1 A Health Economic View on Borderline Personality Disorder Prof. dr. Jan Busschbach Viersprong Institute for studies on Personality Disorders Medical Psychology and Psychotherapy Erasmus MC

2002: Two books, and a hand full of articles

2002: no state-of-the-art studies  Studies did not follow guide lines  Articles and books often promoted state-of-the-art studies…..but did not present results  No use of health economic relevant outcomes  Effects not expressed as QALYs No comparison possible with somatic diseases  No societal cost involved Not all costs 3

2006  Systematic review and preliminary economic evaluation  Borderline personality disorder  John Brazier, Sheffield, 2006  Based on the first studies MBT  Bateman also presented some costs data  No QALYs

Cost offset by less care elsewhere 5

Full health economic model  John Brazier added:  QALYs  All cost  Simultaneously testing of all uncertainty Cost Effects 6

7 We want both costs and effects…. Bad effectsGood effects Low costs (savings) High costs Good Better SUPER ! Forget it ! Cost effective savings …

8 Multiple sensitivity analysis Bad effectsGood effects Low costs (savings) High costs Good Even Better SUPER ! Forget it ! Cost effective savings …

Probability being cost effective Change being cost effective 0.0 Willingness to pay for effects

10 Cost effectiveness plane, Brazier, 2007 Good Better SUPER ! Not so good… Forget it !

11 Cost effectiveness threshold, Brazier, 2007 Our uncertainty about the cost effectiveness is not (further) determined by willingness to pay, but by the uncertainty of our own research results

Conclusion 2007  Converted all existing evidence into a health economic model  “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”  John Brazier 12

2012: More health economics… 13

2012: better health economics…  State of the art studies (in Borderline)  Palmer, Davidson, Tyrer, 2006 Cognitive behavior therapy University of York  Van Asselt, Giesen-Bloo, Arnzt et al, 2008 Schema-focused vs transference-focused University of Maastricht  Soeteman, Busschbach, Verheul et al, 2010 Out patient, day hospital, in-patients Erasmus MC  5 to 7 others…  Bit not in BPD, or with lower quality

Palmer, Davidson,Tyrer  Adding cognitive behavior therapy  Gives lower costs, and lower quality of life  TAU has more changes on being cost effective

Van Asselt, Giesen-Bloo, Arntz  Schema-focused vs transference-focused 16

Bartak, Busschbach, Verheul,  Cluster B patients  Most effect in-patients psychotherapy  Then day hospital  Then out patients

Soeteman, Busschbach, Verheul 18  Low willingness to pay: Out-patient  High willingness to pay: Day hospital

Favorable results in Borderline  Additional CBT is not cost effective  Schema focus is cost effective  Out patient is cost effective  Day hospital also, with high willingness to pay

Why not general accepted?  Only three studies  Cost effectiveness is not all that counts…  Other issues  Burden of disease  Prevalence Budget impact  Own influence on health Perceived own influence  Consensus in the field

Burden of disease  Willingness to pay is function of burden

Costs/QALY versus Burden of disease 22 € € € € € 0 Burden of disease X X X X X

Dutch Council for Public Health and Health Care (RvZ, 2006) 23

Need to demonstrate Burden  Burden often demonstrated in technical terms  Disease specific questionnaire results, jargon  But we need comparisons with (somatic) diseases  Generic measures  EuroQol EQ-5D  Health Utility Index  SF-6D 24  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…..

Burden is considerable 25 Soeteman et al. Assessment of the burden of disease among inpatients in specialized units that provide psychotherapy. Psychiat Serv Sep;56(9):1153-5

Prevalence  Prevalence relates to:  Budget impact The higher the budget impact, the more risk avers policy makers become  Burden “If it is so common: why don’t I see al that misery?”  Own influence on disease “If it is common, others seem to deal with it…” “So why paying for treatment?”  Being enthusiastic about a high prevalence….  ….might not be such a good idea  And… in fact we do not know the prevalence of people that need treatment…

Orphan drugs  Pompe disease  Classical form: € – per QALY  Non classical form: up to € per QALY  If maximum = € Ration is almost 1:200  Low cost effectiveness but…  High burden  Low prevalence  Little own influence on disease  High consensus in the field Coalition patient, industry, doctors and media Low perceived incertainty 27

What can we do now?  We can claim cost effectiveness  But 3 state-of-the-art cost effectiveness analysis in Borderline  More research is on its way  We can claim a high burden  But investigation in the burden of disease is limited  Be restrictive with proclaiming high prevalence  Are all those people patients in need of treatment?  What is the prevalence of patient in need of treatment?  Try to find consensus in the field 28

Can we improve cost effectiveness?  Research into cost effective components of therapy  Like adding CBT (See Palmer, 2005)  What is the added value of for instance ‘drama therapy’  Research in the amount of therapy needed  Volume drives costs  See Soeteman et al, / Bartak et al. 29

Stop rules  We seem to know when a therapy is needed  But do we know when to stop?  If all the ‘potential’ of the patient is reached?

Within social health insurance  Reasonable stop rules might be:  When no progress is made anymore  When the patient is comparable with the general population > 5 – 10%  For this we need to monitor the patient  ….frequently during therapy  Looks like Routine Outcome Measure but with a high frequency  Monitor progress  Monitor position patients / normal population 31

Monitoring reduces the number of treatments  Michael Lambert  N = 400  Kim de Jong et al in press  Erasmus MC

…and gives better results 33 Feed back Non feed back

Conclusion  Cost effectiveness in Borderline is on the break of establishment  We should ‘carefully’ claim cost effectiveness and a high burden  We are in need of research into  Cost effectiveness  Burden of disease  Research focus on dosages  Number of sessions, length of treatment  Monitoring can be of help here  We should be careful with  Statements about high prevalence