In the current issue of Psychotherapy and Psychosomatics data are presented that indicate that treatment of personality disorders may be successful, but requires different levels of care.
Personality disorders (PDs) are starting to be viewed as treatable, with a much better prognosis than previously thought. This is especially true when we consider outcome data from randomised controlled trials of psychotherapy. Despite the many promising developments in the PD treatment research literature, several important issues remain inadequately addressed. Among these is the issue concerning the optimal level of care for the psychotherapeutic treatment of PDs.
The level of care is a multi-dimensional construct that considers containment, intensity, structure, costs per day and duration. Generally speaking, levels of care can be organised hierarchically on the basis of these dimensions (except duration) into inpatient hospitalisation, partial hospitalisation/day treatment and outpatient treatment.
Recently, in a landmark study, a group of Dutch investigators headed by Anna Bartak took on the challenges of studying the effectiveness of different levels of care in the treatment of PDs, as part of the large project SCEPTRE (Study on Cost Effectiveness of Personality Disorder Treatment).
The 3-year study was conducted in 6 mental health care centres in the Netherlands and involved several hundred patients with DSM-IV-TR axis II diagnoses. At each participating centre, patients were assigned to different modalities of psychotherapeutic treatment representing 3 levels of care: outpatient treatment, day treatment and inpatient treatment.
An extensive battery of measures was administered to the patients before treatment assignment in order to assess a wide variety of baseline characteristics. Using intention-to-treat analysis, Bartak and colleagues compared the effectiveness of the different levels of care for the various outcome indices (psychiatric symptoms, social role functioning, interpersonal functioning and quality of life).
As regards cluster C PDs (obsessive-compulsive, avoidant and dependent), the study findings suggest that a level of care characterised by high degrees of containment, intensity and structure for a relatively short duration may provide the greatest potential for improvement. For patients with cluster B PDs (histrionic, narcisistic, borderline, antisocial), the findings suggest that all 3 levels of care (outpatient, day treatment, inpatient) were effective (primarily borderline), yet even after accounting for the strong influence of baseline patient characteristics, there seemed to be a slight advantage for inpatient treatment.
As concerns cluster A disorders, while the outcome findings seem to suggest a superiority of day treatment and inpatient treatment for primarily paranoid PD patients compared to outpatient treatment (at least in terms of psychiatric symptoms), the more cautious conclusion is that even for these patients there is not a contra-indication for psychotherapeutic treatment.
All these outcomes suggest that specialised inpatient psychotherapeutic treatment deserves to be considered as a valuable treatment option for patients with PD pathology. Unfortunately, in many countries, inpatient treatment has been marginalised, having been relegated as a short-term crisis intervention. Whether this trend can be halted and reversed may depend on the outcomes of further investigations of different levels of care for PD patients.