(cost-)effectiveness of psychotherapy for personality disorders prof. dr. jan van busschbach...
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(Cost-)Effectiveness of Psychotherapy for Personality
Disorders
Prof. dr. Jan van BusschbachDepartment of Medical Psychology & Psychotherapy Erasmus MC +31 10 [email protected]
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De Viersprong
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De Viersprong
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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
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Borderline
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Fatal Attraction, 1987, Michael Douglas, Glenn Close
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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
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High economic burden
Prevalence: 5% – 14% € 7500 per year
If treatment seeking
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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
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Low quality of life
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0 0,2 0,4 0,6 0,8 1
Major depression
Heamodialysis
Rheumatic disease
Personality disorder
Lung cancer
Parkinson
Diabetes II
Schizophrenia (treated)
HIV
Normal population
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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
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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)
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SCEPTRE
Study on Cost-Effectiveness of Personality Disorder Treatment
Naturalistic study Start: March 2003 6 clinics
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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
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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”
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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
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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)
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Can super covariate fly?
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Multiple propensity score
Medical Care, 2010
K groups K – 1 Propensity scores
1 reference score
PS as dummy Co-variate 2 PS score per bilateral
comparison
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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
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But assumptions are not met in cluster A
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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
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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.
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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…
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Results cluster C
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Corrected rsults CGSI - 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 0.3035 0.3805** 0.4313**
Long inpatient -0.0030 0.0740 0.1247 -0.3065*
* p < 0.05 ** p < 0.01 *** p < 0.001
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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…
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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
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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)
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QALY
Quality Adjusted Life Years Area under the curve
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1
0 10 20 30 40 50 60 70 80
Life years
Ad
jus
me
nt
fac
tor
QA
LY
Co-morbidity
With psychotherapy
No psychotherapy
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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
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Markov model Cluster B
Soeteman et al. Cost-effectiveness of psychotherapy for cluster B personality disorders. British Journal of Psychiatry 2010;196:396–403.
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Costs and effects in Cluster B
Mu
ch d
ifference
Little d
ifference
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Cost per QALY
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Costs and effects Cluster C
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Soeteman et al. Cost-effectiveness of psychotherapy for cluster C personality disorders. Journal of Clinical Psychiatry (In Press)
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Cost effectiveness Cluster C
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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
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