Mentalization-based Therapy: A summary of the evidence and new developments

1. Mentalization-based Therapy: A summary of the evidence and new developments Dawn Bales, Maaike Smits Psychotherapeutic Center de Viersprong, Viersprong Institute for Studies on Personality Disorders (VISPD) The Netherlands ISSPD: International Congress - New York City 2009

2. Research team De Viersprong – Roel Verheul, Helene Andrea, Fieke vd Meer, Nicole v Beek Erasmus University Rotterdam – Sten Willemsen, Jan van Busschach Tilburg University – Marieke Spreeuwenberg & MBT Staff (De Viersprong, Bergen op Zoom, The Netherlands) Internet: www.vispd.nl / presentations Email maaike.smits@deviersprong.nl

3. Content Mentalization-Based Treatment (MBT) A summary of the evidence Does MBT work? Are the effects lasting? Wat does it cost? Does MBT work in another dosage? Does MBT work for addiction problems? New Developments and future plans MBT DD MBT for caregivers MBT for BPD – ASPD Other new developments

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

5. 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

6. 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 function To prevent reliance on prolonged hospital stays

7. Content Mentalization-Based Treatment (MBT) A summary of the evidence Does MBT work? Are the effects lasting? Wat does it cost? Does MBT work in another dosage? Does MBT work for addiction problems? New Developments and future plans MBT DD MBT for caregivers MBT for BPD – ASPD Other new developments

8. A summary of the evidence • Does MBT work? • RCT Day-hospital (1999 UK, 20.. NL) • Partial Replication Study (2009 NL) • Are the effects lasting? • 18 month Follow-up (2001 UK, 2009 NL) • Long term follow-up (2009 UK) • Cost-effectiveness (2003 UK, 2009 NL) • Does MBT work in another dosage? • RCT IOP (2009 UK, 20.. DK) • Start RCT Dosis (20.. NL) • Does MBT work for addiction problems? • Study MBT for DD (2009 NL) • Start RCT MBT-DD (20.. SWD)

9. RCT:Day hospital MBT versus TAU for BPD patients Results MBT patients showed significant improvement in all outcome measures (Depressive symptoms, suicidal and self-mutilatory acts, reduced inpatient days, better social and interpersonal function) TAU patients showed limited change or deterioration over the same period Conclusion MBT superior to standard psychiatric care IntroductionMBT-effectiveness United Kingdom Bateman & Fonagy, American Journal Psychiatry 1999; 2001; 2008

10. MBT De Viersprong • First MBT setting outside UK • Naturalistic setting Research question: What is the treatment outcome for severe BPD patients after 18 months of day hospital Mentalization Based Treatment in the Netherlands? Bales et al., submitted, 2009

11. Study population (1) 45 patients referred to MBT(Aug.’04 – Apr. ’08) Excluded:n=2 no DSM-IV BPDn=2 refusedn=1 early dropout n=1 no follow-up measurements 39 PATIENTS INCLUDED Bales et al., submitted, 2009

12. Bales et al., submitted, 2009

13. Results: Treatment engagement Low dropout rate (n=5; 12.5%) • n=3 dropouts • n=2 push-outs • Average treatment length: 15.1 months(sd 4.2 months; range 4-18 months) Bales et al., submitted, 2009

14. Results Symptomatic functioning (SCL90, BDI, EQ-5D) Effectsizes 0.75 – 1.79 Bales et al., submitted, 2009

15. Results Social and interpersonal functioning (IIP, OQ) Effectsizes 1.17 – 1.56 Bales et al., submitted, 2009

16. Results Personality pathology SIPP: Verheul et al, 2008 Effectsizes 1.08 – 1.58 large – very large

17. Results care consumption Bales et al., submitted, 2009

18. Conclusions Significant improvement on all outcome measures with effect sizes ranging from large to very large Low drop-out rate despite limited exclusion criteria Results similar to results of Bateman & Fonagy (1999) Bales et al., submitted, 2009

19. A summary of the evidence Does MBT work? RCT Day-hospital (1999 UK, 20.. NL) Partial Replication Study (2009 NL) Are the effects lasting? 18 month Follow-up (2001 UK, 2009 NL) Long term follow-up (2009 UK) Cost-effectiveness (2003 UK, 2009 NL) Does MBT work in another dosage? RCT IOP (2009 UK, 20.. DK) Start RCT Dosis (20.. NL) Does MBT work for addiction problems? Study MBT for DD (2009 NL) Start RCT MBT-DD (20.. SWD)

20. Treatment of Borderline Personality Disorder With Psychoanalytically Oriented Partial hospitalization: An 18 month Follow-up Bateman & Fonagy, American Journal of Psychiatry (2001) Summary follow-up trial: MBT patients maintained and even showed additional improvement of symptomatic and clinical gains during 18 months follow-up 18 month follow-up 2001 Bateman & Fonagy

21. 8-Year follow-up of Patients treated for Borderline Personality Disorder: Mentalization-Based Treatment versus Treatment as usual Bateman & Fonagy 2008 American Journal of Psychiatry

22. 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 8 year follow-up 2008 Bateman & Fonagy

23. Zanarini Rating Scale for BPD : mean (SD) 8 year follow-up 2008 Bateman & Fonagy

24. Suicide attempts : mean (SD) 8 year follow-up 2008 Bateman & Fonagy

25. Global Assessment of Function 8 year follow-up 2008 Bateman & Fonagy

26. 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 8 year follow-up 2008 Bateman & Fonagy

27. A summary of the evidence Does MBT work? RCT Day-hospital (1999 UK, 20.. NL) Partial Replication Study (2009 NL) Are the effects lasting? 18 month Follow-up (2001 UK, 2009 NL) Long term follow-up (2009 UK) Cost-effectiveness (2003 UK, 2009 NL) Does MBT work in another dosage? RCT IOP (2009 UK, 20.. DK) Start RCT Dosis (20.. NL) Does MBT work for addiction problems? Study MBT for DD (2009 NL) Start RCT MBT-DD (20.. SWD)

28. Health Service Utilization Costs for Borderline personality Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care Bateman & Fonagy (2003) American Journal of Psychiatry

29. Total Annual Health Care Utilization Costs Cost-effectiveness Bateman & Fonagy, UK 2003

30. Cost-effectiveness • Significantly lower cost during treatment compared to 6-month pretreatment costs for both MBT and General Care Group • During FU period: annual cost of MBT 1/5 of anual General Care costs Cost-effectiveness Bateman & Fonagy, UK 2003

31. A summary of the evidence Does MBT work? RCT Day-hospital (1999 UK, 20.. NL) Partial Replication Study (2009 NL) Are the effects lasting? 18 month Follow-up (2001 UK, 2009 NL) Long term follow-up (2009 UK) Cost-effectiveness (2003 UK, 2009 NL) Does MBT work in another dosage? RCT IOP (2009 UK, 20.. DK) Start RCT Dosis (20.. NL) Does MBT work for addiction problems? Study MBT for DD (2009 NL) Start RCT MBT-DD (20.. SWD)

32. Treatment Outcome Studies UK Implementation of Outpatient Mentalization Based Therapy for Borderline Personality Disorder Bateman & Fonagy, in press; Am. J. Psychiat.

33. Outcome of mentalization-based and supportive psychotherapy in BPD-patients. Preliminary data from a randomized trial Jørgensen, CR., Kjølbye, M., Freund, C. & Bøye, R. Clinic for Personality Disorders, Aarhus University Hospital, Risskov, Denmark (manuscript 2009)

34. IOP in the Netherlands • Two times group psychotherapy, 75 min per week • One individual contact per week • Maximum duration 18 months RCT • IOP vs day hospital treatment • Minimal a priori exclusion criteria

35. A summary of the evidence Does MBT work? RCT Day-hospital (1999 UK, 20.. NL) Partial Replication Study (2009 NL) Are the effects lasting? 18 month Follow-up (2001 UK, 2009 NL) Long term follow-up (2009 UK) Cost-effectiveness (2003 UK, 2009 NL) Does MBT work in another dosage? RCT IOP (2009 UK, 20.. DK) Start RCT Dosis (20.. NL) Does MBT work for addiction problems? Study MBT for DD (2009 NL) Start RCT MBT-DD (20.. SWD)

36. Substance abuse among MBT patients:Prevalence and relation to treatment outcome

37. Background & Aim Literature: • 57%-67% BPD patients addiction problems -> MBT? • Combination BPD & addiction -> treatment prognosis worse Study objective: What is the prevalence of substance abuse among MBT-patients? Additional explorative analysis: Is substance abuse related to MBT treatment outcome? Substance use disorders study, Bales et al. (manuscript 2009)

38. Study population (1) 45 patients referred to MBT(Aug.’04 – Apr. ’08) Excluded:n=2 no DSM-IV BPDn=2 refusedn=1 early dropout n=1 no follow-up measurements 39 PATIENTS INCLUDED Substance use disorders study, Bales et al. (manuscript 2009)

39. Measurement Substance Abuse Composite International Diagnostic Interview (CIDI) Lifetime auto-version 2.1 Substance Abuse Module (CIDI-SAM): • Alcohol dependence or abuse (section J) • Drugs / medication / other substance abuse or dependence (section L)

40. Study population (continued) 39 eligible patients No CIDI available:n=6 refused n=9 untraceable (not in treatment anymore) 24 PATIENTS with CIDI-SAM results Substance use disorders study, Bales et al. (manuscript 2009)

41. Results: Prevalence substance disorders • Specific prevalences: • Alcohol 67% (N = 16) • 2. Cannabis 58% (N = 14) • 3. Cocaine 42% (N = 10) Mean = 2.8 diagnosis Median = 2 diagnosis

42. Hypothesis from literature: Prevalence liftetime substance abuse 50-70% MBT population: Prevalence 79% Explorative analysis: Association with treatment outcome? Substance use disorders study, Bales et al. (manuscript 2009)

43. Treatment outcome results - Explorative longitudinal analyses Interaction Time x Lifetime substance abuse? Substance use disorders study, Bales et al. (manuscript 2009)

44. Interaction time * Lifetime substance abuse Pattern for 50% of the outcome measures: SCL-90, BDI, OQ Symptom distress, OQ interpersonal relations, OQ social concordance, SIPP identity integration and Quality of life. Substance use disorders study, Bales et al. (manuscript 2009)

45. Improvement for substance abusers and non-abusers Stronger improvement for no lifetime substance abuse Average effect size of 0.61 for the difference between non abusers and abusers at 18 months. (range 0.26 – 1.08) However, only n=5 no lifetime substance abuse! Results Substance use disorders study, Bales et al. (manuscript 2009)

46. N = 5 no lifetime substance abuse N = 19 lifetime substance abuse New comparison subgroups Substance use disorders study, Bales et al. (manuscript 2009)

47. N = 5 no lifetime substance abuse N = 19 lifetime substance abuse Diagnosis starttreatment? Yes: N = 13 No: N = 6 New comparison subgroups Substance use disorders study, Bales et al. (manuscript 2009)

48. N = 5 no lifetime substance abuse N = 19 lifetime substance abuse Diagnosis starttreatment? Yes: N = 13 No: N = 6 New comparison subgroups Diagnosis start treatmentYes: N = 13 No: N = 11 (n = 5 + n = 6) Substance use disorders study, Bales et al. (manuscript 2009)

49. Interaction time * substance abuse start treatment • Pattern: • No significant interaction effect • Improvement substance abusers start treatment (n=13) resembles improvement non abusers start treatment (n=11) Substance use disorders study, Bales et al. (manuscript 2009)

50. Interaction Time * Substanceabuse:Summary Lifetime substance abuse: • N = 19 yes, N = 5 no • Tendency towards stronger improvement forsmall group without lifetime substance abuse Substance abuse start treatment: • N = 13 yes, N = 11 no • No difference in improvement over time Substance use disorders study, Bales et al. (manuscript 2009)