The evidence base

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6.1 APPENDIX I

A SUMMARY OF THE EVIDENCE

THERE IS HIGH QUALITY EVIDENCE FOR THE EFFECTIVENESS OF THE MODEL.
*Effectiveness of Partial Hospitalisation in the Treatment of Borderline Personality Disorder: A Randomised Controlled Trial.
Bateman and Fonagy (Am J Psych 1999)
RCT of an 18-month psychotherapeutic day service for patients with Borderline Personality Disorder.
Results: BDI, SCL-90 (global severity), Spielberger state-trait anxiety, Social adjustment scale, Inventory of interpersonal problems, self mutilations, attempted suicides and inpatient days and episodes, use of medication all significantly improved.

Therapeutic Community Effectiveness: A Systematic International Review Of Therapeutic Community Treatment For People With Personality Disorders And Mentally Disordered Offenders. Lees et al (NHS Centre for reviews and dissemination, 1999)
Meta-analysis and systematic review of therapeutic community treatment.
Conclusion: 'There is accumulating evidence…. of the effectiveness and particular suitability of the therapeutic community model to the treatment of personality disorder, and particularly severe personality disorder.'

GAINS ARE MAINTAINED OR INCREASED AT FOLLOW-UP.

*Bateman and Fonagy follow-up study (personal communication)
RCT 18-month follow-up
Results: All measures remain significantly improved or improve further.

PATIENTS WITH PERSONALITY DISORDERS ARE INTENSIVE USERS OF SERVICES.

The Prevalence of Personality Disorder Among UK Primary Care Attenders. Moran et al (Acta Psych Scand, 2000)
Results: 29% of primary care attenders fulfil criteria for PD. They tend to attend as emergencies, and the diagnosis is associated with psychiatric morbidity. (Community prevalence of personality disorders or difficulties between 2.1% and 18%)

A RANGE OF INTERVENTIONS ARE LIKELY TO BE USEFUL IN THE CONTEXT OF A DAY SERVICE.

Cognitive-Behavioural Treatment of Chronically Parasuicidal Borderline Patients and Naturalistic Follow-up of a Behavioural Treatment for Chronically Parasuicidal Borderline Patients.
Linehan et al (Arch Gen Psych 1991, 1993)
RCT of 12 months of Dialectical Behaviour Therapy (weekly individual therapy, weekly group therapy, telephone contact between sessions) for parasuicidal women with Borderline Personality Disorder.
Results: Parasuicidal acts, treatment dropout, psychiatric inpatient days improved. BDI, Beck Hopelessness Scale, Scale for Suicide Ideators, Reasons for Living Inventory, use of medication unimproved. One patient in DBT group committed suicide. At 12 month follow-up, all improvements lost but Global Assessment Scale improved.

A Randomised Trial Of Psychiatric Day Treatment For Patients With Affective And Personality Disorders.
Piper et al (Hosp Comm Psych 1993)
8-month follow-up of RCT of 18 week psychotherapeutic day service, for patients with affective and personality disorders.
Results: Range of measures improved including SCL-90 (trend), Social adjustment scale.

THE SERVICE WOULD LEAD TO COST SAVINGS.

Changes in Health Service Utilisation by Patients with Severe Personality Disorders Before and after Inpatient Psychosocial Treatment.
Chiesa et al (Br J Psychotherapy 1996)
Health service utilisation survey following psychosocial/therapeutic community treatment at Cassell Hospital, up to 18 months.
Results: Inpatient and outpatient psychiatry and inpatient medical/surgical usage significantly lower in post-treatment group. Average per annum saving of £7,423 per patient (May 1992 costs).

Are Short-term Savings Worth Long-term Costs? Funding Treatment for Personality Disorders. Menzies et al (Psychiatr Bull 1993)
Health service utilisation survey of patients at Henderson Hospital; inpatient therapeutic community treatment (average length of stay 7 months).
Results: Average inpatient and outpatient service use in year after discharge £1308, cf. year before admission £13,966. Cost of treatment recouped in under 2 years. [note: this treatment is more expensive than day service treatment].

Therapeutic Community provision at regional and district levels.
Davies et al (Psychiatr bulletin 1999)
Cost offset study from Francis Dixon Lodge, a therapeutic community in the north of England.
Results: Treatment funded by savings purely from acute admissions in 4 years. There are sufficient patients with SPD to justify each region having an in-patient unit.

* = paired studies
BDI= Beck depression inventory.
SCL-90= Symptom checklist 90.
RCT= randomised controlled trial.
PD= personality disorder; SPD= severe PD
GHQ-12= general health questionnaire (short version).
DBT= Dialectical behaviour therapy.