1. 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

2. 2002: Two books, and a hand full of articles

3. 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

4. 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 2003 4

5. Cost offset by less care elsewhere 5

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

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

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

9. Probability being cost effective 9 1.0 Change being cost effective 0.0 Willingness to pay for effects

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

11. 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

12. 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

13. 2012: More health economics… 13

14. 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

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

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

17. Bartak, Busschbach, Verheul, 2011 17  Cluster B patients  Most effect in-patients psychotherapy  Then day hospital  Then out patients

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

19. 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

20. 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

21. Burden of disease  Willingness to pay is function of burden

22. Costs/QALY versus Burden of disease 22 € 80.000 € 60.000 € 40.000 € 20.000 € 0 Burden of disease X X X X X

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

24. 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…..

25. Burden is considerable 25 Soeteman et al. Assessment of the burden of disease among inpatients in specialized units that provide psychotherapy. Psychiat Serv. 2005 Sep;56(9):1153-5

26. 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…

27. Orphan drugs  Pompe disease  Classical form: € 300.000 – 900.000 per QALY  Non classical form: up to € 15.000.000 per QALY  If maximum = € 80.000 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

28. 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

29. 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

30. 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?

31. 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

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

33. …and gives better results 33 Feed back Non feed back

34. 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