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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?
Halliwick Psychotherapy Unit, London, UK.
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.
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.
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).
In patients with borderline personality disorder, benefits of psychoanalytically oriented partial hospitalisation were maintained 18 months after treatment completion.
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
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.
↵† 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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