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Note: The authors have worked to ensure that all information in this book is ac-
curate at the time of publication and consistent with general psychiatric and medi-
cal standards, and that information concerning drug dosages, schedules, and routes
of administration is accurate at the time of publication and consistent with stan-
dards set by the U.S. Food and Drug Administration and the general medical com-
munity. As medical research and practice continue to advance, however, therapeutic
standards may change. Moreover, specific situations may require a specific thera-
peutic response not included in this book. For these reasons and because human and
mechanical errors sometimes occur, we recommend that readers follow the advice
of physicians directly involved in their care or the care of a member of their family.
Books published by American Psychiatric Publishing, Inc., represent the views and
opinions of the individual authors and do not necessarily represent the policies and
opinions of APPI or the American Psychiatric Association.
If you would like to buy between 25 and 99 copies of this or any other APPI title,
you are eligible for a 20% discount; please contact APPI Customer Service at
[email protected] or 800-368-5777. If you wish to buy 100 or more copies of the
same title, please e-mail us at [email protected] for a price quote.
Copyright © 2010 American Psychiatric Publishing, Inc.
ALL RIGHTS RESERVED
Manufactured in the United States of America on acid-free paper
14 13 12 11 10 5 4 3 2 1
First Edition
Typeset in Adobe’s Janson and Shannon.
American Psychiatric Publishing, Inc.
1000 Wilson Boulevard
Arlington, VA 22209-3901
www.appi.org
Library of Congress Cataloging-in-Publication Data
Psychotherapy is worth it : a comprehensive review of its cost-effectiveness / edited
by Susan G. Lazar. — 1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-87318-215-7 (pbk. : alk. paper)
1. Mental illness—Treatment. 2. Cost effectiveness. I. Lazar, Susan G., 1944–
II. American Psychiatric Publishing.
[DNLM: 1. Mental Disorders—therapy. 2. Psychotherapy—economics.
3. Cost-Benefit Analysis. 4. Treatment Outcome. WM 420 P974355 2010]
RC475.P736 2010
616.89—dc22
2009052593
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
 Contents

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . vii

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Susan G. Lazar, M.D.
William H. Sledge, M.D.
Gerald Adler, M.D.

2 Psychotherapeutic and Psychosocial Interventions

in Schizophrenia: Clinical Outcomes and
Cost-Effectiveness . . . . . . . . . . . . . . . . . . . . . . . 31
Lawrence H. Rockland, M.D.

3 Psychotherapy in the Treatment of Borderline

Personality Disorder. . . . . . . . . . . . . . . . . . . . . . 61
Robert J. Waldinger, M.D.

4 Psychotherapy in the Treatment of Posttraumatic

Stress Disorder . . . . . . . . . . . . . . . . . . . . . . . . . 87
Susan G. Lazar, M.D.
William Offenkrantz, M.D.
5 Psychotherapy in the Treatment of Anxiety
Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Allan Rosenblatt, M.D.

6 Psychotherapy in the Treatment of Depression. . . 135

Susan G. Lazar, M.D.

7 Psychotherapy and Psychosocial Interventions

in the Treatment of Substance Abuse . . . . . . . . . 175
William H. Sledge, M.D.
James Hutchinson, M.D.

8 Psychotherapy for Patients With Medical

Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
William H. Sledge, M.D.
Joel Gold, M.D.

9 Psychotherapy for Children and Adolescents . . . . 267

Jules Bemporad, M.D.

10 The Place of Long-Term and Intensive

Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . 289
Allan Rosenblatt, M.D.

11 Epilogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
William H. Sledge, M.D.
Susan G. Lazar, M.D.
Robert J. Waldinger, M.D.

Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . 315

Index of Treatment Studies . . . . . . . . . . . . . . . . 341
 Contributors
Susan G. Lazar, M.D., Volume Editor
Past Chair, Committee on Psychotherapy, Group for the Advancement of
Psychiatry; Clinical Professor of Psychiatry, Georgetown University
School of Medicine, George Washington University School of Medicine,
and Uniformed Services University of the Health Sciences; Supervising
and Training Analyst, Washington Psychoanalytic Institute

The Committee on Psychotherapy

Group for the Advancement of Psychiatry
William H. Sledge, M.D.
Chair, Committee on Psychotherapy, Group for the Advancement of Psy-
chiatry
Deputy Chair for Clinical Affairs and Program Development and George D.
and Esther S. Gross Professor of Psychiatry, Yale University School Of
Medicine, New Haven, Connecticut

Gerald Adler, M.D.

Training and Supervising Analyst, Boston Psychoanalytic Society and In-
stitute, Boston, Massachusetts

Jules Bemporad, M.D.

Clinical Professor of Psychiatry, New York Medical College, Valhalla, New
York

Joel Gold, M.D.

Clinical Assistant Professor of Psychiatry, New York University School of
Medicine, New York, New York

James Hutchinson, M.D.

Teaching Analyst, Baltimore Washington Institute of Psychoanalysis,
Washington, D.C.

v
vi Psychotherapy Is Worth It

Susan G. Lazar, M.D.

Past Chair, Committee on Psychotherapy, Group for the Advancement of
Psychiatry; Clinical Professor of Psychiatry, Georgetown University
School of Medicine, George Washington University School of Medicine,
and Uniformed Services University of the Health Sciences; Supervising
and Training Analyst, Washington Psychoanalytic Institute

William Offenkrantz, M.D.

Training and Supervising Analyst, Southwest Psychoanalytic Institute,
Tucson

Lawrence H. Rockland, M.D.

Associate Professor of Clinical Psychiatry Emeritus, Weill Cornell College
of Medicine, New York, New York

Allan Rosenblatt, M.D. (deceased)

Supervising and Training Analyst, San Diego Psychoanalytic Institute;
Clinical Professor, Department of Psychiatry, University of California, San
Diego Medical School, La Jolla, California

Robert J. Waldinger, M.D.

Associate Professor of Psychiatry, Harvard Medical School; Director, The
Laboratory of Adult Development, Brigham and Women’s Hospital, Bos-
ton, Massachusetts

The following authors have no competing interests to report:

Gerald Adler, M.D.
Jules Bemporad, M.D.
Joel Gold, M.D.
James Hutchinson, M.D.
Susan G. Lazar, M.D.
William Offenkrantz, M.D.
Lawrence H. Rockland, M.D.
William H. Sledge, M.D.
Robert J. Waldinger, M.D.
 Acknowledgments
The Editor is especially grateful for the unflagging support of co-author
and current Chair of the Committee on Psychotherapy, Group for the Ad-
vancement of Psychiatry and Yale University School of Medicine George
D. and Esther S. Gross Professor of Psychiatry, William H. Sledge, M.D.;
for the help from his assistants Angelina Wing and Christine Holmberg;
and the support of the George D. and Esther S. Gross Professorship En-
dowment.
The Editor could not have completed this volume without the invalu-
able help of her assistant, Susan P. Priester.
The Committee on Psychotherapy, Group for the Advancement of Psy-
chiatry also wishes to acknowledge a grant for the support of this volume
from the American Psychoanalytic Foundation.

vii
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1
Introduction

Susan G. Lazar, M.D.

William H. Sledge, M.D.
Gerald Adler, M.D.

Mental Illness and Psychotherapy:

Background to Considerations of
Cost-Effectiveness
This volume investigating the cost-effectiveness of psychotherapy examines
many aspects of psychotherapeutic interventions for the major psychiatric
diagnoses. Many variables affect the decision to provide psychotherapy.
Often psychotherapy’s efficacy and its ameliorative effect on patients’ dis-
tress, functioning, family life, and work capacity are not well appreciated.
This volume explores the costs of providing psychotherapy in relation-
ship to the impact of psychotherapy both on health and on the costs of
psychiatric illness and related conditions. Its intended audience includes
psychotherapists, psychiatric benefits providers, policy makers, and others
interested in the efficacy and impact on costs of providing psychotherapeu-
tic treatments.

Epidemiology of Mental Illness

According to the World Health Organization (2008), mental illness is the
leading cause of global disability and the most important cause of disability,
as represented by years lived with disability (YLDs), in adults ages 15 and
over, accounting for one-third of YLDs in all regions. Substance abuse is
the second leading cause of global disability. Neuropsychiatric disorders,
1
2 Psychotherapy Is Worth It

which include mental illness and substance use disorders, are more signifi-
cant contributors to disease burden worldwide than are other noncommu-
nicable diseases such as heart disease and cancer. Mood disorders including
depression are a leading cause of disability for men and women, anxiety is
an important cause in women, and alcohol and drug use disorders are dis-
proportionately high in men. Schizophrenia and related psychotic disor-
ders are the fourth leading cause of all disability in developed countries and
the ninth leading cause of disability in people ages 19–44 worldwide.
The burden of mental illness in the United States and the enormous as-
sociated costs to society as a whole constitute a chronic, insufficiently recog-
nized crisis in the health of the nation. Over a lifetime, 50% of the population
will suffer from at least one psychiatric disorder (Kessler et al. 1994, 2005a),
and every year in the United States, nearly 30% of the adult population
over the age of 18 has a diagnosable psychiatric disorder. In a given year, of
all patients with anxiety, mood, impulse control, and substance abuse disor-
ders, only 41.1% receive treatment, 22.8% from a general medical provider,
16% from a nonpsychiatrist mental health provider, and only 12.3% from a
psychiatrist. Of the patients treated, only 32.7% received minimally adequate
treatment, with the likelihood of receiving minimally adequate care being
highest in the mental health service sector and lowest in the general medical
sector, which treats the majority of these mentally ill patients. In fact, most
people with mental disorders in the United States remain untreated or
poorly treated (Wang et al. 2005a, 2005b). However, despite the greater
likelihood of receiving adequate care from the mental health service sector,
an assessment of shifts in the pattern of mental health provider profile from
that measured in the National Comorbidity Survey (1990–1992) compared
with that measured in the more recent National Comorbidity Survey Rep-
lication (2001–2003) reveals that the general medical only profile has expe-
rienced the largest proportional increase (153%) between the two surveys
and is now the most common provider of mental health services. The psy-
chiatry profile increased 29%, as did the general medical in combination
with other mental health specialty profile, which increased 72% (Wang et
al. 2006).
In 1985 the cost of mental illness was $273 billion per year (Rice et al.
1990), including treatment costs, law enforcement costs, reduced produc-
tivity, and mortality. According to a different and less inclusive accounting,
a 1999 report of the Surgeon General estimated the cost in 1996 of the di-
rect treatment of mental disorders in the United States at $99 billion and
the indirect costs at $79 billion, mostly from lost productivity secondary to
illness and lesser amounts in lost productivity due to premature death or in-
carceration and for the time of individuals providing family care (U.S. De-
Introduction 3

partment of Health and Human Services 1999). Overall mental illness costs
account for approximately 7% of total health care expenditures in the
United States. In addition, the indirect costs of mental illness are substan-
tially higher than the direct costs and account for 2% of U.S. gross domes-
tic product (Hu 2006).

Anxiety Disorders
The most prevalent psychiatric illness is the group of anxiety disorders, which
affect 18.1% of adult Americans every year (Kessler et al. 2005b, 2006) and
28.8% of the population at some time during their lifetime (Kessler et al.
2005a). In addition, 22% of all children and adolescents have an anxiety dis-
order (Kashani and Orvaschel 1990).
The annual cost of anxiety disorders in 1990 was $42.3 billion or $1,542
per patient. The total includes $23 billion (54% of the total) in nonpsychi-
atric medical care costs, $13.3 billion (31%) in psychiatric treatment costs,
$4.1 billion (10%) in indirect workplace costs, $1.2 billion (3%) in mortality
costs, and $0.8 billion (2%) in prescription drug costs. Of the $256 in work-
place costs per worker with anxiety, 88% is due to lost productivity at work as
opposed to absenteeism (Greenberg et al. 1999).

Affective Disorders
Affective disorders affect 19.3% of the U.S. population at some point in
their lives, with major depression being the most common diagnosis affect-
ing 17.1% of adults (Kessler et al. 1994) or 16.6% in the more recent
National Comorbidity Survey Replication (Kessler et al. 2005a). Mood dis-
orders also affect children and adolescents, with up to 2.5% of children and
up to 8.3% of adolescents suffering from depression (Birmaher et al. 1996).
In fact, suicide is the second leading cause of death in adolescent males
(Centers for Disease Control 1986). Depression has a serious negative im-
pact on a patient’s functioning and well-being that is comparable to or
worse than that of eight other serious chronic medical conditions, including
back complaints, hypertension, diabetes, advanced coronary artery disease,
angina, arthritis, pulmonary disease, and gastrointestinal disease (Wells et
al. 1992).
The annual cost of depression in 1990 was $43.7 billion (Greenberg et
al. 1993). In a 10-year update of this study (Greenberg et al. 2003), it was
found that while the treatment rate of depression increased by over 50%, its
economic burden rose only 7% from $77.4 billion in 1990 (inflation ad-
justed dollars) to $83.1 billion in 2001. Of the total, $26.1 billion (31%) were
direct medical costs, $5.4 billion (7%) were suicide-related mortality costs,
and $51.5 billion (62%) were losses in the workplace.
4 Psychotherapy Is Worth It

Trauma and Abuse

Childhood trauma and abuse are important causes of psychiatric illness in
the United States, leading to dissociative disorders and borderline person-
ality disorders affecting 5% and 1.8% of the population, respectively (Swartz
et al. 1990). The 12-month prevalence of posttraumatic stress disorder
(PTSD) in American adults over the age of 18 is 3.5% (Kessler et al. 2005b)
with a lifetime prevalence of 6.8% (Kessler et al. 2005a). One-third of all
Vietnam war veterans have suffered from PTSD, and this group has twice as
much divorce, homelessness, and substance abuse as those without PTSD.
Over one-third of those with PTSD committed six or more acts of violence
during 1 year, and nearly half are arrested or jailed at least once. Vietnam
veterans with PTSD are five times as likely to be unemployed and three
times as likely to have four or more chronic health problems as Vietnam
veterans without PTSD (Kulka et al. 1988 ). For returning Iraq and Afghan-
istan war veterans, 14% screen positive for PTSD and 14% for major de-
pression, and only about half of these have sought help from a physician or
a mental health provider for their mental health problem in the past year
(Tanielian and Jaycox 2008). Nearly 40% (Breslau et al. 1991) of inner-city
residents experience severe trauma and nearly one-fourth of these develop
PTSD. One-third of American females experience sexual abuse of incest,
date rape, or other molestation (Russell 1984). One-fifth of rape victims at-
tempt suicide (Kilpatrick et al. 1985). Criminally victimized women visit
physicians twice as often as nonvictimized women, with two and a half times
the medical costs (Koss 1991). Sexually abused children have high rates of
anxiety, fear, sexually transmitted disease, suicide attempts, and borderline
personality disorder (Briere and Runtz 1988; Friederich 1988; Herman et
al. 1989; Schetky 1990).

Other Diagnostic Groups

Of other diagnostic groups, 14.6% of the population suffers at some point
during their lifetime from a substance abuse disorder abusing alcohol
(18.6.%) or drugs (10.9%) (Kessler et al. 2005a). Antisocial personality dis-
order affects 3.5% of the population and schizophrenia affects 1% (Kessler
et al. 1994).
The average prevalence of a psychiatric diagnosis among American
workers is 18.2%. Psychiatric illness in the workforce accounts for signifi-
cant work loss days (6 per month per 100 workers) and work cutback days
(31 per month per 100 workers). The 3.7% of the workforce with more
than one psychiatric disorder accounts for 49 work loss days and 346 work
cutback days per month per 100 workers. Workers with only one diagnosis
(14.5%) have 11 work loss days and 66 work cutback days per 100 workers.
Introduction 5

These work losses compare starkly with the 81.8% of American workers
with no psychiatric diagnosis who experience 2 work loss days and 11 work
cutback days per month per 100 workers. It is clear that work impairment is
a serious adverse consequence of psychiatric illness (Kessler and Frank 1997).
In the National Comorbidity Survey Replication, an estimated 53.4% of
American adults reported one or more of the mental or physical conditions
assessed in the survey. These respondents reported an average of 32.1 more
disability days in the past year than matched controls, with mental condi-
tions accounting for more than half as many disability days as all physical
conditions (Merikangas et al. 2007). Other findings from the National Co-
morbidity Survey Replication demonstrated that in 2002 American workers
with serious mental illness in the preceding 12 months had earnings that av-
eraged $16,306 less than other matched control respondents for a societal-
level total of $193.2 billion (Kessler et al. 2008). Examining all American
workers with mental illness, Marcotte and Wilcox-Gok (2001) estimated
that mental illness decreases annual income by an amount between $3,500
and $6,000.

Concepts of Mental Illness

The concept of mental illness is complex and involves an interplay of envi-
ronmental, cultural, and biological factors. In addition, the definitions of
mental illness can change over time and depend partly on a culture’s view of
what behavior is considered deviant. For example, hallucinations in some
cultures are parts of religious experiences that are integrated into the basic
structure of that culture rather than a possible manifestation of psychosis. A
more current example of a cultural reappraisal of behavior that has been
considered pathological is the debate over the past 25 years about homo-
sexuality as a mental disorder or as a normal behavioral variant. During that
period, the diagnosis of homosexuality as psychopathology was dropped
from the Diagnostic and Statistical Manual of Mental Disorders prepared by
the American Psychiatric Association. Discussions about homosexuality
also illustrate changing perspectives of causation, moving from a certainty
about environmental factors to a greater emphasis on a possible biological
role as well as interactions between biology and environment.
Medical illness, in contrast to mental illness, can usually be more easily
defined as a distinct syndrome, even though specifics are refined as more
knowledge is accumulated. As an example, the importance of hypertension
and its relationship to heart disease have been known for many years. New
knowledge about medical illnesses leads to greater understanding of mech-
anisms of disease and treatment. For instance, the blood pressure level pre-
viously seen as normal has been lowered in recent years, but the basic under-
6 Psychotherapy Is Worth It

standing of hypertension and heart disease has remained intact. And while
hereditary and environmental factors contributing to a predisposition to ill-
ness are more understood, cultural factors of stigma are largely irrelevant,
in contrast to attitudes about mental illness.
Also important to this discussion is the way people minimize or deny the
interconnection of the psyche and the soma in distinguishing between
“mental illness” and “physical illness.” In today’s climate, with a biological
emphasis, there is often a splitting off of emotional factors that interact with
the biological. This biological approach also places some psychiatric illness
into the physical illness category. In addition, within this framework, those
mental illnesses with significant biological components are often treated with
drugs alone, at times accompanied by the expectation that most psycho-
pharmacologic treatments will be brief and inexpensive. Mental illness not
seen as biological will often receive no treatment. However, evidence is
growing that demonstrates the relevance of emotional factors and the use of
psychotherapeutic interventions with illnesses clearly viewed as only or largely
physical. For example, the work of Spiegel et al. (1989) and Lemieux et al.
(2006) with women with metastatic breast cancer demonstrates the effec-
tiveness of group psychotherapy in improving these patients’ symptoms.
Such studies illustrate the need for research on the impact of emotion and
trauma, as well as the effect of psychotherapy on the immune system. Re-
latedly, Fawzy (1993) demonstrated the beneficial impact of a brief group
therapy intervention for malignant melanoma patients who responded with
improved natural killer cell levels and decreased mortality. In addition,
Ornish (1990) showed that coronary heart disease can be reversed by a pro-
gram that utilizes a combined approach, including extended group psycho-
therapy as well as exercise and diet.
Even though it is hard to clarify the multiple factors that lead to mental
illness, there exist important attempts to develop pragmatic categories for
clinicians and researchers. The most widely used current classification of
mental illness consists of disorders defined in the Diagnostic and Statistical
Manual of Mental Disorders, revised on a regular basis by a committee of the
American Psychiatric Association, and presently in its fourth major revision
(American Psychiatric Association 2000). DSM-IV-TR divides mental dis-
orders into two axes: Axis I consists of all mental disorders with the exception
of personality disorders and mental retardation. It thus includes such disor-
ders as schizophrenia and other psychotic disorders, mood disorders, anxiety
disorders, and eating disorders. Axis II defines categories of personality dis-
orders (i.e., constellations of personality characteristics that are beyond the
range of those considered within normal boundaries) and also includes men-
tal retardation. DSM-IV-TR provides a way of collecting statistical data and
sufficiently clear definitions for research purposes. Although the committees
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