Day hospital versus intensive outpatient mentalization-based treatment: 3-year follow-up of patients treated for borderline personality disorder in a multicentre randomized clinical trial.

BACKGROUND: Two types of mentalization-based treatment (MBT), day hospital MBT (MBT-DH) and intensive outpatient MBT (MBT-IOP), have been shown to be effective in treating patients with borderline personality disorder (BPD). This study evaluated trajectories of change in a multi-site trial of MBT-DH and MBT-IOP at 36 months after the start of treatment. METHODS: All 114 patients (MBT-DH n = 70, MBT-IOP n = 44) from the original multicentre trial were assessed at 24, 30 and 36 months after the start of treatment. The primary outcome was symptom severity measured with the Brief Symptom Inventory. Secondary outcome measures included borderline symptomatology, personality and interpersonal functioning, quality of life and self-harm. Data were analysed using multilevel modelling and the intention-to-treat principle. RESULTS: Patients in both MBT-DH and MBT-IOP maintained the substantial improvements made during the intensive treatment phase and showed further gains during follow-up. Across both conditions, 83% of patients improved in terms of symptom severity, and 97% improved on borderline symptomatology. No significant differences were found between MBT-DH and MBT-IOP at 36 months after the start of treatment. However, trajectories of change were different. Whereas patients in MBT-DH showed greater improvement during the intensive treatment phase, patients in MBT-IOP showed greater continuing improvement during follow-up. CONCLUSIONS: Patients in both conditions showed similar large improvements over the course of 36 months, despite large differences in treatment intensity. MBT-DH and MBT-IOP were associated with different trajectories of change. Cost-effectiveness considerations and predictors of differential treatment outcome may further inform optimal treatment selection.

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.

Day hospital versus intensive out-patient mentalisation-based treatment for borderline personality disorder: multicentre randomised clinical trial.

BACKGROUND: Two types of mentalisation-based treatment (MBT) have been developed and empirically evaluated for borderline personality disorder (BPD): day hospital MBT (MBT-DH) and intensive out-patient MBT (MBT-IOP). No trial has yet compared their efficacy. AIMS: To compare the efficacy of MBT-DH and MBT-IOP 18 months after start of treatment. MBT-DH was hypothesised to be superior to MBT-IOP because of its higher treatment intensity. METHOD: In a multicentre randomised controlled trial (Nederlands Trial Register: NTR2292) conducted at three sites in the Netherlands, patients with BPD were randomly assigned to MBT-DH (n = 70) or MBT-IOP (n = 44). The primary outcome was symptom severity (Brief Symptom Inventory). Secondary outcome measures included borderline symptomatology, personality functioning, interpersonal functioning, quality of life and self-harm. Patients were assessed every 6 months from baseline to 18 months after start of treatment. Data were analysed using multilevel modelling based on intention-to-treat principles. RESULTS: Significant improvements were found on all outcome measures, with moderate to very large effect sizes for both groups. MBT-DH was not superior to MBT-IOP on the primary outcome measure, but MBT-DH showed a clear tendency towards superiority on secondary outcomes. CONCLUSIONS: Although MBT-DH was not superior to MBT-IOP on the primary outcome measure despite its greater treatment intensity, MBT-DH showed a tendency to be more effective on secondary outcomes, particularly in terms of relational functioning. Patients receiving MBT-DH and MBT-IOP, thus, seem to follow different trajectories of change, which may have important implications for clinical decision-making. Longer-term follow-up and cost-effectiveness considerations may ultimately determine the optimal intensity of specialised treatments such as MBT for patients with BPD.

Continuity Between DSM-5 Section II and III Personality Disorders in a Dutch Clinical Sample.

The goal of this study was to evaluate the continuity across the Section II personality disorders (PDs) and the proposed Section III model of PDs in the Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM-5]; American Psychiatric Association, 2013a ). More specifically, we analyzed association between the DSM-5 Section III pathological trait facets and Section II PDs among 110 Dutch adults (M age = 35.8 years, range = 19-60 years) receiving mental health care. We administered the Structured Clinical Interview for DSM-IV Axis II Disorders to all participants. Participants also completed the self-report Personality Inventory for DSM-5 (PID-5) as a measure of pathological trait facets. The distributions underlying the dependent variable were modeled as criterion counts, using negative binomial regression. The results provided some support for the validity of the PID-5 and the DSM-5 Section III Alternative Model, although analyses did not show a perfect match. Both at the trait level and the domain level, analyses showed mixed evidence of significant relationships between the PID-5 trait facets and domains with the traditional DSM-IV PDs.

Prevalence rates of borderline personality disorder symptoms: a study based on the Netherlands Mental Health Survey and Incidence Study-2.

BACKGROUND: Despite increasing knowledge of the prevalence of borderline personality disorder (BPD) in the general population, and rising awareness of mental disorders both as a categorical and a dimensional construct, research is still lacking on the prevalence of the number of BPD symptoms and their associated consequences, such as comorbidity, disability, and the use of mental health services) in the general population. METHODS: Data were obtained from the second wave of the Netherlands Mental Health Survey and Incidence Study-2 (N = 5303), a nationally representative face-to-face survey of the general population. BPD symptoms were measured by means of questions from the International Personality Disorder Examination. Comorbidity of common mental disorders was assessed with the Composite International Diagnostic Interview version 3.0. RESULTS: Of the total population studied, 69.9 % reported no BPD symptoms, while 25.2 % had 1-2 symptoms, 3.8 % had 3-4 symptoms, and 1.1 % had ≥ 5 BPD symptoms. The number of BPD symptoms reported was found to be positively associated with not living with a partner, having no paid job, and/or having a comorbid mood, anxiety or substance use disorder. Even after adjustment for sociodemographic characteristics and comorbidity, the number of BPD symptoms turned out to be uniquely associated with disability. It also showed a positive relationship with using services for dealing with mental health problems, although this relationship was strongly affected by the presence of comorbid disorders. CONCLUSIONS: Because even a relatively low number of BPD symptoms appears to be associated with psychiatric comorbidity and functional disability, not only full-blown BPD but also subthreshold levels of BPD symptoms need to be identified in clinical practice and research.

Effectiveness of Day Hospital Mentalization-Based Treatment for Patients with Severe Borderline Personality Disorder: A Matched Control Study.

The present study extends the body of evidence regarding the effectiveness of day hospital Mentalization-Based Treatment (MBT) by documenting the treatment outcome of a highly inclusive group of severe borderline personality disorder (BPD) patients, benchmarked by a carefully matched group who received other specialized psychotherapeutic treatments (OPT). Structured diagnostic interviews were conducted to assess diagnostic status at baseline. Baseline, 18-month treatment outcome and 36-month treatment outcome (after the maintenance phase) on psychiatric symptoms (Brief Symptom Inventory) and personality functioning (118-item Severity Indices of Personality Problems) were available for 29 BPD patients assigned to MBT, and an initial set of 175 BPD patients assigned to OPT. Propensity scores were used to determine the best matches for the MBT patients within the larger OPT group, yielding 29 MBT and 29 OPT patients for direct comparison. Treatment outcome was analysed using multilevel modelling. Pre to post effect sizes were consistently (very) large for MBT, with a Cohen's d of -1.06 and -1.42 for 18 and 36 months, respectively, for the reduction in psychiatric symptoms, and ds ranging from 0.81 to 2.08 for improvement in domains of personality functioning. OPT also yielded improvement across domains but generally of moderate magnitude. In conclusion, the present matched control study, executed by an independent research institute outside the UK, demonstrated the effectiveness of day hospital MBT in a highly inclusive and severe group of BPD patients, beyond the benchmark provided by a mix of specialized psychotherapy programmes. Interpretation of the (large) between condition effects warrants cautionary caveats given the non-randomized design, as well as variation in treatment dosages.

Effectiveness of Psychotherapy in Personality Disorders Not Otherwise Specified: A Comparison of Different Treatment Modalities.

OBJECTIVE: Although personality disorder not otherwise specified (PDNOS) is highly prevalent and associated with a high burden of disease, only a few treatment studies in this patient group exist. This study is the first to investigate the effectiveness of different modalities of psychotherapy in patients with PDNOS, i.e., short-term (up to 6 months) and long-term (more than 6 months) outpatient, day hospital, and inpatient psychotherapy. METHOD: A total of 205 patients with PDNOS were assigned to one of six treatment modalities. Effectiveness was assessed over 60 months after baseline. The primary outcome measure was symptom severity, and the secondary outcome measures included psychosocial functioning and quality of life. The study design was quasi-experimental, and the multiple propensity score was used to control for initial differences between treatment groups. RESULTS: All treatment modalities showed positive outcomes, especially in terms of improvements of symptom severity and social role functioning. At 12-month follow-up, after adjustment for initial differences between the treatment groups, short-term outpatient psychotherapy and short-term inpatient psychotherapy showed most improvement and generally outperformed the other modalities concerning symptom severity. At 60 months after baseline, effectiveness remained but observed differences between modalities mostly diminished. CONCLUSION: Patients with PDNOS benefit from psychotherapy both at short-term and long-term follow-up. Short-term outpatient psychotherapy and short-term inpatient psychotherapy seem to be superior to the other treatment modalities at 12-month follow-up. At 60-month follow-up, treatments showed mostly comparable effectiveness. KEY PRACTITIONER MESSAGES: The effectiveness of different modalities of psychotherapy in patients with PDNOS (i.e., short-term vs long-term; outpatient versus day hospital versus inpatient psychotherapy) has not yet been compared. Different modalities of psychotherapy are effective for patients with PDNOS, and positive effects remain after 5 years. In patients with PDNOS short-term (less than 6 months) outpatient psychotherapy and short-term inpatient psychotherapy seem to be superior to the four other treatment modalities at 12-month follow-up. At 60-month follow-up, treatments showed mostly comparable effectiveness.

Day hospital Mentalization-based treatment versus intensive outpatient Mentalization-based treatment for patients with severe borderline personality disorder: protocol of a multicentre randomized clinical trial.

BACKGROUND: Borderline personality disorder (BPD) is associated with a high socioeconomic burden. Although a number of evidence-based treatments for BPD are currently available, they are not widely disseminated; furthermore, there is a need for more research concerning their efficacy and cost-effectiveness. Such knowledge promises to lead to more efficient use of resources, which will facilitate the effective dissemination of these costly treatments. This study focuses on the efficacy and cost-effectiveness of Mentalization-Based Treatment (MBT), a manualized treatment for patients with BPD. Studies to date have either investigated MBT in a day hospitalization setting (MBT-DH) or MBT offered in an intensive outpatient setting (MBT-IOP). No trial has compared the efficacy and cost-effectiveness of these MBT programmes. As both interventions differ considerably in terms of intensity of treatment, and thus potentially in terms of efficacy and cost-effectiveness, there is a need for comparative trials. This study therefore sets out to investigate the efficacy and cost-effectiveness of MBT-DH versus MBT-IOP in patients with BPD. A secondary aim is to investigate the association between baseline measures and outcome, which might improve treatment selection and thus optimize efficacy and cost-effectiveness. METHODS/DESIGN: A multicentre randomized controlled trial comparing MBT-DH versus MBT-IOP in severe BPD patients. Patients are screened for BPD using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and are assessed before randomization, at the start of treatment and 6, 12, 18, 24, 30 and 36 months after the start of treatment. Patients who refuse to participate will be offered care as usual in the same treatment centre. The primary outcome measure is symptom severity as measured by the Brief Symptom Inventory. Secondary outcome measures include parasuicidal behaviour, depression, substance use, social, interpersonal, and personality functioning, attachment, mentalizing capacities, and quality of life. All analyses will be conducted based on the intention-to-treat principle. Cost-effectiveness will be calculated based on costs per quality-adjusted life-year. DISCUSSION: This multisite randomized trial will provide data to refine criteria for treatment selection for severe BPD patients and promises to optimize (cost-)effectiveness of the treatment of BPD patients. TRIAL REGISTRATION: NTR2292 . Registered 16 April 2010.

Specific personality traits and general personality dysfunction as predictors of the presence and severity of personality disorders in a clinical sample.

This study examined the associations of specific personality traits and general personality dysfunction in relation to the presence and severity of Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) personality disorders in a Dutch clinical sample. Two widely used measures of specific personality traits were selected, the Revised NEO Personality Inventory as a measure of normal personality traits, and the Dimensional Assessment of Personality Pathology-Basic Questionnaire as a measure of pathological traits. In addition, 2 promising measures of personality dysfunction were selected, the General Assessment of Personality Disorder and the Severity Indices of Personality Problems. Theoretically predicted associations were found between the measures, and all measures predicted the presence and severity of DSM-IV personality disorders. The combination of general personality dysfunction models and personality traits models provided incremental information about the presence and severity of personality disorders, suggesting that an integrative approach of multiple perspectives might serve comprehensive assessment of personality disorders.

Impact of clinical severity on treatment response in a randomized controlled trial comparing day hospital and intensive outpatient mentalization-based treatment for borderline personality disorder.

This study examined the impact of clinical severity on treatment outcome in two programs that differ markedly in treatment intensity: day hospital mentalization-based treatment (MBT-DH) and intensive outpatient mentalization-based treatment (MBT-IOP) for borderline personality disorder (BPD). A multicenter randomized controlled trial was conducted. Participants include the full intention-to-treat sample of the original trial of N = 114 randomized BPD patients (MBT-DH n = 70, MBT-IOP n = 44), who were assessed at baseline and subsequently every 6 up to 36 months after start of treatment. Outcomes were general symptom severity, borderline features, and interpersonal functioning. Clinical severity was examined in terms of severity of BPD, general symptom severity, comorbid symptom disorders, comorbid personality disorders, and cluster C personality features. None of the severity measures was related to treatment outcome or differentially predicted treatment outcome in MBT-DH and MBT-IOP, with the exception of a single moderating effect of co morbid symptom disorders on outcome in terms of BPD features, indicating less improvement in MBT-DH for patients with more symptom disorders. Overall, patients with varying levels of clinical severity benefited equally from MBT-DH and MBT-IOP, indicating that clinical severity may not be a useful criterion to differentiate in treatment intensity.

The General Assessment of Personality Disorder (GAPD) as an instrument for assessing the core features of personality disorders.

UNLABELLED: This study presents a psychometric evaluation of the General Assessment of Personality Disorder (GAPD), a self-report questionnaire for assessing the core components of personality dysfunction on the basis of Livesley's (2003) adaptive failure model. Analysis of samples from a general (n = 196) and a clinical population (n = 280) from Canada and the Netherlands, respectively, found a very similar two-component structure consistent with the two core components of personality dysfunction proposed by the model, namely, self-pathology and interpersonal dysfunction. Moreover, the GAPD discriminated between patients diagnosed with and without Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR) personality disorder(s) and demonstrated discriminative power in detecting the severity of personality pathology. Correlations with a DSM-IV symptom measure and a pathological traits model suggest partial conceptual overlap. Although further testing is indicated, the present findings suggest the GAPD is suitable for assessing the core components of personality dysfunction. It may contribute to a two-step integrated assessment of personality pathology that assesses both personality dysfunction and personality traits. KEY PRACTITIONER MESSAGE: The core features of personality disorder can be defined as disorders in the self and in the capacity for interpersonal functioning. A clinically useful operationalization of disordered functioning of personality is needed to determine the maladaptivity of personality traits. An integrated assessment of personality (dys)functioning and personality traits provides a more comprehensive clinical picture of the patient, which may aid treatment planning.

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).

Effectiveness of outpatient, day hospital, and inpatient psychotherapeutic treatment for patients with cluster B personality disorders.

BACKGROUND: For patients with cluster B personality disorders there is no consensus regarding the optimal treatment setting. The aim of this study was to compare the effectiveness of different psychotherapeutic settings for patients with cluster B personality disorders, i.e. outpatient, day hospital, and inpatient treatment. METHODS: The study was conducted between March 2003 and June 2008 in 6 mental health care centres in the Netherlands, with a sample of 207 patients with a DSM-IV-TR axis II cluster B diagnosis. Patients were assigned to 3 different settings of psychotherapeutic treatment and effectiveness was assessed at 18 months after baseline. An intention-to-treat analysis was conducted for psychiatric symptoms (Brief Symptom Inventory), psychosocial functioning (Outcome Questionnaire-45), and quality of life (EQ-5D), using multilevel statistical modelling. As the study was non-randomised, the propensity score method was used to control for initial differences. RESULTS: Patients in all 3 settings improved significantly in terms of psychiatric symptoms, social and interpersonal functioning, and quality of life 18 months after baseline. The inpatient group showed the largest improvements. The comparison of outpatient and inpatient treatment regarding psychiatric symptoms showed a marginally significant result (p = 0.057) in favour of inpatient treatment. CONCLUSIONS: Patients with cluster B personality disorders improved in all investigated treatment settings, with a trend towards larger improvements of psychiatric symptoms in the inpatient setting compared to the outpatient setting. Specialised inpatient treatment should be considered as a valuable treatment option for cluster B personality disorders, both in research and in clinical practice.

Patients with cluster a personality disorders in psychotherapy: an effectiveness study.

BACKGROUND: While psychopharmacological studies are common in patients with cluster A personality disorders, the effects of psychotherapy have received little attention. The aim of this study is to explore whether psychotherapeutic treatment yields health gains for these patients. METHODS: The study was conducted between March 2003 and June 2008 in 6 mental health care centres in the Netherlands, with a sample of 57 patients with a DSM-IV-TR axis II cluster A diagnosis. Patients were assigned to 3 settings of psychotherapeutic treatment (outpatient, day hospital, inpatient), and effectiveness was assessed at 18 months after baseline. An intention-to-treat analysis was conducted for psychiatric symptoms (Brief Symptom Inventory), psychosocial functioning (Outcome Questionnaire-45) and quality of life (EQ-5D), using multilevel statistical modelling. As the study was non-randomised, the propensity score method was used to control for initial differences. RESULTS: Patients in the day hospital and inpatient group improved substantially in terms of psychiatric symptoms, social and interpersonal functioning, and quality of life. Patients in the outpatient group showed less improvement. Direct comparison of the improvement of psychiatric symptoms showed significant results in favour of day hospital (p = 0.046) and inpatient (p = 0.01) treatment, as compared to outpatient treatment. However, due to substantial baseline differences, this direct comparison should be judged carefully. CONCLUSIONS: Cluster A psychopathology is not a contraindication to benefit from psychotherapy. This is especially true for more intensive forms like inpatient and day hospital treatment. Future research should focus more on psychotherapeutic treatment to gain further insight into effective treatment options for this patient group.

Cost-effective psychotherapy for personality disorders in the Netherlands: the value of further research and active implementation.

OBJECTIVE: In a budget-constrained health care system, decisions regarding resource allocation towards research and implementation are critical and can be informed by cost-effectiveness analysis. The objective of this study was to assess the societal value of conducting further research to inform reimbursement decisions and implementation of cost-effective psychotherapy for clusters B and C personality disorders (PDs). METHODS: Value of information and value of implementation analyses were conducted using previously developed cost-effectiveness models for clusters B and C PDs to evaluate the parameters that contribute to most of the decision uncertainty, and to calculate the population expected values of perfect information (pEVPI) and perfect implementation (pEVPIM). RESULTS: The pEVPI was estimated to be €425 million for cluster B PDs and €315 million for cluster C PDs, indicating that gathering additional evidence is expected to be cost-effective. The categories of parameters for which reduction of uncertainty would be most valuable were transition probabilities and health state costs. The pEVPIM was estimated to be €595 million for cluster B PDs and €1,372 million for cluster C PDs, suggesting that investing in implementation of cost-effective psychotherapy is likely to be worthwhile. CONCLUSIONS: The societal value of additional research on psychotherapy for clusters B and C PDs is substantial, especially when prioritizing information on transition probabilities and health state costs. Active implementation of cost-effective treatment strategies into clinical practice is likely to improve the efficiency of health care provision in The Netherlands.

Toward a model for assessing level of personality functioning in DSM-5, part II: empirical articulation of a core dimension of personality pathology.

The extensive comorbidity among Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994 ) personality disorders might be compelling evidence of essential commonalities among these disorders reflective of a general level of personality functioning that in itself is highly relevant to clinical decision making. This study sought to identify key markers of such a level, thought to reflect a core dimension of personality pathology involving impairments in the capacities of self and interpersonal functioning, and to empirically articulate a continuum of severity of these problems for DSM-5. Using measures of hypothesized core dimensions of personality pathology, a description of a continuum of severity of personality pathology was developed. Potential markers at various levels of severity of personality pathology were identified using item response theory (IRT) in 2 samples of psychiatric patients. IRT-based estimates of participants' standings on a latent dimension of personality pathology were significantly related to the diagnosis of DSM-IV personality disorder, as well as to personality disorder comorbidity. Further analyses indicated that this continuum could be used to capture the distribution of pathology severity across the range of DSM-IV personality disorders. The identification of a continuum of personality pathology consisting of impairments in self and interpersonal functioning provides an empirical foundation for a "levels of personality functioning" rating proposed as part of a DSM-5 personality disorder diagnostic formulation.

Cost-effectiveness of psychotherapy for cluster B personality disorders.

BACKGROUND: Recommendations on current clinical guidelines are informed by limited economic evidence. AIMS: A formal economic evaluation of three modalities of psychotherapy for patients with cluster B personality disorders. METHOD: A probabilistic decision-analytic model to assess the cost-effectiveness of out-patient, day hospital and in-patient psychotherapy over 5 years in terms of cost per recovered patient-year and cost per quality-adjusted life-year (QALY). Analyses were conducted from both societal and payer perspectives. RESULTS: From the societal perspective, the most cost-effective choice switched from out-patient to day hospital psychotherapy at a threshold of 12,274 euros per recovered patient-year; and from day hospital to in-patient psychotherapy at 113,298 euros. In terms of cost per QALY, the optimal strategy changed at 56,325 euros and 286,493 euros per QALY respectively. From the payer perspective, the switch points were at 9895 euros and 155,797 euros per recovered patient-year, and 43,427 euros and 561,188 euros per QALY. CONCLUSIONS: Out-patient psychotherapy and day hospital psychotherapy are the optimal treatments for patients with cluster B personality disorders in terms of cost per recovered patient-year and cost per QALY.

Effectiveness of different modalities of psychotherapeutic treatment for patients with cluster C personality disorders: results of a large prospective multicentre study.

BACKGROUND: No previous studies have compared the effectiveness of different modalities of psychotherapeutic treatment, as defined by different settings and durations, for patients with cluster C personality disorders. The aim of this multicentre study was to compare the effectiveness of 5 treatment modalities for patients with cluster C personality disorders in terms of psychiatric symptoms, psychosocial functioning, and quality of life. The following treatment modalities were compared: long-term outpatient (more than 6 months), short-term day hospital (up to 6 months), long-term day hospital, short-term inpatient, and long-term inpatient psychotherapy. METHODS: The study was conducted between March 2003 and June 2008 in 6 mental health care centres in the Netherlands, with a sample of 371 patients with a DSM-IV-TR axis-II cluster C diagnosis. Patients were assigned to 5 different modalities of psychotherapeutic treatment, and effectiveness was assessed at 12 months after baseline. An intention-to-treat analysis was conducted for psychiatric symptoms (Brief Symptom Inventory), psychosocial functioning (Outcome Questionnaire-45), and quality of life (EQ-5D), using multilevel statistical modelling. As the study was non-randomised, the propensity score method was used to control for initial differences. RESULTS: Patients in all treatment groups had improved on all outcomes 12 months after baseline. Patients receiving short-term inpatient treatment showed more improvement than patients receiving other treatment modalities. CONCLUSIONS: Psychotherapeutic treatment, especially in the short-term inpatient modality, is an effective treatment for patients with cluster C personality disorders.

The use of propensity score methods in psychotherapy research. A practical application.

BACKGROUND: Randomized controlled trials are considered the best scientific proof of effectiveness. There is increasing concern, though, about their feasibility in psychotherapy research. We discuss a quasi-experimental study design for situations in which a randomized controlled trial is not feasible. Here, as an alternative strategy, the propensity score (PS) method is used to correct for selection bias. METHODS: We used data from a Dutch research project, SCEPTRE (Study on Cost-Effectiveness of Personality Disorder Treatment). The sample consisted of 749 psychotherapy patients with personality pathology. We tested whether the PS method was useful and applicable. We examined differences between 2 treatment groups (short vs. long treatment duration) in pretreatment characteristics before and after PS correction. This revealed the impact of the PS on outcome differences. RESULTS: The PS offered statistical control over observed pretreatment differences between patients in a non-randomized study. CONCLUSIONS: When a randomized controlled trial is not possible, this quasi-experimental design using the PS could be a feasible alternative. Its advantages and limitations are discussed. Implemented carefully, this method is promising for future effectiveness research.