Psychoeducation with problem-solving (PEPS) therapy for adults with personality disorder: a pragmatic randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of a manualised intervention to improve social functioning

Abstract

If effective, less intensive treatments for people with personality disorder have the potential to serve more people.To compare the clinical effectiveness and cost-effectiveness of psychoeducation with problem-solving (PEPS) therapy plus usual treatment against usual treatment alone in improving social problem-solving with adults with personality disorder.Multisite two-arm, parallel-group, pragmatic randomised controlled superiority trial.Community mental health services in three NHS trusts in England and Wales.Community-dwelling adults with any personality disorder recruited from community mental health services.Up to four individual sessions of psychoeducation, a collaborative dialogue about personality disorder, followed by 12 group sessions of problem-solving therapy to help participants learn a process for solving interpersonal problems.The primary outcome was measured by the Social Functioning Questionnaire (SFQ). Secondary outcomes were service use (general practitioner records), mood (measured via the Hospital Anxiety and Depression Scale) and client-specified three main problems rated by severity. We studied the mechanism of change using the Social Problem-Solving Inventory. Costs were identified using the Client Service Receipt Inventory and quality of life was identified by the European Quality of Life-5 Dimensions questionnaire. Research assistants blinded to treatment allocation collected follow-up information.There were 739 people referred for the trial and 444 were eligible. More adverse events in the PEPS arm led to a halt to recruitment after 306 people were randomised (90% of planned sample size); 154 participants received PEPS and 152 received usual treatment. The mean age was 38 years and 67% were women. Follow-up at 72 weeks after randomisation was completed for 62% of participants in the usual-treatment arm and 73% in the PEPS arm. Intention-to-treat analyses compared individuals as randomised, regardless of treatment received or availability of 72-week follow-up SFQ data. Median attendance at psychoeducation sessions was approximately 90% and for problem-solving sessions was approximately 50%. PEPS therapy plus usual treatment was no more effective than usual treatment alone for the primary outcome [adjusted difference in means for SFQ -0.73 points, 95% confidence interval (CI) -1.83 to 0.38 points; p = 0.19], any of the secondary outcomes or social problem-solving. Over the follow-up, PEPS costs were, on average, £182 less than for usual treatment. It also resulted in 0.0148 more quality-adjusted life-years. Neither difference was statistically significant. At the National Institute for Health and Care Excellence thresholds, the intervention had a 64% likelihood of being the more cost-effective option. More adverse events, mainly incidents of self-harm, occurred in the PEPS arm, but the difference was not significant (adjusted incidence rate ratio 1.24, 95% CI 0.93 to 1.64).There was possible bias in adverse event recording because of dependence on self-disclosure or reporting by the clini...

Lamotrigine for people with borderline personality disorder: a RCT

“…We over-recruited, as it became clear that we were not going to achieve our ambitious target of following up 85% of participants to 12 months after randomisation. The 71% rate of follow-up that we achieved was very similar to that achieved in a UK study of problem-solving therapy for people with personality disorder 71 and may represent a more realistic target for studies that aim to follow up people with personality disorder in community-based studies. A planned secondary analysis using multiple imputation to account for missing data found no difference between the study arms.…”

Structured Psychological Support for people with personality disorder: feasibility randomised controlled trial of a low-intensity intervention

“…Very few clinical trials of low-intensity interventions for people with personality disorder have been conducted. 12 Those that have been conducted have required people to attend therapy groups, [13][14][15] examined adjunctive interventions designed to enhance the effects of longer-term psychological treatments 16,17 or have restricted recruitment to subgroups of patients with coexisting conditions. 18…”

“…Such interviews are lengthy, often taking an hour or more to complete. Data from a previous trial of problem-solving therapy for people with personality disorder that used a structured diagnostic interview to assess eligibility for trial inclusion found that nearly all those referred to the trial (650, 95.3% of 682) met criteria for personality disorder, 15 showing that clinicians referring to the trial were able to accurately identify relevant patients. Time-consuming structured assessments may, therefore, be unnecessary, particularly where the specific type or types of personality disorder are not pertinent.…”

“…However, the negative results of a recent, fully powered, trial of problem-solving therapy for people with personality disorder suggest that time spent with therapists alone is not sufficient to improve patient outcomes. 15 This study was conducted in a secondary care mental health setting, however, many people with personality disorder are managed within primary care. Future research should examine the acceptability and effectiveness of SPS delivered in primary care settings.…”

Psychological Support for Personality (PSP) versus treatment as usual: study protocol for a feasibility randomized controlled trial of a low intensity intervention for people with personality disorder

“…[ 20 ]. In contrast to the promising results of these studies, no benefit was seen among people with personality disorder who were offered a short-term group-based problem-solving therapy for people with personality disorder [ 21 ].…”