1
|
Ip JWY, McMain SF, Chapman AL, Kuo JR. The role of emotion dysregulation and interpersonal dysfunction in nonsuicidal self-injury during dialectical behavior therapy for borderline personality disorder. Behav Res Ther 2024; 180:104594. [PMID: 38945041 DOI: 10.1016/j.brat.2024.104594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 05/29/2024] [Accepted: 06/11/2024] [Indexed: 07/02/2024]
Abstract
Dialectical Behaviour Therapy (DBT) is an evidence-based treatment for borderline personality disorder (BPD), with findings demonstrating improvements in various BPD features and related behaviours, such as nonsuicidal self-injury (NSSI). Theory and research suggest that reductions in emotion dysregulation and interpersonal dysfunction could account for at least some of the reduction in NSSI observed during the course of DBT. The current research investigated: 1) the trajectory of changes in emotion dysregulation, interpersonal dysfunction, and NSSI over the course of DBT, and 2) whether changes in emotion dysregulation mediate the relationship between changes in interpersonal dysfunction and changes in NSSI over treatment. One hundred and twenty individuals with BPD enrolled in a multi-site randomized-clinical trial were assessed at five timepoints over 12 months of standard DBT. Results indicated that interpersonal dysfunction and NSSI decreased over the course of DBT. Emotion dysregulation decreased in a quadratic manner such that most of the gains in emotion dysregulation occurred in earlier phases of DBT. Although changes in interpersonal dysfunction predicted changes in emotion dysregulation, changes in emotion dysregulation did not mediate the relationship between changes in interpersonal dysfunction and changes in NSSI.
Collapse
Affiliation(s)
- Jennifer W Y Ip
- Department of Psychology, Toronto Metropolitan University, Toronto, Canada.
| | - Shelley F McMain
- Centre for Addiction and Mental Health, Toronto, Canada; Department of Psychiatry, University of Toronto, Canada
| | | | - Janice R Kuo
- Department of Psychology, Palo Alto University, California, USA
| |
Collapse
|
2
|
Tracy M, Sharpe L, Bach B, Tiliopoulos N. Connecting DSM-5 and ICD-11 trait domains with schema therapy and dialectical behavior therapy constructs. Personal Ment Health 2023; 17:208-219. [PMID: 36575608 DOI: 10.1002/pmh.1574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 10/23/2022] [Accepted: 11/30/2022] [Indexed: 12/29/2022]
Abstract
The DSM-5 Section III alternative model of personality disorder (AMPD) and the International Classification of Diseases - 11th Edition's (ICD-11) personality disorder classification allow clinicians to identify individual trait domains in which people score highly. However, how these domains relate to constructs associated with efficacious treatment approaches is unclear. The current study aimed to determine whether constructs from two evidence-based treatments (schema therapy [ST] and dialectical behavior therapy [DBT]) were associated with maladaptive personality traits in a way consistent with underlying theories. We examined associations between ST constructs, DBT skill use and maladaptive coping styles, and personality traits in a sample of 525 adults. Bivariate intercorrelations and a series of multiple regression analyses were conducted to investigate the associations. As hypothesized, maladaptive coping was strongly associated with all trait domains. Surprisingly, poor DBT-skill use was only associated with negative affectivity, detachment, and disinhibition trait domains. Specific schema domains were associated with each personality trait domain, supporting trait domain-schema domain specificity. The current study highlights the potential clinical utility of the AMPD and ICD-11 trait models and ultimately contributes to the dearth of evidence on their likely usefulness for treatment selection, planning, and applications.
Collapse
Affiliation(s)
- Mikaela Tracy
- School of Psychology, Faculty of Science, The University of Sydney, Camperdown, New South Wales, Australia
| | - Louise Sharpe
- School of Psychology, Faculty of Science, The University of Sydney, Camperdown, New South Wales, Australia
| | - Bo Bach
- Center for Personality Disorder Research (CPDR), Psychiatric Research Unit, Mental Health Services, Region Zealand, Denmark
| | - Niko Tiliopoulos
- School of Psychology, Faculty of Science, The University of Sydney, Camperdown, New South Wales, Australia
| |
Collapse
|
3
|
O'Connor EA, Perdue LA, Coppola EL, Henninger ML, Thomas RG, Gaynes BN. Depression and Suicide Risk Screening: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2023; 329:2068-2085. [PMID: 37338873 DOI: 10.1001/jama.2023.7787] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Importance Depression is common and associated with substantial burden. Suicide rates have increased over the past decade, and both suicide attempts and deaths have devastating effects on individuals and families. Objective To review the benefits and harms of screening and treatment for depression and suicide risk and the accuracy of instruments to detect these conditions among primary care patients. Data Sources MEDLINE, PsychINFO, Cochrane library through September 7, 2022; references of existing reviews; ongoing surveillance for relevant literature through November 25, 2022. Study Selection English-language studies of screening or treatment compared with control conditions, or test accuracy of screening instruments (for depression, instruments were selected a priori; for suicide risk, all were included). Existing systematic reviews were used for treatment and test accuracy for depression. Data Extraction and Synthesis One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. Findings were synthesized qualitatively, including reporting of meta-analysis results from existing systematic reviews; meta-analyses were conducted on original research when evidence was sufficient. Main Outcomes and Measures Depression outcomes; suicidal ideation, attempts, and deaths; sensitivity and specificity of screening tools. Results For depression, 105 studies were included: 32 original studies (N=385 607) and 73 systematic reviews (including ≈2138 studies [N ≈ 9.8 million]). Depression screening interventions, many of which included additional components beyond screening, were associated with a lower prevalence of depression or clinically important depressive symptomatology after 6 to 12 months (pooled odds ratio, 0.60 [95% CI, 0.50-0.73]; reported in 8 randomized clinical trials [n=10 244]; I2 = 0%). Several instruments demonstrated adequate test accuracy (eg, for the 9-item Patient Health Questionnaire at a cutoff of 10 or greater, the pooled sensitivity was 0.85 [95% CI, 0.79-0.89] and specificity was 0.85 [95% CI, 0.82-0.88]; reported in 47 studies [n = 11 234]). A large body of evidence supported benefits of psychological and pharmacologic treatment of depression. A pooled estimate from trials used for US Food and Drug Administration approval suggested a very small increase in the absolute risk of a suicide attempt with second-generation antidepressants (odds ratio, 1.53 [95% CI, 1.09-2.15]; n = 40 857; 0.7% of antidepressant users had a suicide attempt vs 0.3% of placebo users; median follow-up, 8 weeks). Twenty-seven studies (n = 24 826) addressed suicide risk. One randomized clinical trial (n=443) of a suicide risk screening intervention found no difference in suicidal ideation after 2 weeks between primary care patients who were and were not screened for suicide risk. Three studies of suicide risk test accuracy were included; none included replication of any instrument. The included suicide prevention studies generally did not demonstrate an improvement over usual care, which typically included specialty mental health treatment. Conclusions and Relevance Evidence supported depression screening in primary care settings, including during pregnancy and postpartum. There are numerous important gaps in the evidence for suicide risk screening in primary care settings.
Collapse
Affiliation(s)
- Elizabeth A O'Connor
- Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Leslie A Perdue
- Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Erin L Coppola
- Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Michelle L Henninger
- Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Rachel G Thomas
- Kaiser Permanente Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Bradley N Gaynes
- Gillings School of Global Public Health, University of North Carolina School of Medicine, Chapel Hill
| |
Collapse
|
4
|
Schreiber AM, Cawood CD. Treatment outcomes of Veteran men in a comprehensive dialectical behavior therapy program: Characterizing sex differences in symptom trajectories. J Psychiatr Res 2023; 164:90-97. [PMID: 37331262 DOI: 10.1016/j.jpsychires.2023.05.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 04/13/2023] [Accepted: 05/18/2023] [Indexed: 06/20/2023]
Abstract
Dialectical Behavior Therapy (DBT) is one of the primary psychosocial treatments for reducing suicidal behaviors and improving psychosocial outcomes among patients with borderline personality disorder (BPD) and has been shown to reduce BPD symptoms when delivered in a Veteran Affairs medical center setting. Despite evidence of similar rates of BPD in both men and women, the vast majority of treatment outcome research in BPD has focused on women. We sought to characterize sex differences in symptom trajectories among Veterans participating in a comprehensive DBT program. We found that Veteran men and women who entered the DBT program were diagnostically and demographically similar. Participants exhibited reductions in BPD symptoms and improvements in emotion regulation over the course of treatment. Moreover, Veteran men reported BPD symptom reductions that were not statistically inferior to those of Veteran women and exhibited a sharper reduction in these symptoms. This research provides support for the use of DBT as a psychosocial treatment for Veteran men with BPD symptoms.
Collapse
Affiliation(s)
- Alison M Schreiber
- Ann Arbor VA Medical Center, Ann Arbor, MI, USA; University of North Carolina, Chapel Hill, NC, USA.
| | - Chelsea D Cawood
- Ann Arbor VA Medical Center, Ann Arbor, MI, USA; University of Michigan Medical School, Ann Arbor, MI, USA.
| |
Collapse
|
5
|
Setkowski K, Palantza C, van Ballegooijen W, Gilissen R, Oud M, Cristea IA, Noma H, Furukawa TA, Arntz A, van Balkom AJLM, Cuijpers P. Which psychotherapy is most effective and acceptable in the treatment of adults with a (sub)clinical borderline personality disorder? A systematic review and network meta-analysis. Psychol Med 2023; 53:3261-3280. [PMID: 37203447 PMCID: PMC10277776 DOI: 10.1017/s0033291723000685] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 02/11/2023] [Accepted: 02/27/2023] [Indexed: 05/20/2023]
Abstract
A broad range of psychotherapies have been proposed and evaluated in the treatment of borderline personality disorder (BPD), but the question which specific type of psychotherapy is most effective remains unanswered. In this study, two network meta-analyses (NMAs) were conducted investigating the comparative effectiveness of psychotherapies on (1) BPD severity and (2) suicidal behaviour (combined rate). Study drop-out was included as a secondary outcome. Six databases were searched until 21 January 2022, including RCTs on the efficacy of any psychotherapy in adults (⩾18 years) with a diagnosis of (sub)clinical BPD. Data were extracted using a predefined table format. PROSPERO ID:CRD42020175411. In our study, a total of 43 studies (N = 3273) were included. We found significant differences between several active comparisons in the treatment of (sub)clinical BPD, however, these findings were based on very few trials and should therefore be interpreted with caution. Some therapies were more efficacious compared to GT or TAU. Furthermore, some treatments more than halved the risk of attempted suicide and committed suicide (combined rate), reporting RRs around 0.5 or lower, however, these RRs were not statistically significantly better compared to other therapies or to TAU. Study drop-out significantly differed between some treatments. In conclusion, no single treatment seems to be the best choice to treat people with BPD compared to other treatments. Nevertheless, psychotherapies for BPD are perceived as first-line treatments, and should therefore be investigated further on their long-term effectiveness, preferably in head-to-head trials. DBT was the best connected treatment, providing solid evidence of its effectiveness.
Collapse
Affiliation(s)
- Kim Setkowski
- Research Department, 113 Suicide Prevention, Amsterdam, the Netherlands
- Department of Psychiatry, Amsterdam UMC, VU University, Amsterdam Public Health research institute, and GGZinGeest Specialized Mental Health Care, Amsterdam, the Netherlands
| | - Christina Palantza
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit, Amsterdam, the Netherlands
| | - Wouter van Ballegooijen
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit, Amsterdam, the Netherlands
- Department of Psychiatry, Amsterdam UMC, VU University, Amsterdam Public Health research institute, and GGZinGeest Specialized Mental Health Care, Amsterdam, the Netherlands
| | - Renske Gilissen
- Research Department, 113 Suicide Prevention, Amsterdam, the Netherlands
| | - Matthijs Oud
- Department of Treatment, Care and Reintegration, Trimbos Institute, Utrecht, the Netherlands
| | - Ioana A. Cristea
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- IRCCS Mondino Foundation, Pavia, Italy
| | - Hisashi Noma
- Department of Data Science, The Institute of Statistical Mathematics, Tokyo, Japan
| | - Toshi A. Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Arnoud Arntz
- Department of Clinical Psychological Science, Maastricht University, Maastricht, the Netherlands
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, the Netherlands
| | - Anton J. L. M. van Balkom
- Department of Psychiatry, Amsterdam UMC, VU University, Amsterdam Public Health research institute, and GGZinGeest Specialized Mental Health Care, Amsterdam, the Netherlands
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit, Amsterdam, the Netherlands
| |
Collapse
|
6
|
A Feasibility Study Investigating Mechanisms of Change in Public Mental Health Dialectical Behaviour Therapy Programmes. BEHAVIOUR CHANGE 2023. [DOI: 10.1017/bec.2023.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Abstract
Few studies have investigated the feasibility of researching brief forms of dialectical behaviour therapy (DBT) for borderline personality disorder (BPD) in public mental health settings. This study aimed to provide preliminary evidence for the feasibility of implementing DBT over a 6-month period for BPD symptoms within Australian public mental health services. Of the 79 participants with BPD recruited, 62 commenced and 24 participants completed the therapy. The participants attended one of three outpatient DBT programmes and completed measures of BPD symptoms, DBT skills-use, and difficulties with emotion regulation at baseline and after 6 months of treatment. A major challenge with feasibility identified was the high attrition rate (61%). However, for completers there were significant improvements in BPD symptoms, DBT skills-use, and difficulties with emotion regulation. These effect sizes were used to estimate the sample sizes needed by future larger trials of brief DBT for BPD in public health settings. The implementation of brief DBT for BPD patients within a public mental health outpatient setting, appears to result in significant reductions in BPD symptoms. However, further exploration of strategies to reduce drop-out rates are required.
Collapse
|
7
|
Danayan K, Chisamore N, Rodrigues NB, Vincenzo JDD, Meshkat S, Doyle Z, Mansur R, Phan L, Fancy F, Chau E, Tabassum A, Kratiuk K, Arekapudi A, Teopiz KM, McIntyre RS, Rosenblat JD. Real world effectiveness of repeated ketamine infusions for treatment-resistant depression with comorbid borderline personality disorder. Psychiatry Res 2023; 323:115133. [PMID: 36889160 DOI: 10.1016/j.psychres.2023.115133] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 03/10/2023]
Abstract
Borderline personality disorder (BPD) has high rates of comorbidity with mood disorders, including treatment-resistant depression (TRD). Comorbidity of BPD with depression is associated with poorer response to antidepressants. Intravenous ketamine is a novel treatment for TRD that has not been specifically evaluated in patients with comorbid BPD. In this retrospective analysis of data collected from participants who received care at the Canadian Rapid Treatment Centre of Excellence (CRTCE; Braxia Health; ClinicalTrials.gov: NCT04209296), we evaluated the effectiveness of intravenous ketamine in a TRD population with comorbid BPD (N=100; n=50 BPD-positive compared with n=50 BPD-negative). Participants were administered four doses of intravenous ketamine (0.5-0.75mg/kg over 40 minutes) over two weeks. The primary outcome measures were changes in depressive symptom severity (as measured by Quick Inventory of Depressive Symptomatology-Self Report 16-item (QIDS-SR16)) and borderline symptom severity (as measured by Borderline Symptom List 23-item (BSL-23)). Both BPD-positive and BPD-negative groups improved significantly on the QIDS-SR16, QIDS-SR16 suicide ideation item, anxiety, and functionality scales with large effect sizes. There was no significant difference between groups. The BPD-positive group exhibited significant reduction of 0.64 on BSL-23 scores and a significant reduction of 5.95 on QIDS-SR16 scores. Patients with TRD and comorbid BPD receiving ketamine exhibited a significant reduction in symptoms of depression, borderline personality, suicidality, and anxiety.
Collapse
Affiliation(s)
- Kevork Danayan
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Noah Chisamore
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Nelson B Rodrigues
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Joshua D Di Vincenzo
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Shakila Meshkat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Zoe Doyle
- Braxia Health, Mississauga, ON, Canada
| | - Rodrigo Mansur
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON
| | - Lee Phan
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Farhan Fancy
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | | | - Aniqa Tabassum
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | | | | | - Kayla M Teopiz
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Braxia Health, Mississauga, ON, Canada
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Braxia Health, Mississauga, ON, Canada.
| |
Collapse
|
8
|
Arntz A, Mensink K, Cox WR, Verhoef REJ, van Emmerik AAP, Rameckers SA, Badenbach T, Grasman RPPP. Dropout from psychological treatment for borderline personality disorder: a multilevel survival meta-analysis. Psychol Med 2023; 53:668-686. [PMID: 36453183 PMCID: PMC9975988 DOI: 10.1017/s0033291722003634] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 10/28/2022] [Accepted: 11/02/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Dropout from psychotherapy for borderline personality disorder (BPD) is a notorious problem. We investigated whether treatment, treatment format, treatment setting, substance use exclusion criteria, proportion males, mean age, country, and other variables influenced dropout. METHODS From Pubmed, Embase, Cochrane, Psycinfo and other sources, 111 studies (159 treatment arms, N = 9100) of psychotherapy for non-forensic adult patients with BPD were included. Dropout per quarter during one year of treatment was analyzed on participant level with multilevel survival analysis, to deal with multiple predictors, nonconstant dropout chance over time, and censored data. Multiple imputation was used to estimate quarter of drop-out if unreported. Sensitivity analyses were done by excluding DBT-arms with deviating push-out rules. RESULTS Dropout was highest in the first quarter of treatment. Schema therapy had the lowest dropout overall, and mentalization-based treatment in the first two quarters. Community treatment by experts had the highest dropout. Moreover, individual therapy had lowest dropout, group therapy highest, with combined formats in-between. Other variables such as age or substance-use exclusion criteria were not associated with dropout. CONCLUSION The findings do not support claims that all treatments are equal, and indicate that efforts to reduce dropout should focus on early stages of treatment and on group treatment.
Collapse
Affiliation(s)
- Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Kyra Mensink
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Wouter R. Cox
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Rogier E. J. Verhoef
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Sophie A. Rameckers
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Theresa Badenbach
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Raoul P. P. P. Grasman
- Department of Psychological Methods, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
9
|
Katakis P, Schlief M, Barnett P, Rains LS, Rowe S, Pilling S, Johnson S. Effectiveness of outpatient and community treatments for people with a diagnosis of 'personality disorder': systematic review and meta-analysis. BMC Psychiatry 2023; 23:57. [PMID: 36681805 PMCID: PMC9862782 DOI: 10.1186/s12888-022-04483-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 12/19/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Quality of care and access to effective interventions have been widely criticised as limited for people diagnosed with 'personality disorder' or who have comparable needs (described in some recent papers as "Complex Emotional Needs" (CEN). It is important to identify effective interventions and the optimal context and mode of delivery for people with CEN. We aimed to investigate the effectiveness of psychosocial interventions delivered in community and outpatient settings in treating symptoms associated with 'personality disorder', and the moderating effects of treatment-related variables. METHODS We systematically searched MEDLINE, EMBASE, PsycINFO, CINAHL, HMIC, ASSIA for articles published in English, from inception to November 23, 2020. We included randomized controlled trials examining interventions provided in community or outpatient settings for CEN. The primary outcome was 'personality disorder' symptoms, while secondary outcomes included anxiety symptoms, depressive symptoms, and global psychiatric symptoms. Random-effects meta-analysis was conducted for each outcome, and meta-regression analysis was performed to assess the moderating effects of treatment characteristics. The quality of the studies and the degree of publication bias was assessed. RESULTS We included 54 trials (n = 3716 participants) in the meta-analysis. We found a large effect size (g = 0.78, 95% CI: 0.56 to 1.01, p < 0.0001) favoring interventions for 'borderline personality disorder' (BPD) symptoms over Treatment as Usual or Waitlist (TAU/WL), and the efficacy was maintained at follow-up (g = 1.01, 95% CI: 0.37 to 1.65, p = 0.002). Interventions effectively reduced anxiety symptoms (g = 0.58, 95% CI: 0.21 to 0.95, p = 0.002), depressive symptoms (g = 0.57, 95% CI: 0.32 to 0.83, p < 0.0001), and global psychiatric symptoms (g = 0.50, 95% CI: 0.35 to 0.66, p < 0.0001) compared to TAU/WL. The intervention types were equally effective in treating all symptom categories assessed. Treatment duration and treatment intensity did not moderate the effectiveness of the interventions for any outcome. CONCLUSIONS People with a 'personality disorder' diagnosis benefited from psychological and psychosocial interventions delivered in community or outpatient settings, with all therapeutic approaches showing similar effectiveness. Mental health services should provide people with CEN with specialised treatments in accordance with the availability and the patients' preferences.
Collapse
Affiliation(s)
- Panos Katakis
- Division of Psychiatry, University College London, London, UK.
| | - Merle Schlief
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Phoebe Barnett
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Luke Sheridan Rains
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Sarah Rowe
- Division of Psychiatry, University College London, London, UK
| | - Steve Pilling
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
- National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK
- Camden and Islington NHS Foundation Trust, London, UK
| | - Sonia Johnson
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
- Camden and Islington NHS Foundation Trust, London, UK
| |
Collapse
|
10
|
Stoffers-Winterling JM, Storebø OJ, Simonsen E, Sedoc Jørgensen M, Pereira Ribeiro J, Kongerslev MT, Lieb K. Perspectives on Dialectical Behavior Therapy and Mentalization-Based Therapy for Borderline Personality Disorder: Same, Different, Complementary? Psychol Res Behav Manag 2022; 15:3179-3189. [PMID: 36329713 PMCID: PMC9624210 DOI: 10.2147/prbm.s342257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/11/2022] [Indexed: 11/16/2022] Open
Abstract
Current evidence suggests that individuals with borderline personality disorder (BPD) are likely to benefit from specialized, or BPD-specific, treatments. Dialectical behavior therapy (DBT) and mentalization-based treatment (MBT) are currently the most intensively researched BPD treatments. Reviewing the current research, this paper highlights similarities and differences between the two treatments, and discusses possible ways they could complement each other. As the effectiveness of specialized treatments for BPD in general has been determined with some certainty, research now tends towards individualized approaches, identifying predictors of optimal treatment response. However, it is still to be settled who might profit from a combination of or sequential treatment with DBT and MBT.
Collapse
Affiliation(s)
- Jutta M Stoffers-Winterling
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ole Jakob Storebø
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark,Department of Psychology, University of Southern Denmark, Odense, Denmark,Correspondence: Ole Jakob Storebø, Psychiatric Research Unit, Psychiatry Region Zealand, Fælledvej 6, Slagelse, 4200, Denmark, Tel +45 24965917, Email
| | - Erik Simonsen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark,Mental Health Services East, Psychiatry Region Zealand, Roskilde, Denmark
| | | | - Johanne Pereira Ribeiro
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark,Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Mickey T Kongerslev
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark,Department of Psychology, University of Southern Denmark, Odense, Denmark,Mental Health Services East, Psychiatry Region Zealand, Roskilde, Denmark
| | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| |
Collapse
|
11
|
Ledden S, Rains LS, Schlief M, Barnett P, Ching BCF, Hallam B, Günak MM, Steare T, Parker J, Labovitch S, Oram S, Pilling S, Johnson S. Current state of the evidence on community treatments for people with complex emotional needs: a scoping review. BMC Psychiatry 2022; 22:589. [PMID: 36064337 PMCID: PMC9442944 DOI: 10.1186/s12888-022-04171-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 07/18/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improving the quality of care in community settings for people with 'Complex Emotional Needs' (CEN-our preferred working term for services for people with a "personality disorder" diagnosis or comparable needs) is recognised internationally as a priority. Plans to improve care should be rooted as far as possible in evidence. We aimed to take stock of the current state of such evidence, and identify significant gaps through a scoping review of published investigations of outcomes of community-based psychosocial interventions designed for CEN. METHODS We conducted a scoping review with systematic searches. We searched six bibliographic databases, including forward and backward citation searching, and reference searching of relevant systematic reviews. We included studies using quantitative methods to test for effects on any clinical, social, and functioning outcomes from community-based interventions for people with CEN. The final search was conducted in November 2020. RESULTS We included 226 papers in all (210 studies). Little relevant literature was published before 2000. Since then, publications per year and sample sizes have gradually increased, but most studies are relatively small, including many pilot or uncontrolled studies. Most studies focus on symptom and self-harm outcomes of various forms of specialist psychotherapy: most result in outcomes better than from inactive controls and similar to other specialist psychotherapies. We found large evidence gaps. Adaptation and testing of therapies for significant groups (e.g. people with comorbid psychosis, bipolar disorder, post-traumatic stress disorder, or substance misuse; older and younger groups; parents) have for the most part only reached a feasibility testing stage. We found little evidence regarding interventions to improve social aspects of people's lives, peer support, or ways of designing effective services. CONCLUSIONS Compared with other longer term mental health problems that significantly impair functioning, the evidence base on how to provide high quality care for people with CEN is very limited. There is good evidence that people with CEN can be helped when specialist therapies are available and when they are able to engage with them. However, a much more methodologically robust and substantial literature addressing a much wider range of research questions is urgently needed to optimise treatment and support across this group.
Collapse
Affiliation(s)
- Sarah Ledden
- Division of Psychiatry, University College London, London, UK
| | - Luke Sheridan Rains
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Merle Schlief
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK.
| | - Phoebe Barnett
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Brian Chi Fung Ching
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Brendan Hallam
- Division of Psychiatry, University College London, London, UK
- Research Department of Primary Care & Population Health, University College London, London, UK
| | - Mia Maria Günak
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
- Department of Psychology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Thomas Steare
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Jennie Parker
- NIHR Mental Health Policy Research Unit Co-Production Group, University College London, London, UK
| | - Sarah Labovitch
- NIHR Mental Health Policy Research Unit Co-Production Group, University College London, London, UK
- West London NHS Trust, London, UK
| | - Sian Oram
- NIHR Mental Health Policy Research Unit, Department of Health Service and Population Research, King's College London, London, UK
| | - Steve Pilling
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
- National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK
- Camden and Islington NHS Foundation Trust, London, UK
| | - Sonia Johnson
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
- Camden and Islington NHS Foundation Trust, London, UK
| |
Collapse
|
12
|
Stoffers-Winterling JM, Storebø OJ, Kongerslev MT, Faltinsen E, Todorovac A, Sedoc Jørgensen M, Sales CP, Edemann Callesen H, Pereira Ribeiro J, Völlm BA, Lieb K, Simonsen E. Psychotherapies for borderline personality disorder: a focused systematic review and meta-analysis. Br J Psychiatry 2022; 221:538-552. [PMID: 35088687 DOI: 10.1192/bjp.2021.204] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND A recently updated Cochrane review supports the efficacy of psychotherapy for borderline personality disorder (BPD). AIMS To evaluate the effects of standalone and add-on psychotherapeutic treatments more concisely. METHOD We applied the same methods as the 2020 Cochrane review, but focused on adult samples and comparisons of active treatments and unspecific control conditions. Standalone treatments (i.e. necessarily including individual psychotherapy as either the sole or one of several treatment components) and add-on interventions (i.e. complementing any ongoing individual BPD treatment) were analysed separately. Primary outcomes were BPD severity, self-harm, suicide-related outcomes and psychosocial functioning. Secondary outcomes were remaining BPD diagnostic criteria, depression and attrition. RESULTS Thirty-one randomised controlled trials totalling 1870 participants were identified. Among standalone treatments, statistically significant effects of low overall certainty were observed for dialectical behaviour therapy (self-harm: standardised mean difference (SMD) -0.54, P = 0.006; psychosocial functioning: SMD -0.51, P = 0.01) and mentalisation-based treatment (self-harm: risk ratio 0.51, P < 0.0007; suicide-related outcomes: risk ratio 0.10, P < 0.0001). For adjunctive interventions, moderate-quality evidence of beneficial effects was observed for DBT skills training (BPD severity: SMD -0.66, P = 0.002; psychosocial functioning: SMD -0.45, P = 0.002), and statistically significant low-certainty evidence was observed for the emotion regulation group (BPD severity: mean difference -8.49, P < 0.00001), manual-assisted cognitive therapy (self-harm: mean difference -3.03, P = 0.03; suicide-related outcomes: SMD -0.96, P = 0.005) and the systems training for emotional predictability and problem-solving (BPD severity: SMD -0.48, P = 0.002). CONCLUSIONS There is reasonable evidence to conclude that psychotherapeutic interventions are helpful for individuals with BPD. Replication studies are needed to enhance the certainty of findings.
Collapse
Affiliation(s)
| | - Ole Jakob Storebø
- Mental Health Services, Region Zealand Psychiatry, Denmark; and Department of Psychology, University of Southern Denmark, Denmark
| | - Mickey T Kongerslev
- Mental Health Services, Region Zealand Psychiatry, Denmark; and Department of Psychology, University of Southern Denmark, Denmark
| | - Erlend Faltinsen
- Mental Health Services, Region Zealand Psychiatry, Denmark; Centre for Evidence-Based Medicine Odense (CEBMO), University of Southern Denmark, Denmark; and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Denmark
| | - Adan Todorovac
- Mental Health Services, Region Zealand Psychiatry, Denmark
| | | | - Christian P Sales
- Research & Innovation Department, Nottinghamshire Healthcare NHS Foundation Trust, UK
| | | | | | - Birgit A Völlm
- Department of Forensic Psychiatry, Rostock University Medical Centre, Germany
| | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Germany
| | - Erik Simonsen
- Mental Health Services, Region Zealand Psychiatry, Denmark; and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| |
Collapse
|
13
|
Dialectical Behavior Therapy and Acceptance and Commitment Therapy: Areas of Overlap and Distinction. JOURNAL OF CONTEMPORARY PSYCHOTHERAPY 2022. [DOI: 10.1007/s10879-022-09550-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
14
|
Phalen P, Grossmann J, Bruder T, Jeong JY, Calmes C, McGrath K, Malouf E, James A, Romero E, Bennett M. Description of a Dialectical Behavior Therapy program in a Veterans Affairs Health Care System. EVALUATION AND PROGRAM PLANNING 2022; 92:102098. [PMID: 35525095 DOI: 10.1016/j.evalprogplan.2022.102098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 09/30/2021] [Accepted: 04/17/2022] [Indexed: 06/14/2023]
Abstract
A comprehensive Dialectical Behavior Therapy (DBT) program was created within a VA Health Care System for patients with recent psychiatric hospitalization, suicidality and/or significant emotion dysregulation. The program was notable for being one of a relatively small number of comprehensive DBT programs in the VA system, and for including patients with psychosis and psychotic disorder, with a majority of patients (58%) having a documented history of psychosis or endorsing psychotic symptoms in assessments. We describe the process of creating this program at a VA medical center and present preliminary program evaluation data. All patients completed assessments of suicidality (C-SSRS), emotion dysregulation (DERS), skills use and dysfunctional coping (DBT-WCCL), borderline symptomatology (BSL-23), and depression (PHQ-9) at program entry and subsequently every 6-8 weeks through program completion. Suicide attempts and hospitalizations were also tracked. Twelve patients completed multiple (up to six) assessment timepoints, allowing for evaluation of change during treatment. Patients demonstrated improvements on most measures and no hospitalizations or suicide attempts during active treatment, and the subsample with psychosis showed average improvements on every outcome measure. Eleven of 12 patients completed a full six-month rotation.
Collapse
Affiliation(s)
- Peter Phalen
- VA Maryland Health Care System, United States; University of Maryland School of Medicine, United States.
| | | | | | - Jae Yeon Jeong
- VA Maryland Health Care System, United States; University of Maryland School of Medicine, United States
| | | | | | | | | | - Erin Romero
- VA Maryland Health Care System, United States; University of Maryland School of Medicine, United States
| | - Melanie Bennett
- VA Maryland Health Care System, United States; University of Maryland School of Medicine, United States
| |
Collapse
|
15
|
Chang TH, Liu SI, Korslund K, Lin CJ, Lin Y, Huang HC, Chen SC, Chang YH, Sun FJ, Wu SI. Adapting dialectical behavior therapy in Mandarin-speaking Chinese patients with borderline personality disorder: An open pilot trial in Taiwan. Asia Pac Psychiatry 2022; 14:e12451. [PMID: 33686804 DOI: 10.1111/appy.12451] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 02/01/2021] [Accepted: 02/13/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Dialectical behavior therapy (DBT) is the most commonly used treatment for patients suffering from borderline personality disorder (BPD). However, data on its applications in Asian countries remain lacking. This pilot study aims to evaluate the feasibility and effectiveness of applying Mandarin-translated DBT among suicidal Chinese patients with BPD in Taiwan. METHODS An open-label trial design was implemented for the 1-year standard DBT model. Patients from a psychiatric outpatient department in a general hospital in Taiwan with a history of ≥2 episodes of suicidal behavior within the previous year and who scored >40 on the Borderline Symptom List were invited to participate in this trial. Outcomes of suicidal behaviors, severity of BPD and depression symptoms, suicidal ideation, hopelessness, and quality of life were assessed at the beginning of the treatment and every 3 months until 12 months. RESULTS Eighteen patients participated, three of whom (16.7%) dropped out. Significant improvements were found in the frequency and severity of suicidal behaviors and ideations, depressive symptoms, and BPD symptoms beginning as early as the third month after initiating DBT. DISCUSSION This pilot study found that DBT may be an effective and feasible intervention for Mandarin-speaking individuals with a recent history of suicidal behaviors with BPD. Future randomized controlled trials with comparison groups are needed to further determine the efficacy of DBT on this population.
Collapse
Affiliation(s)
- Ting-Hsin Chang
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shen-Ing Liu
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | | | - Chen-Ju Lin
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan
| | - Ying Lin
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan
| | - Hui-Chun Huang
- Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shu-Chin Chen
- Suicide Prevention Center, Mackay Memorial Hospital, Taipei, Taiwan
| | - Yi-Hung Chang
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan
| | - Fang-Ju Sun
- Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shu-I Wu
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| |
Collapse
|
16
|
Behavioral inhibition and emotional invalidation in the context of personality impairment. CURRENT PSYCHOLOGY 2022. [DOI: 10.1007/s12144-022-02705-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
17
|
Understanding Perceptions of Nonsuicidal Self-Injury: Descriptive and Injunctive Norms. Psychiatr Q 2021; 92:1657-1671. [PMID: 34169388 DOI: 10.1007/s11126-021-09933-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2021] [Indexed: 10/21/2022]
Abstract
Nonsuicidal self-injury (NSSI) is a major public health concern. Web-based personalized feedback interventions (PFIs) may be a cost-effective and efficient way to treat NSSI. In order to develop a PFI, it is imperative to assess descriptive and injunctive norms. The current study examines descriptive and injunctive norms of NSSI within college students and adults in the community, comparing how perceived norms may differ for those who do or do not engage in NSSI. Study 1 calculated percentages of NSSI behavior within the student sample. Study 2 then examined perceived descriptive and injunctive norms between those with and without history of NSSI in both samples. Study 1 indicated that 19% of undergraduate students had histories of NSSI. Additionally, there was a general tendency to overestimate the percentage of people who engage in NSSI and the number of times a typical person engages in NSSI. Finally, those who engaged in NSSI believed that most people do not understand why individuals engage in NSSI; comparatively, the majority of people without history of NSSI still indicated that they understand why others would engage in NSSI. These research findings may be utilized in a PFI to reduce shame and NSSI behavior.
Collapse
|
18
|
Alvi MH, Shiri T, Iqbal N, Husain MO, Chaudhry I, Shakoor S, Ansari S, Kiran T, Chaudhry N, Husain N. Cost-Effectiveness of a Culturally Adapted Manual-Assisted Brief Psychological Intervention for Self-Harm in Pakistan: A Secondary Analysis of the Culturally Adapted Manual-Assisted Brief Psychological Randomized Controlled Trial. Value Health Reg Issues 2021; 27:65-71. [PMID: 34844061 DOI: 10.1016/j.vhri.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Self-harm is a serious public health problem. A culturally adapted manual-assisted problem-solving training (C-MAP) intervention improved and sustained a reduction in suicidal ideation, hopelessness, and depression compared with treatment as usual (TAU) alone. Here, we evaluate its cost-effectiveness. METHODS Patients admitted after an episode of self-harm were randomized individually to either C-MAP plus TAU or TAU alone in Karachi. Improvement in health-related quality-adjusted life-years (QALYs) was measured using the EQ-5D with 3 levels instrument at baseline, 3 months, and 6 months after randomization. The primary economic outcome was health service cost per QALY gained as the incremental cost-effectiveness ratio, based on 2019 US$ and a 6-month time horizon. Nonparametric bootstrapping was used to assess uncertainties and sensitivity analysis to examine the impact of hospitalization costs. RESULTS A total of 108 and 113 participants were enrolled among the intervention and standard arms, respectively. The intervention resulted in 0.04 (95% confidence interval [CI] 0.00-0.08) more QALYs 6 months after enrolment. The mean cost per participant in the intervention arm was $1001 (95% CI 968-1031), resulting in an incremental cost of the intervention of $640 (95% CI 595-679). The incremental cost-effectiveness ratio for the C-MAP intervention versus TAU was $16 254 (95% CI 7116-99 057) per QALY gained. The probability that C-MAP is cost-effective was between 66% and 83% for cost-effective thresholds between $20 000 and $30 000. Cost-effectiveness results remained robust to sensitivity analyses. CONCLUSIONS C-MAP may be a valuable self-harm intervention. Further studies with longer follow-up and larger sample sizes are needed to draw reliable conclusions.
Collapse
Affiliation(s)
- Mohsin H Alvi
- Pakistan Institute of Learning and Living, Karachi, Pakistan
| | - Tinevimbo Shiri
- Division of Psychology and Mental Health, University of Manchester, Manchester, England, UK; International Public Health, Liverpool School of Tropical Medicine, Liverpool, England, UK.
| | - Nasir Iqbal
- Pakistan Institute of Development Economics, Islamabad, Pakistan
| | - Mohammed Omair Husain
- Pakistan Institute of Learning and Living, Karachi, Pakistan; School of Biological Sciences, University of Manchester, Manchester, England, UK
| | - Imran Chaudhry
- Pakistan Institute of Learning and Living, Karachi, Pakistan; School of Biological Sciences, University of Manchester, Manchester, England, UK; Department of Psychiatry, Ziauddin Hospital, Karachi, Pakistan
| | - Suleman Shakoor
- Pakistan Institute of Learning and Living, Karachi, Pakistan
| | - Sami Ansari
- Pakistan Institute of Learning and Living, Karachi, Pakistan
| | - Tayyeba Kiran
- Pakistan Institute of Learning and Living, Karachi, Pakistan
| | - Nasim Chaudhry
- Pakistan Institute of Learning and Living, Karachi, Pakistan
| | - Nusrat Husain
- Division of Psychology and Mental Health, University of Manchester, Manchester, England, UK
| |
Collapse
|
19
|
Laursen SL, Helweg-Jørgensen S, Langergaard A, Søndergaard J, Sørensen SS, Mathiasen K, Lichtenstein MB, Ehlers LH. Mobile Diary App Versus Paper-Based Diary Cards for Patients With Borderline Personality Disorder: Economic Evaluation. J Med Internet Res 2021; 23:e28874. [PMID: 34762057 PMCID: PMC8663638 DOI: 10.2196/28874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/17/2021] [Accepted: 07/27/2021] [Indexed: 01/27/2023] Open
Abstract
Background The cost-effectiveness of using a mobile diary app as an adjunct in dialectical behavior therapy (DBT) in patients with borderline personality disorder is unknown. Objective This study aims to perform an economic evaluation of a mobile diary app compared with paper-based diary cards in DBT treatment for patients with borderline personality disorder in a psychiatric outpatient facility. Methods This study was conducted alongside a pragmatic, multicenter, randomized controlled trial. The participants were recruited at 5 Danish psychiatric outpatient facilities and were randomized to register the emotions, urges, and skills used in a mobile diary app or on paper-based diary cards. The participants in both groups received DBT delivered by the therapists. A cost-consequence analysis with a time horizon of 12 months was performed. Consequences included quality-adjusted life years (QALYs), depression severity, borderline severity, suicidal behavior, health care use, treatment compliance, and system usability. All relevant costs were included. Focus group interviews were conducted with patients, therapists, researchers, and industry representatives to discuss the potential advantages and disadvantages of using a mobile diary app. Results A total of 78 participants were included in the analysis. An insignificantly higher number of participants in the paper group dropped out before the start of treatment (P=.07). Of those starting treatment, participants in the app group had an average of 37.1 (SE 27.55) more days of treatment and recorded an average of 3.16 (SE 5.10) more skills per week than participants in the paper group. Participants in both groups had a QALY gain and a decrease in depression severity, borderline severity, and suicidal behavior. Significant differences were found in favor of the paper group for both QALY gain (adjusted difference −0.054; SE 0.03) and reduction in depression severity (adjusted difference −1.11; SE 1.57). The between-group difference in total costs ranged from US $107.37 to US $322.10 per participant during the 12 months. The use of services in the health care sector was similar across both time points and groups (difference: psychiatric hospitalization <5 and <5; general practice −1.32; SE 3.68 and 2.02; SE 3.19). Overall, the patients showed high acceptability and considered the app as being easy to use. Therapists worried about potential negative influences on the therapist-patient interaction from new work tasks accompanying the introduction of the new technology but pointed at innovation potential from digital database registrations. Conclusions This study suggests both positive and negative consequences of mobile diary apps as adjuncts to DBT compared with paper diary cards. More research is needed to draw conclusions regarding its cost-effectiveness. Trial Registration ClinicalTrials.gov NCT03191565; http://clinicaltrials.gov/ct2/show/NCT03191565 International Registered Report Identifier (IRRID) RR2-10.2196/17737
Collapse
Affiliation(s)
- Sidsel Lund Laursen
- Department of Clinical Medicine, Danish Center for Healthcare Improvements, Aalborg University, Aalborg Oest, Denmark
| | - Stig Helweg-Jørgensen
- Research Unit for Telepsychiatry and E-mental Health, Mental Health Services in the Region of Southern Denmark, Odense, Denmark
| | - Astrid Langergaard
- Department of Clinical Medicine, Danish Center for Healthcare Improvements, Aalborg University, Aalborg Oest, Denmark
| | - Jesper Søndergaard
- Department of Clinical Medicine, Danish Center for Healthcare Improvements, Aalborg University, Aalborg Oest, Denmark
| | - Sabrina Storgaard Sørensen
- Department of Clinical Medicine, Danish Center for Healthcare Improvements, Aalborg University, Aalborg Oest, Denmark
| | - Kim Mathiasen
- Research Unit for Telepsychiatry and E-mental Health, Mental Health Services in the Region of Southern Denmark, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mia Beck Lichtenstein
- Research Unit for Telepsychiatry and E-mental Health, Mental Health Services in the Region of Southern Denmark, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Lars Holger Ehlers
- Department of Clinical Medicine, Danish Center for Healthcare Improvements, Aalborg University, Aalborg Oest, Denmark
| |
Collapse
|
20
|
Juul S, Simonsen S, Poulsen S, Lunn S, Sørensen P, Bateman A, Jakobsen JC. Detailed statistical analysis plan for the short-term versus long-term mentalisation-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder randomised clinical trial (MBT-RCT). Trials 2021; 22:497. [PMID: 34321051 PMCID: PMC8316699 DOI: 10.1186/s13063-021-05450-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 07/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background Psychotherapy for borderline personality disorder is often extensive and resource-intensive. Mentalisation-based therapy is a psychodynamically oriented treatment option for borderline personality disorder, which includes a case formulation, psychoeducation, and group and individual therapy. The evidence on short-term compared with long-term mentalisation-based therapy is currently unknown. Methods/design The Short-Term MBT Project (MBT-RCT) is a single-centre, parallel-group, investigator-initiated, randomised clinical superiority trial in which short-term (20 weeks) will be compared with long-term (14 months) mentalisation-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder. Outcome assessors, data managers, the data safety and monitoring committee, statisticians, and decision-makers will be blinded to treatment allocation. Participants will be assessed before randomisation and at 8, 16, and 24 months after randomisation. The primary outcome will be the severity of borderline symptomatology assessed with the Zanarini Rating Scale for Borderline Personality Disorder. Secondary outcomes will be functional impairment (Work and Social Adjustment Scale), quality of life (Short-Form Health Survey 36—mental component), global functioning (Global Assessment of Functioning), and proportion of participants with severe self-harm. In this paper, we present a detailed statistical analysis plan including a comprehensive explanation of the planned statistical analyses, methods to handle missing data, and assessments of the underlying statistical assumptions. Final statistical analyses will be conducted independently by two statisticians following the present plan. Discussion We have developed this statistical analysis plan before unblinding of the trial results in line with the Declaration of Helsinki and the International Conference on Harmonization of Good Clinical Practice Guidelines, which should increase the validity of the MBT-RCT trial by mitigation of analysis bias. Trial registration ClinicalTrials.gov NCT03677037. Registered on 19 September 2018 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05450-y.
Collapse
Affiliation(s)
- Sophie Juul
- Stolpegaard Psychotherapy Centre, Mental Health Services in the Capital Region of Denmark, Stolpegårdsvej 20, 2820, Gentofte, Denmark. .,Department of Psychology, University of Copenhagen, Copenhagen, Denmark. .,Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Sebastian Simonsen
- Stolpegaard Psychotherapy Centre, Mental Health Services in the Capital Region of Denmark, Stolpegårdsvej 20, 2820, Gentofte, Denmark
| | - Stig Poulsen
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Susanne Lunn
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Per Sørensen
- Stolpegaard Psychotherapy Centre, Mental Health Services in the Capital Region of Denmark, Stolpegårdsvej 20, 2820, Gentofte, Denmark
| | | | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
21
|
Alvi MH, Shiri T, Iqbal N, Husain MO, Chaudhry I, Shakoor S, Ansari S, Kiran T, Chaudhry N, Husain N. Cost-Effectiveness of a Culturally Adapted Manual-Assisted Brief Psychological Intervention for Self-Harm in Pakistan: A Secondary Analysis of the Culturally Adapted Manual-Assisted Problem-Solving Training Randomized Controlled Trial. Value Health Reg Issues 2021; 25:150-156. [PMID: 34198122 DOI: 10.1016/j.vhri.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 01/11/2021] [Accepted: 02/19/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Self-harm is a serious public health problem. A culturally adapted manual-assisted problem-solving training (C-MAP) intervention improved and sustained the reduction in suicidal ideation, hopelessness, and depression compared with treatment as usual (TAU) alone. Here, we evaluate its cost-effectiveness. METHODS Patients admitted after an episode of self-harm were randomized individually to either C-MAP plus TAU or TAU alone in Karachi. Improvement in health-related quality-adjusted life years (QALYs) was measured using the Euro Qol-5D-3L instrument at baseline and at 3 months and 6 months after randomization. The primary economic outcome was health service cost per QALY gained as the incremental cost-effectiveness ratio, based on 2019 US dollars and a 6-month time horizon. Nonparametric bootstrapping was used to assess uncertainties, and sensitivity analysis to examine the impact of hospitalization costs. RESULTS A total of 108 and 113 participants were enrolled among the intervention and standard arms, respectively. The intervention resulted in 0.04 more QALYs (95% confidence interval [CI] 0.00-0.08) 6 months after enrolment. The mean cost per participant in the intervention arm was US $1001 (95% CI 968-1031), resulting in an incremental cost of the intervention of US $640 (95% CI 595-679). The incremental cost-effectiveness ratio for the C-MAP intervention versus TAU was US $16 254 (95% CI 7116-99 057) per QALY gained. The probability that C-MAP is cost-effective was between 66% and 83% for cost-effective thresholds between US $20 000 and US $30 000. Cost-effectiveness results remained robust to sensitivity analyses. CONCLUSIONS C-MAP may be a valuable self-harm intervention. Further studies with longer follow-up and larger sample sizes are needed to draw reliable conclusions.
Collapse
Affiliation(s)
- Mohsin H Alvi
- Pakistan Institute of Learning and Living, Karachi, Pakistan
| | - Tinevimbo Shiri
- Division of Psychology and Mental Health, University of Manchester, Manchester, England, UK; International Public Health, Liverpool School of Tropical Medicine, Liverpool, England, UK.
| | - Nasir Iqbal
- Pakistan Institute of Development Economics, Islamabad, Pakistan
| | | | - Imran Chaudhry
- Pakistan Institute of Learning and Living, Karachi, Pakistan; School of Biological Sciences, University of Manchester, Manchester, England, UK; Department of Psychiatry, Ziauddin Hospital, Karachi, Pakistan
| | - Suleman Shakoor
- Pakistan Institute of Learning and Living, Karachi, Pakistan
| | - Sami Ansari
- Pakistan Institute of Learning and Living, Karachi, Pakistan
| | - Tayyeba Kiran
- Pakistan Institute of Learning and Living, Karachi, Pakistan
| | - Nasim Chaudhry
- Pakistan Institute of Learning and Living, Karachi, Pakistan
| | - Nusrat Husain
- Division of Psychology and Mental Health, University of Manchester, Manchester, England, UK
| |
Collapse
|
22
|
Seow LLY, Collins KRL, Page AC, Hooke GR. Outcomes of brief versions of Dialectical Behaviour Therapy for diagnostically heterogeneous groups in a routine care setting. Psychother Res 2021; 32:179-194. [PMID: 34053405 DOI: 10.1080/10503307.2021.1933240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Brief versions of Dialectical Behaviour Therapy (DBT) may enhance patient outcomes in diverse service settings. This study examined the effectiveness of two DBT-informed treatments for diagnostically heterogeneous groups in routine practice: 5-day group training in DBT skills (DBT-5) and a 12-week DBT program (DBT-12). METHODS : Depression, anxiety, stress, borderline symptoms, self-esteem, and general mental wellbeing were measured at pre-and post-treatment in a sample of inpatients and outpatients (N=395). Rates of clinically significant change on these measures were calculated and effect sizes benchmarked against prior DBT outcome studies. Readmission rates were used to measure treatment response maintenance. RESULTS : Scores on all measures improved significantly from pre- to post-treatment. DBT-5 and DBT-12 yielded similar effect sizes compared to prior DBT outcome studies. At least 43.5% of patients were classified as recovered or improved regarding borderline symptoms at the end of both DBT-5 and DBT-12. Readmission rates were also low (5%-6.8%). CONCLUSIONS Brief DBT-informed treatments may offer a fast reduction in symptoms and quicker return to functioning.
Collapse
Affiliation(s)
- Lillian L Y Seow
- School of Psychological Science, The University of Western Australia, Crawley, Australia
| | - Khan R L Collins
- School of Psychological Science, The University of Western Australia, Crawley, Australia
| | - Andrew C Page
- School of Psychological Science, The University of Western Australia, Crawley, Australia
| | - Geoff R Hooke
- School of Psychological Science, The University of Western Australia, Crawley, Western Australia, Australia.,Perth Clinic, West Perth, Western Australia, Australia
| |
Collapse
|
23
|
Harned MS, Schmidt SC, Korslund KE, Gallop RJ. Does Adding the Dialectical Behavior Therapy Prolonged Exposure (DBT PE) Protocol for PTSD to DBT Improve Outcomes in Public Mental Health Settings? A Pilot Nonrandomized Effectiveness Trial With Benchmarking. Behav Ther 2021; 52:639-655. [PMID: 33990239 PMCID: PMC8124086 DOI: 10.1016/j.beth.2020.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
The Dialectical Behavior Therapy Prolonged Exposure (DBT PE) protocol improves DBT's effects on PTSD in research settings, but its effectiveness in community settings is largely unknown. This pilot nonrandomized controlled trial examined DBT with and without DBT PE in four public mental health agencies. Patients (N = 35, 12-56 years old, 80.0% female, 64.7% racial/ethnic minorities, 44.1% sexual minorities) had PTSD, were receiving DBT, and completed assessments every four months over one year. Sixteen patients (45.7%) initiated DBT PE, 19 (54.3%) did not, and dropout did not differ between groups (31.3% vs. 26.3%). The primary barrier to initiating DBT PE was clinician turnover (57.9% of non-initiators). After adjusting for confounds, DBT PE initiators (g = 1.1) and completers (g = 1.4) showed a greater reduction in PTSD than patients who received DBT only (g = 0.5; p's < .05). Rates of reliable improvement in PTSD were 71.4% (DBT PE completers), 53.8% (DBT PE initiators), and 31.3% (DBT). Similar patterns were observed for posttraumatic cognitions, emotion dysregulation, general psychological distress, and limited activity days. There was no worsening of self-injurious behavior or crisis service use among patients who received DBT PE. Benchmarking analyses indicated comparable feasibility, acceptability, and safety, but a smaller magnitude of clinical change, than in efficacy studies. Results require replication in a randomized trial but suggest that DBT PE can be transported effectively to community settings.
Collapse
Affiliation(s)
- Melanie S. Harned
- University of Washington, Seattle, WA, USA,VA Puget Sound Health Care System, Seattle, WA, USA
| | - Sara C. Schmidt
- University of Washington, Seattle, WA, USA,VA Puget Sound Health Care System, Seattle, WA, USA
| | | | | |
Collapse
|
24
|
Witt KG, Hetrick SE, Rajaram G, Hazell P, Taylor Salisbury TL, Townsend E, Hawton K. Psychosocial interventions for self-harm in adults. Cochrane Database Syst Rev 2021; 4:CD013668. [PMID: 33884617 PMCID: PMC8094743 DOI: 10.1002/14651858.cd013668.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most counties, often repeated, and associated with suicide. There has been a substantial increase in both the number of trials and therapeutic approaches of psychosocial interventions for SH in adults. This review therefore updates a previous Cochrane Review (last published in 2016) on the role of psychosocial interventions in the treatment of SH in adults. OBJECTIVES To assess the effects of psychosocial interventions for self-harm (SH) compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator) for adults (aged 18 years or older) who engage in SH. SEARCH METHODS We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020). SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing interventions of specific psychosocial treatments versus treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, or a combination of these, in the treatment of adults with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide. DATA COLLECTION AND ANALYSIS We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratio (ORs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) or standardised mean differences (SMDs) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach. MAIN RESULTS We included data from 76 trials with a total of 21,414 participants. Participants in these trials were predominately female (61.9%) with a mean age of 31.8 years (standard deviation [SD] 11.7 years). On the basis of data from four trials, individual cognitive behavioural therapy (CBT)-based psychotherapy may reduce repetition of SH as compared to TAU or another comparator by the end of the intervention (OR 0.35, 95% CI 0.12 to 1.02; N = 238; k = 4; GRADE: low certainty evidence), although there was imprecision in the effect estimate. At longer follow-up time points (e.g., 6- and 12-months) there was some evidence that individual CBT-based psychotherapy may reduce SH repetition. Whilst there may be a slightly lower rate of SH repetition for dialectical behaviour therapy (DBT) (66.0%) as compared to TAU or alternative psychotherapy (68.2%), the evidence remains uncertain as to whether DBT reduces absolute repetition of SH by the post-intervention assessment. On the basis of data from a single trial, mentalisation-based therapy (MBT) reduces repetition of SH and frequency of SH by the post-intervention assessment (OR 0.35, 95% CI 0.17 to 0.73; N = 134; k = 1; GRADE: high-certainty evidence). A group-based emotion-regulation psychotherapy may also reduce repetition of SH by the post-intervention assessment based on evidence from two trials by the same author group (OR 0.34, 95% CI 0.13 to 0.88; N = 83; k = 2; moderate-certainty evidence). There is probably little to no effect for different variants of DBT on absolute repetition of SH, including DBT group-based skills training, DBT individual skills training, or an experimental form of DBT in which participants were given significantly longer cognitive exposure to stressful events. The evidence remains uncertain as to whether provision of information and support, based on the Suicide Trends in At-Risk Territories (START) and the SUicide-PREvention Multisite Intervention Study on Suicidal behaviors (SUPRE-MISS) models, have any effect on repetition of SH by the post-intervention assessment. There was no evidence of a difference for psychodynamic psychotherapy, case management, general practitioner (GP) management, remote contact interventions, and other multimodal interventions, or a variety of brief emergency department-based interventions. AUTHORS' CONCLUSIONS Overall, there were significant methodological limitations across the trials included in this review. Given the moderate or very low quality of the available evidence, there is only uncertain evidence regarding a number of psychosocial interventions for adults who engage in SH. Psychosocial therapy based on CBT approaches may result in fewer individuals repeating SH at longer follow-up time points, although no such effect was found at the post-intervention assessment and the quality of evidence, according to the GRADE criteria, was low. Given findings in single trials, or trials by the same author group, both MBT and group-based emotion regulation therapy should be further developed and evaluated in adults. DBT may also lead to a reduction in frequency of SH. Other interventions were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to the use of these interventions is inconclusive at present.
Collapse
Affiliation(s)
- Katrina G Witt
- Orygen, Parkville, Melbourne, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Sarah E Hetrick
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Gowri Rajaram
- Orygen, Parkville, Melbourne, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Philip Hazell
- Speciality of Psychiatry, University of Sydney School of Medicine, Sydney, Australia
| | - Tatiana L Taylor Salisbury
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ellen Townsend
- Self-Harm Research Group, School of Psychology, University of Nottingham, Nottingham, UK
| | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK
| |
Collapse
|
25
|
Chakhssi F, Zoet JM, Oostendorp JM, Noordzij ML, Sommers-Spijkerman M. Effect of Psychotherapy for Borderline Personality Disorder on Quality of Life: A Systematic Review and Meta-Analysis. J Pers Disord 2021; 35:255-269. [PMID: 31609187 DOI: 10.1521/pedi_2019_33_439] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Whereas several meta-analyses have shown that psychotherapy is effective for reducing borderline personality disorder (BPD) pathology, the overall impact of psychotherapy for BPD on quality of life (QoL) remains as yet unclear. Because impaired QoL is associated with poor long-term outcomes after therapy for BPD, this seems a timely and relevant issue. The authors conducted a systematic review and meta-analysis of randomized controlled trials of psychotherapies for adults diagnosed with BPD that reported results of QoL at posttreatment. Fourteen trials were included (1,370 individuals with BPD). Psychotherapies for BPD relative to control conditions showed significant effect sizes for QoL (Cohen's d = 0.31; 95% CI [0.18, 0.44]), and for BPD pathology (d = 0.43; 95% CI [0.23, 0.64]). The effect on QoL was not significantly moderated by the effect on BPD pathology. Psychotherapies for BPD have a positive effect on QoL of patients with BPD. However, more studies are needed to examine the impact of psychotherapy on QoL and long-term outcome, including recovery.
Collapse
|
26
|
Harned MS, Korslund KE, Schmidt SC, Gallop RJ. The Dialectical Behavior Therapy Adherence Coding Scale (DBT ACS): Psychometric properties. Psychol Assess 2021; 33:552-561. [PMID: 33764118 DOI: 10.1037/pas0000999] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The Dialectical Behavior Therapy Adherence Coding Scale (DBT ACS) is an observer-rated measure used to evaluate the extent to which therapists deliver individual and group DBT with adherence to the manual. Despite its frequent use in clinical trials of DBT, relatively little is known about its psychometric properties. The present study utilized data from six clinical trials conducted in research and community settings with a variety of patient populations. Across these studies, the DBT ACS was used to code a total of 1,271 DBT individual therapy sessions and 180 DBT group sessions. Results indicate the DBT ACS computed global score has good internal consistency (α = .81) and excellent interrater reliability (ICC = .93). A confirmatory factor analysis found that a single factor yielded acceptable goodness of fit indices. The DBT ACS discriminated between DBT and another treatment and between research and community therapists. Across studies, variability in adherence scores was attributable more to therapists (33%) than to patients (15%). Both therapist and patient variability were higher in effectiveness than efficacy trials. Generalizability coefficients indicated that 5 sessions are needed to estimate a dependable adherence score at the patient level, whereas 9-15 sessions are needed to achieve adequate generalizability at the therapist level. Fewer sessions were needed to yield dependable scores for community therapists compared to research therapists. The DBT ACS appears to be a reliable, valid, and dependable method of assessing therapist adherence to individual and group DBT across diverse treatment settings, therapist types, and patient populations. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Collapse
|
27
|
Westad YAS, Hagen K, Jonsbu E, Solem S. Cessation of Deliberate Self-Harm Behavior in Patients With Borderline Personality Traits Treated With Outpatient Dialectical Behavior Therapy. Front Psychol 2021; 12:578230. [PMID: 33716851 PMCID: PMC7952764 DOI: 10.3389/fpsyg.2021.578230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 02/15/2021] [Indexed: 11/13/2022] Open
Abstract
The first aim of the study was to identify when deliberate self-harm (DSH) behavior ceased in patients with borderline symptoms undergoing dialectical behavioral treatment (DBT). The second aim was to compare patients who ceased their self-harm behavior early or late in the course of treatment, with regard to demographics, comorbidity, and symptom severity. The study used a naturalistic design and included 75 treatment completers at an outpatient DBT clinic. Of these 75 patients, 46 presented with self-harming behavior at pre-treatment. These 46 participants where split into two groups, based on median amount of time before ceasing self-harm behavior, termed early (up to 8 weeks) and late (8+ weeks) responders. Treatment duration varied from 16 to 160 weeks. Patients were assessed pre- and post-treatment using measures of depression, hopelessness, personality traits, quality of life, and global assessment of symptoms and functioning. The majority (93.5%) ceased their self-harming within the first year, and the average number of weeks was 15.5 (SD = 17.8). Twenty-five percent of patients ceased their DSH behavior during the first week of treatment. For the remaining patients, the cessation of DSH continued gradually across a 1 year period. We found no differences between early and late responders with respect to demographics, comorbidity, symptom severity, or treatment outcome. None of the patients committed suicide. The findings indicate that self-harming behavior decreases gradually across the first year after starting DBT.
Collapse
Affiliation(s)
| | - Kristen Hagen
- Helse Møre og Romsdal Hospital Trust, Molde, Norway.,Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Egil Jonsbu
- Helse Møre og Romsdal Hospital Trust, Molde, Norway.,Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Stian Solem
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| |
Collapse
|
28
|
Guillén Botella V, García-Palacios A, Bolo Miñana S, Baños R, Botella C, Marco JH. Exploring the Effectiveness of Dialectical Behavior Therapy Versus Systems Training for Emotional Predictability and Problem Solving in a Sample of Patients With Borderline Personality Disorder. J Pers Disord 2021; 35:21-38. [PMID: 32250206 DOI: 10.1521/pedi_2020_34_477] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Dialectical behavior therapy (DBT) and systems training for emotional predictability and problem solving (STEPPS) are two treatment protocols for people with borderline personality disorder (BPD) that have received important empirical support. However, their possible differential effectiveness has not yet been studied. The objective of this study is to explore the effectiveness of these two treatment programs. A nonrandomized clinical trial was carried out in which both treatments were applied for six months. The sample consisted of 72 patients diagnosed with BPD. The results indicate that both groups experienced a statistically significant reduction in BPD symptom, emotional regulation, impulsiveness, dissociative experiences, suicidal risk, depression, or anger. However, the DBT condition obtained statistically significant differences in BPD behavioral symptoms and fear of suicide. DBT and STEPPS treatment are effective treatments for participants with BPD, and DBT was more effective for the behavioral symptoms of BPD.
Collapse
Affiliation(s)
| | - Azucena García-Palacios
- Universitat Jaume I de Castellón, Castellón, Spain.,Ciber Fisiopatologia Obesidad y Nutricion (CB06/03 Instituto Salud Carlos III), Madrid, Spain
| | | | - Rosa Baños
- Universidad de Valencia, Valencia, Spain.,Ciber Fisiopatologia Obesidad y Nutricion (CB06/03 Instituto Salud Carlos III), Madrid, Spain
| | - Cristina Botella
- Universitat Jaume I de Castellón, Castellón, Spain.,Ciber Fisiopatologia Obesidad y Nutricion (CB06/03 Instituto Salud Carlos III), Madrid, Spain
| | | |
Collapse
|
29
|
Dialectical Behavior Therapy and Motivational Interviewing: Conceptual Convergence, Compatibility, and Strategies for Integration. COGNITIVE AND BEHAVIORAL PRACTICE 2021. [DOI: 10.1016/j.cbpra.2019.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
30
|
Richter C. Subjektive Nebenwirkungsklagen von Borderline-Patienten – zwei Jahre nach einer tagesklinischen Behandlung. VERHALTENSTHERAPIE 2020. [DOI: 10.1159/000511619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
<b><i>Einleitung:</i></b> Die Erfassung von negativen Effekten (nE) von Psychotherapie (PT) ist wichtig, um Schwachstellen von PT zu identifizieren und die Behandlungsqualität zu verbessern. Studienziel ist, zu untersuchen, welche nE Patienten nach einer tagesklinischen Behandlung für Borderline-Persönlichkeitsstörungen (BPS) mit einem Dialektisch-Behavioralen Therapieschwerpunkt (DBT) beschreiben, welche Einflussfaktoren vorliegen und wie die Klagen inhaltlich zu verstehen sind. <b><i>Material und Methoden:</i></b> Katamnestisch wurden BPS-Patienten 22,6 Monate nach Therapieende befragt, an welche nE sie sich mit Bezug zu einer zwölfwöchigen tagesklinischen Behandlung erinnern. Messinstrumente waren BDI, BSL-95 und INEP. <b><i>Ergebnisse:</i></b> 35 Frauen und 6 Männer antworteten (50% von 82). Im Mittel wurden 11,2 nE benannt, die subjektiv auf die DBT-Behandlung zurückgeführt wurden. 97,6% berichten von Verschlechterung ihres Befindens, 87,8% erinnern sich an Probleme in der therapeutischen Beziehung, 43,9% klagten über Verschlechterungen in der Beziehung, 70,7% über finanzielle Probleme in Folge der tagesklinischen Behandlung und 29,3% über Stigmatisierungserleben. Die Zahl der nE korrelierte mit höherem Alter zum Therapiestart (<i>p</i> < 0,01) sowie höherer Symptomlast anhand der BSL-95 (<i>p</i> < 0,01) bzw. BDI (<i>p</i> < 0,01) zum Befragungszeitpunkt. <b><i>Diskussion:</i></b> Es konnte gezeigt werden, dass Patienten bei Vorlage des INEP über eine erhebliche Rate an Negativerfahrungen im Rahmen der tagesklinischen Behandlung klagen. Der lange Rückerinnerungszeitraum von 3 bis 51 Monaten und die Korrelation mit der aktuellen Symptomatik stellen die Validität der Antwort in Frage. Ergebnisse von Selbstratinginstrumenten zur Nebenwirkungserfassung bedürfen einer sehr sorgfältigen Interpretation.
Collapse
|
31
|
Mayoral M, Valencia F, Calvo A, Roldan L, Espliego A, Rodriguez-Toscano E, Kehrmann L, Arango C, Delgado C. Development of an early intervention programme for adolescents with emotion dysregulation and their families: Actions for the treatment of adolescent personality (ATraPA). Early Interv Psychiatry 2020; 14:619-624. [PMID: 32026614 DOI: 10.1111/eip.12934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 11/17/2019] [Accepted: 01/27/2020] [Indexed: 12/29/2022]
Abstract
AIM Borderline personality disorder and severe emotion dysregulation in adolescence is a major public health concern. Dialectical Behaviour Therapy is a promising treatment for suicidality in adolescents. The aim of this work is to present an adaptation of this intervention to the Spanish national health system, Actions for the Treatment of Adolescent Personality (ATraPA). METHOD Data consists of a description of the different ATraPA subprogrammes, including interventions for adolescents aged 13 to 17 and their families. Participants were referred to ATraPA from different hospitals within the region of Madrid, Spain. RESULTS ATraPA has been developed as an intensive outpatient treatment and it comprises different subprogrammes. ATraPA-TAI is an intensive outpatient treatment, including a skills-based group, individual therapy and email therapy. ATraPA-FAL is a psychoeducational intervention for families, including emotion regulation strategies for parents themselves. Finally, the Alternatives Group is offered to adolescents during the hospital admission, with the aim of promoting alternative coping skills. The group of therapists provides a support network to the professionals involved in ATraPA. CONCLUSIONS ATraPA has been successfully implemented in a Child and Adolescent Psychiatry Service within the Spanish national health system. Future studies should address the efficacy of ATraPA using a controlled design.
Collapse
Affiliation(s)
- Maria Mayoral
- Child and Adolescent Psychiatry Service, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain
| | - Fatima Valencia
- Child and Adolescent Psychiatry Service, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain
| | - Ana Calvo
- Child and Adolescent Psychiatry Service, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain.,Health Science Faculty, Universidad Internacional de La Rioja (UNIR), La Rioja, Spain
| | - Laura Roldan
- Child and Adolescent Psychiatry Service, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain
| | - Ana Espliego
- Child and Adolescent Psychiatry Service, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain
| | - Elisa Rodriguez-Toscano
- Child and Adolescent Psychiatry Service, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain
| | - Lara Kehrmann
- Child and Adolescent Psychiatry Service, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain
| | - Celso Arango
- Child and Adolescent Psychiatry Service, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain
| | - Carlos Delgado
- Child and Adolescent Psychiatry Service, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain
| |
Collapse
|
32
|
Gibbon S, Khalifa NR, Cheung NHY, Völlm BA, McCarthy L. Psychological interventions for antisocial personality disorder. Cochrane Database Syst Rev 2020; 9:CD007668. [PMID: 32880104 PMCID: PMC8094166 DOI: 10.1002/14651858.cd007668.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties. This review updates Gibbon 2010 (previous version of the review). OBJECTIVES To evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also searched reference lists and contacted study authors to identify studies. SELECTION CRITERIA Randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment. The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called 'standard Maintenance'(SM) in some studies). Eight of the 18 psychological interventions reported data on our primary outcomes. Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD. Data were available from only 10 studies involving 605 participants. Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands. Study duration ranged from 4 to 156 weeks (median = 26 weeks). Most participants (75%) were male; the mean age was 35.5 years. Eleven studies (58%) were funded by research councils. Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%. Cognitive behaviour therapy (CBT) + TAU versus TAU One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention. One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) -1.60 points, 95% CI -5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention. Impulsive lifestyle counselling (ILC) + TAU versus TAU One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI -0.35 to 0.49; very low-certainty evidence). One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up. Contingency management (CM) + SM versus SM One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD -0.08, 95% CI -0.14 to -0.02; low-certainty evidence) for outpatients at six months. 'Driving whilst intoxicated' programme (DWI) + incarceration versus incarceration One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI -0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months. Schema therapy (ST) versus TAU One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years. The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD -137.33, 95% CI -271.31 to -3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19). The certainty of the evidence for all outcomes was very low. Social problem-solving (SPS) + psychoeducation (PE) versus TAU One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants' level of social functioning (MD -1.60 points, 95% CI -5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention. Dialectical behaviour therapy versus TAU One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU. Psychosocial risk management (PSRM; 'Resettle') versus TAU One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison. It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence). AUTHORS' CONCLUSIONS There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour. Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported. The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.
Collapse
Affiliation(s)
- Simon Gibbon
- Arnold Lodge, Nottinghamshire Healthcare NHS Foundation Trust, Leicester, UK
| | - Najat R Khalifa
- Department of Psychiatry, Queen's University, Kingston, Canada
| | - Natalie H-Y Cheung
- Forensic Research, Nottinghamshire Healthcare NHS Foundation Trust, Leicester, UK
| | - Birgit A Völlm
- Department of Forensic Psychiatry, Center for Neurology, University Rostock, Rostock, Germany
| | - Lucy McCarthy
- Arnold Lodge, Nottinghamshire Healthcare NHS Foundation Trust, Leicester, UK
| |
Collapse
|
33
|
Stoffers-Winterling J, Storebø OJ, Simonsen E, Lieb K. Störungsspezifische Psychotherapie der Borderline-Persönlichkeitsstörung. PSYCHOTHERAPEUT 2020. [DOI: 10.1007/s00278-020-00443-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
34
|
Herzog P, Feldmann M, Voderholzer U, Gärtner T, Armbrust M, Rauh E, Doerr R, Rief W, Brakemeier EL. Drawing the borderline: Predicting treatment outcomes in patients with borderline personality disorder. Behav Res Ther 2020; 133:103692. [PMID: 32801095 DOI: 10.1016/j.brat.2020.103692] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 04/22/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND A routinely collected big data set was analyzed to determine the effectiveness of naturalistic inpatient treatment and to identify predictors of treatment outcome and discontinuation. METHODS The sample included 878 patients with borderline personality disorder who received non-manualized dialectic behavioral therapy in a psychosomatic clinic. Effect sizes (Hedge's g) were calculated to determine effectiveness. A bootstrap-enhanced regularized regression with 91 potential predictors was used to identify stable predictors of residualized symptom- and functional change and treatment discontinuation. Results were validated in a holdout sample and repeated cross validation. RESULTS Effect sizes were small to medium (g = 0.28-0.51). Positive symptom-related outcome was predicted by low affect regulation skills and no previous outpatient psychotherapy. Lower age, absence of work disability, high emotional and physical role limitations and low bodily pain were associated with greater improvement in functional outcome. Higher education and comorbid recurrent depressive disorder were the main predictors of treatment completion. The predictive quality of the models varied, with the best being found for symptom-related outcome (R2 = 18%). CONCLUSION While the exploratory process of variable selection replicates previous findings, the validation results suggest that tailoring treatment to the individual patient might not be based solely on sociodemographic, clinical and psychological baseline data.
Collapse
Affiliation(s)
- Philipp Herzog
- Philipps-University of Marburg, Department of Clinical Psychology and Psychotherapy, Gutenbergstraße 18, D-35032, Marburg, Germany.
| | - Matthias Feldmann
- Philipps-University of Marburg, Department of Clinical Psychology and Psychotherapy, Gutenbergstraße 18, D-35032, Marburg, Germany
| | - Ulrich Voderholzer
- Schön-Klinik Roseneck, Psychosomatic Clinic, Am Roseneck 6, D-83209, Prien Am Chiemsee, Germany
| | - Thomas Gärtner
- Schön-Klinik Bad Arolsen, Psychosomatic Clinic, Hofgarten 10, D-34454, Bad Arolsen, Germany
| | - Michael Armbrust
- Schön-Klinik Bad Bramstedt, Psychosomatic Clinic, Birkenweg 10, D-24576, Bad Bramstedt, Germany
| | - Elisabeth Rauh
- Schön-Klinik Bad Staffelstein, Psychsomatic Clinic, Am Kurpark 11, D-96231, Bad Staffelstein, Germany
| | - Robert Doerr
- Schön-Klinik Berchtesgadener Land, Psychosomatic Clinic, Malterhöh 1, D-83471, Schönau Am Königssee, Germany
| | - Winfried Rief
- Philipps-University of Marburg, Department of Clinical Psychology and Psychotherapy, Gutenbergstraße 18, D-35032, Marburg, Germany
| | - Eva-Lotta Brakemeier
- Philipps-University of Marburg, Department of Clinical Psychology and Psychotherapy, Gutenbergstraße 18, D-35032, Marburg, Germany
| |
Collapse
|
35
|
D’Elia A, Bawor M, Dennis BB, Bhatt M, Litke K, McCabe K, Whattam J, Garrick L, O’Neill L, Simons S, Chalmers S, Key B, Goyert S, Laplante P, Vanstone M, Xie F, Guyatt G, Thabane L, Samaan Z. Feasibility of behavioral activation group therapy in reducing depressive symptoms and improving quality of life in patients with depression: the BRAVE pilot trial. Pilot Feasibility Stud 2020; 6:61. [PMID: 32411381 PMCID: PMC7206724 DOI: 10.1186/s40814-020-00596-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 04/07/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Depression impacts the lives of millions of people worldwide. Behavioral activation (BA), derived from cognitive behavioral therapy, has the potential for improving depressive symptoms in patients with depression. Studies evaluating the effectiveness of BA specifically in the context of group therapy programs in a hospital setting for patients with depression are limited. In this study, we report findings from a pilot trial evaluating group BA for major depressive disorder. OBJECTIVE The objectives of this pilot trial are to assess the potential of a full trial of BA group therapy in a large-scale tertiary care setting and to provide preliminary information about possible results regarding mood symptoms and quality of life in adults with depression. METHODS Using a parallel single-cohort pragmatic pilot randomized controlled trial design, we evaluated the potential of conducting a large trial of BA effectiveness among adults with depression. Participants were randomized to the intervention (BA in addition to usual care) or control (support group in addition to usual care) groups and were assessed weekly for 18 consecutive weeks. Participants randomized to intervention underwent 28 2-h group BA therapy visits administered by trained therapists and completed assessments to examine treatment outcomes. Feasibility was measured in terms of enrollment rates (min. 20%), completion rates of study (min. 80%), and completion rates of weekly measurement scales (min. 80%). The reporting of this pilot trial is in accordance with the CONSORT extension for randomized pilot and feasibility trials. RESULTS We randomized 20 individuals of mean age of 48.8 years (standard deviation = 9.7) with a DSM-5 diagnosis of major depressive disorder to intervention (n = 10) or control (n = 10) groups. Based on our feasibility criteria, our recruitment rate was excellent (20/27; 74%), study completion was found to be a moderate (80% of the total participants in both arms completed the study; BA = 100%, control = 60%), and completeness of measurements on a weekly basis was adequate overall (82%; BA = 86%, control = 79%). CONCLUSIONS The study has demonstrated the potential feasibility to perform a larger scale trial upon modifications to the control group to avoid the low rate of study completion (60%) in this group. TRIAL REGISTRATION ClinicalTrials NCT02045771, Registered January 22, 2014.
Collapse
Affiliation(s)
- Alessia D’Elia
- Department of Psychiatry and Behavioural Neuroscience, McMaster University, 100 West 5th Street, Hamilton, ON Canada
| | - Monica Bawor
- Department of Psychiatry and Behavioural Neuroscience, McMaster University, 100 West 5th Street, Hamilton, ON Canada
- Population Genomics Program, Chanchlani Research Centre, McMaster University, 1280 Main St. W, Hamilton, ON Canada
| | - Brittany B. Dennis
- Population Genomics Program, Chanchlani Research Centre, McMaster University, 1280 Main St. W, Hamilton, ON Canada
- Department of Health Research, Evidence and Impact, McMaster University, 1280 Main St. W, Hamilton, ON Canada
| | - Meha Bhatt
- Department of Health Research, Evidence and Impact, McMaster University, 1280 Main St. W, Hamilton, ON Canada
| | - Kathryn Litke
- Population Genomics Program, Chanchlani Research Centre, McMaster University, 1280 Main St. W, Hamilton, ON Canada
| | - Kathleen McCabe
- Department of Psychiatry and Behavioural Neuroscience, McMaster University, 100 West 5th Street, Hamilton, ON Canada
- Mood Disorders Program, St. Joseph’s Healthcare Hamilton, 100 West 5th St, Hamilton, ON Canada
| | - Jeff Whattam
- Mood Disorders Program, St. Joseph’s Healthcare Hamilton, 100 West 5th St, Hamilton, ON Canada
| | - Laura Garrick
- Mood Disorders Program, St. Joseph’s Healthcare Hamilton, 100 West 5th St, Hamilton, ON Canada
| | - Laura O’Neill
- Department of Psychiatry and Behavioural Neuroscience, McMaster University, 100 West 5th Street, Hamilton, ON Canada
- Mood Disorders Program, St. Joseph’s Healthcare Hamilton, 100 West 5th St, Hamilton, ON Canada
| | - Scott Simons
- Mood Disorders Program, St. Joseph’s Healthcare Hamilton, 100 West 5th St, Hamilton, ON Canada
| | - Sandra Chalmers
- Mood Disorders Program, St. Joseph’s Healthcare Hamilton, 100 West 5th St, Hamilton, ON Canada
| | - Brenda Key
- Department of Psychiatry and Behavioural Neuroscience, McMaster University, 100 West 5th Street, Hamilton, ON Canada
- Mood Disorders Program, St. Joseph’s Healthcare Hamilton, 100 West 5th St, Hamilton, ON Canada
| | - Stefanie Goyert
- Mood Disorders Program, St. Joseph’s Healthcare Hamilton, 100 West 5th St, Hamilton, ON Canada
| | - Phillip Laplante
- Department of Psychiatry and Behavioural Neuroscience, McMaster University, 100 West 5th Street, Hamilton, ON Canada
| | - Meredith Vanstone
- Department of Health Research, Evidence and Impact, McMaster University, 1280 Main St. W, Hamilton, ON Canada
| | - Feng Xie
- Department of Health Research, Evidence and Impact, McMaster University, 1280 Main St. W, Hamilton, ON Canada
| | - Gordon Guyatt
- Department of Health Research, Evidence and Impact, McMaster University, 1280 Main St. W, Hamilton, ON Canada
- Department of Medicine, McMaster University, 1280 Main St. W, Hamilton, ON Canada
| | - Lehana Thabane
- Department of Health Research, Evidence and Impact, McMaster University, 1280 Main St. W, Hamilton, ON Canada
- Biostatistics Unit, Centre for Evaluation of Medicine, Hamilton, ON Canada
- System-Linked Research Unit, McMaster University, 1280 Main St. W, Hamilton, ON Canada
- Department of Anesthesia, McMaster University, 1280 Main St. W, Hamilton, ON Canada
- Department of Pediatrics, McMaster University, 1280 Main St. W, Hamilton, ON Canada
| | - Zainab Samaan
- Department of Psychiatry and Behavioural Neuroscience, McMaster University, 100 West 5th Street, Hamilton, ON Canada
- Population Genomics Program, Chanchlani Research Centre, McMaster University, 1280 Main St. W, Hamilton, ON Canada
- Department of Health Research, Evidence and Impact, McMaster University, 1280 Main St. W, Hamilton, ON Canada
- Mood Disorders Program, St. Joseph’s Healthcare Hamilton, 100 West 5th St, Hamilton, ON Canada
| |
Collapse
|
36
|
Storebø OJ, Stoffers-Winterling JM, Völlm BA, Kongerslev MT, Mattivi JT, Jørgensen MS, Faltinsen E, Todorovac A, Sales CP, Callesen HE, Lieb K, Simonsen E. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2020; 5:CD012955. [PMID: 32368793 PMCID: PMC7199382 DOI: 10.1002/14651858.cd012955.pub2] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers-Winterling 2012). OBJECTIVES To assess the beneficial and harmful effects of psychological therapies for people with BPD. SEARCH METHODS In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication. SELECTION CRITERIA Randomised controlled trials comparing different psychotherapeutic interventions with treatment-as-usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects. DATA COLLECTION AND ANALYSIS At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis. MAIN RESULTS We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation-based treatment (MBT). The comparator interventions included treatment-as-usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months. Psychotherapy versus TAU Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.70 to -0.33; 22 trials, 1244 participants; moderate-quality evidence. This corresponds to a mean difference (MD) of -3.6 (95% CI -4.4 to -2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is -3.0 points). Psychotherapy may be more effective at reducing self-harm compared to TAU (SMD -0.32, 95% CI -0.49 to -0.14; 13 trials, 616 participants; low-quality evidence), corresponding to a MD of -0.82 (95% CI -1.25 to 0.35) on the Deliberate Self-Harm Inventory Scale (range 0 to 34). The MIREDIF of -1.25 points was not reached. Suicide-related outcomes improved compared to TAU (SMD -0.34, 95% CI -0.57 to -0.11; 13 trials, 666 participants; low-quality evidence), corresponding to a MD of -0.11 (95% CI -0.19 to -0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of -0.17 points was not reached. Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD -0.45, 95% CI -0.68 to -0.22; 22 trials, 1314 participants; low-quality evidence), corresponding to a MD of -2.8 (95% CI -4.25 to -1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of -4.0 points was not reached. Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases. A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning. Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD -0.39, 95% CI -0.61 to -0.17; 22 trials, 1568 participants; very low-quality evidence), corresponding to a MD of -2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of -3.0 points was not reached. BPD-specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data. Psychotherapy versus waiting list or no treatment Greater improvements in BPD symptom severity (SMD -0.49, 95% CI -0.93 to -0.05; 3 trials, 161 participants), psychosocial functioning (SMD -0.56, 95% CI -1.01 to -0.11; 5 trials, 219 participants), and depression (SMD -1.28, 95% CI -2.21 to -0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low-quality evidence). No evidence of a difference was found for self-harm and suicide-related outcomes. Individual treatment approaches DBT and MBT have the highest numbers of primary trials, with DBT as subject of one-third of all included trials, followed by MBT with seven RCTs. Compared to TAU, DBT was more effective at reducing BPD severity (SMD -0.60, 95% CI -1.05 to -0.14; 3 trials, 149 participants), self-harm (SMD -0.28, 95% CI -0.48 to -0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD -0.36, 95% CI -0.69 to -0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self-harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD -0.58, 95% CI -1.22 to 0.05, 4 trials, 333 participants). All findings are based on low-quality evidence. For secondary outcomes see review text. AUTHORS' CONCLUSIONS Our assessments showed beneficial effects on all primary outcomes in favour of BPD-tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF-defined cut-off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) . The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low-quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self-harm and suicide-related outcomes. However, compared to TAU, we observed effects in favour of DBT for BPD severity, self-harm and psychosocial functioning and, for MBT, on self-harm and suicidality at end of treatment, but these were all based on low-quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.
Collapse
Affiliation(s)
- Ole Jakob Storebø
- Child and Adolescent Psychiatric Department, Region Zealand, Roskilde, Denmark
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | | | - Birgit A Völlm
- Department of Forensic Psychiatry, Center for Neurology, University Rostock, Rostock, Germany
| | - Mickey T Kongerslev
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Jessica T Mattivi
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Mie S Jørgensen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Erlend Faltinsen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Adnan Todorovac
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Christian P Sales
- Duncan MacMillan House, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
- Institute of Mental Health, Department of Psychiatry & Applied Psychology, Nottingham, UK
| | | | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Erik Simonsen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| |
Collapse
|
37
|
Lyng J, Swales MA, Hastings RP, Millar T, Duffy DJ, Booth R. Standalone DBT Group Skills Training Versus Standard (i.e. All Modes) DBT for Borderline Personality Disorder: A Natural Quasi-experiment in Routine Clinical Practice. Community Ment Health J 2020; 56:238-250. [PMID: 31673877 DOI: 10.1007/s10597-019-00485-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 09/25/2019] [Indexed: 11/26/2022]
Abstract
We describe a naturally occurring, real-world comparison of outcomes following 6 months in standalone DBT skills training group for adults with Borderline Personality Disorder (BPD) without recent suicidal or severe self-harming behaviours and standard (i.e. all modes) DBT for BPD including patients with recent high-risk behaviours. 34 patients chose standalone skills over waiting for standard DBT and 54 were offered standard DBT. Dropout was higher for standalone skills than standard DBT (38.2% vs. 16.7%). No statistically or clinically significant differences were found among completers between conditions on borderline symptoms, general psychopathology, and suicide ideation. There was a moderate effect for standalone skills on hopelessness and emotion regulation difficulties which may have reflected non-equivalence of treatment groups. Significant methodological factors limit generalisability of findings which offer support for feasibility of standalone DBT skills as an effective alternative to waitlist for standard DBT for at least some patients with BPD in the community.
Collapse
Affiliation(s)
- Jim Lyng
- Department of Psychology, Cluain Mhuire Community Mental Health Services, Blackrock, Co. Dublin, Ireland.
- School of Psychology, Bangor University, Adeilad Brigantia, Bangor, Gwynedd, LL57 2AS, UK.
| | - Michaela A Swales
- School of Psychology, Bangor University, Adeilad Brigantia, Bangor, Gwynedd, LL57 2AS, UK
| | - Richard P Hastings
- Centre for Educational Development, Appraisal and Research, University of Warwick, Coventry, West Midlands, CV4 7AL, UK
| | - Tracy Millar
- South Eastern Health and Social Care Trust, Dundonald, BT16 1RH, UK
| | - Daniel J Duffy
- Department of Psychology, Cluain Mhuire Community Mental Health Services, Blackrock, Co. Dublin, Ireland
| | - Richard Booth
- Department of Psychology, St Patrick's University Hospital, Dublin, D08 K7YW, Ireland
| |
Collapse
|
38
|
Witt K, Townsend E, Arensman E, Gunnell D, Hazell P, Taylor Salisbury T, Van Heeringen K, Hawton K. Psychosocial Interventions for People Who Self-Harm: Methodological Issues Involved in Trials to Evaluate Effectiveness. Arch Suicide Res 2020; 24:S32-S93. [PMID: 30955501 DOI: 10.1080/13811118.2019.1592043] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We have assessed the methodological quality of randomized controlled trials (RCTs) of interventions to prevent self-harm repetition and suicide. Trials were identified in two systematic reviews of RCTs of psychosocial treatments following a recent (within six months) episode of self-harm indexed in any of five electronic databases (CCDANCTR-Studies and References, CENTRAL, Medline, Embase, and PsycINFO) between 1 January, 1998 and 29 April, 2015. A total of 66 trials were included, 55 in adults and 11 in children and adolescents. While evidence for efficacy of some approaches has grown, there were few trials from low-to-middle income countries, little information on interventions for males, information on the control condition was often limited, data on suicides were often not reported, and, while trials have increased in size in recent years, most have included too few participants to detect clinically significant results. There are major limitations in many trials of interventions for individuals who self-harm. Improved methodology, especially with regard to study size, provision of details of control therapy, and evaluation of key outcomes, would enhance the evidence base for clinicians and service users.
Collapse
|
39
|
Murphy A, Bourke J, Flynn D, Kells M, Joyce M. A cost-effectiveness analysis of dialectical behaviour therapy for treating individuals with borderline personality disorder in the community. Ir J Med Sci 2019; 189:415-423. [PMID: 31482522 DOI: 10.1007/s11845-019-02091-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 08/27/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND/AIMS This paper investigates the cost-effectiveness of dialectical behaviour therapy (DBT) for treating individuals with borderline personality disorder (BPD) in a community setting in Ireland, in the short term. METHODS Resource utilisation and effectiveness data were collected as part of the National DBT Project, Ireland, and are incorporated into a cost-effectiveness analysis. The perspective taken was that of the service provider and payer. Direct health resources were included and effectiveness was measured using the EQ-5D-5L questionnaire. To examine cost-effectiveness, incremental costs are compared with incremental quality-adjusted life years, to estimate an incremental cost-effectiveness ratio. A probabilistic sensitivity analysis was employed to investigate parameter uncertainty. Scenario analyses are employed to investigate cost-effectiveness of DBT with varying assumptions around effectiveness and costs. RESULTS The baseline analysis reveals that DBT is more expensive and more effective than routine clinical care (without DBT). The low incremental cost-effectiveness ratio suggests DBT can be considered cost effective in the short term. In each scenario analyses considered, the probability that DBT is cost effective is greater than 50%. CONCLUSIONS Mental health care provision, including that of DBT, varies across jurisdictions, necessitating economic evaluations of current practice in community-based services, on a country-by-country basis, to inform resource allocation decisions. In line with previous research, the analysis here indicates DBT can be considered cost effective in the short term. Future data collection on alternative comparators and long-term outcomes associated with DBT is warranted to investigate the longer term cost-effectiveness of DBT.
Collapse
Affiliation(s)
- Aileen Murphy
- Department of Economics, Cork University Business School, Aras na Laoi, University College Cork, Cork, Ireland.
| | - Jane Bourke
- Department of Economics, Cork University Business School, Aras na Laoi, University College Cork, Cork, Ireland
| | - Daniel Flynn
- Cork Mental Health Services, Cork Kerry Community Healthcare, Health Service Executive, St Finbarr's Hospital, Douglas Road, Cork, Ireland
| | - Mary Kells
- Cork Mental Health Services, Cork Kerry Community Healthcare, Health Service Executive, Inniscarraig House, Western Road, Cork, Ireland
| | - Mary Joyce
- National Suicide Research Foundation, Western Gateway Building, University College Cork, Cork, Ireland
| |
Collapse
|
40
|
Shearer J, Lynch TR, Chamba R, Clarke S, Hempel RJ, Kingdon DG, O'Mahen H, Remington B, Rushbrook SC, Russell IT, Stanton M, Swales M, Watkins A, Whalley B, Byford S. Refractory depression - cost-effectiveness of radically open dialectical behaviour therapy: findings of economic evaluation of RefraMED trial. BJPsych Open 2019; 5:e64. [PMID: 31352916 PMCID: PMC6669879 DOI: 10.1192/bjo.2019.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Refractory depression is a major contributor to the economic burden of depression. Radically open dialectical behaviour therapy (RO DBT) is an unevaluated new treatment targeting overcontrolled personality, common in refractory depression, but it is not yet known whether the additional expense of RO DBT is good value for money.AimsTo estimate the cost-effectiveness of RO DBT plus treatment as usual (TAU) compared with TAU alone in people with refractory depression (trial registration: ISRCTN85784627). METHOD We undertook a cost-effectiveness analysis alongside a randomised trial evaluating RO DBT plus TAU versus TAU alone for refractory depression in three UK secondary care centres. Our economic evaluation, 12 months after randomisation, adopted the perspective of the UK National Health Service (NHS) and personal social services. It evaluated cost-effectiveness by comparing the net cost of RO DBT with the net gain in quality-adjusted life-years (QALYs), estimated using the EQ-5D-3L measure of health-related quality of life. RESULTS The additional cost of RO DBT plus TAU compared with TAU alone was £7048 and was associated with a difference of 0.032 QALYs, yielding an incremental cost-effectiveness ratio (ICER) of £220 250 per QALY. This ICER was well above the National Institute for Health and Care Excellence (NICE) upper threshold of £30 000 per QALY. A cost-effectiveness acceptability curve indicated that RO DBT had a zero probability of being cost-effective compared with TAU at the NICE £30 000 threshold. CONCLUSIONS In its current resource-intensive form, RO DBT is not a cost-effective use of resources in the UK NHS.Declaration of interestR.H. is co-owner and director of Radically Open Ltd, the RO DBT training and dissemination company. D.K. reports grants outside the submitted work from the National Institute for Health Research (NIHR). T.L. receives royalties from New Harbinger Publishing for sales of RO DBT treatment manuals, speaking fees from Radically Open Ltd, and a grant outside the submitted work from the Medical Research Council. He was co-director of Radically Open Ltd between November 2014 and May 2015 and is married to Erica Smith-Lynch, the principal shareholder and one of two directors of Radically Open Ltd. H.O'M. reports personal fees outside the submitted work from the Charlie Waller Institute and Improving Access to Psychological Therapy. S.R. provides RO DBT supervision through her company S C Rushbrook Ltd. I.R. reports grants outside the submitted work from NIHR and Health & Care Research Wales. M. Stanton reports personal fees outside the submitted work from British Isles DBT Training, Stanton Psychological Services Ltd and Taylor & Francis. M. Swales reports personal fees outside the submitted work from British Isles DBT Training, Guilford Press, Oxford University Press and Taylor & Francis. B.W. was co-director of Radically Open Ltd between November 2014 and February 2015.
Collapse
Affiliation(s)
- James Shearer
- Lecturer in Health Economics,Institute of Psychiatry, Psychology & Neuroscience, King's College London,UK
| | - Thomas R Lynch
- Emeritus Professor of Clinical Psychology,University of Southampton,UK
| | - Rampaul Chamba
- Patient and Public Representative,Member of Trial Management Committee responsible for Public & Patient Inclusion,West Midlands,UK
| | - Susan Clarke
- Visiting Professor, Intensive Psychological Therapies Service,Dorset Healthcare University NHS Foundation Trust,UK
| | - Roelie J Hempel
- Senior Research Fellow,University of Southampton; andRadically Open Ltd,London,UK
| | - David G Kingdon
- Professor of Mental Health Care Delivery, Department of Medicine,University of Southampton,UK
| | - Heather O'Mahen
- Senior Lecturer in Clinical Psychology, Department of Psychology,University of Exeter,UK
| | - Bob Remington
- Emeritus Professor in Psychology,University of Southampton,UK
| | - Sophie C Rushbrook
- Consultant Clinical Psychologist, Intensive Psychological Therapies Service,Dorset Healthcare University NHS Foundation Trust,UK
| | - Ian T Russell
- Professor of Clinical Trials, Medical School,University of Swansea,UK
| | - Maggie Stanton
- Consultant Clinical Psychologist, Psychological Services,Southern Health NHS Foundation Trust,UK
| | - Michaela Swales
- Consultant Clinical Psychologist and Reader in Clinical Psychology, School of Psychology,University of Bangor,UK
| | - Alan Watkins
- Associate Professor of e-Trials Research, Medical School,University of Swansea,UK
| | - Ben Whalley
- Lecturer in Psychology, Cognition Institute, School of Psychology,University of Plymouth,UK
| | - Sarah Byford
- Professor of Health Economics,Institute of Psychiatry, Psychology & Neuroscience, King's College London,UK
| |
Collapse
|
41
|
Barnicot K, Crawford M. Dialectical behaviour therapy v. mentalisation-based therapy for borderline personality disorder. Psychol Med 2019; 49:2060-2068. [PMID: 30303061 DOI: 10.1017/s0033291718002878] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Dialectical behaviour therapy (DBT) and mentalisation-based therapy (MBT) are both widely used evidence-based treatments for borderline personality disorder (BPD), yet a head-to-head comparison of outcomes has never been conducted. The present study therefore aimed to compare the clinical outcomes of DBT v. MBT in patients with BPD. METHODS A non-randomised comparison of clinical outcomes in N = 90 patients with BPD receiving either DBT or MBT over a 12-month period. RESULTS After adjusting for potentially confounding differences between participants, participants receiving DBT reported a significantly steeper decline over time in incidents of self-harm (adjusted IRR = 0.93, 95% CI 0.87-0.99, p = 0.02) and in emotional dysregulation (adjusted β = -1.94, 95% CI -3.37 to -0.51, p < 0.01) than participants receiving MBT. Differences in treatment dropout and use of crisis services were no longer significant after adjusting for confounding, and there were no significant differences in BPD symptoms or interpersonal problems. CONCLUSIONS Within this sample of people using specialist personality disorder treatment services, reductions in self-harm and improvements in emotional regulation at 12 months were greater amongst those receiving DBT than amongst those receiving MBT. Experimental studies assessing outcomes beyond 12 months are needed to examine whether these findings represent differences in the clinical effectiveness of these therapies.
Collapse
Affiliation(s)
- Kirsten Barnicot
- Department of Medicine, Imperial College London, Centre for Psychiatry, Commonwealth Building, Du Cane Road, London, W12 0NN, UK
| | - Mike Crawford
- Department of Medicine, Imperial College London, Centre for Psychiatry, Commonwealth Building, Du Cane Road, London, W12 0NN, UK
| |
Collapse
|
42
|
Dixon LJ, Linardon J. A systematic review and meta-analysis of dropout rates from dialectical behaviour therapy in randomized controlled trials. Cogn Behav Ther 2019; 49:181-196. [PMID: 31204902 DOI: 10.1080/16506073.2019.1620324] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Dropout is an important factor that may compromise the validity of findings from randomized controlled trials (RCTs) of dialectical behaviour therapy (DBT). We conducted a targeted meta-analytic review of dropout from RCTs of DBT, with the aims of (1) calculating average rates of dropout from DBT; (2) investigating factors that moderate dropout; (3) examining whether dropout rates from DBT differ to control interventions; (4) synthesising reasons for dropout. Forty RCTs of DBT met full inclusion criteria. The weighted mean dropout rate was 28.0% (95% CI = 23.6, 32.9). Dropout rates were not related to target disorder, dropout definition, delivery format, therapist experience, and therapist adherence. Unexpectedly, dropout rates were significantly higher in trials that offered telephone coaching and utilized a therapist consultation team. DBT dropout rates did not significantly differ to dropout rates from control interventions. Few trials reported reasons for dropout, and there was little consistency in the reported reasons. Findings suggest that over one in four patients drop out from DBT in RCTs. This review highlights the urgency for future trials to explicitly report detail pertaining to patient dropout, as this may assist in the development of strategies designed to prevent future dropouts in RCTs of DBT.
Collapse
|
43
|
Duarte R, Lloyd A, Kotas E, Andronis L, White R. Are acceptance and mindfulness-based interventions 'value for money'? Evidence from a systematic literature review. BRITISH JOURNAL OF CLINICAL PSYCHOLOGY 2019; 58:187-210. [PMID: 30499217 PMCID: PMC6588093 DOI: 10.1111/bjc.12208] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 10/26/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Acceptance and mindfulness-based interventions (A/MBIs) are recommended for people with mental health conditions. Although there is a growing evidence base supporting the effectiveness of different A/MBIs for mental health conditions, the economic case for these interventions has not been fully explored. The aim of this systematic review was to identify and appraise all available economic evidence of A/MBIs for the management of mental health conditions. METHODS Eight electronic bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Web of Science, NHS Economic Evaluation Database (EED), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA) database, and EconLit) were searched for relevant economic evaluations published from each database's inception date until November 2017. Study selection, quality assessment, and data extraction were carried out according to published guidelines. RESULTS Ten relevant economic evaluations presented in 11 papers were identified. Seven of the included studies were full economic evaluations (i.e., costs and effects assessed), and three studies were partial economic evaluations (i.e., only costs were considered in the analysis). The A/MBIs that had been subjected to economic evaluation were acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), mindfulness-based cognitive therapy (MBCT), and mindfulness-based stress reduction (MBSR). In terms of clinical presentations, the evaluation of cost-effectiveness of A/MBIs has been more focused on depression and emotional unstable personality disorder with three and four economic evaluations, respectively. Three out of seven full economic evaluations observed that A/MBIs were cost-effective for the management of mental health conditions. Nevertheless, the heterogeneity of included populations, interventions, and economic evaluation study types limits the extent to which firm conclusions can currently be made. CONCLUSION This first substantive review of economic evaluations of A/MBIs indicates that more research is needed before firm conclusions can be reached on the cost-effectiveness of A/MBIs for mental health conditions. PRACTITIONER POINTS The findings of the review provide information that may be relevant to mental health service commissioners and decision-makers as all economic evidence available on acceptance and mindfulness-based interventions for mental health conditions is summarized. Evidence relating to the cost-effectiveness and cost-saving potential of acceptance and mindfulness-based interventions is focused mainly on depression and emotional unstable personality disorder to date. Heterogeneity in the specific forms of acceptance and mindfulness-based interventions may limit generalizability of the findings. The number of health economic evaluations relating to acceptance and mindfulness-based interventions remains relatively small. Further research in this area is required.
Collapse
Affiliation(s)
- Rui Duarte
- Liverpool Reviews and Implementation GroupUniversity of LiverpoolUK
| | | | - Eleanor Kotas
- Liverpool Reviews and Implementation GroupUniversity of LiverpoolUK
| | - Lazaros Andronis
- Populations, Evidence and Technologies GroupDivision of Health SciencesUniversity of WarwickCoventryUK
- Division of Clinical TrialsUniversity of WarwickCoventryUK
| | - Ross White
- School of PsychologyUniversity of LiverpoolUK
| |
Collapse
|
44
|
Juul S, Lunn S, Poulsen S, Sørensen P, Salimi M, Jakobsen JC, Bateman A, Simonsen S. Short-term versus long-term mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder: a protocol for a randomized clinical trial. Trials 2019; 20:196. [PMID: 30953536 PMCID: PMC6451226 DOI: 10.1186/s13063-019-3306-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 03/19/2019] [Indexed: 11/23/2022] Open
Abstract
Background Psychotherapy for borderline personality disorder is often lengthy and resource-intensive. However, the current length of outpatient treatments is arbitrary and based on trials that never tested if the treatment intensity could be reduced. As a result, there is insufficient evidence to inform the decision between short-term and long-term psychotherapy for borderline personality disorder. Mentalization-based therapy is one treatment option for borderline personality disorder and consists traditionally of an 18-month treatment program. Methods/design This trial is an investigator-initiated single-center randomized clinical superiority trial of short-term (20 weeks) compared to long-term (14 months) mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder. Participants will be recruited from the Outpatient Clinic for Personality Disorders at Stolpegaard Psychotherapy Centre, Mental Health Services, Capital Region of Denmark. Participants will be included if they meet a minimum of four DSM-V criteria for borderline personality disorder. Participants will be assessed before randomization, and at 8, 16, and 24 months after randomization. The primary outcome is severity of borderline symptomatology assessed with the Zanarini Rating Scale for borderline personality disorder. Secondary outcomes include self-harm incidents, functional impairment (Work and Social Adjustment Scale, Global Assessment of Functioning) and quality of life (Short-Form Health Survey 36). Severity of psychiatric symptoms (Symptom Checklist 90-R) will be included as an exploratory outcome. Measures of personality functioning, attachment, borderline symptoms, group alliance, and mentalization skills will be included to explore potential predictors and mechanisms of change. Discussion This trial will provide evidence of the beneficial and harmful effects of short-term compared to long-term mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder. Trial registration ClinicalTrials.gov, NCT03677037. Registered on September 19, 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3306-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Sophie Juul
- Stolpegaard Psychotherapy Centre, Mental Health Services, Gentofte, Capital Region of Denmark, Denmark. .,Department of Psychology, University of Copenhagen, Copenhagen, Denmark.
| | - Susanne Lunn
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Stig Poulsen
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Per Sørensen
- Stolpegaard Psychotherapy Centre, Mental Health Services, Gentofte, Capital Region of Denmark, Denmark
| | - Mehrak Salimi
- Stolpegaard Psychotherapy Centre, Mental Health Services, Gentofte, Capital Region of Denmark, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Center for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Sebastian Simonsen
- Stolpegaard Psychotherapy Centre, Mental Health Services, Gentofte, Capital Region of Denmark, Denmark
| |
Collapse
|
45
|
Kvarstein EH, Pedersen G, Folmo E, Urnes Ø, Johansen MS, Hummelen B, Wilberg T, Karterud S. Mentalization-based treatment or psychodynamic treatment programmes for patients with borderline personality disorder - the impact of clinical severity. Psychol Psychother 2019; 92:91-111. [PMID: 29582581 PMCID: PMC6585931 DOI: 10.1111/papt.12179] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 02/23/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Mentalization-based treatment (MBT), originally designed for patients with borderline personality disorder (BPD), may be particularly indicated for severe conditions. However, there is limited documentation of how increasing severity of personality disorder (PD) effect outcomes of highly specialized treatments. This study aimed to investigate associations between clinical severity and outcomes for patients in MBT as compared to a psychodynamic group-based treatment programme (PDT). DESIGN A naturalistic, longitudinal, comparison study. METHODS The sample included 345 patients with BPD (PDTn = 281, MBTn = 64). The number of diagnosed PDs, PD criteria, and symptom disorders were chosen as baseline indicators of clinical severity. Clinical outcomes (global functioning, symptom distress, interpersonal problems) were repeatedly assessed over three years. Therapists' fidelity to MBT was satisfactory. Linear mixed models were the applied statistics. RESULTS In PDT, greater clinical severity was associated with poorer improvement rates. Clinical severity was not associated with significant differences in outcomes for patients in MBT. Differences in outcomes for patients in MBT and PDT increased significantly with higher severity of disorder. CONCLUSIONS Supporting previous research, this study indicates that clinical benefits associated with MBT also apply for BPD patients with severe conditions. The results also suggest that increasing severity was a challenge in PDT. PRACTITIONER POINTS MBT may be particularly beneficial for severely disordered BPD patients Differences between MBT and PDT were less pronounced in moderately disordered BPD patients.
Collapse
Affiliation(s)
| | - Geir Pedersen
- Section for Personality PsychiatryOslo University HospitalNorway,University of OsloNorway
| | - Espen Folmo
- Section for Personality PsychiatryOslo University HospitalNorway
| | - Øyvind Urnes
- Section for Personality PsychiatryOslo University HospitalNorway
| | | | - Benjamin Hummelen
- Department of Research and DevelopmentOslo University HospitalNorway
| | - Theresa Wilberg
- Section for Personality PsychiatryOslo University HospitalNorway,Department of Research and DevelopmentOslo University HospitalNorway
| | - Sigmund Karterud
- Section for Personality PsychiatryOslo University HospitalNorway
| |
Collapse
|
46
|
Barnicot K, Crawford M. Posttraumatic Stress Disorder in Patients With Borderline Personality Disorder: Treatment Outcomes and Mediators. J Trauma Stress 2018; 31:899-908. [PMID: 30398678 DOI: 10.1002/jts.22340] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 08/13/2018] [Accepted: 08/20/2018] [Indexed: 11/07/2022]
Abstract
Posttraumatic stress disorder (PTSD) is highly comorbid with personality disorder (PD). We evaluated whether comorbid PTSD has a negative effect on patients' ability to benefit from evidence-based psychological treatments for PD and tested potential mediators of any effect. The effect of PTSD on self-harm and borderline PD symptoms was evaluated in 90 patients with borderline PD who were receiving dialectical behavior therapy or mentalization-based therapy. Self-report and interview measures were administered every 3 months over a 12-month period. Three-quarters of participants met criteria for PTSD. In the 12 months after beginning treatment, participants with PTSD did not engage in self-harm more often or present with more severe borderline PD symptoms. However, a higher level of PTSD symptom severity at baseline was associated with more frequent self-harm during follow-up, incidence rate ratio = 1.03, 95% CI [1.01, 1.06], p = .005. Participants whose PTSD did not improve or worsened were more likely to still self-harm, odds ratio (OR) = 0.91, 95 % CI [0.85, 0.97], p = .004, and report more severe borderline PD symptoms, b = 0.53, 95% CI [0.34, 0.73], p < .001, at the end of 12 months. The negative effects of PTSD symptoms remained significant after adjusting for potential confounders and were partially mediated by high ongoing levels of emotional dysregulation, indirect effect b = 0.32, 95% CI [0.19, 0.50]. These findings identify subgroups at risk of poorer outcomes from evidence-based psychological treatments for PD and support the idea that treating PTSD may improve outcomes.
Collapse
Affiliation(s)
- Kirsten Barnicot
- Centre for Psychiatry, Department of Medicine, Imperial College London, London, UK
| | - Mike Crawford
- Centre for Psychiatry, Department of Medicine, Imperial College London, London, UK
| |
Collapse
|
47
|
Abstract
Findings from randomized controlled trials and meta-analyses suggest that there are several efficacious treatments for borderline personality disorder, including those based on cognitive behavior theories and psychodynamic theories. In addition, there are generalist and adjunctive approaches. These treatments and the corresponding evidence associated with each are described. It is concluded randomized controlled trials and meta-analyses suggest little to no difference between any active specialty treatments for borderline personality disorder; there are no differences between dialectical behavior therapy and non-dialectical behavior therapy treatments or between cognitive behavior-based and psychodynamic theory-based treatments. Thus, clinicians are justified in using any of these efficacious treatments.
Collapse
Affiliation(s)
- Kenneth N Levy
- Department of Psychology, The Pennsylvania State University, State College, PA 16802, USA; Department of Psychiatry, Joan and Sanford I. Weill Medical College of Cornell University, New York, NY 10065, USA.
| | - Shelley McMain
- Department of Psychiatry, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, M5S 2S1, Canada
| | - Anthony Bateman
- Mentalization Training Unit, Saint Ann's Hospital, North London, NW3 5SU, UK
| | - Tracy Clouthier
- Department of Psychology, The Pennsylvania State University, State College, PA 16802, USA; Department of Psychiatry, Upstate Medical University, Syracuse, NY 13210, USA
| |
Collapse
|
48
|
Oud M, Arntz A, Hermens MLM, Verhoef R, Kendall T. Specialized psychotherapies for adults with borderline personality disorder:
A systematic review and meta-analysis. Aust N Z J Psychiatry 2018; 52:949-961. [PMID: 30091375 PMCID: PMC6151959 DOI: 10.1177/0004867418791257] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Borderline personality disorder affects up to 2% of the population and is associated with poor functioning, low quality of life and increased mortality. Psychotherapy is the treatment of choice, but it is unclear whether specialized psychotherapies (dialectical behavior therapy, mentalization-based treatment, transference-focused therapy and schema therapy) are more effective than non-specialized approaches (e.g. protocolized psychological treatment, general psychiatric management). The aim of this systematic review is to investigate the effectiveness of these psychotherapies. METHODS PubMed, PsycINFO, CINAHL, EMBASE and CENTRAL were searched from inception to November 2017. Included randomized controlled trials were assessed on risk of bias and outcomes were meta-analyzed. Confidence in the results was assessed using the Grading of Recommendations Assessment, Development and Evaluation method. The review has been reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS A total of 20 studies with 1375 participants were included. Specialized psychotherapies, when compared to treatment as usual or community treatment by experts, were associated with a medium effect based on moderate quality evidence on overall borderline personality disorder severity (standardized mean difference = -0.59 [95% confidence interval: -0.90, -0.28]), and dialectical behavior therapy, when compared to treatment as usual, with a small to medium effect on self-injury (standardized mean difference = -0.40 [95% confidence interval: -0.66, -0.13]). Other effect estimates were often inconclusive, mostly due to imprecision. CONCLUSION There is moderate quality evidence that specialized psychotherapies are effective in reducing overall borderline personality disorder severity. However, further research should identify which patient groups profit most of the specialized therapies.
Collapse
Affiliation(s)
- Matthijs Oud
- Department of Healthcare Innovation, Trimbos
Institute, Utrecht, The Netherlands,Matthijs Oud, Department of Healthcare Innovation,
Trimbos Institute, Da Costakade 45, 3521 VS Utrecht, The Netherlands.
| | - Arnoud Arntz
- Department of Clinical Psychology, University
of Amsterdam, Amsterdam, The Netherlands
| | - Marleen LM Hermens
- GGZ inGeest and Department of Psychiatry,
Amsterdam Public Health Research Institute, VU University Medical Center Amsterdam,
Amsterdam, The Netherlands
| | - Rogier Verhoef
- Department of Developmental Psychology,
Utrecht University, Utrecht, The Netherlands
| | | |
Collapse
|
49
|
King JC, Hibbs R, Saville CWN, Swales MA. The survivability of dialectical behaviour therapy programmes: a mixed methods analysis of barriers and facilitators to implementation within UK healthcare settings. BMC Psychiatry 2018; 18:302. [PMID: 30231865 PMCID: PMC6146662 DOI: 10.1186/s12888-018-1876-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 09/05/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Dialectical Behaviour Therapy (DBT) is an evidence-based intervention that has been included in the National Institute of Health and Care Excellence guidelines as a recommended treatment for Borderline Personality Disorder in the UK. However, implementing and sustaining evidence-based treatments in routine practice can be difficult to achieve. This study compared the survival of early and late adopters of DBT as well as teams trained via different training modes (on-site versus off-site), and explored factors that aided or hindered implementation of DBT into routine healthcare settings. METHODS A mixed-method approach was used. Kaplan-Meier survival analyses were conducted to quantify and compare survivability as a measure of sustainability between early and late implementers and those trained on- and off-site. An online questionnaire based on the Consolidated Framework for Implementation Research was used to explore barriers and facilitators in implementation. A quantitative content analysis of survey responses was carried out. RESULTS Early implementers were significantly less likely to survive than late implementers, although, the effect size was small. DBT teams trained off-site were significantly more likely to survive. The effect size for this difference was large. An unequal amount of censored data between groups in both analyses means that findings should be considered tentative. Practitioner turnover and financing were the most frequently cited barriers to implementation. Individual characteristics of practitioners and quality of the evidence base were the most commonly reported facilitators to implementation. CONCLUSIONS A number of common barriers and facilitators to successful implementation of DBT were found among DBT programmes. Location of DBT training may mediate programme survival.
Collapse
Affiliation(s)
- Joanne C. King
- 0000000118820937grid.7362.0School of Psychology, Bangor University, Bangor, Gwynedd UK
| | | | | | - Michaela A. Swales
- 0000000118820937grid.7362.0School of Psychology, Bangor University, Bangor, Gwynedd UK ,Besti Cadwaladr University Health Board, Bangor, Gwynedd UK
| |
Collapse
|
50
|
Richter C. Tagesklinische dialektisch-behaviorale Therapie: Eine Verlaufsuntersuchung nach Entlassung. Gibt es Prädiktoren für eine Verschlechterung? VERHALTENSTHERAPIE 2018. [DOI: 10.1159/000488360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|