Efficacy and cost-effectiveness of an experimental short-term inpatient Dialectical Behavior Therapy (DBT) program: Study protocol for a randomized controlled trial

__Abstract__ Background: Borderline Personality Disorder (BPD) is a serious psychiatric condition associated with substantial mortality, burden and public health costs. DBT is the treatment model with the largest number of published research articles showing effectiveness. However, some patients are not sufficiently engaged in outpatient treatment while presenting severe parasuicidal behavior, making hospitalization necessary. The Center for Personality Disorders Jelgersma developed an intensive 12-week inpatient DBT program that (i) rapidly reduces core borderline symptoms like suicidal behavior, (ii) minimizes the negative effects of an inpatient setting, and (iii) enhances compliance with outpatient treatment. We evaluate the (cost-) effectiveness of this experimental program.Methods/design: Seventy patients, aged 18 to 45 years with a primary diagnosis of BPD, showing a chronic pattern of parasuicidal gestures and/or reporting high degrees of severity of other borderline symptoms, are randomly allocated to the control and intervention groups. Subjects in the control group receive standard outpatient DBT, provided in one of three regular mental health settings in GGZ Rivierduinen. Subjects in the intervention group receive 12 weeks of intensified inpatient DBT plus six months of standard DBT, provided in the Center for Personality Disorders Jelgersma. The primary outcome is the number of suicide attempts/self-harming acts. Secondary outcomes are severity of other borderline complaints, quality of life, general psychopathological symptoms and health care utilization and productivity costs. Data are gathered using a prospective, two (group: intervention and control) by five (time of measurement) repeated measures factorial design.Participants will complete three-monthly outcome assessments in the course of therapy: at baseline, and 12, 24, 36 and 52 weeks after the start of the treatment. The period of recruitment started in March 2012 and the study will end in December 2014.Discussion: Highly suicidal outpatient patients can pose a dilemma for mental health care professionals. Although hospitalization seems inevitable under some circumstances, it has proven to be harmful in its own right. This paper outlines the background and methods of a randomized trial evaluating the possible surplus value of a short-term inpatient DBT program

De effectiviteit van re-integratietraining versus boostersessies na kortdurende klinische psychotherapie: een gerandomiseerd klinisch onderzoek

Abstract BACKGROUND: Standardised evaluation studies performed in the Netherlands in a large number of inpatient and day-treatment hospitals providing psychotherapy have shown significant symptomatic improvements in patients between the date of entry to the studies and follow-up after one year. However, the work situation of ex-patients hardly changed and a large number of patients were still receiving psychotherapy. AIM: To examine the effectiveness of a specifically designed course of re-integration training. METHOD: A group of 128 patients were assigned randomly either to a re-integration training course aimed at improved functioning at work and improved relationships, or to booster sessions. Outcome measures were symptom level, work status, absence from work, and further psychotherapy. results After two years the number of patients in paid employment remained the same (76%) in the re-integration training course and increased from 67 to 87% in the booster sessions. Attendance was significantly higher in the booster sessions than in the re-integration training. There were no differences in the other outcome measures. CONCLUSION: We conclude that re-integration training was no more effective than the booster sessions. Our hypothesis is that continuity of care (therapists plus programme) explains the favourable result of the booster sessions

Initial Stages of Bose-Einstein Condensation

We present the quantum theory for the nucleation of Bose-Einstein condensation in a dilute atomic Bose gas. This quantum theory comfirms the results of the semiclassical treatment, but has the important advantage that both the kinetic and coherent stages of the nucleation process can now be described in a unified way by a single Fokker-Planck equation.Comment: Four pages of ReVTeX and no figure

Superfluidity of spin-polarized 6Li

We study the prospects for observing superfluidity in a spin-polarized atomic gas of $^6$Li atoms, using state-of-the-art interatomic potentials. We determine the spinodal line and show that a BCS transition to the superfluid state can indeed occur in the (meta)stable region of the phase diagram if the densities are sufficiently low. Moreover, for a total density of $10^{12}~cm^{-3}$, which still fulfills this requirement, we find a critical temperature of only $29~nK$. We also discuss the stability of the gas due to exchange and dipolar relaxation and conclude that the prospects for observing superfluidity in a magnetically trapped atomic $^6$Li gas are particularly promising for magnetic bias fields larger than $10~T$.Comment: 4 pages of ReVTeX and 2 uuencoded figures. Submitted for publication in Physical Review Letter

Atomic Bose Gas with Negative Scattering Length

We derive the equation of state of a dilute atomic Bose gas with an interatomic interaction that has a negative scattering length and argue that two continuous phase transitions, occuring in the gas due to quantum degeneracy effects, are preempted by a first-order gas-liquid or gas-solid transition depending on the details of the interaction potential. We also discuss the consequences of this result for future experiments with magnetically trapped spin-polarized atomic gasses such as lithium and cesium.Comment: 16 PAGES, REVTEX 3.0, ACCEPTED FOR PUBLICATION IN PHYS. REV.

Effectiveness of step-down versus outpatient dialectical behaviour therapy for patients with severe levels of borderline personality disorder

__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 stepdown 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 longterm effectiveness of step-down DBT, and moderators of treatment response, remain to be evaluated

Cost-effectiveness of blended vs. face-to-face cognitive behavioural therapy for severe anxiety disorders: study protocol of a randomized controlled trial

Background: Anxiety disorders are among the most prevalent psychiatric conditions, and are associated with poor quality of life and substantial economic burden. Cognitive behavioural therapy is an effective treatment to reduce anxiety symptoms, but is also costly and labour intensive. Cost-effectiveness could possibly be improved by delivering cognitive behavioural therapy in a blended format, where face-to-face sessions are partially replaced by online sessions. The aim of this trial is to determine the cost-effectiveness of blended cognitive behavioural therapy for adults with anxiety disorders, i.e. panic disorder, social phobia or generalized anxiety disorder, in specialized mental health care settings compared to face-to-face cognitive behavioural therapy. In this paper, we present the study protocol. It is hypothesized that blended cognitive behavioural therapy for anxiety disorders is clinically as effective as face-to-face cognitive behavioural therapy, but that intervention costs may be reduced. We thus hypothesize that blended cognitive behavioural therapy is more cost-effective than face-to-face cognitive behavioural therapy. Methods/design: In a randomised controlled equivalence trial 156 patients will be included (n = 78 in blended cognitive behavioural therapy, n = 78 in face-to-face cognitive behavioural therapy) based on a power of 0.80, calculated by using a formula to estimate the power of a cost-effectiveness analysis: $n = \frac{2(z_\alpha + z_\beta)^2(sd^2 + (W^2sd^2) - (2Wpsd_csd_q))}{(WE-C)^2}$ Measurements will take place at baseline, midway treatment (7 weeks), immediately after treatment (15 weeks) and 12-month follow-up. At baseline a diagnostic interview will be administered. Primary clinical outcomes are changes in anxiety symptom severity as measured with the Beck Anxiety Inventory. An incremental cost-effectiveness ratio will be calculated to obtain the costs per quality-adjusted life years (QALYs) measured by the EQ-5D (5-level version). Health-economic outcomes will be explored from a societal and health care perspective. Discussion: This trial will be one of the first to provide information on the cost-effectiveness of blended cognitive behavioural therapy for anxiety disorders in routine specialized mental health care settings, both from a societal and a health care perspective

Excitation-assisted inelastic processes in trapped Bose-Einstein condensates

We find that inelastic collisional processes in Bose-Einstein condensates induce local variations of the mean-field interparticle interaction and are accompanied by the creation/annihilation of elementary excitation. The physical picture is demonstrated for the case of three body recombination in a trapped condensate. For a high trap barrier the production of high energy trapped single particle excitations results in a strong increase of the loss rate of atoms from the condensate.Comment: 4 pages, no figure

Adiabatically changing the phase-space density of a trapped Bose gas

We show that the degeneracy parameter of a trapped Bose gas can be changed adiabatically in a reversible way, both in the Boltzmann regime and in the degenerate Bose regime. We have performed measurements on spin-polarized atomic hydrogen in the Boltzmann regime demonstrating reversible changes of the degeneracy parameter (phase-space density) by more than a factor of two. This result is in perfect agreement with theory. By extending our theoretical analysis to the quantum degenerate regime we predict that, starting close enough to the Bose-Einstein phase transition, one can cross the transition by an adiabatic change of the trap shape.Comment: 4 pages, 3 figures, Latex, submitted to PR