Open door review

Cost-effectiveness studies


The effects of long-term psychoanalytic treatment on healthcare utilization and work impairment and their associated costs

Berghout, C. C., Zevalkink, J., & Hakkaart-Van Roijen, L. (2010). The effects of long-term psychoanalytic treatment on healthcare utilization and work impairment and their associated costs. Journal of Psychiatric Practice 16, (4), 209-216.
De Maat, S., Philipszoon, F., Schoevers, R., Dekker, J., & De Jonghe, F.  (2007). Costs and benefits of long-term psychoanalytic therapy: Changes in health care use and work impairment. Harvard Review Psychiatry, 15, 289-300.

Brief summary

Long-term psychoanalytic treatment is perceived as an expensive ambulatory treatment for mental illnesses. However, there are indications that psychoanalytic treatment can result in cost savings in the long term. In this study, the effects of long-term psychoanalytic treatment on healthcare utilization and work impairment were investigated and the associated societal costs were calculated. The authors assessed healthcare utilization and work impairment of patients before, during, and after long-term psychoanalytic treatment (N = 231). The results show that the difference in total costs associated with healthcare utilization and work impairment between pre- and post-treatment was €2,444 (U.S.$3,070 using average exchange rates for 2006, the year for which these data were calculated) per person per year. Two years after treatment termination, these cost savings had increased to €3,632 ($4,563) per person per year. This indicates that one can expect decreased consumption of medical care and higher work productivity right after psychoanalytic treatment, but also that long-term psychoanalytic treatment can generate economic benefits in the long run. However, one cannot conclude that all invested costs will be earned back eventually. More research is needed on the cost-effectiveness of psychoanalytic treatment.


Of course, long-term psychoanalytic treatment should be considered beneficial not only because it can reduce costs associated with healthcare utilization and work impairment. The primary goal of psychotherapy is to improve a patient’s psychological state, with reductions in societal costs being a secondary goal. The authors emphasize that indirect cost savings should not be a prerequisite for funding of psychotherapy. A cost-effective treatment is not necessarily cheap or cost-saving, but rather is characterized by clinically significant psychological and/or societal gains that make the invested costs worthwhile. It is recommend that state-of-the-art cost-effectiveness analyses be conducted in future studies.


Prof. Caspar C. Berghout

Department of Research and Quality Assurance, Netherlands Psychoanalytic Institute, PO; Box 7031, 1007 JA Amsterdam



Cost-effectiveness of therapies of different mode and length

Maljanen, T., Paltta, P., Härkänen, T., Virtala, E., Lindfors, O., Laaksonen, M., . . . the Helsinki Psychotherapy Study Group. (2012). The cost-effectiveness of short-term psychodynamic psychotherapy and solution-focused therapy in the treatment of depressive and anxiety disorders during a 1-year follow-up. Journal of Mental Health Policy and Economy, 15, 3-13.
Maljanen, T., Tillman, P., Härkänen, T., Virtala, E., Lindfors, O., Knekt, P., & the Helsinki Psychotherapy Study Group. (2014). The cost-effectiveness of short-term psychodynamic psychotherapy and solution-focused therapy in the treatment of depressive and anxiety disorders during a three-year follow-up. Open Journal of Psychiatry, 4, 238-250.

Brief summary

The aims of this ongoing study are to evaluate the cost-effectiveness of two short-term and two long-term psychotherapies (Knekt et al. 2012). The study is based on the data of 367 psychiatric outpatients, participants of the Helsinki Psychotherapy Study, having long-standing depressive or anxiety disorder causing work dysfunction. Patients with psychotic disorder, severe personality disorder, adjustment disorder, bipolar disorder or substance abuse were excluded. Solution-focused therapy included 12 and short-term psychodynamic psychotherapy 20 therapy sessions, both therapies lasting about half a year. The long-term therapies were open-ended, psychodynamic psychotherapy lasting about 3years with about 240 sessions and psychoanalysis lasting about 5 years with about 650 sessions. All the therapists had received standard training and were experienced. Both direct costs (therapy sessions, outpatient visits, medication, inpatient care) and indirect costs (production losses due to work absenteeism, value of neglected household work, lost leisure time and unpaid help received) due to the treatment of psychiatric problems were estimated, prior to start of treatment and at 14 pre-chosen time points during a 10-follow-up from start of treatment. Likewise, the assessment of effectiveness was based on repeated measurement of psychiatric symptoms and recovery, need for treatment, and work ability. Incremental cost-effectiveness will be estimated.

Original contributions (Maljanen et al. 2012, 2014) have been published from this sub-study and are ongoing (see cited literature above and our homepage).


This cost-effectiveness study, with an exceptionally long- follow-up, will provide information for evaluating the economic and health-related benefits of different short-term and long-term psychotherapies. The study may have implications for the allocation of health-care resources.


Dr. Paul Knekt

National Institute for Health and Welfare, P.O. Box 30, 00271 Helsinki



Cost-offset effect of psychotherapy in reducing medical health service utilization

Kraft, S., Puschner, B., Lambert, M. J., & Kordy, H. (2006). Medical utilization and treatment outcome in mid- and long-term outpatient psychotherapy. Psychotherapy Research, 16 (2), 241-249.


This study examined service use and its relation to outcome in people receiving outpatient psychotherapy with a special focus on the possible cost-offset effect of psychotherapy in reducing medical health service utilization.


Between September 1998 and February 2000 all adult insurees of a large private insurance company (“Deutsche Krankenversicherung”, DKV) who applied for reimbursement of their outpatient psychotherapy were asked to participate in the TRANS-OP study (see Open Door Review…). Due to the considerable time and effort for the collection and analysis of service use data, a randomized subsample of 200 participants who had applied either for cognitive behavioral therapy (CBT, N=100) or psychodynamic psychotherapy (PD, N=100), was drawn of the original sample (N=939). Medical utilization data were analyzed only for participants who had returned at least the baseline questionnaire (N=176).


Information about medical utilization (outpatient and inpatient treatments) was made available by the DKV via computerized, aggregated records of insurance claims. Psychological distress was assessed with the German adaptation (EB-45; Lambert, Hannöver, Nisslmüller, Richard, &Kordy, 2002) of the Outcome Questionnaire-45 (OQ-45.2; Lambert et al., 1996). Somatic distress was measured with the GiessenerComplaints Questionnaire (GBB-24; Brähler&Scheer,1995).


Mean medical costs continually increased before the start of outpatient psychotherapy and decreased thereafter. This pattern was more pronounced for hospital days, with a sharp decline immediately after the start of treatment. Medical costs during 6 months decreased  from 2,183.36 € (SD=/2491.29) at start of psychotherapy to 1,609.44 € (SD=1,951.62) two years later (26.3%). During the same time, hospital days showed a 78.7% decrease from  3.33 (SD=10.35) to 0.71 (SD=4.11). However, these differences were not statistically significant.

Improvement in somatic well-being within the 18 months after start of therapy was significantly related to a reduction in medical costs, even when controlling for pretreatment medical costs. Furthermore, the reduction in health care costs was somewhat larger in younger patients, and cost reduction was somewhat larger in patients with fewer sessions. No difference in reduction of medical care utilization was found between the two forms of psychotherapy.


This is one of the few studies which examined cost offset after mid- and long-term outpatient psychotherapy. To our knowledge, by then it was the first that analyzed the association of cost offset and mental health treatment outcome, and it was the only European study besides Sandell et al. (2001) in which direct health care costs, and not only hospital or disability days, were obtained from objective data sources (i.e., insurance claims).


Dr. Hans Kordy

Center for Psychotherapy Research, Heidelberg University, Heidelberg, Germany.