Economic evaluation of day hospital versus intensive outpatient mentalization-based treatment alongside a randomized controlled trial with 36-month follow-up.

Mentalization-based treatment (MBT) has demonstrated robust effectiveness in the treatment of borderline personality disorder (BPD) in both day-hospital (MBT-DH) and intensive outpatient MBT (MBT-IOP) programs. Given the large differences in intensity and associated treatment costs, there is a need for studies comparing their cost-effectiveness. A health economic evaluation of MBT-DH versus MBT-IOP was performed alongside a multicenter randomized controlled trial with a 36-month follow-up. In three mental health-care institutions in the Netherlands, 114 patients were randomly allocated to MBT-DH (n = 70) or MBT-IOP (n = 44) and assessed every 6 months. Societal costs were compared with quality-adjusted life years (QALYs) gained and the number of months in remission over 36 months. The QALY gains over 36 months were 1.96 (SD = .58) for MBT-DH and 1.83 (SD = .56) for MBT-IOP; the respective number of months in remission were 16.0 (SD = 11.5) and 11.1 (SD = 10.7). Societal costs were €106,038 for MBT-DH and €91,368 for MBT-IOP. The incremental cost for one additional QALY with MBT-DH compared with MBT-IOP was €107,000. The incremental cost for 1 month in remission was almost €3000. Assuming a willingness-to-pay threshold of €50,000 for a QALY, there was a 33% likelihood that MBT-DH is more cost-effective than MBT-IOP in terms of costs per QALY. Although MBT-DH leads to slightly more QALYs and remission months, it is probably not cost-effective when compared with MBT-IOP for BPD patients, as the small additional health benefits in MBT-DH did not outweigh the substantially higher societal costs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Trauma and Outcomes of Mentalization-Based Therapy for Individuals With Borderline Personality Disorder.

OBJECTIVE: Recent meta-analyses suggest that many patients with borderline personality disorder have a history of complex trauma. Although trauma is central in mentalization-based approaches to the understanding of borderline personality disorder, surprisingly little is known about the effects of trauma on outcomes of mentalization-based treatment (MBT). This article investigates the prevalence and impact of childhood trauma among patients with borderline personality disorder participating in a randomized controlled trial (RCT) comparing day hospital MBT (MBT-DH) and intensive outpatient MBT (MBT-IOP). METHODS: All 114 patients from the original multicenter RCT in the Netherlands were included in this study. Childhood trauma was assessed at baseline (with the Childhood Trauma Questionnaire), and its impact on symptom severity, interpersonal functioning, and borderline pathology was investigated through multilevel modeling for 36 months after the start of treatment. RESULTS: Childhood trauma was common among patients with borderline personality disorder referred to MBT, with more than 85% meeting cutoff criteria for substantial childhood trauma. Childhood trauma had little impact on outcomes of either MBT-DH or MBT-IOP in terms of improved borderline personality disorder features or interpersonal functioning. However, patients with substantial childhood trauma seemed to improve more rapidly with MBT-DH, as compared with MBT-IOP, in terms of symptom severity. In addition, patients with a history of emotional neglect showed more rapid changes in symptoms of borderline personality disorder with MBT-DH compared with MBT-IOP. CONCLUSIONS: Findings are discussed in the context of a social communicative approach to borderline personality disorder, with a focus on the need to address trauma in MBT.

Investigating the stress-related fluctuations of level of personality functioning: A critical review and agenda for future research.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD-11) proposed a dimensional approach to the assessment of personality disorders (PDs). Both models dictate that the clinician first determines PD severity before assessing maladaptive traits, invoking the level of personality functioning (LPF) construct. We consider LPF a promising dimensional construct for translational research because of its clinical importance and conceptual overlap with the Research Domain Criteria (RDoC) Social Processes. We aim to identify biomarkers that co-vary with fluctuations in LPF in adulthood, ultimately to predict persistent decrease in LPF, associated with suicidality and morbidity. However, a theoretical framework to investigate stress-related oscillations in LPF is currently missing. In this article, we aim to fill this hiatus with a critical review about stress and LPF. First, we discuss acute stress and LPF. We briefly present the basics of the neurophysiological stress response and review the literature on momentary and daily fluctuations in LPF, both at a subjective and physiological level. Second, we review the effects of chronic stress on brain function and social behaviour and recapitulate the main findings from prospective cohort studies. This review underlies our suggestions for multimethod assessment of stress-related oscillations in LPF and our theoretical framework for future longitudinal studies, in particular studies using the experience sampling method (ESM).

Modeling BAS Dysregulation in Bipolar Disorder.

Time series analysis is a technique that can be used to analyze the data from a single subject and has great potential to investigate clinically relevant processes like affect regulation. This article uses time series models to investigate the assumed dysregulation of affect that is associated with bipolar disorder. By formulating a number of alternative models that capture different kinds of theoretically predicted dysregulation, and by comparing these in both bipolar patients and controls, we aim to illustrate the heuristic potential this method of analysis has for clinical psychology. We argue that, not only can time series analysis elucidate specific maladaptive dynamics associated with psychopathology, it may also be clinically applied in symptom monitoring and the evaluation of therapeutic interventions.

Recovery of Work-Related Stress: Complaint Reduction and Work-Resumption are Relatively Independent Processes.

PURPOSE: The process of recovery from work-related stress, consisting of complaint reduction and work-resumption, is not yet fully understood. The aim of this study was to investigate predictors of complaint reduction and work-resumption, as well as testing complaint reduction as a mediator in the association between predictors and work-resumption. METHODS: Seventy-one patients on sickness-leave because of work-related stress complaints were followed over a period of 13 months. Predictors comprised personal (demographics, coping, cognitions), work-related (job-characteristics, social support), and illness-related (complaint duration, absence duration) variables. Dependent variables were distress complaints, burnout complaints, and work-resumption. RESULTS: Complaints reduced considerably over time to borderline clinical levels and work-resumption increased to 68% at 13 months. Predictors of stronger reduction of distress complaints were male gender, less working hours, less decision authority, more co-worker support, and shorter absence duration. Predictors of stronger reduction of burnout complaints were male gender, lower age, high education, less avoidant coping, less decision authority, more job security, and more co-worker support. Predictors of work-resumption were lower age and stronger reduction of burnout complaints. No indication for a mediating role of burnout complaints between the predictor age and work-resumption was found. CONCLUSIONS: Complaint reduction and work-resumption are relatively independent processes. Symptom reduction is influenced by individual and work-related characteristics, which holds promise for a multidisciplinary treatment approach for work-related stress.

Prioritizing Child Pornography Notifications: Predicting Direct Victimization.

The growing number of notifications for child pornography (CP) possession constitutes a capacity problem for police forces entrusted with the investigation of these offenses. Notifications of CP offenses in which the investigation reveals concurrent direct victimization, in the form of contact offenses, grooming, online offending, or the production of CP material, form a potential target group for prioritization. The first of the twofold aims of this study was to validate the occurring distinction between mixed suspects (i.e., CP possession suspects who were also ever associated with direct victimization) and CP-only suspects (i.e., CP possession suspects who were never associated with direct victimization) to predict an outcome of the investigation including direct victimization. The second aim was to explore variables related to direct victimization among CP-only suspects. A total of 150 files of police investigations into notifications for CP offenses were studied. Findings confirmed significantly greater prevalence of direct victimization as an outcome of the investigation among mixed suspects than CP-only suspects (90% vs. 10%). Among CP-only suspects, direct victimization was predicted by (a) prior police contacts, charges, or convictions concerning noncontact sexual offending, (b) the confiscation of more than two computers during the house search, and (c) a more serious nature of the CP material that formed the basis for the notification in terms of younger victims and more extreme content. These variables may point to a small subgroup of heavily invested CP offenders who are at a higher risk to cross the line to direct victimization. Cross-validation of these preliminary findings is indicated.

Treatment referral for sex offenders based on clinical judgment versus actuarial risk assessment: match and analysis of mismatch.

The Risk Need Responsivity (RNR) principles (Andrews & Bonta, 2010) dictate that higher risk sex offenders should receive more intensive treatment. The present study investigates how clinically based treatment assignment relates to risk level in a sex offender sample from The Netherlands. Correlational analyses served to identify sources of mismatches: that is, variables differing significantly in their relation between treatment selection and risk level. Our study sample consisted of 194 convicted rapists and 214 convicted child molesters. All participants' criminal files were retrospectively coded in terms of the items of the STATIC-99R, PCL: SV, and SVR-20. A low to moderate correlation was observed between clinical treatment selection and actuarial risk levels. A substantial part of the sex offenders, especially child molesters, received overly intensive treatment and another substantial part, especially rapists, received treatment of lesser intensity than indicated by their risk levels. General violent and antisocial risk factors seemed to be underemphasized in the clinical evaluation of sex offenders, especially rapists. A negative attitude toward intervention was negatively associated with clinical treatment selection. It is concluded that clinical treatment selection leads to an insufficient match between risk level and treatment level and systematic use of validated structured risk assessment instruments is necessary to ensure optimal adherence to the risk principle.

Self-Verification Strivings in Children Holding Negative Self-Views: The Mitigating Effects of a Preceding Success Experience.

Research among adults has consistently shown that people holding negative self-views prefer negative over positive feedback. The present study tested the hypothesis that this preference is less robust among pre-adolescents, such that it will be mitigated by a preceding positive event. Pre-adolescents (n = 75) holding positive or negative global self-esteem were randomized to a favorable or unfavorable peer evaluation outcome. Next, preferences for positive versus negative feedback were assessed using an unobtrusive behavioral viewing time measure. As expected, results showed that after being faced with the success outcome children holding negative self-views were as likely as their peers holding positive self-views to display a significant preference for positive feedback. In contrast, children holding negative self-views displayed a stronger preference for negative feedback after being faced with the unfavorable outcome that matched their pre-existing self-views.

How do intake clinicians use patient characteristics to select treatment for patients with personality disorders?

Treatment selection in clinical practice is a poorly understood, often largely implicit decision process, perhaps especially for patients with personality disorders. This study, therefore, investigated how intake clinicians use information about patient characteristics to select psychotherapeutic treatment for patients with personality disorder. A structured interview with a forced-choice format was administered to 27 experienced intake clinicians working in five specialist mental health care institutes in the Netherlands. Substantial consensus was evident among intake clinicians. The results revealed that none of the presented patient characteristics were deemed relevant for the selection of the suitable treatment setting. The appropriate duration and intensity are selected using severity or personal strength variables. The theoretical orientation is selected using personal strength variables.

Children's coping with in vivo peer rejection: an experimental investigation.

We examined children's behavioral coping in response to an in vivo peer rejection manipulation. Participants (N=186) ranging between 10 and 13 years of age, played a computer game based on the television show Survivor and were randomized to either peer rejection (i.e., being voted out of the game) or non-rejection control. During a five-min. post-feedback waiting period children's use of several behavioral coping strategies was assessed. Rejection elicited a marked shift toward more negative affect, but higher levels of perceived social competence attenuated the negative mood shift. Children higher in depressive symptoms were more likely to engage in passive and avoidant coping behavior. Types of coping were largely unaffected by gender and perceived social competence. Implications are discussed.