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Treatment benefits of psychoanalytically oriented partial hospitalisation were maintained over 18 months in borderline personality disorder
  1. Chris Evans, MBBS
  1. Rampton Hospital Nottinghamshire, UK

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 QUESTION: In patients with borderline personality disorder, are the short term benefits of psychoanalytically oriented partial hospitalisation maintained over an 18 month follow up period?

    Design

    Randomised {allocation concealed*}, unblinded*, controlled trial with 36 months total follow up.

    Setting

    Halliwick Psychotherapy Unit, London, UK.

    Patients

    44 patients with borderline personality disorder diagnosed using DSM-III-R and the Diagnostic Interview for Borderline Patients. Exclusion criteria were schizophrenia, bipolar disorder, substance misuse, mental impairment, or evidence of organic brain disorder. 3 patients in the control group refused continued participation.

    Intervention

    22 patients were allocated to psychoanalytically oriented partial hospitalisation and 22 to standard psychiatric care. Treatment was for a maximum of 18 months. A follow up programme was offered to those assigned to partial hospitalisation which consisted of analytic therapy twice a week over 18 months. The control group continued to receive general psychiatric treatment.

    Main outcome measures

    Frequency of suicide attempts and acts of self harm, number and duration of inpatient admissions, service utilisation, and self reported measures of depression, anxiety, general symptom distress, interpersonal functioning, and social adjustment.

    Main results

    Analysis was by intention to treat. At 36 months follow up, fewer patients assigned partial hospitalisation reported engaging in self mutilation and fewer had made serious suicidal gestures (table). Over the 18 month extended follow up period, patients in the partial hospitalisation group had fewer inpatient treatment days (1.7 v 15.8 mean d in the control group), outpatient psychiatric visits (0.7 v 4.3 mean visits), partial hospitalisation days (0 v 13.9 mean d), and days in community centre attendance (0.9 v 17.3 mean d) (p<0.002 for all comparisons). Patients in the partial hospitalisation group improved more than the control patients on all self report measures (p<0.001).

    Psychoanalytically oriented partial hospitalisation (PH) v standard psychiatric care (SC) at 36 months in borderline personality disorder§

    Conclusion

    In patients with borderline personality disorder, benefits of psychoanalytically oriented partial hospitalisation were maintained 18 months after treatment completion.

    Commentary

    This article by Bateman et al reports on the 18 months of follow up of an 18 month trial.1 The day hospital programme combined recent psychoanalytic theory with enthusiastic community outreach. Therapy included weekly individual sessions, thrice weekly group analytic therapy, weekly expressive therapy, and a community meeting. This was supplemented with medication and acute admissions as necessary. Most work fell on nurses without formal psychotherapy training but they received ongoing supervision during the programme.

    There seems to be 2 messages. The first is that nihilistic prognoses for borderline personality disorder are not evidence based,2 psychoanalytic day hospital treatment and cognitive behavioural treatment3 have support from randomised controlled trials, and therapeutic communities have systematic review support.4 Nihilism may have arisen because treatment needs commitment, a clear model, time to influence behaviours, and a longer time to affect depression.

    The second message is that we need more effectiveness data and practice based evidence5 on how best to train staff and replicate these treatments, and perhaps to identify and extend what is effective within them. Anyone serious about implementing something similar should read Bateman's review.6

    References

    View Abstract

    Footnotes

    • Source of funding: no external funding.

    • For correspondence: Dr A Bateman, Haringey Healthcare NHS Trust, Halliwick Day Unit, St Ann's Hospital, University College London, London N15 3TH, UK. Fax +44 (0) 208 442 6545.

    • * See glossary.

    • Information provided by the author.

    • Information from Bateman A, Fonagy P. Effectiveness of partial hospitaliztion in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry. 1999;156:1563–9.

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