Is psychotherapy for personality disorders worth it?

P sychiatrists' eyes may glaze upon encountering an article with " economic " in the title and containing jargon like " QALY " (quality-adjusted life-years) and " nonparametric bootstrap replication. " As a profession, psychiatrists are not terribly good with numbers and money (or we' d be in better economic shape). Yet the study by Bamelis and colleagues in this issue 1 deserves your rapt attention. As a non-economically focused psychiatrist, I recommend it to you. There is a dearth of good studies of the cost-effectiveness, cost-utility, and cost-offset of psychiatric treatments, particularly psychotherapies. The authors of this sophisticated Dutch multisite trial compared the costs of schema therapy, clarification-oriented therapy, and treatment as usual (which in the Netherlands tends to mean adequate treatment) in a large randomized trial of 320 patients meeting DSM-IV criteria for avoidant, dependent, obsessive-compulsive, paranoid, histrionic, or narcissistic personality disorders. Schema therapy, the most clinically effective treatment, also had the best economic outcomes across a broad range of health-related and other societal variables. It is interesting to study the costs of treating personality disorders, which by definition are chronically debilitating and for which psychotherapy is the keystone of treatment. Moreover, the 6 personality disorders studied have received relatively little treatment attention relative to borderline personality disorder. Historically, the first hurdle psychotherapy research had to leap was whether psychotherapy worked. 2 With several psychotherapies having now amply demonstrated efficacy and effectiveness for multiple diagnoses, including some personality disorders, the next hurdle for psychotherapy may be cost. In the United States, insurance companies have continued to reward psychiatrists for prescribing medications rather than sitting, listening, and talking with patients, which the insurers still seem to consider an endless process and a black hole for costs. Even though most patients with mood and anxiety disorders prefer psychotherapy to pharmacotherapy, 3 the ratio of treatments they are receiving has increasingly tilted toward pharmacotherapy, 4 no doubt in part because of wrong-headed insurance-related economic incentives. 5 Personality disorders are precisely the sort of diagnoses insurance companies have most feared: chronic conditions requiring potentially endless, costly psychotherapy. This study shows not only that patients with personality disorders improved but also that delivering effective treatment saved money. American psychiatrists and other mental health professionals interested in preserving (and prescribing) psychotherapies should thank our Dutch colleagues for this economic research supporting the use of talking therapy for personality disorders. This is a study to …