We set about developing a randomized controlled trial (RCT) of a psychoanalytically oriented treatment of BPD (Bateman and Fonagy, 1999). The severity of the patients' symptoms, many of whom had received compulsory treatment in secure settings and most of whom had made serious attempts on their life in the six months prior, meant that treatment in a partial-hospitalization program was necessary. Forty-four patients were randomized either to a psychoanalytically informed partial-hospitalization program or routine general psychiatric care. Treatment included individual and group psychoanalytic psychotherapy for a maximum of 18 months. Outcome measures included frequency of suicide attempts and acts of self-harm, number and duration of inpatient admissions, use of psychotropic medication, and self-report measures of depression, anxiety, general symptom distress, interpersonal function and social adjustment. Patients in the partial-hospitalization program showed a statistically significant decrease on all measures in contrast to the control group, which showed limited change or deterioration over the same period. Improvement in depressive symptoms, decrease in suicidal and self-mutilatory acts, reduced inpatient days, and better social and interpersonal function began after six months and continued to the end of treatment at 18 months. The dropout rate was low at 12%.
Long-term follow-up was built into the study, and patients who participated in the original study were assessed every three months after completion of the treatment phase (Bateman and Fonagy, 2001). Patients who completed the partial-hospitalization program not only maintained their substantial gains but also showed a statistically significant continued improvement on most measures in contrast to patients treated with standard psychiatric care, who showed only limited change during the same period. Their continued improvement in social and interpersonal functioning suggests that longer-term changes were stimulated. The control group used more of all types of health and social care monitored in the study including attendance at emergency rooms, particularly following impulsive acts of self-harm. The maintenance of a reduction in episodes of self-harm and suicide attempts (Figures 1
) and low rates of hospital admission in the patients with BPD who completed a psychoanalytically oriented partial-hospitalization program (compared with those patients who received standard psychiatric care) reduced to a minimal level the need for costly emergency treatment and expensive inpatient care. This suggests considerable cost savings following treatment.