(Cost-)Effectiveness of Psychotherapy for Personality Disorders Jan van Busschbach Prof. Dr. J. van Busschbach Department of Medical Psychology and Psychotherapy Erasmus MC PO Box CA Rotterdam (direct: )

An different mindset: Comparing “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

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

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? Separate PhD, 2010 Medical Care, 2010 Psychotherapy and Psychosomatics, 2009

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, 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 Long day hospital Short inpatient **0.4313** Long inpatient * * 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)

19 QALY  Quality Adjusted Life Years  Area under the curve

20 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

21 Burden of disease: EQ-5D Soeteman et al. Journal of Personality Disorders, 2008;22: Soeteman et al. Psychiatric Services, 56, , 2005

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 Much difference Little difference

Cost per QALY

Costs and effects Cluster C 25 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 27