themselves with its supporting research and the laws that demand its provision.

There have been shifts over time in the value placed on long-term psychotherapeutic modalities even though they can be life-saving. For example, the province of Ontario in Canada has been dealing with a government proposal put forward in 2019 to limit the length of psychotherapy treatment. In response, stakeholders from numerous groups came together to advocate for the importance of continuing unrestricted access to long-term psychotherapy. Approaches to this advocacy then had to unexpectedly adapt to the Coronavirus Disease 2019 (COVID-19) pandemic that came to the forefront in 2020 and will continue to develop in response to this changing landscape.

The founding members of the Coalition for Psychotherapy Parity present Clinical Necessity Guidelines for Psychotherapy, Insurance Medical Necessity and Utilization Review Protocols, and Mental Health Parity. These guidelines support access to psychotherapy as prescribed by the clinician without arbitrary limitations on duration or frequency. The authors of the guidelines first review the evidence that psychotherapy is effective, cost-effective, and often provides a cost-offset in decreased overall medical expenses, morbidity, mortality, and disability. They highlight the disparity between clinicians' knowledge of generally accepted standards of care for mental health and substance use disorders and the much more limited "crisis stabilization" focus of many insurance companies. The clinical trials that health insurers cite as justification for authorizing only brief treatment for all patients involve highly selected, atypical populations that are not representative of the general population of patients in need of mental health care, who typically have complex conditions and chronic, recurring symptoms requiring ongoing availability of treatment. The standard for other medical conditions reimbursed by insurance is continuation of effective treatment until meaningful recovery, which is therefore the standard required by the Mental Health Parity and Addiction Equity Act for mental health care. However, insurance companies frequently evade the legal requirement to cover treatment of mental illness at parity with other medical conditions. They do this by applying inaccurate proprietary definitions of medical necessity and imposing utilization review procedures much more restrictively for mental health treatment than for other medical care to block access to ongoing care, thus containing insurance company costs in the short term without consideration of the adverse sequelae of undertreated illness (eg, increased costs of other medical services and increased morbidity, mortality, and costs to society in increased disability). The authors of the guidelines conclude that, given appropriate medical necessity guidelines at parity with other medical care, consistent with provider expertise and a broad range of psychotherapy research, there would be no need or place for utilization review protocols. Individuals and psychotherapy organizations are invited to visit the website psychotherapyparity.org to sign on to the guidelines to indicate agreement and support.

Psychodynamic treatment provides benefits for patients with personality disorders, chronic depressive and anxiety disorders, and chronic complex disorders, and its intensity and duration have independent positive effects. Obstacles to its provision include a bias privileging brief treatments, especially cognitive behavior therapy , seen as a gold standard of treatment, despite difficulties with the design of, and ability to generalize from, its supporting research and the diagnostic nosology of the illnesses studied. Another obstacle lies in insurance company protocols that violate the mandate for mental health parity and focus on conserving insurers' costs rather than the provision of optimum treatment to patients.

Back to table of contents Previous article Psychiatry and PsychotherapyFull AccessCost-Effectiveness and the Role of Psychodynamic PsychotherapiesSusan G. Lazar,M.D.Susan G. Lazar,Search for more papers by this authorM.D.Published Online:15 Dec 2016https://doi.org/10.1176/appi.pn.2016.12b18AbstractIn 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.2012.1203034115. 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.2009.0904053916. 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.08m04200gre35. 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/kph01438. 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/s026646230999079139. 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.0000386907.99536.75Susan G. Lazar, M.D., is a clinical professor of psychiatry at Georgetown University School of Medicine, George Washington University School of Medicine, and the Uniformed Services University of the Health Sciences. She is also a supervising and training analyst at the Washington Psychoanalytic Institute. This column is coordinated by the Committee on Psychotherapy of the Group for the Advancement of Psychiatry. ISSUES NewArchived

Though psychiatric residents are expected to be competent psychotherapists on graduation, further growth in skill and versatility requires continued experience in their ongoing career. Maturity as a psychotherapist is essential because a psychiatrist is the only mental health provider who, as a physician, can assume full responsibility for biopsychosocial patient care and roles as supervisor, consultant, and team leader. Graduating residents face an environment in which surveys show a steady and alarming decline in practice of psychotherapy by psychiatrists, along with a decline in job satisfaction. High educational debts, practice structures, intrusive management, and reimbursement policies that devalue psychotherapy discourage early career psychiatrists from a practice style that enables providing it. For the early-career psychiatrist there is thus the serious risk of being unable to develop a critical mass of experience or a secure identity as a psychiatric psychotherapist. Implementation of parity laws and the Affordable Care Act (ACA) will affect the situation in unpredictable ways that call for vigilance and active response. Additional service and administrative demands may result from the ACA, creating ethical dilemmas about meeting urgent patient needs versus biopsychosocial standards of care. The authors recommend 1) vigorous advocacy for better payment levels for psychotherapy and freedom from disruptive management; 2) aggressive action against violations of the parity act, 3) active preparation of psychiatric residents for dealing with career choices and the environment for providing psychotherapy in their practice, and 4) post-graduate training in psychotherapy through supervision/consultation, continuing education courses, computer instruction, and distance learning.

Guest Editors' IntroductionSusan G. Lazar and Frank E. YeomansSusan G. LazarSearch for more papers by this author and Frank E. YeomansSearch for more papers by this authorPublished Online:September 2014https://doi.org/10.1521/pdps.2014.42.3.347PDFPDF PLUS ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations About Previous article Next article FiguresReferencesRelatedDetails Volume 42Issue 3Sep 2014 Information© 2014 The American Academy of Psychoanalysis and Dynamic PsychiatryPDF download

While it is known that psychiatric illness and subclinical psychiatric illness can be very disabling, their impact on workers' productivity has been little appreciated or appropriately addressed. Complex variables are involved in fashioning an appropriate policy to ameliorate the impact of mental illness on productivity including the identification of effective treatments and potential negative effects of controlling patients' access to them. The cost-effectiveness of such treatments is considered from the differing perspectives and goals of the various stakeholders involved, including employers, insurers, and workers with psychiatric illness. Depression in workers leads to significant absenteeism, "presenteeism" (diminished capacity due to illness while still present at work), and significantly increased medical expenses in addition to the costs of psychiatric care. In addition to the specific usefulness of psychotropic medication, there are a variety of studies on the cost-effectiveness of different psychotherapeutic treatments that improve health and productivity in psychiatrically ill workers. Research indicates the usefulness of approaches including employee assistance programs, specialized cognitive-behavioral treatments, and brief and longer term psychodynamic interventions. It is clear that substance abuse disorders and especially depression and subsyndromal depression have a profound negative effect on work productivity and increases in medical visits and expenses. The current system of mental health care suffers from ignorance of the negative effects of psychiatric illness in workers, from a lack of subtle awareness of which treatments are most appropriate for which diagnoses and from the reluctance by payers to invest in them. Access to evidence-based appropriate treatment can improve the negative impact on productivity as well as workers' health. This article considers these issues and argues for a role of psychotherapy in the treatment of mental illness and substance abuse from the perspective of worker productivity.

Biographical Sketch of Guest EditorsSusan G. Lazar and Frank Elton YeomansSusan G. Lazar9104 Quintana Drive, Bethesda, MD 20817. [email protected]Search for more papers by this author and Frank Elton Yeomans286 Madison Avenue, PH, New York, NY 10017. [email protected]Search for more papers by this authorPublished Online:September 2014https://doi.org/10.1521/pdps.2014.42.3.345PDFPDF PLUS ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations About"Biographical Sketch of Guest Editors." , 42(3), pp. 345–346 Previous article Next article FiguresReferencesRelatedDetails Volume 42Issue 3Sep 2014 Information© 2014 The American Academy of Psychoanalysis and Dynamic PsychiatryPDF download

The objective was to review established literature on approaches to the psychotherapy of borderline personality disorder with specfic reference to suicide in order to determine if there were common factors across these efforts that would guide future teaching, practice and research. The publications from the proponents of five therapies for the treatment of suicidal behavior in individuals with borderline personality disorder (BPD), were reviewed and discussed by the members of the Group for the Advanced of Psychiatry, Psychotherapy Committee (GAPPC). Twenty nine published research and summary reports were reviewed of the specific treatments noted above along with two other reviews of common factors for this group of treatments. We used expert consensus as to the salient articles for review and the appropriate level of abstraction for the common factor definition. We formulated a definition of effectiveness and identified six common factors: 1) negotiation of a specific frame for treatment, 2) recognition and insistence on the patient's responsibilities within the therapy, 3) provision to the therapist of a conceptual framework for understanding and intervening, 4) use of the therapeutic relationship to engage and address suicide, 5) prioritization of suicide as a topic to be actively addressed whenever it emerges, and 6) provision of support for the therapist in the form of supervision, consultation or peer support. We discuss common factors, their formulation, and implications for development and teaching of psychotherapeutic approaches specific to suicide in patients with borderline personality disorder and note that there should be greater attention in practice and education to these issues.

Psychotherapy is an effective and often highly cost-effective medical intervention for many serious psychiatric conditions. Psychotherapy can also lead to savings in other medical and societal costs. It is at times the firstline and most important treatment and at other times augments the efficacy of psychotropic medication. Many patients are in need of more prolonged and intensive psychotherapy, including those with personality disorders and those with chronic complex psychiatric conditions often with severe anxiety and depression. Many patients with serious and complex psychiatric illness have experienced severe early life trauma in an atmosphere in which family members or caretakers themselves have serious psychiatric disorders. Children and adolescents with learning disabilities and those with severe psychiatric disorders can also require more than brief treatment. Other diagnostic groups for whom psychotherapy is effective and cost-effective include patients with schizophrenia, anxiety disorders (including posttraumatic stress disorder), depression, and substance abuse. In addition, psychotherapy for the medically ill with concomitant psychiatric illness often lowers medical costs, improves recovery from medical illness, and at times even prolongs life compared to similar patients not given psychotherapy. While "cost-effective" treatments can yield savings in healthcare costs, disability claims, and other societal costs, "cost-effective" by no means translates to "cheap" but instead describes treatments that are clinically effective and provided at a cost that is considered reasonable given the benefit they provide, even if the treatments increase direct expenses. In the current insurance climate in which Mental Health Parity is the law, insurers nonetheless often use their own non-research and non-clinically based medical necessity guidelines to subvert it and limit access to appropriate psychotherapeutic treatments. Many patients, especially those who need extended and intensive psychotherapy, are at risk of receiving substandard care due to inadequate insurance reimbursement. These patients remain vulnerable to residual illness and the concomitant sequelae in lost productivity, dysfunctional interpersonal and family relationships, comorbidity including increased medical and surgical services, and increased mortality.

The prevalence in active duty military service members of 30-day DSM-IV psychiatric disorders, including posttraumatic stress disorders and major depressive disorder, is greater than among sociodemographically-matched civilians. Only 23-40% of returning military who met strict criteria for any mental health problem in 2004 had received professional help in the past year. One-fourth of Regular Army soldiers meet criteria for a 30-day DSM-IV mental disorder, two-thirds of whom report a pre-enlistment age of onset. Both pre- and post-enlistment age of onset are predictors of severe role impairment which was reported by 12.8% of respondents. In addition, three-fifths of those with severe role impairment had at least one psychiatric diagnosis. The number of deployments, especially three or more, is positively correlated with all disorders, especially major depressive disorder, bipolar disorder, generalized anxiety disorder, posttraumatic stress disorder, and intermittent explosive disorder. Patients with posttraumatic stress disorder and major depressive disorder frequently have comorbidity with other psychiatric diagnoses and an increased death rate from homicide, injury, and cardiovascular disease, and are at increased risk of medical illness, smoking and substance abuse, decreased employment and work productivity, marital and family dysfunction and homelessness. Active duty suicides have increased from a rate lower than among civilians to one exceeding that in civilians in 2008. Suicides among veterans climbed to 22 per day in 2010 with male veterans having twice the risk of dying from suicide as their civilian counterparts. Associated extremely high costs of psychiatric illness in decreased productivity and increased morbidity and mortality can be ameliorated with appropriate treatment which is not yet fully available to veterans in need. In addition, Veterans Administration/Department of Defense treatment guidelines to date do not recognize the need for intensive and extended psychotherapies for chronic complex psychiatric conditions including personality disorders and chronic anxiety and depressive disorders. It has been suggested that treatment should be available for all military service member mental illness regardless of whether or not it predates military service, a goal which remains distant.

Goals. The use of motivational interviewing (MI) when the goals of patient and physician are not aligned is examined. A clinical example is presented of a patient who, partly due to anxiety and fear, wants to opt out of further evaluation of his hematuria while the physician believes that the patient must follow up on the finding of hematuria. Background. As patients struggle in making decisions about their medical care, physician interactions can become strained and medical care may become compromised. Physicians sometimes rely on their authority within the doctor-patient relationship to assist patients in making decisions. These methods may be ineffective when there is a conflict in motivations or goals, such as with patient ambivalence and resistance. Furthermore, the values of patient autonomy may conflict with the values of beneficence. Method. A patient simulation exercise is used to demonstrate the value of MI in addressing the motivations of a medical patient when autonomy is difficult to realize because of a high level of resistance to change due to fear. Discussion. The salience of MI in supporting the value of patient autonomy without giving up the value of beneficence is discussed by providing a method of evaluating the patient’s best interests by psychotherapeutically addressing his anxious, fear-based ambivalence. (Journal of Psychiatric Practice 2013;19:98–108)

Back to table of contents Previous article Next article From the ExpertsFull AccessThe Economics of Providing PsychotherapySusan G. Lazar, M.D.Susan G. LazarSearch for more papers by this author, M.D.Published Online:7 Sep 2012https://doi.org/10.1176/pn.47.17.psychnews_47_17_12-bMental illness is the leading cause of global disability, accounting for one-third of disability worldwide, according to 2008 data from the World Health Organization. In the United States, costs of mental illness are 7 percent of total health care expenditures, with the indirect costs substantially higher at 2 percent of U.S. GDP. Over a lifetime, 50 percent of the population will suffer from at least one psychiatric disorder, and each year, nearly 30 percent of adults have a diagnosable psychiatric disorder. Of patients treated, only 32.7 percent receive minimally adequate treatment, the greatest likelihood of receiving it being highest in the mental health service sector and lowest in the general medical sector, which treats the majority of psychiatric patients. Most U.S. psychiatric patients remain untreated or poorly treated.Psychotherapy is often unrecognized as a low-cost, effective lever to decrease many kinds of costs caused by mental illness. Psychotherapy is defined broadly as treatment of one or more patients with psychological processes, primarily through talking, and includes a therapeutic relationship and a trained therapist. It can include individual, family, and group treatment from several theoretical orientations. Its effectiveness has been established for many conditions, and a growing body of evidence indicates that psychotherapy is cost-effective; reduces disability, morbidity, and mortality; and at times leads to a reduction of medical and surgical services.Psychotherapy is especially cost-effective for severe disorders, including schizophrenia, bipolar affective disorder, and borderline personality disorder, by leading to improved work functioning and decreased use of hospitalization.To contain costs, many managed care programs employ as psychotherapists mental health workers with no graduate training. Mojtabai and Olfson reported in 2008 that in U.S. office-based psychiatry practices from 1996 through 2005, psychiatrists provided increasingly more pharmacotherapy and less psychotherapy. Managed care has stressed short-term treatment and biological approaches for mental illness, leaving at risk patients who require a more intensive course of psychotherapy, either alone or in conjunction with psychotropic medication.Cost-effective analyses determine the relationship between the value of an intervention and its economic impact. Benefits, often difficult to measure economically, include increased earnings of the individual affected, improved role functioning in terms of family and economic behavior, and improved physical and mental health.“Cost-effective” does not mean “cheap.” It refers to the value returned per dollar spent (as opposed to cost reduction or dollars saved) and indicates a measure of efficiency that can at times be improved by spending more and at times less. Focusing solely on cost reduction may actually result in increased inefficiency. In fact, the need to demonstrate that psychotherapy provides cost savings in medical and surgical services, or “cost-offset,” is a double standard for psychotherapy compared with other medical treatments.Three percent of the population has been in outpatient therapy, with the poor and near-poor using long-term treatment in proportion to their numbers in the population, disconfirming the stereotype of psychotherapy as an unnecessary self-indulgence for the affluent. Just as sicker people consume more services for most chronic medical conditions, patients in long-term psychotherapy (over 20 sessions) comprise 16 percent of therapy patients, account for 63 percent of psychotherapy costs, are more distressed and in poorer general health, have higher general medical costs and more functional impairment, are more likely to need psychotropic medication, and more likely to have a psychiatric hospitalization than patients in short-term therapy. Despite fear that readily available outpatient psychotherapy would be overused, a Rand Corporation study demonstrated that when weekly outpatient psychotherapy is fully covered, only 4.3 percent of the insured population uses it for an average of 11 sessions.In an update of their 1994 study published in the November 2002 American Journal of Psychiatry, Olfson, Marcus, and Druss found no change in the overall rate of use of psychotherapy from 1987 to 1997, but the number of visits per patient was significantly lower, with a marked decline in the proportion of patients in longer-term psychotherapy from 15.7 percent to 10.3 percent. In 1987 a much larger percentage of psychotherapy patients (61.5 percent) were also receiving medication. One-third of psychotherapy patients received only one or two sessions, indicating that there is a decreased emphasis on a psychotherapeutic approach and that much of the psychotherapy in the United States is shallow and of limited benefit.For years insurance companies have limited coverage for psychotherapy with higher copayments, stricter yearly limits, and lower lifetime limits than for other medical care. Despite the widespread assumption that psychotherapy benefits will be overused and inflate health care expenditures more than other medical benefits, studies document that higher copayments for mental health services reduce both initial access to and treatment intensity of mental health care and impact patients at all levels of clinical need. Very ill psychiatric patients are equally affected by discriminatory copayments, and managed care has caused a generalized reduction of psychiatric care.In reality, there is a very low additional expense for providing parity for all appropriate treatments for mental illness, and a 2005 study found that parity increased costs by a few percentage points at most, reduced out-of-pocket costs for patients, and should be affordable on a national level.In October 2008, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act mandating insurance coverage for mental health treatment equal to that for other medical care was signed into law. The mandate applies to insurance plans that already cover mental health care in plans covering 50 or more, does not preempt stronger state laws, and took effect in 2010.The volume Psychotherapy Is Worth It: A Comprehensive Review of Its Cost-Effectiveness examines the literature on the cost-effectiveness of psychotherapy for the years 1994 through 2007. For some illnesses (anxiety disorders, posttraumatic stress disorder, and substance abuse), cost-effectiveness can be demonstrated indirectly by comparing the high costs of the untreated illness with the known efficacy of specific psychotherapeutic treatments. The majority of the studies document the cost-effectiveness of the psychotherapeutic treatments for schizophrenia, borderline personality disorder, depression, and psychiatric illness in medical patients and for chronic anxiety, depression, and personality disorders requiring extended and intensive psychotherapy. Susan G. Lazar, M.D., is a clinical professor of psychiatry at Georgetown University School of Medicine, George Washington University School of Medicine, and the Uniformed Services University of the Health Sciences. She is a supervising and training analyst at the Washington Psychoanalytic Institute. She is the coauthor and editor of Psychotherapy Is Worth It: A Comprehensive Review of Its Cost-Effectiveness from American Psychiatric Publishing. APA members can order the book at a discount at www.appi.org/SearchCenter/Pages/SearchDetail.aspx?ItemId=7215. ISSUES NewArchived