title: Health service costs and clinical gains of psychotherapy for personality disorders: a randomized controlled trial of day-hospital-based step-down treatment versus outpatient treatment at a specialist practice.
abstract: BACKGROUND
  Day-hospital-based treatment programmes have been recommended for poorly functioning patients with personality disorders (PD). However, more research is needed to confirm the cost-effectiveness of such extensive programmes over other, presumably simpler, treatment formats.
  
  
  METHODS
  This study compared health service costs and psychosocial functioning for PD patients randomly allocated to either a day-hospital-based treatment programme combining individual and group psychotherapy in a step-down format, or outpatient individual psychotherapy at a specialist practice. It included 107 PD patients, 46% of whom had borderline PD, and 40% of whom had avoidant PD. Costs included the two treatment conditions and additional primary and secondary in- and outpatient services. Psychosocial functioning was assessed using measures of global (observer-rated GAF) and occupational (self-report) functioning. Repeated assessments over three years were analysed using mixed models.
  
  
  RESULTS
  The costs of step-down treatment were higher than those of outpatient treatment, but these high costs were compensated by considerably lower costs of other health services. However, costs and clinical gains depended on the type of PD. For borderline PD patients, cost-effectiveness did not differ by treatment condition. Health service costs declined during the trial, and functioning improved to mild impairment levels (GAF > 60). For avoidant PD patients, considerable adjuvant health services expanded the outpatient format. Clinical improvements were nevertheless superior to the step-down condition.
  
  
  CONCLUSIONS
  Our results indicate that decisions on treatment format should differentiate between PD types. For borderline PD patients, the costs and gains of step-down and outpatient treatment conditions did not differ. For avoidant PD patients, the outpatient format was a better alternative, leaning, however, on costly additional health services in the early phase of treatment.
  
  
  BACKGROUND
  Clinical Trials NCT00378248.
authors.affiliation: Department of Personality Psychiatry, Oslo University Hospital, Kirkeveien 166, 0407 Oslo, Norway. elfridak@online.no.
authors.forename: Elfrida Hartveit
authors.initials: EH
authors.lastname: Kvarstein
authors.forename: Espen
authors.initials: E
authors.lastname: Arnevik
authors.forename: Vidar
authors.initials: V
authors.lastname: Halsteinli
authors.forename: Frida Gullestad
authors.initials: FG
authors.lastname: Rø
authors.forename: Sigmund
authors.initials: S
authors.lastname: Karterud
authors.forename: Theresa
authors.initials: T
authors.lastname: Wilberg
mesh_terms: D000328:Adult; D000553:Ambulatory Care / Q000191:economics*; D003362:Cost-Benefit Analysis; D003631:Day Care, Medical / Q000191:economics* / Q000379:methods; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D010045:Outpatients; D010554:Personality Disorders / Q000191:economics / Q000523:psychology / Q000628:therapy*; D011613:Psychotherapy / Q000191:economics* / Q000379:methods; D016896:Treatment Outcome