A cost-effectiveness analysis of dialectical behaviour therapy for treating individuals with borderline personality disorder in the community.

BACKGROUND/AIMS: This paper investigates the cost-effectiveness of dialectical behaviour therapy (DBT) for treating individuals with borderline personality disorder (BPD) in a community setting in Ireland, in the short term. METHODS: Resource utilisation and effectiveness data were collected as part of the National DBT Project, Ireland, and are incorporated into a cost-effectiveness analysis. The perspective taken was that of the service provider and payer. Direct health resources were included and effectiveness was measured using the EQ-5D-5L questionnaire. To examine cost-effectiveness, incremental costs are compared with incremental quality-adjusted life years, to estimate an incremental cost-effectiveness ratio. A probabilistic sensitivity analysis was employed to investigate parameter uncertainty. Scenario analyses are employed to investigate cost-effectiveness of DBT with varying assumptions around effectiveness and costs. RESULTS: The baseline analysis reveals that DBT is more expensive and more effective than routine clinical care (without DBT). The low incremental cost-effectiveness ratio suggests DBT can be considered cost effective in the short term. In each scenario analyses considered, the probability that DBT is cost effective is greater than 50%. CONCLUSIONS: Mental health care provision, including that of DBT, varies across jurisdictions, necessitating economic evaluations of current practice in community-based services, on a country-by-country basis, to inform resource allocation decisions. In line with previous research, the analysis here indicates DBT can be considered cost effective in the short term. Future data collection on alternative comparators and long-term outcomes associated with DBT is warranted to investigate the longer term cost-effectiveness of DBT.

Societal costs of Borderline Personality Disorders: a matched-controlled nationwide study of patients and spouses.

OBJECTIVE: Information on societal cost of patients with Borderline Personality Disorder (BPD) and spouses is limited. The aim was to investigate factual societal costs before and after initial BPD diagnosis. METHOD: A register-based cohort study of 2756 patients with incident BPD (ICD F60.3) with spouses and 11 024 matched controls, during 2002-2016. RESULTS: Total direct healthcare costs and lost productivity costs amounted €40 441 for patients with BPD, which was more than 16 times higher than the matched controls. Somatic and psychiatric health care costs and costs of lost productivity were increased during 5 years before initial diagnosis of BPD. Before and after initial diagnosis, health care costs and lost productivity were increased among spouses of patients with BPD. CONCLUSION: Patients with BPD differed substantially from the general population with respect to all included costs. The study documented a significant burden on their spouses. Besides the early onset of BPD, which implies that patients are affected before they finish school and enter labor market, the neurocognitive impairment and fundamental symptoms of BPD, e.g. unstable, intense relationships, impulsivity, and lack of stable sense of self together with psychiatric and somatic comorbidity are part of explanation of the excess costs of BPD.

PRO*BPD: effectiveness of outpatient treatment programs for borderline personality disorder: a comparison of Schema therapy and dialectical behavior therapy: study protocol for a randomized trial.

BACKGROUND: Borderline Personality Disorder (BPD) is a severe mental illness that is associated with low quality of life, low psychosocial functioning, and high societal costs. Treatments for BPD have improved in the last decades. Dialectical behavior therapy (DBT) and Schema therapy (ST) have demonstrated efficacy in reducing BPD symptoms and costs. However, research has not compared these two treatment approaches. In addition, there is a lack of 'real world studies' that replicate positive findings in regular mental healthcare settings. Thus, the PROgrams for Borderline Personality Disorder (PRO*BPD) study will compare the (cost-) effectiveness of DBT and ST in structured outpatient treatment programs in the routine clinical setting of an outpatient clinic. METHODS/DESIGN: We aim to recruit 160 BPD patients, who will be randomly assigned to either DBT or ST. In both conditions, patients receive one group therapy and one individual therapy session/week for a maximum of 18 months. Both treatment programs have similar frameworks, which guarantee clinical equipoise. The primary outcome is a reduction of BPD-symptoms. Also, the costs related to BPD are assessed and an economic evaluation is performed from a societal perspective. Secondary outcomes examine other measures of BPD-typical and general psychopathology, comorbidity, quality of life, psychosocial functioning and participation. Data are collected prior to the beginning therapy and every six months until the end of therapy, as well as at six months, one year and two years of follow-up after the end of therapy. Finally, we conduct a qualitative study to understand patients' experiences with the two methods. DISCUSSION: The PRO*BPD study is the first randomized trial to compare the (cost-) effectiveness of DBT and ST. By examining the clinical effectiveness of a broad spectrum of outcome parameters, conducting an economic evaluation and assessing patients' experiences, this study will significantly advance our knowledge on psychotherapy for BPD and will provide insight into the treatment approaches that should be offered to different BPD patients from clinical, economic and stakeholder's perspectives. TRIAL REGISTRATION: German Clinical Trial Register, DRKS00011534 , Date of registration: 11/01/2017, retrospectively registered.

The effectiveness of 6 versus 12-months of dialectical behaviour therapy for borderline personality disorder: the feasibility of a shorter treatment and evaluating responses (FASTER) trial protocol.

BACKGROUND: Although Dialectical Behaviour Therapy (DBT) is an evidence-based psychosocial treatment for borderline personality disorder (BPD), the demand for it exceeds available resources. The commonly researched 12-month version of DBT is lengthy; this can pose a barrier to its adoption in many health care settings. Further, there are no data on the optimal length of psychotherapy for BPD. The aim of this study is to examine the clinical and cost-effectiveness of 6 versus 12 months of DBT for chronically suicidal individuals with BPD. A second aim of this study is to determine which patients are as likely to benefit from shorter treatment as from longer treatment. METHODS/DESIGN: Powered for non-inferiority testing, this two-site single-blind trial involves the random assignment of 240 patients diagnosed with BPD to 6 or 12 months of standard DBT. The primary outcome is the frequency of suicidal or non-suicidal self-injurious episodes. Secondary outcomes include healthcare utilization, psychiatric and emotional symptoms, general and social functioning, and health status. Cost-effectiveness outcomes will include the cost of providing each treatment as well as health care and societal costs (e.g., missed work days and lost productivity). Assessments are scheduled at pretreatment and at 3-month intervals until 24 months. DISCUSSION: This is the first study to directly examine the dose-effect of psychotherapy for chronically suicidal individuals diagnosed with BPD. Examining both clinical and cost effectiveness in 6 versus 12 months of DBT will produce answers to the question of how much treatment is good enough. Information from this study will help to guide decisions about the allocation of scarce treatment resources and recommendations about the benefits of briefer treatment. TRIAL REGISTRATION: NCT02387736 . Registered February 20, 2015.

The Clinical Effectiveness and Cost-Effectiveness of Lamotrigine in Borderline Personality Disorder: A Randomized Placebo-Controlled Trial.

OBJECTIVE: The authors examined whether lamotrigine is a clinically effective and cost-effective treatment for people with borderline personality disorder. METHOD: This was a multicenter, double-blind, placebo-controlled randomized trial. Between July 2013 and November 2016, the authors recruited 276 people age 18 or over who met diagnostic criteria for borderline personality disorder. Individuals with coexisting bipolar affective disorder or psychosis, those already taking a mood stabilizer, and women at risk of pregnancy were excluded. A web-based randomization service was used to allocate participants randomly in a 1:1 ratio to receive either an inert placebo or up to 400 mg/day of lamotrigine. The primary outcome measure was score on the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD) at 52 weeks. Secondary outcome measures included depressive symptoms, deliberate self-harm, social functioning, health-related quality of life, resource use and costs, side effects of treatment, and adverse events. RESULTS: A total of 195 (70.6%) participants were followed up at 52 weeks, at which point 49 (36%) of those in the lamotrigine group and 58 (42%) of those in the placebo group were taking study medication. The mean ZAN-BPD score was 11.3 (SD=6.6) among those in the lamotrigine group and 11.5 (SD=7.7) among those in the placebo group (adjusted difference in means=0.1, 95% CI=-1.8, 2.0). There was no evidence of any differences in secondary outcomes. Costs of direct care were similar in the two groups. CONCLUSIONS: The results suggest that treating people with borderline personality disorder with lamotrigine is not a clinically effective or cost-effective use of resources.

The value of psychological treatment for borderline personality disorder: Systematic review and cost offset analysis of economic evaluations.

AIM: Borderline Personality Disorder (BPD) is a common mental health condition with high patterns of service utilisation of inpatient and community treatment. Over the past five years there has been significant growth in research with economic data, making this systematic review a timely update. METHODS: Empirical studies written in English or German, published up to December 2015, and cited in major electronic databases were examined using the PRISMA systematic review method. Papers were included that had one of the following: data related to cost of BPD to society, the individual, the carer or families; cost benefits of interventions. Reported cost data were inflated to the year 2015 and converted into US- dollars (USD $) using purchasing power parities. RESULTS: We identified 30 economic evaluations providing cost data related to interventions for BPD across 134,136 patients. The methodological quality was good, almost all studies fulfilled ≥ 50% of the quality criteria. The mean cost saving for treating BPD with evidence-based psychotherapy across studies was USD $2,987.82 per patient per year. A further mean weighted reduction of USD $1,551 per patient per year (range $83 - $29,392) was found compared to treatment as usual. Evidence-based psychological treatment was both less expensive as well as more effective, despite considerable differences in health cost arrangements between individual studies and countries. Where it was able to be calculated, a significant difference in cost-savings between different types of evidence-based psychotherapies was found. DISCUSSION: Individuals with BPD consistently demonstrate high patterns of service utilization and therefore high costs. The findings of this review present a strong argument in favour of prioritizing BPD treatments in reimbursement decisions, both for the affected individual and the family. The provision of evidence based treatment, irrespective of the type of psychological treatment, may lead to widespread reductions in healthcare costs.

Cost-effectiveness and Budget Impact of Specialized Psychotherapy for Borderline Personality Disorder: A Synthesis of the Evidence.

BACKGROUND: Specialized outpatient psychotherapy for patients with borderline personality disorder (BPD) is expected to reduce their use of other health care resources. It is currently unknown to what extent the costs of providing these interventions can be expected to be offset by a reduction in other health care costs in the Netherlands. To establish the cost-effectiveness and budget impact of specialized outpatient psychotherapy, the estimated incremental costs are synthesized with the estimated incremental effects. We have developed a method for the synthesis of all relevant evidence on clinical effectiveness as well as health care resource use. AIM OF THE STUDY: The aim of this article is to present a method for the synthesis of evidence for cost-effectiveness and budget impact analysis with a specific application to specialized outpatient psychotherapy for borderline personality disorder in the Netherlands. METHODS: A systematic search of the English-language literature is performed to retrieve evidence on the clinical effectiveness and the health care resource use following 12 months of specialized outpatient psychotherapy for borderline personality disorder. The available evidence is used as an input for a model-based economic evaluation. Simulated patient-level data are used to provide overall estimates of the incremental costs and incremental effects, which serve to assess the cost-effectiveness and budget impact of specialized outpatient psychotherapy for borderline personality disorder in the Netherlands. RESULTS: The results indicate that specialized outpatient psychotherapy for BPD can be considered cost-effective and that its scaling up to Dutch national level would require an investment of 2.367 million (95% C.I.: 1,717,000 - 3,272,000) per 1,000 additional patients with BPD. Sensitivity analyses demonstrated the robustness of our findings in light of several uncertain components and assumptions in our calculations, but also their sensitivity to the choice of included studies based on the comparator condition and the assumption of high intervention costs. DISCUSSION: We present a method for the synthesis of evidence from different types of studies in a way that respects the uncertainty surrounding those findings. Limitations of the study pertain to the inclusion of findings from studies with suboptimal designs, the transferability of research findings, and uncertainty regarding the time horizon considered. More research is needed on the sensitivity of our findings to the choice of included studies based on the comparator condition. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: THE results suggest that the provision of specialized outpatient psychotherapy for BPD leads to a reduction in other health care resource use. Overall, the results are promising and encourage future studies on aspects that are currently still uncertain. IMPLICATIONS FOR HEALTH POLICIES: The results may support policy makers in deciding whether or not to allocate health care budget for the provision of specialized outpatient psychotherapy for patients with BPD in the Netherlands. IMPLICATIONS FOR FURTHER RESEARCH: The results provide important directions for future research. This includes the need for future studies to make a comparison between specialized outpatient psychotherapy and treatment as usual and to have longer follow-up time.

Health care costs of borderline personality disorder and matched controls with major depressive disorder: a comparative study based on anonymized claims data.

BACKGROUND: Borderline personality disorder (BPD) and major depressive disorder (MDD) pose a significant burden to the German health care system in terms of direct and indirect costs. The aim of this study was to determine the incremental costs that arise due to the treatment of patients with BPD, in relation to MDD patients adjusted for gender and age. METHODS: Insured persons who suffered from BPD (F60.3; N = 6599) or MDD (F32, F33; N = 26,396) in the year 2010 were identified from the German Health Risk Institute research database. To estimate the costs resulting from disorder-specific health care service utilization and the mean total costs per patient for the health care system, we analyzed anonymized claims data of individuals with BPD and matched individuals with MDD. RESULTS: The costs resulting from disorder-specific health care service utilization 1 year after index diagnosis amounted to 8508 EUR for BPD and 8281 EUR for MDD per patient utilizing services. With mean total annual costs per patient of 4636 EUR versus 2020 EUR 1 year preceding index diagnosis, 7478 EUR versus 3638 EUR in the year after index diagnosis, and 11,817 EUR versus 6058 EUR 2 years after index diagnosis, BPD patients incurred markedly higher costs. CONCLUSIONS: Since the treatment of BPD causes incremental costs for the German health care system compared to the treatment of MDD, and since both conditions are associated with a high level of suffering, there is a need for establishing adequate and early treatment of these mental disorders.

The burden of disease in patients eligible for mentalization-based treatment (MBT): quality of life and costs.

BACKGROUND: Mentalization-Based Treatment (MBT) is a promising, though expensive treatment for severely ill patients with Borderline Personality Disorder (BPD). A high burden of disease in terms of quality of life (QoL) and life years lost can be a reason to prioritize mental health interventions, and specifically for BPD patients. Moreover, when the societal costs of the illness are high, spending resources on high treatment costs would be more easily legitimized. Therefore, the purpose of this study was to calculate the burden of disease of BPD patients eligible for MBT. METHODS: The 403 patients included in this study were recruited from two mental health care institutes in the Netherlands. All patients were eligible for MBT. Burden of disease consisted of QoL, measured with the EuroQol EQ-5D-3L, and costs, calculated using the Trimbos and Institute for Medical Technology Assessment Questionnaire for Costs Associated with Psychiatric Illness. RESULTS: The mean QoL index score was .48. The mean total costs in the year prior to treatment were €16,879 per patient, of which 21 % consisted of productivity costs. CONCLUSIONS: The burden of disease in BPD patients eligible for MBT is high, which makes it more likely that society is willing to invest in treatment for these patients. However, this finding should not be interpreted as a license to unlimitedly use resources to reimburse treatment for severe BPD patients, as these findings do not provide any information on the effectiveness of MBT or other available treatment programs for BPD. The effectiveness of available treatments should be evident by studies on the effectiveness of the treatment itself and by comparing the effectiveness of these treatments to treatment as usual and to other treatment options for BPD patients. TRIAL REGISTRATION: The data on this paper came from two trials: NTR2175 and NTR2292 .

Is borderline personality disorder only a mental health problem?

Patients with borderline personality disorder (BPD) have been shown to have increased rates of the use of medical services. The objective of this multicentre study was to compare the utilization of physical health services by patients with severe BPD (n = 36) with that of two control groups: one with other personality disorders (PDs) (n = 38) and one with matched subjects randomly selected from the general population (n = 165). Information was drawn from an insurance database collected over a 5-year period. The results showed that the BPD group had a higher mean number of medication prescriptions (377.3 vs. 97.4, p < 0.001), general medical consultations (34.4 vs. 13.2, p < 0.05) and days of medical or surgical hospitalization (10.2 vs. 1.9, p = 0.03). However, there were no significant differences between the groups with BPD and other PDs. The annual health-care cost for each BPD patient is estimated to be 12 761 euros, of which 17.6% is due to somatic care. In the BPD group, co-morbidity for narcissistic PD (NPD) contributed to the overall use of medications and hospitalization use. Combined with other data, this exploratory study shows that BPD is a medical burden and not just a psychiatric one. Copyright © 2016 John Wiley & Sons, Ltd.

Description and prediction of the income status of borderline patients over 10 years of prospective follow-up.

BACKGROUND: Research shows that individuals suffering from borderline personality disorder are economically disadvantaged, but longitudinal data is lacking. AIM: This study examined the income of borderline personality disorder (BPD) patients and axis II comparison subjects over 10 years of follow-up and assessed predictors of income among BPD patients. METHOD: Data on income was obtained for 264 BPD patients and 63 axis II comparison subjects at 6-year follow-up and for surviving patients at five follow-up waves. Baseline and time-varying predictors of income were assessed using information from interviews and self-report measures. RESULTS: Regardless of diagnosis, a greater proportion of people shifted into the higher income groups over time. Being in a higher income group was more likely to happen and happened more rapidly for axis II comparison subjects than for BPD patients. Results regarding the BPD patients indicated that childhood emotional, verbal and/or physical abuse were associated with a greater likelihood of being in a lower income group, whereas years of education and a higher IQ were associated with a greater likelihood of being in a higher income group. CONCLUSION: Borderline personality disorder (BPD) patients show enduring lowered economic functioning. Their economic functioning seems to be negatively affected by childhood emotional, verbal and/or physical abuse but positively affected by years of education and IQ. Copyright © 2016 John Wiley & Sons, Ltd.

The Influence of Posttraumatic Stress Disorder on Treatment Outcomes of Patients With Borderline Personality Disorder.

The aim of this study was to determine the influence of posttraumatic stress disorder (PTSD) on treatment outcomes in patients with borderline personality disorder (BPD). Participants were 180 individuals diagnosed with BPD enrolled in a randomized controlled trial that compared the clinical and cost effectiveness of dialectical behavior therapy (DBT) and general psychiatric management (GPM). Multilevel linear models and generalized linear models were used to compare clinical outcomes of BPD patients with and without PTSD. BPD patients with comorbid PTSD reported significantly higher levels of global psychological distress at baseline and end of treatment compared to their non-PTSD counterparts. Both groups evidenced comparable rates of change on suicide attempts and non-suicidal self-injury (NSSI), global psychological distress, and BPD symptoms over the course of treatment and post-treatment follow-up. DBT and GPM were effective for BPD patients with and without PTSD across a broad range of outcomes.

Lamotrigine versus inert placebo in the treatment of borderline personality disorder: study protocol for a randomized controlled trial and economic evaluation.

BACKGROUND: People with borderline personality disorder (BPD) experience rapid and distressing changes in mood, poor social functioning and have high rates of suicidal behaviour. Several small scale studies suggest that mood stabilizers may produce short-term reductions in symptoms of BPD, but have not been large enough to fully examine clinical and cost-effectiveness. METHODS/DESIGN: A two parallel-arm, placebo controlled randomized trial of usual care plus either lamotrigine or an inert placebo for people aged over 18 who are using mental health services and meet diagnostic criteria for BPD. We will exclude people with comorbid bipolar affective disorder or psychosis, those already taking a mood stabilizer, those who speak insufficient English to complete the baseline assessment and women who are pregnant or contemplating becoming pregnant. Those meeting inclusion criteria and provide written informed consent will be randomized to up to 200mg of lamotrigine per day or an inert placebo (up to 400mg if taking combined oral contraceptives). Participants will be randomized via a remote web-based system using permuted stacked blocks stratified by study centre, severity of personality disorder, and level of bipolarity. Follow-up assessments will be conducted by masked researchers 12, 24 weeks, and 52 weeks after randomization. The primary outcome is the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD). The secondary outcomes are depressive symptoms, deliberate self-harm, social functioning, health-related quality of life, resource use and costs, side effects of treatment, adverse events and withdrawal of trial medication due to adverse effects. The main analyses will use intention to treat without imputation of missing data. The economic evaluation will take an NHS/Personal Social Services perspective. A cost-utility analysis will compare differences in total costs and differences in quality of life using QALYs derived from the EQ-5D. DISCUSSION: The evidence base for the use of pharmacological treatments for people with borderline personality disorder is poor. In this trial we will examine the clinical and cost-effectiveness of lamotrigine to assess what if any impact offering this has on peoples' mental health, social functioning, and use of other medication and other resources. TRIAL REGISTRATION: Current Controlled Trials ISRCTN90916365 (registered 01/08/2012).

Is research on borderline personality disorder underfunded by the National Institute of Health?

The relationship between bipolar disorder and borderline personality disorder has generated intense interest. Similar to patients with bipolar disorder, patients with borderline personality disorder are frequently hospitalized, are chronically unemployed, abuse substances, attempt and commit suicide. However, one significant difference between the two disorders is that patients with borderline personality disorder are often viewed negatively by mental health professionals. In the present paper we examined whether this negative bias against borderline personality disorder might be reflected in the level of research funding on the disorder. We searched the National Institute of Health (NIH) Research Portfolio Online Portfolio Reporting Tool (RePORT) for the past 25 years and compared the number of grants funded and the total amount of funding for borderline personality disorder and bipolar disorder. The yearly mean number of grants receiving funding was significantly higher for bipolar disorder than for borderline personality disorder. Results were the same when focusing on newly funded grants. For every year since 1990 more grants were funded for bipolar disorder than borderline personality disorder. Summed across all 25 years, the level of funding for bipolar disorder was more than 10 times greater than the level of funding for borderline personality disorder ($622 million vs. $55 million). These findings suggest that the level of NIH research funding for borderline personality disorder is not commensurate with the level of psychosocial morbidity, mortality, and health expenditures associated with the disorder.

Veterans' service utilization and associated costs following participation in dialectical behavior therapy: a preliminary investigation.

CONTEXT: Dialectical Behavior Therapy (DBT) is an evidence-based therapy developed for the treatment of suicidal behaviors and disorders characterized by emotional and behavioral dyscontrol that is effective in veteran populations. The impact of DBT on veterans' Veterans Affairs (VA) service utilization and cost is unknown. EVIDENCE ACQUISITION: This study evaluated the impact of DBT in a VA outpatient mental health setting on VA service utilization and cost of services. Veterans treated for symptoms of Borderline Personality Disorder, who had completed at least 6 months of the DBT program were sampled (N = 41). Use of physical and mental health services during the years prior and following DBT was assessed using medical record information. RESULTS: There was a significant decrease in mental health service utilization. Psychiatric hospitalization dropped in half, and for those with a hospitalization, length of stay decreased significantly. Direct costs associated with all health care were significantly reduced. CONCLUSION: Changes in service utilization resulted in a significant reduction in direct costs of providing care to veterans with symptoms of Borderline Personality Disorder. Additional research is needed to compare the reduction in overall costs to the cost of implementing DBT and to compare these changes to a control group.

Day hospital Mentalization-based treatment versus intensive outpatient Mentalization-based treatment for patients with severe borderline personality disorder: protocol of a multicentre randomized clinical trial.

BACKGROUND: Borderline personality disorder (BPD) is associated with a high socioeconomic burden. Although a number of evidence-based treatments for BPD are currently available, they are not widely disseminated; furthermore, there is a need for more research concerning their efficacy and cost-effectiveness. Such knowledge promises to lead to more efficient use of resources, which will facilitate the effective dissemination of these costly treatments. This study focuses on the efficacy and cost-effectiveness of Mentalization-Based Treatment (MBT), a manualized treatment for patients with BPD. Studies to date have either investigated MBT in a day hospitalization setting (MBT-DH) or MBT offered in an intensive outpatient setting (MBT-IOP). No trial has compared the efficacy and cost-effectiveness of these MBT programmes. As both interventions differ considerably in terms of intensity of treatment, and thus potentially in terms of efficacy and cost-effectiveness, there is a need for comparative trials. This study therefore sets out to investigate the efficacy and cost-effectiveness of MBT-DH versus MBT-IOP in patients with BPD. A secondary aim is to investigate the association between baseline measures and outcome, which might improve treatment selection and thus optimize efficacy and cost-effectiveness. METHODS/DESIGN: A multicentre randomized controlled trial comparing MBT-DH versus MBT-IOP in severe BPD patients. Patients are screened for BPD using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and are assessed before randomization, at the start of treatment and 6, 12, 18, 24, 30 and 36 months after the start of treatment. Patients who refuse to participate will be offered care as usual in the same treatment centre. The primary outcome measure is symptom severity as measured by the Brief Symptom Inventory. Secondary outcome measures include parasuicidal behaviour, depression, substance use, social, interpersonal, and personality functioning, attachment, mentalizing capacities, and quality of life. All analyses will be conducted based on the intention-to-treat principle. Cost-effectiveness will be calculated based on costs per quality-adjusted life-year. DISCUSSION: This multisite randomized trial will provide data to refine criteria for treatment selection for severe BPD patients and promises to optimize (cost-)effectiveness of the treatment of BPD patients. TRIAL REGISTRATION: NTR2292 . Registered 16 April 2010.

Design of an international multicentre RCT on group schema therapy for borderline personality disorder.

BACKGROUND: Borderline personality disorder (BPD) is a severe and highly prevalent mental disorder. Schema therapy (ST) has been found effective in the treatment of BPD and is commonly delivered through an individual format. A group format (group schema therapy, GST) has also been developed. GST has been found to speed up and amplify the treatment effects found for individual ST. Delivery in a group format may lead to improved cost-effectiveness. An important question is how GST compares to treatment as usual (TAU) and what format for delivery of schema therapy (format A; intensive group therapy only, or format B; a combination of group and individual therapy) produces the best outcomes. METHODS/DESIGN: An international, multicentre randomized controlled trial (RCT) will be conducted with a minimum of fourteen participating centres. Each centre will recruit multiple cohorts of at least sixteen patients. GST formats as well as the orders in which they are delivered to successive cohorts will be balanced. Within countries that contribute an uneven number of sites, the orders of GST formats will be balanced within a difference of one. The RCT is designed to include a minimum of 448 patients with BPD. The primary clinical outcome measure will be BPD severity. Secondary clinical outcome measures will include measures of BPD and general psychiatric symptoms, schemas and schema modes, social functioning and quality of life. Furthermore, an economic evaluation that consists of cost-effectiveness and cost-utility analyses will be performed using a societal perspective. Lastly, additional investigations will be carried out that include an assessment of the integrity of GST, a qualitative study on patients' and therapists' experiences with GST, and studies on variables that might influence the effectiveness of GST. DISCUSSION: This trial will compare GST to TAU for patients with BPD as well as two different formats for the delivery of GST. By combining an evaluation of clinical effectiveness, an economic evaluation and additional investigations, it will contribute to an evidence-based understanding of which treatment should be offered to patients with BPD from clinical, economic, and stakeholders' perspectives. TRIAL REGISTRATION: Netherlands Trial Register NTR2392. Registered 25 June 2010.

Cost of borderline personality disorder in Catalonia (Spain).

INTRODUCTION: The available information on the cost of illness of Borderline Personality Disorder (BPD) is overtly insufficient for policy planning. Our aim was to estimate the costs of illness for BPD in Catalonia (Spain) for 2006. METHODS: This is a multilevel cross-design synthesis study combining a qualitative nominal approach, quantitative 'top-down' analysis of multiple health databases, and 'bottom-up' data of local surveys. Both direct and indirect costs have been estimated from a governmental and societal perspective. RESULTS: Estimated year-prevalence of BPD was 0.7% (41,921 cases), but only 9.6% of these cases were treated in the mental health system (4033 cases). The baseline of the total cost of BPD in Catalonia was 45.6 million€, of which 15.8 million€ (34.7%) were direct costs related to mental health care. The cost distribution was 0.4% in primary care; 4% in outpatient mental health care; 4.7% in hospitalisation; 0.7% in emergency care; and 24.9% in pharmacotherapy. Additionally, the cost of drug addiction treatment for persons with BPD was 11.2%; costs associated with sheltered employment were 23.9% and those of crime and justice were 9.7%. Indirect costs - including temporary sick leave and premature death (suicide) - represented 20.5% of total costs. The average annual cost per patient was 11,308€. CONCLUSIONS: An under-reporting of BPD was identified by the experts in all health databases and official registries. Most of the BPD costs were not related to mental health care. Amongst the direct cost categories, pharmacotherapy had the largest proportion despite the lack of specificity for BPD. This distribution of costs reinforces the idea of BPD complexity related to an inadequate and inefficient use of health resources.

Societal cost-of-illness in patients with borderline personality disorder one year before, during and after dialectical behavior therapy in routine outpatient care.

Societal cost-of-illness in a German sample of patients with borderline personality disorder (BPD) was calculated for 12 months prior to an outpatient Dialectical Behavior Therapy (DBT) program, during a year of DBT in routine outpatient care and during a follow-up year. We retrospectively assessed resource consumption and productivity loss by means of a structured interview. Direct costs were calculated as opportunity costs and indirect costs were calculated according to the Human Capital Approach. All costs were expressed in Euros for the year 2010. Total mean annual BPD-related societal cost-of-illness was €28026 (SD = €33081) during pre-treatment, €18758 (SD = €19450) during the DBT treatment year for the 47 DBT treatment completers, and €14750 (SD = €18592) during the follow-up year for the 33 patients who participated in the final assessment. Cost savings were mainly due to marked reductions in inpatient treatment costs, while indirect costs barely decreased. In conclusion, our findings provide evidence that the treatment of BPD patients with an outpatient DBT program is associated with substantial overall cost savings. Already during the DBT treatment year, these savings clearly exceed the additional treatment costs of DBT and are further extended during the follow-up year. Correspondingly, outpatient DBT has the potential to be a cost-effective treatment for BPD patients. Efforts promoting its implementation in routine care should be undertaken.

Population-based cost-offset estimation for the treatment of borderline personality disorder: projected costs in a currently running, ideal health system.

Borderline personality disorder (BPD) is considered one of the most expensive mental disorders in terms of direct and indirect costs. The aim of this study was to carry out a cost-offset estimation of disorder-specific psychotherapy for BPD at the population level. The study investigated whether the possible financial benefits of dialectical behavior therapy outweigh the therapy costs, assuming a currently running, ideal health system, and whether the estimated cost-benefit relationships change depending upon the number of patients willing to be treated. A formula was elaborated that allows the user to calculate cost-benefit relationships for various conservative or progressive scenarios, with different stages of individuals' willingness to be treated (10%-90%). The possible costs and benefits of BPD-related treatment were evaluated using a 12-month, prevalence-based approach. The annual costs for untreated BPD were 8.69 billion EUR annually. The cost-benefit relationship for the treatment remained constant at 1.52 for all scenarios, implying that for each EUR invested, 1.52 EUR can be gained within one year, independent of the willingness to be treated. Additional intangible benefits were calculated with the aid of Quality-Adjusted Life Years. Findings suggest that BPD-related treatment might well be efficient at the population level.