Economic evaluation of psychotherapy for personality disorders: burden of disease and cost-effectiveness Djøra Soeteman Viersprong Institute for Studies on Personality Disorders Erasmus Medical Center, Rotterdam Harvard School of Public Health, Boston, MA Rotterdam, October 30,

2 Necessity Effectiveness Cost-effectiveness Reimbursement decision

Reimbursement decision: 3 criteria  Necessary care –How severe is the disease?  Effectiveness –Is treatment effective?  Cost-effectiveness –Are the effects worth the costs? 3

Reimbursement decision: criterion 1  Necessity: how severe is the disease? –Is it a common disease? (prevalence) –Does the patient suffers? (individual burden) –What are the costs? (economic burden) 4

Prevalence  Prevalence in the general population: 13,5% –Verheul et al., 1999  Treatment seeking: 19,1% –in the year prior to interview –Andrews et al., 2001  patients in the Netherlands –Prevalence x population x treatment seekers –13,5% x x 19,1% 5

Individual burden 6 Soeteman et al., 2008 The burden of disease in personality disorders: diagnosis-specific quality of life. Journal of Personality Disorders, 22, Major depressive disorder Pt with renal failure on heamodialysis Rheumatic disease Personality disorders Lung cancer Parkinson’s disease Type II diabetes Schizophrenia outpatients (treated with neuroleptics) HIV infected pt General population EQ-5D score

Economic burden 7

 Health care utilization€ 3,12 billion  Productivity losses€ 0,24- € 3,60 billion  Criminal justice resources€ 0,27 billion  Total annual costs€ 3,6- € 7,0 billion (conservative estimate not included e.g., costs of non-treatment seekers, intergenerational transfer) 8 Total societal costs +

Economic burden 9 Soeteman et al., 2008 The economic burden of personality disorders in mental health care. Journal of Clinical Psychiatry, 69, Mean annual costs per patient € - € 2,000 € 4,000 € 6,000 € 8,000 € 10,000 € 12,000 Personality disordersSchizophreniaDepressionGeneralized anxiety disorder Costs (€) Total costs Direct Indirect

 Necessary care –Highly prevalent –Low quality of life –High societal costs Reimbursement decision: criterion 1 10

 Necessary care –Highly prevalent –Low quality of life –High societal costs  Effectiveness –Is treatment effective? Reimbursement decision: criterion 2 11

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Evidence for effectiveness 14 Broad spectrum Borderline PD Avoidant PD Outpatient individual Outpatient group Day hospital Inpatient +++--

Reimbursement decision: criterion 2  Necessary care –Highly prevalent –Low quality of life –High societal costs  Effectiveness –Psychotherapeutic treatments are effective 15

Reimbursement decision: criterion 3  Necessary care –Highly prevalent –Low quality of life –High societal costs  Effectiveness –Psychotherapeutic treatments are effective  Cost-effectiveness –Are the effects worth the costs? 16

Current evidence? 17

Current evidence ‘a promise’ Brazier et al., 2007  John Brazier, Prof. of Health economics. –University of Sheffield –Psychological therapies […] for borderline personality disorder: a systematic review and preliminary economic evaluation  Integrating existing evidence in health economic model –“The results are promising [for psychotherapy], though […] surrounded by a high degree of uncertainty. There is a need for considerable research in this area.” 18

First (!) state-of-the-art cost-effectiveness study from the Netherlands  RCT Van Asselt et al., 2008 (BJP) –Compared Transference-Focused Psychotherapy and Schema-Focused Therapy for borderline PD  % recovered after 4 years –SFT: 52.3% –TFP: 28.6%  Treatment costs –SFT: € 12,946 –TFP: € 10,876  Total costs over 4 years –SFT: € 37,826 –TFP: € 46,795 19

SCEPTRE trial  Patient-level primary data was available from the largest existing clinical trial of psychotherapy for personality disorders (N = 924)  Decision analytic (Markov) model: 5-year time horizon  Dosage specified by treatment setting and duration  Cluster C PD: N = 466  Cluster B PD: N =

Cluster C PD 21

22 Different dosages  Short-term outpatientexcl.  Long-term outpatient21.4%  Short-term day hospital19.0%  Long-term day hospital23.0%  Short-term inpatient14.1%  Long-term inpatient22.5%  Short-term < = 6 months  Long-term > 6 months

Different costs Psychotherapy dosageTreatment costs (€) Long-term outpatient 10,005 Short-term day hospital 16,813 Long-term day hospital 27,648 Short-term inpatient 25,933 Long-term inpatient 49,260 23

Total costs over 5 years Psychotherapy dosage Treatment costs (€) Total costs over 5 years (€) Long-term outpatient10,005 89,936 Short-term day hospital16,813 89,411 Long-term day hospital27, ,940 Short-term inpatient25,933 91,620 Long-term inpatient49, ,946 24

Only costs?  Health economics is more than just costs…  Effects are equally important: –Cost-effectiveness  Are the effects worth the additional costs? –What if the more expensive treatment is more effective? –Costs per recovered patient? 25

26 Definition “recovered patient”  Clinically significant change: (Jacobson and Truax, 1991) –Recovered: statistically reliable  + ends up within normal limits –Improved: statistically reliable , but ends still dysfunctional –Unchanged: no statistically reliable  –Relapsed or deteriorated: statistically reliable  in the opposite direction  General Symptom Index (BSI/SCL-90)

Effect 27 Psychotherapy dosagerecovered patient- years Long-term outpatient 1.38 Short-term day hospital 1.93 Long-term day hospital 2.32 Short-term inpatient 2.79 Long-term inpatient 2.11

Costs per recovered patient year 28 Psychotherapy dosagerecovered patient- years Costs (€) Long-term outpatient ,735 Short-term day hospital ,131 Long-term day hospital ,442 Short-term inpatient ,837 Long-term inpatient ,285

Is that a lot?  How do we know if € x,- per recovered patient-year concerns a ‘cost-effective’ treatment strategy?  Compare it with other interventions –E.g., compared to lung transplantation or breast cancer screening  Generic outcome measure required in order to compare different illnesses –Survival –Quality of life 29

 Life years x quality of life index score  Quality of life index score –1.0 = perfect health –0.0 = death  Example –Loss of eyesight –Quality of life index = 0.5 –Life years = 80 –0.5 x 80 = 40 QALYs 30 Quality Adjusted Life Years (QALY) 30

Example of QALY gain because of treatment  QALYs gained = blue area 31

QALY league table 32

Effect over 5 years Psychotherapy dosageQALYs Long-term outpatient 3.30 Short-term day hospital 3.44 Long-term day hospital 3.49 Short-term inpatient 3.57 Long-term inpatient

Costs per QALY Psychotherapy dosage QALYsCosts per QALY (€) Long-term outpatient ,239 Short-term day hospital ,027 Long-term day hospital ,353 Short-term inpatient ,674 Long-term inpatient ,350 34

Interested in both costs and effect Less effectiveMore effective Low costs (savings) High costs Good Better Superb! Forget it! Difficult… 35

Sensitivity analysis Less effectiveMore effective Low costs (savings) High costs Superb! Forget it! Difficult… 36 Good Better

Cost-effectiveness plane 37 Good Better

Acceptability curve 38

Cost-effectiveness of different dosages of psychotherapy for cluster C PD Psychotherapy dosageCosts per QALY (threshold value €0 – €16,570) Costs per QALY (> €16,570) Long-term outpatient Short-term day hospital 1 st choice Long-term day hospital Short-term inpatient 1 st choice Long-term inpatient 39

Cost-effectiveness of different dosages of psychotherapy for cluster C PD Psychotherapy dosage Costs per QALY (threshold value €0 – €16,570) Costs per QALY (> €16,570) Costs per QALY (threshold value of €40,000) Long-term outpt Short-term day h 1 st choice Long-term day h Short-term inpt 1 st choice Long-term inpt 40

Cluster B PD 41

Acceptability curve 42

Cost-effectiveness of different modalities of psychotherapy for cluster B PD Modality of psychotherapy Costs per QALY (threshold value €0 – €56,325) Costs per QALY (> €56,325) Outpatient 1 st choice Day hospital 1 st choice Inpatient 43

Cost-effectiveness of different modalities of psychotherapy for cluster B PD Modality of psychotherapy Costs per QALY (threshold value €0 – €56,325) Costs per QALY (> €56,325) Costs per QALY (threshold value of €40,000) Outpatient 1 st choice Day hospital 1 st choice Inpatient 44

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 45

Conclusion  Necessary care –Highly prevalent –Low quality of life –High societal costs  Effectiveness –Psychotherapeutic treatments are effective  Cost-effectiveness –There are cost-effective treatments for cluster B en C PD 46

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