A few days ago, I read yet another article comparing the costs and effectiveness of psychotherapy and medication. While both have benefits, the article stated, medication is cheaper. Hmm. I wondered. My insurance company has a handy calculator that allows me to estimate the costs of various types of care, so I figured I’d check it out.

Well, as it turns out, generic antidepressants are pretty inexpensive—definitely cheaper than psychotherapy for insured and insurer. But let’s consider my modal client. You’ve all worked with someone very much like her. She is a midlife woman with trauma, a history of addiction and/or an eating disorder, and a lifetime collection of upwards of a dozen other psychiatric diagnoses. She occupies that portion of the diagnostic map variously labeled as bipolar, borderline, or PTSD. She has had several therapists and hospitalizations, and has had numerous trials of medications. She is rarely just taking an inexpensive generic antidepressant.

Suppose, like many, she found that a brand name antidepressant was more effective for her than the generic? Or that she had already tried just about everything and needed something “new”” Ahh. Let us ask the expense calculator. Twenty dollars for a month’s supply quickly jumps into the $150-200 per month range for a newer drug such as Pristiq, or even for a brand medication that has been around for decades such as Effexor. And suppose that little black rain cloud is still following her around? Suppose she needs a little dash of Abilify to amplify the effects of her antidepressant? Well, now we’re talking. Adding the lowest dose of this medication would add just under $700 per month (sometimes used similarly, Geodon is about half this cost, Seroquel less than a quarter). So now the cost of her medication is up to $800-850 per month. If we create a pharmaceutical cocktail that is far from uncommon by throwing in a mood stabilizer, or maybe a benzodiazepine or sleep medication (Ambien and Lunesta are impressive at over $200 per month), the price tag soars even higher.

Granted, assuming you are fortunate enough to have insurance, this is not the out-of-pocket cost. A client with insurance will pay a co-pay that is generally tiered, with generics and “preferred” medications costing less than brand products. Brand products can easily cost $50 per month, often more. So let’s see, with a brand antidepressant tweaked with Abilify we get $100 per month for the client, and, so the insurance company tells us, $750 ($850 minus co-pays) for the insurance company, or $1200 per year for the client, and a whopping $9,000 per year cost for the insurance company. If I were an insurance company and I were telling the truth about my costs, I’d really be thinking about talking up talk therapy.

Now let’s look at the costs of psychotherapy and imagine that a therapist might be paid by an insurer at a “reasonable and customary” rate of $100 for an individual session (and for many areas of the country, this would be a very sweet dream indeed). Say you see your client once weekly. Perhaps your client’s co-pay is $40 per session, or $160 per month. The insurance company pays a balance of $240. Say, though, just for kicks, the insurance company has set its rates just a tad lower. Suppose they set their R&C at $65 per session. Let’s give our client a $25 co-pay, leaving the insurer responsible for the $40 balance. Anybody seen this? Checked out Medicare rates lately? At 44 sessions a year (the number of annual visits I estimate for a weekly client, given illnesses, vacations, etc.) the $100 session costs the client $1760 per year; the insurer $2640. The $65 session costs the client $1100; the insurer $1760. Now return to Paragraph Four and review the annual costs of a newer or brand antidepressant and Abilify.

You will say, fairly, that I’m comparing an expensive medication option to a typical psychotherapy option. Yes, I am. But this happens every day in my practice—I am providing a typical psychotherapy protocol to clients on complex and expensive psychiatric medications. You will also say that no one would treat this modal client with only medication or only talk therapy, and you would probably be right. It should not be an either/or issue. We could wonder, however, for the sake of argument, which option offers your client or their insurer the most bang for their buck? Is it one year of Abilify for $8400, or one year of weekly individual sessions at $100 for $4400, or one year of individual sessions at $65 for $2860, or, heaven forfend, one year of twice weekly sessions for $8800 (at $100) or $5720 (at $65)?

Co-pays of course increase the cost of psychotherapy to the client. Twice weekly sessions for our $40 co-pay client add up to a hefty $320 per month. This reality is probably partly where we get the idea that therapy costs more. But in the total dollars that someone is paying—insured and/or insurer—it is not always quite so clear. If the total cost is roughly the same, how do we assess the relative value of 365 pills vs. 88 sessions of psychotherapy for a complex client? A year of Pristiq and Ambien or a year of psychotherapy? What is their relative potential for healing? How do we measure their respective long term effectiveness? How do we compare potential side effects? Who is benefitting from the argument that medication is cheaper than psychotherapy? Who funds outcome research for medications? Who funds outcome research for psychotherapy? Who is framing our discourse? Let’s talk about it.

File under: The Art of Psychotherapy, A Day in the Life of a Therapist