1. (Cost-)Effectiveness of Psychotherapy for Personality Disorders Jan van Busschbach Prof. Dr. J. van Busschbach Department of Medical Psychology and Psychotherapy Erasmus MC PO Box 2040 3000 CA Rotterdam +31 10 7043807 (direct: 7044306) J.vanbusschbach@erasmusmc.nl

2. Jan van Busschbach, Roel Verheul, Anna Bartak, Djora Soeteman, Helene Andrea, Janine van Manen

3. An different mindset: Comparing “dosages”  Usually... –Comparison between theoretical orientation of therapy  Typically... –Amount of therapy is keep constant –Little differences Nonspecific factors seems to drive treatment success  This assumes... –amount of therapy is relevant  Amount of therapy relates to costs  Yet... –Relation between costs and effects is rarely investigated

4. SCEPTRE  Study on Cost-Effectiveness of Personality Disorder Treatment  Start: March 2003  6 clinics

5. 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

6. Selection bias  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”

7. 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

8. 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)

9. Is the super covariate valid? Separate PhD, 2010 Medical Care, 2010 Psychotherapy and Psychosomatics, 2009

10. Cluster A: one of the largest studies ever Bartak, Andrea, Spreeuwenberg, Ziegler, Dekker, Rossum, Hamers, Scholte, Aerts, Busschbach, Verheul, Stijnen, & Emmelkamp, (in press). Effectiveness of outpatient, day hospital, and inpatient psychotherapeutic treatment for patients with cluster A personality disorder. Under review

11. But assumptions are not met in cluster A

12. 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

13. Results cluster B Bartak, Andrea, Spreeuwenberg, Ziegler, Dekker, Rossum, Hamers, Scholte, Aerts, Busschbach, Verheul, Stijnen, & Emmelkamp. Effectiveness of outpatient, day hospital, and inpatient psychotherapeutic treatment for patients with cluster B personality disorder. Psychotherapy and Psychosomatics, in press

14. 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…

15. Results cluster C

16. Corrected rsults C GSI - 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 0.30350.3805**0.4313** Long inpatient -0.00300.07400.1247-0.3065* * p < 0.05 ** p < 0.01 *** p < 0.001

17. 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…

18. 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

19. 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)

20. 20 QALY  Quality Adjusted Life Years  Area under the curve

21. 21 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

22. 22 Burden of disease: EQ-5D Soeteman et al. Journal of Personality Disorders, 2008;22:259-68. Soeteman et al. Psychiatric Services, 56, 1153-1155, 2005

23. Markov model Cluster B Soeteman, Verheul, Delimon, Meerman, Van den Eijnden, Rossum, Ziegler, Thunnissen, Busschbach, Kim. Cost-effectiveness of psychotherapy for cluster B personality disorders. British Journal of Psychiatry 2010;196:396–403.

24. Costs and effects in Cluster B Much difference Little difference

25. Interested in both costs and effect Less effectiveMore effective Low costs (savings) High costs Good Better Superb! Forget it! Difficult… 25

26. Sensitivity analysis Less effectiveMore effective Low costs (savings) High costs Superb! Forget it! Difficult… 26 Good Better

27. Cost-effectiveness plane 27 Good Better

28. Acceptability curve 28

29. Cluster B Out / Day / in – patient

31. Cluster C 31 Soeteman, Verheul, Meerman, Rossum, Delimon, Rijnierse, Thunnissen, Busschbach, & Kim. Cost-effectiveness of psychotherapy for cluster C personality disorders. Journal of Clinical Psychiatry (in press).

32. Cluster C 32

33. 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 33

34. 34 Dutch Council for Public Health and Health Care (RvZ, 2006)

35. 35 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)