Cost-Effectiveness of Psychotherapy
(for Personality Disorders)
Prof. dr. Jan van Busschbach
Cost-Effectiveness of Psychotherapy
 Cost effectiveness analyses in psychotherapy are
scarce
– Especially in long term treatment
– Irrespectivelly of the books that appeared
 Results might are favorable
– Strong arguments towards insurers
 But they might give undesirable answers
– There will be winners and loserss
Nonspecific factors
 Most effectivenss research...
– Compairs theoretical orientation of therapy
 Little differences
– Nonspecific factors seems to drive treatment success
Comparing “dosages”
 Typically ...
– Amount of therapy is keep constant
 This assumes ...
– amount of therapy is relevant
 Relation costs and effects is rarely investigated
Illustration of the 'dose-effect' relationship showing the
majority of improvement happens early in therapy
(Howard et al, 1996)
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
Less than 6 months
More than 6 months
Outpatient
Outpatient
Day hospital
Day hospital
Inpatient psychotherapy
Inpatient psychotherapy
 Clusters
– A; N = 58
– B; N = 241
– C; N = 466
Naturalistic design
 No randomisation
– Difficult when dosages differ
 Not seen as big problem in health econics
– Economist hardly randomize
– Randomization jeopardizes generalisabilty
• Inclusion; exclusion is strict
• Interference in clinical process
• Randomization of disappointment
 Use co-variance analysis
– The standard economic design
In need of a super covariate
 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
– Epidemiology
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)
Can super covariate fly?
Psychotherapy and
Psychosomatics, 2009
Separate PhD, 2010
Medical Care, 2010
Cluster A
 N= 58: one of the largest studies ever
 But groups got very small
Less than 6 months
More than 6 months
Outpatient
Outpatient
Day hospital
Day hospital
Inpatient psychotherapy
Inpatient psychotherapy
No time constrains
Outpatient
Day hospital
Inpatient psychotherapy
Cluster A raw results:
Day hospital and inpatient seem best
But assumptions are not met in cluster A
Assumptions were met when using…
 3 groups in Cluster B
No time constrains
Outpatient
Day hospital
Inpatient psychotherapy
 5 groups in Cluster C
Less than 6 months
More than 6 months
Outpatient
Outpatient
Day hospital
Day hospital
Inpatient psychotherapy
Inpatient psychotherapy
Cluster B: Again day hospital and
inpatient seem best…
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
Results hold in Cluster C
 Short inpatient better than
– Short day hospital
– Long day hospital
– Long inpatient psychotherapy
Winner and losers
 Short term inpatient is better that long term inpatient
– In cluster C
 When incorporating cost argument
– Short term inpatient dominates long term patient
• Better and cheaper
– In cluster C
 At de Vierspong
– Closing long term inpatient treatment for cluster C
– Expanding short term inpatient treatment for cluster C
Still inconclusive cost effectiveness…
 Non difference in Cluster B (after correction)
– Between outpatient, day hospital and inpatient
– But costs can be decisive ….
 Cluster C
– Favorable results for short-term inpatient psychotherapy
– It is reasonable to assume
• that short inpatient dominates long in-patient
– But is short-term inpatient worth the additional costs…?
• compared to long day hospital / short day hospital
QALY
 Health economics compare the efficient allocation of
health care resources
 For instance:
– Psychotherapy Short Inpatient versus Day Hospital
– 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)
Quality Adjusted Life Years (QALY)
 Example
– Blindness
– Time trade-off value is 0.5
– Life span = 80 years
– 0.5 x 80 = 40 QALYs
1.00
X
0.5 x 80 = 40 QALYs
0.00
40
80
Life years
23
QALY
 Quality Adjusted Life Years
 Area under the curve
1
Adjusment factor QALY
0,9
0,8
0,7
0,6
Co-morbidity
With psychotherapy
No psychotherapy
0,5
0,4
0,3
0,2
0,1
0
0
10
20
30
40
Life years
24
50
60
70
80

MOBILITY
– I have no problems in walking about
– I have some…….
– I am confined to bed
EQ-5D

SELF-CARE
– I have no problems with self-care
– I have some problems…..
– I am unable…
The EuroQol EQ-5D is
specially designed to
measure the quality of
life index for QALYs

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
Sensitivity EQ-5D
Normal population
HIV
Schizophrenia (treated)
Diabetes II
Parkinson
Lung cancer
Personality disorder
Rheumatic disease
Heamodialysis
Major depression
0
26
0,2
0,4
0,6
0,8
1
Cost per QALY in Cluster B
High cost effectiveness ratio
compared to out-patient
Cost effectiveness Cluster C
Favorable
cost effectiveness ratio
compared to Short Day Hospital
Soeteman DI, Verheul R, Meerman AMMA, Rossum BV, Delimon J, Rijnierse P, Thunnissen M, Busschbach JJV, & Kim
JJ. Cost-effectiveness of psychotherapy for cluster C personality disorders: a decision-analytic model in the Netherlands.
Journal of Clinical Psychiatry 2011 Jan;72(1):51-9
Conclusion cost effectiveness

Cluster C PD:
1. Short-term inpatient psychotherapy (first choice)
2. Short-term day hospital psychotherapy
3. Sub-optimal treatment options are:
•
•
•

long-term out patient,
long term day hospital and
long-term inpatient
Cluster B PD:
1. Outpatient psychotherapy (first choice)
2. Day hospital psychotherapy
3. Sub-optimal treatment option is:
•
29
Inpatient psychotherapy