Treatment of Borderline Personality Disorder With Psychoanalytically Oriented Partial Hospitalization: An 18-Month Follow-Up

Of 44 patients in the original study, three patients had left the partial hospitalization program prematurely (after 1 month, 2 months, and 4 months), and an additional three patients crossed over to the partial hospitalization program from the control group within 1 month of treatment assignment. The previous report analyzed data from the 38 patients (19 in each group) who remained in the group to which they had been assigned up to the end of the 18-month treatment period. This follow-up study reports on all patients assigned to the partial hospitalization program regardless of treatment duration (i.e., dropouts were included) and therefore represents a more conservative approach. Written informed consent was obtained after the procedure had been fully explained. An attempt was made at 18 months following admission to follow all 44 patients for an additional 18 months. No patient in the partial hospitalization program was lost to follow-up, but some refused to complete all assessments at all time points. Three patients in the control group refused continued participation. Complete medical records were, however, available for these patients. While assessments were not blind, all the outcome variables were based on objective clinical records confirmed by independent evaluation or were self-report measures.

Subject characteristics, the trial methodology, and details about the treatment program and the quality of randomization were presented in our original report (1). The two groups did not significantly differ on any demographic or clinical characteristic or on any of the outcome variables with the exception of a slightly higher state anxiety score and a lower social adjustment score for patients assigned to the partial hospitalization program. Outcome measures were assessed with the same instruments as during the treatment phase of the study. The SCL-90-R (8) was administered three times during the follow-up period (at the 24-, 30-, and 36-month evaluations) to assess self-reported general psychiatric symptoms. The Beck Depression Inventory (9) and Spielberger State and Trait Inventory (10) were administered five times during the follow-up period (at the 21-, 24-, 27-, 30-, and 36-month evaluations) to monitor depression and anxiety, respectively. Social and interpersonal functioning were measured with the Social Adjustment Scale (11) and the Inventory of Interpersonal Problems—circumflex version (12), respectively, at the end of the treatment phase (month 18) and the end of the follow-up period (month 36). Only 5% of the data for the patients in the partial hospitalization program (including dropouts) and less than 25% of the control group data were lost because of incomplete measures.

A semistructured interview (Suicide and Self-Harm Inventory) was used to obtain details of both suicidal and self-damaging acts at the 24-, 30-, and 36-month evaluations. Details of the method of collection of this information can be found in our original study (1). For all patients, searches of the hospital inpatient database were made at the 24-, 30-, and 36-month evaluations to obtain the number of hospital admissions and the lengths of stay over the preceding 6 months. These were cross-checked with the medical notes. All patients were admitted to the local unit because of the contracted nature of the service.

It was not possible to prevent patients from having further treatment. Participation in other treatment programs was monitored throughout the study for all patients, including medication data ascertained from prescription charts and dispensing records. A follow-up program was offered to the patients assigned to the partial hospitalization program, which was attended by all except the three who prematurely terminated treatment. The program consisted of group analytic therapy twice a week (180 hours over 18 months) and review in a psychiatric outpatient clinic if requested every 3 months (conducted by A.B.). Group attendance was 75% during the follow-up period, which indicates the stability of this cohort of treated patients. Community center attendance and general psychiatric partial hospitalization programs were available through self-referral. The control group continued to receive general psychiatric treatment, which could involve inpatient admission when required, a general psychiatric partial hospitalization program, outpatient consultation, community center attendance, or medication. None received any formal psychotherapy, although this was not precluded during the follow-up period.

All analyses were carried out using SPSS for Windows (Version 8, Chicago). We applied the multivariate analog of the analysis of covariance (ANCOVA) model to all interval data, including all self-report variables, with pretreatment scores as covariates and the time points of follow-up assessments as repeated measures variables (time). We predicted a significant main effect of treatment group (group), which is a test for continued treatment effectiveness. If there were trends toward relapse in the patients who completed the partial hospitalization program or remission in the control group patients during the follow-up period, we would expect significant interactions between the group and time factors. We used pair-wise comparisons with Bonferroni corrections to test if mean differences were significant at each of the follow-up assessment points. When the assumptions of the general-linear model were not met, nonparametric (Mann-Whitney U) tests were performed to test the difference between groups at each follow-up assessment, and a test of differences (Friedman’s test) was performed separately for each group to assess if there was evidence for significant tendency for relapse or remission. In the case of binary variables, Fisher’s exact test was used to compare groups, and these are reported as bare probabilities. All statistical analyses were repeated after including the subjects who had crossed over to the partial hospitalization program (i.e., N=25 versus 19) as well as after excluding dropouts (i.e., N=19 versus 19). These analyses led to an almost identical pattern of findings.

Long-term follow-up of patients treated in an 18-month psychoanalytically oriented partial hospitalization program showed not only that the substantial symptomatic and clinical gains made during treatment were maintained but also that there was additional improvement. The continuing decline in symptom distress, the absence of major clinical problems, and the associated low admission rates and minimal acts of self-harm throughout the follow-up period suggest that the partial hospitalization patients developed the psychological capacities necessary to withstand the normal stresses and strains of everyday life. This is in keeping with the aims of psychoanalytically informed treatment.

Although acts of self-harm and a need for hospital admission continued in the control group, there was some evidence of symptomatic improvement. This can be seen as spontaneous remission, but in light of the amount of treatment they received it seems appropriate to see these as attenuated treatment effects. Information about the natural course of borderline personality disorder over time is limited (13). If it is correct that supportive measures with medication lead to symptomatic improvement, this further emphasizes the need for future studies to be carefully controlled. Follow-up data in this study may be influenced by distortion of sampling, e.g., that nonimprovers kept returning to the service. But only three patients in the control group were partially lost to follow-up, there was minimal attrition in self-report measures for the remaining patients, and accurate clinical information about self-harm and hospital admissions was available for all patients. This limits the likelihood of sampling problems.

The recovery from depression is of interest. Although Gunderson and Phillips (14) concluded that borderline personality disorder and depression exhibit “a surprisingly weak and non-specific relationship,” the difficulty in evaluating the relationship between the disorders remains. In this study the improvement in depression was in the context of stability in other areas, such as social adjustment and interpersonal functioning, which suggests that depression in borderline personality disorder is an indicator of affect dysregulation rather than part of an affective disorder.

There was continued use of medication in both groups. Medication patterns are influenced by a large number of factors unrelated to a patient’s mental state, such as physician prescribing patterns, patient’s attitudes about medication, and frequency of visits to the psychiatrist’s office. However, the substantial differences observed between the groups would be hard to explain in terms of such artifacts alone. In Great Britain, individual prescribing patterns in the hospital are governed by guidelines, which are monitored. Individual physician choice plays an attenuated part. It seems that patients who completed the partial hospitalization program gave fewer indications to their physicians that they would still benefit from psychoactive medication. This is in keeping with their overall reduction in service utilization. The observed reduction in symptoms is even more impressive in the light of reduced use of medication.

While we do not have detailed data on cost-effectiveness, the gains made during and after treatment are important from a health care service perspective. The control group used more of all types of services monitored in this study. Borderline patients dominate psychiatric referrals to emergency rooms, particularly following impulsive acts of self-harm. The maintenance of a reduction in episodes of self-harm and suicide attempts and low rates of hospital admission in the borderline personality disorder patients who completed a psychoanalytically oriented partial hospitalization program (compared with patients who received standard psychiatric care) reduced to a minimal level the need for costly emergency treatment and expensive inpatient care. This suggests considerable savings following treatment.

This study has a number of limitations. The study group size was small, with additional loss of power from some attrition of subjects and consequent loss of self-report data at some time points. It is notable that no patient who completed the partial hospitalization program was lost to follow-up. We have no treatment integrity measure, making it difficult to identify the active ingredients of this treatment and make specific clinical recommendations. Treatment differences may be related to such factors as experience of staff with borderline patients and enthusiasm of the treatment team. Finally, we considered the possibility that the amount of staff time used by patients may be a factor, but patients in the control group received considerably more staff time during follow-up than the partial hospitalization patients as evidenced by service utilization statistics.

Further studies will be needed to establish if attendance at a partial hospitalization program is necessary for the effective delivery of psychotherapeutic help. The data from the control group demonstrated that mere attendance at a general psychiatric partial hospitalization program is insufficient to ensure enduring symptomatic change. But it remains possible that the psychotherapeutic intervention would have been equally effective had it been delivered in a modified form in an outpatient setting. This is the subject of an ongoing trial.

(Reprinted with permission from the American Journal of Psychiatry 2001; 158:36–42)