Background: A primary goal of dialectical behaviour therapy (DBT) is to reduce self-harm, but findings from empirical studies are inconclusive. The aim of this study was to assess the effectiveness and cost-effectiveness of DBT in reducing self-harm in patients with personality disorder. Methods: Participants with a personality disorder and at least 5 days of self-harm in the previous year were randomised to receive 12 months of either DBT or treatment as usual (TAU). The primary outcome was the frequency of days with self-harm; secondary outcomes included borderline personality disorder symptoms, general psychiatric symptoms, subjective quality of life, and costs of care. Results: Forty patients each were randomised to DBT and TAU. In an intention-to-treat analysis, there was a statistically significant treatment by time interaction for self-harm (incidence rate ratio 0.91, 95% CI 0.89–0.92, p < 0.001). For every 2 months spent in DBT, the risk of self-harm decreased by 9% relative to TAU. There was no evidence of differences on any secondary outcomes. The economic analysis revealed a total cost of a mean of 5,685 GBP (6,786 EUR) in DBT compared to a mean of 3,754 GBP (4,481 EUR) in TAU, but the difference was not significant (95% CI –603 to 4,599 GBP). Forty-eight per cent of patients completed DBT. They had a greater reduction in self-harm compared to dropouts (incidence rate ratio 0.78, 95% CI 0.76–0.80, p < 0.001). Conclusions: DBT can be effective in reducing self-harm in patients with personality disorder, possibly incurring higher total treatment costs. The effect is stronger in those who complete treatment. Future research should explore how to improve treatment adherence.

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Dialectical behaviour therapy (DBT) is an evidence-based intensive treatment for borderline personality disorder and self-harm created by Linehan. In its original form it offers a year-long treatment consisting of 2-2.5 hours per week of group-based skills training, 1 hour a week of a one-to-one session, the opportunity for between-session crisis skills coaching and weekly peer supervision for the treatment team.1,2 Randomised controlled trials (RCTs) in the USA, The Netherlands and the UK have demonstrated that DBT is effective at helping people reduce self-harming behaviour. [3][4][5][6][7][8][9] The average treatment retention rate in non-UK-based studies was 67%. However, the UK-based RCTs comparing DBT with treatment as usual 3,10 demonstrated much higher treatment drop-out rates: 58 and 52%, whereas an earlier UK-based observational study reported an even higher drop-out rate of 67%. 11The McMain et al 7 study of treatment as usual v. DBT in Canada also had a relatively high drop-out rate of 39%.Previous studies on drop out and disengagement from mental health services identified associations with socioeconomic characteristics such as younger age, male gender, ethnic minority background, low socioeconomic status and social isolation.12,13 Those studies also linked clinical characteristics such as substance misuse, forensic history, high levels of psychopathology and lack of insight to higher drop-out rates. Some research has found poor alliance with the therapist as well as a lack of active participation in treatment by the patient to be correlated with drop out. 14,15Drop out is more likely to occur during the early period of treatment. 12,13 In contrast to those studies, Barnicot et al's 16 meta-analysis on drop out for patients with borderline personality disorder revealed that sociodemographic variables are consistently non-significantly associated with drop out for this group of patients, whereas lower commitment to change, a poorer therapeutic relationship, and higher impulsivity consistently predicted drop out. Other work has shown that patients with borderline personality disorder who perceive their treatment as less credible, do not use the skills taught in therapy, and have lower self-efficacy, and are also more likely to drop out of DBT (further details from K.B., on request).McMain et al 7 put down treatment context as a possible explanatory factor for their high drop-out rate -and specifically, the availability of other publicly funded treatment options -and Priebe et al 10 speculated that the National Health Service (NHS) context might lead to higher drop-out rates since alternative treatments or (crisis) management options are more easily available in the UK than in other settings, such as the healthcare system in the USA. Yet, no further research has been conducted to explore this. The current study examines the characteristics of patients dropping out from DBT in the UK and focuses on the question of whether being the recipient of care coordination under the care programme approach at the ...

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