Costs and returns on training investment for empirically supported psychological interventions
Erica Crome A C , Joanne Shaw B and Andrew Baillie A
+ Author Affiliations
- Author Affiliations
A NHMRC Centre of Research Excellence in Mental Health and Substance Use, Centre for Emotional Health, Psychology Department, Macquarie University, NSW 2109, Australia. Email: andrew.baillie@mq.edu.au
B Psycho-oncology Co-operative Research Group, School of Psychology, The University of Sydney, NSW 2006, Australia. Email: joanne.shaw@sydney.edu.au
C Corresponding author. Email: erica.crome@mq.edu.au
Australian Health Review 41(1) 82-88 https://doi.org/10.1071/AH15129
Submitted: 9 July 2015 Accepted: 1 February 2016 Published: 24 March 2016
Abstract
Objective Financial costs are a significant barrier to the uptake of empirically supported psychological interventions in clinical settings. Training may be among the largest of these costs; however, the potential magnitude of these costs is unclear. The aim of the present study was to develop a hypothetical model of potential training costs associated with adopting a novel therapy using systematic review of anticipated training durations and publicly available data on workshop costs, training materials and income.
Methods Direct and indirect costs were estimated for reference categories being cognitive behavioural therapy for social anxiety disorder delivered by registered psychologists. These were based on averages of 39 workshops and eight treatment manuals available in Australia identified through online searches.
Results This model demonstrated that upper cost ranges for training can exceed A$55 000, and even didactic training (reading manuals, attending workshops) may cost up to A$9000. Indirect costs of forfeited income account for a substantial proportion of these costs.
Conclusions This hypothetical model highlights why training costs should be considered in decisions about disseminating and implementing novel empirically supported psychological interventions, particularly within private workforces. In addition, the direct return on training investment for practitioners in private practice is unclear, and may vary based on caseloads and current treatment modalities. Initiatives to track competence, support training and identify novel training solutions may be required to ensure the sustainability of high-quality mental healthcare.
What is known about the topic? Financial costs are one of the leading factors determining whether empirically supported mental health treatments are adopted or sustained. Training costs may be one of the largest costs of disseminating and implementing novel psychological therapies within existing workforces, including both direct (e.g. workshop fees) and indirect (e.g. lost income) costs. However, little is understood about the potential magnitude of these costs.
What does this paper add? This paper presents a hypothetical modelling of potential costs associated with adopting a novel therapy, with reference categories for an empirically supported treatment (cognitive behaviour therapy) for one mental disorder (social anxiety disorder) for one mental health profession (psychologist). This model was developed and populated using systematic review of anticipated training durations and publicly available data on workshop costs, training materials and income.
What are the implications for practitioners? With potential costs for adopting one novel psychological intervention exceeding A$55 000, we highlight why training costs and pathways should be a focal point for ensuring the sustainable provision of high-quality mental healthcare in Australia.
References
[1] Department of Health. Medicare benefits schedule online. 2013. Available at: http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/the-mbs [verified December 2015].[2] Australian Psychological Society (APS). Evidence-based psychological interventions: a literature review. 3rd edn. Melbourne: APS; 2010.
[3] National Institute for Health and Care Excellence (NICE). NICE clinical guidelines. 2016. Available at: http://www.nice.org.uk/guidance/published?type=cg [verified May 2015].
[4] McHugh RK, Whitton SW, Peckham AD, Welge JA, Otto MW. Patient preference for psychological vs. pharmacological treatment of psychiatric disorders: a meta-analytic review. J Clin Psychiatry 2013; 74 595–602.
| Patient preference for psychological vs. pharmacological treatment of psychiatric disorders: a meta-analytic review.Crossref | GoogleScholarGoogle Scholar | 23842011PubMed |
[5] Shafran R, Clark D, Fairburn C, Arntz A, Barlow D, Ehlers A, Freeston M, Garety PA, Hollon SD, Ost LG, Salkovskis PM, Williams JMG, Wilson GT. Mind the gap: improving the dissemination of CBT. Behav Res Ther 2009; 47 902–9.
| Mind the gap: improving the dissemination of CBT.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD1MjktVKrtQ%3D%3D&md5=bebf9785c72c289897c51b04644a673fCAS | 19664756PubMed |
[6] Andrade LH, Alonso J, Mneimneh Z, Wells JE, Al-Hamzawi A, Borges G, Bromet E, Bruffaerts R, de Girolamo G, de Graaf R, Florescu S, Gureje O, Hinkov HR, Huang Y, Hwang I, Jin R, Karam EG, Kovess-Masfetv V, Levinson D, Matschinger H, O’Neill S, Posada-Villa J, Sagar R, Sampson NA, Sasu C, Stein DJ, Takeshima T, Viana MC, Xavier M, Kessler RC. Barriers to mental health treatment: results from the WHO World Mental Health surveys. Psychol Med 2014; 44 1303–17.
| Barriers to mental health treatment: results from the WHO World Mental Health surveys.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC3sfotlWisg%3D%3D&md5=6fea9a7e1d7692002882ea5624411577CAS | 23931656PubMed |
[7] Condon TP, Miner LL, Balmer CW, Pintello D. Blending addiction research and practice: strategies for technology transfer. J Subst Abuse Treat 2008; 35 156–60.
| Blending addiction research and practice: strategies for technology transfer.Crossref | GoogleScholarGoogle Scholar | 18337054PubMed |
[8] Weisz JR, Ng MY, Bearman SK. Odd couple? Reenvisioning the relation between science and practice in the dissemination–implementation era. Clin Psychol Sci 2014; 2 58–74.
| Odd couple? Reenvisioning the relation between science and practice in the dissemination–implementation era.Crossref | GoogleScholarGoogle Scholar |
[9] Holmes BJ, Schellenberg M, Schell K, Scarrow G. How funding agencies can support research use in healthcare: an online province-wide survey to determine knowledge translation training needs. Implement Sci 2014; 9 71–81.
| How funding agencies can support research use in healthcare: an online province-wide survey to determine knowledge translation training needs.Crossref | GoogleScholarGoogle Scholar | 24906229PubMed |
[10] Stewart RE, Chambless DL, Baron J. Theoretical and practical barriers to practitioners’ willingness to seek training in empirically supported treatments. J Clin Psychol 2012; 68 8–23.
| Theoretical and practical barriers to practitioners’ willingness to seek training in empirically supported treatments.Crossref | GoogleScholarGoogle Scholar | 21901749PubMed |
[11] Bond GR, Drake RE, McHugo GJ, Peterson AE, Jones AM, Williams J. Long-term sustainability of evidence-based practices in community mental health agencies. Adm Policy Ment Health 2014; 41 228–36.
| Long-term sustainability of evidence-based practices in community mental health agencies.Crossref | GoogleScholarGoogle Scholar | 23266661PubMed |
[12] Becker K, Stirman S. The science of training in evidence-based treatments in the context of implementation programs: current status and prospects for the future. Adm Policy Ment Health 2011; 38 217–22.
| The science of training in evidence-based treatments in the context of implementation programs: current status and prospects for the future.Crossref | GoogleScholarGoogle Scholar | 21644028PubMed |
[13] Greenhalgh T, Robert G, Bate P, Macfarlane F, Kyriakidou O. Diffusion of innovations in health service organisations: a systematic literature review. India: Blackwell Publishing Ltd; 2005.
[14] Wisdom JP, Chor KHB, Hoagwood KE, Horwitz SM. Innovation adoption: a review of theories and constructs. Admn Policy Ment Hlth 2014; 180–202.
[15] Cook JM, Dinnen S, Coyne JC, Thompson R, Simiola V, Ruzek J, Schnurr PP. Evaluation of an implementation model: a national investigation of VA residential programs. Admn Policy Ment Hlth 2014; 147–56.
| 1:CAS:528:DC%2BC2cXnt1KrtQ%3D%3D&md5=8357b9da4e0bde2f92d417dd1fe18f19CAS |
[16] McHugh RK, Barlow DH. The dissemination and implementation of evidence-based psychological treatments: a review of current efforts. Am Psychol 2010; 65 73–84.
| The dissemination and implementation of evidence-based psychological treatments: a review of current efforts.Crossref | GoogleScholarGoogle Scholar | 20141263PubMed |
[17] Fairburn CG, Cooper Z. Therapist competence, therapy quality, and therapist training. Behav Res Ther 2011; 49 373–8.
| Therapist competence, therapy quality, and therapist training.Crossref | GoogleScholarGoogle Scholar | 21492829PubMed |
[18] Lysaght RM, Altschuld JW. Beyond initial certification: the assessment and maintenance of competency in professions. Eval Program Plann 2000; 23 95–104.
| Beyond initial certification: the assessment and maintenance of competency in professions.Crossref | GoogleScholarGoogle Scholar |
[19] Health Workforce Australia. Mental health workforce study: mental health workforce planning data inventory. Adelaide: Health Workforce Australia; 2013.
[20] Australian Institute of Health and Welfare (AIHW). Medical workforce 2011. Canberra: AIHW; 2013.
[21] Herschell AD, Kolko DJ, Baumann BL, Davis AC. The role of therapist training in the implementation of psychosocial treatments: a review and critique with recommendations. Clin Psychol Rev 2010; 30 448–66.
| The role of therapist training in the implementation of psychosocial treatments: a review and critique with recommendations.Crossref | GoogleScholarGoogle Scholar | 20304542PubMed |
[22] Rakovshik SG, McManus F. Establishing evidence-based training in cognitive behavioral therapy: a review of current empirical findings and theoretical guidance. Clin Psychol Rev 2010; 30 496–516.
| Establishing evidence-based training in cognitive behavioral therapy: a review of current empirical findings and theoretical guidance.Crossref | GoogleScholarGoogle Scholar | 20488599PubMed |
[23] Fairburn CG, Wilson GT. The dissemination and implementation of psychological treatments: problems and solutions. Int J Eat Disord 2013; 46 516–21.
| The dissemination and implementation of psychological treatments: problems and solutions.Crossref | GoogleScholarGoogle Scholar | 23658103PubMed |
[24] Sholomskas DE, Syracuse-Siewert G, Rounsaville BJ, Ball SA, Nuro KF, Carroll KM. We don’t train in vain: a dissemination trial of three strategies of training clinicians in cognitive-behavioral therapy. J Consult Clin Psychol 2005; 73 106–15.
| We don’t train in vain: a dissemination trial of three strategies of training clinicians in cognitive-behavioral therapy.Crossref | GoogleScholarGoogle Scholar | 15709837PubMed |
[25] Karlin BE, Ruzek JI, Chard KM, Eftekhari A, Monson CM, Hembree EA, Resick PA, Foa EB. Dissemination of evidence‐based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. J Trauma Stress 2010; 23 663–73.
| Dissemination of evidence‐based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration.Crossref | GoogleScholarGoogle Scholar | 21171126PubMed |
[26] Kessler R, Aguilar-Gaxiola S, Alonso J, Chatterji S, Lee S, Ormel J, Ustun TB, Wang PS. The global burden of mental disorders: an update from the WHO World Mental Health (WMH) surveys. Epidemiol Psichiatr Soc 2009; 18 23–33.
| The global burden of mental disorders: an update from the WHO World Mental Health (WMH) surveys.Crossref | GoogleScholarGoogle Scholar | 19378696PubMed |
[27] Crome E, Grove R, Baillie AJ, Sunderland M, Teesson M, Slade T. DSM-IV and DSM-5 social anxiety disorder in the Australian community. Aust N Z J Psychiatry 2015; 49 227–35.
| DSM-IV and DSM-5 social anxiety disorder in the Australian community.Crossref | GoogleScholarGoogle Scholar | 25122449PubMed |
[28] Acarturk C, Cuijpers P, van Straten A, de Graaf R. Psychological treatment of social anxiety disorder: a meta-analysis. Psychol Med 2009; 39 241–54.
| Psychological treatment of social anxiety disorder: a meta-analysis.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD1M%2FntVemuw%3D%3D&md5=cf8f1035678bcf755249ff1eea90ce26CAS | 18507874PubMed |
[29] Pirkis J, Harris M, Hall W, Ftanou M. Evaluation of the better access to psychiatrists, psychologists and general practitioners through the Medicare benefits schedule initiative. Melbourne: Centre For Health Policy, Programs and Economics; 2011.
[30] Department of Employment. Job outlook: an Australian Government initiative. 2012. Available at: http://joboutlook.gov.au/occupation.aspx?code=2723&search=alpha&Tab=stats&graph=EA [verified December 2014].
[31] Posnett J, Jan S. Indirect cost in economic evaluation: the opportunity cost of unpaid inputs. Health Econ 1996; 5 13–23.
| Indirect cost in economic evaluation: the opportunity cost of unpaid inputs.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK283js1Oksw%3D%3D&md5=f761f2e9f29783c955a83d1130fb797bCAS | 8653189PubMed |
[32] Australian Psychological Society. Australian Psychological Society: fees and rebates. 2014. Available at: http://www.psychology.org.au/community/fees_rebates/2014 [verified October 2014].
[33] Beidas RS, Kendall PC. Training therapists in evidence‐based practice: a critical review of studies from a systems‐contextual perspective. Clin Psychol Sci Pract 2010; 17 1–30.
| Training therapists in evidence‐based practice: a critical review of studies from a systems‐contextual perspective.Crossref | GoogleScholarGoogle Scholar |
[34] Teesson M, Slade T, Mills K. Comorbidity in Australia: findings of the 2007 National Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry 2009; 43 606–14.
| Comorbidity in Australia: findings of the 2007 National Survey of Mental Health and Wellbeing.Crossref | GoogleScholarGoogle Scholar | 19530017PubMed |
[35] Reavley NJ, Jorm AF. National survey of mental health literacy and stigma. Canberra: Department of Health and Ageing; 2011.
[36] Psychology Board of Australia. Continuing professional development guidelines. Australian Health Practitioners Regulation Agency; 2010. Available at: http://www.psychologyboard.gov.au/Standards-and-Guidelines/Codes-Guidelines-Policies.aspx [verified July 2015].
[37] Cottraux J, Note I, Albuisson E, Nan Yao S, Note B, Mollard E, Bonasse F, Jalenques I, Guerin J, Julien Coudert A. Cognitive behavior therapy versus supportive therapy in social phobia: a randomized controlled trial. Psychother Psychosom 2000; 69 137–46.
| Cognitive behavior therapy versus supportive therapy in social phobia: a randomized controlled trial.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3c3jsl2jsA%3D%3D&md5=aea3e4f5e5cc9daf33abe727c3d9aa3fCAS | 10773778PubMed |
[38] Koszycki D, Benger M, Shlik J, Bradwejn J. Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder. Behav Res Ther 2007; 45 2518–26.
| Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder.Crossref | GoogleScholarGoogle Scholar | 17572382PubMed |
[39] Davidson JR Foa EB Huppert JD Keefe FJ Franklin ME Compton JS Zhao N Connor KM Lynch TR Gadde KM 2014
[40] Neimeyer GJ, Taylor JM, Rozensky RH. The diminishing durability of knowledge in professional psychology: a Delphi poll of specialties and proficiencies. Prof Psychol Res Pr 2012; 43 364–71.
| The diminishing durability of knowledge in professional psychology: a Delphi poll of specialties and proficiencies.Crossref | GoogleScholarGoogle Scholar |
[41] Stokes D, Mathews R, Grenyer BF, Crea K. The Australian Psychology Workforce 3: a national profile of psychologists in salaried employment or in independent private practice. Aust Psychol 2010; 45 178–88.
| The Australian Psychology Workforce 3: a national profile of psychologists in salaried employment or in independent private practice.Crossref | GoogleScholarGoogle Scholar |
[42] Chisholm D. Dollars, DALYs and decisions: economic aspects of the mental health system. Geneva: World Health Organization; 2006.
[43] Graeff‐Martins AS, Flament MF, Fayyad J, Tyano S, Jensen P, Rohde LA. Diffusion of efficacious interventions for children and adolescents with mental health problems. J Child Psychol Psychiatry 2008; 49 335–52.
| Diffusion of efficacious interventions for children and adolescents with mental health problems.Crossref | GoogleScholarGoogle Scholar | 18333931PubMed |
[44] Jacobson NS, Truax P. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol 1991; 59 12–19.
| Clinical significance: a statistical approach to defining meaningful change in psychotherapy research.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK3M7mtFOmsg%3D%3D&md5=db967901d051853f37840e107364c769CAS | 2002127PubMed |
[45] Hart JT. The political economy of health care: a clinical perspective. Bristol: The Policy Press; 2006.
[46] Ribisl KM, Leeman J, Glasser AM. Pricing health behavior interventions to promote adoption: lessons from the marketing and business literature. Am J Prev Med 2014; 46 653–9.
| Pricing health behavior interventions to promote adoption: lessons from the marketing and business literature.Crossref | GoogleScholarGoogle Scholar | 24842743PubMed |
[47] Taylor S, Abramowitz JS. Dissemination of psychosocial treatments for anxiety: the importance of taking a broad perspective. J Anxiety Disord 2013; 27 802–4.
| Dissemination of psychosocial treatments for anxiety: the importance of taking a broad perspective.Crossref | GoogleScholarGoogle Scholar | 24148748PubMed |
