Assessing the quality of the care offer for people with personality disorders in Italy: the QUADIM project. A multicentre research based on the database of use of Mental Health services

BACKGROUND

Italy can be viewed as a laboratory to assess the quality of mental healthcare delivered in a community-oriented system, especially for severe mental disorders, such as personality disorders. Although initiatives based on clinical indicators for assessing the quality of mental healthcare have been developed by transnational-organisations, there is still no widespread practice of measuring the quality of care pathways delivered to patients with severe mental disorders in a community-oriented system, especially using administrative healthcare databases. The aim of the study is to evaluate the quality of care delivered to patients with personality disorders taken-in-care by mental health services of four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily).

METHODS

A set of thirty-three clinical indicators, concerning accessibility, appropriateness, continuity, and safety of care, was implemented using regional healthcare utilization databases, containing data on mental health treatments and diagnosis, hospital admissions, outpatient interventions and exams and drug prescriptions.

RESULTS

31,688 prevalent patients with personality disorders treated in 2015 were identified, of whom 2,331 newly taken-in-care. One-in-10 patients received a standardized assessment, the treatment discontinuity affected half of the cases. 12.7% of prevalent patients received at least one hospitalization, 10.6% in the newly taken-in-care cohort. 6-out-of-10 patients had contact with community-services within 14 days from hospital discharge. Access to psychotherapy and psychoeducational treatments was low and delivered with a low intensity. The median of psychosocial interventions per person-year was 19.1 and 9.4, respectively, in prevalent and newly taken-in-care cases. Nearly 50% of patients received pharmacological treatments.

CONCLUSIONS

Healthcare utilization databases were used to systematically evaluate and assess service delivery across regional mental health systems; suggesting that in Italy the public mental health services provide to individuals with personality disorders suboptimal treatment paths.

Influencing Factors and Machine Learning-Based Prediction of Side Effects in Psychotherapy

Background: Side effects in psychotherapy are a common phenomenon, but due to insufficient understanding of the relevant predictors of side effects in psychotherapy, many psychotherapists or clinicians fail to identify and manage these side effects. The purpose of this study was to predict whether clients or patients would experience side effects in psychotherapy by machine learning and to analyze the related influencing factors. Methods: A self-compiled "Psychotherapy Side Effects Questionnaire (PSEQ)" was delivered online by a WeChat official account. Three hundred and seventy participants were included in the cross-sectional analysis. Psychotherapy outcomes were classified as participants with side effects and without side effects. A number of features were selected to distinguish participants with different psychotherapy outcomes. Six machine learning-based algorithms were then chosen and trained by our dataset to build outcome prediction classifiers. Results: Our study showed that: (1) the most common side effects were negative emotions in psychotherapy, such as anxiety, tension, sadness, and anger, etc. (24.6%, 91/370); (2) the mental state of the psychotherapist, as perceived by the participant during psychotherapy, was the most relevant feature to predict whether clients would experience side effects in psychotherapy; (3) a Random Forest-based machine learning classifier offered the best prediction performance of the psychotherapy outcomes, with an F1-score of 0.797 and an AUC value of 0.804. These numbers indicate a high prediction performance, which allowed our approach to be used in practice. Conclusions: Our Random Forest-based machine learning classifier could accurately predict the possible outcome of a client in psychotherapy. Our study sheds light on the influencing factors of the side effects of psychotherapy and could help psychotherapists better predict the outcomes of psychotherapy.

A naturalistic longitudinal study of extended inpatient treatment for adults with borderline personality disorder: An examination of treatment response, remission and deterioration

BACKGROUND

Experts express reluctance to hospitalize patients with borderline personality disorder (BPD) for more than a few days, arguing that extended inpatient care leads to deterioration and adverse events. To date, there is no empirical support for these assertions.

AIMS

The current study examined the assumption of iatrogenic effects among BPD adults.

METHODS

Clinically significant and reliable change in symptoms, functional capacities, and adverse events were quantified for both inpatients with BPD (n = 245) and a well-matched inpatient reference (n = 220) sample. Latent growth curve (LGC) models were used to evaluate moderators of the trajectory of PHQ-9 depression scores over the course of hospitalization.

RESULTS

Large effect size improvements were observed in depression, anxiety, suicidal ideation and functional disability among patients with BPD (Cohen's d ≥ 1.0) and those in the reference sample (Cohen's d ≥ .80). Clinical deterioration and adverse events were rare (occurring in no more than 1.1% of BPD and reference patients on any outcome) with no difference across patient cohorts. BPD diagnosis failed to influence the trajectory of continuous depression severity. Rather, trait emotion dysregulation was associated with initial depression severity.

CONCLUSIONS

Twenty-five years ago it was assumed that adults with BPD could not benefit from psychiatric treatment. Today there are a number of effective evidence-based outpatient treatments for BPD, but beliefs about extended inpatient treatment have changed little. Current results indicate that extended inpatient treatment can result in significant and clinically meaningful symptomatic and functional improvement in BPD patients without iatrogenic effects.

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.

Exploring narratives of psychological input in the acute inpatient setting

OBJECTIVES

This research explored what happens when psychological input is offered in the inpatient setting and examined service users' and staff members' understanding and portrayal of these experiences.

DESIGN

Narrative analysis, an interview design, was used to examine experiences of inpatient psychological interventions in National Health Service inpatient mental health settings.

METHODS

Ten participants (four service users and six staff members; five males and five females; seven White British, one White Irish, one Black African, and one Black Caribbean) were recruited via clinical psychologists from an inpatient psychology department and participated in 18- to 90-min interviews.

RESULTS

Evidence suggested that direct, indirect, and strategic psychological interventions were used in the inpatient setting, with formulation and the therapeutic relationship conceptualized as common features. Connections between inpatient psychology and change, evidenced in the stories, suggested that interventions can help people make sense of a crisis, improve relationships, and contribute to meaningful recovery. Evidence of barriers suggests that psychological input in this setting might not always be compatible with everyone's needs.

CONCLUSIONS

This paper explored service users' and staff members' experiences of psychological input in the inpatient setting. The analysis revealed that psychological provision in the inpatient mental health setting is varied and encompasses direct and indirect input, valued by service users and clinicians. It also identified that psychological input in the acute inpatient mental health setting is perceived as meaningful and can lead to changes at an interpersonal and intrapersonal level. There is a sense that providing psychological thinking in the inpatient setting can be challenging due to environmental constraints and individual factors. This highlights the need for further research focused on the costs and clinical effectiveness of providing psychological thinking within the acute inpatient mental health setting.

PRACTITIONER POINTS

Staff members and service users made connections between psychological input and change, suggesting that interventions can improve relationships, help people make sense of a crisis, and contribute to meaningful recovery. There are significant barriers to and challenges of providing psychological input in this setting: Some participants suggested that this approach might not suit everyone.

Outcomes of therapeutic community treatment for personality disorder

Purpose

– The purpose of this paper is to review quantitative research since 1999 evaluating the effectiveness of democratic therapeutic community (DTC) treatment for individuals with personality disorders (PD) with reference to interpersonal and offending risk outcomes.

Design/methodology/approach

– A systematic search resulted in the review of ten studies. All of the studies investigated DTCs treating PD in community, inpatient residential and forensic settings. Only peer-reviewed, English-language articles employing a quantitative design were included.

Findings

– The majority of studies were conducted poorly and of low methodological quality, with limitations located in the representativeness of participants, limited use of control and comparison groups, follow up periods and controls for confounders. Heterogeneity remained in use of measures and limited consideration was given to the validity of interpersonal measures used. While improved interpersonal outcomes post DTC treatment were noted in forensic and residential settings, results were mixed in day and mini TC settings. Inconsistent findings in offending risk outcomes were also indicated. A study with increased methodological rigour indicated residential treatment had limited effects on interpersonal outcomes, when compared to combination treatment (residential TC and step-down treatment).

Originality/value

– The study provided an evaluation of the limitations of DTC research across a range of settings and highlighted a combination of residential TC and step-down treatment may achieve superior outcomes to residential TC treatment alone in a community inpatient population. Recommendations are made for future research to contribute to the treatment of PD.

Social plastic at work: structure for dialogues in a therapeutic community

Purpose

– Reports about therapeutic communities usually focus on specific therapeutic activities: the various ways of the community functioning correctively, the communal-personal dynamics of the community, the dramaturgically graspable problems and the operating and integrative function of the staff. There is relatively little attention paid to the features of the structure composed of the systems of norms and values of these communities. The purpose of this paper is to focus on this normative dimension of the culture of a therapeutic community.

Design/methodology/approach

– The authors wish to show this focus with the developmental process of the system of values, rules and norms of the therapeutic community of Thalassa House in Budapest, thinking mainly in self-psychological and ethical paradigm.

Findings

– The way of operating values, norms and rules – the systems of metanorms – creates the cognitive matrix in which members of the community are both acting and perceiving parties, simultaneously suffering and interpreting the communal occurrence of self-pathologies. It develops the cooperative potential of the community along this “ethical” dimension. In the view, the structure of rules, norms and values operated in the culture of relationships of the community, as a consciously elaborated collective agent, has a specific effect in the healing of self-pathologies.

Originality/value

– In the view, the efficiency of the actuation of norms depends primarily on the emergence of metanorms, that is of the ”how” of the application of norms. The values of the metanorms can be found both in the circumstances of the birth of self-according to the attachment theory and in the world of dialogical ethics.

A psychoanalytically informed hospitalization-based treatment of personality disorders

This study presents a model of psychic change in personality disorders focusing on three dimensions: felt safety, mentalization and self-object relations. Based upon this model a hospitalization-based therapy program was created. Four scales to measure these three dimensions on the Object Relation Interview are discussed: the Felt Safety Scale, the Reflective Functioning Scale and the Bion Grid Scale and the Differentiation-Relatedness Scale. A naturalistic symptom outcome study of the program showed a large effect on both symptoms and personality functioning. Furthermore, trajectory based on pre-treatment patient characteristics (i.e., anaclitic versus introjective personality styles). Importantly, we also found a relation between symptomatic and personality change and change in felt safety and object relations. At 5-year follow-up, patients showed sustained improvement in symptomatic distress and further improvement in terms of personality and interpersonal functioning.

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.

Outcome of mentalization-based and supportive psychotherapy in patients with borderline personality disorder: a randomized trial

OBJECTIVE

This study presents data from a randomized outcome study comparing mentalization-based and supportive psychotherapy for patients with borderline personality disorder (BPD).

METHOD

Eighty-five SCID-II diagnosed borderline patients were randomized to either i) 2 years of intensive (twice weekly) combined (individual and group), mentalization-based psychotherapy (MBT) or ii) 2 years of less-intensive (biweekly) supportive group therapy. Treatment outcome was assessed using a battery of self-report questionnaires, SCID-II interviews and therapist-rated global assessment of functioning (GAF).

RESULTS

Fifty-eight patients completed 2 years of treatment. Significant changes in both treatment groups were identified for several outcome measures, including self-reported measures of general functioning, depression, social functioning and number of diagnostic criteria met for BPD, as outlined by the SCID-II interview. General linear modelling was used to compare treatment outcome in the two groups. Only GAF showed a significantly higher outcome in the MBT group. A trend was found for a higher rate of recovery from BPD in the MBT group. Pre-post effect sizes were high (0.5-2.1) and for the most part highly significant in both groups.

CONCLUSION

The study indicates that both MBT and supportive treatment are highly effective in treating BPD when conducted by a well-trained and experienced psychodynamic staff in a well-organized clinic.

The struggle to establish a research culture in the psychotherapy hospital: reflections from the Cassel Hospital experience

The institutional impact and defensive reactions to the results of a longitudinal controlled outcome trial carried out within a psychotherapy hospital specializing in the treatment of personality disorder are described and discussed. The authors argue that integration of research findings with clinical practice, the development of a research culture, and building bridges with other disciplines such as psychology and neuroscience will enhance the prospect of long-term survival of psychoanalytically oriented institutions.

Raising adults as children? A report on milieu therapy in a psychiatric ward in Norway

Milieu therapy is widely used as a therapeutic approach in psychiatric wards in the Nordic countries, but few studies exist that report on what practices a milieu therapy approach implies as seen from an ethnographic perspective. Therefore, there is a need to obtain insight into how milieu therapy unfolds in a psychiatric ward setting. The present ethnographic study aims to explore this in a locked-up psychiatric ward that was tied to a psychodynamic-oriented milieu therapy approach. Metaphors from traditional nuclear family life were widely used. Patients were often understood as harmed children and were taught self-management skills; the staff aimed at providing a caring atmosphere; and the patients seemed to behave, sometimes, in a childlike manner. In a Foucaultian framework, milieu therapy can be seen as a therapeutic normalization technique used to produce self-governing individuals. Milieu therapy "raises" patients in order to transform patients' odd behaviour and nonconforming lifestyles. We see this "raising children" approach as a type of intervention that nicely connects to the national policy of normalization and integration politics towards persons with psychiatric diagnoses.

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.