Psychotherapy and medication are used in the treatment of BPD. Selective serotonin reuptake inhibitors (SSRIs) have been shown to be effective in improving anger dysregulation, dysphoria, and anxiety.1 SSRIs reduce the “affective noise” in BPD patients. As a result, patients are more stable emotionally and, therefore, are more apt to be better engaged in psychotherapy. They will then have an increased capacity to reflect on their internal world and to mentalize the experiences of others.
Recent evidence suggests that SS-RIs also have a significant effect on the hippocampus. They have been known to stimulate neurogenesis in the hippocampal regions, which subsequently results in improved verbal declarative memory.21 Additionally, SSRIs decrease the hypersecretion of corticotropin-releasing factor (CRF) hyperactivity of the HPA axis.22 Rinne et al23 evaluated the effects of fluvoxamine on the HPA axis in 30 women with BPD. They compared the effects of this medication to patients with and without a history of childhood abuse. Seventeen patients had a history of abuse, and 13 patients had no abuse history. Each patient was administered a combined dexamethasone and corticotropin-releasing hormone test (DEX/CRH) before and after treatment with fluvoxamine. The dose of fluvoxamine was 150 mg/d. There was a significant reduction of ACTH and cortisol response to the DEX/CRH test after both 6 and 12 weeks of fluvoxamine treatment. There was a greater magnitude of reduction in ACTH and cortisol response in patients who had a history of sustained experience with childhood abuse. Furthermore, the degree of the reduction was not correlated with the presence of comorbid posttraumatic stress disorder or major depression. These researchers concluded that fluvoxamine decreases HPA hyperresponsiveness in patients with BPD who have experienced sustained childhood abuse. This reduction in cortisol release may, in turn, mitigate against the brain and systemic changes related to excessive cortisol secretion.
Because BPD patients have more frequent inpatient hospitalizations, increased emergency room visits, poorer adherence to hospital and clinic staff treatment plans, instability of consistent mental health providers, and are non-compliant with outpatient follow-up appointments, studies have proposed that integrated treatment with prolonged psychotherapy and medication management is highly cost-effective. The Table (see page 998) summarizes those studies. In 1992, Stevenson and Meares24 studied 30 patients with a diagnosis of BPD who received individual psychodynamic psychotherapy twice weekly. Each patient was evaluated before and after treatment a year later. Throughout the course of treatment, patients demonstrated marked improvement in various domains. Patients exhibited improvement in occupational functioning, self-injurious behavior, and utilization of medical resources. Before treatment, these patients spent an average of 4.47 months away from work each year. After completion of therapy, the time away from work diminished to an average of 1.37 months. The number of parasuicidal gestures decreased by 25% of the occurrences before initiation of treatment. Correspondingly, less parasuicidal behavior was one of the major contributors to the reduction in the necessity for medical care. The number of visits to medical providers declined to one-seventh of the pretreatment rates. Hospital admission decreased by 59%, and the course of hospital stays decreased by 50%. Thirty percent of the patients no longer met Diagnostic and Statistical Manual of Mental Disorders, third edition, (DSM-III) criteria for BPD after termination of treatment.
Table. Effect of Psychotherapy on BPD
These patients were followed up 5 years after the completion of treatment.25 Many of the treatment outcomes of year-long therapy remained. There continued to be a reduction in absences from work, medical visits, self-injurious behavior, hospital admissions, and hospital course. Additionally, there was less necessity for prescription drug use. These findings suggest that a specific modality of treatment for BPD has more continual efficacy. Meares et al26 compared these 30 patients with a group of 30 patients with BPD who received treatment as usual, which consisted of patients who were on a waiting list to receive psychotherapy at a clinic. Treatment as usual was characterized as crisis intervention, supportive therapy, and pharmacological management. At the completion of therapy, there was a significant reduction in DSM-IV symptoms scores for the patients receiving psychotherapy. However, scores for the treatment-as-usual control group were unchanged.
Hall et al27 conducted an economic analysis of the cost-effectiveness of psychotherapy for the same sample. They collected data on the use of inpatient hospitalizations, emergency room visits, ambulatory care, diagnostic tests, and medication 12 months before and after completion of psychotherapy. They also collaborated with two health economic researchers to assist with the analysis of economic data. Upon completion of therapy, there was a total of $670,000 in savings of health service use. The majority of these savings were secondary to decreased use of inpatient care. The cost of psychotherapy alone for these patients was $130,050. This resulted in a net savings of $546,509, or a net cost savings of approximately $18,000 per patient.
Linehan and colleagues28 evaluated 44 women with BPD in a randomized, controlled trial comparing dialectical behavioral therapy (DBT) to treatment as usual (TAU). DBT is a manualized treatment that combines strategies from behavioral, cognitive, and supportive therapies.29 Treatment entails weekly group psychotherapy and individual psychotherapy sessions. The treatment course is 1 year in duration. In this study, patients averaged 20 mental health visits per year in the TAU group. When compared with the TAU patients during this time frame, DBT patients had significantly fewer days in the psychiatric hospital (8.46 per year compared with 38.86 for TAU). There was also less parasuicidal behavior that necessitated treatment. The progress made by DBT patients were sustained at 6-month and 1-year follow-up.29 After 1 year of treatment, DBT patients continued to have better employment performance and fewer psychiatric hospitalizations compared with TAU patients. The cost savings averaged $10,000 per patient per year with the use of DBT compared with TAU in the community.30 Most of these savings are primarily attributed to the reduced use of inpatient beds.
Two-thirds of BPD patients meet criteria for a coexisting substance abuse diagnosis.31 Linehan and colleagues32 also conducted a randomized, controlled trial of women who had a dual diagnosis of BPD and substance abuse/dependence. In 1999, they studied 28 women with BPD using a modified version of DBT that focused on additional problems related to substance use. They compared this group with TAU. There was no difference between groups in severity of psychopathology. Urine drug screens were used to monitor substance use. Patients were evaluated at 4, 6, 8, and 12 months during the course of treatment. DBT patients demonstrated significant improvement in substance use compared with the TAU group. The medical consequences of substance abuse are well-known, so reduction in ingestion of alcohol and drugs can be expected to prevent those medical sequelae.
In 1999, Bateman and Fonagy33 conducted a randomized, controlled trial to compare the effectiveness of psychoanalytically oriented partial hospitalization with standard psychiatric care for patients with BPD. Thirty-eight patients were assigned to either a partially hospitalized group or general psychiatric services (control group) for 18 months. The partial hospitalization consisted of individual and group mentalization-based psychotherapy (MBT). The general psychiatric service entailed regular psychiatric review with a senior psychiatrist, averaging two times per month, inpatient admissions if necessary, and regular outpatient follow-up every 2 weeks. Members of this group did not receive formal psychotherapy. Results of this study showed that patients in the partial hospital group had a significant decrease in the frequency of suicide attempts and self-injurious behavior. There was also significant reduction in the number and duration of inpatient admissions, the use of psychotropic medications, symptoms of depression and anxiety, level of distress, interpersonal dysfunction, and social maladjustment. These changes were present after 6 months of treatment and were sustained until the discontinuation of treatment at 18 months.
In 2003, Bateman and Fonagy evaluated a cost analysis of the data from this previously mentioned trial.34 They collected information on the healthcare utilization of all BPD patients from case notes and service providers. Costs were compared for the 6 months before treatment, 18 months of treatment, and 18 months following the termination of treatment. The two groups had comparable health-related expenditures before the initiation of treatment. During treatment, the overall cost of the partial hospitalization group counterbalanced the lower costs of inpatient and outpatient care, medication, or emergency room treatment. However, for the 18-month treatment period, the annual costs were significantly lowered for the partial hospitalization and general psychiatric care groups, compared with the 6-month pretreatment rate. However, the cost of medication and emergency room care decreased significantly only in the partial hospitalization group. There was even more of a significant decrease in costs for the partial hospitalization group after discharge. The average annual cost for this group decreased by one-fifth of that for the general psychiatric care group. Moreover, only the partial hospitalization group demonstrated a significant reduction in emergency room costs.
An 8-year follow-up study of the same cohort35 showed continued superiority for those who had mentalization-based psychotherapy. Research psychologists conducted interviews of 41 patients from the original trial. They were blinded to which treatment group the patients belonged. Members of the mentalization-based treatment group continued to have less suicidality compared with the TAU group (23% vs. 74%). Only 13% of patients who had MBT met criteria for a diagnosis of BPD at the end of the follow-up period. Eight-seven percent of the TAU group maintained a diagnosis of BPD. Utilization of services was significantly decreased with MBT (2 versus 3.5 years of psychiatric outpatient treatment) along with the use of medication (0.02 versus 1.9 years taking three or more medications). Forty-five percent of MBT patients maintained a global functioning above 60, compared with 10% in TAU group. MBT patients also maintained better occupational functioning. They maintained employment for an average of 3.2 years, compared with 1.2 years in patients belonging to the TAU group.
The foregoing studies, summarized in the Table (see page 998), clearly indicate that there is a powerful effect on the utilization of medical services when psychotherapy is provided. In addition, there is a strong possibility that psychotherapy makes an effect on the brain abnormalities that are associated with BPD. Preliminary neuroimaging data suggest that the kind of conscious reflection required in psychotherapy may activate greater frontal cortical control over subcortical structures, such as the amygdala.36 A preliminary study involving five borderline patients and five controls used brain perfusion single-photon emission tomography (SPECT) to study these changes.37 All five BPD patients showed a lower level of activation in the frontal areas pre-treatment compared with controls. Each patient received 16 months of drug-free, mentalization-based psychotherapy, but only two of the five BPD patients who completed the treatment underwent the repeat SPET. The posttreatment neural patterns showed a strong frontal activation in these two subjects that was absent in pretreatment, suggesting more effective cortical modulation of subcortical areas. Although these data are by no means definitive, they suggest that psychotherapy may have far-ranging effects on the basic neurobiological phenomena associated with BPD.