Outpatient Psychotherapy for Borderline Personality Disorder: The Cost-Effectiveness of Schema-Focused Therapy Versus Transference-Focused Psychotherapy

Abstract

Background Borderline Personality Disorder (BPD) is a chronic condition and is estimated to be present in 1% to 2.5% of the general population. Total societal costs associated with BPD are substantial. Although until recently, there was no single therapy that had showed efficacy for all aspects of BPD, the effectiveness of Schema Focused Therapy (SFT) and Transference Focused Psychotherapy (TFP), which are both outpatient psychotherapies, for the treatment of BPD has been proven in a randomized trial now.

Aims To assess the cost-effectiveness of STF versus TFP in treating BPD. Method A multicenter, randomized, 2-group design was used. Of the 88 patients who were randomized, 86 were taken into account in the analysis, 44 for SFT and 42 for TFP. Treatment consisted of 50-minute sessions, twice a week, for three years. A cost-interview was administered every three months for three years, and once again at follow-up at 4 years. Quality of Life was measured with the EQ5D. Outcomes were costs per recovered patient as measured with the Borderline Personality Disorder Severity Index-IV (BPDSI), and costs per QALY. A number of secondary analyses were performed.

Results Bootstrapped total costs over all 4 years for SFT were €37,826, and €46,795 for TFP. The 95% uncertainty interval for the difference ranged from -€21,775 to €3,546. QALYs were 2,15 for SFT and 2,27 for TFP (ns), due to a lower utility score for SFT in the first 18 months of treatment. For cost per recovered patient, SFT is dominant. For the QALY outcome, SFT is less costly and slightly less effective than TFP; the ICER is €90,457 for one QALY loss. The secondary analyses showed the cost per recovered patient outcome to be robust. The cost per QALY outcome was sensitive to imputing baseline value instead of carrying the last observation forward for dropouts, in the sense that SFT became dominant.

Conclusions Both therapies save costs and improve QoL compared to baseline. Despite the initial slight disadvantage in QALYs for SFT, there is a high probability that, compared to TFP, SFT is a cost-effective treatment for BPD.

Keywords: Cost-effectiveness, Psychotherapy