In This Issue

Combining psychotropic medications and psychotherapy generally leads to improved outcomes and therefore reduces the overall cost of care

Is a combination of psychotherapy and pharmacotherapy more effective than medication alone for most mental disorders? Do combinations reduce the cost of care?

By Morgan T. Sammons, PhD, and Kevin M. McGuinness, PhD, ABPP

Disclaimer: This article was prepared by the authors in their private capacities. The opinions expressed in this article are the authors' own and do not necessarily reflect the opinions of the U.S. Public Health Service, the Health Resources and Services Administration, the Department of Health and Human Services, the United States government or any other.

In this brief research paper we provide recent findings answering two key points. We first ask if a combination of psychotherapy and pharmacotherapy are more effective than medication alone for most mental disorders. Then we ask if combinations of psychotherapy and pharmacotherapy reduce the cost of care.

To answer this, we queried PubMed, the National Library of Medicine's online database. We only examined studies that included a cost component and a comparison between the addition of medicine or psychotherapy to treatment as usual, or to an existing regimen. We looked mainly at studies conducted in the US, but there is a large body of work from Europe and Great Britain that also supports the cost-efficacy of combined treatment (e.g., Wiles et al, 2010; Richards, et al., 2013). 1,2,3 Almost all the studies we examined were published in the past decade.

Please note that this is a brief research paper, not an in-depth review, so conclusions must be interpreted with caution. We believe, however, that this brief review is reflective of findings in the larger clinical literature. A summary of key points follows:

1. The number of Americans seeking treatment for depression and other mental health problems has increased dramatically in the past several decades. Most patients, however, receive only medication, and the percentage of patients receiving psychotherapy instead of medication has declined, largely because patients are being treated in primary care settings where only medication is generally available. It is unclear if this results in overall improvement, but it has resulted in a dramatic rise in Medicare costs. 4

2. Most patients prefer psychotherapy to pharmacotherapy; however, a significant number of patients require both interventions in order to achieve clinical improvement in symptoms. Nonetheless, patient preference is a strong determinant of outcome, and most patients prefer either psychotherapy alone or psychotherapy with added medication. Patel and colleagues found that patients with obsessive compulsive disorder preferred psychotherapy alone over medication by a wide margin (43 percent to 16 percent, followed by a combination of psychotherapy and medication. 5

3. A number of individuals do not respond to psychotropic medication alone. For these individuals, the combination of psychotherapy with medication can both improve outcomes and reduce costs. The opposite can also be true. For patients not responding to psychotherapy alone, the addition of pharmacotherapy to the treatment regimen can improve outcomes and lower overall costs. Cost-benefit is measured not only in the additional costs of providing another treatment, but in terms of the effectiveness of those treatments in reducing healthcare utilization and future treatment. In other words, patients who recover more completely are less like to use mental health resources in the future as opposed to those who do not experience significant improvement or only achieve partial remission. Van Aapeldorn and colleagues found that in patients with depression and panic disorder, patients preferred either psychotherapy or a combination of psychotherapy and medication. The cost of either of these was overall less than medication alone. 6 Lynch et al. (2011) examined combination psychotherapy in depressed youth who had not responded to an antidepressant, and found that combination treatment, while having a higher initial cost, was significantly more cost-effective in the long run. 7 Even in patients with serious and persistent mental illness, such as schizophrenia, the addition of psychotherapy to a medication regimen often reduces the need for subsequent inpatient admission and is highly cost-effective. 8 Similarly, the addition of medication to psychotherapy for patients to one to three sessions of psychotherapy for depression (note that this number of sessions is generally lower than that thought needed for effective treatment) improved costs and outcomes. 9 Other authors have recommended that cognitive behavioral therapy be offered to all patients who have not responded to a trial of antidepressants. 10 More recent findings note that adding cognitive therapy to medication improves outcomes, largely among more depressed patients, for whom the cost of care is likely to be higher. 11 In primary care settings, where use of medication is the predominant form of treatment, cost analyses have found that increasing primary care providers' skill in offering behavioral interventions may serve as a significant cost reducer. 12

4. In patients with both physical and psychological illness, the addition of a psychotherapy treatment can reduce the cost of care and improve overall cost-effectiveness. A large study of Hispanic Americans with diabetes found very significant reductions in cost and improvements in cost-effectiveness by adding psychotherapy to a treatment regimen. 13

In a very large study of patients with anxiety disorders, Joesch et al. (2012) found that while adding psychotherapy to a medication alone treatment resulted in a small initial cost increase, the cost-benefit equation was positive in the longer term. 14

Another large study of enhanced treatment of panic disorder in emergency departments found significantly enhanced clinical outcomes as well as enhanced cost-benefit ratios (less expensive than medication alone) for providing behavioral management of panic in emergency departments. This is a particularly important study in that Emergency Department visits are not only extremely costly overall, but often result only in the patient receiving a prescription and a future referral to a mental health provider. Incremental cost-effectiveness ratios indicated that behavioral interventions were approximately one-half the cost of medication alone. 15

Other large trials have found not only that patients prefer treatments with either psychotherapy alone or with medication added to psychotherapy, but also that patient preference is a strong determinant of outcome. In a study of 200 patients with Post-Traumatic Stress Disorder, Le et al. (2014) found highly significant improvements in quality of life and significant cost-efficacy of care for those receiving psychotherapy in addition to medication and for those who got the treatment they preferred. 16 Another review, however, while reporting promising results, could not conclude that combination therapies for PTSD yielded better outcomes or cost-savings than individual interventions alone. 17

5. If a patient is receiving multiple prescriptions for the same problem (polypharmacy), adding psychotherapy can significantly reduce the number of prescriptions, with significant reductions in cost and improvement in outcome. One study found cost savings of over $250,000 annually by reducing the number of prescriptions given to troubled youth in a residential treatment center. 18

6. For patients with addictive disorders, such as alcoholism or nicotine dependence, which are among the most costly disorders in terms of expense and public health burden, or those who desire to stop smoking, combined treatments have repeatedly been demonstrated to be either more effective than medication alone (and, in the case of nicotine dependence, not only cost effective but potentially life-saving). 19 ,20 Sleep disorders are also extremely common and therefore costly. In the case of sleep disorders, either psychotherapy alone or a combination of psychotherapy with sleep medication clearly leads to better outcomes and reduced costs. 21 ,22

7. Polypharmacy is an important risk factor for falls among middle-aged and older adults. 23, 24 Psychotherapy and pharmacotherapy have been shown to be of equivalent efficacy. 25, 26 The adverse side effects of antidepressant, antianxiety and antipsychotic medications, which may include increased risk of complicating illnesses, injuries, and death, are not associated with EB psychotherapies. 27, 28 Therefore, the use of polypharmacy when evidence based (EB) psychotherapeutic alternatives exist, such as Cognitive Behavior Therapy (CBT), may not only be costlier, but also riskier.

The reduction of polypharmacy through the use of alternative EB psychotherapies is not only equally effective, but less costly in consideration of the prevention of avoidable morbidity and mortality.

Footnotes

1. Wiles, N. Thomas, L., Abel, A., Barnes, M., Carroll, F. et al (2014). Clinical effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: the CoBalT randomised controlled trial. Health Technology Assessment, 18, 1-167.

2. Richards, D. A., Hill, J. J., Gask, L., Lovell, K., Chew-Graham, C., et al. (2013). Clinical effectiveness of collaborative care for depression in UK primary care (CADET): cluster randomised controlled trial. British Medical Journal, 19, 347:f4913 . doi: 10.1136/bmj.f4913.

3. Fernández-Arias, I., Labrador, F.J., Estupiñá, F.J., Bernaldo de Quirós, M., Alonso, P, et al. Does adding pharmaceutical medication contribute to empirically supported psychological treatment for anxiety disorders? Psicothema, 25, 313-318. doi: 10.7334/psicothema2012.238.

4. Marcus, S. C., & Olfson, M. (2010). National trends in the treatment for depression from 1998 to 2007. Archives of General Psychiatry, 67 , 1265-1273. doi: 10.1001/archgenpsychiatry.2010.151

5. Patel, S.R., & Simpson, H.B. (2010). Patient preferences for obsessive-compulsive disorder treatment. Journal of Clinical Psychiatry, 71, 1434-1439. doi: 10.4088/JCP.09m05537blu.

6. van Apeldoorn, F.J., Stant, A.D., van Hout, W.J., Mersch, P.P., & den Boer, J. A.(2014). Cost-effectiveness of CBT, SSRI, and CBT+SSRI in the treatment for panic disorder. Acta Psychiatrica Scandinavica, 129, 286-295. doi: 10.1111/acps.12169. Epub 2013 Jul 3.

7. Lynch, F.L., Dickerson, J.F., Clarke, G., Vitiello, B., Porta, G., Wagner, K.D., et al. (2011). Incremental cost-effectiveness of combined therapy vs medication only for youth with selective serotonin reuptake inhibitor-resistant depression: treatment of SSRI-resistant depression in adolescents trial findings. Archives of General Psychiatry, 68, 253-262. doi: 10.1001/archgenpsychiatry.2011.9.

8. Karow, A., Reimer, J., König, H.H., Heider, D., Bock,T, et al. (2012). Cost-effectiveness of 12-month therapeutic assertive community treatment as part of integrated care versus standard care in patients with schizophrenia treated with quetiapine immediate release (ACCESS trial). Journal of Clinical Psychiatry, 73, 402-408. doi: 10.4088/JCP.11m06875.

9. Watkins, K.E., Burnam, M.A., Orlando, M., Escarce, J.J., Huskamp, H.A., et al. (2009). The health value and cost of care for major depression. Value Health, 12, 65-72. doi: 10.1111/j.1524-4733.2008.00388.x.

10. Button, K.S., Turner, N., Campbell, J., Kessler, D., Kuyken, W. et al. (2014). Moderators of response to cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care. Journal of Affective Disorders, 174 , 272-280. doi: 10.1016/j.jad.2014.11.057. [Epub ahead of print]

11. Hollon, S. D., DeRubeis, R. J., Fawcett, J., Amsterdam, J. A., Shelton, R. C., et al. (2014). Effects of Cognitive therapy with antidepressants alone on the rate of recovery in major depressive disorder: A randomized clinical trial. JAMA Psychiatry, 71 , 1157-1164. doi:10.1001/jamapsychiatry.2014.1054.

12. Lokkerbol, J., Weehuizen, R., Mavranezouli, I., Mihalopoulos, C., & Smit, F. (2014). Mental health care system optimization from a health-economics perspective: where to sow and where to reap? Journal of Mental Health Policy and Economics, 17, 51-60.

13. Hay, J.W., Katon, W.J., Ell, K., Lee, P.J., & Guterman, J.J. (2012). Cost-effectiveness analysis of collaborative care management of major depression among low-income, predominantly Hispanics with diabetes. Value Health, 15, 249-254. doi: 10.1016/j.jval.2011.09.008. Epub 2011 Dec 15.

14. Joesch, J.M., Sherbourne, C. D., Sullivan. G., Stein, M.B., Craske, M.G., & Roy-Byrne, P. (2012). Incremental benefits and cost of coordinated anxiety learning and management for anxiety treatment in primary care. Psychological Medicine, 42, 1937-1948. doi: 10.1017/S0033291711002893. Epub 2011 Dec 13.

15. Poirier-Bisson, J., Marchand, A., Pelland, M.E., Lessard, M.J., Dupuis, G., Fleet, R., & Roberge, P. (2013). Incremental cost-effectiveness of pharmacotherapy and two brief cognitive-behavioral therapies compared with usual care for panic disorder and noncardiac chest pain. Journal of Nervous and Mental Disorders, 201, 753-759. doi: 10.1097/NMD.0b013e3182a2127d.

16. Le, Q.A., Doctor, J.N., Zoellner, L.A., & Feeny, N.C. (2014). Cost-effectiveness of prolonged exposure therapy versus pharmacotherapy and treatment choice in posttraumatic stress disorder (the Optimizing PTSD Treatment Trial): a doubly randomized preference trial. Journal of Clinical Psychiatry, 75, 222-230. doi: 10.4088/JCP.13m08719.

17. Hetrick, S.E., Purcell, R., Garner, B., & Parslow,R. (2010). Combined pharmacotherapy and psychological therapies for post traumatic stress disorder (PTSD). Cochrane Database Systematic Reviews, 7 ;(7):CD007316. doi: 10.1002/14651858.CD007316.pub2.

18. van Wattum, P.J., Fabius, C., Roos, C., Smith, C., & Johnson, T. (2013). Polypharmacy reduction in youth in a residential treatment center leads to positive treatment outcomes and significant cost savings. Journal of Child and Adolescent Psychopharmacology, 23, 620-627. doi: 10.1089/cap.2013.0014.

19. Zarkin, G.A., Bray, J.W., Aldridge, A., Mitra, D, Mills, M.J., et al. (2008). Cost and cost-effectiveness of the COMBINE study in alcohol-dependent patients. Archives of General Psychiatry, 65, 1214-1221. doi: 10.1001/archpsyc.65.10.1214.

20. Ruger, J. P., & Lazar, C. M. (2012). Economic evaluation of pharmaco- and behavioral therapies for smoking cessation: a critical and systematic review of empirical research. Annual Review of Public Health, 33, 279-305. doi: 10.1146/annurev-publhealth-031811-124553. Epub 2012 Jan 3.

21. Britton, W.B., Haynes, P.L., Fridel, K.W., & Bootzin, R.R. (2012). Mindfulness-based cognitive therapy improves polysomnographic and subjective sleep profiles in antidepressant users with sleep complaints. Psychotherapy and Psychosomatics, 81, 296-304. doi: 10.1159/000332755. Epub 2012 Jul 20.

22. Morin, C. M., Vallieres, A., Guay, B., Ivers, H. Savard J., et al (2009). Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. Journal of the American Medical Association, 301 , 2005-2015. doi: 10.1001/jama.2009.682.

23. Browne, C., C. Kingston, C., & Keane, C.. Falls Prevention Focused Medication Review by a Pharmacist in an Acute Hospital: Implications for Future Practice.” International Journal of Clinical Pharmacy , 3,5 (2014): 969-75. Web.

24. Richardson, K., K. Bennett, and R. Kenny. “Polypharmacy Including Falls Risk-Increasing Medications and Subsequent Falls in Community-Dwelling Middle-Aged and Older Adults.” Age and Ageing 1st ser. 44 (2015): 90-96. Web.

25. Spielmans, Glen I., Margit I. Berman, and Ashley N. Usitalo. “Psychotherapy Versus Second-Generation Antidepressants in the Treatment of Depression.” The Journal of Nervous and Mental Disease 199.3 (2011): 142-49. Web.

26. Spielmans, Glen, Eowyn Gatlin, and Joseph Mcfall. “The Efficacy of Evidence-based Psychotherapies versus Usual Care for Youths: Controlling Confounds in a Meta-reanalysis.” Psychotherapy Research, 20 .2 (2010): 234-46. Web.

27. Donoghue, O. A., O'Hare C, B. King-Kallimanis, and R. A. Kenny. “Antidepressants Are Independently Associated with Gait Deficits in Single and Dual Task Conditions .” American Journal of General Psychiatry 23 .2 (2015): 189-99. Web.

28. Wu, Yu-Hsuan, Chun-Yang Lai, and Yu-San Chang. “Antipsychotic Polypharmacy among Elderly Patients with Schizophrenia and Dementia during Hospitalization at a Taiwanese Psychiatric Hospital.” Psychogeriatrics (2015): N/a. Web.