Author's response to reviews Title:Step-down versus outpatient psychotherapeutic treatment for personality disorders: 6-year follow-up of the Ulleval Personality Project Authors: Bjørnar T Antonsen (bjornar.antonsen@medisin.uio.no) Ole Klungsøyr (ole.klungsoyr@medisin.uio.no) Anne Kamps (anne.kamps@gmail.com) Benjamin Hummelen (uxbeum@ous-hf.no) Merete S Johansen (uxemoh@ous-hf.no) Geir Pedersen (geir.pedersen@medisin.uio.no) Øyvind Urnes (oyvurn@ous-hf.no) Elfrida H Kvarstein (elfridak@online.no) Sigmund Karterud (sigmund.karterud@medisin.uio.no) Theresa Wilberg (uxthwi@ous-hf.no) Version:3Date:13 March 2014 Author's response to reviews: see over
Alice Murray, PhD Executive Editor BMC-Psychiatry BioMed Central 236 Gray's Inn Road London, WC1X 8HL U.K March 12, 2014 Dear Dr. Murray, Thank you for useful comments from the reviewers on our paper Step-down versus outpatient psychotherapeutic treatment for personality disorders: 6-year follow-up of the Ullevål Personality Project. We would like to resubmit the paper and have revised it in accordance with the reviewers comments in the following way; Concerning the comments from Dr. Marco Chiesa: 1) We did not control for other kinds of treatments that patients may have received during the trail, this is reported under study limitations at the end if the discussion section. We do however present the patient- reported use of health care services during the past year at the 6-year follow-up in table 3, this showed no statistically significant differences between treatment conditions. This issue raised by the referee is also specified with an additional comment in the discussion section. Page 12, first paragraph: Treatment received after secession of UPP treatment could potentially explain the differences seen in clinical course between treatment arms, however self-reported use of health care services in the past year conducted at both 36 and 72 months follow-up indicate no significant differences in received treatment between groups. 2) We agree with the reviewer and have changed the sentence `the present findings are contrary to the findings of Chiesa et al.,` to` The present findings differ from the findings of Chiesa et al., The two proposed articles are also added in the text, page 10, third paragraph: Chiesa (2009,2011) [43, 44] reports a beneficial outcome for PD patients receiving low intensity community based treatment when compared to intensive long- term residential stay, especially more severe PD patients seemed to respond better to a less intensive community based treatment regime. 3) The reviewer has a good point, but we believe we do comment sufficiently on future research in the conclusion. Page 13, third paragraph: In concordance with most treatment studies of patients with PDs, there was considerable variation in outcome among the patients across treatments. We need to understand more about various patient and treatment characteristics that might influence the long-term course of these patients, and whether some treatments work better for certain patients.
Concerning the comments from Dr.Anna Bartak: 1) The unpublished data that is referred to are now published: Kvarstein EH, Arnevik E, Halsteinli V, Rø FG, Karterud S, Wilberg T: Health service costs and clinical gains of psychotherapy for personality disorders: a randomized controlled trial of day-hospitalbased step-down treatment versus outpatient treatment at a specialist practice. BMC Psychiatry 2013, 13:315 We do not have the resources to conduct a cost-effectiveness analysis of the data acquired from the 72 months follow-up. We have though addressed this issue with an additional sentence in the discussion section. Page 11, first paragraph. Since there was no difference between treatment conditions in past year use of health care services at 6 year follow-up, this suggests minor difference in costs between treatment conditions at the end of this study. 2) - We agree with Dr. Bartak that this could be confusing, and have now specified our point in the text page 11, second paragraph: Taking into account the differences in outcome between groups at 36 months follow- up, the divergence in the pattern of the clinical course between the treatment conditions seen at the 72 months follow-up was unexpected. - The accurate sentence Longer term changes were stimulated is not mentioned in the discussion section, however we do stress that experiences from intensive therapy and especially group psychotherapy may serve as a basis for further development after the end of treatment. - Unfortunately, it is not planned for further follow-up analysis in UPP. This due to both financial reasons and internal validity of the study since the response rate are declining relatively fast each year post treatment. 3) The sentence on page 13 is now altered to: Treatment outside UPP was not uncommon (kvarstein et al., 2013). Kvarsteins study shows that treatment outside UPP varies between different categories of PDs. It is beyond the scope of this article to elaborate the specifics of hers findings. The issue of treatment outside UPP is also more precisely addressed in the discussion section, page 12, first paragraph. Treatment received after secession of UPP treatment could potentially explain the differences seen in clinical course between treatment arms, however self-reported use of health care services in the past year conducted at both 36 and 72 months follow-up indicate no significant differences in received treatment between groups. Also, the past year self-reported use of health care services at 6 year follow-up is reported in table 3. 4) This is now corrected according to the reviewers comment.
5) The PhD students and research assistants were blind to treatment condition, this is now specified in the text page 6, second paragraph. 6) The patient flow through the study is shown in figure 1. Unfortunately, we do not possess data showing which exclusion criteria caused each patient to be excluded from the study. 7) The reason for this confusion was a typing mistake in figure 1. The right number of patients at the six year follow-up is 37 in the outpatient condition and 42 in the step-down condition. This is now corrected. 8) This is now corrected according to the reviewers comment. 9) This is now corrected according to the reviewers comment. 10) Diagnostic evaluations were only conducted at baseline, 36 and 72 months follow-up, thus the 8 and 18 months numbers are missing. 11) The reviewer has a good point, however this is already a long article and we believe this point does not add any crucial information. Also, we believe this argument is more essential if a step-down program includes an inpatient setting. 12) It is a good point that studies of international interest should use established instruments that allow comparison with other studies. Unfortunately, such instrument was not chosen at the start of this study. 13) The reviewer is right; this could be worth mentioning in the discussion, on the other hand there were no differences between treatment conditions, and the discussion section is already long. Altogether we do not believe this point adds enough to the paper to defend a place in the discussion. 14) We certainly agree with the reviewer that the finding of differences in course of psychosocial functioning between groups is an important finding. The main question of the study was however if there were differences between groups from baseline to 72 months follow-up. Further, the differences in clinical course between treatment conditions are discussed quite carefully later in the discussion section. We believe the current organization of the discussion section is ok. 15) The reviewers point adds some more information; however we believe figure 2 shows the difference in clinical course between treatment conditions, and that this point is made clearer graphically than in a table. We hope you will find these changes satisfactory and look forward to hear from you again. Best regards, Bjørnar Antonsen, MD Department of Personality Psychiatry Oslo University Hospital tele: 0047 22 11 84 67 Norway