(Cost-)Effectiveness of Psychotherapy for Personality Disorders Prof. dr. Jan van Busschbach...

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Transcript of (Cost-)Effectiveness of Psychotherapy for Personality Disorders Prof. dr. Jan van Busschbach...

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  • (Cost-)Effectiveness of Psychotherapy for Personality Disorders Prof. dr. Jan van Busschbach Department of Medical Psychology & Psychotherapy Erasmus MC +31 10 7043807 [email protected] 1
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  • De Viersprong 2
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  • Personality Disorders Related to social interactions Inflexible and pervasive behavior and thoughts Maladaptive coping skills Unable to switch perspective Mentalization Unable to stand in some others shoes Insecure attachment in child hood Inadequate representation of social rules Functional in family, not functional outside Genetic vulnerability 4
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  • Borderline 5 Fatal Attraction, 1987, Michael Douglas, Glenn Close
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  • 10 personality disorders Cluster A:odd or eccentric Paranoid Schizoid: lack of interest in social relationships Schizotypal: odd behavior or thinking Cluster B: dramatic, emotional or erratic Antisocial: disregard for the law and the rights of others. Borderline: "black and white" thinking, instability in relationships, self-image, identity and behavior often leading to self-harm and impulsivity. Histrionic: pervasive attention-seeking Narcissistic Cluster C: anxious or fearful disorders Avoidant Dependent Obsessive-compulsive 6
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  • High economic burden Prevalence: 5% 14% 7500 per year If treatment seeking 7 Soeteman DI, Hakkaart-van Roijen L, Verheul R, Busschbach JJ. The Economic Burden of Personality Disorders in Mental Health Care. J Clin Psychiatry. 2008 Feb;69(2):259-65
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  • Low quality of life 8
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  • Not theories but dosages Usually... Comparison between theoretical orientation of therapy Typically... Amount of therapy is keep constant This assumes... amount of therapy is relevant Little differences Nonspecific factors seems to drive treatment success Amount of therapy relates to costs Yet... Relation between costs and effects is rarely investigated
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  • Randomization failed RCT 3 month in patient treatment Out patient treatment Patients preference dominate After 1,5 year, 1 patient included Patients SES influences treatment allocation Van Manen et al.Relationship between patient characteristics and treatment allocation for patients with personality disorders. Journal of Personality Disorders (in press) 10
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  • SCEPTRE Study on Cost-Effectiveness of Personality Disorder Treatment Naturalistic study Start: March 2003 6 clinics
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  • 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
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  • In need of a super covariate 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
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  • 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 Epidemiology
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  • 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)
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  • Can super covariate fly?
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  • Multiple propensity score Medical Care, 2010 K groups K 1 Propensity scores 1 reference score PS as dummy Co-variate 2 PS score per bilateral comparison
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  • Cluster A: one of the largest studies ever Bartak, et al. Effectiveness of outpatient, day hospital, and inpatient psychotherapeutic treatment for patients with cluster A personality disorder. Accepted for publication Psychotherapy and Psychosomatics
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  • But assumptions are not met in cluster A
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  • 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
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  • Results cluster B Bartak et al. Effectiveness of outpatient, day hospital, and inpatient psychotherapeutic treatment for patients with cluster B personality disorder. Psychotherapy and Psychosomatics, 2011 Oct 23;80(1):28-38.
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  • 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
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  • Results cluster C
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  • 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 0.30350.3805**0.4313** Long inpatient -0.00300.07400.1247-0.3065* * p < 0.05 ** p < 0.01 *** p < 0.001
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  • 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
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  • 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
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  • 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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  • 28 QALY Quality Adjusted Life Years Area under the curve
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  • 29 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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  • Markov model Cluster B Soeteman et al. Cost-effectiveness of psychotherapy for cluster B personality disorders. British Journal of Psychiatry 2010;196:396403.
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  • Costs and effects in Cluster B Much difference Little difference
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  • Cost per QALY
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  • Costs and effects Cluster C 33 Soeteman et al. Cost-effectiveness of psychotherapy for cluster C personality disorders. Journal of Clinical Psychiatry (In Press)
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  • Cost effectiveness 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 35