Introduction
In a budget constrained health care system, the cost and benefits of psychological interventions are increasingly of interest as decisions regarding resource allocation have forced individuals to re-examine the cost effectiveness of psychological treatments [1,2]. In particular clinicians are increasingly faced with numerous challenges surrounding decisions regarding treatment options which need to be both ethically informed and based on available research findings. Concurrent with the debate on health care reform, and the relative dearth of evidence-based treatment for Personality Disorders (PD), clinicians have become increasingly interested in evaluating the cost-effectiveness of psychological treatments [3]. Attention to the cost-benefit analysis is crucial in weighing the benefits versus disadvantages of specific interventions and treatment approaches [4], clearly defining the method, duration and outcomes of interventions. Managed care providers demand that treatments have demonstrated efficacy, minimize costs, and reduce future utilization of expensive resources.
Previous research in the field has highlighted that individuals suffering Borderline Personality Disorder (BPD) pose a high economic burden on society due to their extensive use of treatment services [5–7]. This is understandable as BPD is present in 1–2% of the population, 10% of psychiatric outpatients and between 15% and 25% of inpatients [8–10]. Additionally patients with BPD present to services at a high risk of self-harm, with up to 10% of psychiatric outpatients committing suicide, a rate almost 50 times higher than the general population [11]. The widespread economic impacts of the condition is aggravated by the fact that individuals suffering BPD typically need several repeated treatments, including urgent interventions in emergency departments and seek help repeatedly and simultaneously from multiple sources [12,13].
Within mental health settings, Sansone and colleagues (2011) [6] found that patients with BPD symptomology appear to have a significantly higher turnover with primary care physicians and see a greater number of specialists than patients without these symptoms. Additionally, Bender and colleagues (2001) [5] found that compared to individuals with major depression, those with BPD were significantly more likely to use most types of psychiatric treatment. Finally, in an Australian community sample, Jackson and Burgess (2004) [14] found that individuals with BPD were more likely than other individuals to seek psychiatric or psychological consultations. Given the seemingly consistent pattern of high utilization of mental health services among individuals with BPD, these findings may reflect the underlying psychological processes of the disorder as well as a general pattern of demand for healthcare services [15].
Treatment guidelines for BPD support psychotherapy in the community as the treatment of choice [16]. Studies of different psychological therapies such as mentalization based treatment, transference focused therapy and dialectical behaviour therapy, have demonstrated positive outcomes in relation to symptomology and levels of service use [9]. However, due to the nature of BPD symptoms, the identification of psychotherapies and utilisation of interventions that are cost-effective with this population is of considerable importance. While many factors influence the likelihood that a treatment is effective, one of the primary factors has become the affordability of treatment. That is, the pure monetary value one saves or loses by investing in one treatment compared to another. Brazier and colleagues (2006) [17] completed a systematic review and a preliminary economic evaluation of available therapies for BPD patients [17]. In 2014, Brettschneider and colleagues [18] performed a systematic literature review of 15 existing economic evaluations of treatments for BPD up to 2012, but the economic evaluations reviewed used different comparators to define costs, which made comparability of the data difficult and the findings not sufficient to draw robust conclusions for all treatments. There has been no updated review over the past 5 years despite a surge in economic data available.
Therefore the present study aims to systematically review and synthesize the literature on this topic and provide an updated overview (i.e. up to December 2015). We are specifically focused at looking at the cost-benefit of recognised evaluated treatments, as the results can be used to gain insight into how much society is spending on BPD, and potentially how much can be saved if effective therapy is offered. The information can be helpful in setting priorities for health care efficiency research as high societal costs present a strong argument in favour of prioritizing BPD treatments in reimbursement decisions, in terms of health insurance benefits for affected individuals and funding grants to provide accessible and effective treatment services.