Abstract
BackgroundStep-down dialectical behaviour therapy (DBT) is a treatment consisting of 3 months of residential DBT plus 6 months of outpatient DBT. The program was specifically developed for people suffering from severe borderline personality disorder (BPD). The present study examines the effectiveness and cost-effectiveness of step-down DBT compared to 12 months of regular, outpatient DBT.MethodsEighty-four participants reporting high levels of BPD-symptoms (mean age 26 years, 95% female) were randomly assigned to step-down versus standard DBT. Measurements were conducted at baseline and after 3, 6, 9 and 12 months. The Lifetime Parasuicide Count and BPD Severity Index (BPDSI) were used to assess suicidal behaviour, non-suicidal self-injury (NSSI) and borderline severity. Costs per Quality Adjusted Life Year (QALY) were calculated using data from the EQ-5D-3L and the Treatment Inventory Cost in Psychiatric Patients (TIC-P).ResultsIn step-down DBT, 95% of patients started the program, compared to 45% of patients in outpatient DBT. The probability of suicidal behaviour did not change significantly over 12 months. The probability of NSSI decreased significantly in step-down DBT, but not in outpatient DBT. BPDSI decreased significantly in both groups, with the improvement leveling off at the end of treatment. While step-down DBT was more effective in increasing quality of life, it also cost significantly more. The extra costs per gained QALY exceeded the €80,000 threshold that is considered acceptable for severely ill patients in the Netherlands.ConclusionsA pragmatic randomized controlled trial in the Netherlands showed that 9 months of step-down DBT is an effective treatment for people suffering from severe levels of BPD. However, step-down DBT is not more effective than 12 months of outpatient DBT, nor is it more cost-effective. These findings should be considered tentative because of high noncompliance with the treatment assignment in outpatient DBT. Furthermore, the long-term effectiveness of step-down DBT, and moderators of treatment response, remain to be evaluated.Trial registrationwww.clinicaltrials.govNCT01904227. Registered 22 July 2013 (retrospectively registered).
Highlights
Step-down dialectical behaviour therapy (DBT) is a treatment consisting of 3 months of residential Dialectical Behaviour Therapy (DBT) plus 6 months of outpatient DBT
Participant flow A total of 187 participants were assessed for eligibility from February 2012 to January 2014 (Fig. 1)
One participant died by suicide before he received outpatient DBT
Summary
Step-down dialectical behaviour therapy (DBT) is a treatment consisting of 3 months of residential DBT plus 6 months of outpatient DBT. Outpatient dialectical behaviour therapy: an efficacious treatment for BPD Borderline Personality Disorder (BPD) is a severe and persistent mental disorder. A recent prospective study of the course and outcome of 290 inpatients diagnosed with BPD found a completed suicide rate of about 4% in the first 6 years of follow-up [3]. Dialectical Behaviour Therapy (DBT) was developed for chronically suicidal individuals diagnosed with BPD. The treatment strategies are rooted in Linehan’s emotion regulation (skills deficit) model, which states that dysfunctional behaviour in BPD can be explained as either consequences of pervasive emotion dysregulation or ways of coping with it [8, 9]. The first phase of DBT focusses on skills to stop the vicious circle of emotion dysregulation. Individual therapy to enhance motivation and to help apply DBT skills in daily life. The fourth and fifth components include specific case management strategies and team meetings to help therapists stay motivated and competent [8, 9]
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