(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

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

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

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

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

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”

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

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)

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

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

But assumptions are not met in cluster A

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

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

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…

Results cluster C

Corrected rsults C
Treatment group
Short day hospital
Long day hospital
Short inpatient
GSI - Difference score
Long outpatient
Short day hospital
Long day hospital
-0.0770
-0.1278
0.3035
-0.0508
0.3805** 0.4313**
Long inpatient -0.0030
0.0740
0.1247
* p < 0.05 ** p < 0.01 *** p < 0.001
Short inpatient
-0.3065*

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…

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

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)

QALY
 Quality Adjusted Life Years
 Area under the curve
1
0,9
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0
0 10 20 30 40
Life years
50 60 70 80
20
Co-morbidity
With psychotherapy
No psychotherapy

EQ-5D
The EuroQol EQ-5D is specially designed to measure the quality of life index for QALYs
 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…..
21

22
Burden of disease: EQ-5D
Normal population
HIV
Schizophrenia (treated)
Diabetes II
Parkinson
Lung cancer
Personality disorder
Rheumatic disease
Heamodialysis
Major depression
0 0,2 0,4 0,6 0,8
Soeteman et al. Journal of Personality Disorders, 2008;22:259-68 .
Soeteman et al. Psychiatric Services, 56, 1153-1155, 2005
1

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.

Costs and effects in Cluster B

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

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

27
Cost-effectiveness plane
€ 250 000
€ 200 000
€ 150 000
€ 100 000
Good
€ 50 000
€ 0
2,8 2,9 3,0 3,1 3,2 3,3
QALYs
3,4 3,5 3,6 3,7
Better
3,8 long out short day long day short in long in

28
0,2
0,1
0
0,5
0,4
0,3
1
0,9
0,8
0,7
0,6
Acceptability curve
Long outpatient
Short day hospital
Long day hospital
Short inpatient
Long inpatient
Societal WTP for a QALY (
€)

Cluster B
Out /
Day / in – patient

Cluster B
Out /
Day / in – patient

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

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

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

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)