Health service costs and clinical gains of psychotherapy for personality disorders: a randomized controlled trial of day-hospital-based step-down treatment versus outpatient treatment at a specialist practice

Elfrida Hartveit Kvarstein, Espen Arnevik, Vidar Halsteinli, Frida Gullestad Rø, Sigmund Karterud, Theresa Wilberg, Elfrida Hartveit Kvarstein, Espen Arnevik, Vidar Halsteinli, Frida Gullestad Rø, Sigmund Karterud, Theresa Wilberg

Abstract

Background: Day-hospital-based treatment programmes have been recommended for poorly functioning patients with personality disorders (PD). However, more research is needed to confirm the cost-effectiveness of such extensive programmes over other, presumably simpler, treatment formats.

Methods: This study compared health service costs and psychosocial functioning for PD patients randomly allocated to either a day-hospital-based treatment programme combining individual and group psychotherapy in a step-down format, or outpatient individual psychotherapy at a specialist practice. It included 107 PD patients, 46% of whom had borderline PD, and 40% of whom had avoidant PD. Costs included the two treatment conditions and additional primary and secondary in- and outpatient services. Psychosocial functioning was assessed using measures of global (observer-rated GAF) and occupational (self-report) functioning. Repeated assessments over three years were analysed using mixed models.

Results: The costs of step-down treatment were higher than those of outpatient treatment, but these high costs were compensated by considerably lower costs of other health services. However, costs and clinical gains depended on the type of PD. For borderline PD patients, cost-effectiveness did not differ by treatment condition. Health service costs declined during the trial, and functioning improved to mild impairment levels (GAF > 60). For avoidant PD patients, considerable adjuvant health services expanded the outpatient format. Clinical improvements were nevertheless superior to the step-down condition.

Conclusion: Our results indicate that decisions on treatment format should differentiate between PD types. For borderline PD patients, the costs and gains of step-down and outpatient treatment conditions did not differ. For avoidant PD patients, the outpatient format was a better alternative, leaning, however, on costly additional health services in the early phase of treatment.

Trial registration: Clinical Trials NCT00378248.

Figures

Figure 1
Figure 1
Longitudinal change of health service costs and global functioning. The figures illustrate the longitudinal course (mixed-model estimations) of health service costs (mean total health service costs: solid black line, mean treatment costs: blue dotted line, and mean emergency costs: red dotted line) with costs (in euros) given on the left Y-axis. The change trajectory for global functioning (given on the right Y-axis) is represented by the black dotted line. Separate figures demonstrate (1) the full sample of patients with different personality disorders (mixed PD) in the step-down (SDC) and the outpatient condition (OPC), (2) patients with borderline PD (BPD), and (3) with avoidant PD (APD) in the two treatment conditions. The point of randomisation is denoted by Time = 0 months.

References

    1. Ansell EB, Sanislow CA, McGlashan TH, Grilo CM. Psychosocial impairment and treatment utilization by patients with borderline personality disorder, other personality disorders, mood and anxiety disorders, and a healthy comparison group. Compr Psychiatry. 2007;48:329–336. doi: 10.1016/j.comppsych.2007.02.001.
    1. Bender DS, Skodol AE, Pagano ME, Dyck IR, Grilo CM, Shea MT, Sanislow CA, Zanarini MC, Yen S, McGlashan TH. et al.Prospective assessment of treatment use by patients with personality disorders. Psychiatr Serv. 2006;57:254–257. doi: 10.1176/appi.ps.57.2.254.
    1. Frankenburg FR, Zanarini MC. Personality disorders and medical comorbidity. Curr Opin Psychiatry. 2006;19:428–431. doi: 10.1097/01.yco.0000228766.33356.44.
    1. Pascual JC, Martin-Blanco A, Soler J, Ferrer A, Tiana T, Alvarez E, Perez V. A naturalistic study of changes in pharmacological prescription for borderline personality disorder in clinical practice: from APA to NICE guidelines. Int Clin Psychopharmacol. 2010;25:349–355. doi: 10.1097/YIC.0b013e32833e23ed.
    1. Powers AD, Oltmanns TF. Personality Disorders and Physical Health. A Longitudinal Examination of Physical Functioning, Healthcare Utilization, and Health-Related Behaviors in Middle-Aged Adults. J Pers Disord. 2012;26(4):524–538. doi: 10.1521/pedi.2012.26.4.524.
    1. Horz S, Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G. Ten-year use of mental health services by patients with borderline personality disorder and with other axis II disorders. Psychiatr Serv. 2010;61:612–616. doi: 10.1176/appi.ps.61.6.612.
    1. Zanarini MC, Jacoby RJ, Frankenburg FR, Reich DB, Fitzmaurice G. The 10-year course of social security disability income reported by patients with borderline personality disorder and axis II comparison subjects. J Personal Disord. 2009;23:346–356. doi: 10.1521/pedi.2009.23.4.346.
    1. Jackson HJ, Burgess PM. Personality disorders in the community: results from the Australian National Survey of Mental Health and Wellbeing Part II. Relationships between personality disorder, Axis I mental disorders and physical conditions with disability and health consultations. Soc Psychiatry Psychiatr Epidemiol. 2002;37:251–260. doi: 10.1007/s001270200017.
    1. Newton-Howes G, Tyrer P, Weaver T. Social functioning of patients with personality disorder in secondary care. Psychiatr Serv. 2008;59:1033–1037. doi: 10.1176/appi.ps.59.9.1033.
    1. Soeteman DI, Hakkaart-van RL, Verheul R, Busschbach JJ. The economic burden of personality disorders in mental health care. J Clin Psychiatry. 2008;69:259–265. doi: 10.4088/JCP.v69n0212.
    1. Soeteman DI, Verheul R, Busschbach JJ. The burden of disease in personality disorders: diagnosis-specific quality of life. J Personal Disord. 2008;22:259–268. doi: 10.1521/pedi.2008.22.3.259.
    1. Bateman A, Fonagy P. Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. Am J Psychiatry. 2001;158:36–42. doi: 10.1176/appi.ajp.158.1.36.
    1. Bateman A, Fonagy P. Health service utilization costs for borderline personality disorder patients treated with psychoanalytically oriented partial hospitalization versus general psychiatric care. Am J Psychiatry. 2003;160:169–171. doi: 10.1176/appi.ajp.160.1.169.
    1. Chiesa M, Fonagy P, Holmes J, Drahorad C, Harrison-Hall A. Health service use costs by personality disorder following specialist and nonspecialist treatment: a comparative study. J Personal Disord. 2002;16:160–173. doi: 10.1521/pedi.16.2.160.22552.
    1. Verheul R, Herbrink M. The efficacy of various modalities of psychotherapy for personality disorders: a systematic review of the evidence and clinical recommendations. Int Rev Psychiatry. 2007;19:25–38. doi: 10.1080/09540260601095399.
    1. Karterud S, Urnes O. Short-term day treatment programmes for patients with personality disorders. What is the optimal composition? Nord J Psychiatry. 2004;58:243–249. doi: 10.1080/08039480410006304.
    1. Ogrodniczuk JS, Piper WE. Day treatment for personality disorders: a review of research findings. Harv Rev Psychiatry. 2001;9:105–117. doi: 10.1080/10673220127889.
    1. Karterud S, Pedersen G, Bjordal E, Brabrand J, Friis S, Haaseth O, Haavaldsen G, Irion T, Leirvag H, Torum E. et al.Day treatment of patients with personality disorders: experiences from a Norwegian treatment research network. J Personal Disord. 2003;17:243–262. doi: 10.1521/pedi.17.3.243.22151.
    1. Svartberg M, Stiles TC, Seltzer MH. Randomized, controlled trial of the effectiveness of short-term dynamic psychotherapy and cognitive therapy for cluster C personality disorders. Am J Psychiatry. 2004;161:810–817. doi: 10.1176/appi.ajp.161.5.810.
    1. Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry. 2007;164:922–928. doi: 10.1176/appi.ajp.164.6.922.
    1. McMain SF, Links PS, Gnam WH, Guimond T, Cardish RJ, Korman L, Streiner DL. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. Am J Psychiatry. 2009;166:1365–1374. doi: 10.1176/appi.ajp.2009.09010039.
    1. Paris J. Effectiveness of different psychotherapy approaches in the treatment of borderline personality disorder. Curr Psychiatry Rep. 2010;12:56–60. doi: 10.1007/s11920-009-0083-0.
    1. Palmer S, Davidson K, Tyrer P, Gumley A, Tata P, Norrie J, Murray H, Seivewright H. The cost-effectiveness of cognitive behavior therapy for borderline personality disorder: results from the BOSCOT trial. J Personal Disord. 2006;20:466–481. doi: 10.1521/pedi.2006.20.5.466.
    1. van Asselt AD, Dirksen CD, Arntz A, Giesen-Bloo JH, van DR, Spinhoven P, van TW, Kremers IP, Nadort M, Severens JL. Out-patient psychotherapy for borderline personality disorder: cost-effectiveness of schema-focused therapy v. transference-focused psychotherapy. Br J Psychiatry. 2008;192:450–457. doi: 10.1192/bjp.bp.106.033597.
    1. Dimaggio G, Carcione A, Salvatore G, Semerari A, Nicolo G. A rational model for maximizing the effects of therapeutic relationship regulation in personality disorders with poor metacognition and over-regulation of affects. Psychol and Psychother: Theory, Res and Pract. 2010;83:363–384. doi: 10.1348/147608310X485256.
    1. Wilberg T, Karterud S, Pedersen G, Urnes O. The impact of avoidant personality disorder on psychosocial impairment is substantial. Nord J Psychiatry. 2009. pp. 1–7.
    1. Kvarstein E, Karterud S. Large variations of global functioning over five years in treated patients with personality traits and disorders. J Personal Disord. 2012;26:141–161. doi: 10.1521/pedi.2012.26.2.141.
    1. Soeteman DI, Verheul R, Delimon J, Meerman AM, van den Eijnden E, Rossum BV, Ziegler U, Thunnissen M, Busschbach JJ, Kim JJ. Cost-effectiveness of psychotherapy for cluster B personality disorders. Br J Psychiatry. 2010;196:396–403. doi: 10.1192/bjp.bp.109.070482.
    1. Soeteman DI, Verheul R, Meerman AM, Ziegler U, Rossum BV, Delimon J, Rijnierse P, Thunnissen M, Busschbach JJ, Kim JJ. Cost-effectiveness of psychotherapy for cluster C personality disorders: a decision-analytic model in the Netherlands. J Clin Psychiatry. 2011;72:51–59. doi: 10.4088/JCP.09m05228blu.
    1. Arnevik E, Wilberg T, Urnes O, Johansen M, Monsen JT, Karterud S. Psychotherapy for personality disorders: short-term day hospital psychotherapy versus outpatient individual therapy - a randomized controlled study. Eur Psychiatry. 2009;24:71–78. doi: 10.1016/j.eurpsy.2008.09.004.
    1. Sheehan DV, Lecrubier Y, Janavs J, Weiller E, Baker R, Hergueta P. Mini International Neuropsychiatric Interview (M.I.N.I.) Tampa, Florida and Paris: University of South Florida Institute for Research in Psychiatry and INSERM-Hôpital de la Salpétrière; 1994.
    1. First M. Structured clinical interview for DSM-IV (version 2.0) New York: New York State Psychiatric Institute; 1994.
    1. Halsteinli V, Hatling T, Kaleth J. Aktivitetsbaserte poliklinikktakster i psykisk helsevern -mellom visjon og virkelighet. 2003.
    1. Petersen SØ. Sektorrapport for somatisk spesialisthelsetjeneste 2006. 2007.
    1. Pedersen PB. Sektorrapport for det psykiske helsevernet 2006. 2007.
    1. The Norwegian Labour and Welfare Administration. Hva foregår på legekontorene? Konsultasjonsstatistikk for 2006. 2008.
    1. Pedersen G, Hagtvet KA, Karterud S. Generalizability studies of the Global Assessment of Functioning-Split version. Compr Psychiatry. 2007;48:88–94. doi: 10.1016/j.comppsych.2006.03.008.
    1. Singer JD, Willett JB. Applied longitudinal data analysis. New York: Oxford University Press; 2003.
    1. Field A. Discovering statistics using SPSS. London: Sage publications Ltd.; 2009.
    1. Hedeker D, Gibbons RD. Psychological methods. 1997. pp. 64–78.
    1. Soeteman DI, Kim JJ. Cost-effectiveness of psychotherapy for personality disorders: treatment recommendations and implementation. Expert Rev Pharmacoecon Outcomes Res. 2013;13:73–81. doi: 10.1586/erp.12.87.
    1. Livesley J. Integrated therapy for complex cases of personality disorder. J Clin Psychol. 2008;64:207–221. doi: 10.1002/jclp.20453.
    1. Kvarstein EH, Karterud S. Large variation of severity and longitudinal change of symptom distress among patients with personality disorders. Personal Ment Health. 2013. doi:10.1002/pmh.1226.
    1. Dimaggio G, Attina G, Popolo R, Salvatore G. Personality disorders with over-regulation of emotions and poor self-reflectivity - The case of a man with avoidant and not-otherwise specified personality disorder and social phobia treated with Metacognitive Interpersonal Therapy. Personal Ment Health. 2012;6:156–162. doi: 10.1002/pmh.1193.
    1. Fiore D, Dimaggio G, Nicolo G, Semerari A, Carcione A. Metacognitive interpersonal therapy in a case of obsessive-compulsive and avoidant personality disorders. J Clin Psychol. 2008;64:168–180. doi: 10.1002/jclp.20450.
    1. Nicolo G, Semerari A, Lysaker PH, Dimaggio G, Conti L, D'Angerio S, Procacci M, Popolo R, Carcione A. Alexithymia in personality disorders: correlations with symptoms and interpersonal functioning. Psychiatr Res. 2011;190:37–42. doi: 10.1016/j.psychres.2010.07.046.
    1. Ulvenes PG, Berggraf L, Hoffart A, Stiles TC, Svartberg M, McCullough L, Wampold BE. Different processes for different therapies: therapist actions, therapeutic bond, and outcome. Psychother (Chic) 2012;49:291–302.
    1. Johansen PO, Krebs TS, Svartberg M, Stiles TC, Holen A. Change in defense mechanisms during short-term dynamic and cognitive therapy in patients with cluster C personality disorders. J Nerv Ment Dis. 2011;199:712–715. doi: 10.1097/NMD.0b013e318229d6a7.
    1. Schanche E, Stiles TC, McCullough L, Svartberg M, Nielsen GH. The relationship between activating affects, inhibitory affects, and self-compassion in patients with Cluster C personality disorders. Psychother (Chic ) 2011;48:293–303.
    1. Chiesa M, Fonagy P. Psychosocial treatment for severe personality disorder. 36-month follow-up. Br J Psychiatry. 2003;183:356–362. doi: 10.1192/bjp.183.4.356.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe