1. Cost-Effectiveness of Psychotherapy for Personality Disorders Soeteman, Busschbach, Verheul

2. Comparing different dosages  Usually... –comparison between theoretical orientation of therapy  Typically... – amount of therapy is keep constant  This assumes... –amount of therapy is relevant  Amount of therapy relates to costs  Yet... –Relation between costs and effects is rarely investigated

3. 3 But isn’t there already evidence of cost effectiveness? No state of the art

4. 4 White raven  The cost-effectiveness of cognitive behavior therapy for borderline personality disorder: results from he BOSCOT trial. –Palmer, Davidson, et al. (2006). –J Personal Disord 20(5): 466-81  Out-patient psychotherapy for borderline personality disorder: cost-effectiveness of schema-focused therapy v. transference- focused psychotherapy. –van Asselt, Dirksen et al –Br J Psychiatry. 2008 Jun;192(6):450-7.

5. 5  John Brazier, Prof in Health Economics –Leading institute, University of Sheffield –Psychological therapies […] for borderline personality disorder: a systematic review and preliminary economic evaluation –January, 2007  On the basis of an extensive review –“The results for [psychotherapy] are promising, though […] surrounded by a high degree of uncertainty. There is a need for considerable research in this area.” Cumulative evidence can be classified as “a promise”

6. Challenges  Randomization –Difficult to randomize patients between different treatment settings and duration of treatment –Use of naturalistic data –Use statistical ‘corrections’ for different baseline levels  Collection of all cost data –Including productivity costs  Introducing cost effectiveness models –Djøra Soeteman  Quality Adjusted Life Years (QALY) as outcome

7. 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)

8. 8 QALY  Quality Adjusted Life Years  Area under the curve

9. 9 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

10. 10 Burden of disease: EQ-5D Soeteman et al. Journal of Personality Disorders. 2007 in press. Soeteman et al. Psychiatric Services, 56, 1153-1155, 2005

11. 11 5000 Citations in PubMed

12. 12  A new wheelchair for elderly (iBOT)  Special post natal care Which health care program is the most cost-effective?

13. 13  A new wheelchair for elderly (iBOT) –Increases quality of life = 0.1 –10 years benefit –Extra costs: $ 3,000 per life year –QALY = Y x V(Q) = 10 x 0.1 = 1 QALY –Costs are 10 x $3,000 = $30,000 –Cost/QALY = 30,000/QALY  Special post natal care –Quality of life = 0.8 –35 year –Costs are $250,000 –QALY = 35 x 0.8 = 28 QALY –Cost/QALY = 8,929/QALY Which health care program is the most cost-effective?

14. 14 QALY league table

15. 15 Burden as criteria Pronk & Bonsel, Eur J Health Econom 2004, 5: 274-277

16. 16 Dutch Council for Public Health and Health Care (RvZ, 2006)

17. 17 Burden of disease: EQ-5D Soeteman et al. Journal of Personality Disorders. 2007 in press. Soeteman et al. Psychiatric Services, 56, 1153-1155, 2005

18. SCEPTRE  Study on Cost-Effectiveness of Personality Disorder Treatment  Start: March 2003  6 clinics

19. 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

20. Correction for selection bias  Propensity score –To correct for baseline differences –A sophisticated co-variance analysis –Combines several co-variates  If successful –Results can be interpreted as an RCT  Several checks on validity  Often used in (health) economics

21. Co-variates used in propensity score  Age  Sex  Diagnosis (SIDP-IV)  Baseline GSI  Motivation  Measures of pathology –DAPP-BQ; SIPP; OQ-45  Quality of life (EQ-5D)

22. 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

23. First some effect data…  Global Severity Index Score (GSI) –Anna Bartak Bartak, Spreeuwenberg, Andrea, Holleman, Rijnierse, Rossum, Hamers, Meerman, Aerts J, Busschbach, Verheul, Stijnen, Emmelkamp Effectiveness of different modalities of psychotherapeutic treatment for patients with cluster C personality disorder: results of a large prospective multicentre study. Psychotherapy and Psychosomatics –In press  Cost effectiveness later on… –Djøra Soeteman

24. Uncorrected results cluster B

25. Propensity score in cluster B  Differences diminish till P = 0.06 –Complicates conclusions  But costs could make the difference…

26. Uncorrected results cluster C

27. Corrected results 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

28. Propensity score in cluster C  Better effects of short-term inpatient psychotherapy remain significant  But costs could still make a difference…

29. Conclusions: effects  Non difference in B (after correction) –But costs can then be decisive ….  Cluster C –Favorable results for short-term inpatient psychotherapy –But is short-term inpatient worth the costs?