(Cost-)Effectiveness of Psychotherapy for Personality

Disorders

Prof. dr. Jan van BusschbachDepartment of Medical Psychology & Psychotherapy Erasmus MC +31 10 7043807J.vanbusschbach@erasmusmc.nl

1

De Viersprong

2

De Viersprong

3

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

Borderline

5

Fatal Attraction, 1987,  Michael Douglas, Glenn Close

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

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

Low quality of life

8

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

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

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

SCEPTRE

Study on Cost-Effectiveness of Personality Disorder Treatment

Naturalistic study 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

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”

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

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)

Can super covariate fly?

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

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

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 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.

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 CGSI - 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)

28

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

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

Markov model Cluster B

Soeteman et al. Cost-effectiveness of psychotherapy for cluster B personality disorders. British Journal of Psychiatry 2010;196:396–403.

Costs and effects in Cluster B

Mu

ch d

ifference

Little d

ifference

Cost per QALY

Costs and effects Cluster C

33

Soeteman et al. Cost-effectiveness of psychotherapy for cluster C personality disorders. Journal of Clinical Psychiatry (In Press)

Cost effectiveness Cluster C

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