Purpose: To compare from a societal perspective the cost-effectiveness and cost-utility of schema therapy, clarification-oriented
psychotherapy, and treatment as usual for patients with avoidant, dependent, obsessive-compulsive, paranoid, histrionic, and/or
narcissistic personality disorder.
Method: A multicenter, randomized controlled trial, single-blind parallel design,
was conducted between May 2006 and December 2011 in 12 Dutch mental health institutes. Data from 320 patients (diagnosed according
to DSM-IV criteria) randomly assigned to schema therapy (n = 145), treatment as usual (n = 134), or clarification-oriented
psychotherapy (n = 41) were analyzed. Costs were repeatedly measured during 36 months by interview and patient registries.
Primary outcome measures were proportion of recovered patients as measured with the Structured Clinical Interview for DSM-IV
Axis II Personality Disorders for the cost-effectiveness analysis, and quality-adjusted life-years (QALYs) for the cost-utility
analysis. Bootstrap replications in the cost-effectiveness and the cost-utility planes were used to estimate the probability
that one treatment was more cost-effective than the other. Mixed gamma regression on net monetary benefit for different levels
of willingness to pay for extra effects was used as sensitivity analysis. Additional sensitivity analyses were done to assess
robustness of the results.
Results: Due to higher clinical effects and lower costs, schema therapy was dominant over
the other treatments in the cost-effectiveness analyses. Schema therapy has the probability of being the most cost-effective
treatment (78% at €0 to 96% at €37,500 [$27,375] willingness to pay per extra recovery). Treatment as usual was more cost-effective
than clarification-oriented psychotherapy due to lower costs. In the cost-utility analysis, schema therapy had a stable 75%
probability of being cost-effective. Sensitivity analyses confirmed these findings.
Conclusions: The results support
the cost-effectiveness of schema therapy but not of clarification-oriented psychotherapy.