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Effectiveness of a 6-Week Day Hospital Treatment for Personality Disorders

Data From a Naturalistic Study

SAVARD, CLAUDIA, PhD; CHRÉTIEN, MAXIME, PhD; GAMACHE, DOMINICK, PhD; MARANDA, JOHANNE, PhD; VILLENEUVE, EVENS, MD

Journal of Psychiatric Practice®: May 2019 - Volume 25 - Issue 3 - p 199–205
doi: 10.1097/PRA.0000000000000382
Articles
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Objective: To report on the effectiveness of a time-limited day-hospital crisis treatment for personality disorders (PDs) in a naturalistic setting.

Method: Archival data from 260 patients diagnosed with PDs (202 female, 58 male) who completed a 6-week day-hospital treatment program between 2012 and 2015 were analyzed. Treatment was available upon referral by psychiatrists at local emergency rooms and short-term hospitalization units. Pre-post change was assessed using the Outcome Questionnaire (OQ-45.2).

Results: Patients significantly improved during treatment on the total OQ-45.2 scale and its 3 subscales. Pre-post changes yielded large effect sizes for the total OQ-45.2 scale and the Symptom Distress subscale, and moderate effect sizes for the Interpersonal Relations and Social Role subscales. Reliable change was observed for 55% of patients for the total scale. Younger patients (18 to 24 y of age) showed larger improvements on social role satisfaction than patients over the age of 30. Overall improvement was larger for patients engaged in social participation at the beginning of treatment.

Conclusions: This study conducted in a naturalistic setting suggests that a time-limited, 6-week day-hospital treatment program tailored to patients wiith PDs may be effective in reducing overall symptomatology in patients experiencing a crisis episode.

SAVARD: Department of Fundamentals and Basics in Education, Université Laval, and CERVO Brain Research Center, Quebec City, QC, Canada

CHRÉTIEN: Integrated University Health and Social Services Centre National Capital Region, Quebec City, QC, Canada

GAMACHE: Department of Psychology, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada, and CERVO Brain Research Center, Quebec City, QC, Canada

MARANDA and VILLENEUVE: Integrated University Health and Social Services Centre National Capital Region, Quebec City, QC, Canada and CERVO Brain Research Center, Quebec City, QC, Canada

J.M. and E.V. are both employees of the University Institute of Mental Health in Quebec City, part of the Integrated University Health and Social Services Centre National Capital Region where the day hospital treatment program is offered. The remaining authors declare no conflicts of interest

Please send correspondence to: Claudia Savard, PhD, Faculté des Sciences de l’éducation, 2325 rue des Bibliothèques, Université Laval, Québec City, QC, Canada G1V 0A6 (e-mail: claudia.savard@fse.ulaval.ca).

Personality disorders (PDs) are pervasive mental disorders characterized by an enduring pattern of inner experience and behavior that deviates markedly from the expectations of an individual’s culture and is manifested in the domains of cognition, affectivity, interpersonal functioning, and/or impulse control.1 Prevalence rates of PDs vary between 1.5% and 15% in the general population,1,2 and these disorders are overrepresented in psychiatric inpatient and outpatient settings, with reported prevalence rates reaching 40% in some studies.3–5 Deliberate self-harm and impulsive and disruptive behaviors (eg, substance abuse, assaults) are common among these patients. Suicidality is also very prominent, with 30% to 40% of completed suicides committed by individuals with PDs.6,7 Relational and occupational disturbances are numerous, including marital conflicts and violence,8–12 poor parenting,13–15 and an impaired capacity to work.16 Comorbid diagnoses are the norm, and mental health utilization rates and costs are alarmingly high.2,17

Data from several naturalistic longitudinal and randomized controlled treatment studies have shown that several long-term individual psychotherapy approaches, such as dialectical behavior therapy (DBT),18 mentalization-based treatment,19,20 transference-focused psychotherapy,21 and schema-focused therapy,22 can be effective in treating PDs. However, these treatments are of at least 1 year duration. Considering that patients with PDs often use more intensive services and need crisis interventions, intensive treatments inspired by these long-term approaches are warranted. Day-treatment programs for patients with PDs have been developed over the past years as cost-efficient alternatives to lengthy hospitalizations and to manage crisis episodes. Efficacy studies have shown significant and lasting results in reducing admission to emergency services, suicide attempts, self-harm, and target symptoms such as depression, hopelessness, anger expression, and dissociation.19,20,23–31 Researchers have also noted significant improvement in general functioning and a better capacity to regulate emotions.20,23–27 These considerable benefits seem to persist over time after 12, 18, and 36 months, even up to 6 years.20,23–25,27 Most of these programs are based on weekly individual therapy and daily group therapy, with substantial variance in treatment length (ranging from 5 d to 18 mo) and intensity (between 6 and 16 h/wk).23,24,26,30,32 Despite these promising findings, the optimal therapeutic dosage remains unknown. Karterud and Urnes28 have proposed that the recommended therapeutic dose for patients with severe PDs in day-hospital programs should be 11 hours of treatment per week, 3 days a week, but these authors did not specify the treatment length per se (in terms of weeks or months). Sample sizes in previous studies were mostly small and/or included only patients with borderline personality disorder (BPD). Furthermore, day-treatment programs are mainly based on only 1 psychotherapeutic approach (psychodynamic,23 DBT30,32), except for the program described by Chiesa et al,24 who combined a psychoanalytic psychotherapy approach with a sociotherapeutic program (eg, community meeting, dance therapy).

The goal of this study was to evaluate the effectiveness of a day-hospital treatment program that includes individual and group therapy. The group therapy sessions are inspired by different psychotherapy approaches (motivational, psychodynamic, DBT, and art therapy). This program was developed for patients with a moderate or severe PD diagnosis (not restricted to BPD) who have experienced a crisis episode (ie, disorganization following an unsettling life event leading to an emergency room consultation).

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METHODS

Participants

Among the 1059 patients who were referred to the Faubourg Saint-Jean Treatment Centre (part of the Integrated University Health and Social Services Centre in Quebec City, Canada) between 2012 and 2015, 451 refused services and never showed up for the first intake interview. Of the other 608 patients who were referred, 52.47% dropped out before the end of the treatment program, and 4.77% were reoriented to another service. Therefore, archival data from 260 patients diagnosed with PDs (202 women, 58 men) who completed the day-hospital treatment program (completion rate=42.76%) were analyzed. Age distribution was as follows: 18 to 24 years=23.8%; 25 to 30 years=22.7%; 31 to 40 years=26.2%; 41 to 50 years=17.7%; and 51+ years=9.6%. The most prevalent PD diagnosis (provided by emergency units’ psychiatrists upon referral) was BPD (68.2%), followed by cluster B features (14%), narcissistic (7.4%), mixed (5.8%), dependent and histrionic (both 1.6%), obsessive-compulsive (1.2%), and schizotypal (0.4%; data missing for 1 participant). Eighty-eight percent also evidenced other mental disorders: depressive disorder or symptoms (21.4%), adjustment disorder (20.1%), substance-related disorders (17%), bipolar disorder (7.9%), anxiety disorders (7.9%), attention-deficit/hyperactivity disorder (5.2%), and eating disorders (3.9%) were the most common. Patients’ occupational status at the beginning of treatment was recorded into 4 categories: employment (29.4%); full-time studies, volunteer work, or parenthood (11.1%); temporary or permanent sick leave with health insurance (38.1%); and unemployment or benefiting from welfare payments (21.4%).

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Program Description

The Faubourg Saint-Jean Treatment Centre has developed an innovative 6-week time-limited day-hospital program following American Psychiatric Association guidelines33 for patients with moderate to severe PDs. Referrals to the program (including initial diagnosis) are made by psychiatrists from local emergency and hospitalization units. Treatment eligibility requires that patients have a PD diagnosis according to DSM-IV-TR criteria34 and be experiencing a crisis episode. There is no exclusion criterion, except for severe substance-related disorders or extreme/imminent risk of suicidality or aggression. After the initial referral, prospective patients are quickly (within <72 h) offered an intake interview conducted by a senior member of the nursing staff. Following admission, the intensive 6-week treatment program is proposed. It includes individual therapy (30 min/wk) and group therapy (7 h/wk) for patients with moderate/severe PDs.35 Individual and group therapy, which are delivered by licensed mental health professionals (psychologists, social workers, occupational therapists), focus on crisis resolution and rehabilitation. Four thematic groups focusing on resolving crises and interpersonal conflicts, reducing symptoms, and fostering insight are offered in a predetermined sequence. The Monday group emphasizes motivation and stages of change36 and encourages participants to elaborate specific objectives for the week. The Tuesday group focuses on interpersonal problems using a psychodynamic approach.37 The Wednesday group is based on a DBT38 approach and addresses different topics each week (introduction to personality disorders, distress tolerance, managing emotions, problems resolution, defense mechanisms, and cognitive distortions). Finally, the Thursday group, called “expressive group,” is an art therapy group following guidelines described by Johns and Karterud.39 Staff members have 2 meetings per week to discuss new referrals, therapeutic needs, and the clinical evolution of every patient.

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Assessment

All of the patients in our sample first completed the Outcome Questionnaire (OQ-45.2) during the intake interview conducted by a member of the nursing staff (baseline), and then completed it again later, at the end of the sixth week of the program during their last individual session with their therapist (post-treatment). The OQ-45.2 is a 45-item self-report designed for repeated measurement of client progress; it assesses symptom distress (SD), interpersonal relations (IR), and social role functioning (SR).40 Scores range from 0 to 180 for the total scale, with higher scores indicating more severe distress. The OQ-45.2 has demonstrated sensitivity to psychotherapeutic change,41 and its psychometric properties have been extensively studied worldwide.42–45

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Data Analyses

Descriptive analyses were run for the whole sample. Paired sample t tests were then conducted to assess pre-post treatment differences on the outcome measure. Cohen d was also used to report effect size. Analyses of variance with Tukey post hoc tests were performed to assess group differences (for sex, age, and occupational status) on change scores. The Statistical Package for Social Sciences (SPSS), Version 25 was used for statistical analyses. All significance tests were 2-tailed.

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RESULTS

According to OQ-45.2 cut-off scores proposed by Lambert et al,40 95% of the patients in our sample showed overall significant clinical distress at baseline (OQ-45.2 total ≥63). In addition, 94.6% of the sample showed significant symptoms of distress (SD≥36), 80.8% had interpersonal problems (IR≥15), and 76.9% were unsatisfied with their social role (SR≥12).

As shown in Table 1, results from the pre-post analyses revealed that patients significantly improved during treatment on the OQ-45.2 total scale and its 3 subscales (all changes significant at P<0.001). Pre-post changes yielded large effect sizes for the total scale and the SD subscale, and moderate effect sizes for the IR and SR subscales. Overall, 55% obtained reliable change on the OQ-45.2 total score (Δ total ≥14). Percentages of reliable change for the SD, IR, and SR subscales were 50%, 18.8%, and 20%, respectively. Because most of the patients were diagnosed with BPD, comparisons based on diagnosis were not performed. However, the same pattern of results (all changes significant at P<0.001) with similar effect sizes (total score=0.83, SD=0.79, IR=0.55, and SR=0.60) was obtained when computing analyses with BPD patients only (n=177).

TABLE 1

TABLE 1

Table 2 displays group differences for sex, age, and occupational status on change scores. No difference was observed for sex. Younger patients (18 to 24 y) achieved greater improvement on the SR subscale compared with the 3 patient groups over 30 years of age, F (4,259)=4.15, P=0.003; all 3 pairwise group comparisons at P<0.01. Patients from the unemployed group improved significantly less on the total OQ-45.2 score, F (3,251)=3.76, P=0.011, than those who were employed (P=0.035) or part of the study/volunteer work/parenthood group (P=0.029). They also improved significantly less on the SD subscale, F(3,251)=3.90; P=0.010, than employed patients (P=0.007).

TABLE 2

TABLE 2

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DISCUSSION

The purpose of the study was to assess the effectiveness of a 6-week intensive day-hospital treatment program for patients with moderate to severe PDs who were experiencing a crisis episode. Results showed significant improvement rates on symptom distress, interpersonal relationships, and social role functioning, with moderate to large effect sizes. These results support previous findings concerning short-term and intensive treatment for neurotic46 and PDs.47 Well-specified treatments for PDs that are delivered in a consistent, coherent, and continuous way tend to be effective, regardless of the theoretical orientation underlying the interventions.47 The largest improvement in our sample was observed for SD, which is consistent with the program’s crisis intervention perspective targeting symptom reduction as a priority. Reduction in SD fared very well in comparison with other time-limited programs for PDs of longer duration (18 wk to 6 mo).27,41,42 Our findings suggest that a program with a 6-week duration may result in a modest improvement in interpersonal and social functioning. However, this relatively short duration may not offer a sufficient therapeutic dosage for sustained changes in most patients (only about 20% obtained reliable change in these 2 areas). Although the results reported here are superior to findings from some previous studies,30,32 various other programs of longer duration did report better results on interpersonal functioning.27,41,42

In terms of sociodemographic characteristics, younger age and engagement in social participation at the beginning of treatment were associated with better outcomes. The 18 to 24 year old group evidenced more improvement in life role satisfaction compared with older adults, an intriguing result that may reflect the greater flexibility and more diverse range of social/occupational opportunities among emerging adults, along with perhaps less reluctance to try new experiences. Patients active in a social role showed more global improvement and reduction in symptoms, in line with a recent study that revealed that engaging in diverse roles (eg, parenting, education, volunteer work, and employment) helped patients with PDs achieve recovery.48

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LIMITATIONS

Some limitations of this study must be addressed, the main one being the absence of a control group receiving no treatment or treatment-as-usual. Second, intent-to-treat analysis was not performed. Third, results from only one outcome measure were available, and the use of a broader set of measures is warranted in future studies on the program’s effectiveness. Fourth, while DSM diagnoses were made by experienced psychiatrists from emergency rooms, they were not based on structured or semi-structured diagnostic interviews. Fifth, data on concurrent and previous psychotherapeutic/pharmacological treatments were unavailable. Finally, we did not have access to follow-up measures to assess the sustainability of change.

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CONCLUSIONS

The results of this study suggest that the time-limited 6-week treatment program developed by the Faubourg Saint-Jean Treatment Center is effective in improving overall functioning and symptom distress in patients with PDs who are experiencing a crisis. As proposed by Paris,49 it may be a cost-efficient alternative to hospitalization (which sometimes can lead to regression and “psychiatrization”) and to longer treatments when acute symptoms are the main treatment target. It can also be an alternative when there is a lack of motivation to engage in long-term therapy, as is often the case, and thus can serve as a first step toward treatment of longer duration. Indeed, despite the efficacy of time-limited treatment programs, treatment of longer duration may be warranted to improve interpersonal functioning and social role satisfaction in most patients. Moreover, because this report presents preliminary results concerning the effectiveness of a day-hospital treatment program of very short duration (6 wk), it would be beneficial for future studies to look at the contribution of other variables that are likely to influence the efficacy of such treatments (eg, support resources, group cohesion, concurrent pharmacological treatment, comorbidity).

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Keywords:

personality disorders; day hospital; crisis intervention; symptom relief; Outcome Questionnaire; naturalistic study

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