East Midlands Centre for Forensic Mental Health, Leciester
Francis Dixon Lodge Therapeutic Community, Leicester, UK
Correspondence: Dr Steffan Davies, Academic Unit, Arnold Lodge, East Midlands Centre for Forensic Mental Health, Cordelia Close, Leicester LE5 0LE, UK. Tel: 01162 256124; fax: 01162 256065; e-mail: drsteffand{at}aol.com
* Paper presented at the second conference of the British and Irish Group for
the Study of Personality Disorders (BIGSPD), University of Leicester, UK, 31
January to 3 February 2001.
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ABSTRACT |
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Aims To identify hospital admissions before and after therapeutic community treatment of personality disorder.
Method A naturalistic clinical cohort of patients admitted between January 1993 and December 1995 was followed up for 3 years. All subjects were traced to their current consultant psychiatrist, general practitioner or death.
Results All patients were traced at 3-year follow-up. The significant reduction in in-patient admissions seen in the first year was maintained over 3 years. Those with the poorest outcomes, suicide, accidental death or prolonged admission were all in the quartile with the shortest admissions (under 42 days) to the therapeutic community.
Conclusions Previously reported reductions in psychiatric admissions following therapeutic community treatment of personality disorder are maintained over 3 years.
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INTRODUCTION |
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In addition to outcome literature, there has been an increasing interest in the economic benefits of psychotherapies, including therapeutic community treatment. An international review of economic analyses of psychotherapy (Gabbard et al, 1997) found 18 controlled studies of psychotherapy with cost or comparable data. Of these, 80% of randomised and 100% of controlled studies suggested that psychotherapy reduced costs. Much of the impact accrued from reductions in in-patient treatment. Papers included in this review examined a wide range of psychotherapeutic treatments for a wide range of psychiatric conditions.
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METHOD |
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RESULTS |
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The mean acute in-patient-occupied bed-days for each of the 3 years preceding and following admission to Francis Dixon Lodge are given for the local, out-of-district and total cohort in Table 1. Acute bed occupancy was lower in each year of follow-up than in the year before admission for the whole group and for the local patients (P between <0.05 and <0.001, Wilcoxon signed ranks test). Occupancy over the 3 years after treatment was lower than for the 3 years before treatment for the out-of-district patients and for the whole sample. The difference in the year before treatment and the first (P=0.09) and third years (P=0.07) after treatment approached significance for the small out-of-district group.
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During the period of follow-up there were two deaths: one suicide and one from natural causes. Shortly after the 3-year follow-up there were a further two deaths: one accidental and the other suicide.
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DISCUSSION |
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Sample sizes for all the studies were small: Henderson 24, Cassel 26 and Francis Dixon Lodge 52. Follow-up was limited to 1 year. For the Henderson sample there was a drop-out rate of 17%. For the Cassel study the pre- and post-admission samples differed, with a 50% drop-out rate in the post-admission sample. Both the Cassel and Henderson Hospitals had large catchment areas, predominantly in Greater London but with referrals coming from many parts of the country. In the Francis Dixon Lodge sample, 80% were from the local district (population 900 000) and 20% from other districts. Diagnoses, when made, were predominantly of DSMIIIR borderline (Henderson 74%) or ICD-10 emotionally unstable (Francis Dixon Lodge 87%) personality disorder.
All the studies demonstrated a reduction in the utilisation of in-patient psychiatric services for the year after admission compared with the year before (Table 2). For Francis Dixon Lodge the in-patient usage of the local and out-of-district groups is displayed separately because the pre-admission in-patient usage of these groups was significantly different (Davies et al, 1999). We have earlier argued that this might be due to a filtering effect caused by the ease of making referrals for local patients and the difficulties (e.g. obtaining funding) for the out-of-district patients. This easy access might result in local patients receiving treatment earlier and avoiding prolonged admissions, whereas the out-of-district group's acute bed usage is similar to that reported by the Henderson study. The initial papers all argued that therapeutic community treatment was self-financing over a period of 2 to 4 years, depending on cost base and service-items offset.
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There are a number of criticisms of the studies (Davies, 1999). They were uncontrolled; measurement of resource usually relied on patient self-report; the resources studied did not provide a full picture (for example, they excluded taxation and social security payments, general practice contacts, etc.); follow-up was incomplete and limited to 1 year. That studies were uncontrolled is unsurprising, since the units involved struggled at times to attract patients and were often referred to as a last resort in the absence of other services offering any specialist treatment. The use of patient self-report and of information from general practitioners limited both the proportions followed up and the range of variables that could be studied. Following up patients for only 1 year after admission may have resulted in an unduly optimistic view of their outcomes resulting from a ceilingfloor effect. The ceiling would have been an unusually high service usage in the year before referral, possibly precipitating referral; the floor would have been low usage in the year after discharge, not maintained over time. The current study was designed to achieve more complete and longer follow-up, at the expense of the range of variables studied.
We can see in Table 1 that the reduction in acute occupancy, seen in the first year after therapeutic community treatment in all previous studies, was maintained over time. For the local group, acute bed usage declined in each year after therapeutic community treatment. For the out-of-district group, usage was constant in years 1 and 3 and was considerably less than the peak in the year before admission. An increase in year 2 was predominantly due to one patient who had a short admission at Francis Dixon Lodge (39 days). In terms of the years before admission, the local group had shorter mean admissions, increasing in length year on year. The out-of-district group had a mean occupancy in every year higher than the local group. Usage was substantial in every year before admission and peaked in the year immediately before admission. A small ceiling effect in the year before admission seems likely but there does not seem to have been a floor effect. Gains in reducing acute in-patient admissions seem to be sustained, at least to 3 years, although the cost-offset benefits are reduced owing to the peak in the year before admission.
All four patients with the poorest outcomes, i.e. the three suicides or accidental deaths and the prolonged admission in the second year, were in the quartile with the shortest admission to Francis Dixon Lodge (under 42 days), implying that they engaged poorly with treatment. Previous follow-up studies have reported a mortality rate from suicide of 8.5% among patients with borderline personality disorder followed up over 16 years (Stone, 1993). The 6% mortality from suicide and accidental death at just over 3 years in this study (23% of the shortest admission quartile) is very much in line with these figures.
The similarities in primary diagnosis and service utilisation between the Henderson sample and the Francis Dixon Lodge out-of-district group suggest that our results may be generalisable to the Henderson Hospital, where a similar treatment model is used.
The completeness and length of follow-up in this study provides further evidence of the efficacy of therapeutic community treatment for personality disorder, at least in terms of reductions in acute in-patient occupancy. This is likely to indicate benefits for the patient, although some of the effects may be due to changes in psychiatric practice over the time of the study. Acute in-patient admissions in this group are usually a containing response to crises rather than of intrinsic therapeutic value (Norton & Hinshelwood, 1996). Although not matching the effects reported in previous studies, these findings support the argument that therapeutic community treatment is self-funding in the medium term. For those who are admitted but fail to engage and leave within a few weeks the outcome is very poor, with a mortality of 23% at just over 3 years.
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Clinical Implications and Limitations |
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LIMITATIONS
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REFERENCES |
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Chiesa, M., Iacopani, E. & Morris, M. (1996) Changes in health service utilization by patients with severe personality disorders before and after inpatient psychosocial treatment. British Journal of Psychotherapy, 12, 501-512.
Davies, S. (1999) Survival and growth in the marketplace: does every district need a therapeutic community? In Therapeutic Communities: Past, Present and Future (eds P. Campling & R. Haigh), pp. 223-234. London: Jessica Kingsley.
Davies, S., Campling, P. & Ryan, K. (1999) Therapeutic community provision at regional and district levels. Psychiatric Bulletin, 23, 79-83.
Dolan, B. & Norton, K. (1991) The predicted impact of the NHS White Paper on the use and funding of a specialist service for personality disordered patients: a survey of clinicians' views. Psychiatric Bulletin, 15, 402-404.
Dolan, B., Warren, D., Menzies, D., et al (1996) Cost-offset following specialist treatment of severe personality disorders. Psychiatric Bulletin, 20, 413-417.
Gabbard, G. O., Lazar, S. G., Hornberger, J., et al (1997) The economic impact of psychotherapy: a review. American Journal of Psychiatry, 154, 147-155.[Abstract]
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Norton, K. & Hinshelwood, R. D. (1996) Severe personality disorder: treatment issues and selection for in-patient psychotherapy. British Journal of Psychiatry, 168, 723-731.[Abstract]
Stone, M. (1993) Long-term outcome in personality disorders. British Journal of Psychiatry, 162, 299-313.[Abstract]