Strengthening the Status of Psychotherapy for Personality Disorders: An Integrated Perspective on Effects and Costs

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 disorders. Data on cost-effectiveness suggest 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-makers can 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. Clinical Implications · From an effectiveness point of view, psychotherapy is the treatment of choice for personality disorders. · The limited evidence about cost-effectiveness and necessity suggests that psychotherapy for personality disorders is a cost-effective treatment for patients with a high burden of disease. · To understand and influence health policy-making in mental health care successfully, clinicians need to adopt an integrated perspective on effectiveness, cost-effectiveness, and necessity. Limitations · Some so-called effectiveness studies are in fact efficacy trials and most effectiveness research is limited to borderline and avoidant personality disorders. · The evidence on cost-effectiveness is limited to borderline personality disorder and involves cost-minimization studies rather than state-of-the-art economic evaluations. · The evidence on burden of disease is still scarce