1. The burden of disease in patients with personality disorder indicated for psychotherapy: Arguments for necessity of care Djøra Soeteman, MSc –Djora.Soeteman@deviersprong.net –+31 164 632200 Psychotherapeutic Centre ‘De Viersprong’, P.O.box 7, 4660 AA Halsteren, The Netherlands In cooperation with the Erasmus University, Rotterdam –Reinier Timman, MSc

2. Introduction ‘Necessity’ (of treatment) is 1 of the 4 criteria of reimbursement policy in The Netherlands –Also internationally YAVIS –Young, Attractive, Verbal, Intelligent and Successful Young, Attractive, Verbal, Intelligent, and Successful Young, Attractive, Verbal, Insightful, and Successful Young, Attractive, Vital, Intelligent, and Successful Young, Affluent, Verbal, Insured, and Single

3. Introduction Burden of disease versus cost-effectiveness –Necessary care defined in terms of burden of disease –The higher the burden of disease, the more willing we are to accept a poor cost-effectiveness Example –Prostate problems low burden, reasonable cost-effectiveness –Lungtransplantation high burden, extreme poor cost-effectiveness Measuring burden of disease –Consequences for Quality of Life –Quality of Life questionnaires

4. Quality of life “…. Health is physical, mental and social well- being and not merely the absence of disease or infirmity...” –World Health Organization, 1947 Extending health to well-being: Quality of Life What is the definition of Quality of Life?

5. Definitions of Quality of Life Quality of life is the degree of need and satisfaction within the physical, psychological, social, activity, material and structural area (Hörnquist, 1982). Quality of life is the subjective evaluation of good and satisfactory character of life as a whole (De Haes, 1988). Health related quality of life is the subjective experiences or preferences expressed by an individual, or members of a particular group of persons, in relation to specified aspects of health status that are meaningful, in definable ways, for that individual or group (Till, 1992). Quality of life is a state of well-being which is a composite of two components: 1) the ability to perform everyday activities which reflects physical psychological, and social well-being and 2) patient satisfaction with levels of functioning and the control of disease and/or treatment related symptoms (Gotay et al., 1992). NO CONSENSUS

6. How to measure Quality of Life? Quality of Life is subjective…. –“Given its inherently subjective nature, consensus was quickly reached that quality of life ratings should, whenever possible, be elicited directly from patients themselves”. Aaronson, in B Spilker (Ed): Quality of life and Pharmacoeconomics in Clinical Trails, 1996, page 180

7. How to measure Quality of Life? EuroQol-5D –Developed by EuroQol Group (1987) –Self-report questionnaire –Generic instrument Yields the possibility to compare between different diagnostic groups

8. Descriptive system 5 questions covering 5 dimensions: –Mobility, self-care, usual activities, pain/discomfort, anxiety/depression 3 levels –No problems (1), some or moderate problems (2), extreme problems or unable (3) 243 health states (3 5 ) –Values available for all 243 health states

9. Value a health state 22113 –‘Some problems in walking about’ –‘Some problems washing and dressing myself’ –‘No problems with performing usual activities’ –‘No pain or discomfort’ –‘Extremely anxious or depressed’ Value: 0.25

10. The present study Standard Evaluation Project (STEP) –Standard quality monitoring system –Patients who received a clinical therapy of at least two days a week were included 861 patients were included during the admissison for psychotherapy 19 institutes

11. Results SCL-90

12. Compared to (somatic) illnesses

13. Conclusion Patients with personality disorder who search for therapy, are patients with a severe burden of disease –Contradictory to the YAVIS argument Any cost-effective treatment of personality disorder must be seen as necessary care for a serious illness –This statement favours the reimbursement of psychotherapy

14. General conclusion There is a legitimate need of care –A considerable burden of disease Research questions –Effectiveness (in terms of dose-effect relationships) –Cost-effectiveness –Patient-treatment matching