Cost-Effectiveness of Cognitive-Behavioural Therapy for Mental Disorders: Implications for Public Health Care Funding Policy in Canada

Article excerpt

Objective: Publicly funded cognitive-behavioural therapy (CBT) for mental disorders is scarce in Canada, despite proven efficacy and guidelines recommending its use. This paper reviews published data on the economic impact of CBT to inform recommendations for current Canadian mental health care funding policy.

Method: We searched the literature for economic analyses of CBT in the treatment of mental disorders.

Results: We identified 22 health economic studies involving CBT for mood, anxiety, psychotic, and somatoform disorders. Across health care settings and patient populations, CBT alone or in combination with pharmacotherapy represented acceptable value for health dollars spent, with CBT costs offset by reduced health care use.

Conclusions: International evidence suggests CBT is cost-effective. Greater access to CBT would likely improve outcomes and result in cost savings. Future research is warranted to evaluate the economic impact of CBT in Canada.

(Can J Psychiatry 2006;51:662-670)

Information on funding and support and author affiliations appears at the end of the article.

Clinical Implications

* For anxiety and depression, treatment with evidence-based care packages featuring CBT costs less and increases societal benefit, compared with current care featuring medication use.

* For treatment-resistant depression and psychosis, the addition of CBT typically costs no more than usual care, with cost offsets related to reduced health care resource use.

* Greater accessibility of CBT could produce significant cost savings to the Canadian government in conjunction with better mental health outcomes.

Limitations

* No studies included training or start-up costs of implementing more widespread CBT.

* Studies typically measured narrow cost and outcome variables over a relatively short time.

* More research is necessary to assess the extent to which the results from other countries are generalizable to Canada.

Key Words: costs, cost-effectiveness, economic, cognitive-behavioural therapy, mental disorders

Abbreviations used in this article

CBT cognitive-behavioural therapy

CC cost consequence analysis

CEA cost-effectiveness analysis

CGI Clinical Global Impression

DALY disability adjusted life year

DFD depression-free day

EQ-5D EuroQol 5D

GAD generalized anxiety disorder

GAF Global Assessment of Functioning

GP general practitioner

ICER incremental cost-effectiveness ratio

MDD major depressive disorder

PANSS Positive and Negative Syndrome Scale

PD panic disorder

PTSD posttraumatic stress disorder

QALY quality adjusted life year

RC routine care

RCT randomized controlled trial

SP social phobia

SSRI selective serotonin reuptake inhibitor

TAU treatment as usual

TCA tricyclic antidepressant

UC usual care

YLD years living with disability

The total cost of mental illness in Canada has been estimated at $ 14.4 billion ( 1998 dollars), which includes both direct and indirect costs ( 1 ). Mental illness accounts for more than 50% of physician billing and uses more hospital bed-days than cancer (2).

Medications are considered first-line, mainstay treatment for mental health disorders and contribute most to rising care costs (3). There is growing interest, therefore, in nonpharmacologic interventions with strong empirical support, such as CBT.

CBT is a time-limited, evidence-based psychotherapy that is as efficacious as medication as a sole intervention in anxiety disorders and MDD (4). As an adjunct to medication, CBT has improved outcomes in schizophrenia (5) and bipolar disorder (4). Published guidelines, including Canadian ones, recommend CBT as a component of optimal care (6-9). Advantages of CBT over pharmacotherapy include fewer dropouts (10) and relapses (11), higher satisfaction (12), and fewer side effects. …