Abstract
BackgroundSpecialized evidence-based treatments have been developed and evaluated for borderline personality disorder (BPD), including Dialectical Behavior Therapy (DBT) and Schema Therapy (ST). Individual differences in treatment response to both ST and DBT have been observed across studies, but the factors driving these differences are largely unknown. Understanding which treatment works best for whom and why remain central issues in psychotherapy research. The aim of the present study is to improve treatment response of DBT and ST for BPD patients by a) identifying patient characteristics that predict (differential) treatment response (i.e., treatment selection) and b) understanding how both treatments lead to change (i.e., mechanisms of change). Moreover, the clinical effectiveness and cost-effectiveness of DBT and ST will be evaluated.MethodsThe BOOTS trial is a multicenter randomized clinical trial conducted in a routine clinical setting in several outpatient clinics in the Netherlands. We aim to recruit 200 participants, to be randomized to DBT or ST. Patients receive a combined program of individual and group sessions for a maximum duration of 25 months. Data are collected at baseline until three-year follow-up. Candidate predictors of (differential) treatment response have been selected based on the literature, a patient representative of the Borderline Foundation of the Netherlands, and semi-structured interviews among 18 expert clinicians. In addition, BPD-treatment-specific (ST: beliefs and schema modes; DBT: emotion regulation and skills use), BPD-treatment-generic (therapeutic environment characterized by genuineness, safety, and equality), and non-specific (attachment and therapeutic alliance) mechanisms of change are assessed. The primary outcome measure is change in BPD manifestations. Secondary outcome measures include functioning, additional self-reported symptoms, and well-being.DiscussionThe current study contributes to the optimization of treatments for BPD patients by extending our knowledge on “Which treatment – DBT or ST – works the best for which BPD patient, and why?”, which is likely to yield important benefits for both BPD patients (e.g., prevention of overtreatment and potential harm of treatments) and society (e.g., increased economic productivity of patients and efficient use of treatments).Trial registrationNetherlands Trial Register, NL7699, registered 25/04/2019 - retrospectively registered.
Highlights
Specialized evidence-based treatments have been developed and evaluated for borderline personality disorder (BPD), including Dialectical Behavior Therapy (DBT) and Schema Therapy (ST)
Borderline personality disorder (BPD) patients make extensive use of treatment services resulting in markedly higher healthcare costs of people with BPD compared to people with other mental disorders, such as other personality disorders [14] and depressive disorder [15]
The first objective of this study is to develop a treatment selection model based on a combination of patient characteristics that predict treatment response across DBT and ST
Summary
Specialized evidence-based treatments have been developed and evaluated for borderline personality disorder (BPD), including Dialectical Behavior Therapy (DBT) and Schema Therapy (ST). BPD is associated with severe functional impairment, high rates of comorbid mental disorders, and physical health problems [5,6,7]. BPD is characterized by low quality of life; lower compared to other common mental disorders such as depressive disorder, and comparable to that of patients with severe physical conditions, such as Parkinson’s disease and stroke [8]. BPD patients make extensive use of treatment services resulting in markedly higher healthcare costs of people with BPD compared to people with other mental disorders, such as other personality disorders [14] and depressive disorder [15]. BPD is associated with high non-healthcare costs, including costs related to productivity losses, informal care, and out-of-pocket costs [16, 17]
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