This document summarizes a study evaluating the costs and benefits of providing psychotherapy coverage through France's healthcare insurance systems. Key findings include: - About 32% of people sought help for mental health problems in the past year, with 24% having severe/chronic disorders. An estimated 30% of those would accept psychotherapy. - Providing an average of 12 psychotherapy sessions per patient would cost around €500 total per patient, with insurance covering €300. - The total annual cost of providing psychotherapy to the estimated 1.03 million eligible people is €514 million, of which insurance would cover €308 million. - For every €1 spent on psychotherapy for depression, €1.95 is saved, and for anxiety

1. Methods
1. Data were derived from the “Enquête Indicateurs de santé mentale dans quatre
régions françaises 2005”: a cross-sectional survey of a representative sample of
20,777 non-institutionalized adults in 4 French areas, conducted via computer-
assisted interviews using the CIDI-SF and the Sheehan disability scale (SDS) on 4
daily roles quoted from 0 to 10 which allows together with the counting of symptoms
to set up severity levels.
2. The prioritization of care provision, the number of sessions, according to the type
of MH disorder and their levels of severity that would qualify for cover was
extrapolated from British recommendations of National Institute for Health and
Clinical Experience (NICE).
Background
- Structured psychotherapies are treatments for mental health (MH) disorders,
recommended by international good practice guidelines [APA, NICE, GAC, AIHW,
HAS, CBO].
- Their positive impact on the costs to healthcare funding bodies has been widely
demonstrated [1-5].
- France still has a high rate of psychotropic drug use [6] mainly due to the major role
of general practitioners (GPs) versus non-medical MH professionals [7,8].
Nevertheless, in France, unlike numerous industrialized countries,
psychotherapies delivered by non-medical MH professionals, in private practice
settings are not reimbursed by health insurance systems.
- Since July 2010 new legislation regulates the use of the title of psychotherapist for
non-medical MH providers.
May 15th-16th 2012
Cost and benefit of psychotherapies in France:
Medico-economic evaluation of cover for the cost of psychotherapies
by the healthcare insurance systems
Dezetter A. (Ph.D) [1,2], Kovess-Masfety V. (M.D, Ph.D) [1]
[1] EA4069 - EHESP - Paris Descartes University, France; [2] CERMES3, Paris Descartes University, France
Objectives:
To estimate (A) the costs of financing psychotherapies in France within health
insurance schemes, (B) the cost-benefit ratio of psychotherapy, according to types
and level of severity of MH disorders.
Rencontres scientifiques du Réseau doctoral Paris, France
References:
1. Roth A, Fonagy P: What works for whom: a critical review of psychotherapy research,
Guilford, 2005
2. Gabbard GO, Lazar SG, Hornberger J, et al: The economic impact of psychotherapy: a
review. Am J Psychiatry 154:147-55, 1997
3. Churchill R, Hunot V, Corney R, et al: A systematic review of controlled trials of the
effectiveness and cost-effectiveness of brief psychological treatments for depression.
Health Technol Assess 5:1-173, 2001
4. INSERM: [Psychotherapy: Three approaches evaluated], Paris, 2004
5. Gloaguen V, Cottraux J, Cucherat M, et al: A meta-analysis of the effects of cognitive
therapy in depressed patients. J Affect Disord 49:59-72, 1998
6. OFDT: [Psychotropic medications use in France], 2009
7. Dezetter A, Briffault X, Bruffaerts R, et al: Use of GPs versus MHPs in six European
countries: the decisive role of the organization of MH care systems. SPPE 2012 (accepted)
8. Dezetter A, Briffault X, Alonso J, et al: Factors associated with use of psychiatrists and
nonpsychiatrist providers by ESEMeD Respondents. Psychiatr Serv 62:143-51, 2011
9. NHS: IAPT. Guidance for Commissioning IAPT Training 2011/12-2014/15 2011
10. Dezetter A, Kovess V: [Epidemiological and socio-economic analysis of the situation of
psychotherapies in France, with a view to proposals for reimbursement policies], 2012
11. Andlin-Sobocki, Jonsson, Wittchen ,Eur J Neurol, 2005
12. Clery-Melin P, Kovess V, Pascal JC: [Action plan for the development of the psychiatry
and the promotion of the mental health], 2003
13. Couty E: [Missions and organization of mental health and psychiatry]. Ministère de la
santé et des sports, 2009
Figure 3: Key elements with detailed results
Recommendations:
1. Improve referral of patients suffering from MH disorders from GPs
to psychiatrists for evaluation
2. Better training of GPs in recognition of common MH disorders
3. Define psychologists and psychotherapists as providers of
psychotherapy
4. Improve cooperation between psychiatrists and psychologists
5. Train more psychologists, in brief, diversified interventions and
provide them hospital based experience [10,12,13].
Figure 1: Prioritization, number of sessions
Conclusion
1. Funding psychotherapies appears to be a worthwhile investment
in short and long term the impact of psychotherapies on
remission of somatic disorders has not been evaluated yet.
2. France has the 14,300 non-medical MH professionals qualified to
deliver the psychotherapies required to treat this population.
3. The British IAPT programme could be taken as model for setting
up policy of reimbursement of psychotherapy in France. There
requisites are as follows:
Results
A. Costs of financing psychotherapies: main findings
- Among general population, ~32% reported having contacted some type of
professional for MH problems during the past year
Among these: 24% suffered from severe and/or chronic disorders
Among these: 30% would accept the treatment
- According to NICE guidelines: ~12 sessions were delivered
- The total cost of a psychotherapy was ~500€
- The cost of a psychotherapy for the compulsory systems was ~300€
- The out-of-pocket expenditures were ~200€
- According to these estimations, the yearly cost of psychotherapeutic care was
514M€, which included 308M€ for the compulsory systems, to treat 1.033M
individuals = 2.3% of the population.
- Pure depression lasting > 6 months, SDS ≥ 4
- Comorbid GAD and major depression lasting ≥15 days, SDS ≥ 4
- Pure GAD and other anxiety disorders (agoraphobia, social phobia, specific phobia, panic
disorder, OCD, PTSD) : SDS ≥ 7
Figure 2: Level of chronicity and severity according to types of disorders
Level of severity
Prioritization Type of MH disorders High Moderate Mild
1 Pure depression 24 20 8
2 Comorbid GAD and major depression 24 20 8
3 Pure GAD 17 13 2
4 Other anxiety disorders 14 10 7
3. A more exigent level of chronicity and/or severity was introduced in order not to
take account people with temporary disorders (natural recovery, without
psychological treatment andor without claim for psychotherapy).
4. The proportion of French patients (18-75 years old) to treat was performed using
the methodology of the British programme: Improving Access to Psychological
Therapies (IAPT 2005) [9]
Among users of any services for and with MH problems: 30% would accept
psychotherapeutic treatment.
The methodology of IAPT is transposable because rates of use are very similar to
those in France.
5. The total cost of a session was based on session with a psychiatrist: 41€, which is
consistent with self-reported costs of a session of psychotherapy delivered by a
psychiatrist or a psychologist in France [10].
6. The level of reimbursement, by the French National Health Service (compulsory
systems), of a session with a medical auxiliary (e.g. nurse, physical therapist), was
applied = 60% ( 24.60€ per session).
Among French people (18-75 y.o): use of any
professional for MH reasons, in the past year
31,61%
(male = 24,4%; female = 38,6%)
Among these: proportion of patients suffering
from severe / chronic disorders
24% (Depression = 35%;
Anxiety disorders = 65%)
Among these: proportion of patients would
accept psychotherapeutic treatment (based on
IAPT Programme)
30%
Rate and number of patients to treat, per year 2,28% = 1,033 million
Number of sessions, per patient, according to type
of MH and level of severity (based on NICE
guidelines)
12,1 sessions (Depression =
17,6; Anxiety disorders = 9,6)
Total cost of a psychotherapy, per patient (cost of
a session = 41€)
498€ (Depression = 723€;
Anxiety disorders = 395€)
Cost of a psychotherapy, per patient, for the
compulsory systems (level of reimbursement =
60%)
299€ (Depression = 434€;
Anxiety disorders = 237€)
Out-of-pocket expenditures, per patient 199€
Yearly cost for psychotherapeutic care (to treat
1,033M patients)
514 M€ (Depression = 178M€;
Anxiety disorders = 336M€)
For Compulsory systems 308 M€
For Supplementary healthcare insurance (or
out-of-pocket expenditure)
206M€
Cost-benefit ratio of psychotherapy (with sensibility
analysis)
Depression = 1.95€ (1.30-2.6);
Anxiety disorders = 1.14€ (0.76-
1.52)
B. Cost-benefit ratio of psychotherapy
According to the findings of the literature review: Burden of
depression was estimated to 4702€, anxiety disorders to 1500€ [11].
The recovery rate attributable to psychotherapy (i.e. recovery -
relapse - (natural recovery – relapse)) was estimated to 30% +/-10%
(6-24 months post-treatment) [3-5]. It was calculated on the whole of
society.
1€ invested in psychotherapy could save: per depressed patient:
1.95€; per anxious patient: 1.14€.
Financial support was received from ‘Caisse Nationale d’Assurance Maladie des Travailleurs
Salariés’ [French National Public Health Insurance for Employees]
The authors have no conflicts of interest to declare