Is Psychotherapy for Personality Disorders Worth It?

See article by Bamelis et al

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Psychiatrists’ eyes may glaze upon encountering an article with “economic” in the title and containing jargon like “QALY” (quality-adjusted life-years) and “nonparametric bootstrap replication.” As a profession, psychiatrists are not terribly good with numbers and money (or we’ d be in better economic shape). Yet the study by Bamelis and colleagues in this issue1 deserves your rapt attention. As a non-economically focused psychiatrist, I recommend it to you.

There is a dearth of good studies of the cost-effectiveness, cost-utility, and cost-offset of psychiatric treatments, particularly psychotherapies. The authors of this sophisticated Dutch multisite trial compared the costs of schema therapy, clarification-oriented therapy, and treatment as usual (which in the Netherlands tends to mean adequate treatment) in a large randomized trial of 320 patients meeting DSM-IV criteria for avoidant, dependent, obsessive-compulsive, paranoid, histrionic, or narcissistic personality disorders. Schema therapy, the most clinically effective treatment, also had the best economic outcomes across a broad range of health-related and other societal variables.

It is interesting to study the costs of treating personality disorders, which by definition are chronically debilitating and for which psychotherapy is the keystone of treatment. Moreover, the 6 personality disorders studied have received relatively little treatment attention relative to borderline personality disorder.

Historically, the first hurdle psychotherapy research had to leap was whether psychotherapy worked.2 With several psychotherapies having now amply demonstrated efficacy and effectiveness for multiple diagnoses, including some personality disorders, the next hurdle for psychotherapy may be cost. In the United States, insurance companies have continued to reward psychiatrists for prescribing medications rather than sitting, listening, and talking with patients, which the insurers still seem to consider an endless process and a black hole for costs. Even though most patients with mood and anxiety disorders prefer psychotherapy to pharmacotherapy,3 the ratio of treatments they are receiving has increasingly tilted toward pharmacotherapy,4 no doubt in part because of wrong-headed insurance-related economic incentives.5

Personality disorders are precisely the sort of diagnoses insurance companies have most feared: chronic conditions requiring potentially endless, costly psychotherapy. This study shows not only that patients with personality disorders improved but also that delivering effective treatment saved money. American psychiatrists and other mental health professionals interested in preserving (and prescribing) psychotherapies should thank our Dutch colleagues for this economic research supporting the use of talking therapy for personality disorders. This is a study to cite to your patients’ insurers. The Dutch have treated us well: the Europeans did the research for us, showing American insurers they should have to pay!

Schema therapy scored a rousing success in this study, reflecting its clinical success relative to treatment as usual and clarification-oriented therapy.6 Schema therapy produced not only greater Axis II remission but also improved depressive disorder and psychosocial functioning more than the other treatments.6 Nor was the schema therapy outcome just a halo effect of offering patients a specialized therapy instead of treatment as usual. Clarification-oriented treatment, manualized7 but never previously tested,8 showed no clinical advantages over and was less cost effective than usual treatment.1 Moreover, money aside, none of the treatments performed terribly: although schema therapy showed greatest effectiveness (81% 3-year recovery), treatment as usual (52%) and clarification-oriented therapy (51%) also helped many patients.

Study strengths include (1) the wide economic net the researchers cast, capturing the pervasive costs of personality disorders—not just health care costs, but losses in work productivity too; (2) the relatively large sample size; and (3) the relatively lengthy 3-year time frame. As the authors point out, however, successfully treating a personality disorder may yield greater and longer-term future savings than this 3-year study could measure.

How nice to see such a rational approach to social problems! This study builds on previous research showing that schema therapy9 and other treatments10,11 may be both clinically effective and cost effective for borderline personality disorder. Large treatment samples and complex methodology are necessary to measure such economic factors, so we still know too little about this area. Let us hope that studies like this one by Bamelis and colleagues encourage researchers, governments, and even insurers to pursue better understanding of the economics of our often potent treatments.

Author affiliations: New York State Psychiatric Institute, New York and Columbia University College of Physicians & Surgeons, New York.

Potential conflicts of interest: Dr Markowitz receives research funding from the National Institute of Mental Health, the National Cancer Institute, and the Earle I. Mack Foundation; salary support from the New York State Psychiatric Institute; modest book royalties relating to psychotherapy (including Interpersonal Psychotherapy) from American Psychiatric Publishing, Basic Books, and Oxford University Press; and an editorial stipend from Elsevier Press.

Funding/support: The author reports no conflict of interest with the study on which he is commenting.

REFERENCES

1. Bamelis LLM, Arntz A, Wetzelaer P, et al. Economic evaluation of schema therapy and clarification-oriented psychotherapy for personality disorders: a multicenter, randomized controlled trial. J Clin Psychiatry. 2015;76(11);e1432-e1440.

2. Smith ML, Glass GV, Miller TI. The Benefits of Psychotherapy. Baltimore, MD: Johns Hopkins University Press; 1980.

3. McHugh RK, Whitton SW, Peckham AD, et al. Patient preference for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review. J Clin Psychiatry. 2013;74(6):595-602. PubMed doi:10.4088/JCP.12r07757

4. Olfson M, Marcus SC. National trends in outpatient psychotherapy. Am J Psychiatry. 2010;167(12):1456-1463. PubMed doi:10.1176/appi.ajp.2010.10040570

5. Appelbaum PS. The “quiet” crisis in mental health services. Health Aff. 2003;22(5):110-116. doi:10.1377/hlthaff.22.5.110

6. Bamelis LLM, Evers SMAA, Spinhoven P, et al. Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. Am J Psychiatry. 2014;171(3):305-322. doi:10.1176/appi.ajp.2013.12040518 PubMed

7. Sachse R, ed. Psychologische psychotherapie der persönlichkeitsstöringen. Göttingen, Germany: Hogrefe-Verlag; 2001.

8. Bamelis LL, Evers SM, Arntz A. Design of a multicentered randomized controlled trial on the clinical and cost effectiveness of schema therapy for personality disorders. BMC Public Health. 2012;12(1):75. PubMed doi:10.1186/1471-2458-12-75

9. van Asselt AD, Dirksen CD, Arntz A, et al. Out-patient psychotherapy for borderline personality disorder: cost-effectiveness of schema-focused therapy v. transference-focused psychotherapy. Br J Psychiatry. 2008;192(6):450-457. PubMed doi:10.1192/bjp.bp.106.033597

10. Wagner T, Fydrich T, Stiglmayr C, et al. Societal cost-of-illness in patients with borderline personality disorder one year before, during and after dialectical behavior therapy in routine outpatient care. Behav Res Ther. 2014;61:12-22. PubMed doi:10.1016/j.brat.2014.07.004

11. Leichsenring F, Leibing E. The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: a meta-analysis. Am J Psychiatry. 2003;160(7):1223-1232. PubMed doi:10.1176/appi.ajp.160.7.1223

Submitted: January 20, 2015; accepted January 21, 2015.

Corresponding author: John C. Markowitz, MD, New York State Psychiatric Institute, 1051 Riverside Drive, Unit #129, New York, NY 10032 (jcm42@columbia.edu).

J Clin Psychiatry 2015;76(11):e1472-e1473

dx.doi.org/10.4088/JCP.15com09814

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