http://repub.eur.nl/res/aut/10536/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/34236/ 2011-03-01T00:00:00Z Objective: In a budget-constrained health care system, decisions regarding resource allocation towards research and implementation are critical and can be informed by cost-effectiveness analysis. The objective of this study was to assess the societal value of conducting further research to inform reimbursement decisions and implementation of cost-effective psychotherapy for clusters B and C personality disorders (PDs). Methods: Value of information and value of implementation analyses were conducted using previously developed cost-effectiveness models for clusters B and C PDs to evaluate the parameters that contribute to most of the decision uncertainty, and to calculate the population expected values of perfect information (pEVPI) and perfect implementation (pEVPIM). Results: The pEVPI was estimated to be €425 million for cluster B PDs and €315 million for cluster C PDs, indicating that gathering additional evidence is expected to be cost-effective. The categories of parameters for which reduction of uncertainty would be most valuable were transition probabilities and health state costs. The pEVPIM was estimated to be €595 million for cluster B PDs and €1,372 million for cluster C PDs, suggesting that investing in implementation of cost-effective psychotherapy is likely to be worthwhile. Conclusions: The societal value of additional research on psychotherapy for clusters B and C PDs is substantial, especially when prioritizing information on transition probabilities and health state costs. Active implementation of cost-effective treatment strategies into clinical practice is likely to improve the efficiency of health care provision in The Netherlands. Copyright http://repub.eur.nl/res/pub/23040/ 2011-01-01T00:00:00Z Abstract BACKGROUND: No previous studies have compared the effectiveness of different modalities of psychotherapeutic treatment, as defined by different settings and durations, for patients with cluster C personality disorders. The aim of this multicentre study was to compare the effectiveness of 5 treatment modalities for patients with cluster C personality disorders in terms of psychiatric symptoms, psychosocial functioning, and quality of life. The following treatment modalities were compared: long-term outpatient (more than 6 months), short-term day hospital (up to 6 months), long-term day hospital, short-term inpatient, and long-term inpatient psychotherapy. METHODS: The study was conducted between March 2003 and June 2008 in 6 mental health care centres in the Netherlands, with a sample of 371 patients with a DSM-IV-TR axis-II cluster C diagnosis. Patients were assigned to 5 different modalities of psychotherapeutic treatment, and effectiveness was assessed at 12 months after baseline. An intention-to-treat analysis was conducted for psychiatric symptoms (Brief Symptom Inventory), psychosocial functioning (Outcome Questionnaire-45), and quality of life (EQ-5D), using multilevel statistical modelling. As the study was non-randomised, the propensity score method was used to control for initial differences. RESULTS: Patients in all treatment groups had improved on all outcomes 12 months after baseline. Patients receiving short-term inpatient treatment showed more improvement than patients receiving other treatment modalities. CONCLUSIONS: Psychotherapeutic treatment, especially in the short-term inpatient modality, is an effective treatment for patients with cluster C personality disorders. http://repub.eur.nl/res/pub/21994/ 2010-11-01T00:00:00Z There is a need in clinical practice for a concise measure to screen for personality pathology in patients seeking treatment for common mental disorders, such as mood or anxiety disorders. A shortened version of the Dimensional Assessment of Personality Pathology Basic Questionnaire (DAPP-BQ)-the DAPP-Short Form (DAPP-SF), comprising 136 items (6-10 items for each dimension), was tested on its criterion-related validity and ability to screen for personality disorders. Scores on the dimensions and the second-order factors of the instrument were compared for two samples: patients with personality disorders (N = 1 091) and a community-based sample (N = 478). The mean score of the two groups differed significantly on most of the scales of the DAPP-SF, a finding in support of the criterion-related validity of the instrument. Identity problems and the second-order factor emotional dysregulation were best suited to discriminate patients with personality disorders from the control group. Cut-off values with optimum sensitivity or optimum specificity for screening of personality disorders are presented for men and women separately. In the community sample, the proposed cut-off value suggests a prevalence of 13.8% for personality disorders. Applied to a sample of patients with mood, anxiety and somatoform disorders (N = 1 329), the proposed cut-off with optimum specificity suggests a prevalence of 45.6% of personality psychopathology in this sample. http://repub.eur.nl/res/pub/22245/ 2010-10-23T00:00:00Z Abstract Background: For patients with cluster B personality disor- ders there is no consensus regarding the optimal treatment setting. The aim of this study was to compare the effective- ness of different psychotherapeutic settings for patients with cluster B personality disorders, i.e. outpatient, day hos- pital, and inpatient treatment. Methods: The study was con- ducted between March 2003 and June 2008 in 6 mental health care centres in the Netherlands, with a sample of 207 patients with a DSM-IV-TR axis II cluster B diagnosis. Patients were assigned to 3 different settings of psychotherapeutic treatment and effectiveness was assessed at 18 months after baseline. An intention-to-treat analysis was conducted for psychiatric symptoms (Brief Symptom Inventory), psychoso- cial functioning (Outcome Questionnaire-45), and quality of life (EQ-5D), using multilevel statistical modelling. As the study was non-randomised, the propensity score method was used to control for initial differences. Results: Patients in all 3 settings improved significantly in terms of psychiatric symptoms, social and interpersonal functioning, and quality of life 18 months after baseline. The inpatient group showed the largest improvements. The comparison of outpatient and inpatient treatment regarding psychiatric symptoms showed a marginally significant result (p = 0.057) in favour of inpatient treatment. Conclusions: Patients with cluster B personality disorders improved in all investigated treatment settings, with a trend towards larger improvements of psy- chiatric symptoms in the inpatient setting compared to the outpatient setting. Specialised inpatient treatment should be considered as a valuable treatment option for cluster B personality disorders, both in research and in clinical prac- tice. http://repub.eur.nl/res/pub/20870/ 2010-08-01T00:00:00Z Using the concept map method, this study revealed patient characteristics that are important for treatment selection decisions in patients with personality disorders. Concept mapping is a specific type of structured conceptualization process and describes the underlying structure of specific phenomena. The method uses qualitative and quantitative methods. In this study, we integrated a literature investigation with the opinions of 29 experts in the field of treatment allocation and/or personality disorders. Our goal was to reduce and describe the number of patient characteristics that are important for treatment allocation in personality disorders. The concept map procedure resulted in eight patient characteristics: (1) severity of symptoms, (2) severity of personality pathology, (3) ego-adaptive capacity, (4) motivation and capacity for a therapeutic alliance, (5) patient’s social system, (6) social demographic variables, (7) traumata, (8) treatment history and physical examination. This report describes in detail the concept mapping procedure and the outcomes are discussed. http://repub.eur.nl/res/pub/22153/ 2010-05-01T00:00:00Z Background Recommendations on current clinical guidelines are informed by limited economic evidence. Aims A formal economic evaluation of three modalities of psychotherapy for patients with cluster B personality disorders. Method A probabilistic decision-analytic model to assess the cost- effectiveness of out-patient, day hospital and in-patient psychotherapy over 5 years in terms of cost per recovered patient-year and cost per quality-adjusted life-year (QALY). Analyses were conducted from both societal and payer perspectives. Results From the societal perspective, the most cost-effective choice switched from out-patient to day hospital psychotherapy at a threshold of e12 274 per recovered patient-year; and from day hospital to in-patient psychotherapy at e113 298. In terms of cost per QALY, the optimal strategy changed at e56 325 and e286 493 per QALY respectively. From the payer perspective, the switch points were at e9895 and e155 797 per recovered patient-year, and e43 427 and e561 188 per QALY. Conclusions Out-patient psychotherapy and day hospital psychotherapy are the optimal treatments for patients with cluster B personality disorders in terms of cost per recovered patient- year and cost per QALY. Declaration of interest None. http://repub.eur.nl/res/pub/22154/ 2010-05-01T00:00:00Z http://repub.eur.nl/res/pub/20861/ 2009-01-01T00:00:00Z Abstract BACKGROUND: Standardised evaluation studies performed in the Netherlands in a large number of inpatient and day-treatment hospitals providing psychotherapy have shown significant symptomatic improvements in patients between the date of entry to the studies and follow-up after one year. However, the work situation of ex-patients hardly changed and a large number of patients were still receiving psychotherapy. AIM: To examine the effectiveness of a specifically designed course of re-integration training. METHOD: A group of 128 patients were assigned randomly either to a re-integration training course aimed at improved functioning at work and improved relationships, or to booster sessions. Outcome measures were symptom level, work status, absence from work, and further psychotherapy. results After two years the number of patients in paid employment remained the same (76%) in the re-integration training course and increased from 67 to 87% in the booster sessions. Attendance was significantly higher in the booster sessions than in the re-integration training. There were no differences in the other outcome measures. CONCLUSION: We conclude that re-integration training was no more effective than the booster sessions. Our hypothesis is that continuity of care (therapists plus programme) explains the favourable result of the booster sessions. http://repub.eur.nl/res/pub/23041/ 2009-01-01T00:00:00Z Abstract BACKGROUND: Randomized controlled trials are considered the best scientific proof of effectiveness. There is increasing concern, though, about their feasibility in psychotherapy research. We discuss a quasi-experimental study design for situations in which a randomized controlled trial is not feasible. Here, as an alternative strategy, the propensity score (PS) method is used to correct for selection bias. METHODS: We used data from a Dutch research project, SCEPTRE (Study on Cost-Effectiveness of Personality Disorder Treatment). The sample consisted of 749 psychotherapy patients with personality pathology. We tested whether the PS method was useful and applicable. We examined differences between 2 treatment groups (short vs. long treatment duration) in pretreatment characteristics before and after PS correction. This revealed the impact of the PS on outcome differences. RESULTS: The PS offered statistical control over observed pretreatment differences between patients in a non-randomized study. CONCLUSIONS: When a randomized controlled trial is not possible, this quasi-experimental design using the PS could be a feasible alternative. Its advantages and limitations are discussed. Implemented carefully, this method is promising for future effectiveness research. http://repub.eur.nl/res/pub/14198/ 2008-11-25T00:00:00Z Treatment selection in clinical practice is a poorly understood, often largely implicit decision process, perhaps especially for patients with personality disorders. This study, therefore, investigated how intake clinicians use information about patient characteristics to select psychotherapeutic treatment for patients with personality disorder. A structured interview with a forced-choice format was administered to 27 experienced intake clinicians working in five specialist mental health care institutes in the Netherlands. Substantial consensus was evident among intake clinicians. The results revealed that none of the presented patient characteristics were deemed relevant for the selection of the suitable treatment setting. The appropriate duration and intensity are selected using severity or personal strength variables. The theoretical orientation is selected using personal strength variables. http://repub.eur.nl/res/pub/22859/ 2007-12-01T00:00:00Z Objective: Despite scientific evidence of effectiveness, psychotherapy for personality disorders is not yet fully deployed, nor is its reimbursement self-evident. Both clinicians and health care policy-makers increasingly rely on evidence-based medicine and health economics when determining a treatment of choice and reimbursement. This article aims to contribute to that understanding by applying these criteria on psychotherapy as a treatment for patients with personality disorder. Method: We have evaluated the available empirical evidence on effectiveness and cost-effectiveness, and integrated this with “necessity of treatment” as a moderating factor. Results: The effectiveness of psychotherapy for personality disorders is well documented with favourable randomized trial results, 2 metaanalyses, and a Cochrane review. However, the evidence does not yet fully live up to modern standards of evidence-based medicine and is mostly limited to borderline and avoidant personality disorder. Data on cost-effectiveness suggests that psychotherapy for personality disorders may lead to cost-savings. However, state-of-the-art cost-effectiveness data are still scarce. An encouraging factor is that the available studies indicate that patients with personality disorder experience a high burden of disease, stressing the necessity of treatment. Conclusions: When applying an integrated vision on outcome, psychotherapy can be considered not only an effective treatment for patients with personality disorder but also most likely a cost-effective and necessary intervention. However, more state-of-the-art research is required before clinicians and health care policy decision makers will fully appreciate the benefits of psychotherapy for personality disorders. Considerable progress is possible if researchers focus their efforts on evidence-based medicine and cost-effectiveness research. http://repub.eur.nl/res/pub/10066/ 2007-01-01T00:00:00Z This report describes a series of studies among 2231 subjects on the development of the Severity Indices for Personality Problems (SIPP), a self-report questionnaire measuring the core components of (mal)adaptive personality functioning. Results show that the 16 facets have good psychometric properties and test-retest reliability, are generic across various types of personality disorders, and have good discriminative validity between various populations. The facets fit well into a common factor model with five higher-order domains (i.e., self-control, identity integration, responsibility, relational capacities, and social concordance) that are eminently interpretable, and replicable across various populations. Domain scores are strongly associated with interview ratings of the severity of personality pathology. Taken together, the SIPP-118 provides a set of five reliable, robust and valid indices of personality problems.