Mobile Diary App Versus Paper-Based Diary Cards for Patients With Borderline Personality Disorder: Economic Evaluation

Sidsel Lund Laursen, Stig Helweg-Jørgensen, Astrid Langergaard, Jesper Søndergaard, Sabrina Storgaard Sørensen, Kim Mathiasen, Mia Beck Lichtenstein, Lars Holger Ehlers, Sidsel Lund Laursen, Stig Helweg-Jørgensen, Astrid Langergaard, Jesper Søndergaard, Sabrina Storgaard Sørensen, Kim Mathiasen, Mia Beck Lichtenstein, Lars Holger Ehlers

Abstract

Background: The cost-effectiveness of using a mobile diary app as an adjunct in dialectical behavior therapy (DBT) in patients with borderline personality disorder is unknown.

Objective: This study aims to perform an economic evaluation of a mobile diary app compared with paper-based diary cards in DBT treatment for patients with borderline personality disorder in a psychiatric outpatient facility.

Methods: This study was conducted alongside a pragmatic, multicenter, randomized controlled trial. The participants were recruited at 5 Danish psychiatric outpatient facilities and were randomized to register the emotions, urges, and skills used in a mobile diary app or on paper-based diary cards. The participants in both groups received DBT delivered by the therapists. A cost-consequence analysis with a time horizon of 12 months was performed. Consequences included quality-adjusted life years (QALYs), depression severity, borderline severity, suicidal behavior, health care use, treatment compliance, and system usability. All relevant costs were included. Focus group interviews were conducted with patients, therapists, researchers, and industry representatives to discuss the potential advantages and disadvantages of using a mobile diary app.

Results: A total of 78 participants were included in the analysis. An insignificantly higher number of participants in the paper group dropped out before the start of treatment (P=.07). Of those starting treatment, participants in the app group had an average of 37.1 (SE 27.55) more days of treatment and recorded an average of 3.16 (SE 5.10) more skills per week than participants in the paper group. Participants in both groups had a QALY gain and a decrease in depression severity, borderline severity, and suicidal behavior. Significant differences were found in favor of the paper group for both QALY gain (adjusted difference -0.054; SE 0.03) and reduction in depression severity (adjusted difference -1.11; SE 1.57). The between-group difference in total costs ranged from US $107.37 to US $322.10 per participant during the 12 months. The use of services in the health care sector was similar across both time points and groups (difference: psychiatric hospitalization <5 and <5; general practice -1.32; SE 3.68 and 2.02; SE 3.19). Overall, the patients showed high acceptability and considered the app as being easy to use. Therapists worried about potential negative influences on the therapist-patient interaction from new work tasks accompanying the introduction of the new technology but pointed at innovation potential from digital database registrations.

Conclusions: This study suggests both positive and negative consequences of mobile diary apps as adjuncts to DBT compared with paper diary cards. More research is needed to draw conclusions regarding its cost-effectiveness.

Trial registration: ClinicalTrials.gov NCT03191565; https://ichgcp.net/clinical-trials-registry/NCT03191565.

International registered report identifier (irrid): RR2-10.2196/17737.

Keywords: borderline personality disorder; cost-consequence; dialectical behavior therapy; mHealth; mobile app; mobile phone; psychotherapy.

Conflict of interest statement

Conflicts of Interest: The mDiary program was developed and owned by the private sector company Monsenso. SHJ has been employed at a public sector psychiatric ward, and he has no affiliation with Monsenso, nor does any of the other researchers.

©Sidsel Lund Laursen, Stig Helweg-Jørgensen, Astrid Langergaard, Jesper Søndergaard, Sabrina Storgaard Sørensen, Kim Mathiasen, Mia Beck Lichtenstein, Lars Holger Ehlers. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 11.11.2021.

References

    1. Ekselius L, Tillfors M, Furmark T, Fredrikson M. Personality disorders in the general population: DSM-IV and ICD-10 defined prevalence as related to sociodemographic profile. Pers Individ Dif. 2001 Jan 19;30(2):311–20. doi: 10.1016/s0191-8869(00)00048-9.
    1. Torgersen S, Kringlen E, Cramer V. The prevalence of personality disorders in a community sample. Arch Gen Psychiatry. 2001 Jun;58(6):590–6. doi: 10.1001/archpsyc.58.6.590.yoa20243
    1. Pedersen L, Simonsen E. Incidence and prevalence rates of personality disorders in Denmark-a register study. Nord J Psychiatry. 2014 Nov;68(8):543–8. doi: 10.3109/08039488.2014.884630.
    1. National Collaborating Centre for Mental Health (UK) Borderline Personality Disorder: Treatment and Management. Leicester (UK): The British Psychological Society & The Royal College of Psychiatrists; 2009.
    1. Kjær JN, Biskin R, Vestergaard C, Munk-J Rgensen P. All-cause mortality of hospital-treated borderline personality disorder: a nationwide cohort study. J Pers Disord. 2020 Dec;34(6):723–35. doi: 10.1521/pedi_2018_32_403.
    1. Wagner T, Fydrich T, Stiglmayr C, Marschall P, Salize H, Renneberg B, Fleßa S, Roepke S. Societal cost-of-illness in patients with borderline personality disorder one year before, during and after dialectical behavior therapy in routine outpatient care. Behav Res Ther. 2014 Oct;61:12–22. doi: 10.1016/j.brat.2014.07.004.S0005-7967(14)00107-7
    1. Stoffers JM, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2012 Aug 15;(8):CD005652. doi: 10.1002/14651858.CD005652.pub2.
    1. Rizvi SL, Steffel LM, Carson-Wong A. An overview of dialectical behavior therapy for professional psychologists. Prof Psychol Res Pr. 2013;44(2):73–80. doi: 10.1037/a0029808.
    1. Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, Korslund KE, Tutek DA, Reynolds SK, Lindenboim N. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006 Jul;63(7):757–66. doi: 10.1001/archpsyc.63.7.757.63/7/757
    1. Linehan MM, Dimeff LA, Reynolds SK, Comtois KA, Welch SS, Heagerty P, Kivlahan DR. Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug Alcohol Depend. 2002 Jun 01;67(1):13–26. doi: 10.1016/s0376-8716(02)00011-x.S037687160200011X
    1. McMain SF, Links PS, Gnam WH, Guimond T, Cardish RJ, Korman L, Streiner DL. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. Am J Psychiatry. 2009 Dec;166(12):1365–74. doi: 10.1176/appi.ajp.2009.09010039.appi.ajp.2009.09010039
    1. Verheul R, Van Den Bosch LM, Koeter MW, De Ridder MA, Stijnen T, Van Den Brink W. Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in the Netherlands. Br J Psychiatry. 2003 Feb;182:135–40. doi: 10.1192/bjp.182.2.135.S0007125000269778
    1. Brettschneider C, Riedel-Heller S, König HH. A systematic review of economic evaluations of treatments for borderline personality disorder. PLoS One. 2014 Sep 29;9(9):e107748. doi: 10.1371/journal.pone.0107748. PONE-D-14-00795
    1. Murphy A, Bourke J, Flynn D, Kells M, Joyce M. A cost-effectiveness analysis of dialectical behaviour therapy for treating individuals with borderline personality disorder in the community. Ir J Med Sci. 2020 May;189(2):415–23. doi: 10.1007/s11845-019-02091-8.10.1007/s11845-019-02091-8
    1. Priebe S, Bhatti N, Barnicot K, Bremner S, Gaglia A, Katsakou C, Molosankwe I, McCrone P, Zinkler M. Effectiveness and cost-effectiveness of dialectical behaviour therapy for self-harming patients with personality disorder: a pragmatic randomised controlled trial. Psychother Psychosom. 2012;81(6):356–65. doi: 10.1159/000338897. 000338897
    1. Swales M, Hibbs RA, Bryning L, Hastings RP. Health related quality of life for young people receiving dialectical behaviour therapy (DBT): a routine outcome-monitoring pilot. Springerplus. 2016 Jul 20;5(1):1137. doi: 10.1186/s40064-016-2826-9. 2826
    1. Chapman AL. Dialectical behavior therapy: current indications and unique elements. Psychiatry (Edgmont) 2006 Sep;3(9):62–8.
    1. O'Connell B, Dowling M. Dialectical behaviour therapy (DBT) in the treatment of borderline personality disorder. J Psychiatr Ment Health Nurs. 2014 Aug;21(6):518–25. doi: 10.1111/jpm.12116.
    1. Lindenboim N, Comtois KA, Linehan MM. Skills practice in dialectical behavior therapy for suicidal women meeting criteria for borderline personality disorder. Cogn Behav Pract. 2007 May;14(2):147–56. doi: 10.1016/j.cbpra.2006.10.004.
    1. Linehan MM. DBT Skills Training Manual, Second Edition. New York: Guilford Publications; 2015.
    1. Helweg-Joergensen S, Schmidt T, Lichtenstein MB, Pedersen SS. Using a mobile diary app in the treatment of borderline personality disorder: mixed methods feasibility study. JMIR Form Res. 2019 Sep 30;3(3):e12852. doi: 10.2196/12852. v3i3e12852
    1. Marceau L, Link C, Smith L, Carolan S, Jamison R. In-clinic use of electronic pain diaries: barriers of implementation among pain physicians. J Pain Symptom Manage. 2010 Sep;40(3):391–404. doi: 10.1016/j.jpainsymman.2009.12.021. S0885-3924(10)00361-1
    1. Rizvi SL, Hughes CD, Thomas MC. The DBT coach mobile application as an adjunct to treatment for suicidal and self-injuring individuals with borderline personality disorder: a preliminary evaluation and challenges to client utilization. Psychol Serv. 2016 Nov;13(4):380–8. doi: 10.1037/ser0000100.2016-39463-001
    1. Rodante DE, Kaplan MI, Olivera Fedi R, Gagliesi P, Pascali A, Quintero PS, Compte EJ, Perez AI, Weinstein M, Chiapella LC, Daray FM. CALMA, a mobile health application, as an accessory to therapy for reduction of suicidal and non-suicidal self-injured behaviors: a pilot cluster randomized controlled trial. Arch Suicide Res. 2020 Oct 18;:1–18. doi: 10.1080/13811118.2020.1834476.
    1. Schroeder J, Suh J, Wilks C, Czerwinski M, Munson S, Fogarty J, Althoff T. Data-driven implications for translating evidence-based psychotherapies into technology-delivered interventions. Int Conf Pervasive Comput Technol Healthc. 2020 May;2020:274–87. doi: 10.1145/3421937.3421975.
    1. Lederer N, Grechenig T, Baranyi R. unCUT: bridging the gap from paper diary cards towards mobile electronic monitoring solutions in borderline and self-injury. Proceedings of the IEEE 3nd International Conference on Serious Games and Applications for Health (SeGAH); IEEE 3nd International Conference on Serious Games and Applications for Health (SeGAH); May 14-16, 2014; Rio de Janeiro, Brazil. IEEE; 2014.
    1. Husereau D, Drummond M, Petrou S, Carswell C, Moher D, Greenberg D, Augustovski F, Briggs AH, Mauskopf J, Loder E, ISPOR Health Economic Evaluation Publication Guidelines-CHEERS Good Reporting Practices Task Force Consolidated health economic evaluation reporting standards (CHEERS) --explanation and elaboration: a report of the ISPOR health economic evaluation publication guidelines good reporting practices task force. Value Health. 2013;16(2):231–50. doi: 10.1016/j.jval.2013.02.002. S1098-3015(13)00022-3
    1. The mDIARY Study. ENTER. [2020-06-25]. .
    1. Helweg-Jørgensen S, Lichtenstein MB, Fruzzetti AE, Møller Dahl C, Pedersen SS. Daily self-monitoring of symptoms and skills learning in patients with borderline personality disorder through a mobile phone app: protocol for a pragmatic randomized controlled trial. JMIR Res Protoc. 2020 May 25;9(5):e17737. doi: 10.2196/17737. v9i5e17737
    1. Hartfiel N, Edwards R. Applied Health Economics for Public Health Practice and Research. Oxford, United Kingdom: Oxford University Press; 2019. Cost–consequence analysis of public health interventions.
    1. International statistical classification of diseases and related health problems 10th revision (ICD-10) World Health Organization. 2019. [2021-01-21]. .
    1. Monsenso. mDiary App. 2021. [2021-07-16].
    1. Janssen MF, Pickard AS, Golicki D, Gudex C, Niewada M, Scalone L, Swinburn P, Busschbach J. Measurement properties of the EQ-5D-5L compared to the EQ-5D-3L across eight patient groups: a multi-country study. Qual Life Res. 2013 Sep;22(7):1717–27. doi: 10.1007/s11136-012-0322-4.
    1. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606–13. doi: 10.1046/j.1525-1497.2001.016009606.x. jgi01114
    1. Zanarini MC, Vujanovic AA, Parachini EA, Boulanger JL, Frankenburg FR, Hennen John. Zanarini rating scale for borderline personality disorder (ZAN-BPD): a continuous measure of DSM-IV borderline psychopathology. J Pers Disord. 2003 Jun;17(3):233–42. doi: 10.1521/pedi.17.3.233.22147.
    1. Osman A, Bagge CL, Gutierrez PM, Konick LC, Kopper BA, Barrios FX. The suicidal behaviors questionnaire-revised (SBQ-R): validation with clinical and nonclinical samples. Assessment. 2001 Dec;8(4):443–54. doi: 10.1177/107319110100800409.
    1. Jensen C, Sørensen SS, Gudex C, Jensen M, Pedersen K, Ehlers L. The Danish EQ-5D-5L value set: a hybrid model using cTTO and DCE data. Appl Health Econ Health Policy. 2021 Jul;19(4):579–91. doi: 10.1007/s40258-021-00639-3. 10.1007/s40258-021-00639-3
    1. Manca A, Hawkins N, Sculpher MJ. Estimating mean QALYs in trial-based cost-effectiveness analysis: the importance of controlling for baseline utility. Health Econ. 2005 May;14(5):487–96. doi: 10.1002/hec.944.
    1. Schmidt M, Pedersen L, Sørensen HT. The Danish Civil Registration System as a tool in epidemiology. Eur J Epidemiol. 2014 Aug;29(8):541–9. doi: 10.1007/s10654-014-9930-3.
    1. Andersen JS, Olivarius ND, Krasnik A. The Danish National Health Service Register. Scand J Public Health. 2011 Jul;39(7 Suppl):34–7. doi: 10.1177/1403494810394718.39/7_suppl/34
    1. Schmidt M, Schmidt SA, Sandegaard JL, Ehrenstein V, Pedersen L, Sørensen HT. The Danish National Patient Registry: a review of content, data quality, and research potential. Clin Epidemiol. 2015 Nov 17;7:449–90. doi: 10.2147/CLEP.S91125. doi: 10.2147/CLEP.S91125.clep-7-449
    1. Lewis JR. The System Usability Scale: past, present, and future. Int J Hum Comput Interact. 2018 Mar 30;34(7):577–90. doi: 10.1080/10447318.2018.1455307.
    1. Net price index. Statistics Denmark. 2020. [2020-11-04]. .
    1. Valutakurser [Exchange rates] EUROinvestor. 2019. [2020-06-25].
    1. Drummond M, Sculpher M, Claxton K, Stoddart G, Torrance G. Methods for the Economic Evaluation of Health Care Programmes. 4th Edition. Oxford: Oxford University Press; 2015. Sep,
    1. Kildemoes HW, Sørensen HT, Hallas J. The Danish National Prescription Registry. Scand J Public Health. 2011 Jul;39(7 Suppl):38–41. doi: 10.1177/1403494810394717.39/7_suppl/38
    1. Bouwmans C, De Jong K, Timman R, Zijlstra-Vlasveld M, Van der Feltz-Cornelis F, Tan SS, Hakkaart-van Roijen L. Feasibility, reliability and validity of a questionnaire on healthcare consumption and productivity loss in patients with a psychiatric disorder (TiC-P) BMC Health Serv Res. 2013 Jun 15;13:217. doi: 10.1186/1472-6963-13-217. 1472-6963-13-217
    1. Kirisits A, Redekop WK. The economic evaluation of medical devices: challenges ahead. Appl Health Econ Health Policy. 2013 Feb;11(1):15–26. doi: 10.1007/s40258-012-0006-9.
    1. Drummond M, Tarricone R, Torbica A. Economic evaluation of medical devices. Oxford Res Encycl Econ Financ. 2018 Mar 28;:A. doi: 10.1093/acrefore/9780190625979.013.105.
    1. Statistikbanken - LONS20: Løn efter arbejdsfunktion, sektor, aflønningsform, lønmodtagergruppe, lønkomponenter og køn [Statistikbanken - LONS20: Wages estimated based on job function, sector, payment form, employment group, wage component and gender] Statistics Denmark. 2018. [2020-06-10]. .
    1. Levetider [Service lives] Agency for Modernisation - Ministry of Finance. [2020-06-18].
    1. Den samfundsøkonomiske diskonteringsrente [The economic discount rate] Ministry of Finance. [2021-09-17]. .
    1. Ehlers LH, Vestergaard AS. Costing in Health Economic Evaluation. Aalborg: Aalborg University Press; 2019. pp. 1–88.
    1. Faria R, Gomes M, Epstein D, White IR. A guide to handling missing data in cost-effectiveness analysis conducted within randomised controlled trials. Pharmacoeconomics. 2014 Dec;32(12):1157–70. doi: 10.1007/s40273-014-0193-3.
    1. Sterne JA, White IR, Carlin JB, Spratt M, Royston P, Kenward MG, Wood AM, Carpenter JR. Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls. Br Med J. 2009 Jun 29;338:b2393. doi: 10.1136/bmj.b2393.
    1. Kirkwood B, Sterne J. Essential Medical Statistics. Malden, Mass: Wiley-Blackwell; 2003.
    1. Franklin M, Enrique A, Palacios J, Richards D. Psychometric assessment of EQ-5D-5L and ReQoL measures in patients with anxiety and depression: construct validity and responsiveness. Qual Life Res. 2021 Sep;30(9):2633–47. doi: 10.1007/s11136-021-02833-1. 10.1007/s11136-021-02833-1
    1. van Asselt AD, Dirksen C, Arntz A, Giesen-Bloo J, Severens J. The EQ-5D: a useful quality of life measure in borderline personality disorder? Eur Psychiatry. 2009 Mar;24(2):79–85. doi: 10.1016/j.eurpsy.2008.11.001.S0924-9338(08)01654-4
    1. Bergmo TS. Using QALYs in telehealth evaluations: a systematic review of methodology and transparency. BMC Health Serv Res. 2014 Aug 03;14:332. doi: 10.1186/1472-6963-14-332. 1472-6963-14-332
    1. Lauritsen K, Innocenti AD, Hendel L, Praest J, Lytje MF, Clemmensen-Rotne K, Wiklund I. Symptom recording in a randomised clinical trial: paper diaries vs. electronic or telephone data capture. Control Clin Trials. 2004 Dec;25(6):585–97. doi: 10.1016/j.cct.2004.09.001.S0197-2456(04)00086-8
    1. Derks YP, Klaassen R, Westerhof GJ, Bohlmeijer ET, Noordzij ML. Development of an ambulatory biofeedback app to enhance emotional awareness in patients with borderline personality disorder: multicycle usability testing study. JMIR Mhealth Uhealth. 2019 Oct 15;7(10):e13479. doi: 10.2196/13479. v7i10e13479
    1. Carter MC, Burley VJ, Nykjaer C, Cade JE. Adherence to a smartphone application for weight loss compared to website and paper diary: pilot randomized controlled trial. J Med Internet Res. 2013 Apr 15;15(4):e32. doi: 10.2196/jmir.2283. v15i4e32
    1. Abu-El-Noor N, Aljeesh Y, Bottcher B, Abu-El-Noor M. Impact of a mobile phone app on adherence to treatment regimens among hypertensive patients: a randomised clinical trial study. Eur J Cardiovasc Nurs. 2021 Jun 29;20(5):428–35. doi: 10.1177/1474515120938235.6145550
    1. Austin SF, Jansen JE, Petersen CJ, Jensen R, Simonsen E. Mobile app integration into dialectical behavior therapy for persons with borderline personality disorder: qualitative and quantitative study. JMIR Ment Health. 2020 Jun 11;7(6):e14913. doi: 10.2196/14913. v7i6e14913
    1. Innovation Fund Denmark. [2021-10-19]. .

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner