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Reyes-Ortega 2019 ACT or DBT or Both - With Borderline Personality Disorder
Reyes-Ortega 2019 ACT or DBT or Both - With Borderline Personality Disorder
*Correspondence should be addressed to Rebeca Robles Garcıa, Center of Research on Global Mental Health, Department of
Innovation and Global Health, Directorate of Epidemiological and Psychosocial Research, Ramon de la Fuente Mu~niz National
Institute of Psychiatry, Calzada Mexico-Xochimilco 101, Tlalpan 14370, Mexico City, Mexico (email: reberobles@imp.edu.mx).
DOI:10.1111/papt.12240
2 Michel A. Reyes-Ortega et al.
Practitioner points
Brief adaptations of acceptance and commitment therapy and dialectical behavioural therapy are
effective interventions for BPD patients, in combined or isolated modalities, and with or without the
inclusion of functional analytic psychotherapy.
The reduction of experiential avoidance and the acquisition of mindfulness skills are related with the
diminution of BPD symptoms severity, including emotional dysregulation and negative interpersonal
attachment.
Methods
Participants and procedures
Sixty-five patients attending a BPD Clinic were included in the study. Before patients were
invited to take part in the study, the Ethics Review Board of the local institution approved
the study protocol and materials. Participation was voluntary, and all patients gave written
informed consent after the study procedures had been fully explained.
A total of 22 patients were assigned to the ACT group, 20 received DBT, and 23 were
given combined ACT + DBT + FAP therapy. This was based on a sequential assignment
(first ACT alone, then DBT alone, then the combined intervention). All sessions were
videotaped for the assessment of treatment fidelity by two independent certified
psychotherapists using an ad hoc checklist based on the structured manuals of each
intervention to record the number of activities and strategies planned for each session,
and compute the corresponding percentage of compliance, which proved high in all
Brief interventions for borderline personality disorder 5
groups (85–95% of the activities and strategies scheduled for each session were delivered
during the field trial by the therapists in charge of the groups). The inter-rater reliability
achieved in each group was very high (ACT Kappa = .90, DBT Kappa = .87,
ACT + DBT + FAP Kappa = .85; Calculations and interpretation of Cohen0 s kappa
coefficients based on procedures detailed by McHugh, 2012).
Clinical baseline information was obtained through a face-to-face interview with
patients. This interview was performed by one of the psychiatrists from the BPD Clinic,
and BPD diagnosis was confirmed through a structured interview. Patients were assessed
at baseline and after the therapeutic trial for borderline symptom severity, emotion
dysregulation, experiential avoidance, attachment, control over experiences, and
awareness of stimuli. All the scales used for the evaluation of these variables were
performed by two independent trained raters (a psychiatrist and a psychologist), who
were blind to the therapeutic intervention received by the patients.
Measures
The Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II;
First, Gibbon, Spitzer, Williams, & Benjamin, 1996) was used to determine BPD diagnosis
in this study. It is a semi-structured interview comprising 119 items for a face-to-face
interview designed to generate personality disorders diagnoses. The Spanish version of
the instrument used in this study was translated and evaluated by Villar et al. (1995). In
their study, overall inter-rater agreement on the presence or absence of the various
diagnoses assessed was high (K = 0.85).
The Borderline Evaluation of Severity Over Time (BEST; Pfohl et al., 2009) is a 15-
item self-report instrument scored on a 5-point Likert scale designed to measure the
severity of the main symptoms of BPD patients. The scale comprises three subscales: (1)
Thoughts and Feelings (first eight items rated from 1 = None/Slight to 5 = Extreme),
including mood reactivity, identity disturbance, suicidal thoughts, unstable relationships,
and emptiness; (2) Behaviors-Negative (next four items rated from 1 = None/Slight to
5 = Extreme), evaluating self-harm behaviours; and (3) Positive Behaviors (final three
items rated from 5 = Almost Always to 1 = Almost Never). A Spanish version of the
instrument for the present study was created using the translation and back translation
process by two bilingual mental health professionals. In our sample, Cronbach’s alpha
was .80 for the total score, suggesting adequate internal consistency.
Emotion dysregulation was assessed through the Difficulties in Emotion Regulation
Scale (DERS; Gratz & Roemer, 2004), which has been used to measure fear of emotional
experience and feelings of loss of control over internal and behavioural expression. It is a
36-item questionnaire designed to evaluate six areas (emotional experience, difficulties in
maintaining goal-oriented behaviour, lack of emotional awareness, and lack of emotional
clarity) on a 5-point Likert scale with higher scores indicating more difficulties in
emotional regulation. Its version in Spanish (Marın-Tejeda, Robles-Garcıa, Gonzalez-
Forteza, & Andrade-Palos, 2012) used in the present study was reduced to 24 items
showing good internal consistency, with a Cronbach’s alpha of .93, and a test–retest
reliability of r = .88.
The Acceptance and Action Questionnaire-II (AAQ-II; Bond et al., 2011) assesses
experiential avoidance, including thoughts, emotions, past experiences, and psycholog-
ical inflexibility as attempts to modify its form, frequency, intensity, or situational
sensitivity, even though this is futile or interferes with valued actions. It is a 7-item, self-
report questionnaire scored on a 7-point Likert scale with higher scores indicating higher
6 Michel A. Reyes-Ortega et al.
experiential avoidance and lower scores reflecting psychological flexibility. The Mexican
version developed earlier by Patr on (2010) showed high internal consistency and a
Cronbach’s alpha of .89.
The Adult Attachment Questionnaire was used for the evaluation of interpersonal
attachment (Melero & Cantero, 2008). It comprises 40 items scored on a 6-point Likert
agreement scale that evaluates four main areas to determine secure or insecure
attachment: (1) low self-esteem, need for approval, and fear of rejection; (2) hostile
conflict resolution, rancour, and possessiveness; (3) expression of feelings and comfort
with relationships, and (4) emotional self-sufficiency and discomfort with intimacy. The
study attempted to develop and evaluate the original version of the instrument in Spanish,
showing that it is a valid measure for identifying individuals with secure or insecure
attachment, with all its subscales lying within an acceptable range of internal consistency
(Cronbach a from .68 for subscale 4 to .86 for subscale 1).
The Experiencing of Self Scale (Kanter, Parker, & Kohlenberg, 2001) is a 37-item self-
report Likert questionnaire designed to assess four main areas in relation to control over
experiences: (1) the experience of self; (2) the influence of other non-close persons on the
expression of needs, opinions, attitudes, and actions; (3) the influence of a close person on
the expression of needs, opinions, attitudes, and actions; and (4) creativity, sensitivity to
criticism, and dissociation. Higher scores reflect low control over experiences. The
translated version of the EOSS into Spanish used in this study (Valero-Aguayo, Ferro-
Garcıa, L
opez-Berm opez, 2014) shows high internal consistency (a = .94).
udez, & Selva-L
Lastly, the Five-Facet Mindfulness Questionnaire (FFMQ; Baer, Smith, Hopkins,
Krietemeyer, & Toney, 2006) was used to assess awareness of internal and external stimuli
by measuring the five facets of mindfulness: observing, describing, acting with awareness,
no judging of inner experience, and no reactivity to inner experience. It comprises 39 self-
report items scored on a 5-point Likert agreement scale. Its total score ranges from 39 to
195, with higher scores indicating greater mindfulness in everyday life. A Spanish version
of the instrument for this study was created through the translation and back translation
process by two bilingual mental health professionals. In our sample, Cronbach’s alpha
coefficients for all subscales were adequate: Observing: .80, Describing: .84, Acting with
awareness: .87, No reactivity: .69, and No judging: .83.
Modalities of treatment
The three treatment modalities were brief adaptations for patients with BPD, developed
by two authors of this study (MARO and ANV verified DBT, ACT, and FAP clinicians). All
treatments included an equivalent number of group and individual sessions (although for
ACT intervention alone, no priority of group over individual session is expected), as well
as daily practice of the skills learned in the session as homework.
in their everyday lives. The structure of group skills is divided into four modules that included
four sessions on Mindfulness, four sessions on Emotional Regulation, five sessions on Distress
Tolerance, and four sessions on Interpersonal Effectiveness.
Individual sessions were designed to examine the specific behaviours of participants
through chain analysis, in order to identify which behaviours the patient should increase
or decrease and then to follow-up in the interaction with other professional team
members in order for them to achieve their goals, and provide reinforcement and
feedback after the implementation of each step. No pre-treatment sessions were
necessary.
The intervention model also included a one-hour weekly consulting team meeting, as
well as telephone assistance for patients.
Statistical analysis
Firstly, all variables were tested for normality using skewness and kurtosis. Demographic
and baseline clinical variables were tested for differences between the therapeutic groups
with v2 or with analyses of variance (ANOVA). If any difference emerged between groups
(p ≤ .05), the corresponding variable(s) was/were included as covariate(s) in the
following analyses.
The three therapeutic groups were included in a repeated multivariate analysis of
variance (MANOVA) model of two measures to examine direction of changes (time effect)
among therapeutic groups (interaction effect) in terms of BPD symptom severity (including
suicidal risk), emotion dysregulation, experiential avoidance, interpersonal attachment,
control over experiences, and awareness of stimuli. We used a p value of .01 as statistically
significant for the MANOVA analyses due to the aim of testing the therapeutic efficacy of the
ACT + DBT + FAP intervention and to reduce Type I error. The effect size of comparisons
was estimated using partial eta squared (g2p ) and reference values for the interpretation of
.01 = small, .06 = medium, .14 = large (Cohen, 1988). All these analyses were performed
using the Statistical Package for the Social Sciences (SPSS), version 20.
Additionally, given that no differences emerged between therapeutic groups in total
scores of main outcome measures (BEST = BPD symptoms and DERS = emotional
dysregulation), tests of equivalency were carried out in the XLSTAT software, using the
TOST procedure for Welsh’s t-test for independent simples (with a prefixed p ≤ .05) and
equivalent bounds (Lakens, Scheel, & Isager, 2018), using the 90% confidence interval of
the mean score of changes (1 SD) in BEST (12.84) and DERS (20.5) as the minimal
effect that should be noticeable in our sample or Smallest Effect Size of Interest (SESOI).
Once again in SPSS, the Pearson correlation coefficient was calculated to determine the
linear association between the changes observed in symptom severity assessed with BEST,
and in emotion dysregulation together with the changes reported in experiential
avoidance (ESS total score) and the five facets of mindfulness across each treatment
condition. A p value of .01 or less was also defined as significant for this analysis.
Results
Patients
A total of 65 patients participated in the study. The vast majority were women (n = 61,
93.8%); and their mean age was 33.7 years (SD = 10.4). A higher percentage were single
(n = 45, 69.3%) and unemployed (n = 51, 78.5%) at the time of their recruitment in the
Brief interventions for borderline personality disorder 9
study. Major depression was the comorbid diagnosis most frequently reported (n = 51,
78.5%) followed by dysthymia (n = 4, 6.2%) and eating disorders (n = 3, 4.6%). No
differences emerged between groups either in the main demographic variables or in
comorbid diagnosis (p > .05).
Clinical variables
The distribution of the main clinical variables assessed in the study showed acceptable
values of skewness and kurtosis. None of the values was excessively out of range
(skewness range 0.76 to 0.91 and kurtosis range 1.07 to 0.30). The ANOVA analyses
revealed no differences between the three therapeutic groups in the baseline assessment
of BPD symptom severity, emotion dysregulation, experiential avoidance, attachment,
control over experiences, or awareness of stimuli (p > .05). The mean values of these
variables are summarized in Table 1.
The assumption of equal covariance matrices according to Box’s test was not met
(Box’s M = 515.7, p = .03). Results of the MANOVA model showed significant
differences in most dependent measures over time (Wilk’s Lambda = .21, F = 10.3,
p < .001) but not between therapeutic groups (Wilk’s Lambda = .651, F = 0.67,
p = .89), or in an interaction effect time per group (Wilk’s Lambda = .57, F = 0.91,
p = .60).
Similar improvements with large size effects were observed in all therapeutic groups,
with a reduction of BPD symptom severity, emotion dysregulation, and experiential
avoidance, and an increase in psychological flexibility and mindfulness skills. Moreover,
two areas of interpersonal attachment showed significant improvements in the three
therapeutic groups: self-esteem and conflict resolution (Table 1).
A comparison of the 90% confidence interval of the mean score of the changes
observed in the BEST severity score and DERS emotion dysregulation with the TOST
interval fixed for the analysis (1 SD) shows that both assessments were equivalent
between the three therapeutic groups (BEST-ACT≃BEST-ACT + DBT + FAP: t(41) 3.90,
p ≤ .0001; BEST-DBT≃BEST-ACT + DBT + FAP: t(39) 4.37, p ≤ .0001; BEST-ACT≃B-
EST-DBT: t(38) 2.53, p = .008; DERS-ACT≃DERS-ACT + DBT + FAP: t(41) 2.95,
p = 003; DERS-DBT≃BEST-ACT + DBT + FAP: t(39) 3.95, p ≤ .001; DERS-ACT≃
DERS-DBT: t(38) 2.03, p = .02).
Mean changes towards a decrease in global symptom severity (BEST total mean change
score) and emotion dysregulation were significantly correlated with a decrease in
experiential avoidance in the three therapeutic groups. These associations were more
closely related to the BEST subscale Thoughts & Feelings in the three groups and with the
Positive Behaviors subscale for the ACT group (Table 2). Higher awareness in the
Describing subscale of the FFMQ was related to a decrease in symptom severity of the
BEST Thoughts & Feelings subscale, while higher FFMQ Nonreactivity was associated
with the three BEST symptom severity subscales.
In terms of mindfulness, for the three therapeutic groups, mean increases reported in
the facet ‘Acting with awareness’ were related to a decrease in emotion dysregulation. For
the DBT and ACT + DBT + FAP groups, increases in ‘Nonreactivity’, and increases in
‘Nonjudging’ for the ACT and ACT + DBT + FAP were also associated with a reduction in
emotion dysregulation. Only in the DBT group was a reduction in emotion regulation
associated with an increase in the mindfulness facet of Describing (Table 2).
10 Michel A. Reyes-Ortega et al.
Statistics
Total scores
BEST
ACT 40.5 12.0 26.6 8.0 Group 0.8 2 .44 .02
DBT 43.9 9.7 27.6 10.9 Time 73.1 1 <.001 .54
ACT + DBT + FAP 42.2 10.9 31.3 11.0 Group 9 time 0.9 2 .39 .03
DERS
ACT 79.3 17.2 53.9 18.2 Group 0.1 2 .82 .006
DBT 85.1 23.9 53.9 17.7 Time 119.3 1 <.001 .65
ACT + DBT + FAP 81.0 16.9 54.4 17.8 Group 9 time 0.41 2 .66 .01
AAQ-II
ACT 48.0 10.5 34.3 11.8 Group 0.3 2 .71 .01
DBT 54.9 12.7 32.3 14.4 Time 93.6 1 <.001 .60
ACT + DBT + FAP 51.4 13.0 34.5 11.3 Group 9 time 1.9 2 .15 .06
Adult Attachment Questionnaire
Low self-esteem
ACT 52.6 14.0 38.0 10.7 Group 0.6 2 .51 .02
DBT 58.8 14.5 39.6 15.9 Time 69.6 1 <.001 .53
ACT + DBT + FAP 54.9 10.1 39.6 14.0 Group 9 time 0.5 2 .60 .01
Hostile conflict resolution
ACT 40.3 9.1 28.5 9.2 Group 1.5 2 .22 .04
DBT 45.2 14.6 32.8 11.7 Time 53.1 1 <.001 .46
ACT + DBT + FAP 39.0 9.4 31.5 8.8 Group 9 time 1.1 2 .31 .03
Expression of feelings
ACT 35.0 6.9 36.8 7.1 Group 0.5 2 .60 .01
DBT 35.2 9.3 39.6 7.4 Time 8.0 1 .06 .11
ACT + DBT + FAP 35.3 5.6 35.9 5.0 Group 9 time 1.8 2 .16 .05
Emotional self-sufficiency
ACT 22.1 5.9 19.2 5.5 Group 0.06 2 .93 .002
DBT 21.3 8.7 20.4 7.4 Time 3.0 1 .08 .04
ACT + DBT + FAP 21.6 5.4 20.9 5.5 Group 9 time 0.6 2 .51 .02
Experiencing of Self Scale
Experience of self
ACT 28.1 8.3 19.3 6.2 Group 0.5 2 .57 .01
DBT 30.2 8.5 20.8 6.5 Time 79.6 1 <.001 .56
ACT + DBT + FAP 27.6 5.1 20.4 5.6 Group 9 time 0.4 2 .62 .01
Influence of others
ACT 31.7 16.3 19.9 8.7 Group 0.5 2 .58 .01
DBT 36.1 19.0 20.2 10.4 Time 37.6 1 <.001 .38
ACT + DBT + FAP 30.0 14.8 19.5 8.6 Group 9 time 0.5 2 .56 .01
Influence of a close person
ACT 38.1 16.4 24.8 11.0 Group 0.2 2 .78 .008
DBT 42.2 18.7 25.8 13.0 Time 44.5 1 <.001 .42
ACT + DBT + FAP 38.1 13.3 26.9 11.4 Group 9 time 0.5 2 .59 .01
Sensitivity to criticism
ACT 37.8 10.7 29.5 6.1 Group 0.3 2 .69 .01
DBT 40.6 10.5 30.7 8.0 Time 57.1 1 <.001 .48
Continued
Brief interventions for borderline personality disorder 11
Table 1. (Continued)
Statistics
ACT + DBT + FAP 38.6 9.1 29.7 8.1 Group 9 time 0.1 2 .85 .005
FFMQ Questionnaire
Observing
ACT 23.6 6.1 25.8 5.6 Group 1.6 2 .20 .05
DBT 24.7 9.3 28.0 8.0 Time 6.8 1 .01 .10
ACT + DBT + FAP 27.6 5.8 28.5 5.7 Group 9 time 0.7 2 .46 .02
Describing
ACT 23.6 6.0 25.4 5.5 Group 1.2 2 .30 .03
DBT 20.9 8.4 26.4 7.6 Time 11.9 1 .001 .16
ACT + DBT + FAP 25.3 6.9 27.5 7.2 Group 9 time 1.5 2 .22 .04
Acting with awareness
ACT 22.0 6.1 26.1 5.5 Group 1.8 2 .16 .05
DBT 17.1 8.0 24.0 7.0 Time 47.2 1 <.001 .43
ACT + DBT + FAP 19.9 7.0 26.3 7.6 Group 9 time 0.9 2 .37 .03
Nonreactivity
ACT 18.2 4.1 22.5 3.5 Group 0.4 2 .63 .01
DBT 17.8 5.8 23.2 6.2 Time 39.6 1 <.001 .39
ACT + DBT + FAP 17.0 3.4 22.0 4.3 Group 9 time 0.1 2 .86 .005
Nonjudging
ACT 18.7 5.8 27.3 7.5 Group 0.6 2 .50 .02
DBT 16.3 6.0 25.9 6.9 Time 66.1 1 <.001 .52
ACT + DBT + FAP 19.0 7.4 26.2 6.9 Group 9 time 0.4 2 .65 .01
Discussion
The principal aim of the present study was to evaluate a brief combined contextual
behavioural therapy (ACT + DBT + FAP) in terms of its effectiveness in reducing the
most frequent problems in patients with BPD, including emotional dysregulation,
negative self-image, and interpersonal dysfunction (American Psychiatric Association,
2013). This was in light of the available evidence from well-controlled clinical trials
regarding the efficacy of ACT, DBT, and FAP separately and together to achieve these
therapeutic goals (Gratz & Gunderson, 2006; Morton et al., 2012; Shearin & Linehan,
1992); and the recognition of the need for brief psychological treatment to provide the
necessary care for this population in saturated clinical contexts, such as public institutions
in developing countries such as Mexico.
The state of the art indicated that it was time to progress to the development,
evaluation, and dissemination of brief combined adaptations that would yield similar or
even better results, thereby incrementing their cost-effectiveness. The first step is an
open-label study like the present one that provides evidence to evaluate the need for
subsequent controlled confirmatory studies in the field.
According to our results, the three modalities of brief contextual behavioural therapy
were useful for decreasing BPD symptom severity, emotional dysregulation, and negative
interpersonal functioning, specifically in regard to hostile conflict resolution. This is in
line with Hayes, Villatte, Levin, and Hildebrant’s (2015) suggestion about the possibility
12
Michel A. Reyes-Ortega et al.
Table 2. Association between mean changes in symptom severity and emotion dysregulation with experiential avoidance and mindfulness across treatment
conditions
AAQ-II score .65 (.001) .60 (.004) .67 (<.001) .69 (<.001) .62 (.003) .64 (.001)
FFMQ-observing .24 (.28) .42 (.06) .16 (.45) .17 (.43) .14 (.53) .01 (.93)
FFMQ-describing .31 (.14) .36 (.11) .56 (.005) .44 (.03) .56 (.010) .51 (.012)
FFMQ-acting with awareness .37 (.08) .13 (.57) .51 (.013) .74 (<.001) .68 (.001) .71 (<.001)
FFMQ-Nonreactivity .04 (.84) .27 (.24) .80 (<.001) .31 (.15) .55 (.010) .56 (.005)
FFMQ-Nonjudging .46 (.02) .11 (.63) .42 (.04) .73 (<.001) .32 (.16) .60 (.002)
that contextual behaviour therapies such as ACT, DBT, and FAP share similar mechanisms
and therefore have similar impacts. This study suggests that therapeutic changes were
related to the reduction of experiential avoidance (targeted in ACT interventions) and the
acquisition of mindfulness skills (also included in ACT interventions and DBT), which
explains why no differences were observed between the three different treatment
modalities (ACT alone, DBT alone, and ACT + DPT + FAP).
Thus, although DBT alone does not make a specific effort to reduce experiential
avoidance in the same way as ACT does, it is possible that its emphasis on radical
acceptance of emotions, validation, and mindfulness skills serves to reduce experiential
avoidance. Increases in psychological flexibility in all interventions can also be a
consequence of the constant practice of goal-oriented behaviour in distressing situations
and in response to challenging emotions. Additionally, all the interventions under study
include mindfulness techniques, and all of them showed similar effects in the acquisition
of these skills by the end of treatment.
Interestingly, although we hypothesize that the incorporation of FAP principles into
the intervention (ACT + DBT + FAP) will increase beneficial changes in interpersonal
functioning (Levy et al., 2006), the effect sizes (g2p ) of the combined intervention for the
two interpersonal dimensions modified (self-esteem and conflict resolution) were similar
to those observed with DBT and ACT alone (medium, according to Cohen, 1988). In DBT
alone, the strategies designed to achieve emotional regulation are expected to have a
beneficial impact on interpersonal functioning (Linehan, 1993); and in ACT alone,
interpersonal functioning might improve as a consequence of strategies intended to
facilitate present-moment awareness, acceptance of difficult emotions, identification of
values, and committed action on values (Morton & Shaw, 2012; Morton et al., 2012).
However, it is important to recognize that the interventions evaluated in this study are
brief adaptations to our context (e.g., in the case of DBT, using customized index cards
translated into Spanish and modified to use suitable examples for Mexican culture), which
were applied by clinicians previously certified by official institutions dedicated to training
in the use of ACT, DBT, and FAP, with at least five years’ experience in their
implementation with BPD patients. Thus, although these interventions might offer cost-
effective therapeutic options for Spanish-speaking and/or Latin American countries that
share cultural aspects, they do not represent gold standard ACT, DBT, or FAP
implementation (Hayes, Strosahl, & Wilson, 2012; Koerner, 2011; Kohlenberg & Tsai,
1991). Thus, the effectiveness of these brief interventions should be compared with the
original ones in future controlled studies in order to determine whether similar results
could be obtained in a more cost-effective way.
Future studies should also evaluate moderating mediating variables, including the
reduction of experiential avoidance and the acquisition and practice of mindful skills (to
confirm whether these variables that showed a relationship with beneficial changes in our
study are indeed a mechanism of therapeutic change). Neacsiu, Rizvi, and Linehan (2010)
demonstrated that DBT skills fully mediated the decrease in suicide attempts and
depression and the increase in anger management over time, indicating that increasing
skills use is a mechanism of change for suicidal behaviour, depression, and anger control.
Similarly, given our results, it is possible to hypothesize that the increase in functionally
flexible behaviours (vs. experiential avoidance) and specific mindfulness skills (such as
awareness, non-reactivity, and non-judging) are at least partially mediating the decrease in
global symptom severity and emotion dysregulation in BPD patients.
Finally, one of the main limitations is the non-randomized nature of the study. Although
the present design does not suffice to offset doubts about the equivalence of the analysed
14 Michel A. Reyes-Ortega et al.
groups, the fact that there were no baseline differences among them is promising at this
early stage of evidence for these treatments. Moreover, our results support the
undertaking of a controlled clinical trial in the near future.
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