A new study analyzed the long-term effects of psychotherapy on borderline personality disorder. Authors report the effect of  Dialectical Behavior Therapy (DBT) versus treatment-as-usual (TAU) on inpatient service use, and a follow-up 6 months after the end of treatment.

Data on psychiatric hospitalization were collected by interviewing patients at two monthly intervals using the Client Service Receipt Inventory, which was then triangulated with data from electronic patient records. In the year prior to treatment, 24 patients had been hospitalized with the number of inpatient days ranging from 0 to 365 (mean 20.5, SD 63.1).

The number of inpatient days in the year prior to treatment did not differ between conditions. During the 12-month intervention period, 2 patients allocated to Dialectical Behavior Therapy and 11 allocated to treatment-as-usual were hospitalized. For the 2 patients hospitalized in the DBT condition, 1 was hospitalized following dropping out of Dialectical Behavior Therapy, while the other was a long-term inpatient when beginning DBT, and remained so for the first 3 months of treatment.

A logistic regression showed that the odds of hospitalization during the intervention period were significantly higher in patients allocated to the TAU condition. This difference remained significant after adjusting for whether patients had been hospitalized in the year prior to treatment.

A standardized self-harm interview was also used to assess self-harm frequency during the follow-up period. The mean number of days with self-harm in the last 2 months of treatment for DBT completers was 1.79 (SD 3.68) whilst the mean number of days with self-harm during the 6 months after treatment was 1 (SD 1.80), i.e. a rate of 0.33 days per 2-month period. A Wilcoxon signed-rank test showed that this was not a significant difference (z = 1.42, p = 0.16). No DBT completers had any inpatient hospitalizations during the 6-month follow-up period. For treatment dropouts, the rate of follow-up was too low (8 of 21 participants) to render statistical comparison valid.

These findings on hospitalization concur with international RCTs that have shown DBT can reduce hospitalization, but are in contrast with another UK RCT which found hospitalization days did not differ between DBT and TAU. Treatments which reduce the use of inpatient resources are particularly important, given that patients with Borderline Personality Disorder have been found in several studies to make greater use of inpatient psychiatric services than patients with major depressive disorder or other personality disorders.

The high healthcare costs (and presumably patient distress) resulting from such frequent hospitalization render the implementation of interventions that can reduce hospitalization an important priority for this patient group. They conclude DBT should be considered an effective intervention for keeping self-harming patients with BPD out of hospital, and that positive effects on self-harm and hospitalization are sustained once treatment is over.

Citation: Barnicot K, Savill M, Bhatti N, Priebe S. A Pragmatic Randomised Controlled Trial of Dialectical Behaviour Therapy: Effects on Hospitalisation and Post-Treatment Follow-Up. Psychother Psychosom 2014;83:192-193 DOI:10.1159/000357365