(Cost-)Effectiveness of Psychotherapy for Personality Disorders

Jan van Busschbach

Prof. Dr. J. van BusschbachDepartment of Medical Psychology and Psychotherapy Erasmus MC PO Box 2040  3000 CA Rotterdam  +31 10 7043807 (direct: 7044306)J.vanbusschbach@erasmusmc.nl

Jan van Busschbach, Roel Verheul, Anna Bartak, Djora Soeteman, Helene

Andrea, Janine van Manen

An different mindset: Comparing “dosages”

Usually ...– Comparison between theoretical orientation of therapy

Typically ...– Amount of therapy is keep constant– Little differences

• Nonspecific factors seems to drive treatment success

This assumes ...– amount of therapy is relevant

Amount of therapy relates to costs Yet ...

– Relation between costs and effects is rarely investigated

SCEPTRE

Study on Cost-Effectiveness of Personality Disorder Treatment

Start: March 2003 6 clinics

SCEPTRE

About 900 patient with PD Followed over 3 years Dosages compared

– Outpatient, day-hospital and inpatient psychotherapy

– Shorter than or equal to 6 months, longer than 6 months Clusters

– A; N = 58

– B; N = 241

– C; N = 466 Naturalistic design

Selection bias

Question to clinician: – “What are the important variables for treatment allocation?”

Answer:– “Everything is important!”

How to control for everything?– “We are in need of a super covariate”

Correction for selection bias

Propensity score– A sophisticated co-variance analysis

– Combines several co-variates

– To correct for baseline differences If successful

– Results can be interpreted as an RCT Several checks on validity Often used in (health) economics

Super Covariate: the propensity score

Age Sex Diagnosis (SIDP-IV) Baseline GSI Motivation Measures of pathology

– DAPP-BQ; SIPP; OQ-45 Quality of life (EQ-5D)

Is the super covariate valid?

Separate PhD, 2010

Medical Care, 2010

Psychotherapy and Psychosomatics, 2009

Cluster A: one of the largest studies ever

Bartak, Andrea, Spreeuwenberg, Ziegler, Dekker, Rossum, Hamers, Scholte, Aerts, Busschbach, Verheul, Stijnen, & Emmelkamp, (in press). Effectiveness of outpatient, day hospital, and inpatient psychotherapeutic treatment for patients with cluster A personality disorder. Under review

But assumptions are not met in cluster A

Assumptions met in:

3 groups in cluster B– Inpatient

– Day-hospital

– Outpatient 5 groups in cluster C

– Short-term inpatient

– Long-term inpatient

– Short-term day-hospital

– Long-term day-hospital

– Long-term out-patient

Results cluster B

Bartak, Andrea, Spreeuwenberg, Ziegler, Dekker, Rossum, Hamers, Scholte, Aerts, Busschbach, Verheul, Stijnen, & Emmelkamp. Effectiveness of outpatient, day hospital, and inpatient psychotherapeutic treatment for patients with cluster B personality disorder. Psychotherapy and Psychosomatics, in press

But no significant results in cluster B…

Differences diminish till P = 0.06– After correction with the propensity score

– Complicates conclusions Assumptions of propensity score are met

– Effect are reduces after correction But costs could make the difference…

Results cluster C

Corrected rsults C

GSI - Difference score

Treatment group

Long outpatient

Short day hospital

Long day hospital

Short inpatient

Short day hospital

-0.0770

Long day hospital

-0.1278 -0.0508

Short inpatient 0.3035 0.3805** 0.4313**

Long inpatient -0.0030 0.0740 0.1247 -0.3065*

* p < 0.05 ** p < 0.01 *** p < 0.001

Propensity escore in cluster C

Better effects of short-term inpatient psychotherapy remain significant

Assumptions propensity score are met– Results maintain

But costs could still make a difference…

Conclusions: effects

No comparison possible in cluster A– But psychotherapy seems to work

– Inpatient / day hospital seems better Non difference in B (after correction)

– But costs can be decisive …. Cluster C

– Favorable results for short-term inpatient psychotherapy

– Expect to dominates long in-patient

– But is short-term inpatient worth the costs?• Compared to long day hospital / short day hospital

QALY

Health economics addresses the efficient allocation of health care resources

For instance– Psychotherapy “long” versus “short”

– “Psychotherapy in PD” versus “Care for diabetics” Make effects comparable

– Same effect parameter in diabetes as in PD Survival and Quality of Life Combined: Quality Adjusted Life Years (QALY)

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QALY

Quality Adjusted Life Years Area under the curve

0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1

0 10 20 30 40 50 60 70 80

Life years

Ad

jus

me

nt

fac

tor

QA

LY

Co-morbidity

With psychotherapy

No psychotherapy

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EQ-5D MOBILITY

– I have no problems in walking about – I have some……. – I am confined to bed

SELF-CARE

– I have no problems with self-care – I have some problems….. – I am unable…

USUAL ACTIVITIES

– I have no problems with performing my usual activities

– I have some problems… – I am unable….

PAIN/DISCOMFORT

– I have no pain or discomfort – I have moderate ….. – I have extreme……..

ANXIETY/DEPRESSION

– I am not anxious or depressed – I am moderately……..– I am extremely…..

The EuroQol EQ-5D is specially designed to measure the quality of life index for QALYs

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Burden of disease: EQ-5D

0 0,2 0,4 0,6 0,8 1

Major depression

Heamodialysis

Rheumatic disease

Personality disorder

Lung cancer

Parkinson

Diabetes II

Schizophrenia (treated)

HIV

Normal population

Soeteman et al. Journal of Personality Disorders, 2008;22:259-68 . Soeteman et al. Psychiatric Services, 56, 1153-1155, 2005

Markov model Cluster B

Soeteman, Verheul, Delimon, Meerman, Van den Eijnden, Rossum, Ziegler, Thunnissen, Busschbach, Kim. Cost-effectiveness of psychotherapy for cluster B personality disorders. British Journal of Psychiatry 2010;196:396–403.

Costs and effects in Cluster B

Much difference

Much difference

Little difference

Interested in both costs and effect

Less effective More effective

Low costs (savings)

High costs

Good

Better

Superb!

Forget it!

Difficult…

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Sensitivity analysis

Less effective More effective

Low costs (savings)

High costs

Superb!

Forget it!

Difficult…

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Good

Better

Cost-effectiveness plane

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Good

Better

Acceptability curve

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Cluster BOut / Day /in – patient

Cluster BOut / Day /in – patient

Cluster C

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Soeteman, Verheul, Meerman, Rossum, Delimon, Rijnierse, Thunnissen, Busschbach, & Kim. Cost-effectiveness of psychotherapy for cluster C personality disorders. Journal of Clinical Psychiatry (in press).

Cluster C

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Conclusion

Cost-effective treatment strategies are: Cluster C PD:

– Short-term inpatient psychotherapy (first choice)– Short-term day hospital psychotherapy

Sub-optimal treatment options are:– Long-term day hospital and long-term inpatient

Cluster B PD:– Outpatient psychotherapy (first choice)– Day hospital psychotherapy

Sub-optimal treatment option is:– Inpatient psychotherapy

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Dutch Council for Public Health and Health Care (RvZ, 2006)

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Definition “recovered patient”

Clinically significant change: (Jacobson and Truax, 1991)

– Recovered: statistically reliable + ends up within normal limits– Improved: statistically reliable , but ends still dysfunctional– Unchanged: no statistically reliable – Relapsed or deteriorated: statistically reliable in the opposite

direction

General Symptom Index (BSI/SCL-90)