A Schema Therapy-Based eHealth Program for Patients with Borderline Personality Disorder (priovi): Naturalistic Single-Arm Observational Study

A digital therapeutic for people with borderline personality disorder in Germany (EPADIP-BPD): a pragmatic, assessor-blind, parallel-group, randomised controlled trial

BACKGROUND

Fewer than 25% of patients with borderline personality disorder (BPD) receive guideline-adherent psychotherapy. Digital therapeutics can help reduce this gap. Therefore, we tested the effectiveness and safety of priovi, a digital therapeutic for BPD.

METHODS

We conducted a pragmatic, assessor-blind, parallel-group, randomised controlled trial, recruiting patients with BPD, according to DSM-5 classification, of at least moderate severity on the 23-item Borderline Symptom List (BSL-23) via online advertisements in Germany. Patients were aged 18 years or older, agreed on an emergency plan for suicidal crises, and gave informed consent to participate. Patients were excluded if they had a primary diagnosis of a substance use disorder or a diagnosis of a psychotic disorder. Simple computerised coin-toss randomisation (1:1) without stratification was used to assign patients to either the unguided digital therapeutic based on schema therapy together with treatment as usual (TAU; intervention group) or TAU alone (control group) and study investigators were masked to group assignment until after the analysis of the primary outcome and main safety outcome. All patients could use any form of usual care. The control group received freely available BPD-specific self-help material. The primary outcome was the time by treatment interaction in the intention-to-treat sample at 3 months measured by BSL-23 score. Safety was established via the number of serious adverse events (ie, suicide attempts, other life-threatening events, and hospitalisation), assessed via online questionnaire. Individuals with BPD were involved in the development of the digital therapeutic, but not in the design of this study. The trial was registered on German Clinical Trials Register (DRKS00028888) and is completed.

FINDINGS

Between May 3 and Oct 20, 2022, 1766 patients were screened for eligibility and 580 patients (520 [90%] women, 47 [8%] men, and 13 [2%] gender diverse) were randomly assigned to the intervention group (n=302) and control group (n=278). Ethnicity data were not recorded. At the primary timepoint of 3 months, 35 (12%) patients dropped out of the intervention group and 15 (5%) of the control group. The median age of patients was 29 years (IQR 24-37). Intention-to-treat analysis with linear mixed models showed a significant time by treatment interaction (p=0·0005) at 3 months in favour of the intervention group (d=0·24 [95% CI 0·07-0·42]). Regarding safety, there were significantly fewer suicide attempts in the intervention group (n=7) than in the control group (n=21; incidence rate ratio 0·34 [95% CI 0·14-0·79]; p=0·0081) and there were no differences regarding other serious adverse events.

INTERPRETATION

This trial provides tentative evidence of the effectiveness and absence of safety concerns of the digital therapeutic, priovi, in the treatment of individuals with BPD.

FUNDING

GAIA.

Digital Interventions for Symptoms of Borderline Personality Disorder: Systematic Review and Meta-Analysis

BACKGROUND

Borderline personality disorder (BPD) is a mental health condition with insufficient care availability worldwide. Digital mental health interventions could reduce this treatment gap. Persuasive system design (PSD) is a conceptual framework outlining elements of digital interventions that support behavior change.

OBJECTIVE

This systematic review aims to characterize digital interventions targeting BPD symptoms, assess treatment efficacy, and identify its association with intervention features, including PSD elements.

METHODS

A systematic review of automated digital interventions targeting symptoms of BPD was conducted. Eligible studies recruited participants aged ≥18 years, based on a diagnosis of BPD or one of its common comorbidities, or as healthy volunteers. OVID Embase, OVID MEDLINE, OVID PsycINFO, and the Cochrane Central Register for Controlled Trials were searched on July 19, 2022, and February 28, 2023. Intervention characteristics were tabulated. A meta-analysis of randomized controlled trials (RCTs) determined treatment effects separately for each core symptom of BPD using Hedges g. Associations between the treatment effect and intervention features, including PSD elements, were assessed by subgroup analysis (Cochran Q test). Risk of bias was assessed using the Cochrane Risk of Bias 2 tool for RCTs and the National Institutes of Health Quality Assessment Tool for pre-post studies.

RESULTS

A total of 40 (0.47%) publications out of 8520 met the inclusion criteria of this review, representing 6611 participants. Studies comprised examinations of 38 unique interventions, of which 32 (84%) were RCTs. Synthesis found that included interventions had the following transdiagnostic treatment targets: severity of BPD symptoms (4/38, 11%), suicidal ideation (17/38, 45%), paranoia (5/38, 13%), nonsuicidal self-injury (5/38, 13%), emotion regulation (4/38, 11%), and anger (3/38, 8%). Common therapeutic approaches were based on dialectical behavioral therapy (8/38, 21%), cognitive behavioral therapy (6/38, 16%), or both (5/38, 13%). Meta-analysis found significant effects of digital intervention for both symptoms of paranoia (Hedges g=-0.52, 95% CI -0.86 to -0.18; P=.01) and suicidal ideation (Hedges g=-0.13, 95% CI -0.25 to -0.01; P=.03) but not overall BPD symptom severity (Hedges g=-0.17, 95% CI -0.42 to 0.10; P=.72). Subgroup analysis of suicidal ideation interventions found that evidence-based treatments such as cognitive behavioral therapy and dialectical behavior therapy were significantly more effective than alternative modalities (Cochran Q=4.87; P=.03). The degree of human support was not associated with the treatment effect. Interventions targeting suicidal ideation that used reminders, offered self-monitoring, and encouraged users to rehearse behaviors were associated with a greater reduction in ideation severity.

CONCLUSIONS

Evidence suggests that digital interventions may reduce the symptoms of suicidal ideation and paranoia and that the design of digital interventions may impact the efficacy of treatments targeting suicidal ideation. These results support the use of transdiagnostic digital interventions for paranoia and suicidal ideation.

TRIAL REGISTRATION

PROSPERO CRD42022358270; https://tinyurl.com/3mz7uc7k.

Feasibility, Adherence, and Effectiveness of Blended Psychotherapy for Severe Mental Illnesses: Scoping Review

BACKGROUND

Blended psychotherapy (bPT) combines face-to-face psychotherapy with digital interventions to enhance the effectiveness of mental health treatment. The feasibility and effectiveness of bPT have been demonstrated for various mental health issues, although primarily for patients with higher levels of functioning.

OBJECTIVE

This scoping review aims to investigate the feasibility, adherence, and effectiveness of bPT for the treatment of patients with severe mental illnesses (SMIs).

METHODS

Following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines, we conducted searches in PubMed, MEDLINE, Embase, PsycINFO, and PsycArticles for studies published until March 23, 2023.

RESULTS

Out of 587 screened papers, we incorporated 25 studies encompassing 23 bPT interventions, involving a total of 2554 patients with SMI. The intervention formats and research designs exhibited significant variation. Our findings offer preliminary evidence supporting the feasibility of bPT for SMI, although there is limited research on adherence. Nevertheless, the summarized studies indicated promising attrition rates, spanning from 0% to 37%, implying a potential beneficial impact of bPT on adherence to SMI treatment. The quantity of evidence on the effects of bPT for SMI was limited and challenging to generalize. Among the 15 controlled trials, 4 concluded that bPT interventions were effective compared with controls. However, it is noteworthy that 2 of these studies used the same study population, and the control groups exhibited significant variations.

CONCLUSIONS

Overall, our review suggests that while bPT appears promising as a treatment method, further research is necessary to establish its effectiveness for SMI. We discuss considerations for clinical implementation, directions, and future research.

The efficacy of schema therapy for personality disorders: a systematic review and meta-analysis

OBJECTIVE

Personality disorders (PDs) are prevalent and associated with functional impairment and psychological disability. Studies suggest that schema therapy (ST) may be an effective treatment for PDs. This review aimed to evaluate the efficacy of ST in treating PDs.

METHOD

We conducted a comprehensive literature search using PubMed, Embase, Web of Science, CENTRAL, PsycInfo, and Ovid Medline. We identified eight randomized controlled trials (587 participants) and seven single-group trials (163 participants).

RESULTS

Meta-analyses revealed that ST had a moderate effect size (g = 0.359) compared to control conditions in reducing symptoms of PDs. Subgroup analysis indicated that the effect of ST on different types of PDs varied slightly, and that group ST (g = 0.859) was more effective than individual ST (g = 0.163) in treating PDs. Secondary outcome analysis revealed a moderate effect size (g = 0.256) for ST compared to control conditions in improving quality of life, and ST was found to reduce early maladaptive schema (g = 0.590). Single-group trials analysis showed that ST had a positive effect on PDs (OR = 0.241).

CONCLUSION

ST appears to be an effective treatment for PDs, as it reduces symptoms and improves quality of life. This review provides support for the use of ST in the treatment of PDs.

A systematic review and meta-analysis of digital interventions targeted at individuals with borderline personality disorder (BPD), emotionally unstable personality disorder (EUPD), and related symptoms

OBJECTIVES

The present review investigates the impact of digital interventions for individuals with features of borderline personality disorder (BPD)/emotional unstable personality disorder (EUPD) as digital interventions show promise as therapeutic tools in underserved groups. BPD/EUPD features are identified as clinically relevant, yet previous reviews on the use of digital interventions fail to include subthreshold symptomatology.

METHODS

Five online databases were searched for terminology in three categories: BPD/EUPD and related symptoms, mental-health interventions, and digital technology. Additionally, four relevant journals and two trial registers were searched for additional papers meeting the inclusion criteria.

RESULTS

Twelve articles met all inclusion criteria. Meta-analyses revealed statistically significant differences in symptom measures between intervention and control groups at postintervention and decreases in BPD/EUPD symptomatology and well-being from pre- to postintervention. Service users' engagement, satisfaction, and acceptability of interventions were high. Results support the previous literature on the value of using digital interventions in populations with BPD/EUPD.

CONCLUSION

Overall, it was identified that digital interventions show promise for successful implementation with this population.

The Use of Computer-Driven Technologies in the Treatment of Borderline Personality Disorder: A Systematic Review

The objective of this study was to perform a systematic review of the effectiveness of computer-driven technologies for treatment of patients suffering from BPD. A systematic literature review was conducted using the Pubmed, EMBASE, PsycNET (PsycINFO), CINAHL and Google Scholar electronic databases for the period from their inception dates until 2022. Thirty studies were selected for abstract screening. Seven studies were excluded for not meeting inclusion criteria. The remaining 23 studies were fully assessed, and 12 were excluded. Therefore, 11 studies were included in the analysis of the effectiveness of computer-driven technologies, which encompassed mobile applications, telehealth interventions, internet-based interventions, virtual reality MBT and dialogue-based integrated interventions. Computer-driven interventions are showing signs of effectiveness in the treatment of BPD symptoms. The limited number of articles found on the subject demonstrates a need for further exploration of this subject.

Effectiveness of family connections intervention for family members of persons with personality disorders in two different formats: Online vs face-to-face

INTRODUCTION

Personality disorders (PD) have a serious impact on the lives of individuals who suffer from them and those around them. It is common for family members to experience high levels of burden, anxiety, and depression, and deterioration in their quality of life. It is curious that few interventions have been developed for family members of people with PD. However, Family Connections (FC) (Hoffman and Fruzzetti, 2005) is the most empirically supported intervention for family members of people with Borderline Personality Disorder (BPD).

AIM

The aim of this study is to explore the effectiveness of online vs face-to-face FC. Given the current social constraints resulting from SARS-CoV-2, interventions have been delivered online and modified.

METHOD

This was a non-randomized pilot study with a pre-post evaluation and two conditions: The sample consisted of 45 family members distributed in two conditions: FC face-to-face (20) performed by groups before the pandemic, and FC online (25), performed by groups during the pandemic. All participants completed the evaluation protocol before and after the intervention.

RESULTS

There is a statistically significant improvement in levels of burden (η 2 = 0.471), depression, anxiety, and stress (η 2 = 0.279), family empowerment (η 2 = 0.243), family functioning (η 2 = 0.345), and quality of life (μ2 η 2 = 0.237). There were no differences based on the application format burden (η 2 = 0.134); depression, anxiety, and stress (η 2 = 0.087); family empowerment (η 2 = 0,27), family functioning (η 2 = 0.219); and quality of life (η 2 = 0.006), respectively).

CONCLUSIONS

This study provides relevant data about the possibility of implementing an intervention in a sample of family members of people with PD in an online format without losing its effectiveness. During the pandemic, and despite the initial reluctance of family members and the therapists to carry out the interventions online, this work shows the effectiveness of the results and the satisfaction of the family members. These results are particularly relevant in a pandemic context, where there was no possibility of providing help in other ways. All of this represents a great step forward in terms of providing psychological treatment.

Internet-delivered interventions for personality disorders - A scoping review

Background

Personality disorders (PDs) form a substantial part of the mental health disease burden. Effective therapies to treat PDs exist, but they are time-consuming, costly, and difficult to scale up. Delivery through the internet could facilitate the scalability of effective treatment methods.

Objective

This review summarizes existing evidence on internet-delivered psychotherapy for personality disorders.

Methods

Because few randomized controlled trials (RCTs) have been carried out, we conducted a scoping review. We performed a systematic literature search in PubMed, Embase, MEDLINE, CINAHL, PsycInfo, and Cochrane. Studies were selected if they conveyed research findings on internet-delivered PD interventions.

Results

Eleven studies were included. The majority (n = 8) focused specifically on borderline personality disorder (BPD) and the other three on PD in general. The most frequently used form of intervention (n = 7) was the addition of a mobile app to a conventional evidence-based face-to-face treatment such as dialectical behavioral therapy (DBT). Most interventions (n = 8) were still in the development and piloting phase; only two RCTs were found. Usability and patient satisfaction were moderate to high in all studies. Three studies demonstrated significant decreases in borderline personality disorder symptoms.The majority of the studies found were pilot or feasibility studies, most involving mobile apps offered in addition to face-to-face treatment. The add-ons were rated feasible, acceptable, and useful by patients. Reported challenges involved technical difficulties such as programming errors and bugs. Only 45% of the included studies reported on changes in PD symptoms, all showing reduction of symptoms and absence of adverse effects.

Conclusions

This scoping review found that internet interventions for PD are still under-researched, although initial outcomes show promise. The outcomes also encourage future research in terms of developing internet interventions as an add-on to existing treatments, as well as working toward the creation and testing of more encompassing internet-delivered treatments for PD.

A Personalized, Interactive, Cognitive Behavioral Therapy-Based Digital Therapeutic (MODIA) for Adjunctive Treatment of Opioid Use Disorder: Development Study

BACKGROUND

Opioid use disorder (OUD) is characterized by the inability to control opioid use despite attempts to stop use and negative consequences to oneself and others. The burden of opioid misuse and OUD is a national crisis in the United States with substantial public health, social, and economic implications. Although medication-assisted treatment (MAT) has demonstrated efficacy in the management of OUD, access to effective counseling and psychosocial support is a limiting factor and a significant problem for many patients and physicians. Digital therapeutics are an innovative class of interventions that help prevent, manage, or treat diseases by delivering therapy using software programs. These applications can circumvent barriers to uptake, improve treatment adherence, and enable broad delivery of evidence-based management strategies to meet service gaps. However, few digital therapeutics specifically targeting OUD are available, and additional options are needed.

OBJECTIVE

To this end, we describe the development of the novel digital therapeutic MODIA.

METHODS

MODIA was developed by an international, multidisciplinary team that aims to provide effective, accessible, and sustainable management for patients with OUD. Although MODIA is aligned with principles of cognitive behavioral therapy, it was not designed to present any 1 specific treatment and uses a broad range of evidence-based behavior change techniques drawn from cognitive behavioral therapy, mindfulness, acceptance and commitment therapy, and motivational interviewing.

RESULTS

MODIA uses proprietary software that dynamically tailors content to the users' responses. The MODIA program comprises 24 modules or "chats" that patients are instructed to work through independently. Patient responses dictate subsequent content, creating a "simulated dialogue" experience between the patient and program. MODIA also includes brief motivational text messages that are sent regularly to prompt patients to use the program and help them transfer therapeutic techniques into their daily routines. Thus, MODIA offers individuals with OUD a custom-tailored, interactive digital psychotherapy intervention that maximizes the personal relevance and emotional impact of the interaction.

CONCLUSIONS

As part of a clinician-supervised MAT program, MODIA will allow more patients to begin psychotherapy concurrently with opioid maintenance treatment. We expect access to MODIA will improve the OUD management experience and provide sustainable positive outcomes for patients.

Effectiveness and safety of the adjunctive use of an internet-based self-management intervention for borderline personality disorder in addition to care as usual: results from a randomised controlled trial

IMPORTANCE

Borderline personality disorder (BPD) is a severe mental disorder that is often inadequately treated.

OBJECTIVE

To determine if adding a self-management intervention to care as usual (CAU) is effective and safe.

DESIGN

Randomised, controlled, rater-blind trial. Duration of treatment and assessments: 12 months.

SETTING

Secondary care, recruited mainly via the internet.

PARTICIPANTS

Patients with BPD and BPD Severity Index (BPDSI) of at least 15.

INTERVENTIONS

CAU by treating psychiatrist and/or psychotherapist alone or adjunctive use of an internet-based self-management intervention that is based on schema therapy (priovi).

MAIN OUTCOME MEASURE

Outcomes were assessed by trained raters. The primary outcome was change in BPDSI. The safety outcome was the number of serious adverse events (SAEs). The primary outcome time point was 12 months after randomisation.

RESULTS

Of 383 participants assessed for eligibility, 204 were included (91.7% female, mean age: 32.4 years; 74% were in psychotherapy and 26% were in psychiatric treatment). The slope of BPDSI change did not differ significantly between groups from baseline to 12 months (F_3,248= 1.857, p=0.14). At 12 months, the within-group effect sizes were d=1.38 (95% CI 1.07 to 1.68) for the intervention group and d=1.02 (95% CI 0.73 to 1.31) for the control group. The between-group effect size was d=0.27 (95% CI 0.00 to 0.55) in the intention-to-treat sample and d=0.39 (95% CI 0.09 to 0.68) for those who used the intervention for at least 3 hours (per-protocol sample). We found no significant differences in SAEs.

CONCLUSIONS

We have not found a significant effect in favour of the intervention. This might be due to the unexpectedly large effect in the group receiving CAU by a psychiatrist and/or psychotherapist alone.

TRIAL REGISTRATION

NCT03418142.

Technology-Based Psychosocial Interventions for People with Borderline Personality Disorder: A Scoping Review of the Literature

Evidence-based psychosocial interventions for borderline personality disorder (BPD) still face multiple challenges regarding treatment accessibility, adherence, duration, and economic costs. Over the last decade, technology has addressed these concerns from different disciplines. The current scoping review aimed to delineate novel and ongoing clinical research on technology-based psychosocial interventions for patients with BPD. Online databases (PubMed, Cochrane Library, EMBASE, Web of Science, PsycInfo, and Google Scholar) were searched up to June 2020. Technology-based psychosocial treatments included innovative communication (eHealth) and computational (e.g., artificial intelligence), computing (e.g., computer-based), or medical (e.g., functional magnetic resonance imaging [fMRI]) software. Clinical research encompassed any testing stage (e.g., feasibility, efficacy). Fifteen studies met the inclusion criteria. The main findings were the following: almost two-thirds of the studies (9/15) tested software explicitly conceived as adjunctive interventions to conventional therapy; nearly half of the studies (7/15) were referred to as dialectical behavior therapy-based software; most studies (13/15) were focused on the initial stage of the clinical research cycle (feasibility/acceptance/usability testing), reporting good results at this point; more than one-third of the studies (6/15) tested mobile apps; there is emerging evidence for Internet-based interventions and real-time fMRI biofeedback but only little evidence for mHealth interventions, virtual and augmented reality, and computer-based interventions; there was no computational technology-based clinical research; and there was no satisfaction/preference, security/safety, or efficiency testing for any software. Taken together, the results suggest that there is a growing but still incipient amount of technology-based psychosocial interventions for BPD supported by some kind of clinical evidence. The limitations and directions for future research are discussed.

Therapeutic Relationship in eHealth-A Pilot Study of Similarities and Differences between the Online Program Priovi and Therapists Treating Borderline Personality Disorder

eHealth programs have been found to be effective in treating many psychological conditions. Regarding Borderline Personality Disorder (BPD), few programs have been tested; nevertheless, results are promising. The therapeutic alliance is an important factor predicting treatment outcome in BPD. However, we do not know yet to what extent BPD patients form a therapeutic alliance with an eHealth tool and how this relationship differs from the relationship with their human therapist. This study aims to address this question using priovi, an interactive schema therapy-based eHealth tool for BPD. Semi-structured interviews were conducted to explore how patients perceived the therapeutic alliance with priovi and its differences compared to the alliance with their human therapist (N = 9). Interview data were analyzed following the procedures of qualitative content analysis. Additionally, the Working Alliance Inventory (WAI-SR) was administered in two versions (regarding the human therapist and priovi, N = 16) every three months during the treatment phase of one year. Results indicate that patients were able to form a good therapeutic relationship with priovi, but it differed from the relationship to their human therapist. Important categories were “priovi is helpful, supportive and always there” and “priovi is less flexible”. WAI ratings for the task subscale were high in both relationships but significantly higher in WAI_therapist compared to WAI_priovi in two measurements (nine-months measurement: t = 2.76, df = 15, p = 0.015; twelve-months measurement: t = 3.44, df = 15, p = 0.004). These results indicate that BPD patients can form a functioning alliance with an eHealth program and that eHealth programs may be especially useful for psychoeducation and cognitive exercises.

How to understand and help a person with borderline personality. Case report and literature review on the therapeutic possibilities

Introduction: The study aims to present 1) a case report of an 18-year-old female patient with borderline personality disorder (BPD) 2) the diagnostic and treatment difficulties in BPD patients.

Materials and methods: The review of the literature from the years 1953-2020 searched from PubMed, Google Scholar, and Web of Science databases.

Discussion: Patient, 18-years old, hospitalized five times for psychiatric care, presenting self-injurious behaviours, hurting herself within forearms. A patient attempted suicide eight times. She is living with her divorced parents. The patient’s father has a new partner with whom he has children. The patient used marijuana and she was experiencing psychotic symptoms under its influence. She smokes 10 cigarettes per day and drinks alcohol once a week since she was 16 years old. Psychiatric problems appeared when the patient started learning in high school.

Conclusions:

1. Borderline personality disorder (BPD) is a serious psychiatric condition of a difficult diagnosis that should be differentiated with many other psychiatric disorders such as an atypical or subclinical course of psychosis, affective disorders, or dissocial personality.

2. A therapeutic process of a person with BPD is based on psychotherapy and personalized treatment strategies, whereas, pharmacological treatment plays only a supporting role during BPD treatment.

Experiences of Patients With Borderline Personality Disorder With Imagery Rescripting in the Context of Schema Therapy-A Qualitative Study

Imagery Rescripting (IR) is a therapeutic technique that is used in a wide spectrum of therapeutic methods for various mental disorders. As an important component of Schema Therapy (ST), IR is frequently used in the treatment of patients with borderline personality disorder (BPD). However, little is known about how IR is experienced by individuals with BPD. The aim of this study was to explore BPD patients' experiences with receiving IR. Qualitative data were collected through semi-structured interviews with 21 individuals (86% females) with a primary diagnosis of BPD who received IR within their ST treatment. Interview data were analyzed following the procedures of qualitative content analysis. Participants reported various effects of IR including initial high emotionality and exhaustion. Long-term effects included a better understanding of schemas and an improvement regarding emotion regulation and interpersonal relationships. Participants reported factors hindering the successful implementation of IR, such as external noise, stress, and a fast pace during IR. Facilitating factors included adequate time for debriefing, a transparent structure, and preparation of IR as well as the therapist providing safety. Implications of the findings for optimizing IR in clinical practice are discussed.

Using a Mobile Diary App in the Treatment of Borderline Personality Disorder: Mixed Methods Feasibility Study

BACKGROUND

Borderline personality disorder (BPD) is a disorder characterized by difficulties with regulating emotions and impulsive behavior. Long-term monitoring of progress during BPD psychotherapy constitutes a challenge using paper and pencil registration. Hence, a mobile app assessing emotions and progress in treatment may be useful.

OBJECTIVE

The aim of this study was to examine the feasibility of using the mDiary app as an adjunct to dialectical behavior therapy (DBT) for the treatment of BPD.

METHODS

A total of 9 focus group interviews were conducted and analyzed according to the grounded theory approach. Furthermore, the usability of the mDiary app was examined using the System Usability Scale (SUS). The app was implemented in a standard DBT program as an adjunct to DBT. In total, 16 patients (age range 19-41 years) and 23 therapists (age range 25-64 years) from 5 Danish public outpatient psychiatric treatment facilities participated in the study.

RESULTS

Overall, patients were satisfied with the mDiary app, as it was "easy to use" and "always there." Inside-out innovation, meaning new work tasks generated during implementation and communication of modifications needed in the app, was found to influence the perceived usability negatively among the interviewed therapists. The patients rated the usability as high (mean SUS score 81.2, SD 9.9), whereas therapists rated the mDiary app at an average level (mean 68.3, SD 14.3). Older age of the users correlated with lower usability ratings on the SUS score (Pearson r=-0.60).

CONCLUSIONS

The mDiary app was considered as an acceptable and relevant way of registering DBT diary data for both patients and therapists generating increased long-term overview. Older users were overall more reluctant to accept this new technology in clinical practice. Time to align expectations among involved parties needs to be set aside when implementing this new approach to patient monitoring. Here, the focus should be on the realistic use of resources and expected impact on present clinical work.