1. (Cost-)Effectiveness of Psychotherapy for Personality Disorders Prof. dr. Jan van Busschbach Department of Medical Psychology & Psychotherapy Erasmus MC +31 10 7043807 J.vanbusschbach@erasmusmc.nl 1

2. De Viersprong 2

3. 3

4. 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

5. Borderline 5 Fatal Attraction, 1987, Michael Douglas, Glenn Close

6. 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

7. 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

8. Low quality of life 8

9. 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

10. 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

11. SCEPTRE  Study on Cost-Effectiveness of Personality Disorder Treatment  Naturalistic study  Start: March 2003  6 clinics

12. 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

13. 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”

14. 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

15. 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)

16. Can super covariate fly?

17. 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

18. 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

19. But assumptions are not met in cluster A

20. 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

21. 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.

22. 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…

23. Results cluster C

24. 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

25. 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…

26. 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

27. 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. 28 QALY  Quality Adjusted Life Years  Area under the curve

29. 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

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

31. Costs and effects in Cluster B Much difference Little difference

32. Cost per QALY

33. Costs and effects Cluster C 33 Soeteman et al. Cost-effectiveness of psychotherapy for cluster C personality disorders. Journal of Clinical Psychiatry (In Press)

34. Cost effectiveness Cluster C

35. 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