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Antoinette D. I. van Asselt, Carmen D. Dirksen, Arnoud Arntz, Josephine H. Giesen-Bloo, Richard van Dyck, Philip Spinhoven, Willem van Tilburg, Ismay P. Kremers, Marjon Nadort, and Johan L. Severens
Out-patient psychotherapy for borderline personality disorder: cost-effectiveness of schema-focused therapy v. transference-focused psychotherapy
The British Journal of Psychiatry 2008; 192: 450-457 [Abstract] [Full text] [PDF]
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[Read eLetter] The cost of effective therapy
T Everett Julyan   (18 June 2008)

The cost of effective therapy 18 June 2008
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T Everett Julyan,
SpR in Liaison Psychiatry
Stirling Royal Infirmary

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Re: The cost of effective therapy

everett.julyan{at}nhs.net T Everett Julyan

Editor

As the last frontier of psychopathology, effective interventions for personality disorders are in high demand but short supply. Their cost- effectiveness analysis lead van Asselt et al to conclude that schema- focused therapy (SFT) is likely to be a cost-effective treatment for borderline personality disorder (BPD) [1]. However, several significant methodological issues cast doubt on the accuracy and "real world" relevance of this conclusion.

51% in the transference-focused psychotherapy (TFP) group did not complete treatment, compared with 27% of patients in the SFT group [2]. As van Asselt et al used the "last observation carried forward", this is a potentially serious source of bias in interpreting the results.

Moreover, Yeomans [3] raised his concerns about the quality of the TFP itself, a modified form of psychodynamic psychotherapy that was only being developed at the time the original study was done. This is particularly noteworthy as he acted as a consultant to the TFP therapists in the study and was of the opinion that approximately half of the therapists did not adhere to the TFP model. This suggests that any conclusions based on a comparison of TFP with SFT (where the therapists were generally more experienced in that model) is on rather shaky ground.

Perhaps even more importantly, there was no control group in the study. It was reported that 52% of patients in the SFT group recovered after 4 years, compared to 29% in the TFP. But this is meaningless without a control group for comparison. It has been reported that one would expect around 50% of patients with BPD severe enough to require hospitalisation to be in remission after 4 years - without SFT or TFP [4]. Therefore, SFT may in fact be no better than placebo or treatment as usual - hardly cost- effective.

In light of these methodological considerations, and in a climate where patients have difficulty in accessing psychotherapy even for conditions with a more robust evidence base [5], to conclude that twice weekly psychotherapy delivered by highly trained therapists for 3 years for BPD is cost-effective appears to go somewhat beyond the evidence.

As always, and as the authors rightly acknowledge, further research is required to address these issues.

1 van Asselt ADI, Dirksen CD, Arntz A, Giesen-Bloo JH, van Dyck R, Spinhoven P, van Tilburg W, Kremers IP, Nadort M, Severens JL. Outpatient Psychotherapy for Borderline Personality Disorder. Arch Gen Psych 2006; 63: 649-658.

2 Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, Kremers I, Nadort M, Arntz A. Outpatient Psychotherapy for Borderline Personality Disorder. Arch Gen Psych 2006; 63: 649-658.

3 Yeomans, F. Questions Concerning the Randomized Trial of Schema- Focused Therapy vs Transference-Focused Psychotherapy. Arch Gen Psych 2007; 64: 609-610.

4 Fonagy P, Bateman A. Progress in the treatment of borderline personality disorder. Br J Psych 2006; 188: 1-3.

5 Revill J. Therapy on NHS “must be increased”. The Observer 2006; Sunday, June 18.