(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) [email protected]

An different mindset: Comparing “dosages”

     

Usually ...

– Comparison between theoretical orientation of therapy

Typically ...

– Amount of therapy is keep constant

This assumes ...

– amount of therapy is relevant

Little differences

– Nonspecific factors seems to drive treatment success

Amount of therapy relates to costs Yet ...

– Relation between costs and effects is rarely investigated

SCEPTRE

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

SCEPTRE

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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

In need of a super covariate

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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

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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 – Epidemiology

Super Covariate: the propensity score

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Age Sex Diagnosis (SIDP-IV) Baseline GSI Motivation Measures of pathology

– DAPP-BQ; SIPP; OQ-45

Quality of life (EQ-5D)

Can super covariate fly?

Psychotherapy and Psychosomatics, 2009 Separate PhD, 2010 Medical Care, 2010

Cluster A: one of the largest studies ever

Bartak, et al. Effectiveness of outpatient, day hospital, and inpatient psychotherapeutic treatment for patients with cluster A personality disorder. Accepted for publication

Psychotherapy and Psychosomatics

But assumptions are not met in cluster A

Assumptions met in:

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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 et al. 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…

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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

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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

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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

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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

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Quality Adjusted Life Years Area under the curve 0,3 0,2 0,1 0 1 0,9 0,8 0,7 0,6 0,5 0,4 0 10 20 30 40 Life years 50 60 70 80

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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…..

20

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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 et al. Cost-effectiveness of psychotherapy for cluster B personality disorders. British Journal of Psychiatry 2010;196:396 –403.

Costs and effects in Cluster B

Cost per QALY

Costs and effects Cluster C

Soeteman et al. Cost-effectiveness of psychotherapy for cluster C personality disorders. Journal of Clinical Psychiatry (In Press) 25

Cost effectiveness Cluster C

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Conclusion

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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