THE EVALUATION OF PSYCHOANALYTICALLY INFORMED TREATMENT PROGRAMS FOR SEVERE PERSONALITY DISORDER: A CONTROLLED STUDY Marco Chiesa & Peter Fonagy

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1 THE EVALUATION OF PSYCHOANALYTICALLY INFORMED TREATMENT PROGRAMS FOR SEVERE PERSONALITY DISORDER: A CONTROLLED STUDY Marco Chiesa & Peter Fonagy Aims Summary The aim of this study was to compare the effectiveness of three treatment models for personality disorder: 1) a long-term psychoanalytically oriented residential specialist program, 2) a phased 'step down' specialist psychosocial program including a briefer residential and an outpatient component, and 3) a general community psychiatric model (treatment as usual). Methods One hundred and forty-three patients with a diagnosis of personality disorder were allocated according to geographical criteria to the three treatment conditions. Outcome was prospectively evaluated at 6, 12, 24, 36 and 72 months through the use of a standardized battery of instruments that included measures of general symptom severity, social adaptation, assessment of mental health functioning, frequency of self-harm and suicide attempts, rates and duration of hospital re-admissions. A cost-effectiveness analysis was also carried out to evaluate the relative costs of each program relative to clinical outcome. The Adult Attachment Interview was used to identify attachment status as predictor of clinical outcome at 24 months follow-up, as well as ascertain whether structural change occurred as a result of treatment exposure. Results By twenty-four months patients in the step down condition showed significant improvements on all measures. Patients in the long-term residential model showed significant improvements in symptom severity, social adaptation and global functioning while no changes were achieved in self-harm, attempted suicide and readmission rates. Patients in the general psychiatric group showed no improvement on all variables except self-harm and hospital readmissions. For example, the odds ratios revealed that patients in the step down program were 3 times less likely to self-mutilate by 24 months (CI: ), while membership of the purely inpatient group predicted a 1.5 increase in self-mutilation (CI: ) In the year after expected discharge patients in the step down program were 4 times less likely to be readmitted to a psychiatric service (CI: ). The results of this study suggest that a specialist step down program is more effective than both long-term residential treatment and general psychiatric treatment in the community for personality disorder. Replication is needed which includes a random allocation of patients to conditions to ensure that geographical factors did not account for the observed differences. The economic evaluation showed that both specialist programmes were more effective than routine psychiatric services but more costly. Using an extended dominance approach the incremental costeffectiveness ratio showed that achieving one extra person with clinically relevant outcomes required an investment in the Step-Down programme of around 3400 over 18 months. Small sample sizes and non-random allocation to programmes are limitations of this study but the costs and effectiveness findings consistently point to advantages for the shorter residential programme followed by community-based psychotherapeutic support.

2 The analysis of the Adult Attachment Interviews is still ongoing and results will become available at the end of See component study 1: The evaluation of psychoanalytically informed treatment programs for severe personality disorder: A controlled study See component study 2: Health service utilisation costs by personality disorder following specialist and non-specialist treatment: A comparative study Implications for psychoanalysis Psychoanalytically-informed model of treatment is more effective than a general psychiatric approach based on pharmacotherapy and case-management for personality disorder. Formal psychoanalyticallybased therapies (individual and group) combined with management based on an understanding of transference and countertransference phenomena as well as a specific approach to the primitive defensive organizations presented by borderline patients translate into clinically relevant improvement that can be sustained years after treatment ends. The cohesiveness and consistency of approach by a multi-disciplinary team provides a containing and transformative milieu and improves the overall prognostic outlook for personality-disordered patients. The study also confirms that psycho-analytically informed treatment can be cost-effective and decrease the amount of health-service use by these patients and increases their productivity for society. Keywords Adult Attachment Interview, borderline personality disorder, Cassel Hospital, cost-effectiveness, inpatient treatment, long-term follow-up, milieu therapy, outcome study, personality disorder, psychoanalytically-informed treatment, therapeutic community Bibliography Chiesa, M. (2000). Hospital adjustment in personality disorder patients admitted to a therapeutic community milieu. British Journal of Medical Psychology, 73, Chiesa, M., Bateman, A., Friis, S., & Wiberg, T. (2002a). Patient characteristics, outcome and costbenefit of hospital-based treatment for patients with personality disorder: A comparison of three treatment programmes. Psychology and Psychotherapy, 75, Chiesa, M., Drahorad, C., & Longo, S. (2000). Early termination of treatment in personality disorder treated in a psychotherapy hospital: A quantitative and qualitative study. British Journal of Psychiatry, 177, Chiesa, M., & Fonagy, P. (2000). Cassel Personality Disorder Study. Methodology and treatment effects. Br J Psychiatry, 176, Chiesa, M., & Fonagy, P. (2002). From the therapeutic community to the community: A preliminary evaluation of a psychosocial outpatient service for severe personality disorders. Therapeutic Communities: International Journal for Therapeutic and Supportive Organizations, 23(4), Chiesa, M., & Fonagy, P. (2003). Psychosocial treatment for severe personality disorder. 36-month follow-up. Br J Psychiatry, 183, Chiesa, M., Fonagy, P., & Holmes, J. (2003a). An experimental study of treatment outcome at the Cassel Hospital. In J. Lees, N. Manning, D. Menzies & M. Morant (Eds.), Researching Therapeutic Communities (pp ). London: Jessica Kingsley Publications. Chiesa, M., Fonagy, P., & Holmes, J. (2003b). When less is more: An exploration of psychoanalytically oriented hospital based treatment for severe personality disorder. International Journal of Psychoanalysis, 84,

3 Chiesa, M., Fonagy, P., Holmes, J., & Drahorad, C. (2004). Residential versus community treatment of personality disorder: A comparative study of three treatment programs. American Journal of Psychiatry, 161, Chiesa, M., Fonagy, P., Holmes, J., Drahorad, C., & Harrison-Hall, A. (2002b). Health service use costs by personality disorder following specialist and nonspecialist treatment: a comparative study. J Personal Disord, 16(2),

4 COMPONENT STUDY 1: RESIDENTIAL VERSUS COMMUNITY TREATMENT OF PERSONALITY DISORDER: A COMPARATIVE STUDY OF THREE TREATMENT PROGRAMS Aims The aim of this study was to compare the effectiveness of three treatment models for personality disorder: 1) a long-term psychoanalytically oriented residential specialist program, 2) a phased 'step down' specialist psychosocial program including a briefer residential and an outpatient component, and 3) a general community psychiatric model. Methods One hundred and forty-three patients with a diagnosis of personality disorder were allocated according to geographical criteria to the three treatment conditions. Outcome was prospectively evaluated at 6, 12 and 24 months through the use of a standardized battery of instruments that included measures of general symptom severity, social adaptation, assessment of mental health functioning, frequency of self-harm and suicide attempts, rates and duration of hospital re-admissions. Results By twenty-four months patients in the step down condition showed significant improvements on all measures. Patients in the long-term residential model showed significant improvements in symptom severity, social adaptation and global functioning while no changes were achieved in self-harm, attempted suicide and readmission rates. Patients in the general psychiatric group showed no improvement on all variables except self-harm and hospital readmissions. See Table 1: comparing the socio-demographic and diagnostic characteristics of the treatment samples See Table 2: showing rates of clinically significant change (CSC) in symptom severity, social adaptation and global adjustment at each assessment interval in patients in the Inpatient Program (N=49), in the Step Down Program (N=45) and in the General Psychiatric Program (N=49) See Table 3: showing clinical outcome and service utilization in personality disordered patients Conclusions The results of this study suggest that a specialist step down program is more effective than both longterm residential treatment and general psychiatric treatment in the community for personality disorder. Replication is needed which includes a random allocation of patients to conditions to ensure that geographical factors did not account for the observed differences.

5 TABLE 1: COMPARISON OF SOCIO-DEMOGRAPHIC AND DIAGNOSTIC CHARACTERISTICS OF THE TREATMENT SAMPLES Return to component 1

6 TABLE 2: RATES OF CLINICALLY SIGNIFICANT CHANGE (CSC) IN SYMPTOM SEVERITY, SOCIAL ADAPTATION AND GLOBAL ADJUSTMENT AT EACH ASSESSMENT INTERVAL IN PATIENTS IN THE INPATIENT PROGRAM (N=49), IN THE STEP DOWN PROGRAM (N=45) AND IN THE GENERAL PSYCHIATRIC PROGRAM (N=49) Return to component 1

7 TABLE 3: CLINICAL OUTCOME AND SERVICE UTILIZATION IN PERSONALITY DISORDERED PATIENTS Return to component 1

8 COMPONENT STUDY 2: HEALTH SERVICE UTILISATION COSTS BY PERSONALITY DISORDER FOLLOWING SPECIALIST AND NON-SPECIALIST TREATMENT: A COMPARATIVE STUDY Aims The impact of specialist psychosocial treatment on health service utilisation costs by patients with personality disorder is not yet sufficiently documented. In this study three groups of patients with personality disorder were prospectively evaluated with respect to levels of healthcare utilisation, relative costs and clinical outcome over a two-year period. Two samples were treated with a specialist psychosocial inpatient model and a specialist psychosocial 'step down' model respectively at the Cassel Hospital, Richmond, UK, while the third received standard psychiatric care within North Devon NHS Healthcare Trust, UK. The aim was to assess whether specialist models for personality disorder achieved greater reduction in healthcare utilisation related costs and were more cost effective than standard psychiatric care. In addition we investigated the influence of Borderline Personality Disorder and Major Depression alone or in combination on health service utilisation costs. Methods 143 patients were selected and approached for consent. 94 were consecutive admission to the Cassel Hospital between April 1994 and July Of those 46 were allocated to a Step down programme (SDP- 6 months inpatient admission followed by eighteen months twice weekly group therapy and concurrent outreach psychosocial nursing for the first 6 months) and forty-eight to a hospital-based programme (IPP- twelve months hospital stay with no outpatient follow-up). Allocation to the Cassel specialist treatment programmes followed criteria of geographical accessibility, whereby patients within the Greater London Area were placed to the SDP and patients from outside the GLA were placed to the IPP. Forty-nine patients who met operational criteria for personality disorder were selected from the caseload of several Consultant psychiatrists within the North Devon NHS Healthcare Trust (GPP). After considering refusals to participate in the study and patients that did not contribute data after the intake interview, the study sample comprised of thirty-three patients in both SDP (72%) and IPP (69%), and of thirty-four patients in GPP (69%). Patients were in their early thirties, mostly female and unemployed. About half of the subjects reported experiences of sexual abuse by the age of ten; had self-mutilated; attempted suicide; and had at least one acute psychiatric admission in the year prior to intake. Mood disorders and anxiety disorders or both were present in over half of the total sample, while up to seventy percent met diagnostic criteria for borderline personality disorder. The three samples appeared to be evenly matched on most demographic, diagnostic and clinical variables, although they were significantly different in marital and educational status. Results Total service utilisation costs at follow up compared to intake costs showed that significantly higher savings were achieved by SDP and IIP compared to GPP. Cost reductions in SDP were significantly greater than in IPP. Significant cost reductions were found between treatment programmes in social worker & community psychiatric nursing and psychotherapy. The cost-effectiveness of the two specialist treatment programmes was indicated by the significant association between total cost reduction and clinical outcome in GPP and IPP, but not in GPP.The effect of Major Depression and Borderline Personality Disorder on health service utilisation alone and in combination was also investigated. We found that Major Depression was found to be more significantly associated with higher health service utilisation costs than Borderline Personality Disorder.

9 Conclusions This study confirms that personality disordered individuals are high utilisers of healthcare resources. However, we found that patients with current major depression without a borderline diagnosis were also associated with high levels of health service utilisation costs, and on some variables even higher than those shown by borderline patients. It is possible that attitudes as to the nature of the disorder in general psychiatric settings and in primary care may influence service input. The significant differences in total costs reductions between intake and follow-up in the step down (7265 Euros), in the specialist inpatient (5045 Euros) and in the general psychiatric (3440 Euros) programmes, and the significant associations between cost reductions and clinical outcome indicated that the two specialist programmes were more effective in reducing healthcare utilisation costs and were more cost effective than a model based on general psychiatric management. In particular a phased model based on a shorter hospital stay followed by long-term outpatient psychosocial treatment, was revealed to be particularly effective in achieving greater savings in relation to clinical outcome for this group of patients.