Bateman, A; Fonagy, P; (2013) Impact of clinical severity on outcomes of mentalisation-based treatment for borderline personality disorder. British Journal of Psychiatry , 203 221 - 227. 10.1192/bjp.bp.112.121129.

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Abstract

Objective – Evidence of remission without specialized treatment for BPD is accumulating. The authors investigated whether specialized treatments are particularly indicated for patients at high levels of clinical severity. They examined the impact of clinical severity on outcomes of a randomized controlled trial of mentalization-based treatment (MBT) contrasted with supportive clinical management (SCM). Method – 134 patients were randomly allocated to MBT or SCM. The primary outcome was the absence of crisis events (including suicidal and severe self-injurious behaviors and hospitalization) in the last 6 months. Secondary outcomes included symptom distress and social and interpersonal function. Severity indicators were defined as (a) severity of comorbid psychiatric syndromes (number of Axis I diagnoses); (b) severity of BPD (number of positive criteria met); (c) severity of personality disturbance (number of comorbid Axis II diagnoses); and (d) severity of symptom distress as indicated by SCL-90 GSI scores. Logistic regressions were used to predict the likelihood of recovery at 18 months. Mixed-effects regressions were applied to examine rates of change across time on the primary outcome and a selective subset of secondary outcomes. Results – Of the four severity criteria, only one was significantly associated with superior outcomes from specialized treatment. Greater numbers of Axis II diagnoses predicted increasing differences in rates of improvement between MBT and SCM. Three or more diagnoses precluded significant improvement without specialist therapy. Conclusions – Patients with BPD with significant Axis II comorbidity do better with specialist treatment. Patients whose only PD diagnosis is BPD do equally well with supportive clinical management.

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