( Cost- ) Effectiveness of Psychotherapy for Personality Disorders

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

2. De Viersprong

3. De Viersprong

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

5. Borderline 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

7. High economic burden 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 • Prevalence: 5% – 14% • € 7500 per year • If treatment seeking

8. Low quality of life

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)

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 K groups K – 1 Propensity scores 1 reference score PS as dummy Co-variate 2 PS score per bilateral comparison Medical Care, 2010

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. 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… But no significant results in cluster B…

23. Results cluster C

24. Corrected rsults C

25. Better effects of short-term inpatient psychotherapy remain significant Assumptions propensity score are met Results maintain But costs could still make a difference… Propensity escore in cluster C

26. 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 Conclusions: effects

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. QALY • Quality Adjusted Life Years • Area under the curve

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

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