Evaluation of intensive inpatient treatment of patients with severe personality disorders

Crisis and acute mental health care for people who have been given a diagnosis of a 'personality disorder': a systematic review

BACKGROUND

People who have been given a diagnosis of a 'personality disorder' need access to good quality mental healthcare when in crisis, but the evidence underpinning crisis services for this group is limited. We synthesised quantitative studies reporting outcomes for people with a 'personality disorder' diagnosis using crisis and acute mental health services.

METHODS

We searched OVID Medline, PsycInfo, PsycExtra, Web of Science, HMIC, CINAHL Plus, Clinical Trials and Cochrane CENTRAL for randomised controlled trials (RCTs) and observational studies that reported at least one clinical or social outcome following use of crisis and acute care for people given a 'personality disorder' diagnosis. We performed a narrative synthesis of evidence for each model of care found.

RESULTS

We screened 16,953 records resulting in 35 studies included in the review. Studies were published between 1987-2022 and conducted in 13 countries. Six studies were RCTs, the remainder were non randomised controlled studies or cohort studies reporting change over time. Studies were found reporting outcomes for crisis teams, acute hospital admission, acute day units, brief admission, crisis-focused psychotherapies in a number of settings, Mother and Baby units, an early intervention service and joint crisis planning. The evidence for all models of care except brief admission and outpatient-based psychotherapies was assessed as low or very low certainty.

CONCLUSION

The literature found was sparse and of low quality. There were no high-quality studies that investigated outcomes following use of crisis team or hospital admission for this group. Studies investigating crisis-focused psychological interventions showed potentially promising results.

Psychological treatment for personality disorders

There is encouraging evidence that some patients with personality disorder are treatable. Psychotherapeutic interventions show promise, although interpretation of the literature is problematic: the number of patients in most trials is small, outcome measures are questionable, follow-up is limited, and treatments are multifaceted, complex interventions in which the effective components are unclear. The evidence base can be assessed according to efficacy and generalisability, and when both are taken into account the best verification is for psychodynamic therapy. However, there is inadequate evidence to make specific recommendations for any particular therapy.

Services for personality disorder: organisation for inclusion

Mental health services are not yet organised to allow patients with personality disorders easy access, and practitioners lack the necessary skills to implement effective treatment. A number of service models have developed, albeit without a clear evidence-base. These include sole-practitioner, divided-functions and specialist-team models. In general, a divided-functions or specialist-team model is probably best for reducing risk and improving outcomes. Both models present difficulties with integrating treatment, but these can be overcome by good communication. Good management of patients requires careful assessment of need and risk, a consistent approach, constancy of staff, team coherence and adequate in-patient support. Not all practitioners can treat patients with personality disorders and the interpersonal skills of the mental health professional may be crucial in maintaining a patient in treatment.

Four years comparative follow-up evaluation of community-based, step-down, and residential specialist psychodynamic programmes for personality disorders

Although the fulcrum of service provision for personality disorder (PD) has shifted from hospital-based to psychodynamically- and cognitively-oriented outpatient programmes, very few studies have attempted to compare specialist moderate intensity outpatient programmes with specialist high-intensity residential models, or to explore whether a period of inpatient treatment may be necessary to improve outcome and prognosis. In this article, we prospectively compare changes over a 4-year period in 3 groups of patients with personality disorders (N = 162) treated in a specialist community-based (CBP, N = 30), a step-down (RT-CBP, N = 87), and a specialist residential programme (RT, N = 45) in psychiatric distress, deliberate self-injury, and suicide attempt using multilevel modelling and multivariate logistic regression analyses. The results showed that percentages of early-dropout were significantly different (p = .0001) for the 3 programmes (CBP = 13.4%, RT-CBP = 10.2%, and RT = 41.4%). A significant interaction between treatment model and time was found for psychiatric distress (p = .001), with CBP and RT-CBP achieving more marked changes (g = 1.20 and g = 0.68, respectively) compared to RT (g = 0.30) at 48-month follow-up. CBP and RT-CBP were found to significantly reduce impulsive behaviour (deliberate self-injury and suicide attempt) compared to RT. Severity of presentation was not found to be a significant predictor of outcome. Long-term RT showed no advantage over long-term CBP, either as stand-alone or as step-down treatment. Replication may be needed to confirm generalizability of results, and a number of limitations in the study design may moderate the inferences that can be drawn from the results.

Comparison of treatment outcomes in severe personality disorder patients with or without substance use disorders: a 36-month prospective pragmatic follow-up study

BACKGROUND

Concurrent personality disorder (PD) and substance use disorder (SUD) are common in clinical practice. However, SUD is the main criterion for study exclusion in most psychotherapeutic studies of PD. As a result, data on treatment outcomes in patients with concurrent PD/SUD are scarce.

METHODS

The study sample consisted of 51 patients diagnosed with severe PD and admitted for psychotherapeutic treatment as a part of routine mental health care. All patients were diagnosed with PD according to the Structured Clinical Interview for PD. Patients were further assessed (DSM-IV diagnostic criteria) to check for the presence of concurrent SUD, with 28 patients diagnosed with both disorders (PD-SUD). These 28 cases were then compared to the 23 patients without SUD (PD-nSUD) in terms of psychiatric hospitalizations and psychiatric emergency room (ER) visits before and during the 6-month therapeutic intervention and every 6 months thereafter for a total of 36 months.

RESULTS

The baseline clinical characteristics correspond to a sample of PD patients (78% met DSM-IV criteria for borderline PD) with poor general functioning and a high prevalence of suicide attempts and self-harm behaviors. Altogether, the five outcome variables - the proportion and the number of psychiatric inpatient admissions, the number of days hospitalized, and the proportion and the number of psychiatric ER visits - improved significantly during the treatment period, and this improvement was maintained throughout the follow-up period. Although PD-SUD patients had more psychiatric hospitalizations and ER visits than PD-nSUD patients during follow-up, the differences between these two groups remained stable over the study period indicating that the treatment was equally effective in both groups.

CONCLUSION

Specialized psychotherapy for severe PD can be effectively applied in patients with concurrent PD-SUD under usual practice conditions. These findings suggest that exclusion of patients with dual disorders from specialized treatments is unjustified.

Tailoring psychotherapy in patients with personality disorders: Matching the level of psychological strengths to the level of stabilizing versus destabilizing psychotherapy

BACKGROUND

Clinical evidence suggests that patients high on psychological strengths profit more from destabilizing psychotherapy, whereas patients low on strengths profit more from stabilizing psychotherapy. This matching hypothesis was tested.

METHODS

This quasi-experimental study was conducted between 2003 and 2008 in 735 patients with personality disorders from 6 psychotherapy centers in the Netherlands. Patients were assigned to different levels of stabilizing and destabilizing psychotherapies. Levels of psychological strengths were measured. We used multilevel modeling to estimate outcome at 12 months after baseline. The propensity score controlled for initial differences at baseline.

RESULTS

The findings show that destabilizing psychotherapies have slightly better outcomes than stabilizing psychotherapies. Patients high on psychological strengths improve slightly more than patients low on psychological strengths. The observed interaction effect contradicted our hypothesis.

CONCLUSION

The results imply that destabilizing psychotherapies can be considered as first treatment option for patients both high and low on psychological strengths.

[Effectiveness of an integrated treatment for severe personality disorders. A 36-month pragmatic follow-up]

INTRODUCTION

Over the past 25 years, several studies have shown the efficacy of a number of psychological interventions for severe personality disorders. However, the generalizability of these positive results from long traditional research settings to more ordinary ones has been questioned, requiring a need for replication in pragmatic studies.

METHODS

This pragmatic study compares hospitalizations and Emergency Room visits before and during a 6-month therapeutic program for severe personality disorders, and at 36 months after starting it. The therapeutic program, which integrates several specific interventions within a coherent framework, was carried out in an ordinary clinical setting. Fifty-one patients, evaluated according DSM-IV criteria by using the Spanish version of the Structured Clinical Interview for Personality Disorders (SCID-II), were included.

RESULTS

The clinical characteristics showed a group of severely disturbed patients, of which 78.4% met criteria for borderline personality disorder. The percentage of patients hospitalized and visiting the Emergency Room, as well as the number of days of hospitalization and Emergency Room visits was significantly reduced during the treatment, and this improvement was maintained throughout.

CONCLUSIONS

An integrated treatment for severe personality disorders could be effective in preventing reliance on readmissions, or prolonged hospital stays, when it is implemented by clinicians in ordinary clinical settings.

Long-term outcome of inpatient psychotherapy for adolescents (IPA) with personality pathology

Little is known about the effectiveness of treatment programs for adolescents with personality disorders (PDs). This descriptive study investigated long-term outcomes of inpatient psychotherapy for adolescents (IPA). In addition, predictors of long-term treatment effects were investigated. Seventy adolescents who completed their treatment were followed during and after their stay in IPA. Semistructured interviews were used to assess Axis I and Axis II disorders. Patients completed questionnaires to measure symptom severity and personality styles and functioning. Patients showed improvements (d ranging from .18 to .80). After leaving IPA, a small relapse rate was shown. Higher levels of dependency or more Cluster C PD traits significantly predicted positive long-term treatment outcome. Although IPA might be effective for a particular group of adolescents, mean long-term treatment effects were at best modest. Given the high costs of IPA, developing adjustments to IPA and their guidelines is warranted to ensure cost-effectiveness.

Effectiveness of Psychotherapy in Personality Disorders Not Otherwise Specified: A Comparison of Different Treatment Modalities

OBJECTIVE

Although personality disorder not otherwise specified (PDNOS) is highly prevalent and associated with a high burden of disease, only a few treatment studies in this patient group exist. This study is the first to investigate the effectiveness of different modalities of psychotherapy in patients with PDNOS, i.e., short-term (up to 6 months) and long-term (more than 6 months) outpatient, day hospital, and inpatient psychotherapy.

METHOD

A total of 205 patients with PDNOS were assigned to one of six treatment modalities. Effectiveness was assessed over 60 months after baseline. The primary outcome measure was symptom severity, and the secondary outcome measures included psychosocial functioning and quality of life. The study design was quasi-experimental, and the multiple propensity score was used to control for initial differences between treatment groups.

RESULTS

All treatment modalities showed positive outcomes, especially in terms of improvements of symptom severity and social role functioning. At 12-month follow-up, after adjustment for initial differences between the treatment groups, short-term outpatient psychotherapy and short-term inpatient psychotherapy showed most improvement and generally outperformed the other modalities concerning symptom severity. At 60 months after baseline, effectiveness remained but observed differences between modalities mostly diminished.

CONCLUSION

Patients with PDNOS benefit from psychotherapy both at short-term and long-term follow-up. Short-term outpatient psychotherapy and short-term inpatient psychotherapy seem to be superior to the other treatment modalities at 12-month follow-up. At 60-month follow-up, treatments showed mostly comparable effectiveness.

KEY PRACTITIONER MESSAGES

The effectiveness of different modalities of psychotherapy in patients with PDNOS (i.e., short-term vs long-term; outpatient versus day hospital versus inpatient psychotherapy) has not yet been compared. Different modalities of psychotherapy are effective for patients with PDNOS, and positive effects remain after 5 years. In patients with PDNOS short-term (less than 6 months) outpatient psychotherapy and short-term inpatient psychotherapy seem to be superior to the four other treatment modalities at 12-month follow-up. At 60-month follow-up, treatments showed mostly comparable effectiveness.

Predictors of treatment outcome of Inpatient Psychotherapy for Adolescents with personality pathology

Little is known about the effectiveness of treatment programmes for personality disordered adolescents. This study investigates the treatment outcome of Inpatient Psychotherapy for Adolescents (IPA), i.e. an intensive programme for treatment refractory adolescents with personality pathology. In addition, this study examines predictors of treatment outcome. One hundred and nine adolescents admitted for treatment of their personality problems were followed up during their stay in IPA. Axis I and Axis II disorders were measured using semi-structured interviews, and the adolescents completed several questionnaires to measure symptom severity (global indices of distress), personality styles and functioning, and quality of life at both start and 12 months after start of treatment. Patients showed improvement in level of symptom severity, personality functioning and quality of life (d ranging from 0.49 to 0.97). As for level of symptom severity, 29% of the adolescents moved into a normative range of symptom severity. Higher levels of self-criticism significantly predicted poorer outcome in terms of symptom severity. Type of personality disorder did not predict treatment outcome. IPA is a potentially effective treatment programme for (a subgroup of) treatment refractory adolescents with personality pathology.

Is the residential combined (psychotherapy plus medication) treatment of patients with severe personality disorder effective in terms of suicidality and impulsivity?

The aim of this study was to compare the effectiveness of combined treatment-medication plus psychodynamic psychotherapy-and psychodynamic psychotherapy alone on the outcome variables of suicidality and impulsivity in a population of adult inpatients with severe personality disorder (SPD). This is a naturalistic-empirical (observational) study under the conditions of clinical practice (an intensive specialized inpatient psychotherapeutic program [SIPP]). The sample consisted of 33 inpatients with SPD who were allocated to two subgroups (groups A and B). The patients in group A received psychodynamic psychotherapy and adjunctive pharmacotherapy, whereas the patients in group B received multimodal psychodynamic psychotherapy only. A statistically significant reduction in suicidality score was observed in the patients in group A, whereas a tendency for significant reduction in impulsivity score was observed in group B after the SIPP termination. Pharmacotherapy combined with multimodal psychodynamic psychotherapy, always within the SIPP, seems more effective in the case of suicidality rather than impulsivity.

Three-week inpatient Cognitive Evolutionary Therapy (CET) for patients with personality disorders: evidence of effectiveness in symptoms reduction and improved treatment adherence

OBJECTIVES

The aim of this study was to evaluate the efficacy of Cognitive Evolutionary Therapy (CET) in an intensive short residential treatment of a wide range of severe personality disorders (PDs) that resulted in a reduction of social functioning and significant personal distress.

DESIGN

Each patient was assessed at admission, discharge, and 3 months later in order to determine if there was a reduction in symptoms and an improved adherence to former outpatient programs and to check if patients were undergoing new treatment after discharge.

METHOD

Fifty-one patients participated in this study. The 20-hr weekly program consisted of two individual sessions and various group modules. Outcome measures included: self-reported measures of depression, anxiety, general symptoms, number and duration of inpatient admissions after the programme, and continuation in an outpatient treatment programme.

RESULTS

The results show an overall improvement in general psychopathology after the release and in follow-up sessions, a decrease in the number of further hospital admissions, and an increased level of attendance of outpatient therapy.

CONCLUSIONS

This study shows that intensive short residential treatment is an effective treatment for patients with a wide range of PDs.

Psychological therapies for people with borderline personality disorder

BACKGROUND

Psychotherapy is regarded as the first-line treatment for people with borderline personality disorder. In recent years, several disorder-specific interventions have been developed. This is an update of a review published in the Cochrane Database of Systematic Reviews in 2006.

OBJECTIVES

To assess the effects of psychological interventions for borderline personality disorder (BPD).

SEARCH METHODS

We searched the following databases: CENTRAL 2010(3), MEDLINE (1950 to October 2010), EMBASE (1980 to 2010, week 39), ASSIA (1987 to November 2010), BIOSIS (1985 to October 2010), CINAHL (1982 to October 2010), Dissertation Abstracts International (31 January 2011), National Criminal Justice Reference Service Abstracts (15 October 2010), PsycINFO (1872 to October Week 1 2010), Science Citation Index (1970 to 10 October 2010), Social Science Citation Index (1970 to 10 October 2010), Sociological Abstracts (1963 to October 2010), ZETOC (15 October 2010) and the metaRegister of Controlled Trials (15 October 2010). In addition, we searched Dissertation Abstracts International in January 2011 and ICTRP in August 2011.

SELECTION CRITERIA

Randomised studies with samples of patients with BPD comparing a specific psychotherapeutic intervention against a control intervention without any specific mode of action or against a comparative specific psychotherapeutic intervention. Outcomes included overall BPD severity, BPD symptoms (DSM-IV criteria), psychopathology associated with but not specific to BPD, attrition and adverse effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the risk of bias in the studies and extracted data.

MAIN RESULTS

Twenty-eight studies involving a total of 1804 participants with BPD were included. Interventions were classified as comprehensive psychotherapies if they included individual psychotherapy as a substantial part of the treatment programme, or as non-comprehensive if they did not.Among comprehensive psychotherapies, dialectical behaviour therapy (DBT), mentalisation-based treatment in a partial hospitalisation setting (MBT-PH), outpatient MBT (MBT-out), transference-focused therapy (TFP), cognitive behavioural therapy (CBT), dynamic deconstructive psychotherapy (DDP), interpersonal psychotherapy (IPT) and interpersonal therapy for BPD (IPT-BPD) were tested against a control condition. Direct comparisons of comprehensive psychotherapies included DBT versus client-centered therapy (CCT); schema-focused therapy (SFT) versus TFP; SFT versus SFT plus telephone availability of therapist in case of crisis (SFT+TA); cognitive therapy (CT) versus CCT, and CT versus IPT.Non-comprehensive psychotherapeutic interventions comprised DBT-group skills training only (DBT-ST), emotion regulation group therapy (ERG), schema-focused group therapy (SFT-G), systems training for emotional predictability and problem solving for borderline personality disorder (STEPPS), STEPPS plus individual therapy (STEPPS+IT), manual-assisted cognitive treatment (MACT) and psychoeducation (PE). The only direct comparison of an non-comprehensive psychotherapeutic intervention against another was MACT versus MACT plus therapeutic assessment (MACT+). Inpatient treatment was examined in one study where DBT for PTSD (DBT-PTSD) was compared with a waiting list control. No trials were identified for cognitive analytical therapy (CAT).Data were sparse for individual interventions, and allowed for meta-analytic pooling only for DBT compared with treatment as usual (TAU) for four outcomes. There were moderate to large statistically significant effects indicating a beneficial effect of DBT over TAU for anger (n = 46, two RCTs; standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.43 to -0.22; I(2) = 0%), parasuicidality (n = 110, three RCTs; SMD -0.54, 95% CI -0.92 to -0.16; I(2) = 0%) and mental health (n = 74, two RCTs; SMD 0.65, 95% CI 0.07 to 1.24 I(2) = 30%). There was no indication of statistical superiority of DBT over TAU in terms of keeping participants in treatment (n = 252, five RCTs; risk ratio 1.25, 95% CI 0.54 to 2.92).All remaining findings were based on single study estimates of effect. Statistically significant between-group differences for comparisons of psychotherapies against controls were observed for BPD core pathology and associated psychopathology for the following interventions: DBT, DBT-PTSD, MBT-PH, MBT-out, TFP and IPT-BPD. IPT was only indicated as being effective in the treatment of associated depression. No statistically significant effects were found for CBT and DDP interventions on either outcome, with the effect sizes moderate for DDP and small for CBT. For comparisons between different comprehensive psychotherapies, statistically significant superiority was demonstrated for DBT over CCT (core and associated pathology) and SFT over TFP (BPD severity and treatment retention). There were also encouraging results for each of the non-comprehensive psychotherapeutic interventions investigated in terms of both core and associated pathology.No data were available for adverse effects of any psychotherapy.

AUTHORS' CONCLUSIONS

There are indications of beneficial effects for both comprehensive psychotherapies as well as non-comprehensive psychotherapeutic interventions for BPD core pathology and associated general psychopathology. DBT has been studied most intensely, followed by MBT, TFP, SFT and STEPPS. However, none of the treatments has a very robust evidence base, and there are some concerns regarding the quality of individual studies. Overall, the findings support a substantial role for psychotherapy in the treatment of people with BPD but clearly indicate a need for replicatory studies.

Treatment duration and premature termination of psychotherapy in personality disorders: predictive performance of psychodynamic personality functioning

OBJECTIVE

Little is known about predictors of treatment duration and premature termination of psychotherapy.

METHOD

Sociodemographic variables, descriptive DSM-IV psychiatric diagnoses, general symptom severity, and psychodynamic personality functioning were assessed in 148 inpatients with personality disorders who were receiving psychotherapy. Psychodynamic personality functioning was assessed using the Developmental Profile (DP). Predictive performance and incremental value over and beyond demographics and descriptive diagnoses were determined.

RESULTS

In contrast to DSM-IV diagnoses and symptom severity, psychodynamic variables and the level of personality functioning significantly predicted treatment duration and premature treatment termination. Longer treatment duration was predicted by adaptive DP levels of personality functioning, whereas shorter treatment duration was associated with maladaptive personality functioning (primitive DP levels, including fragmentation and self-centeredness). DP variables independently explained 6% of the variance.

CONCLUSION

In contrast to DSM-IV diagnoses and general symptom severity, psychodynamic personality variables significantly predicted treatment duration and premature discharge. These findings support the relevance of psycho-dynamic assessments in clinical practice, the DSM-5 proposals for the definition of personality functioning, and the predictive validity of the DP.

Engagement and early termination of contact with a community-based early intervention service for personality disorder in young adults

BACKGROUND

Few studies have examined factors associated with continuity of care in a community-based early intervention service for personality disorder in patients aged 16-25.

AIMS

To estimate the probability of dropping out of care in patients attending an early intervention service for personality disorder and identify patient characteristics associated with those who drop out, are discharged or continue using the service.

METHOD

A 24-month cohort of first-contact patients attending the early intervention service was followed up for 12 months to identify drop-outs, discharges and those still using the service.

RESULTS

One hundred eighty-three first contact patients were referred/self-referred during the study timescale. After 12-month follow-up, 83 (45%) were discharged, 39 (21%) still using the service and 61 (33%) dropped out. Drop out was most likely among patients aged 21-25, from higher socio-economic groups and highest during months 3-5 of service use. No discharges occurred until at least 3 months into the service, with a peak at 6-8 months.

CONCLUSIONS

Although sharing many factors predicting increased levels of drop-out, the rate of drop-out among young adults aged between 16-25 attending an early intervention service for personality disorder was equivalent to that experienced by services for adults with a long history of personality disorder diagnosis. Concerns exist, however, concerning increased rates of drop-out among patients reporting a greater number of difficulties, reporting a common mental health or substance abuse problem, and during months 3-5 of service use. Implications of the results for future service developments are discussed.

Community-based psychodynamic treatment program for severe personality disorders: clinical description and naturalistic evaluation

Long-term inpatient treatment for personality disorders has become infrequent in the last two decades, and the gap left in service provision has been filled by psychodynamically and cognitively oriented partial hospitalization and outpatient, community-based approaches. It is still uncertain how these low-cost, lower-intensity models have fared relative to residential models that treat patients with severe personality disorders with the containment and control offered by the inpatient setting. In this article, we describe key features of a community-based psychodynamic program developed at the Cassel Hospital in the United Kingdom and present preliminary findings of a 2-year prospective naturalistic outcome study that monitored psychiatric morbidity (Brief Symptom Inventory General Severity Index [BSI-GSI]) and clinical outcome (self-mutilation, suicide attempts, and hospital admissions) in 68 patients with personality disorders who were consecutively admitted to the program. Improvements shown by the community-based sample on all variables were compared with the results in a comparable sample of inpatients treated in a long-term psychosocial treatment program in the same institution. The naturalistic comparison of the two non-randomized treatment models revealed that the community-based sample improved to a significantly greater degree on all three clinical outcome dimensions and had significantly lower early dropout rates than those who received the long-term residential treatment. The findings indicate that, at least in terms of impulsive behavior and treatment adherence, the community-based program appears to offer a viable adequate alternative to long-term inpatient admission.

Psychiatric nurses' knowledge, experience and attitudes towards clients with borderline personality disorder

There is evidence in the literature to suggest that mental health care staffs' attitudes towards clients with borderline personality disorder (BPD) are less than favourable. This study reports on a survey of psychiatric nurses' knowledge, experience and attitudes towards care received by clients with a diagnosis of BPD. The questionnaire was sent to all clinical nurses (n = 157) working in a psychiatric service in Dublin, Ireland and received a response rate of 41.4% (n = 65). The results indicate that the majority of nurses have regular contact with clients with BPD and nurses on inpatient units reported more frequent contact than nurses in the community. Eighty per cent of nurses view clients with BPD as more difficult to care for than other clients and 81% believe that the care they receive is inadequate. Lack of services was cited as the most important factor contributing to the inadequate care and the development of a specialist service is reported as the most important resource to improve care.

The efficacy of various modalities of psychotherapy for personality disorders: a systematic review of the evidence and clinical recommendations

The aim of this paper is to review the level of empirical evidence for four different formats and settings that are available for psychotherapy delivery, i.e., group psychotherapy, out-patient individual psychotherapy, day hospital psychotherapy, and in-patient psychotherapy. The focus is on studies which include a wide range of DSM-IV-TR Axis II personality disorders. The results show that various psychotherapeutic treatments have proven to be efficacious with respect to reducing symptomatology and personality pathology, and improving social functioning in patients with Cluster A, B, C, or not-otherwise-specified personality disorders. This is especially true for cognitive-behaviorally or psychodynamically oriented out-patient individual psychotherapies. However, some evidence indicates that this also applies to (1) long-term, psychodynamically oriented group psychotherapy, (2) short-term, psychodynamically oriented psychotherapy in a day hospital setting, and (3) various duration variants of psychodynamically oriented, in-patient psychotherapy programmes. The available evidence mostly applies to borderline, dependent, avoidant and not-otherwise-specified personality disorder, and perhaps also paranoid, obsessive-compulsive, and schizotypal personality disorder. It is unknown whether these conclusions also apply to schizoid, antisocial, narcissistic, and histrionic personality disorder.

Outcomes of Inpatient Geropsychiatric Treatment: The Value of Assessment Protocols

The purpose of this evaluative study was to determine if elderly patients' mental health assessment scores improved after receiving specialized inpatient treatment. A random sample of 106 cases was drawn from existing medical records of patients treated during a 2-year time period in a comprehensive geropsychiatric inpatient clinical outcome assessment program. The clinical assessments included measures of cognitive, affective, and functional levels and used scores from the Mini-Mental State Exam, the Geriatric Depression Scale, the Allen Cognitive and Level of Care Assessment, and the Global Assessment of Function on admission and at discharge. Comparisons of these scores revealed a statistical significance between admission and discharge scores, and the mean assessment scores did improve during the average 12-day hospital stay. Although specific treatment efficacy cannot be inferred from these results, at least the overall efficacy of such treatment was supported by this study's findings.

Psychodynamic psychotherapies: Evidence-based practice and clinical wisdom

This article is based on an exhaustive review of the psychotherapy outcomes literature, undertaken originally at the instigation of the UK Department of Health by Roth and Fonagy (Department of Health, 1995). We have recently updated this review (Fonagy, Target, Cottrell, Phillips, & Kurtz, 2002; Roth & Fonagy, 2004) and extended it to identify all studies of psychoanalytic psychotherapy. The usual methods for identifying studies were employed (Fonagy, Target, et al., 2002; Roth & Fonagy, in press). The key questions that should be asked of this literature given the current state of research in this area (also see Westen, Morrison, & Thompson-Brenner, 2004) are: Are there any disorders for which short-term psychodynamic psychotherapy (STPP) can be considered evidence-based, Are there any disorders for which STPP is uniquely effective as either the only evidence-based treatment or as a treatment that is more effective than alternatives, and Is there any evidence base for long-term psychodynamic psychotherapy (LTPP) either in terms of achieving effects not normally associated with short-term treatment or addressing problems that have not been addressed by STPP? In this context, short-term therapy is conceived of as a treatment of around 20 sessions delivered usually once weekly.

Rehabilitative residential treatment in patients with severe mental disorders: personality features associated with short-term outcome

The aims of this study were to evaluate the outcome of inpatients with severe psychiatric disorders after 6 months of multimodal residential treatment. Ninety-one subjects admitted to residential prolonged treatment at an Italian rehabilitative complex were included in the study. Within 6 months, the program of treatment was effective in reducing symptoms and improving the patients' psychosocial functioning. The study of personality can be useful to "dose" symptomatic (pharmacological and psychotherapeutic) and rehabilitative treatments in the therapy program.