The Cassel Hospital, Richmond, UK
Sub-department of Clinical Health Psychology, University College London, UK
Correspondence: Marco Chiesa, Consultant Psychiatrist and Head of Research Unit, The Cassel Hospital, Richmond TW10 7JF, UK. Tel: 020 8237 2902; fax: 020 8332 6424; e-mail: m.chiesa{at}ucl.ac.uk
Declaration of interest Grants from the Henry Smith and Welton Foundations.
1 Reliable change takes into account measurement error according to the
formula
x2x1/Sdiff,
where x1is the pre-test score, x2 is
the post-test score and Sdiff is the standard error of
difference between the two test scores. A reliable change index value below
1.96 represents a change ascribable to the imprecision of the measurement.
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ABSTRACT |
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Aims To evaluate the clinical effectiveness of these two psychosocial specialist programmes over a 3-year follow-up period.
Method Two samples allocated to the in-patient treatment and to the step-down programme were compared prospectively on symptom severity, social adjustment, global assessment of mental health and other clinical indicators at 6, 12, 24 and 36 months after intake.
Results Improvements were significantly greater in the step-down programme for social adjustment and global assessment of mental health. Patients in the programme were found to self-mutilate, attempt suicide and be readmitted significantly less at 24- and 36-month follow-up than patients in the in-patient group.
Conclusions Improvements associated with specialist residential treatment continued 2 years after discharge. A step-down model has significant advantages over a purely in-patient model.
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INTRODUCTION |
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METHOD |
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Clinical programmes
The ingredients of psychosocial residential treatment are based on a
combination of a sociotherapeutic programme (daily unit meetings, community
meetings, structured activities, co-responsibility planning of the running of
the therapeutic community, dance therapy, etc.) and formal psychoanalytical
psychotherapy (individual and in small groups) delivered by medical and
non-medical psychotherapists.
In the outreach stage of the step-down programme patients are offered twice-weekly small-group psychotherapy, once-weekly meetings with the community outreach nurse and regular review with the consultant psychiatrist. Patients are actively supported in networking with other agencies within their community setting.
Subjects and design
A total of 135 patients consecutively admitted to the Cassel Hospital adult
unit between 1993 and 1997 were screened for inclusion (age 1955 years,
IQ above 90 and meeting the diagnostic criteria for at least one personality
disorder) and exclusion criteria (diagnosis of schizophrenia or paranoid
psychosis or evidence of organic brain disorder). Two patients were excluded
from the study on account of organic brain pathology (epilepsy). Of the 74
patients allocated to the one-stage condition, 28 either did not give consent
to the research participation or dropped out after completing the baseline
battery only. Among the 59 patients allocated to the step-down programme, 15
either did not consent or failed to comply after completing baseline measures.
Between 12 and 36 months, only six and four patients dropped out of the study
in the one-stage and step-down programme, respectively. This left 80 patients
(40 in each sample) for whom results are outlined and discussed.
Four patients who gave consent for the study and were allocated to the one-stage group subsequently died by suicide: two were excluded from the analysis because they did not complete the baseline assessment; the other two killed themselves by 6 and 12 months after admission, respectively, and were included in the multivariate analysis after we carried over the values of the standardised measures from the last assessment point but were excluded from the analysis of clinical outcome variables. The mean duration of in-patient treatment was 8.1 months (s.d.=4.4, median=9.8) for the one-stage group and 6.2 months (s.d.=1.7, median=6.4) for patients in the step-down group. Average duration of out-patient continuation treatment for step-down patients was 10.6 months (s.d.=6.9, median=13.4). Twenty-three (57.5%) of the patients in the one-stage programme dropped out of treatment before the expected termination date, whereas in the step-down group eight (20%) patients prematurely terminated the in-patient stage of treatment and a further eight (20.0%) prematurely left the out-patient group. Because we adopted an intent-to-treat design, all subjects were recalled or traced for assessments.
Measures
Forty-eight socio-demographic and clinical variables were collected at
intake. The National Adult Reading Test
(Nelson, 1982), which consists
of a list of 50 words printed in order of increasing difficulty, was used to
obtain IQ equivalents. The Structured Clinical Interview for the
DSMIIIR, Version 1.0
(Spitzer et al, 1990)
yielded full diagnostic Axis I and II profiles. Interrater reliability testing
with a second researcher reviewing taped interviews showed that values
for each Axis I diagnosis yielded a median of 0.85 (range 0.731.00). On
Axis II, reliability of diagnosis varied between 0.61 for cluster A, 0.67 for
cluster B and 1.00 for cluster C.
The Symptom Checklist90R (SCL90R; Derogatis, 1983), a four-point self-report clinical rating scale, identifies symptoms in nine major areas of the patients psychosomatic and interpersonal functioning. The SCL90R General Severity Index (GSI) was the total score used in the study to report changes in degree of symptomatic distress. The interviewer-based version of the Social Adjustment Scale (SAS; Weissman, 1975) yields ratings on a four-point scale of adjustment in the areas of work, family of origin, marriage, gender and social leisure. A total social adjustment score is derived from the mean values of the subcategories. An interclass correlation coefficient of 0.78 obtained for the total score showed satisfactory interrater agreement. The Global Assessment Scale (GAS; Endicott et al, 1976) is an anchored rating scale that allows evaluation of patients general outcome in accordance with his or her level of functioning assessed during a specified time period (4 weeks in the present study). The rating is on a continuous scale from 0 (successful suicide) to 100 (perfect functioning). Good interrater reliability was found (interclass correlation coefficient=0.79).
A team of research psychologists and psychiatrists independent of the clinical teams was trained in the reliability criteria on all measures through the use of original training videotapes. Each rater had a fort-nightly supervision meeting with a senior psychiatrist experienced in the delivery of the instruments used in the study. Coding and data entry were monitored regularly and adherence to protocol was checked using audiotapes and physical records. Outcome measures were applied longitudinally at intake and at 6, 12, 24 and 36 months.
Details of self-mutilation episodes, suicide attempts and number and length of psychiatric in-patient episodes over the year prior to the assessment were obtained through a structured interview applied at intake and at 12, 24 and 36 months. The conservative data gathering and coding protocol described by Bateman & Fonagy (1999) was used to define incidence of self-mutilation, parasuicide and readmission to hospital. A random sample of the interviews was cross-checked against the records of the patients general practitioners and a second sample was subjected to testretest reliability checks.
Data analysis
All analyses were performed using the Statistical Package for the Social
Sciences, version 11 (SPSS,
2001). Three separate analyses taking a multivariate approach to
repeated-measures analysis of variance were used to test the significance of
changes in mean scores on the three standardised measures (GAS, GSI and SAS)
and the differences between the treatment conditions. Estimated marginal means
for the two groups were contrasted at each follow-up point, with
levels adjusted for the number of significance tests performed using
Bonferroni corrections.
Improvement was also examined as a categorical variable. A reliable change
index1 was calculated
for all three variables using the formula provided by Jacobson et al
and later amended by Christensen & Mendoza
(1986). Kendalls
b test was used to assess the significance of differences in
reliable improvement and deterioration rates between the two samples. Patients
also were allocated to improved (if they showed reliable change on at least
two measures with no concomitant deterioration on the third measure) and
non-improved categories.
Differences between groups on dichotomised clinical variables (self-mutilation, suicide attempts and hospital readmissions) at 12, 24 and 36 months were examined using separate hierarchical logistic regressions, with group membership as predictor and baseline status on each clinical variable as covariate.
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RESULTS |
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Severity of psychiatric symptoms
The repeated-measures analysis of variance showed a significant effect of
time (Wilks =0.51, F=17.98, d.f.=4,75,
P<0.001) for the GSI. At 36 months, 11 (27.5%) of the one-stage
group and 19 (47.5%) of the step-down group were below the cut-off point for
caseness (Derogatis, 1983).
However, no significant groupxtime interaction (Wilks
=0.92, F=1.56, d.f.=4,75, NS) was found, indicating that the
means displayed in Table 2 are
not significantly different for the two groups.
Both one-stage and step-down groups achieved relatively high rates of reliable change by 6 months (38% and 45%, respectively), with progressive increases through to the 36-month follow-up; at that assessment point, 80% and 70% of the subjects showed reliable improvement (Table 3). No significant differences between the two groups were found overall.
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Social adjustment
A significant time effect (Wilks =0.61, F=11.93,
d.f.=4,75, P<0.001) was revealed, with amelioration in the degree
of social adaptation over time in both samples reflected in the significant
linear effects (F=44.20, d.f.=4,75, P<0.001). Pairwise
comparisons showed significant differences between the two groups both at 24
(P=0.04) and 36 months (P=0.04) in favour of the step-down
model. However, no significant groupxtime interaction was found
(Wilks
=0.98, F=0.31, d.f.=1,78, NS).
The two samples did not differ significantly in their respective rates of reliable change at any of the four assessment points (Table 3). Improvement in social adaptation appeared to be slower than in the psychiatric symptoms dimension. However, 40% of the subjects in both groups were found to have improved reliably by 24 months. This improvement declined at 36 months to 35% and 38% in the one-stage and step-down condition, respectively.
Global assessment of functioning
Changes in GAS mean scores over the five assessment points showed a
significant effect of time (Wilks =0.57, F=14.12,
d.f.=4,75, P<0.001). Although the groupxtime interaction was
not significant (Wilks
=0.96, F=1.18, d.f.=4,75, NS),
greater improvement was shown by the step-down group relative to the one-stage
group at 12 months (P=0.02) and this was marginally significant at 36
months (P<0.06) on pairwise comparisons.
Significant differences in rates of reliable change on the GAS between the
two groups were found at 12 months (Kendalls b=0.34,
d.f.=2, P<0.001), 24 months (Kendalls
b=0.27, d.f.=2, P<0.02) and 36 months
(Kendalls
b=0.37, d.f.=2, P<0.001).
Patients in the step-down group were more likely to meet the reliable
improvement criteria for GAS than patients in the one-stage condition
(Table 3).
Overall improvement
By 12 months, 33% of patients in the step-down model v. 13% of the
one-stage group were reliably improved on two out of the three standardised
measures (GSI, SAS and GAS); the difference was significant
(2=4.59, d.f.=1, P=0.03). However, the difference was
no longer significant at 24 (45% v. 35%) and 36 months (50%
v. 38%).
Clinical change
Table 4 summarises figures
for the two groups with regard to clinical variables. We found a marked
decrease in the number of patients in the step-down programme who committed
acts of self-mutilation by 12, 24 and 36 months. In contrast, after an
increase at 12 months, the number of patients allocated to the one-stage
programme who carried out self-mutilation remained constant at 24 and 36
months. Hierarchical logistic regression showed that belonging to the
one-stage group was predictive of self-mutilation at 12 (B=2.28,
s.e.=0.68, d.f.=1, P<0.001), 24 (B=1.38, s.e.=0.57,
d.f.=1, P<0.02) and 36 (B=1.14, s.e.=0.58, d.f.=1,
P<0.05) months. The odds ratio revealed that patients allocated to
the one-stage programme were ten (95% CI 2.5836.96), four (95% CI
1.2912.22) and three (95% CI 1.019.79) times more likely to
mutilate themselves at 12, 24 and 36 months, respectively, than patients in
the step-down condition.
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Group status also predicted attempted suicide, with the one-stage membership more likely to attempt suicide at 12 (B=2.03, s.e.=0.63, P<0.002) and 36 (B=1.74, s.e.=0.72, d.f.=1, P<0.02) months; the odds ratio showed that patients in the one-stage programme were eight (95% CI 2.2226.11) and six (95% CI 1.4023.15) times more likely to attempt suicide than step-down patients.
Significant group differences were found in psychiatric readmission rates. By the 24- and 36-month follow-ups, patients treated in the step-down condition were less likely to be readmitted to psychiatric units than patients in the one-stage programme. Logistic regression showed that the one-stage group was significantly different from the other group at 24 (B=2.09, s.e.=0.64, d.f.=1, P<0.002) and 36 (B=1.69, s.e.=0.60, d.f.=1, P<0.005) months. One-stage patients were eight (95% CI 2.2928.25) and five (95% CI 1.6917.55) times more likely to have at least one acute admission to a psychiatric unit at 24 and 36 months, respectively, than patients who were treated with the step-down model.
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DISCUSSION |
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Reliable change
Improvement in the two samples cannot be ascribable to the unreliability of
the measures, but rather is a reflection of true improvement that met the
stringent reliable change index criteria. Although change was more marked in
psychiatric symptoms (75% of patients reliably improved by 36 months),
improvement in the area of social adjustment stabilised by 24 months (40% of
patients reliably improved); improvement in global assessment of mental health
continued through to 24 months, after which a slight decrease at 36 months
occurred in both samples.
The relatively lower rate of reliable improvement in social adjustment compared with the higher symptom severity improvement in the samples leads to a number of considerations, because this dimension represents the main target of therapeutic community work:
Outcome differences and treatment models
Although patients treated according to both models maintained improvements
from discharge to follow-up, on a number of measures the improvements observed
in the step-down group are more substantial than in the one-stage group. Thus,
the differences observed at discharge reported in our previous communication
are generally maintained at 36 months. This is particularly notable for
clinical variables. Patients exposed to shorter residential stay followed by
long-term psychosocial therapy in the external community showed significantly
greater improvement in self-mutilation, attempted suicide and readmission to
hospital than patients allocated to the long-term residential treatment with
no planned after-care. The considerable difference found in these variables
between the two groups suggests that follow-up psychotherapy treatment after a
period of hospitalisation is important to the stabilisation of these patients
back into their community, and reduces the number of cases of acute distress
or breakdown that may lead to acute psychiatric admission. The planned
post-discharge ongoing support provided by the outreach psychosocial team
engenders a sense of belonging and being contained that compensates for the
deep-rooted sense of aloneness typical of these patients
(Gunderson, 1996).
The absence of supportive after-care in the one-stage group seems to undermine the continuation of the healing process initiated while in in-patient treatment. In contrast, the provision of a phased long-term (albeit less intensive) treatment seems more effective in meeting the severe anxieties connected with relational and socialising difficulties presented by personality disorder than a purely residential approach. These results are consistent with the rationale of the step-down programme as enhancing patients resilience to psychosocial stressors and maintaining satisfactory functioning in the community. In contrast, although improved on some dimensions, the one-stage group did not show any significant improvement in self-mutilation, parasuicide and acute readmission compared with the year prior to admission to the Cassel Hospital, which is a sign of continuing vulnerability to acute decompensations.
Improvement shown by the step-down group compares well with that found in a group of patients with borderline personality disorder treated in a psychotherapeutic partial hospitalisation programme (Bateman & Fonagy, 2001) on similar dimensions. Psychosocial residential programmes have been questioned as realistic treatment options for personality disorder, because third-party payers regard the cost associated with in-patient admission as excessive. In a previous study we investigated if the cost of in-patient admission relative to that of treatment as usual reduces health and social care cost in the year after treatment termination (Chiesa et al, 2002). The results showed that the two specialist programmes might be justifiable in economic terms, because savings in service use would offset the cost of delivering treatment in the long run.
Methodological considerations
The non-randomised allocation of subjects to the two treatment programmes
and the absence of an untreated or treatment-as-usual control condition limit
claims concerning the effectiveness of the two specialist models, because
possible geographical factors may have accounted for some or all of the
observed differences. In the event, a remarkable similarity between the two
groups was found in terms of demographic, diagnostic and other clinical
variables: no significant difference was found in any of the 37 variables
(including severity of presentation) that were measured. It is likely that
referral for the same specialist treatment created moderate differences that
would be expected from the geographical criteria used for patients
allocation to treatment condition.
Although over 80% of patients met the criteria for at least one diagnosis belonging to the dramatic personality disorder cluster (or cluster B), thus making it a relatively homogeneous cohort, comorbidity with other Axis I and Axis II diagnoses was invariably present in both samples. The presence of multiple diagnoses raises the question of the impact of comorbidity as a moderator of outcome. In addition, the crucial issue of outcome for different categories of individual personality disorder (Tyrer & Seivewright, 2000) was not addressed here. However, this study was not powered for subgroup analyses and disregarding the risk of type II errors would compromise the analysis of data.
The study did not address the dimension of treatment process and leaves unanswered the question of what aspect of the intervention in the two samples was the effective component in bringing about improvement. It remains unclear whether the residential aspect of psychosocial treatment is in fact a necessary condition to effectiveness for this group of patients. These outcome results have to take into account recent studies demonstrating that day hospital (Bateman & Fonagy, 2001) and specialist out-patient programmes (Clarkin et al, 2001) are a promising and effective alternative to hospitalisation for borderline personality disorder.
The incremental loss of subjects to the 36-month follow-up also limits the inferences that can be drawn about treatment effectiveness, and reduces the power and sensitivity of statistical analysis to detect differences between the two groups in other variables. Although we tried to limit the impact of clinical drop-out by employing an intent-to-treat analysis, the extent of attrition over the course of the study raises the legitimate question of its interaction with the treatment in the results that were produced (Kazdin, 1994).
An additional potential source of bias was the lack of independent rater blindness with regard to subject treatment allocation.
Strength of the study
Despite these limitations we feel that our design addressed some of the
methodological weaknesses present in previous studies of personality disorder.
The use of operational diagnostic criteria, a full characterisation of the
sample in terms of demographic and clinical features, the use of standardised
outcome measures, the prospective nature of the investigation, the use of
trained independent raters and the presence of interrater reliability checks
strengthen the internal validity of the study. The adoption of stringent and
conservative criteria of improvement based on reliable change and the use of
multivariate and regression statistics on all measures improve the validity of
the outcome results found in the samples.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication November 27, 2002. Revision received May 12, 2003. Accepted for publication May 14, 2003.
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