Economic evaluation of psychotherapy for personality disorders:

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• Economic evaluation of psychotherapy for
  personality disorders
• burden of disease, cost-effectiveness, and value
  of information and implementation
• Djøra Soeteman
• Viersprong Institute for Studies on Personality
  Disorders
• Erasmus Medical Center, Rotterdam
• Center for Health Decision Science, Boston, MA
• Boston, December 2, 2009

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Efficient health care provision

• Three questions need to be addressed
• - Which treatments are cost-effective and should
  be adopted? (reimbursement decision)
• - Is it worthwhile to conduct additional research
  (research decision)
• - Is it cost-effective to implement treatments
  into clinical practice (implementation decision).

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• Reimbursement decision

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Reimbursement decision
Necessity
Effectiveness
Cost-effectiveness
Reimbursement decision
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Reimbursement decision 3 criteria

• Necessary care
• How severe is the disease?
• Effectiveness
• Is treatment effective?
• Cost-effectiveness
• Are the effects worth the costs?

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Reimbursement decision criterion 1

• Necessity how severe is the disease?
• Is it a common disease? (prevalence)
• Does the patient suffers? (individual burden)
• What are the costs? (economic burden)

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Prevalence

• Prevalence in the general population 13,5
• Verheul et al., 1999
• Treatment seeking 19,1
• in the year prior to interview
• Andrews et al., 2001
• 422.285 patients in the Netherlands
• Prevalence x population x treatment seekers
• 13,5 x 16.377.153 x 19,1

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Individual burden
Soeteman et al., 2008 The burden of disease in
personality disorders diagnosis-specific quality
of life. Journal of Personality Disorders, 22,
259-268
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Relation between funding and burden
Pronk et al., 2004 Outpatient drug policy by
clinical assessment rather than financial
constraints. Eur J Health Econom, 5, 274-277
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Economic burden
Soeteman et al., 2008 The economic burden of
personality disorders in mental health care.
Journal of Clinical Psychiatry, 69, 259-265
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Total societal costs

• Health care utilization 3,12 billion
• Productivity losses 0,24- 3,60 billion
• Criminal justice resources 0,27 billion
• Total annual costs 3,6- 7,0 billion
• (conservative estimate not included e.g., costs
  of non-treatment seekers, intergenerational
  transfer)

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Reimbursement decision criterion 1

• Necessary care
• Highly prevalent
• Low quality of life
• High societal costs

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Reimbursement decision criterion 2

• Necessary care
• Highly prevalent
• Low quality of life
• High societal costs
• Effectiveness
• Is treatment effective?

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Evidence for effectiveness
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Reimbursement decision criterion 2

• Necessary care
• Highly prevalent
• Low quality of life
• High societal costs
• Effectiveness
• Psychotherapeutic treatments are effective

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Reimbursement decision criterion 3

• Necessary care
• Highly prevalent
• Low quality of life
• High societal costs
• Effectiveness
• Psychotherapeutic treatments are effective
• Cost-effectiveness
• Are the effects worth the costs?

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Current evidence?
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Current evidence a promise Brazier et al., 2007

• John Brazier, Prof. of Health economics.
• University of Sheffield
• Psychological therapies for borderline
  personality disorder a systematic review and
  preliminary economic evaluation
• Integrating existing evidence in health economic
  model
• The results are promising for psychotherapy,
  though surrounded by a high degree of
  uncertainty. There is a need for considerable
  research in this area.

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First (!) state-of-the-art cost-effectiveness
study from the Netherlands

• RCT Van Asselt et al., 2008 (BJP)
• Compared Transference-Focused Psychotherapy and
  Schema-Focused Therapy for borderline PD
• recovered after 4 years
• SFT 52.3
• TFP 28.6
• Treatment costs
• SFT 12,946
• TFP 10,876
• Total costs over 4 years
• SFT 37,826
• TFP 46,795

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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

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• Cluster C PD

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Different dosages

• Short-term outpatient excl.
• Long-term outpatient 21.4
• Short-term day hospital 19.0
• Long-term day hospital 23.0
• Short-term inpatient 14.1
• Long-term inpatient 22.5
• Short-term lt 6 months
• Long-term gt 6 months

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Model structure

• Markov model 5-year time horizon

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Different costs
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Total costs over 5 years
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Effect over 5 years
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Costs per QALY
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Uncertainty
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CEAC
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Cost-effectiveness of different dosages of
psychotherapy for cluster C PD
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Cost-effectiveness of different dosages of
psychotherapy for cluster C PD
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Conclusion

• Cluster C PD
• Cost-effective treatment strategies are
• Short-term inpatient psychotherapy (first choice)
• Short-term day hospital psychotherapy
• Sub-optimal treatment options are
• Long-term day hospital and long-term inpatient

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Reimbursement decision 3 criteria

• Necessary care
• Highly prevalent
• Low quality of life
• High societal costs
• Effectiveness
• Psychotherapeutic treatments are effective
• Cost-effectiveness
• Cost-effective treatment strategies for cluster C
  PD are available

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• Research decision

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Decision uncertainty

• Uncertainty in cost-effectiveness
• Current information on costs and effects is
  imperfect

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EVPI

• Population expected value of perfect information

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EVPPI

• EVPI for parameter groups

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• Implementation decision

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EVPIM

• Population expected value of perfect
  implementation

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Efficient health care provision

• Recommendations based on three questions
• Based on currently available evidence short-term
  inpatient psychotherapy is the most
  cost-effective choice (at threshold value of
  40,000 per QALY)
• Before implementing this cost-effective treatment
  strategy into clinical practice, further research
  is valuable especially when prioritizing
  information on treatment costs and transition
  probabilities.

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