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Cost-effectiveness in Personality Disorder

• Dr. J.J.V. Busschbach

• Psychotherapeutic centre ‘De Viersprong’– PO Box 7

4660 AA Halsteren +31 164 632200+31 164 632220 (fax)jan.busschbach@devierspong.nl

• Erasmus MC, Rotterdam– Department of Medical Psychology & Psychotherapy

• www.xs4all.nl/~jannetvb/busschbach– Contains the slides of this presentation

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The usual convention….

• Doubt about the cost-effectiveness– Treatment of personality disorder is expensive

» Treatment is long

– Effect is low

– Cost-effectiveness is unfavourable

• How to deal with such stigma?

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Stigma is not unique

• Typical for new interventions– Especially new pharmacy

• Prozac is example• Prozac was said to be

– More expensive– As effective as old medication

» As established in RCT– Therefore not a cost-effective alternative

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Stigma versus science

• Reaction of Ely Lilly…– Manufacturer of Prozac– Two main arguments

• They questioned the randomised trial results– The generalisability of results for clinical practice– Introducing ‘Outcome Research’

• They questioned the assumption about higher costs– Medication cost may be higher, but total cost may be lower– Introducing ‘Health Economics’

                                                                                                  

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Outcome Research

• Clinical research– Does it work?

– Efficacy

– Perfect patient» No co morbidity

• Randomized Clinical Trial

– Controlled conditions

• Outcome research– Does it work in practice

– Effectiveness

– Every day patient» Normal co morbidity

• Trials in a naturalistic setting

– Real life conditions

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In RCT no differences in efficacy…

• Between Prozac and old medication– No differences between TCA and SSRI

• Citation British Medical Journal:– “Randomised, controlled clinical trial (RCTs ) generally show equal

efficacy among antidepressants”

– Song F et al. BMJ, 1993;306:683-7

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But in outcome research…

• In practice: much better effectiveness

• Drop out ration TCA : SSRI = 3 : 1– Lobowitz, JAMA 1997;278:1186-90

• After drop out, recurrence depression 2 to 4 time higher

• Minimal effective dose– SSRI 98% (Prozac)

– TCA 61%

– N = 23000, General Practitioner» De Waal et al, NTVG 1996;140:2131-4

• Randomised trials mask differences compliance!– Outcome research reveals remarkable results

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Health economics

• Simon et al, JAMA 1996;275:1897-902• Six-month health care expenditures

– Total cost, not just medication costs• Compared

– Desipramine: N = 181» Old TCA» $ 2361

– Imipramine: N = 182» Old TCA» $ 2105

– Fluoxetine N = 173» New SSRI: Prozac» $ 1967

• No statistical significant differences

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Regression in quasi-experimentcontrolled for sex, age, prior-period expenditures etc.

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36 412

208187

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$-200

$-100

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$100

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Regression weights TCA vs SSRI

Sclar et al, 1994

N = 701

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What can we learn?

• Randomised trials are not the holy grail– They do serve in efficacy

– But there are higher order measurements

• Effectiveness– Outcome research

» Randomised trials AND naturalistic studies

» Quasi experimental design

• Cost-effectiveness– Health economics

» Randomised trials AND naturalistic studies

» Quasi experimental design

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Where do we stand?

• Favourable results in (randomised) trials– Psychotherapy versus usual care

– 6 Reviews en 1 meta analysis» Perry et al, Am J Psychiatry 1999;57:1312-21

• What about cost effectiveness….?– …is psychotherapy in personality disorder worth the costs?

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Self-report Observer-rating

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Existing evidence suggests considerable savings

• New investigations– Bateman, Fonagy, Am

J Psychiatry 2003;160:169-71

• Reviews– Gabbard et al. Am J

Psychiatry 1997;154:147-50

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

6 monthsbefore

treatment

18 months oftreatment

18 monthfollow-up

Experimental group

General Care

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Problem in cost effectiveness results

• Cost estimates made in trial environment– No ‘real’ cost estimates

– No adjustment made for trial situation

• No formal cost-effectiveness study designs

• Typical elements are missing– Discounting

» Costs and effects in the future are valued lower

– Generic outcome measures» Quality adjusted life years (QALYs)

» Disease specific outcome do not allow for comparisons between different allocations in health care

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What do we need?….

• Naturalistic trial– To prove the effects in practice

– To estimate costs in practice

• Formal cost-effectiveness study– Following international guidelines

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Sceptre hopes to fulfil these demands

• Quasi experimental trial in a naturalistic setting– Introducing outcome research

• The design follows standards in health economics– Introducing health economics

• But even more than Sceptre we need….

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Confidence

• Good treatment will be cost effective– If a treatment works in practice, it will almost certainly be cost-

effective

– Like Prozac

• In that conviction we need to put our treatments to the test….