ARTICLE IN PRESS
ARTICLE
Reducing Healthcare Costs
for Mental Health
Hospitalizations With the
Evidence-based COPE
Program for Child and
Adolescent Depression and
Anxiety: A Cost Analysis
Bernadette Mazurek Melnyk, PhD, APRN-CNP, FAANP, FNAP, FAAN
Introduction: Although depression and anxiety affect approxi-
mately 20% of children and adolescents, many of those affected do
not receive treatment because, in large part to the shortage of men-
tal health providers across the United States. As an alternative to
traditional mental health counseling, the Creating Opportunities
for Personal Empowerment (COPE) program is an evidence-based
manualized 7-session cognitive behavioral therapy−based program
that is being effectively delivered to children and teens with depres-
sion and anxiety by pediatric and family healthcare providers in pri-
mary care practices with reimbursement from insurers.
Methods: The purpose of this study was to perform a cost analysis
of delivering COPE and compare it to the cost of hospitalization
for primary mental health diagnosis.
Results: Findings indicated a cost savings of $14,262 for every
hospitalization that is prevented.
Bernadette Mazurek Melnyk, Founder, COPE2Thrive, Powell, OH.
Bernadette Melnyk owns a company entitled COPE2Thrive that
disseminates the evidence-based COPE program.
Correspondence: Bernadette Mazurek Melnyk, PhD, APRN-CNP,
FAANP, FNAP, FAAN, COPE2Thrive, 10452 Forest Glen Drive,
Powell, OH 43065.; e-mail: cope.melnyk@gmail.com
J Pediatr Health Care. (2019) 00, 1−5
0891-5245/$36.00
Copyright © 2019 by the National Association of Pediatric Nurse
Practitioners. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.pedhc.2019.08.002
www.jpedhc.org
Discussion: Implementation of COPE can improve outcomes for
children and teens with depression and anxiety, and could poten-
tially result in millions of dollars of cost savings for the U.S. health-
care system. J Pediatr Health Care. (2019) XX, 1−5
KEY WORDS
Pediatric mental health, COPE, depression, anxiety, cognitive-
behavior therapy, adolescents
Pediatric and adolescent mental health disorders have
become a public health epidemic. Approximately one out of
five children, teens, and college-age youth suffer from a
mental health problem, such as depression and anxiety
(Perou et al., 2013). However, many of those who are
affected by a mental health problem do not receive treat-
ment, largely because of an inadequate number of mental
health providers, especially in rural areas of the United
States, and ongoing issues with mental health stigma that
deter families from seeking intervention (Reardon et al.,
2017).
Mental health disorders are responsible for the largest
area of aggregate medical spending among all health disor-
ders that contribute to overall child health expenses ($8.9 bil-
lion; Soni, 2009). Nationally, the most frequent and costly
primary mental health diagnosis in children and teens is
depression, which accounts for 44.1% of all mental health
admissions and costs the U.S. healthcare system $1.33 billion
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 ARTICLE IN PRESS

per year (Bardach et al., 2014). Depression is the leading
predictor of suicide, which is now the second leading cause
of death in 10−34-year-olds (CDC, 2017). Children and
teens with one mental health disorder are likely to have
another co-occurring mental health problem. For example,
approximately three in four children aged 3−17 years with
depression also have anxiety (73.8%), and nearly one in two
have behavior problems (47.2%; Ghandour et al., 2019).
The recommended evidence-based treatment for child
and adolescent depression and anxiety is cognitive behav-
ioral therapy (CBT), yet many of those affected by these dis-
orders do not receive it (Cheung et al., 2018; Weersing,
Jeffreys, Do, Schwartz, & Bolano, 2017). Although the U.S.
Preventive Services Task Force recommends the screening
of all teens 12−18 years of age for depression (US Preven-
tive Services Task Force, 2019), many healthcare providers
do not provide screening because they do not have systems
in place to manage it when found. Depression in youth is
under-identified and undertreated in primary care settings,
and it is common for children and adolescents with mental
health problems to wait for at least two to three months
for treatment in many areas throughout the United States
(Steinman, Shoben, Dembe, & Kelleher, 2015). Even
though the identification and treatment of depressed and
anxious children and teens are feasible and effective in pri-
mary care settings, healthcare providers report persistent
challenges that include inadequate knowledge and skills in
assessing and managing mental health disorders as well as
discomfort in addressing them (Pop, Kinney, Grannemann,
Emslie, & Trivedi, 2019).
The Creating Opportunities for Personal Empowerment
(COPE) program is an innovative, evidence-based solution
to address the high prevalence of child and adolescent
depression and anxiety. COPE is a manualized intervention
program that incorporates the key concepts from CBT into
a 7-session cognitive behavioral skills-building program that
can be delivered in brief 25−30-minute sessions by both
mental health providers and non-psychiatric mental healthcare
professionals, including pediatric and family nurse practi-
tioners, pediatricians, family practice physicians, and teachers,
in primary care and school-based settings. Having the COPE
program available makes mental health screening, and treat-
ment achievable as this CBT-based program can be offered
immediately to those children and teens with mild to moder-
ately elevated symptoms of depression and anxiety who are
seen in primary care settings. COPE provides access to timely
evidence-based treatment to children and teens who might
not otherwise ever receive it (Lusk & Melnyk, 2013). Because
of the high reoccurrence rate of depression if not treated ade-
quately the first time (Curry et al., 2011), being able to deliver
an evidence-based program to both treat and prevent depres-
sion and anxiety by teaching children and youth cognitive
behavioral skills that were once only delivered by mental
health providers is a key solution to this significant public
health epidemic.
In deciding whether to implement a program in primary
care settings, healthcare providers typically consider its
strength of evidence, the feasibility of delivery, and associ-
ated costs (Melnyk & Fineout-Overholt, 2019). Therefore,
the purpose of this study was to perform a cost analysis of
delivering the 7-session COPE program in primary care and
compare it to the costs for a pediatric mental health hospital-
ization. Cost analyses of evidence-based interventions
should be routinely performed so that healthcare decision-
makers can factor in the benefits and costs of translating
efficacious interventions into real-world clinical practice set-
tings (Melnyk & Morrison-Beedy, 2019).
DESCRIPTION OF THE 7-SESSION COPE
PROGRAM
The COPE program contains all of the key concepts in
CBT. The basic premise of CBT is that an individual’s emo-
tions and behaviors are, in large part, determined by how he
or she cognitively think and appraise the world (Beck, 2011).
Therefore, a person who has negative beliefs tends to have
negative emotions (e.g., depression and anxiety) and behaves
in negative ways (e.g., risky behaviors). Negative emotions
and behaviors are even more profound when there are skill
deficits (e.g., poor emotional regulation and problem-solv-
ing, and lack of communication and assertiveness skills;
Beck, Rush, Shaw, & Emery, 1979). A key concept taught in
the COPE program is the thinking-feeling-behaving triangle;
that is, children and teens are taught that how they think
affects how they feel and how they behave. The ABCs also
are taught in the program, which refers to Activating event,
that is, a stressful event that triggers a negative Belief, which
then has a Consequence (e.g., feeling anxious or depressed).
A key strategy in COPE is to monitor for these activating
events that trigger a negative belief or thought and learn to
turn them into a positive thought in order to feel emotionally
better and behave in healthy ways. Strategies to regulate
emotions and to cope with stress also are covered in the
program along with mindfulness, problem-solving and goal
setting (TABLE). As homework is a critical component of

TABLE. Content in the 7-session COPE program

Session Content
1 Addressing the connection between thinking, feeling, and behaving
2 Developing positive thinking habits
3 Building coping/stress reduction skills
4 Problem-solving and goal setting
5 Learning coping skills through positive thinking and communication skills
6 Applying coping skills to stressful situations
7 Pulling it all together

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 ARTICLE IN PRESS
CBT, skills-building activities follow each of the COPE ses-
sions so that children and teens can put into practice what
they are learning in the program. Developmentally tailored
versions of the 7-session COPE program are available in
workbooks for children 7−11 years of age, adolescents
from 12−17 years of age, and college-age youth who are
18−24 years of age.
EXPANDED VERSION OF THE COPE PROGRAM
A 15-session version of the program entitled COPE Healthy
Lifestyles Thinking, Emotions, Exercise, and Nutrition
(TEEN) is also available that adds eight sessions to the
seven CBT-based sessions that contain content and skill-build-
ing activities in nutrition and physical activity. The National
Cancer Institute selected the 15-session COPE TEEN pro-
gram as an obesity control program for its Research Tested
Intervention Programs and gave it the highest rating for its
dissemination capability (see https://rtips.cancer.gov/rtips/
programDetails.do?programId=22686590).
EVIDENCE TO SUPPORT THE EFFICACY AND
WIDE-SCALE USE OF COPE
Several studies have supported positive outcomes of COPE
when delivered to school-age children, adolescents, and col-
lege students. Findings from studies that have provided the
7-session COPE program to depressed and/or anxious
school-age children, teens and college students in brief out-
patient visits have shown decreases in depression, anxiety,
anger and destructive behavior as well as increases in self-
esteem and functioning at school and home (Hart Abney,
Lusk, Hovermale, & Melnyk, 2019; Kozlowski, Lusk, &
Melnyk, 2015; Lusk & Melnyk, 2011). Delivery of the 7-ses-
sion COPE program to small groups of adolescents in two
high schools also resulted in decreases in depression and
anxiety, up to four weeks following the completion of the
intervention (Mazurek Melnyk, Kelly, & Lusk, 2014). The
7-session COPE program also was delivered in an on-line
format to freshmen college students and found to be effec-
tive in decreasing anxiety in students who had elevated
symptoms and increasing academic performance (Melnyk
et al., 2015a).
Findings from other studies that have delivered the
15-session COPE program in classroom settings to children
and youth in middle schools, high schools, and universities
have resulted in decreases in depression, anxiety, suicidal ide-
ation, alcohol use, body mass index, and increases in healthy
lifestyle behaviors and academic performance, up to 12 months
following the completion of the intervention (Buffington,
Melnyk, Morales, Lords, & Zupan, 2016; Hoying & Melnyk,
2016; Hoying, Melnyk, & Arcoleo, 2016; Melnyk et al., 2013;
Melnyk et al., 2015b; Melnyk, Kelly, Jacobson, Arcoleo, &
Shaibi, 2013).
The COPE programs have been reported to be effective
in enhancing mental health outcomes and healthy lifestyle
behaviors across socioeconomic status and race and ethnic-
ity, including White, Black, and Hispanic children and teens
as well as in those with diverse demographics from urban
www.jpedhc.org
and rural areas. Primary care and private practices, schools,
and community mental health clinics are using the COPE
programs in 44 states across the United States and five other
countries, including Canada, the United Kingdom, Australia,
South Africa, and Lebanon. To date, over 10,000 children
and teens have received the program.
METHODS
Most primary care providers across the country are using the
99214 evaluation and management current procedural ter-
minology (CPT) code to deliver the seven COPE sessions.
Reimbursement using this code was used for this cost analy-
sis, although it is recognized that healthcare providers may
use different CPT codes to bill for reimbursement to cover
the costs of providing the COPE program. The CPT code
of 99214 is used for an office or other outpatient visits for
the evaluation and management of an established patient,
which requires at least two of the following components:
detailed history, detailed examination, and medical decision
making of moderate complexity. The cost of the on-line
four-hour educational module required to deliver the COPE
program also was included in the analysis (i.e., $385) along
with the cost of a COPE manual for each child or teen who
receives the program (i.e., $20). Although the costs for a
pediatric mental health hospitalization may vary according
to region, state, and facility, the average cost of hospitaliza-
tion for a primary mental health diagnosis for a child or teen
was used, which is $15,430 (Bardach et al., 2014).
RESULTS
Reimbursement to deliver the 7-session COPE program in
primary care using the 99214 CPT code is $109 per session
or $763 for all seven sessions. For the 10,000 children and
teens in 44 states who have received COPE, the reimburse-
ment cost to the healthcare system for delivery of the pro-
gram is $7.63 million. With the added costs of $20 per
COPE manual for each of the 10,000 children and teens
($200,000) who have received the program in addition
to the provider training costs ($385 £ 500 providers =
$192,500), the total cost to deliver COPE to 10,000 children
and teens is $8.02 million. Using the average cost for a pedi-
atric mental health hospitalization (i.e., $15,430), if 10,000
children and teens were hospitalized for depression, it would
cost the healthcare system $154.3 million. If hospitalization
were prevented for the 10,000 children and teens who
received the COPE 7-session program, the cost savings to
the healthcare system would be $146.2 million. Conserva-
tively, if only 25% of 10,000 children and teens who did not
receive COPE were hospitalized, the cost to the healthcare
system would be $38.6 versus $2.01 million (the reimburse-
ment cost of delivering COPE to 2,500 children and teens
[$1.9 million], the cost of the COPE books [$50,000] and
training 125 providers to deliver the program [$48,125]),
which would still be a savings of $36.57 million. For every
hospitalization that is avoided with the COPE program, it
would save $14,262 (i.e., $15,430 − $385 [cost of on-line
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 ARTICLE IN PRESS
training for the provider] − $20 [cost of the COPE manual
for the child and teen).
DISCUSSION
Mental health disorders in childhood and adolescence can
negatively affect a healthy developmental trajectory by inter-
fering with children's and teens’ ability to attain cognitive,
emotional, social, and academic milestones and to function
in their daily lives.
CBT is the recommended gold standard treatment for
mild to moderate depression in children and youth, yet few
children and adolescents receive it because of the shortage
of mental healthcare providers across the United States. The
COPE program, which is based on CBT, offers primary
healthcare providers one evidence-based solution to begin
management immediately for children and adolescents who
present with mild to moderate symptoms of depression and
anxiety. Findings from this cost analysis indicate that provid-
ing the COPE program in primary care practices throughout
the United States could prevent pediatric mental health hos-
pitalizations and potentially save the healthcare system mil-
lions of dollars each year. These savings do not take into
consideration the emotional hardship for the children, ado-
lescents, and families who experience a psychiatric hospitali-
zation that could have been avoided through early timely
intervention with the use of the 7-session COPE CBT-based
program. Because COPE is completely manualized and can
be delivered after a four-hour on-line training program,
healthcare providers who adhere to intervention fidelity and
deliver the program as designed can expect similar positive
outcomes.
In addition to delivering COPE in primary care settings
to children and teens who are depressed and anxious, the
program is being delivered as a preventive intervention strat-
egy in schools and colleges across the United States because
of the rise in stress and mental health problems (Connolly &
Slade, 2019). The costs to deliver COPE in schools and uni-
versities include the cost of the on-line training program and
the cost of the COPE manuals for each of the students
receiving the program. Learning cognitive behavioral skills
to cope with stress in childhood and adolescence can serve
as a protective factor to guard against the development of
mental health disorders, as 33% and 75% of cases occur by
16 and 24 years of age, respectively (Costello, Mustillo,
Erkanli, Keeler, & Angold, 2003).
The National Academy of Medicine (formerly known as
the Institute of Medicine) set the goal that, by 2020, 90% of
healthcare decisions will be evidence-based (Institute of
Medicine, 2009). The National Institutes of Health also have
established implementation science as a high priority so that
evidence-based interventions can be scaled more rapidly
into real-world practice settings to improve health and well-
being outcomes. Despite goals, mandates, and even new
policies from federal agencies, national professional organi-
zations, insurers, and healthcare leaders that specify clini-
cians and public agencies should implement care and
programs that are evidence-based, there are numerous
4 Volume 000  Number 000
research-supported interventions with positive outcomes
that are not being implemented in real-world clinical settings.
Adding cost analyses to intervention studies could help to
speed the translation of evidence-based interventions into
practice to ultimately improve child and adolescent outcomes.
Childhood is the foundation for the rest of adult life. As a
nation, we must invest more in the prevention and early
treatment of mental health disorders by equipping our chil-
dren and youth with the cognitive behavioral and life skills
needed to cope with the stressors that are commonplace
throughout their development so that their potential is real-
ized and they can lead long productive healthy lives.
Limitations of this study include the fact that hospitaliza-
tion costs vary by state, region, and facility, and therefore,
the calculated cost savings could be somewhat different
based on those costs. Co-payments also may be required in
certain circumstances, and these costs should be added
where applicable.
CONCLUSION
Although mental health disorders are currently a public
health epidemic in children and teens, few receive evidence-
based treatment in the form of CBT because of a shortage
of mental health providers across the United States. Imple-
mentation of the COPE CBT-based program in primary
care and school settings can improve outcomes for children
and adolescents with depression and anxiety, and could
potentially result in millions of dollars of cost savings for the
U.S. healthcare system.
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