Schindler Andreas, Warkentin H F, Bierbrodt J, König H, Konnopka A, Pepic A, Peth J, Lambert M, Gallinat J, Karow A, König H-H, Härter M, Schulz H, Rohenkohl A, Krog K, Biedermann S V, Schäfer I
Center for Psychosocial Medicine, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
Center for Psychosocial Medicine, Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
Borderline Personal Disord Emot Dysregul. 2024 Aug 14;11(1):18. doi: 10.1186/s40479-024-00261-4.
Though Dialectical Behavior Therapy (DBT) and other treatment models for individuals with Borderline Personality Disorder (BPD) have shown to be efficient in inpatient and outpatient settings, there is a general shortage of these treatments. In Germany, most resources are spent on inpatient treatments and unspecific crisis interventions, while it is difficult to implement the necessary team structures in an outpatient setting. This study is testing an alternative approach focussing on outpatient treatment: Integrated Care Borderline (ICB) provides DBT for persons with severe BPD within the structures of an Assertive Community Treatment (ACT). ICB is team-based, integrating psychiatric and social support as well as crisis interventions into a DBT-strategy.
ICB was compared to TAU in a prospective, randomized controlled trial. This study is part of RECOVER, a comprehensive stepped care approach in Germany, which enrolled a total of 891 participants. 146 persons were diagnosed with BPD as main diagnosis. Of these, 100 were allocated to the highest level of severe mental illness (SMI) and randomly assigned to either ICB (n = 50) or TAU (n = 50). Data were collected at baseline and 12 months later. The main outcomes were psychosocial functioning (GAF), severity of BPD (BSL-23) and other mental symptoms (BSI, PHQ-9, GAD-7, self-harm), employment status (VILI), as well as hospital days and associated costs.
Data show a significant increase of psychosocial functioning and a significant decrease of BPD and other psychiatric symptoms in both groups (r = .28 - .64), without any significant differences between the groups. The proportion of self-harming persons decreased in both groups without statistical significance. Patients were significantly more likely to be employed after a year of treatment in ICB (p = .001), but not in the TAU group (p = .454). Analyses showed a significant difference between the groups (p = .032). Moreover, psychiatric hospital days were significantly reduced in ICB (-89%, p < .001, r = .61), but not in TAU (-41%, p = .276, r = .15), resulting in a significant difference between the groups (p = .016) and in lower annual hospital costs in ICB (5,546€ vs. 10,726€, -48%, p = .011) compared to TAU.
Our results replicate earlier studies, showing that DBT can be efficient in outpatient settings. Furthermore, they indicate additional effects on employment and hospital days. The ICB-approach seems to offer a viable framework for multiprofessional outpatient DBT-teams. Future research will have to test whether the additional effects are brought about by the additional features of ICB compared to standard outpatient DBT.
Registration number with ClinicalTrials.gov (NCT03459664), RECOVER.
尽管辩证行为疗法（DBT）和其他针对边缘型人格障碍（BPD）患者的治疗模式在住院和门诊环境中已被证明是有效的，但这些治疗方法普遍短缺。在德国，大部分资源都用于住院治疗和非特定的危机干预，而在门诊环境中难以实施必要的团队结构。本研究正在测试一种侧重于门诊治疗的替代方法：综合护理边缘型人格障碍（ICB）在积极社区治疗（ACT）的结构内为重度BPD患者提供DBT。ICB是以团队为基础的，将精神科和社会支持以及危机干预整合到DBT策略中。
在一项前瞻性随机对照试验中，将ICB与常规治疗（TAU）进行比较。本研究是德国一项全面的分级护理方法RECOVER的一部分，该研究共招募了891名参与者。146人被诊断为以BPD为主诊断。其中，100人被分配到重度精神疾病（SMI）的最高级别，并随机分配到ICB组（n = 50）或TAU组（n = 50）。在基线和12个月后收集数据。主要结局包括心理社会功能（GAF）、BPD严重程度（BSL - 23）和其他精神症状（BSI、PHQ - 9、GAD - 7、自我伤害）、就业状况（VILI）以及住院天数和相关成本。
数据显示两组的心理社会功能均显著提高，BPD和其他精神症状均显著降低（r = 0.28 - 0.64），两组之间无任何显著差异。两组中自我伤害者的比例均下降，但无统计学意义。在接受ICB治疗一年后，患者就业的可能性显著更高（p = 0.001），但TAU组则不然（p = 0.454）。分析显示两组之间存在显著差异（p = 0.032）。此外，ICB组的精神科住院天数显著减少（-89%，p < 0.001，r = 0.61），而TAU组则不然（-41%，p = 0.276，r = 0.15），导致两组之间存在显著差异（p = 0.016），并且与TAU组相比，ICB组的年度住院成本更低（5546欧元对10726欧元，-48%，p = 0.011）。
我们的结果重复了早期研究，表明DBT在门诊环境中可能是有效的。此外，它们表明对就业和住院天数有额外影响。ICB方法似乎为多专业门诊DBT团队提供了一个可行的框架。未来的研究将必须测试与标准门诊DBT相比，ICB的附加特征是否带来了额外影响。
ClinicalTrials.gov注册号（NCT03459664），RECOVER。
