Assessing the Costs and Benefits of Insuring Psychological Services as Part of Medicare for Depression in Canada

The results of the 40-year model of the base-case scenario and the alternative scenario, in which there was increased access to psychological services, are presented in Table 2. A preliminary validation of the base-case scenario showed that the lifetime prevalence of suicide attempts and hospitalizations for mental health reasons among respondents with depression reached 14.6% and 30.2%, respectively. These results are similar to those from analyses of mental health data from the 2012 CCHS, which found that lifetime rates of attempted suicides and hospitalizations among respondents with major depression in the past year reached 14.1% and 29.9%, respectively.

In addition, in the base-case model, there were 250 suicides over the 40-year period, which translates into 9.1 suicides per 100,000 population per year. Earlier published results indicated that the percentage of suicides attributable to the population of individuals with mental or substance use disorders reached 74% (67). The suicide rate in the Canadian population for persons ages 20 to 85 was close to 12.1 per 100,000 in 2011 (68); it can be estimated that 8.9 suicides per 100,000 are attributable to affective disorders, such as depression, a rate similar to the rate that we observed in the model.

In the increased-access scenario, a significant decrease was noted in the number of days suicidal and depressed, with an increase in the number of days in a well or healthy state (Table 2). This translated into an average benefit of .17 quality-adjusted life years gained per person. The increased-access model also showed a decrease in health system and societal costs. The results indicated that by increasing access to psychotherapy, the alternative scenario dominated the status quo in that it was more effective and less costly (Table 3). The sensitivity analyses showed that the most important influence on the results was the use of the friction cost method and the human capital approach in assessing loss of productivity.

This 40-year, prospective-value implementation study showed that rendering psychological services as a publicly funded treatment in Canada for adults with depression reporting an unmet mental health need leads to improved health-related quality of life and cost savings to the health system and society. Respondents with a reported unmet mental health need, mainly for counseling, who have not received adequate mental health care for their depression represent 8.1% of prevalent cases of depression in Canada. Increasing access and rendering publicly funded psychological services for this adult population would translate into additional costs, on average, of $123,212,872 CAD ($1,292 [two GP/FP visits plus eight psychotherapy sessions in a year] per individual multiplied by 95,366 individuals with unmet needs) (range $67,709,860–$190,922,732). The savings to society, calculated by using the human capital approach, would reach, on average, $246,997,940 CAD (range $120,733,356–$602,713,120).

These estimates need to be interpreted in light of the study’s limitations. First, the unit cost analyses were based on national data and the costs are for the province of Quebec, which may limit generalizability to other countries with public health care systems similar to Canada’s (69). Second, the results presented assume that eight psychotherapy sessions and two physician visits would, on average, be covered in the scenario of increased access to psychotherapy (20). Previous publications in Australia have reported that most people use six sessions, with improved outcomes on the ten-item Kessler Psychological Distress Scale and the 21-item Depression and Anxiety Stress Scale (33). Third, not all individuals with a need for mental health care would avail themselves of the services (20), and thus the average costs associated with increased access may be an overestimate. Inversely, one may argue that individuals without a significant need for mental health care may receive treatment because of the greater availability of services. Canadian population data indicate that 8.1% of those who do not meet criteria for a mental or substance use disorder report a need for mental health counseling and may want to access such care (13). A previous study showed that individuals who did not report a common mental or substance use disorder had consulted a psychologist in the previous year, with a median of four visits (16). How this would affect the estimates of cost and quality-adjusted life years is difficult to predict. However, in this subgroup of individuals without a clinical diagnosis who express a need for counseling, consulting a mental health professional may be associated with a decrease in psychological distress, which may be accompanied by improved quality of life and increased productivity, even if only marginal, and which may prevent an episode of major depression.

Fourth, the model did not consider factors, such as gender and general medical comorbidities. In regard to gender, females are usually more likely to seek services for mental health reasons (16), and thus the health outcomes may be overestimated for males. In addition, treatment of mental health problems with evidence-based psychological interventions can also significantly benefit general medical conditions. Therefore, the study may have underestimated the potential gain in health-related quality of life (70) and the decrease in health service use by individuals with depression and chronic general medical illnesses (71), as reported elsewhere. Fifth, the model did not account for any positive or negative lifetime events (for example, a new job or the loss of a job or bereavement after the death of a family member), which may also affect the incidence and persistence of episodes. Sixth, although the analyses included the costs and decrements in utility associated with the prevalence and persistence of antidepressant use, the direct effect that publicly funded psychotherapy may have on patterns of prescription—for example, incidence and persistence of antidepressant use—is difficult to estimate and was not considered. Finally, most mental health problems start in childhood (72), and the study may have underestimated the potential benefits of providing services to children with depression, including cost savings to society.

If one were to consider covering psychotherapy sessions for all Canadian adults with incident depression (2.9%), the program costs would reach $1.008 billion CAD. This estimate is similar to those in previous reports. In Australia, in the first three years of the Better Access initiative, close to 2,017,000 individuals received close to 11.1 million psychotherapy sessions (six sessions per individual) (73), for a total budget, in Canadian dollars, of $2.80 billion or $1,514 per individual. More than half of individuals had never consulted a professional for their mental health problems. In the United Kingdom, the cost of the IAPT program in 2006 was estimated at £600 million to treat 800,000 patients opting for psychological therapy (21). Recently, the National Health Service invested an additional £400 million in the IAPT program to offer services to children, adolescents, older adults, and persons with severe mental illness and chronic general medical problems (74). In France, the estimated yearly cost of covering 12 psychological sessions for persons with depression and those with anxiety disorders (close to 2.3% of the population) was $729 million (in Canadian dollars) (22). This estimate is lower than in our study, because a psychotherapy session in France costs €41 ($65 CAD), and in Canada it costs an average of $145 CAD.

Finally, our results indicate that covering psychological services as part of Medicare for individuals with major depression who do not receive adequate care would pay for itself. In Canada, every $1 invested in the program would yield on average $2 ($1.78–$3.15) in savings to society. In the United Kingdom, the return on investment for the IAPT program reached £1.75 for every £1 in health care expenditures (20,65,66). In France, spending €1 in psychotherapy for people with depression yielded savings of €1.95 (€1.30–€2.60) (23).

To put the results of this study into perspective for decision makers, public expenditures for mental health and addictions account for only 7.2% of the total health budget in Canada, amounting to $540 per capita (75). An additional investment of $3.42 per capita, representing .07% of the total health care budget, would lead to a more efficient publicly managed health care system that would produce cost savings for society and improved indicators of mental health in the population, including reductions in disability, in premature loss of life, and in loss of productivity. Major depression has been identified as a leading cause of disease burden (76), and health planners and decision makers should aim to develop mental health policies that reduce income barriers to accessing psychotherapy services in primary care (16,17) for individuals who are not otherwise able to access such care.

The health policy of covering psychological services as part of Medicare in a public managed health care system may have important implications. In Australia, the increasing costs of the Better Access program caused great concern, and many argued that the program was widening the socioeconomic gap in mental health service use (77). However, Harris and colleagues (78) showed that over 90% of Better Access users had a 12-month ICD-10 mental disorder or other relevant indication. Those without an affective or anxiety disorder who used services were not from higher socioeconomic groups, and those with a mental disorder received significantly more services than those without.

Finally, a successful health policy that is aimed at improving access to mental health services and that is relevant to a public health care system should consider the following: access (who gets treatment?), equity, type of services offered, effectiveness and cost-effectiveness (are health outcomes improved at a sustainable cost?), and patient-centered care (does the service meet individual mental health needs?) (79). Future research should also focus on modeling the impact of improved access to psychological services for children, adolescents, and clinically complex populations with multiple morbidities for whom the return on investment may be more important compared with the adult population (80).

The authors acknowledge the help of Alexandre Ouellet, Eng. M.Sc., Ph.D., in the creation of the ARENA model used in the study.