1. Cost-effectiveness of psychotherapy for personality disorders Djøra Soeteman Viersprong Institute for Studies on Personality Disorders Erasmus Medical Center, Rotterdam Harvard School of Public Health, Boston, MA ISSPD NYC, August 23, 2009 1

2. SCEPTRE trial  Patient-level primary data was available from the largest existing clinical trial of psychotherapy for personality disorders (N = 924)  Dosage specified by treatment setting and duration  Cluster C PD: N = 466  Cluster B PD: N = 241 2

3. Cluster C PD 3

4. 4 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

5. 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 5

6. 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 hospital27,648 105,940 Short-term inpatient25,933 91,620 Long-term inpatient49,260 119,946 6

7. Just costs?  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? –What are the costs per recovered patient? 7

8. 8 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)

9. Effect 9 Psychotherapy dosage% recovered after 12 months Long-term outpatient 19% Short-term day hospital 26% Long-term day hospital 37% Short-term inpatient 61% Long-term inpatient 41%

10. Costs per recovered patient year 10 Psychotherapy dosage% recovered after 12 months Costs (€) Long-term outpatient19% 64,735 Short-term day hospital26% 46,131 Long-term day hospital37% 45,442 Short-term inpatient61% 32,837 Long-term inpatient41% 57,285

11. 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 11

12.  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 12 Quality Adjusted Life Years (QALY) 12

13. 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 3.49 13

14. Costs per QALY Psychotherapy dosage QALYsCosts per QALY (€) Long-term outpatient3.30 27,239 Short-term day hospital3.44 26,027 Long-term day hospital3.49 30,353 Short-term inpatient3.57 25,674 Long-term inpatient3.49 34,350 14

15. Interested in both costs and effect Less effectiveMore effective Low costs (savings) High costs Good Better Superb! Forget it! Difficult… 15

16. Sensitivity analysis Less effectiveMore effective Low costs (savings) High costs Superb! Forget it! Difficult… 16 Good Better

17. Cost-effectiveness plane 17 Good Better

18. Acceptability curve 18

19. 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 19

20. 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 20

21. Cluster B PD 21

22. Acceptability curve 22

23. 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 23

24. 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 24

25. 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 25