Thomas R. Lynch

Obsessive-compulsive personality disorder (OCPD) is commonly comorbid with major depressive disorder, and their comorbidity is associated with worsened outcomes and treatment refraction. Radically open dialectical behavior therapy (RO DBT) is a novel transdiagnostic psychosocial intervention. RO DBT targets OCPD-related traits (e.g., maladaptive perfectionism, inflexibility) and has been theorized as an OCPD treatment. This study examined RO DBT efficacy for treatment-refractory depression (TRD), with and without comorbid OCPD. RefraMED was a multisite randomized controlled trial of treatment as usual (TAU) versus RO DBT + TAU for TRD (N = 250). In this secondary data analysis, linear regression predicted 7-month (end of treatment) and 12-month (follow-up) symptoms, controlling for baseline symptoms. Three models examined: (a) outcomes for participants with OCPD (n = 117) comparing RO DBT + TAU and TAU, (b) outcomes among participants receiving RO DBT (n = 162) comparing OCPD and no OCPD, and (c) OCPD diagnosis moderating treatment effects for all participants (N = 250). At 12 months, participants with OCPD had significantly improved emotional approach coping (emotion recognition and communication) and psychological flexibility in RO DBT + TAU (vs. TAU alone; false discovery rate-adjusted ps = .008), with no significant differences observed for depression or interpersonal functioning. OCPD presence did not predict any outcomes within the RO DBT group, nor moderate the effect of treatment on outcomes, suggesting treatment effects were not significantly inhibited by OCPD presence. In conclusion, RO DBT shows promise as a potential evidence-based treatment for OCPD, particularly when comorbid with TRD. Treatment effects were equivalent for those with and without OCPD. Moreover, RO DBT may be particularly beneficial for improving emotional approach coping and flexibility. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Background: Individuals with depression often do not respond to medication or psychotherapy. Radically open dialectical behaviour therapy (RO DBT) is a new treatment targeting overcontrolled personality, common in refractory depression.Aims: To compare RO DBT plus treatment as usual (TAU) for refractory depression with TAU alone (trial registration: ISRCTN 85784627).Method: RO DBT comprised 29 therapy sessions and 27 skills classes over 6 months. Our completed randomised trial evaluated RO DBT for refractory depression over 18 months in three British secondary care centres. Of 250 adult participants, we randomised 162 (65%) to RO DBT. The primary outcome was the Hamilton Rating Scale for Depression (HRSD), assessed masked and analysed by treatment allocated.Results: After 7 months, immediately following therapy, RO DBT had significantly reduced depressive symptoms by 5.40 points on the HRSD relative to TAU (95% CI 0.94–9.85). After 12 months (primary end-point), the difference of 2.15 points on the HRSD in favour of RO DBT was not significant (95% CI –2.28 to 6.59); nor was that of 1.69 points on the HRSD at 18 months (95% CI –2.84 to 6.22). Throughout RO DBT participants reported significantly better psychological flexibility and emotional coping than controls. However, they reported eight possible serious adverse reactions compared with none in the control group.Conclusions: The RO DBT group reported significantly lower HRSD scores than the control group after 7 months, but not thereafter. The imbalance in serious adverse reactions was probably because of the controls' limited opportunities to report these.

Background: Refractory depression is a major contributor to the economic burden of depression. Radically open dialectical behaviour therapy (RO DBT) is an unevaluated new treatment targeting overcontrolled personality, common in refractory depression, but it is not yet known whether the additional expense of RO DBT is good value for money.Aims: To estimate the cost-effectiveness of RO DBT plus treatment as usual (TAU) compared with TAU alone in people with refractory depression (trial registration: ISRCTN85784627).Method: We undertook a cost-effectiveness analysis alongside a randomised trial evaluating RO DBT plus TAU versus TAU alone for refractory depression in three UK secondary care centres. Our economic evaluation, 12 months after randomisation, adopted the perspective of the UK National Health Service (NHS) and personal social services. It evaluated cost-effectiveness by comparing the net cost of RO DBT with the net gain in quality-adjusted life-years (QALYs), estimated using the EQ-5D-3L measure of health-related quality of life.Results: The additional cost of RO DBT plus TAU compared with TAU alone was £7048 and was associated with a difference of 0.032 QALYs, yielding an incremental cost-effectiveness ratio (ICER) of £220 250 per QALY. This ICER was well above the National Institute for Health and Care Excellence (NICE) upper threshold of £30 000 per QALY. A cost-effectiveness acceptability curve indicated that RO DBT had a zero probability of being cost-effective compared with TAU at the NICE £30 000 threshold.Conclusions: In its current resource-intensive form, RO DBT is not a cost-effective use of resources in the UK NHS.Declaration of interest: R.H. is co-owner and director of Radically Open Ltd, the RO DBT training and dissemination company. D.K. reports grants outside the submitted work from the National Institute for Health Research (NIHR). T.L. receives royalties from New Harbinger Publishing for sales of RO DBT treatment manuals, speaking fees from Radically Open Ltd, and a grant outside the submitted work from the Medical Research Council. He was co-director of Radically Open Ltd between November 2014 and May 2015 and is married to Erica Smith-Lynch, the principal shareholder and one of two directors of Radically Open Ltd. H.O'M. reports personal fees outside the submitted work from the Charlie Waller Institute and Improving Access to Psychological Therapy. S.R. provides RO DBT supervision through her company S C Rushbrook Ltd. I.R. reports grants outside the submitted work from NIHR and Health & Care Research Wales. M. Stanton reports personal fees outside the submitted work from British Isles DBT Training, Stanton Psychological Services Ltd and Taylor & Francis. M. Swales reports personal fees outside the submitted work from British Isles DBT Training, Guilford Press, Oxford University Press and Taylor & Francis. B.W. was co-director of Radically Open Ltd between November 2014 and February 2015.

Background: About one-third of patients who are depressed do not respond to antidepressant medication (ADM) and traditional psychotherapy shows limited benefits. However, most randomised trials have excluded the most sick patients, especially with comorbid personality disorder. Radically open dialectical behaviour therapy (RO DBT) is a new treatment targeting emotionally overcontrolled personality, which is common in refractory depression.Objective: To evaluate the efficacy, cost-effectiveness and therapeutic mechanisms of RO DBT for patients with refractory depression.Design: The Refractory depression: Mechanisms and Efficacy of RO DBT (RefraMED) trial was a multicentre, parallel-group, randomised trial in which participants were randomised to receive either RO DBT plus treatment as usual (TAU) or TAU alone. Participants were assessed at 7, 12 and 18 months after randomisation. Therapeutic mechanisms were explored in causal analyses.Setting: Participants were recruited from three secondary care NHS organisations in the UK: Dorset, Hampshire and North Wales.Participants: Patients were eligible if they were aged ≥ 18 years, had a Hamilton Rating Scale for Depression (HRSD) score of at least 15, had a current diagnosis of major depressive disorder in the Structured Clinical Interview forDiagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I, were suffering either refractory or chronic depression and, in their current episode, had taken an adequate dose of ADM for at least 6 weeks without relief. Patients who met criteria for dramatic-erratic personality disorder (Cluster B), bipolar disorder or psychosis or who had a primary diagnosis of substance dependence or abuse were excluded.Interventions: The intervention, RO DBT, comprised 29 weekly individual sessions lasting 1 hour and 27 weekly skills classes lasting 2.5 hours. Participants allocated to TAU could access any treatment offered by the NHS or privately.Main outcome measures: The reported HRSD score 12 months after randomisation and cost per quality-adjusted life-year (QALY).Results: A total of 250 participants were allocated at random: 162 (65%) participants were randomised to RO DBT plus TAU and 88 (35%) were randomised to TAU. The difference between RO DBT and TAU in the primary outcome at 12 months was not statistically significant. Nevertheless, after 7 months, participants randomised to RO DBT had substantially, and significantly, reduced depressive symptoms, relative to TAU, by 5.40 HRSD points [standardised mean difference 1.03 points, 95% confidence interval (CI) 0.94 to 9.85 points;p = 0.02]. Thereafter, RO DBT remained the better treatment with net, but non-significant, reductions of 2.15 HRSD points (standardised mean difference 0.41 points, 95% CI –2.28 to 6.59 points;p = 0.29) after 12 months and 1.69 points (standardised mean difference 0.32 points, 95% CI –2.84 to 6.22 points;p = 0.42) after 18 months. Participants allocated to TAU could access any treatment offered by the NHS or privately. Participants randomised to RO DBT reported significantly better psychological flexibility and emotional coping than TAU participants; these differences increased over time. From the perspective of the NHS and personal social services, RO DBT was not cost-effective; the incremental cost-effectiveness ratio was £220,000 per QALY, which is considerably above the willingness-to-pay threshold of £30,000 set by the National Institute for Health and Care Excellence (NICE). RO DBT participants reported eight possible serious adverse reactions compared with none by TAU participants; however, we believe that this imbalance was a result of major differences in reporting opportunities. The Data Monitoring and Ethics Committee agreed that there was no reason to suspect that RO DBT was harmful.Conclusions: Although RO DBT achieved the target effect size (Cohen’sd) with ad of 0.4 at the primary end point of 12 months, this was not significant. RO DBT was not cost-effective by NICE criteria. Nevertheless, RO DBT enhanced psychological flexibility and emotional coping, which are potential mechanisms of change.Limitations: Analysing only 190 participants, instead of the target of 245, reduced the statistical power of the trial.Future work: Future studies should aim to refine RO DBT, by maintaining clinical effectiveness while reducing costs, and to evaluate it for a wider range of overcontrolled disorders over a longer period.Trial registration: Current controlled trials ISRCTN85784627.Funding: This project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a MRC and NIHR partnership, and will be published in full inEfficacy and Mechanism Evaluation; Vol. 5, No. 7. See the NIHR Journals Library website for further project information.

Radically Open-Dialectical Behavior Therapy (RO-DBT) is a transdiagnostic treatment designed to address a spectrum of difficult-to-treat disorders sharing similar phenotypic and genotypic features ...

Mindfulness-based stress reduction (MBSR) is a secular meditation training program that reduces depressive symptoms. Little is known, however, about the degree to which a participant's spiritual and religious background, or other demographic characteristics associated with risk for depression, may affect the effectiveness of MBSR. Therefore, this study tested whether individual differences in religiosity, spirituality, motivation for spiritual growth, trait mindfulness, sex, and age affect MBSR effectiveness. As part of an open trial, multiple regression was used to analyze variation in depressive symptom outcomes among 322 adults who enrolled in an 8-week, community-based MBSR program. As hypothesized, depressive symptom severity decreased significantly in the full study sample (d=0.57; p<0.01). After adjustment for baseline symptom severity, moderation analyses revealed no significant differences in the change in depressive symptoms following MBSR as a function of spirituality, religiosity, trait mindfulness, or demographic variables. Paired t tests found consistent, statistically significant (p<0.01) reductions in depressive symptoms across all subgroups by religious affiliation, intention for spiritual growth, sex, and baseline symptom severity. After adjustment for baseline symptom scores, age, sex, and religious affiliation, a significant proportion of variance in post-MBSR depressive symptoms was uniquely explained by changes in both spirituality (β=-0.15; p=0.006) and mindfulness (β=-0.17; p<0.001). These findings suggest that MBSR, a secular meditation training program, is associated with improved depressive symptoms regardless of affiliation with a religion, sense of spirituality, trait level of mindfulness before MBSR training, sex, or age. Increases in both mindfulness and daily spiritual experiences uniquely explained improvement in depressive symptoms.