Here in the woodland we’ve considered which treatments might be most effective for borderline personality disorder (Tomlin 2012a, 2012b; Judge 2014). But as we all know, the cost of these treatments matters too. The more we spend on one treatment, the less we have available to spend on another.
There are few studies on the cost to society of borderline personality disorder. One analysis of data from a Dutch sample estimated the cost to The Netherlands to be about €2.2million per year, or €17,000 per person (van Asselt et al. 2007). Brettschneider et al (Brettschneider et al. 2014) recently carried out a systematic review of economic evaluations in borderline personality disorder (BPD) to try and find out which treatments are cost-effective.
The authors conducted a literature search of MEDLINE, EMBASE, PsycINFO, and NHSEED in August 2013 based on a combination of economic- and BPD-related search terms.
The authors extracted data and recorded which types of cost data (e.g. direct or indirect costs) the study included. They then estimated costs per-person and converted the estimates to 2012 US dollars.
The quality of studies was assessed using the checklist developed by the Consensus on
Health Economic Criteria (CHEC) project.
The search identified 561 records. After deduplication and initial exclusions there were 23 articles remaining for full-text assessment. Thirteen records were subsequently excluded, leaving 10 in the final review.
Between them the papers reported on 9 full economic evaluations and 6 partial evaluations (comparing costs but not outcomes). Most of the studies were carried out in the UK and included fewer than 100 participants. All the full economic evaluations considered psychotherapeutic interventions.
Treatments being investigated included:
- dialectical behavioural therapy (DBT)
- cognitive behavioural therapy (CBT)
- client centred therapy (CCT)
- mentalisation based partial hospitalisation (MBT)
- manual assisted cognitive behavioural therapy (MACT)
- schema focussed therapy (SFT)
- transference focussed psychotherapy (TFP)
- a crisis intervention programme
- joint crisis plans
The treatment with the best available data was DBT, but even this was ambiguous. Some studies demonstrated greater efficacy of DBT compared with either treatment as usual or CCT. But there was a lot of variation in reported incremental costs, which ranged from cost savings to large additional costs.
Methodological quality was moderate. One of the primary shortcomings was the inclusion of relevant costs. Ten of the 15 reported evaluations did not identify all important and relevant costs.
The authors conclude that:
The economic evidence is not sufficient to draw robust conclusions. It is possible that some treatments are cost-effective.
This is despite several studies being identified and the quality of the studies being moderate (when often they are poor). The problem is that two well-conducted studies can be difficult to compare if they are not consistent with one another. This is a problem with studies of effectiveness – where different outcome measures might be used – but it is an even greater problem for economic evaluations. Different studies can include very different sets of costs.
This is where decision modelling can become incredibly valuable. The data from all of these different studies can be plugged together in a sensible (and transparent) way. And in doing this we can generate cost-effectiveness estimates for the different treatments. Where we’re really in the dark about what numbers to put into the model we can elicit expert opinion. My fellow elf Andrew Jones and I recently reported on a study of a treatment for smoking cessation that did just that (Jones and Sampson 2014). In their HTA study, Brazier and colleagues carried out a “preliminary” economic evaluation of DBT (Brazier et al. 2006). The time has come for the real deal.
Brettschneider C, Riedel-Heller S, König H-H. A systematic review of economic evaluations of treatments for borderline personality disorder. PLoS One 2014 Sep 29;9(9):e107748 [PubMed].
Van Asselt ADI, Dirksen CD, Arntz A, Severens JL. The cost of borderline personality disorder: societal cost of illness in BPD-patients. Eur Psychiatry 2007 Sep;22(6):354–61 [PubMed].
Brazier JE, Tumur I, Holmes M, Ferriter M, Parry G, Dent-Brown K, et al. Psychological therapies including dialectical behaviour therapy for borderline personality disorder: a systematic review and preliminary economic evaluation. Health Technol Assess 2006 Sep;10(35):iii, ix–xii, 1–117 [PubMed].
Jones A, Sampson C. Cytisine and varenicline for smoking cessation. The Mental Elf 2014.
Judge J. Which psychological therapies work best for borderline personality disorder? The Mental Elf 2014.
McCrone P, Knapp M, Lawton-smith S, Dhanasiri S, Patel A. Paying the price: the cost of mental health care in England to 2026. The King’s Fund; 2008.
Tomlin A. Borderline personality disorder improves with dialectical behaviour therapy and general psychiatric management. The Mental Elf 2012a.
Tomlin A. New Cochrane review points to best psychotherapies for borderline personality disorder. The Mental Elf 2012b.