逐步递减疗法与门诊辩证行为疗法对重度边缘型人格障碍患者的疗效比较：一项实用随机对照试验
Effectiveness of step-down versus outpatient dialectical behaviour therapy for patients with severe levels of borderline personality disorder: a pragmatic randomized controlled trial.
作者信息
Sinnaeve Roland, van den Bosch Louisa M C, Hakkaart-van Roijen Leona, Vansteelandt Kristof
机构信息
1GGZ Rivierduinen - Centre for Personality Disorders Jelgersma, Rhijngeesterstraatweg 13-C, 2342 AN Oegstgeest, The Netherlands.
3Z.org KU Leuven, University of Leuven, Leuvensesteenweg 517, 3070 Kortenberg, Belgium.
出版信息
Borderline Personal Disord Emot Dysregul. 2018 Jul 10;5:12. doi: 10.1186/s40479-018-0089-5. eCollection 2018.
BACKGROUND
Step-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.
METHODS
Eighty-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).
RESULTS
In 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.
CONCLUSIONS
A 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 REGISTRATION
www.clinicaltrials.govNCT01904227. Registered 22 July 2013 (retrospectively registered).
背景
逐步递减式辩证行为疗法（DBT）是一种治疗方法，包括3个月的住院DBT加6个月的门诊DBT。该项目是专门为患有严重边缘型人格障碍（BPD）的人开发的。本研究考察了与12个月的常规门诊DBT相比，逐步递减式DBT的有效性和成本效益。
方法
84名报告有高水平BPD症状的参与者（平均年龄26岁，95%为女性）被随机分配到逐步递减式DBT组和标准DBT组。在基线以及3、6、9和12个月后进行测量。终身自杀未遂计数和BPD严重程度指数（BPDSI）用于评估自杀行为、非自杀性自伤（NSSI）和边缘型严重程度。使用来自EQ-5D-3L和精神科患者治疗费用清单（TIC-P）的数据计算每质量调整生命年（QALY）的成本。
结果
在逐步递减式DBT中，95%的患者开始了该项目，而门诊DBT组为45%。自杀行为的概率在12个月内没有显著变化。逐步递减式DBT中NSSI的概率显著下降，但门诊DBT组没有。两组的BPDSI均显著下降，治疗结束时改善趋于平稳。虽然逐步递减式DBT在提高生活质量方面更有效，但成本也显著更高。每获得一个QALY的额外成本超过了荷兰认为对重症患者可接受的80,000欧元阈值。
结论
荷兰的一项实用随机对照试验表明，9个月的逐步递减式DBT对患有严重BPD的人是一种有效的治疗方法。然而，逐步递减式DBT并不比12个月的门诊DBT更有效，也没有更高的成本效益。由于门诊DBT组对治疗分配的高不依从性，这些发现应被视为初步的。此外，逐步递减式DBT的长期有效性以及治疗反应的调节因素仍有待评估。
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