Four years comparative follow‐up evaluation of community‐based, step‐down, and residential specialist psychodynamic programmes for personality disorders

Abstract

Although the fulcrum of service provision for personality disorder (PD) has shifted from hospital-based to psychodynamically- and cognitively-oriented outpatient programmes, very few studies have attempted to compare specialist moderate intensity outpatient programmes with specialist high-intensity residential models, or to explore whether a period of inpatient treatment may be necessary to improve outcome and prognosis. In this article, we prospectively compare changes over a 4-year period in 3 groups of patients with personality disorders (N = 162) treated in a specialist community-based (CBP, N = 30), a step-down (RT-CBP, N = 87), and a specialist residential programme (RT, N = 45) in psychiatric distress, deliberate self-injury, and suicide attempt using multilevel modelling and multivariate logistic regression analyses. The results showed that percentages of early-dropout were significantly different (p = .0001) for the 3 programmes (CBP = 13.4%, RT-CBP = 10.2%, and RT = 41.4%). A significant interaction between treatment model and time was found for psychiatric distress (p = .001), with CBP and RT-CBP achieving more marked changes (g = 1.20 and g = 0.68, respectively) compared to RT (g = 0.30) at 48-month follow-up. CBP and RT-CBP were found to significantly reduce impulsive behaviour (deliberate self-injury and suicide attempt) compared to RT. Severity of presentation was not found to be a significant predictor of outcome. Long-term RT showed no advantage over long-term CBP, either as stand-alone or as step-down treatment. Replication may be needed to confirm generalizability of results, and a number of limitations in the study design may moderate the inferences that can be drawn from the results.

A preliminary service evaluation of a personality disorder case management service

“…Step‐down facilities post‐admission (i.e. outpatient therapy and outreach nursing) significantly improved outcomes, and at 4‐year follow‐up, the benefits were maintained …”

“…outpatient therapy and outreach nursing) significantly improved outcomes, 4 and at 4-year followup, the benefits were maintained. 5 Specific psychological interventions for BPD have been examined, with randomized controlled trials showing the effectiveness of mentalizationbased treatment, 6,7 dialectical behaviour therapy 8 and systems training for emotional predictability and problem solving. 9 However, those diagnosed with BPD may not meet the criteria for specialized therapy.…”

Improving social functioning and life satisfaction among patients with personality dysfunction: Connectedness and engagement in integrative group treatment

“…By bringing together multiple types of intervention, integrative group treatment offers a fertile environment in which patients may address social functioning difficulties (Chiesa, Cirasola, & Fonagy, ). Indeed, intensive day treatment has been found to promote improvement in social role and health‐related quality of life among patients with personality dysfunction (Horn et al, ).…”

Two-year follow-up and changes in reflective functioning in specialist and nonspecialist treatment models for personality disorder.

“…Effect sizes were further reduced when publication bias was taken into account, inviting caution when considering the results of these specialized treatment approaches. In addition, only a handful of studies have investigated the clinical efficacy of residential models versus less intensive approaches for PD (Bartak et al, 2010(Bartak et al, , 2011Chiesa et al, 2017). Although changes in mentalizing have been suggested to be a common factor underpinning symptomatic improvements and changes in functioning in all these contexts (Bateman, Campbell, Luyten, & Fonagy, 2018;Goodman, 2013;Montgomery-Graham, 2016), there is a dearth of research with regard to the evaluation of improvement in RF as a result of these different treatment approaches and the association between clinical changes and changes in RF in samples of patients with PD.…”

“…Several studies have shown that day-hospital and outpatient specialist approaches based on mentalization-based treatment (Bateman & Fonagy, 2009; Gullestad et al, 2012; Laurenssen et al, 2018), transference-focused psychotherapy (Clarkin, Levy, Lenzenweger, & Kernberg, 2007; Doering et al, 2010), a modified form of cognitive–behavioral therapy (DeCou, Comtois, & Landes, 2019; McMain, Guimond, Streiner, Cardish, & Links, 2012; Mehlum et al, 2016; Neacsiu, Bohus, & Linehan, 2014), schema-focused therapy (Sempértegui, Karreman, Arntz, & Bekker, 2013), and community-based psychosocial (CBP) treatment (Chiesa, Cirasola, & Fonagy, 2017; Chiesa, Fonagy, & Gordon, 2009) are promising treatment approaches in improving a number of clinical outcomes in a range of PDs. However, a recent meta-analysis (Cristea et al, 2017) of 33 randomized controlled trials found small to moderate differences in effectiveness between specialized psychotherapy and nonspecialized treatment in improving PD outcomes.…”