1. 1 Cost-effectiveness in Personality Disorder Dr. J.J.V. Busschbach Psychotherapeutic centre ‘De Viersprong’ –PO Box 7 4660 AA Halsteren +31 164 632200 +31 164 632220 (fax) jan.busschbach@devierspong.nl Erasmus MC, Rotterdam –Department of Medical Psychology & Psychotherapy www.xs4all.nl/~jannetvb/busschbach –Contains the slides of this presentation

2. 2 The usual convention…. Doubt about the cost-effectiveness –Treatment of personality disorder is expensive »Treatment is long –Effect is low –Cost-effectiveness is unfavourable How to deal with such stigma?

3. 3 Stigma is not unique Typical for new interventions –Especially new pharmacy Prozac is example Prozac was said to be –More expensive –As effective as old medication »As established in RCT –Therefore not a cost-effective alternative

4. 4 Stigma versus science Reaction of Ely Lilly… –Manufacturer of Prozac –Two main arguments They questioned the randomised trial results –The generalisability of results for clinical practice –Introducing ‘Outcome Research’ They questioned the assumption about higher costs –Medication cost may be higher, but total cost may be lower –Introducing ‘Health Economics’

5. 5 Outcome Research Clinical research –Does it work? –Efficacy –Perfect patient »No co morbidity Randomized Clinical Trial –Controlled conditions Outcome research –Does it work in practice –Effectiveness –Every day patient »Normal co morbidity Trials in a naturalistic setting –Real life conditions

6. 6 In RCT no differences in efficacy… Between Prozac and old medication –No differences between TCA and SSRI Citation British Medical Journal: –“Randomised, controlled clinical trial (RCTs ) generally show equal efficacy among antidepressants” –Song F et al. BMJ, 1993;306:683-7

7. 7 But in outcome research… In practice: much better effectiveness Drop out ration TCA : SSRI = 3 : 1 –Lobowitz, JAMA 1997;278:1186-90 After drop out, recurrence depression 2 to 4 time higher Minimal effective dose –SSRI 98% (Prozac) –TCA 61% –N = 23000, General Practitioner »De Waal et al, NTVG 1996;140:2131-4 Randomised trials mask differences compliance! –Outcome research reveals remarkable results

8. 8 Health economics Simon et al, JAMA 1996;275:1897-902 Six-month health care expenditures –Total cost, not just medication costs Compared –Desipramine: N = 181 »Old TCA »$ 2361 –Imipramine: N = 182 »Old TCA »$ 2105 –Fluoxetine N = 173 »New SSRI: Prozac »$ 1967 No statistical significant differences

9. 9 Regression in quasi-experiment controlled for sex, age, prior-period expenditures etc. Sclar et al, 1994 N = 701

10. 10 What can we learn? Randomised trials are not the holy grail –They do serve in efficacy –But there are higher order measurements Effectiveness –Outcome research »Randomised trials AND naturalistic studies »Quasi experimental design Cost-effectiveness –Health economics »Randomised trials AND naturalistic studies »Quasi experimental design

11. 11 Where do we stand? Favourable results in (randomised) trials –Psychotherapy versus usual care –6 Reviews en 1 meta analysis »Perry et al, Am J Psychiatry 1999;57:1312-21 What about cost effectiveness….? –…is psychotherapy in personality disorder worth the costs?

12. 12 Existing evidence suggests considerable savings New investigations –Bateman, Fonagy, Am J Psychiatry 2003;160:169-71 Reviews –Gabbard et al. Am J Psychiatry 1997;154:147-50

13. 13 Problem in cost effectiveness results Cost estimates made in trial environment –No ‘real’ cost estimates –No adjustment made for trial situation No formal cost-effectiveness study designs Typical elements are missing –Discounting »Costs and effects in the future are valued lower –Generic outcome measures »Quality adjusted life years (QALYs) »Disease specific outcome do not allow for comparisons between different allocations in health care

14. 14 What do we need?…. Naturalistic trial –To prove the effects in practice –To estimate costs in practice Formal cost-effectiveness study –Following international guidelines

15. 15 Sceptre hopes to fulfil these demands Quasi experimental trial in a naturalistic setting –Introducing outcome research The design follows standards in health economics –Introducing health economics But even more than Sceptre we need….

16. 16 Confidence Good treatment will be cost effective –If a treatment works in practice, it will almost certainly be cost- effective –Like Prozac In that conviction we need to put our treatments to the test….