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Out-patient psychotherapy for borderline personality disorder: Cost-effectiveness of schema-focused therapy v. transference-focused psychotherapy

  • Antoinette D. I. van Asselt (a1), Carmen D. Dirksen (a1), Arnoud Arntz (a2), Josephine H. Giesen-Bloo (a3), Richard van Dyck (a4), Philip Spinhoven (a5), Willem van Tilburg (a6), Ismay P. Kreimers (a5), Marjon Nadort (a4) and Johan L. Severens (a7)...
Abstract
Background

Schema-focused therapy (SFT) and transference-focused psychotherapy (TFP) for borderline personality disorder were recently compared in a randomised multicentre trial.

Aims

To assess the societal cost-effectiveness of SFT v. TFP in treating borderline personality disorder.

Method

Costs were assessed by interview. Health-related quality of life was measured using EQ-5D. Outcomes were costs per recovered patient (recovery assessed with the Borderline Personality Disorder Severity Index) and costs per quality-adjusted life-year (QALY).

Results

Mean 4-year bootstrapped costs were $37826 for SFT and $46 795 for TFP (95% uncertainty interval for difference −21 775 to 3546); QALYs were 2.15 for SFT and 2.27 for TFP (95% UI −0.51 to 0.28). The percentages of patients who recovered were 52% and 29% respectively. The SFT intervention was less costly and more effective than TFP (dominant), for recovery; it saved $90457 for one QALY loss.

Conclusions

Despite the initial slight disadvantage in QALYs, there is a high probability that compared with TFP, SFT is a cost-effective treatment for borderline personality disorder.

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Copyright
Corresponding author
Thea van Asselt, University Hospital Maastricht, Department KEMTA, PO Box 5800, 6202 AZ Maastricht, The Netherlands. Email: avas@kemta.azm.nl
Footnotes
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Declaration of interest

None.

Funding detailed in Acknowledgements.

Footnotes
References
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Out-patient psychotherapy for borderline personality disorder: Cost-effectiveness of schema-focused therapy v. transference-focused psychotherapy

  • Antoinette D. I. van Asselt (a1), Carmen D. Dirksen (a1), Arnoud Arntz (a2), Josephine H. Giesen-Bloo (a3), Richard van Dyck (a4), Philip Spinhoven (a5), Willem van Tilburg (a6), Ismay P. Kreimers (a5), Marjon Nadort (a4) and Johan L. Severens (a7)...
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eLetters

The cost of effective therapy

T Everett Julyan, SpR in Liaison Psychiatry
18 June 2008

Editor

As the last frontier of psychopathology, effective interventions for personality disorders are in high demand but short supply. Their cost-effectiveness analysis lead van Asselt et al to conclude that schema-focused therapy (SFT) is likely to be a cost-effective treatment for borderline personality disorder (BPD) [1]. However, several significant methodological issues cast doubt on the accuracy and "real world" relevance of this conclusion.

51% in the transference-focused psychotherapy (TFP) group did not complete treatment, compared with 27% of patients in the SFT group [2]. Asvan Asselt et al used the "last observation carried forward", this is a potentially serious source of bias in interpreting the results.

Moreover, Yeomans [3] raised his concerns about the quality of the TFP itself, a modified form of psychodynamic psychotherapy that was only being developed at the time the original study was done. This is particularly noteworthy as he acted as a consultant to the TFP therapists in the study and was of the opinion that approximately half of the therapists did not adhere to the TFP model. This suggests that any conclusions based on a comparison of TFP with SFT (where the therapists were generally more experienced in that model) is on rather shaky ground.

Perhaps even more importantly, there was no control group in the study. It was reported that 52% of patients in the SFT group recovered after 4 years, compared to 29% in the TFP. But this is meaningless withouta control group for comparison. It has been reported that one would expectaround 50% of patients with BPD severe enough to require hospitalisation to be in remission after 4 years - without SFT or TFP [4]. Therefore, SFT may in fact be no better than placebo or treatment as usual - hardly cost-effective.

In light of these methodological considerations, and in a climate where patients have difficulty in accessing psychotherapy even for conditions with a more robust evidence base [5], to conclude that twice weekly psychotherapy delivered by highly trained therapists for 3 years for BPD is cost-effective appears to go somewhat beyond the evidence.

As always, and as the authors rightly acknowledge, further research is required to address these issues.

1 van Asselt ADI, Dirksen CD, Arntz A, Giesen-Bloo JH, van Dyck R, Spinhoven P, van Tilburg W, Kremers IP, Nadort M, Severens JL. Outpatient Psychotherapy for Borderline Personality Disorder. Arch Gen Psych 2006; 63: 649-658.

2 Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, Kremers I, Nadort M, Arntz A. Outpatient Psychotherapy for Borderline Personality Disorder. Arch Gen Psych 2006; 63: 649-658.

3 Yeomans, F. Questions Concerning the Randomized Trial of Schema-Focused Therapy vs Transference-Focused Psychotherapy. Arch Gen Psych 2007; 64: 609-610.

4 Fonagy P, Bateman A. Progress in the treatment of borderline personality disorder. Br J Psych 2006; 188: 1-3.

5 Revill J. Therapy on NHS “must be increased”. The Observer 2006; Sunday, June 18.
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Conflict of interest: None Declared

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