PMC:5332029 / 36059-45025 JSONTXT

{"project":"2_test","denotations":[{"id":"28249032-17544636-91797316","span":{"begin":1458,"end":1459},"obj":"17544636"},{"id":"28249032-21309623-91797317","span":{"begin":1460,"end":1462},"obj":"21309623"},{"id":"28249032-21195251-91797318","span":{"begin":3346,"end":3347},"obj":"21195251"},{"id":"28249032-26190067-91797319","span":{"begin":3348,"end":3350},"obj":"26190067"},{"id":"28249032-25265185-91797320","span":{"begin":3633,"end":3635},"obj":"25265185"},{"id":"28249032-25014129-91797321","span":{"begin":3636,"end":3638},"obj":"25014129"},{"id":"28249032-25265185-91797322","span":{"begin":3934,"end":3936},"obj":"25265185"},{"id":"28249032-25265185-91797323","span":{"begin":5473,"end":5475},"obj":"25265185"},{"id":"28249032-17032159-91797324","span":{"begin":6803,"end":6805},"obj":"17032159"},{"id":"28249032-12369475-91797325","span":{"begin":6806,"end":6808},"obj":"12369475"},{"id":"28249032-22964561-91797326","span":{"begin":6812,"end":6814},"obj":"22964561"},{"id":"28249032-10518167-91797327","span":{"begin":6815,"end":6817},"obj":"10518167"},{"id":"28249032-12946081-91797328","span":{"begin":6818,"end":6820},"obj":"12946081"},{"id":"28249032-12369475-91797329","span":{"begin":6841,"end":6843},"obj":"12369475"},{"id":"28249032-10518167-91797330","span":{"begin":6847,"end":6849},"obj":"10518167"},{"id":"28249032-12946081-91797331","span":{"begin":6850,"end":6852},"obj":"12946081"},{"id":"28249032-25265185-91797332","span":{"begin":7033,"end":7035},"obj":"25265185"},{"id":"28249032-17032159-91797333","span":{"begin":7270,"end":7272},"obj":"17032159"},{"id":"28249032-22964561-91797334","span":{"begin":7306,"end":7308},"obj":"22964561"},{"id":"28249032-17032159-91797335","span":{"begin":7586,"end":7588},"obj":"17032159"},{"id":"28249032-25403144-91797336","span":{"begin":8795,"end":8797},"obj":"25403144"},{"id":"28249032-24885551-91797336","span":{"begin":8795,"end":8797},"obj":"24885551"},{"id":"28249032-25407009-91797336","span":{"begin":8795,"end":8797},"obj":"25407009"}],"text":"Discussion\n\nSummary of main findings\nThis paper reviews data published in peer review journals on the economic evaluations of evidence-based treatments for BPD, to inform recommendations for current mental health care funding policy. The results indicate that providing evidence-based treatments for BPD is cost-effective and results in cost savings. Our 2015 US dollar cost-offset calculations indicated that each individual in BPD treatment showed a reduction of USD $2,988 per patient per year in total healthcare costs in the year following BPD treatment as compared to the year prior to BPD. Perhaps more importantly, this review demonstrated that compared to treatment as usual, that the provision of psychotherapy resulted in an additional cost-saving of USD $1,551 per patient per year.\nUp to December 2015, thirty economic evaluations across 29 studies met the inclusion criteria of this review and provided valuable cost-data for calculating a cost-savings for the psychotherapies evaluated. Of the studies included in this review, fifteen evaluations examined the economic benefits of a psychotherapeutic intervention using pre- and/or post-measures, but without a control group. Another fifteen evaluations provided data on the use of mental health services and related costs of psychotherapeutic intervention compared to treatment as usual (TAU) or client centred therapy (CCT) as a control group. The costs data presented in three evaluations [3,27,52] could not be used to calculate cost-savings. However, because our aim was to include all original studies reporting cost or cost-effectiveness data of BPD and to reflect the financial burden associated with BPD, these studies were included in the review and used to maximise the available information about the economic value of the provision of psychological treatment of BPD. Examining the studies included, DBT was the most evaluated treatment for BPD (15 evaluations). Other psychotherapeutic interventions examined by the studies included in this review were CM (2 evaluations), MBT (2 evaluations), SFT (2 evaluations) and one each for CBT, CBT-PD CI, CP, LT-P, MACT, OPC, SCP, SDC and TFP, representing a variety of intervention approaches (see Table 2 for description of treatments). The mean cost-savings derived from the provision DBT compared to TAU, did differ significantly from the additional cost-savings as a result from other forms of psychotherapy (6 DBT vs. 7 non-DBT comparisons). These findings could suggest that there is a greater cost-benefit of non-DBT vs DBT approaches compared to TAU. However, this finding is exploratory in nature and should not be used to draw firm conclusion about the cost savings of DBT or other forms of psychotherapy as there are variations across studies in approach, setting, and context. Future studies should compare costs of alternative treatments within the same project under similar conditions.\nOur results suggest that psychotherapy for borderline personality disorders, independent of the type of treatment, can lead to cost-savings. Comparison of the cost savings of DBT versus other forms of psychotherapies did not lead to a significant difference in cost reduction; strengthening the status of the use of any form of well evaluated psychological therapy as the main treatment of borderline personality disorders [9,55]. Our findings furthermore provide evidence to support the assertion that offering effective therapy in BPD generates cost-saving advantages in terms of both direct and indirect healthcare costs.\n\nStrengths and limitations\nOther reviews that have looked at economic evaluations [17,18,56], similarly found evidence for cost-effective treatments for patients with BPD. To the best of our knowledge, there is no recent study that estimated annual net cost-savings of providing treatment in patients with BPD in a systematic way as conducted here. Brettschneider and colleagues (2014) [18] older study reviewed 15 economic evaluations of psychological therapies for BPD, concluding that the economic evidence is not sufficient to draw conclusions and current evidence should be interpreted with caution due to methodological shortcomings. Our review updated this previous work and now includes 30 evaluations, providing firmer evidence for cost benefit.\nOur estimates for cost benefit should be interpreted with caution as there was significant variation between studies. However, as most studies included a control or active treatment comparison, our estimates do reflect the entire evidence we were able to systematically review.\nThe key strength of our review is that it has used full resource-use data that have been reported by researchers who have either conducted an economic evaluation of clinical trials or reported healthcare costs associated with the provision of treatment for BPD. Moreover, the focus of our review was not limited to specific psychological therapies and/or economic evaluations performed alongside clinical effectiveness randomized controlled trials. Hence, in this review, adjustment of the cost-data to account for variation in the cost-methods used in the different economic evaluations allowed comparison between treatments and enhanced generalizability of the study results.\nHowever, this review was restricted to a certain extent by some limitations. We found that among the economic evaluation studies there was a great heterogeneity in the definition of costs, as have previous reviews [18]. Although we made a concerted effort to identify cost-categories, in some cases classifying the reported healthcare costs as either direct or indirect costs was not clearly and based upon common-sense reasoning. Furthermore, the studies in this review reported data from different countries, which could possible affect the generalisability of study findings. There are differences in economic circumstances and in health systems across various countries resulting in corresponding differences in health outcomes and their costs. For example, the health service and societal perspective in the Netherlands is different compared to the UK and Australian system. In the Australian, there is universal coverage for health care services; with the federal government paying a large part of the cost of health services, whereas Health insurance in the Netherlands is mandatory and everyone has to take out their own basic healthcare insurance [57]. Although we have made a considerable effort by calculating costs using purchasing power parity PPP, this should be taken into consideration when interpreting the results.\nDespite the demonstrated overall cost savings across the majority of the 30 evaluations included, the cost-offset calculations for six economic evaluations included in this review did not result in cost-savings [26,41,42,45,47,50]. In four of these [41,42,47,50] it may be that the extra costs associated with the alternative therapy compared to the costs of the provision of TAU may be due to the method of cost modelling in the studies [17,18]. In some cases, resource use was estimated by authors by regression models [17], and for these economic evaluations costs may have been overestimated. Furthermore, the healthcare costs incurred before and after the provision of CBT [26] and after the provision of DBT [45] compared to TAU, did not result in cost-savings. However, the cost differences in both studies were small and did not approach conventional levels of statistical significance. In addition, it must be noted that the intervention (CBT) examined by Palmer and colleagues (2006) [26] did result in an overall saving of USD $131 (per patient per year) in healthcare costs when compared with the provision of TAU.\nThis systematic review aimed to provide an overview of the cost savings associated with the provision of psychotherapeutic interventions for the treatment of BPD and was not intended as a statement of the clinical effectiveness of these treatments. Data was extracted based on cost alone, without further consideration of clinical effectiveness of these treatments and is outside the scope of this review. However, the evidence on economic outcomesalone is one factor informing clinical decision making in health care. Future studies may investigate the interaction between cost and clinical improvement, although this will rely upon an even larger pool of studies of sufficient methodological rigour to allow such an evaluation.\nAlthough we were able to identify thirty economic evaluations in total, a paucity of material is apparent in this field, especially if we compare the modest number of economic findings with the larger number of clinical evaluations. We have found some papers aiming to evaluate the clinical and cost-effectiveness of evidence-based BPD treatment [58–60]. However, since these papers only outline the background and methods of randomised controlled trials and are still ongoing, these studies may inform future reviews."}