Dialectical behaviour therapy for posttraumatic stress disorder (DBT-PTSD): transportability to everyday clinical care in a residential mental health centre

ABSTRACT

Background: Dialectical Behaviour Therapy for Posttraumatic Stress Disorder (DBT-PTSD) is a phase-based treatment for PTSD. The DBT-PTSD treatment programme’s efficacy has not been tested during standard operation, outside of laboratory outcome studies.

Objective: The present pilot study investigated the transportability of the DBT-PTSD treatment to a real word clinical setting in a residential mental health centre.

Methods: The DBT-PTSD treatment was compared to a treatment as usual (TAU) condition in a non-randomized study. Overall, 156 patients from a residential mental health centre were included. Propensity score matching was used to match participants in the two treatment arms based on baseline characteristics. Primary and secondary outcomes (PTSD and other symptoms) were assessed at the time of admission and at the time of discharge.

Results: The DBT-PTSD treatment outperformed the TAU condition in the improvement of all primary outcomes, as indicated by a significant time and group interaction. There were notable differences in the effect sizes between the unmatched and matched sample as well as between the available and the intent-to-treat (ITT) data analyses. The effect sizes in the ITT data analyses were much lower. Both treatment groups showed similar improvements in secondary outcomes.

Conclusions: This study provides initial evidence for the transportability of the DBT-PTSD treatment to a naturalistic clinical care setting, but with considerably lower effect sizes than in previously published laboratory RCTs. The higher efficacy of DBT-PTSD compared to TAU may largely depend on patient’s adherence to treatment.

HIGHLIGHTS

• The objective of the present study was to investigate the transportability of the DBT-PTSD programme to a real word clinical setting in a residential mental health centre.

• The DBT-PTSD treatment outperformed the TAU condition in the reduction of trauma-related symptoms, dissociative symptoms and DSO related but with lower effect sizes compared to previously published RCTs.

• The study results indicate the influence of treatment adherence on estimates of treatment effects and stress the necessity to routinely monitor the symptoms of patients who are at high risk of dropout or deterioration.

Antecedentes: La Terapia Dialéctica Conductual para el Trastorno de Estrés Postraumático (DBT-PTSD) es un tratamiento basado en fases para el TEPT. La eficacia del programa de tratamiento DBT-PTSD no se ha probado durante el funcionamiento estándar, fuera de los estudios de resultados de laboratorio.

Objetivo: El presente estudio piloto investigó la transportabilidad del tratamiento DBT-PTSD a un entorno clínico de mundo real en un centro residencial de salud mental.

Métodos: El tratamiento DBT-PTSD se comparó con una condición de tratamiento habitual (TAU) en un estudio no aleatorizado. En total, se incluyeron 156 pacientes de un centro residencial de salud mental. Se utilizó el emparejamiento por puntuación de propensión para emparejar a los participantes en los dos brazos de tratamiento en función de las características basales. Los resultados primarios y secundarios (TEPT y otros síntomas) se evaluaron en el momento del ingreso y en el momento del alta.

Resultados: El tratamiento DBT-PTSD superó a la condición TAU en la mejora de todos los resultados primarios, como indica una interacción significativa de tiempo y grupo. Hubo diferencias notables en los tamaños del efecto entre la muestra no emparejada y la emparejada, así como entre los análisis de datos disponibles y los de intención de tratar (ITT, siglas en inglés). Los tamaños del efecto en los análisis de datos ITT fueron mucho menores. Ambos grupos de tratamiento mostraron mejoras similares en los resultados secundarios.

Conclusiones: Este estudio proporciona evidencia inicial de la transportabilidad del tratamiento DBT-PTSD a un entorno de atención clínica naturalista, pero con tamaños del efecto considerablemente más bajos que en los ECA de laboratorio publicados anteriormente. La mayor eficacia de la DBT-TEPT en comparación con la TAU puede depender en gran medida de la adherencia del paciente al tratamiento.

抽象背景：创伤后应激障碍辩证行为疗法 (DBT-PTSD) 是一种阶段性的 PTSD 治疗方法。 DBT-PTSD 治疗计划的疗效尚未在实验室结果研究之外的标准操作期间被检验。

目的：本试点研究考查了 DBT-PTSD 治疗在居民心理健康中心真实临床环境中的可推广性。

方法：在一项非随机研究中，将 DBT-PTSD 治疗与常规治疗 (TAU) 条件进行比较。 总共纳入了156名来自居民心理健康中心的患者。根据基线特征使用倾向得分匹配两个治疗组的参与者。 在入院时和出院时评估了主要和次要结果（PTSD 和其他症状）。

结果：DBT-PTSD 治疗在所有主要结果的改善上优于 TAU 条件，如显著的时间和组相互作用所示。 不匹配样本和匹配样本之间以及可用性和意向性 (ITT) 数据分析之间，效应量存在显著差异。 ITT 数据分析中的效应量低得多。 两个治疗组在次要结果上均表现出相似的改善。

结论：本研究为 DBT-PTSD 治疗在自然临床护理环境中的可推广性提供了初步证据，但其效应量远低于先前发表的实验室 RCT。 与 TAU 相比，DBT-PTSD 的更高疗效可能在很大程度上取决于患者对治疗的依从性。

KEYWORDS:

• Dialectical behaviour therapy
• posttraumatic stress disorder
• DBT-PTSD
• transportability
• dissemination

PALABRAS CLAVE:

• Terapia dialéctica conductual
• trastorno de estrés postraumático
• DBT-PTSD
• Transportabilidad
• Diseminación

关键词:

• 辩证行为疗法
• 创伤后应激障碍
• DBT-PTSD
• 可推广性
• 传播

Acknowledgements

The authors thank all patients and therapists from the trauma treatment units at the University Hospital for Psychosomatic Medicine Eggenburg as well as Elisabeth Busta and Thomas Schütt who conducted the routine clinical outcome monitoring. The authors also like to thank Friedrich Riffer who made this study possible through his lobbying for the establishment of the endowed professorship in clinical psychology at the Karl Landsteiner University and his advocacy for the implementation of the DBT-PTSD treatment programme at the University Hospital for Psychosomatic Medicine Eggenburg. Author Contributions: CO, MS were involved in designing and conceptualization of the research study. CO, MS, SG and JB were responsible for the data analysis and data curation. CO and MS prepared the original draft and were responsible for revisions and prepared the final version. SG and JB were involved in the review and editing of the manuscript. All authors have read and agreed to the published version of the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The datasets presented in this article are not readily available because of the vulnerability of the study sample. Participants of this study did not agree for their data to be shared publicly, so supporting data is not available.

Statement of ethics

The present study is a retrospective analysis of data collected during routine clinical care. The analysis was approved by the ethics commission of the Karl Landsteiner University of Health Sciences (Nr: 1020/2021). Written informed consent was obtained from all study participants and the study follows the ethical standards proposed in the Declaration of Helsinki (World Medical Association, 2013). All participants consented to the use of their data.

Additional information

Funding

We gratefully acknowledge the financial support of the Society for Research Promotion Lower Austria [Gesellschaft für Forschungsförderung Niederösterreich (GFF)] as part of the endowed professorship in clinical psychology (MS, JB, SG). We also thank the VAMED for funding the position held by CO. We further acknowledge support by Open Access Publishing Fund of Karl Landsteiner University of Health Sciences, Krems, Austria. These funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.