The need for implementation of effective treatments for individuals at high-risk for suicide — and those diagnosed with borderline personality disorder (BPD) — is greater than ever. The most recent and highest quality epidemiological evidence indicates that the lifetime prevalence of BPD is between three and six percent in the U.S. population (Grant et al., 2008; Trull et al., 2010). Worldwide, nearly 1 million people die annually as a result of suicide (World Health Organization, 2016). Recently released data from the Centers for Disease Control and Prevention (CDC) indicates that rate of death by suicide has reached its highest level since 1991 (13.0 deaths per 100,000), making it the 10th leading cause of death for all ages (CDC, 2016). The rate of death by suicide has increased nearly uninterrupted since 1999, a 24 percent increase. And of great concern, over 40 percent of individuals who attempt suicide do not receive mental health care; half of those who do receive treatment report perceived unmet treatment need (Han, et al 2014). Subsequently, suicide results in an estimated $51 billion in combined medical and work loss costs in the U.S. (CDC, 2013).
Dialectical behavior therapy (DBT) is the gold standard treatment for multidiagnostic and suicidal individuals diagnosed with BPD. DBT is the most intensely studied psychological therapy for treating BPD and is effective in reducing suicide attempts, self-harm, and anger while improving general functioning (Stoffers et al., 2012). The intensity (e.g., time requirements, staffing, space) of providing DBT is greater than traditional standard-of-care within an individual, outpatient treatment setting. This is due to a requirement of four treatment modes in standard, outpatient DBT: (1) DBT individual therapy (1 hour/week), (2) DBT group skills training (2.5 hours/week), (3) therapist consultation team (1-1.5 hours/week), and (4) out-of-session coaching (as needed).
Due to the greater intensity of treatment and perceived increase in the costs of providing treatment, practitioners and organizations are often reluctant to implement DBT.
Is there empirical research on DBT and treatment costs?
While the research literature is not large, numerous studies have examined costs associated with providing DBT. Two published reviews of BPD-specific treatments have examined cost-effectiveness of DBT (Brazier et al., 2006; Brettschneider, Riedel-Heller, & König, 2014). However, these reviews have been inconclusive due to the scarcity of studies providing the necessary cost and clinical efficacy data.
The laboratory at the Behavioral Research and Therapy Clinics at the University of Washington is currently preparing a manuscript that systematically reviews studies on the reduction of mental healthcare costs associated with DBT (Botanov et al., in preparation). We have identified a total of 11 reports that have examined standard outpatient DBT. Five reports were controlled investigations; six studies were prospective cohort trials — it is these 11 reports that inform the following information.
Does DBT reduce the costs of providing mental healthcare treatment?
While reports varied in the healthcare costs calculated, all prospective cohort studies demonstrated a decrease in healthcare costs during treatment with standard outpatient DBT in comparison to prior standard-of-care treatment. Additionally, all but one report demonstrated lower healthcare costs during standard outpatient treatment with DBT in comparison to a control treatment. Standard outpatient DBT led to an average savings — in 2015 U.S. dollars — of nearly $20,000 per person compared to prior treatment and an average of $10,207 in lower costs compared to a control group.
How can DBT reduce costs despite the increase in intensity (i.e., modes of treatment)?
When examining costs related to DBT, it is crucial to calculate not only the costs for outpatient treatment but the associated medical, emergency room, and inpatient treatment costs. The majority of cost savings during DBT, in comparison to treatment before DBT, is accounted for by a decrease in inpatient costs. Emergency room costs, as assessed by six reports, were also lower during treatment with DBT.
What about long-term cost reductions?
Beyond comparison of treatment costs before and during DBT, longitudinal costs of treatment are also important. Three trials (Amner, 2012; Meyers et al., 2014; Wagner et al., 2014) compared mental healthcare costs prior to DBT with a follow-up, post-DBT period. All three demonstrated that treatment costs decreased after DBT in comparison to an equal treatment period before DBT. Therefore, it is reasonable to expect cost savings to increase over the years following treatment and provide additional net savings. The continued cost reductions are attributed to better long-term outcomes for individuals that are treated with DBT.
Is there research on DBT and costs in a residential setting?
DBT adapted to residential settings has also been examined in recent studies. In a randomized controlled trial examining a residential DBT program, Priebe and colleagues (2013) reported inpatient, outpatient, and psychotropic medication costs in the 12 months prior to admission to the program and the 12 months following completion of the program. Results demonstrate an average total cost of €18,100 per participant before the program and an average total cost of €7,233 per participant after the program. Steinbuck (2015) compared a similar residential DBT program to standard outpatient DBT and found that standard outpatient DBT was more cost-effective. These results suggest that while a residential DBT program may reduce overall healthcare costs, standard outpatient DBT may provide greater cost savings without sacrificing clinical efficacy.
Future research on DBT and mental healthcare costs.
It is difficult to synthesize mental healthcare economic data from studies spanning multiple countries with differing healthcare systems and nearly three decades of research. More studies are needed to examine DBT and costs in various treatment settings. Data examining healthcare costs is variable and somewhat limited, yet DBT is an evidence-based treatment that is likely to meet the objectives of funders, economists, accountants, administrators, providers, and consumers.
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Yevgeny Botanov, PhD, is the Postdoctoral Fellow in Dissemination & Implementation (D&I) for Behavioral Tech Institute. Concurrently, Dr. Botanov is a Research Associate at the University of Washington collaborating with Marsha Linehan, PhD at the Behavioral Research and Therapy Clinics. Broadly, his scholarly interests examine the neurological mechanisms underlying emotional regulation in healthy and clinical populations. His research examines the crossroads of clinical and affective neuroscience by elucidating neurobiological and behavioral mechanisms of mental illness and suicide as a consequence of environmental mutations. Dr. Botanov earned his PhD in clinical psychology at the University of Kansas and completed his predoctoral internship at Northwestern University Feinberg School of Medicine. Dr. Botanov will be joining the Department of Psychology at Millersville University in the fall of 2016 as an Assistant Professor.
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