In 2006, a research paper was published in the Canadian Journal of Psychiatry, where the authors argued for greater public access to psychotherapy - specifically Cognitive Behavioural Therapy (CBT). To make their point, the authors did not rely on emotional appeals to compassion or empathy for those in need. Rather, they examined the very thing that directs much of the decision-making in government - the cost.
I have no idea whether any government officials read this paper, but recent changes in mental health benefits for federal employees in Canada suggest someone must be paying attention to the research. As of October 1, 2014, members of the Public Service Health Care Plan will now be reimbursed up to $2000 per year for psychological services.
Given the results of research on the cost-effectiveness of therapy, such an increase should be viewed as an investment.
The Costs
The alarm bells for mental illness having been sounding for some time in public discourse, and the research supports every bit of the hand-wringing. The prevalence of mental illness is fairly high (the 1 in 5 people estimate is likely too low), costs the Canadian economy $14.4 billion annually, and leads to the occupation of more hospital beds than cancer. Let me give a more concrete example of the costs - in 1999/2000, mental illness in Canada accounted for 9,022,382 of days spent in hospital - an average of 45 days per person.
The considerable price tag of mental illness comes at a time when the provincial governments in Canada are having to brainstorm ways of containing unsustainable health care costs.
Which brings us back to the 2006 article examining the cost-effectiveness of CBT.
CBT is now the most popular form of psychotherapy in the Western world, which is due in large part to the tremendous amount of research on its effectiveness. Hundreds of outcome studies have shown that CBT is just as effective as medication for depression and anxiety, and tends to have a lower relapse rate than medication for depression.
In terms of cost-effectiveness, the research shows that CBT is more cost-effective than medication. A major reason for this outcome is due to the fact that patients who use CBT instead of medication make less use of health services following treatment.
For example, patients with clinical depression who receive CBT have been found to relapse around 29% of the time, whereas those who take antidepressants have a relapse rate of 60%. Similarly, panic disorder (PD) tends to respond very well to CBT, but can also be effectively treated with medication. Those who are treated with the medication for PD (ex: imipramine) may have lower costs than CBT after 1 year of treatment, but after two years the cost of medication surpasses therapy. This long-term cost-effectiveness occurs arguably because people who are successfully treated with CBT no longer need treatment (or at least need less ongoing treatment), whereas people prescribed medication continuously require treatment over the years.
Given that CBT is at least as effective as medication and costs less, any effort to increase access to such care seems to be the most fiscally prudent option available to the government, employers and insurance agencies alike.
Moving Forward
Ideally, the increase in benefits to federal employees represents only the beginning of such change across the country. Employers would be wise to make comparable changes to employee insurance packages where possible. Trying to save on premiums and having employees rely solely on medication to manage mental illness is a sub-optimal approach, and likely results in greater long-term costs via sick days and lost productivity.
Increasing insurance benefits increases access to private care, which has become a necessity in Canada. Those wanting psychological treatments must either choose between public care (ex: psychologist in a hospital) or private care (ex: psychologist in private practice). Unfortunately, there tend to be unreasonable wait lists for access to public care (typically one year or longer). Access to a psychologist or counsellor in private practice tends to be much faster, which is ideal when dealing with mental illness. However, private practice can be expensive (it is common for costs in Ontario to be around $200 per hour).
The increase in insurance coverage for private, evidence-based psychological care would pay dividends not only to the patient, but also to the employer, economy and society at large.
The economic and societal costs of mental illness are not going to change on their own - and we can no longer consider therapy to be a luxury.
It is an investment -- in every sense of the word.
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