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

The study took place at The Cassel Hospital and North Devon Healthcare NHS Trust, England.

All patients consecutively admitted to The Cassel Hospital for specialist psychosocial treatment between 1993 and 1997 were considered for the study. Inclusion criteria were ages between 19 and 55, IQ above 80, and meeting diagnostic criteria for at least one personality disorder. Exclusion criteria were a diagnosis of schizophrenia, paranoid psychosis, or drug or alcohol addiction (but not misuse) as well as mental impairment and evidence of organic brain disorder.

Seventy-nine patients were allocated to the purely inpatient program, which consisted of an expected 12-month admission with no planned outpatient follow-up. Fifty-eight patients were assigned to the step-down program, which consisted of an expected 6-month admission followed by 12–18 months of outpatient group analytic psychotherapy and 6–9 months of concurrent outreach nursing. The treatment allocation followed established criteria of geographical accessibility to treatment, whereby patients outside the Greater London area were assigned to the inpatient program.

Of the 79 patients considered for the inpatient program, two (3%) did not meet criteria, and an additional 28 (35%) either refused consent or dropped out of the study immediately after signing consent forms and having contributed no data or after only completing the intake battery of measures. One patient (2%) of those considered for the step-down program did not meet criteria, and 12 patients (21%) either refused to give written consent or refused to cooperate with the study from the outset. Of the four successful suicides in the inpatient program group, two did not complete the baseline assessment, while the other two killed themselves by 6 and 12 months after admission, respectively. For these patients in the data analysis we carried over the values of the standardized measures from the last assessment point, and they were thus included in the multivariate analysis. However, they were excluded from the analysis of clinical outcome variables, since we found no satisfactory way of estimating these data.

The components of the residential treatment were 1) twice-weekly individual psychoanalytically oriented psychotherapy; 2) meetings with unit staff five times a week; 3) twice-weekly community meetings; 4) once-weekly small group psychotherapy; 5) a structured program of activities aimed at the acquisitions of interpersonal skills, resocialization, and rehabilitation; 6) and psychotropic medication. Patients were reviewed formally every 2 months.

The outpatient stage for the step-down program comprised 1) twice-weekly small group analytic psychotherapy; 2) twice-weekly individual and group meetings in the community with a psychosocially trained outreach nurse; 3) active networking with primary and secondary care workers; 4) team meetings to discuss patients’ progress; and 5) meetings with a senior psychiatrist to review progress.

The general psychiatric comparison group, selected from the caseload of all the senior district clinicians during the same period in North Devon, England, comprised 130 patients 19–55 years of age who were identified as suffering from a primary personality disorder diagnosis. These patients were screened with the Personality Diagnostic Questionnaire (9), which confirmed the presence of at least one axis II diagnosis in 73 patients. Fourteen (19%) of these did not wish to participate in the study, and an additional 10 (14%) could not be regularly followed up. Fifty-seven percent had been inpatients in the previous year, and all had a history of hospitalization. Inclusion and exclusion criteria were the same as those used for the specialist treatment samples. Patients received standard general psychiatric care, which included 1) psychotropic medication; 2) supportive outpatient and community contact with one or more care workers, on average at intervals of 2–4 weeks; 3) hospital admission as needed; and 4) a clinical review on average once a month. This group would meaningfully reflect the outcome of expectable nonspecialist treatment in the United Kingdom.

After complete description of the study to all eligible patients, written informed consent was obtained.

The final study sample included 49 patients (62% of eligible) in the inpatient program, 45 (78%) in the step-down program, and 49 (67%) in the general psychiatric comparison group. All consenting patients were assessed for presence of axis I and II diagnoses by using the Structured Clinical Interview for DSM-III-R (SCID) and the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) (10), and thorough demographic and clinical history was obtained, recorded, and coded. Interrater reliability testing with a second psychiatrist reviewing taped interviews showed that kappa values calculated for each axis I diagnosis yielded a median kappa of 0.85 (range=0.73–1.00). Reliability of axis II diagnoses varied between 0.61 for Cluster A, 0.67 for Cluster B, and 1.00 for Cluster C disorders. Intelligence quotient equivalents were obtained through administration of the National Adult Reading Test (11).

The median duration of inpatient stay was 42 weeks (mean=36, SD=19.0) and 28 weeks (mean=27, SD=6.9) for the inpatient program and step-down program patients, respectively. The median duration of outpatient treatment for the step-down program was 57 weeks (mean=44, SD=29.7). Since this was an intent-to-treat study, clinical dropouts were recalled for assessment at the agreed schedule. At the time of the 24-month assessment, all but three patients (6.7%) in the step-down program group who had their therapy extended for clinical reasons had terminated their specialist treatment program. However, because of their better compliance and longer duration of treatment, most patients in the step-down program had been discharged from treatment only 3 months before the 24-month assessment, compared with 14 months for patients in the inpatient program. The data were analyzed excluding program noncompleters, and no substantial difference in the pattern of outcomes on key variables was found.

Demographic and clinical characteristics of the patients in the three treatment groups are shown in Table 1. The three groups were well matched, but significant differences were found in terms of marital status, education, and major depression status. The general psychiatric comparison group had a higher proportion of patients who 1) were in a stable relationship, 2) had no college education, and 3) met criteria for current major depression. Most patients (70%) met criteria for more than two personality disorders, while 83% had a concurrent axis I diagnosis. No significant group differences were found in terms of personality disorder comorbidity or axis I/axis II comorbidity.

We would like first to comment on the limitations of the study. Since the allocation to the study groups was not the result of randomization, the issue of the comparability of the groups needs to be addressed. It is likely that the hospitalized and comparison groups differed at referral for different kinds of treatment and that further bias may be introduced when compared groups are referred from different geographical areas of the country even for the same kind of treatment. The confounding of type of treatment with participant characteristics could be a significant threat to the internal validity of the study. To mitigate this risk we found that the groups were relatively well matched on most demographic, diagnostic, and other clinical criteria, including severity, that were measured. Controlling for the three variables that were significantly different did not affect the observed differences in outcome. The two treatment samples comprised patients referred specifically for specialist psychotherapeutic treatment, so it could be argued that they were selected on the basis of their potential for responsiveness to such approach. In reality the strict funding arrangements introduced in the United Kingdom in 1993 (when recruitment for this study commenced) meant that only “meritorious” patients in terms of severity and chronicity of disturbance were funded for treatment at tertiary care centers such as the hospital under investigation.

The multicomponent nature of the treatment programs under scrutiny complicates assessments of effectiveness due to the complexity of the intervention. It is not clear if mere hospitalization, the nature of the hospital climate, or the treatments offered in the hospital or a combination of these was the effective component of the treatment. The relatively inclusive selection criteria, in specifying a single personality disorder diagnosis as sufficient to qualify for entry into the study, might have led to a heterogeneous patient group. All three samples were largely (80% or more) made up of individuals with at least one cluster B personality disorder diagnosis, and the average participant met two to three sets of diagnostic criteria; the breadth of the original inclusion criteria did not turn out to be a problem. Further limitations of the study included the lack of raters’ blindness with regard to group allocation and assessment point and the asymmetrical follow-up period, which was inevitable given the unequal length of treatment and our intention to follow the natural course of the disorder.

Bearing in mind these limitations, the results showed that a step-down program comprising a medium-term residential stay in a psychosocial therapeutic milieu followed by long-term outpatient group psychotherapy and support in the external community achieved significantly greater improvement on a number of standardized and clinical outcome measures than long-term specialist residential treatment alone with no outpatient follow-up or general psychiatric management. The significant decrease in self-mutilating and parasuicidal behavior and in readmission rates along with a sustained improvement in symptom severity and social and global adjustment in the step-down group is an indication that continuing treatment in the community plays an important role in helping patients make the transition between hospital and community life. We suggest that providing a long-term outpatient specialist psychosocial aftercare program seems to protect patients from the anxieties connected with discharge from the hospital, which in turn enables them to better face the challenges of readapting to community life without breaking down (17). The initial phase of hospitalization in a structured setting with multiple and intense therapeutic input may be an important component of the treatment of individuals with severe personality disorders to initiate a process of reversal of entrenched patterns of dysfunctional behavior, expressed as severe symptoms or self-destructive acting out. However, recent purely community-based approaches to the treatment of personality disorders may suggest that admission to a hospital milieu could be avoided with no detriment to effectiveness (7, 8, 18). Hospital treatment for 6 months or 12 months is no longer regarded as realistic treatment options for the treatment of personality disorders in North America, as third-party payers regard the cost associated with inpatient admission as excessive. However, we have shown that the cost of specialist inpatient admission relative to that of treatment as usual reduces health and social care cost in the year after treatment termination, and if the savings are maintained the cost of treatment would be offset within 5 years for patients in the step-down program (19). Thus, a long-term program that includes a 6-month inpatient stay might be in part justifiable in economic terms, at least in countries where socialized health care would require that these severely problematic individuals receive treatment.

In contrast, the findings concerning long-term specialist residential treatment were mixed. Compared with the general psychiatric group, the inpatient group did generally better in symptom reduction, social adaptation, and global outcome but showed comparable results in clinical and service utilization variables. When the planned length of hospitalization is excessive, this may carry risks in the shape of regressive and iatrogenic effects, as the results in self-harming and parasuicidal behavior confirmed. In addition, the lack of a planned outpatient follow-up treatment leaves patients to a state of continuing vulnerability to acute decompensations as shown by the unchanged rate of readmissions to psychiatric services in the year following expected discharge.

In conclusion, this study suggests that medium-term residential psychotherapeutic treatment as part of a long-term step-down program may be an important component for the effective treatment of severe personality disorders, while the role of long-term inpatient stay may need redefining. Further comparative studies that include a partial hospitalization program or a specialist outpatient program are needed to ascertain that a phase of specialist residential hospitalization is in fact necessary for achieving a better outcome with this group of patients.

Received Oct. 30, 2001; revisions received Oct. 8, 2002, and March 19, 2003; accepted Nov. 21, 2003. From The Cassel Hospital, Richmond, U.K.; and the North Devon Healthcare NHS Trust, Barnstaple, U.K. Address reprint requests to Dr. Chiesa, The Cassel Hospital, Richmond, TW10 7JF, U.K.; [email protected] (e-mail). Supported by grants from the Sir Jules Thorn Charitable Trust, the Welton Foundation, and the International Psychoanalytical Association Research Advisory Board. The authors thank the following researchers for help with data collection: Eduardo Iacoponi, M.D.; Alice Levinson, M.D.; Ilan Diamant, Ph.D.; Jaques China, Ph.D.; and Anna Harrison-Hall, B.Sc.