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

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.