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Mentalization-based Treatment for borderline personality disorder:

Mentalization-based Treatment for borderline personality disorder:. A summary of the evidence, new evidence & recent developments in different dosages and treatment population

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Mentalization-based Treatment for borderline personality disorder:

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  1. Mentalization-based Treatment for borderline personality disorder: A summary of the evidence, new evidence & recent developments in different dosages and treatment population Dawn Bales, Helene Andrea, Maaike Smits, Joost Hutsebaut Psychotherapeutic Center de Viersprong, Viersprong Institute for Studies on Personality Disorders (VISPD) The Netherlands Dedicated to Ab van Wezep † Borderline Congres – Berlin, July 2th 2010

  2. Research team De Viersprong – Roel Verheul, Dawn Bales, Maaike Smits, Helene Andrea, Joost Hutsebaut, Katharina Koch, Fieke v/d Meer Erasmus University Rotterdam – Reinier Timman, Jan van Busschbach Tilburg University – Marieke Spreeuwenberg & MBT Staff (De Viersprong, Bergen op Zoom, The Netherlands) Internet: www.vispd.nl / presentations Email maaike.smits@deviersprong.nl

  3. Does MBT work? A summary of the evidence Dawn Bales

  4. Content Mentalization-Based Treatment (MBT) A summary of the evidence & new evidence Does MBT work? Are the effects lasting? What does it cost? Does MBT work in another dosage? Does MBT work for another population? Double diagnosed patients Adolescents New developments

  5. Mentalization-based Treatment • Psychoanalytically oriented; based on attachment theory • Developed in the UK by Bateman & Fonagy • Evidence-based DH and IOP treatment for patients with severe BPD • Maximum duration of 18 months • Focus: increasing patient’s capacity to mentalize

  6. Essential features of the program • Highly structured • Consistent and reliable • Intensive • Theoretically coherent: all aspects aimed at enhancing mentalizing capacity • Flexible • Relationship focus • Outreaching • Individualized treatment plan • Individualized follow-up

  7. Goals To engage the patient in treatment To reduce general psychiatric symptoms, particularly depression and anxiety To decrease the number of self-destructive acts and suicide attempts To improve social and interpersonal functioning To prevent reliance on prolonged hospital stays

  8. A summary of the evidence • 1. Does MBT work? • RCT Day-hospital vs TAU (1999 UK, 20.. NL) • Partial Replication Study (2010 NL) • 2. Are the effects lasting? • 18 month Follow-up (2001 UK, 2011 NL) • Long term follow-up (2009 UK) • 3. MBT vs. other psychotherapy? (2010 ? NL) • 4. What does MBT cost? (2003 UK, 2011? NL) • 5. Does MBT work in another dosage? • RCT IOP (2009 UK) • Start RCT Dosis (2010 NL) • 6. Does MBT work for another population? • Double diagnosed patients • Adolescents

  9. Does MBT work?MBT De Viersprong • First study manualized DH MBT outside UK • Research question: What is the applicability and treatment outcome of day hospital Mentalization Based Treatment for severe BPD patients in the Netherlands? • Naturalistic setting N=45 severe borderline patients with high comorbidity on both axis I and II Bales et al., submitted, 2010

  10. Example patient • Because of anonimisity reasons, this information has been deleted

  11. Treatment outcome 0-18 months UK & NL Effectsize NL 1.26 Submitted for publicaton – do not quote

  12. Treatment outcome 0-18 months UK & NL Effectsize NL 1.23 Submitted for publicaton – do not quote

  13. Treatment outcome 0-18 months UK & NL Effectsize NL 1.36 Submitted for publicaton – do not quote

  14. Treatment outcome 0-18 months UK & NL Submitted for publicaton – do not quote

  15. Results Personality pathology SIPP: Verheul et al, 2008 Effectsizes 1.23– 1.74 very large

  16. Results and conclusion DH MBT • Low dropout rate (n=4; 8.9%) despite limited exclusion criteria • Significant improvement on all outcome measures with effect sizes ranging from large to very large • Not only symptomatic improvement but also improvement in interpersonal and personality functioning • Results comparable to results of Bateman & Fonagy (1999) Bales et al., submitted, 2010

  17. A summary of the evidence 1. Does MBT work? RCT Day-hospital vs TAU (1999 UK, 20.. NL) Partial Replication Study (2010 NL) 2. Are the effects lasting? 18 month Follow-up (2001 UK, 2011 NL) Long term follow-up (2009 UK) 3. MBT vs. other psychotherapy? (2010 ? NL) 4. What does MBT cost? (2003 UK, 2011? NL) 5. Does MBT work in another dosage? RCT IOP (2009 UK) Start RCT Dosis (2010 NL) 6. Does MBT work for another population? Double diagnosed patients Adolescents

  18. Are the effects lasting? 18 month Follow-up UK 2001: MBT patients maintained and even showed additional improvement of symptomatic and clinical gains during 18 months follow-up 18 month Follow-up Netherlands Preliminary results analyzed June 2010 N= 61 Highly comorbid borderline patients

  19. 18 month follow-up UK and NL Preliminary results 2010 – do not quote

  20. 18 month follow-up UK and NL Preliminary results 2010 – do not quote

  21. 18 month follow-up UK and NL Effectsize NL 18-36 months 1.49 Preliminary results 2010 – do not quote

  22. 18 month follow-up UK and NL Preliminary results 2010 – do not quote

  23. 18 month follow-up UK and NL Effectsize NL 18-36 months 1.98 Cutoff BPDSI Preliminary results 2010 – do not quote

  24. Results Personality pathology 18-36 months SIPP: Verheul et al, 2008 Effectsizes 1.15-2.14 very large

  25. Conclusions 18 month FU NL • Results comparable to results of Bateman & Fonagy (1999): Continuing decline in depression, symptom distress, minimal acts of suicide attempts and self harm throughout follow-up period • Also: continuing improvement in personality functioning and specific borderline symptoms Preliminary results 2010 – do not quote

  26. Patient example: follow-up

  27. Are the effects lasting?8 year follow-up UK • Study: the effect of MBT-PH vs. TAU • N=41 patients from original trial • 8 years after entry in to RCT, 5 years after all MBT treatment was complete • Method: • interviews (research psychologists blind to original group allocation) • structured review medical notes Bateman & Fonagy (2008) Am J Psychiatry

  28. Zanarini Rating Scale for BPD : mean (SD) Bateman & Fonagy (2008) Am J Psychiatry

  29. Suicide attempts : mean (SD) Bateman & Fonagy (2008) Am J Psychiatry

  30. Global Assessment of Function Bateman & Fonagy (2008) Am J Psychiatry

  31. Conclusions from long term follow-up • MBT-PH group continued to do well 5 years after all MBT treatment had ceased • TAU did badly within services despite significant input • TAU is not necessarily ineffective in its components but package or organization is not facilitating possible natural recovery • BUT • Small sample, allegiance effects (despite attempts being made to blind the data collection) limit the conclusions. • GAF scores continue to indicate deficits. Suggests less focus during treatment on symptomatic problems greater concentration on improving general social adaptation Bateman & Fonagy (2008) Am J Psychiatry

  32. A summary of the evidence 1. Does MBT work? RCT Day-hospital vs TAU (1999 UK, 20.. NL) Partial Replication Study (2010 NL) 2. Are the effects lasting? 18 month Follow-up (2001 UK, 2011 NL) Long term follow-up (2009 UK) 3. MBT vs. other psychotherapy? (2010 ? NL) 4.What does MBT cost? (2003 UK, 2011? NL) 5. Does MBT work in another dosage? RCT IOP (2009 UK) Start RCT Dosis (2010 NL) 6. Does MBT work for another population? Double diagnosed patients Adolescents

  33. Matched samples: Patient characteristics and treatment outcome for MBT versus 3 other psychotherapeutic treatment settingsHelene Andrea

  34. Background UK results: MBT superior to standard psychiatric care(Bateman & Fonagy 1999, 2001, 2008) As yet no direct comparison between MBT andother psychotherapeutic programs Study aim: What is the effectiveness of day hospital MBT when compared to other psychotherapeutic treatment settings? SCEPTRE: Direct comparison MBT and - Outpatient, day hospital and inpatient psychotherapy - Matched-control design

  35. Matched control study: Patient sample SCEPTRE: N=923 patients with personality pathology Referred to psychotherapy in the Netherlands N=214 BPD patients N=39 MBT N=175 other treatment setting Assignment not random -> Selection bias

  36. Correction for selection bias(baseline group differences) • Propensity score • A sophisticated co-variance analysis • Combines several co-variates in 1 score • If successful • “Imitation” of random assignment • Applicable innon-randomised studies

  37. MBT (n=39) vs. SCEPTRE (n=175): Baseline differences Severity personalitypathology (SIPP):- Identity integration- Relational functioning- Responsibility- Self control- Social concordance Personality disorders (SIDP-IV interview):- Number cluster C PDs- Number PDNOS- Number BPD criteria Psychiatric symptoms (SCL) Quality of life (EQ-5D) Social rol (OQ-45) Treatment history(outpatient / day hospital / inpatient) Sexe Age Educational level Living situation (partner y/n) Care responsibility for children Combined in 1 score = Propensity Score

  38. MBT versus SCEPTRE before matching MBT: for 31% PS too high (= too severe) -> Matching not possible

  39. Matches for n=21 MBT:

  40. Effectiveness analysis • For the MBT and SCEPTRE matches(hence, without the “more severe MBT-patients”) Mixed model • Between effect: Group comparison • Within effect: Time dependency • Main outcome: GSI change score (SCL)- Change score = Time of follow-up measurement – Baseline- Negative score = improvement

  41. (Preliminary) effectiveness results In favor of effectiveness MBT

  42. Conclusions Treatment groups 31% of MBT patients could not be matched; A considerable amount of MBT patients are likely excluded from other psychotherapeutic treatments Treatment outcome (Preliminary) evidence in favour of MBT when compared to other psychotherapeutic treatments In line with results of Bateman & Fonagy (1999, 2001, 2008)

  43. Limitations N is relatively small; Several relevant severity variables are missing;e.g. substance use disorders, GAF, self-harm, suicidality Relatively large amount of missings in the MBT group; Different treatment setting and durations- subgroup analysis

  44. A summary of the evidence 1. Does MBT work? RCT Day-hospital vs TAU (1999 UK, 20.. NL) Partial Replication Study (2010 NL) 2. Are the effects lasting? 18 month Follow-up (2001 UK, 2011 NL) Long term follow-up (2009 UK) 3. MBT vs. other psychotherapy? (2010 ? NL) 4. What does MBT cost? (2003 UK, 2011? NL) 5. Does MBT work in another dosage? RCT IOP (2009 UK) Start RCT Dosis (2010 NL) 6. Does MBT work for another population? Double diagnosed patients Adolescents

  45. What does MBT cost? Does MBT work in other dosages?- Intensive Outpatient MBT - Patients with substance use disorders Maaike Smits

  46. Total Annual Health Care Utilization Costs • Significantlylowercostduringtreatmentcompared to 6-month pretreatmentcostsforboth MBT and General Care Group • During FU period: annualcost of MBT 1/5 of anual General Care costs Cost-effectiveness Bateman & Fonagy, UK 2003

  47. A summary of the evidence 1. Does MBT work? RCT Day-hospital vs TAU (1999 UK, 20.. NL) Partial Replication Study (2010 NL) 2. Are the effects lasting? 18 month Follow-up (2001 UK, 2011 NL) Long term follow-up (2009 UK) 3. MBT vs. other psychotherapy? (2010 ? NL) 4. What does MBT cost?(2003 UK, 2011? NL) 5. Does MBT work in another dosage? RCT IOP (2009 UK) Start RCT Dosis (2010 NL) 6. Does MBT work for another population? Double diagnosed patients Adolescents

  48. Design of intensive out-patient MBT randomized controlled trial RCT IOP-MBT vs. SCM groups (N = 134) Random allocation (minimisation for age, gender, antisocial PD) Individual (50 mins) + Group (1.5 hrs) weekly for 18 months Assessments at admission, 6 months, 12 months, 18 months Medication followed protocol IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry

  49. Therapy MBT - weekly Support and structure Challenge Basic mentalizing Interpretive mentalizing Mentalizing the transference Medication review Crisis management SCM - weekly Support and structure Challenge Advocacy Social support work Problem solving Medication review Crisis management IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry

  50. Percent of Sample Who Had Attempted Suicide, Self-harmed, or were Hospitalized in Last Six Months n.s. p<.02 p<.0002 IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry

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