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Residential Versus Community Treatment of Personality Disorders: a Comparative Study of Three Treatment Programs

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Residential Versus Community Treatment of Personality Disorders: a Comparative Study of Three Treatment Programs Article Residential Versus Community Treatment of Personality Disorders: A Comparative Study of Three Treatment Programs Marco Chiesa, M.D., M.R.C.Psych. Objective: The aim of this study was to Results: By 24 months, patients in the compare the effectiveness of three treat- step-down condition showed significant Peter Fonagy, Ph.D., F.B.A. ment models for personality disorder: 1) a improvements on all measures. Patients in long-term psychoanalytically oriented resi- the long-term residential model showed Jeremy Holmes, M.D., M.R.C.P., dential specialist program, 2) a phased significant improvements in symptom se- “step-down” specialist psychosocial pro- verity, social adaptation, and global func- F.R.C.Psych. gram that included a briefer residential tioning, while no changes were achieved stay and an outpatient component, and 3) in self-harm, attempted suicide, and read- Carla Drahorad, D.Psychol. a general community psychiatric model. mission rates. Patients in the general psy- chiatric group showed no improvement Method: One hundred forty-three pa- on any variables except self-harm and hos- tients with a personality disorder diagnosis pital readmissions. were allocated according to geographical Conclusions: The results of this study criteria to the three treatment conditions. suggest that for personality disorders, a Outcome was prospectively evaluated at 6, specialist step-down program is more ef- 12, and 24 months through the use of a fective than both long-term residential standardized battery of instruments that treatment and general psychiatric treat- included measures of general symptom ment in the community. Replication is severity, social adaptation, assessment of needed that includes a random allocation mental health functioning, frequency of of patients to conditions to ensure that self-harm and suicide attempts, and rates geographical factors did not account for and duration of hospital readmissions. the observed differences. (Am J Psychiatry 2004; 161:1463–1470) Long-term psychoanalytically oriented treatment for that outpatient programs based on cognitive behavior or severe personality disorders often entailed admission to a psychodynamic approaches are quite effective, particularly residential facility offering milieu therapy in the context of in the treatment of borderline personality disorder (7, 8). a therapeutic community (1). These units offered a combi- None of these alternatives provide the remedial compensa- nation of intensive individual and group psychoanalytic tory environmental experience offered by the therapeutic psychotherapy and a vigorous program of social rehabili- community milieu. Since therapeutic community-based tation (2). This approach, while costly, held promise in treatment has never been evaluated relative to these less in- light of the pervasive developmental deficits of this group tensive community-based treatments, there might be a risk of patients that undermined their capacity to function that psychiatry will lose a possibly effective treatment mo- effectively in interpersonal relationships. In the last two dality without it ever having been properly evaluated. decades, the development of the diagnosis and under- Here we report a comprehensive outcome comparison standing of severe personality disorders (3) along with al- for two models of delivering psychotherapeutic inpatient ternatives to hospitalization, improvements in the biolog- treatment: a long-term residential psychosocial treatment ical approach to severe personality disorders (4), and cost- approach and a “step-down” model with a shorter-term related considerations have resulted in a clear move away inpatient stay followed by longer-term outpatient and from residential treatment of personality disorders. community treatment. Both of these models were com- pared with general psychiatric community treatment on The evaluation of long-term residential psychotherapeu- its own without the benefit of inpatient or outpatient spe- tic treatment for severe personality disorders rests on a few cialist psychotherapeutic treatment. cohort studies, which were limited by methodological problems such as a retrospective design, diagnostic criteria not being operationalized, lack of a comparison or control Method condition, and unstandardized outcome measures (5, 6). At The study took place at The Cassel Hospital and North Devon the same time, a handful of studies have produced evidence Healthcare NHS Trust, England. Am J Psychiatry 161:8, August 2004 http://ajp.psychiatryonline.org 1463 TREATMENT OF PERSONALITY DISORDERS All patients consecutively admitted to The Cassel Hospital for ingfully reflect the outcome of expectable nonspecialist treat- specialist psychosocial treatment between 1993 and 1997 were ment in the United Kingdom. considered for the study. Inclusion criteria were ages between 19 After complete description of the study to all eligible patients, and 55, IQ above 80, and meeting diagnostic criteria for at least written informed consent was obtained. one personality disorder. Exclusion criteria were a diagnosis of The final study sample included 49 patients (62% of eligible) in schizophrenia, paranoid psychosis, or drug or alcohol addiction the inpatient program, 45 (78%) in the step-down program, and (but not misuse) as well as mental impairment and evidence of 49 (67%) in the general psychiatric comparison group. All con- organic brain disorder. senting patients were assessed for presence of axis I and II diag- Seventy-nine patients were allocated to the purely inpatient noses by using the Structured Clinical Interview for DSM-III-R program, which consisted of an expected 12-month admission (SCID) and the Structured Clinical Interview for DSM-III-R Per- with no planned outpatient follow-up. Fifty-eight patients were sonality Disorders (SCID-II) (10), and thorough demographic and assigned to the step-down program, which consisted of an ex- clinical history was obtained, recorded, and coded. Interrater re- pected 6-month admission followed by 12–18 months of outpa- liability testing with a second psychiatrist reviewing taped inter- tient group analytic psychotherapy and 6–9 months of concurrent views showed that kappa values calculated for each axis I diagno- outreach nursing. The treatment allocation followed established sis yielded a median kappa of 0.85 (range=0.73–1.00). Reliability criteria of geographical accessibility to treatment, whereby pa- of axis II diagnoses varied between 0.61 for Cluster A, 0.67 for tients outside the Greater London area were assigned to the inpa- Cluster B, and 1.00 for Cluster C disorders. Intelligence quotient tient program. equivalents were obtained through administration of the Na- Of the 79 patients considered for the inpatient program, two tional Adult Reading Test (11). (3%) did not meet criteria, and an additional 28 (35%) either re- The median duration of inpatient stay was 42 weeks (mean=36, fused consent or dropped out of the study immediately after sign- SD=19.0) and 28 weeks (mean=27, SD=6.9) for the inpatient pro- ing consent forms and having contributed no data or after only gram and step-down program patients, respectively. The median completing the intake battery of measures. One patient (2%) of duration of outpatient treatment for the step-down program was those considered for the step-down program did not meet crite- 57 weeks (mean=44, SD=29.7). Since this was an intent-to-treat ria, and 12 patients (21%) either refused to give written consent or study, clinical dropouts were recalled for assessment at the agreed refused to cooperate with the study from the outset. Of the four schedule. At the time of the 24-month assessment, all but three successful suicides in the inpatient program group, two did not patients (6.7%) in the step-down program group who had their complete the baseline assessment, while the other two killed therapy extended for clinical reasons had terminated their spe- themselves by 6 and 12 months after admission, respectively. For cialist treatment program. However, because of their better com- these patients in the data analysis we carried over the values of pliance and longer duration of treatment, most patients in the the standardized measures from the last assessment point, and step-down program had been discharged from treatment only 3 they were thus included in the multivariate analysis. However, months before the 24-month assessment, compared with 14 they were excluded from the analysis of clinical outcome vari- months for patients in the inpatient program. The data were ana- ables, since we found no satisfactory way of estimating these lyzed excluding program noncompleters, and no substantial dif- data. ference in the pattern of outcomes on key variables was found. The components of the residential treatment were 1) twice- Demographic and clinical characteristics of the patients in the weekly individual psychoanalytically oriented psychotherapy; 2) three treatment groups are shown in Table 1. The three groups meetings with unit staff five times a week; 3) twice-weekly com- were well matched, but significant differences were found in munity meetings; 4) once-weekly small group psychotherapy; 5) a terms of marital status, education, and major depression status. structured program of activities aimed at the acquisitions of in- The general psychiatric comparison group had a higher propor- terpersonal skills, resocialization, and rehabilitation; 6) and psy- tion of patients who 1) were in a stable relationship, 2) had no col- chotropic medication.
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