The Cost-Effectiveness of Intensive Short-Term Dynamic Psychotherapy

Abstract

CME Educational Objectives
1. Expose the reader to various sources of health care costs and diagnoses responsible for these.
2. Review the evidence for multiple categories of cost reduction for intensive short-term dynamic psychotherapy (ISTDP).
3. Review the return-to-work rates for patients receiving ISTDP treatment.

The health care burden of chronic disability, with mental illness and somatic symptom disorders leading the way, is crippling to global economies. 1 In the recent JAMA report by the U.S. Burden of Disease Collaborators, the top diseases with the largest number of years lived with disability in 2010 were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders. Migraine, drug use, alcohol use and dysthymia were also in the top 20. The authors noted that half of the health system cost is due to disability and morbidity. 1

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The health care burden of chronic
disability, with mental illness
and somatic symptom disorders
leading the way, is crippling to global
economies.1 In the recent JAMA report
by the U.S. Burden of Disease Collabo-
rators, the top diseases with the largest
number of years lived with disability in
2010 were low back pain, major depres-
sive disorder, other musculoskeletal dis-
orders, neck pain, and anxiety disorders.
Migraine, drug use, alcohol use and dys-
thymia were also in the top 20. The au-
thors noted that half of the health system
cost is due to disability and morbidity.1
Based on extensive research dur-
ing the past 20 years, psychotherapy is
now acknowledged to be an effective
and cost-effective treatment for a broad
range of conditions.2 Given evidence
that psychotherapy is beneficial, the
relative cost of treatment has become
an important consideration in clinical
decision making.3 With this in mind,
the shorter and less expensive a psycho-
therapy model can be while retaining ef-
fectiveness, the greater the effect it can
have on widespread health system costs.
Based on long wait lists and wait
times for long-term psychotherapy in
public clinics, Habib Davanloo, MD, of
McGill University developed his method
of intensive short-term dynamic psycho-
therapy (ISTDP) between the 1970s and
2000s.4 Thus, two major reasons for this
development were to improve service
access and to reduce service cost per
patient in publically funded Canadian
medicine.
ISTDP is a brief treatment designed
to achieve broad-based gains across
symptoms and personality difficulties.
At its core, the objective of ISTDP is
to help patients overcome emotional
blocks that lead to occupational disabil-
ity, somatic symptoms, depression, anx-
iety, and self-defeating behaviors. The
method includes a specialized series of
interventions designed to overcome high
levels of resistance, low levels of emo-
tional tolerance (depression, somatiza-
tion, conversion), and dissociation (frag-
ile character structure). ISTDP has been
The Cost-Effectiveness of Intensive
Short-Term Dynamic Psychotherapy
1. Expose the reader to various
sources of health care costs and
diagnoses responsible for these.
2. Review the evidence for multiple
categories of cost reduction for
intensive short-term dynamic
psychotherapy (ISTDP).
3. Review the return-to-work rates for
patients receiving ISTDP treatment.
Allan Abbass, MD, FRCPC, is Professor
and Director of Education, as well as Di-
rector, Centre for Emotions and Health,
Dalhousie University Department of
Psychiatry. Jeffrey W. Katzman, MD, is
Professor and Vice Chair, Education and
Academic Affairs, University of New Mex-
ico Department of Psychiatry.
Address correspondence to: Allan Ab-
bass MD, FRCPC, Room 8203, 5909 Veter-
ans Memorial Lane, Halifax NS, Canada
B3H 2E2; email: allan.abbass@dal.ca.
Disclosure: Drs. Abbass and Katzman
have no relevant financial relationships
to disclose.
doi: 10.3928/00485713-20131105-04
EDUCATIONAL OBJECTIVES
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Allan Abbass, MD, FRCPC; and Jeffrey W. Katzman, MD
© Shutterstock
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studied empirically with evidence sup-
porting its effectiveness across the range
of conditions described above, including
anxiety, depression, back pain, headache,
and chronic pain, as well as other condi-
tions such as personality disorders.5
Because it is a brief model of thera-
py, averaging fewer than 20 sessions in
published studies, one would expect it to
be more cost-effective when compared
to longer treatments. Since it addresses
characterological problems and treat-
ment resistance as well as symptoms,
ISTDP may also prove cost-effective
relative to treatments that focus on only
one component of the patient’s problem.
In this article, available published
studies that evaluate ISTDP’s effects on
TABLE 1.
Study Description and Reported Cost Reductions After ISTDP Treatment
Sample nNumber of
Sessions
Control Reference Time Period Cost Domains Included Total Cost
Reduction Per
ISTDP-Treated
Patient
Panic disorder13 40 15 Clomipramine
alone. Randomized.
18-month follow-up
after stopping clomip-
ramine
Medication use rates only –
Mixed sample8166 16.9 Wait list. Non-
randomized.
Before vs. 1.75-year
passive follow-up
Medication use, disability rates –
Mixed sample6* 89 14.9 – 1-2 years post vs. 1 year
pre
Hospital costs, physician costs,
medication costs, disability costs
$6,202
Personality disorders993 Up to 6
months
–2 years post vs. 1 year pre Hospital costs, physician costs,
health professionals cost. Utiliza-
tion rates only
–
Mixed sample11† 88 14.9 – 3 years follow-up vs.
projections
Hospital costs, physician costs $1,827
Treatment-resistant
depression14
10 13.6 – 6 months post vs. 6
months pre
Hospital costs, medication costs,
disability costs
$5,688
Chronic headache7* 29 19.7 – 1 year post vs. 1 year pre Medication costs, disability costs $7,009
Personality disorder15 27 27.7 Randomized wait
list
2 years post vs. 1 year
pre
Medication costs, disability costs $10,148
Mixed sample. Trial
therapy16
30 1 – Pre vs 1 month post Employment rate, medication
use only
–
Medically unex-
plained symptoms17, 18
50 3.8 Non-randomized.
Patients referred
but not seen
1 year post vs. 1 year pre Medical (emergency) visits and
costs
$910
Personality disorder10§155 Up to 6
months
– 10 years post vs. 1 year
pre
Employment rates only –
Psychiatry inpatients12 33 9.0 Other psychiatric
ward. Non-random-
ized.
1 year post vs. 1 year pre Electroconvulsive therapy costs $1,400§
Mixed sample19 140 9.9 – 3 years post vs. 1 year
pre
Physician costs, hospital costs $3,773
*Subsample of Abbass.6
†Extension of Abbass.6
‡Based on estimated cost of $1,000 per electroconvulsive therapy service.
§Sample partially overlaps with Cornelissen,9 counted as 26 sessions.
ISTDP = intensive short-term dynamic psychotherapy.
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health service costs, disability costs, and
medication costs are reviewed.
CURRENT STATE OF COST-
EFFECTIVENESS EVIDENCE
In 2012, we published a review of
all the available outcome studies of
ISTDP retrieved through a broad litera-
ture search.5 This search was repeated in
April 2013. Each of these articles was
scanned for any notation of cost and
service use measurement. All such mea-
sures were tabulated.
These data were tabulated and re-
viewed in terms of total cost-benefits
and then again separately by health ser-
vice use, medication use, and employ-
ment/disability costs.
OVERALL COST-EFFECTIVENESS
A total of 13 studies included cost-
bearing measures. Treatments ranged
from an average of one session to 27.7
sessions and averaged 15.3 (SD 8.2)
sessions overall. Two articles6, 7 includ-
ed a sub-sample of Abbass, 2002a;8
one was an extension of Cornelissen
et al, 2002,9 with a larger sample and
longer follow-up,10 and the other in-
volved a follow-up evaluation from an
earlier study.11 Three studies included
inpatients in an acute care hospital12
or residential treatment facility,9,10
whereas the remainder involved out-
patient samples.13-19 In all, the studies
included two randomized, controlled
trials13,15 and three non-randomized,
controlled trials.8,12,17 The remainder
were case series.
These publications included five
studies of mixed psychiatric samples,
three of personality disorders, one of
treatment resistant depression, one of
panic disorder, one of chronic head-
ache and one of medically unexplained
symptoms. A further study published in
this volume examined the cost-effective-
ness of ISTDP provided by psychiatry
residents. The mixed samples included
patients with most DSM-IV diagnos-
tic groups, including major depression,
anxiety disorders, substance-use disor-
ders, bipolar disorder, dissociative dis-
orders, eating disorders, and psychotic
disorders. Thus, the studies combined
reflect the broad utility of this method in
clinical practice (see Table 1, page 497).
Data reported in the studies included
different outcome domains of health
care use, medication use, and disability
costs. Data were not reported in a uni-
form fashion between studies and had
varying follow-up periods. The cost
reductions reported ranged from $910
counting only emergency visit cost re-
duction over 1 year of follow-up to
$10,148 per patient counting disability
cost and medication cost reduction over
2 years of follow-up (see Table 1, page
497).
MEDICATION USE AND COST
Seven studies included medication
use and cost measures (see Table 2).
These included studies of panic disorder,
headache, treatment-resistant depression,
personality disorder, and mixed disor-
ders. The mean number of medications
reduced per medicated patient was 0.92
(SD .29) medications. The mean percent
of these patients stopping all medica-
tions was 59.7%, including those pro-
vided only one session of treatment, and
increased to 74.5% when excluding this
group. The mean cost reduction in the
follow-up intervals was $558.5 (SD 226).
HEALTH SERVICE USE AND COST
REDUCTION
Six studies included measures of
health service use and costs. Three stud-
ies reported reductions in hospital use.
Two showed modest reductions in physi-
cian use. One reported reductions in com-
bined hospital and physician costs. One
showed a 69% reduction in repeat emer-
gency visits in patients with medically
unexplained symptoms, whereas another
showed a nearly two-thirds reduction in
electroconvulsive therapy (ECT) use.
These last two studies included naturalis-
tic, non-randomized control patients who
did not experience any such service use
reduction (see Table 3, page 499).
TABLE 2.
Medication Use and Cost Reduction
Study
Sample
Number of
Medications
Stopped per
Medicated Patient
Percent of All
Medication
Stopped
Percent of
Cases Stopping
all Medications
Medication
Cost
Reduction per
Medicated
Patient
Panic disorder13 ≥ 0.80 80% 80% –
Mixed sample8– – 69% –
Mixed sample60.83 71% – $454/year
Treatment-resistant
depression14
1.4 56% 30% $880 / 6
months
Chronic headache70.83 65.2% – $360/year
Personality disor-
der15
1.1 74% $540 / 2 years
Mixed sample: trial
therapy16
0.55 – 35%* –
*Response to single trial therapy session.
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EMPLOYMENT RATES AND REDUCED
COST OF DISABILITY
Seven studies reported changes in
employment status and/or disability
costs (see Table 4, page 500). Patients
in these samples were disabled for a
long period of time, averaging 67.2
weeks out of work. Overall, there were
large cost reductions owed to high
return-to-work rates. Between-study
average rates of return to work were
68.4% when including a study of sin-
gle-session trial therapies and 77.4%
when not including this study. Cost
reductions ranged from $6,720 per
patient during a follow-up period of 6
months to $28,114 per patient during a
1-year follow-up period.
COST OUTCOME BY THERAPEUTIC
WORK
The therapeutic objective of ISTDP
is to facilitate an emotional healing pro-
cess by allying with an individual’s
natural drive toward health to confront
self-destructive psychological defens-
es and anxiety. Through this process,
complex feelings are mobilized and ex-
perienced, overcoming anxiety and de-
fenses against these feelings. This trig-
gering event brings images and linkages
to unprocessed pathogenic emotions.
All of this is a process Davanloo4 and
several of his patients called “unlock-
ing the unconscious.” The degree of
unlocking, or dominance of therapeutic
forces over defenses, has been studied
in relation to cost-effectiveness in two
studies. In Town et al,20 patients with at
least one high-level unlocking, called
major unlocking, during treatment had
significantly greater health care cost
reductions. Abbass8 found those with
major unlockings had greater rates of
return to work [(100% (14/14) versus
50% (4/8)] and cessation of all medi-
cations [(92.6 (25/27) versus 37.5%
(6/16)] versus those without major un-
lockings.
COSTS OF PROVIDING ISTDP
To consider cost-effectiveness, we must
consider the costs of providing the treat-
ment. Six studies noted an average therapy
cost of $1,471 for treatment averaging
13.1 sessions (see Table 5, page 500).
DISCUSSION
This mixed set of studies with di-
verse samples provides further data that
ISTDP is a cost-effective treatment.
Large cost reductions compared favor-
ably with relatively low cost estimates
of $1,471 per treated case. It is of fur-
ther interest to see cost reductions cor-
relating with what is considered the key
therapeutic ingredient of ISTDP, emo-
tional experiencing.8,20 This adds fur-
ther data to the notion that emotional
TABLE 3.
Health Service Use and Cost
Study
Sample
Hospital Use
Reduction
Hospital
Cost
Reduction
Physician Service
Use Reduction
Physician
Costs
Health Service Health Service
Cost Reduction
Total Health Care
Cost Reduction
Per Treated Case
Mixed sample685% $338/ 1 year 33% $206/ 1 year – – $544/ 1 year
Personality
disorder9
2% had psychiat-
ric hospitalization
vs. 20.9% before
– 18% saw psychia-
trist/ psychologist
vs. 27.5% before
8% saw general
practitioner vs. 4.4%
before
– 30% had outpa-
tient psycho-
therapy vs. 39.6%
before
– –
Mixed sample11 – – – – – – $ 1,827/ 3 years
Treatment-
resistant depres-
sion14
– $1,440/ 6
months
– – – – $1,440/ 6
months
Medically
unexplained
symptoms17, 18
– – – – 69% reduction in
emergency de-
partment visits
$910/ 1 year $910/ 1 year
Psychiatry in-
patients12
- – – – 65.2% drop in
ECT services
$1,400/ 1 year $1,400/ 1 year
Mixed sample19 - $3,084/ 3
years
– $393/ 3
years
– – $3,733/ 3 years
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processing and experiencing is a key
variable in psychodynamic psychother-
ap y,21,22 if not in psychotherapy overall.
The evidence for cost reduction in
disabled workers bears underscoring,
as this societal burden is a major drain
on global economies where positions
must be backfilled at great expense. As
noted in Table 4, more than two-thirds
of disabled patients were able to make
a return to work with a relatively short
treatment course after long disabilities.
Because of the efficacy of this treat-
ment in resistant and complex popula-
tions, it appears to facilitate returns to
work even in patients unemployed for
years. This is a striking finding consid-
ering population return-to-work rates
after 6 months disability are otherwise
less than 50%, and rates after 1 year of
disability are very low to negligible.23,24
Based on available data showing IST-
DP is effective with the most common
sources of disability, it represents an
inexpensive approach to these major
sources of economic burden.1
These data from published studies
have an array of limitations to consider.
First, therapists in most of these studies
were trained and experienced, calling
into question the generalizability of the
findings. The notable exception to this
was the case series treated by psychia-
try residents.19 Second, all cost-bearing
figures were not available in all studies,
and it is unclear in most studies which
cost measures were determined a priori.
This raises the likelihood of reporting
bias; thus, greater weight should be
given to those studies with more com-
plete reporting. Third, the majority of
these studies were not controlled, so the
causes of cost reduction may not relate
to treatment factors. Fourth, samples
and reporting time frames were highly
diverse rendering combined analysis
and comparison of the data difficult. Fi-
nally, study quality, including verifica-
tion of treatment adherence, was highly
variable,5 limiting our ability to deter-
mine the quality of cost-based outcome
evidence.
CONCLUSION
This series of studies provides evi-
dence that this brief treatment is cost-
effective when applied to a wide range
of patients with benefits noted in studies
across several cost domains. Future re-
search in ISTDP should include further
controlled trials with clearly defined a
priori cost measures and reporting of all
possible cost-related outcomes. Further
research should examine which of the
ingredients, such as emotional experi-
encing, bring greater costs effects with
specific populations. This could inform
tailoring of psychotherapy approaches
to specific populations in order to en-
hance cost benefits.
TABLE 4.
Employment Rates and Reduced Cost of Disability
Sample Total
Number
Unemployed
Duration Off
Work
Pre-ISTDP
(In Weeks)
Rate of
Return to
Work
Total Cost Reduction
Per Treated
Unemployed Patient
Mixed sample831 113.1 80.6 –
Mixed sample622 53.3 81.2 $21,899 / 1 year
Treatment-resistant
depression14
5 104 80 $6,720 / 6 months
Chronic headache77 54 100 $28,114 / 1 year
Personality disor-
der15
10 63.6 90 $25,920 / 2 years
Mixed sample. Trial
therapy16
14 15 14.3* –
Personality disor-
der10
97 – 32.7 –
* Response to single session trial therapy interview.
ISTDP = intensive short-term dynamic psychotherapy.
TABLE 5.
Costs of ISTDP Treatment
Study Number of
Sessions
Setting Cost Estimate
Per Case
Mixed sample614.9 Private psychiatric
office
$ 1,680
Personality disorder15 27.7 Public and private
offices
$ 3,370
Medically unexplained
symptoms17
3.8 Hospital clinic $ 404
Psychiatric inpatients12 9.0 Hospital clinic ~ $1,400
Mixed sample19 9.9 Hospital clinic ~ $500
Unweighted means 13.1 – $ 1,471
ISTDP = intensive short-term dynamic psychotherapy.
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