Kirsten Barnicot

Treatment completion in psychotherapy for borderline personality disorder – a systematic review and meta‐analysis

Barnicot K, Katsakou C, Marougka S, Priebe S. Treatment completion in psychotherapy for borderline personality disorder – a systematic review and meta‐analysis.

Effectiveness and Cost-Effectiveness of Dialectical Behaviour Therapy for Self-Harming Patients with Personality Disorder: A Pragmatic Randomised Controlled Trial

Background: A primary goal of dialectical behaviour therapy (DBT) is to reduce self-harm, but findings from empirical studies are inconclusive. The aim of this study was to assess the effectiveness and cost-effectiveness of DBT in reducing self-harm in patients with personality disorder. Methods: Participants with a personality disorder and at least 5 days of self-harm in the previous year were randomised to receive 12 months of either DBT or treatment as usual (TAU). The primary outcome was the frequency of days with self-harm; secondary outcomes included borderline personality disorder symptoms, general psychiatric symptoms, subjective quality of life, and costs of care. Results: Forty patients each were randomised to DBT and TAU. In an intention-to-treat analysis, there was a statistically significant treatment by time interaction for self-harm (incidence rate ratio 0.91, 95% CI 0.89–0.92, p < 0.001). For every 2 months spent in DBT, the risk of self-harm decreased by 9% relative to TAU. There was no evidence of differences on any secondary outcomes. The economic analysis revealed a total cost of a mean of 5,685 GBP (6,786 EUR) in DBT compared to a mean of 3,754 GBP (4,481 EUR) in TAU, but the difference was not significant (95% CI –603 to 4,599 GBP). Forty-eight per cent of patients completed DBT. They had a greater reduction in self-harm compared to dropouts (incidence rate ratio 0.78, 95% CI 0.76–0.80, p < 0.001). Conclusions: DBT can be effective in reducing self-harm in patients with personality disorder, possibly incurring higher total treatment costs. The effect is stronger in those who complete treatment. Future research should explore how to improve treatment adherence.

Factors predicting the outcome of psychotherapy for borderline personality disorder: A systematic review

BACKGROUND There is substantial variation between individuals with borderline personality disorder (BPD) in the degree of benefit gained from psychotherapy. Information on factors predicting the outcome of therapy for this group could facilitate identification of those at risk for poor outcome, and could enable helpful therapy processes to be identified. METHOD A systematic search of PsycInfo, EMBASE, CINHAL and Medline identified research on factors predicting symptom change during therapy for patients with a BPD diagnosis. Non-English language papers and dissertations were included. RESULTS Two consistent positive predictors of symptom change were identified: pre-treatment symptom severity and patient-rated therapeutic alliance. Contrary to theories predicting increasing immutability with age, there was no evidence that age predicted poorer outcome. CONCLUSION More severely ill patients may have greater potential to achieve change during therapy, and should remain a focus for psychotherapy services. The therapeutic alliance is an important common factor predicting outcome in patients with BPD, even in highly disorder-specific treatments. Outcomes may be improved by further clinical and research focus on forming strong therapeutic alliances. The advancement of the field requires identification and testing of new predictors of outcome, especially those related to specific theories of therapeutic change in BPD.

Skills use and common treatment processes in dialectical behaviour therapy for borderline personality disorder.

BACKGROUND AND OBJECTIVES Dialectical behaviour therapy (DBT) trains participants to use behavioural skills for managing their emotions. The study aimed to evaluate whether skills use is associated with positive treatment outcomes independently of treatment processes that are common across different therapeutic models. METHOD Use of the DBT skills and three common treatment processes (therapeutic alliance, treatment credibility and self-efficacy) were assessed every 2 months for a year in 70 individuals with borderline personality disorder receiving DBT. Mixed-multilevel modelling was used to determine the association of these factors with frequency of self-harm and with treatment dropout. RESULTS Participants who used the skills less often at any timepoint were more likely to drop out of DBT in the subsequent two months, independently of their self-efficacy, therapeutic alliance or perceived treatment credibility. More frequent use of the DBT skills and higher self-efficacy were each independently associated with less frequent concurrent self-harm. Treatment credibility and the alliance were not independently associated with self-harm or treatment dropout. LIMITATIONS The skills use measure could not be applied to a control group who did not receive DBT. The sample size was insufficient for structural equation modelling. CONCLUSION Practising the DBT skills and building an increased sense of self-efficacy may be important and partially independent treatment processes in dialectical behaviour therapy. However, the direction of the association between these variables and self-harm requires further evaluation.

Overcoming Barriers to Skills Training in Borderline Personality Disorder: A Qualitative Interview Study

Despite evidence suggesting that skills training is an important mechanism of change in dialectical behaviour therapy, little research exploring facilitators and barriers to this process has been conducted. The study aimed to explore clients’ experiences of barriers to dialectical behaviour therapy skills training and how they felt they overcame these barriers, and to compare experiences between treatment completers and dropouts. In-depth qualitative interviews were conducted with 40 clients with borderline personality disorder who had attended a dialectical behaviour therapy programme. A thematic analysis of participants’ reported experiences found that key barriers to learning the skills were anxiety during the skills groups and difficulty understanding the material. Key barriers to using the skills were overwhelming emotions which left participants feeling unable or unwilling to use them. Key ways in which participants reported overcoming barriers to skills training were by sustaining their commitment to attending therapy and practising the skills, personalising the way they used them, and practising them so often that they became an integral part of their behavioural repertoire. Participants also highlighted a number of key ways in which they were supported with their skills training by other skills group members, the group therapists, their individual therapist, friends and family. Treatment dropouts were more likely than completers to describe anxiety during the skills groups as a barrier to learning, and were less likely to report overcoming barriers to skills training via the key processes outlined above. The findings of this qualitative study require replication, but could be used to generate hypotheses for testing in further research on barriers to skills training, how these relate to dropout, and how they can be overcome. The paper outlines several such suggestions for further research.

Childhood maltreatment and violence: mediation through psychiatric morbidity

Childhood maltreatment is associated with multiple adverse outcomes in adulthood including poor mental health and violence. We investigated direct and indirect pathways from childhood maltreatment to adult violence perpetration and the explanatory role of psychiatric morbidity. Analyses were based on a population survey of 2,928 young men 21-34 years in Great Britain in 2011, with boost surveys of black and minority ethnic groups and lower social grades. Respondents completed questionnaires measuring psychiatric diagnoses using standardized screening instruments, including antisocial personality disorder (ASPD), drug and alcohol dependence and psychosis. Maltreatment exposures included childhood physical abuse, neglect, witnessing domestic violence and being bullied. Adult violence outcomes included: any violence, violence toward strangers and intimate partners (IPV), victim injury and minor violence. Witnessing domestic violence showed the strongest risk for adult violence (AOR 2.70, 95% CI 2.00, 3.65) through a direct pathway, with psychotic symptoms and ASPD as partial mediators. Childhood physical abuse was associated with IPV (AOR 2.33, 95% CI 1.25, 4.35), mediated by ASPD and alcohol dependence. Neglect was associated with violence toward strangers (AOR 1.73, 95% CI 1.03, 2.91), mediated by ASPD. Prevention of violence in adulthood following childhood physical abuse and neglect requires treatment interventions for associated alcohol dependence, psychosis, and ASPD. However, witnessing family violence in childhood had strongest and direct effects on the pathway to adult violence, with important implications for primary prevention. In this context, prevention strategies should prioritize and focus on early childhood exposure to violence in the family home.

Offering financial incentives to increase adherence to antipsychotic medication: the clinician experience.

Abstract Financial incentives for medication adherence in patients with psychotic disorders are controversial. It is not yet known whether fears expressed by clinicians are borne out in reality. We aimed to explore community mental health clinicians’ experiences of the consequences of giving patients with psychotic disorders a financial incentive to take their depot medication. We implemented descriptive and thematic analyses of semistructured interviews with the clinicians of patients assigned to receive incentives within a randomized controlled trial. Fifty-nine clinicians were interviewed with regard to the effect of the incentives on 73 of the 78 patients allocated to receive incentives in the trial. Most commonly, the clinicians reported benefits for clinical management including improved adherence, contact, patient monitoring, communication, and trust (n = 52). Positive effects on symptoms, insight, or social functioning were reported for some (n = 33). Less commonly, problems for patient management were reported (n = 19) such as monetarization of the therapeutic relationship or negative consequences for the patient (n = 15) such as increased drug and alcohol use. Where requests for increased money occurred, they were rapidly resolved. It seems that, in most cases, the clinicians found that using incentives led to benefits for patient management and for patient health. However, in 33% of cases, some adverse effects were reported. It remains unclear whether certain clinical characteristics are associated with increased risk for adverse effects of financial incentives. The likelihood of benefit versus the smaller risk for adverse effects should be weighed up when deciding whether to offer incentives to individual patients.

The effect of core clinician interpersonal behaviours on depression

BACKGROUND It is well-established that core clinician interpersonal behaviours are important when treating depression, but few studies have evaluated whether outcome is determined by clinicians׳ general behaviour rather than by the perception of the individual being treated. METHODS In the NIMH TDCRP, 157 patients rated their clinician׳s genuineness, positive regard, empathy and unconditional regard during cognitive behavioural therapy, interpersonal therapy or clinical management with placebo. The association between averaged ratings for each of 27 clinicians and their patients׳ self- and observer-rated depression outcomes was evaluated, adjusting for the deviation of individual patient ratings from the average for their clinician and other potential confounders. RESULTS Clinicians in the clinical management condition were rated on average as less genuine and less empathic than those in the psychotherapy conditions. Clinicians׳ average genuineness, positive regard and empathy were significantly associated with lower depression severity during treatment, but not with recovery from depression, after adjusting for the deviation of the individual patient׳s rating of their clinician from the average for that clinician, treatment condition and baseline depression severity. Clinician unconditional regard was not significantly associated with outcome. LIMITATIONS Using averaged ratings of clinician behaviour likely reduced statistical power. CONCLUSIONS Clinicians׳ ability to demonstrate genuineness, positive regard and empathy may represent a stable personal characteristic that influences the treatment of depression beyond the individual clinician-patient relationship or an individual patient׳s perception of their clinician. However, clinicians׳ ability to demonstrate these behaviours may be poorer when delivering an intervention without a specific rationale or treatment techniques.

A Pragmatic Randomised Controlled Trial of Dialectical Behaviour Therapy: Effects on Hospitalisation and Post-Treatment Follow-Up

p = 0.54). However, removing the hospitalisation days for the pa-tient who began treatment as a long-term inpatient, the difference was statistically significant (incidence rate ratio 9.08, 95% CI 1.01–81.6, p = 0.05). Six-month post-intervention follow-up data was obtained for 14 of the 19 patients allocated to DBT who completed the full 12 months of treatment. A standardised self-harm interview was used to assess self-harm frequency during the follow-up period. The mean number of days with self-harm in the last 2 months of treat-ment for DBT completers was 1.79 (SD 3.68) whilst the mean num-ber of days with self-harm during the 6 months after treatment was 1 (SD 1.80), i.e. a rate of 0.33 days per 2-month period. A Wilcox-on signed-rank test showed that this was not a significant differ-ence (z = 1.42, p = 0.16). No DBT completers had any inpatient hospitalisations during the 6-month follow-up period. For treat-ment dropouts, the rate of follow-up was too low (8 of 21 partici-pants) to render statistical comparison valid. Our findings on hospitalisation concur with international RCTs that have shown DBT can reduce hospitalisation [3, 4] , but are in contrast with another UK RCT which found hospitalisation days did not differ between DBT and TAU [5]. Treatments which reduce the use of inpatient resources are particularly important, given that patients with BPD have been found in several studies to make greater use of inpatient psychiatric services than patients with other personality disorders [6] and than patients with major depressive disorder [7]. The high healthcare costs (and presumably patient distress) resulting from such frequent hospitalisation ren-der the implementation of interventions that can reduce hospi-talisation an important priority for this patient group. In 2012 in this journal we published the results of a pragmatic randomised controlled trial (RCT) of dialectical behaviour therapy (DBT) versus treatment as usual (TAU) in the United Kingdom National Health Service for patients with borderline personality disorder (BPD) and frequent self-harm [1] . This was a sample of 80 patients, 40 allocated to DBT and 40 to TAU. In this publication we reported on the primary outcome, self-harm, and showed that patients in the DBT condition achieved a significantly greater re-duction in self-harm frequency over time than patients in the TAU condition. We report here the effect of DBT compared to TAU on inpatient service use, and a follow-up 6 months after the end of treatment. The sample and treatment characteristics are reported in full in the original RCT publication [1] .Data on psychiatric hospitalisation were collected by interview- ing patients at two monthly intervals using the Client Service Re-ceipt Inventory [2] , which was then triangulated with data from electronic patient records. Figure 1 shows the percentage of pa-tients admitted to hospital in each condition in the year before and the year during treatment. In the year prior to treatment, 24 pa-tients had been hospitalised with the number of inpatient days ranging from 0 to 365 (mean 20.5, SD 63.1). The number of inpa-tient days in the year prior to treatment did not differ between conditions. During the 12-month intervention period, 2 patients allocated to DBT and 11 allocated to TAU were hospitalised. For the 2 patients hospitalised in the DBT condition, 1 was hospitalised following dropping out of DBT, whilst the other was a long-term inpatient when beginning DBT, and remained so for the first 3 months of treatment. A logistic regression showed that the odds of hospitalisation during the intervention period were significantly higher in patients allocated to the TAU condition (odds ratio 4.68, 95% CI 1.20–18.3, p = 0.03). This difference remained significant after adjusting for whether patients had been hospitalised in the year prior to treatment (adjusted odds ratio 10.77, 95% CI 1.96–59.2, p < 0.01). The total number of inpatient days per person over the year was lower in the DBT condition (mean 4.0 days, SD 20.0) than in the TAU condition (mean 8.4 days, SD 17.6), but a negative binomial regression showed that this was not a statistically sig-nificant difference (incidence rate ratio 2.06, 95% CI 0.21–20.5,

Negative results in phase III trials of complex interventions: cause for concern or just good science?

Not all interventions that show promise in exploratory trials will be supported in phase III studies. But the high failure rate in recent trials of complex mental health interventions is a concern. Proper consideration of trial processes and greater use of adaptive trial designs could ensure better use of available resources.