Transcript PowerPoint-presentatie

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
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 [email protected]
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
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
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
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
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
A summary of the evidence
 Does MBT work?
 RCT Day-hospital
 Partial Replication Study
(1999 UK, 20.. NL)
(2009 NL)
 Are the effects lasting?


18 month Follow-up
Long term follow-up
 Cost-effectiveness
(2001 UK, 2009 NL)
(2009 UK)
(2003 UK, 2009 NL)
 Does MBT work in another dosage?


RCT IOP
Start RCT Dosis
(2009 UK, 20.. DK)
(20.. NL)
 Does MBT work for addiction problems?


Study MBT for DD
Start RCT MBT-DD
(2009 NL)
(20.. SWD)
Introduction
MBT-effectiveness United Kingdom
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
Bateman & Fonagy, American Journal Psychiatry 1999; 2001; 2008
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
Study population (1)
45 patients referred
to MBT
(Aug.’04 – Apr. ’08)
Excluded:
n=2 no DSM-IV BPD
n=2 refused
n=1 early dropout
n=1 no follow-up
measurements
39 PATIENTS
INCLUDED
Bales et al., submitted, 2009
Clinical characteristics Study population
(N=40)
Mean
Sd
31.7
7.5
N
%
Female sex
28
70%
At least one Axis-I diagnosis
38
95%
More than one Axis-I diagnosis
32
80%
Anxiety Disorders
17
43%
Mood disorders
14
35%
Eating disorders
13
33%
Substance abuse & dependency start treatment
26
66%
PTSD
5
13%
More than 1 comorbid axis II diagnosis
28
70%
Paranoïd personality disorder
9
23%
Avoidant personality disorder
9
23%
Dependant personality disorder
6
15%
Histrionic personality disorder
4
10%
Antisocial personality disorder
3
8%
Age
Bales et al., submitted, 2009
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
Results Symptomatic functioning (SCL90, BDI, EQ-5D)
3
2.8
2.6
2.4
2.2
2
1.8
1.62
1.6
1.4
1.2
1
0.8
0.6
start
Depression
30
25.2
Mean score BDI
Mean score GSI
Symptom distress
1.51
1.30*
0.87***
6 months
12 months
18 months
25
23.6
20
19.3*
15
14.2***
10
5
0
start
6 months
12 months
Mean score EQ
Quality of life
1
0.9
0.8
0.7
0.51
0.6
0.5
0.4
0.3
0.2
0.1
0
start
Effectsizes 0.75 – 1.79
0.67**
0.57
6 months
0.63**
12 months
Bales et al., submitted, 2009
18 months
18 months
Results Social and interpersonal functioning (IIP, OQ)
Dissatisfaction in Interpersonal
Relationships
3.4
Mean score IIP
3.2
2.98
3
2.85**
2.8
2.68**
2.6
2.4
2.45***
2.2
2
start
6 months
12 months
18 months
Mean score OQ
Interpersoonlijke relaties
Interpersonal Problems
26
24
23.3
22
22.3
20
17.7***
18
16
16.5***
14
12
10
start
6 months
12 months
Dissatisfaction in social role
20
Mean score OQ
Social role
18
Effectsizes 1.17 – 1.56
16.94
16.71
16
14
11.83**
12
11.81***
10
start
6 months
12 months
Bales et al., submitted, 2009
18 months
18 months
Selfcontrol
5.5
5.05***
5
4.58***
4.5
Identity Integration
5
4
3.5
6 months
12 months
18 months
Responsibility
Mean score SIPP
Verantwoordelijkheid
5
Mean score SIPP
Identiteitsintegratie
4.16**
3.77
3
start
4.5
3.87*
4
4.08***
3.40*
3.5
3.11
3
2.5
start
4.87***
6 months
12 months
18 months
4.49***
4.5
Relational Functioning
3.96
5
4
3.71
3.5
3
start
6 months
12 months
18 months
Social Condordance
7
Mean score SIPP
Sociale Concordantie
Results Personality pathology
6.5
5.93***
6
5.56***
5.5
5.00
4.38***
4.5
4.19***
4
3.54
3.78*
3.5
3
start
6 months
12 months
SIPP: Verheul et al, 2008
5.32*
Effectsizes 1.08 – 1.58
large – very large
5
4.5
4
start
Mean score SIPP
Relationeell Functioneren
Mean score SIPP
Zelfcontrole
6
6 months
12 months
18 months
18 months
Results care consumption
Medication (start) n=21
81%
Medication (follow-up) n=21
62%
Additional treatments (start) n=28
68%
Additional treatments (follow-up) n=28
21%
Admissions (start) n=28
Admissions (follow-up) n=28
25%
0%
Bales et al., submitted, 2009
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
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
A summary of the evidence
 Does MBT work?


RCT Day-hospital
Partial Replication Study
(1999 UK, 20.. NL)
(2009 NL)
 Are the effects lasting?
 18 month Follow-up
 Long term follow-up
(2001 UK, 2009 NL)
(2009 UK)
 Cost-effectiveness
(2003 UK, 2009 NL)
 Does MBT work in another dosage?


RCT IOP
Start RCT Dosis
(2009 UK, 20.. DK)
(20.. NL)
 Does MBT work for addiction problems?


Study MBT for DD
Start RCT MBT-DD
(2009 NL)
(20.. SWD)
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
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
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
Zanarini Rating Scale for BPD : mean (SD)
MBT-PH TAU
Significance
(n = 22)
(n=15)
Positive criteria n (%)
3 (13.6)
13 (86.7)
χ2 = 16.5 p=.000004
Total mean (SD)
5.5 (5.2)
15.1 (5.3)
F1,35 = 29.7 p=.000004
Affect mean (SD)
1.6 (2.0)
3.7 (2.0)
F1,35 = 9.7p=.004
Cognitive mean (SD)
1.1 (1.4)
2.5 (2.0)
F1,35 = 6.9 p=.02
Impulsivity mean (SD)
1.6 (1.8)
4.1 (2.3)
F1,35 = 13.9 p=.001
Interpersonal mean
(SD)
1.5 (1.7)
4.7 (2.3)
F1,35 = 23.2p=.00003
8 year follow-up 2008 Bateman & Fonagy
Suicide attempts : mean (SD)
MBT-PH TAU
Significance
Total N
mean (SD)
.05 (0.9)
0.52 (.48) U = 73
Z= 3.9
p = .00004
Any attempt N
(%)
5 (23)
14 (74)
8 year follow-up 2008 Bateman & Fonagy
χ2 = 8.7
df- =1
P =.003
Global Assessment of Function
MBT-PH TAU
Mean (SD)
58.3 (10.5)
Number (%) > 10 (45.5)
60
Significance
51.8 (5.7) F1,35 = 5.4 p=.03
2 (10.5)
8 year follow-up 2008 Bateman & Fonagy
χ2 = 6.5
df = 1
p = .02
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
A summary of the evidence
 Does MBT work?


RCT Day-hospital
Partial Replication Study
(1999 UK, 20.. NL)
(2009 NL)
 Are the effects lasting?


18 month Follow-up
Long term follow-up
 Cost-effectiveness
(2001 UK, 2009 NL)
(2009 UK)
(2003 UK, 2009 NL)
 Does MBT work in another dosage?


RCT IOP
Start RCT Dosis
(2009 UK, 20.. DK)
(20.. NL)
 Does MBT work for addiction problems?


Study MBT for DD
Start RCT MBT-DD
(2009 NL)
(20.. SWD)
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
Total Annual Health Care Utilization Costs
Cost-effectiveness Bateman & Fonagy, UK 2003
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
A summary of the evidence
 Does MBT work?


RCT Day-hospital
Partial Replication Study
(1999 UK, 20.. NL)
(2009 NL)
 Are the effects lasting?


18 month Follow-up
Long term follow-up
(2001 UK, 2009 NL)
(2009 UK)
 Cost-effectiveness
(2003 UK, 2009 NL)
 Does MBT work in another dosage?
 RCT IOP
 Start RCT Dosis
(2009 UK, 20.. DK)
(20.. NL)
 Does MBT work for addiction problems?


Study MBT for DD
Start RCT MBT-DD
(2009 NL)
(20.. SWD)
Treatment Outcome Studies UK
Implementation of Outpatient
Mentalization Based Therapy for
Borderline Personality Disorder
Bateman & Fonagy, in press; Am. J. Psychiat.
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)
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
A summary of the evidence
 Does MBT work?


RCT Day-hospital
Partial Replication Study
(1999 UK, 20.. NL)
(2009 NL)
 Are the effects lasting?


18 month Follow-up
Long term follow-up
 Cost-effectiveness
(2001 UK, 2009 NL)
(2009 UK)
(2003 UK, 2009 NL)
 Does MBT work in another dosage?


RCT IOP
Start RCT Dosis
(2009 UK, 20.. DK)
(20.. NL)
 Does MBT work for addiction problems?
 Study MBT for DD
(2009 NL)
 Start RCT MBT-DD
(20.. SWD)
Substance abuse among
MBT patients:
Prevalence and relation to
treatment outcome
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)
Study population (1)
45 patients referred
to MBT
(Aug.’04 – Apr. ’08)
Excluded:
n=2 no DSM-IV BPD
n=2 refused
n=1 early dropout
n=1 no follow-up
measurements
39 PATIENTS
INCLUDED
Substance use disorders study, Bales et al. (manuscript 2009)
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)
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)
Results: Prevalence substance disorders
CIDI-SAM
Abuse /
dependence
Total
population
(N = 24)
79.2%
(N = 19)
Specific prevalences:
1.
Alcohol
67% (N = 16)
2. Cannabis
58% (N = 14)
3. Cocaine
42% (N = 10)
No
substance
Diagnosis
21%
(N = 5)
1
diagnosis
13%
(N = 3)
2
diagnoses
21%
(N = 5)
3-5
diagnoses
29%
(N = 7)
6-7
diagnoses
17%
(N = 4)
Mean =
2.8 diagnosis
Median = 2 diagnosis
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)
Treatment outcome results - Explorative longitudinal analyses
Depression (BDI)
Mean score BDI
Interaction
Time x Lifetime
substance abuse?
30
25.2
25
20
15
10
5
0
start
23.6
19.3*
14.2***
6 months
12 months
Mean score BDI
Depression (BDI)
30
27.3
25
20
22.9
25.0
17.3
15
16.9
19.1
14.9
10
no substance
abuse (n=5)
substance
abuse (n=19)
5.8
5
0
0
6
12
18
Substance use disorders study, Bales et al. (manuscript 2009)
18 months
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)
Results
 Improvement for substance abusers and nonabusers
 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!
Substance use disorders study, Bales et al. (manuscript 2009)
New comparison subgroups
 N = 5 no lifetime
substance abuse
 N = 19 lifetime
substance abuse
Substance use disorders study, Bales et al. (manuscript 2009)
New comparison subgroups
 N = 5 no lifetime
substance abuse
 N = 19 lifetime
substance abuse
Diagnosis start
treatment?
 Yes: N = 13
 No: N = 6
Substance use disorders study, Bales et al. (manuscript 2009)
New comparison subgroups
 N = 5 no lifetime
substance abuse
 N = 19 lifetime
substance abuse
Diagnosis start
treatment?
 Yes: N = 13
 No: N = 6
Diagnosis start treatment
Yes: N = 13
No: N = 11 (n = 5 + n = 6)
Substance use disorders study, Bales et al. (manuscript 2009)
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)
Interaction Time * Substance abuse:
Summary
Lifetime substance abuse:
 N = 19 yes, N = 5 no
 Tendency towards stronger improvement for
small 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)
Limitations
Small N
Retrospective measurement substance
abuse
Broader range of addictive problems
Substance abuse outcome data not yet
available
Substance use disorders study, Bales et al. (manuscript 2009)
Conclusions
Very high prevalence (79%) lifetime
substance abuse diagnosis among
MBT patients
Significant improvement possible for
DD patients (severe BPD and
substance use disorders)
Substance use disorders study, Bales et al. (manuscript 2009)
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
New Developments: MBT-DD
 MBT-PH and IOP: parallel low-frequent outpatient contact in addiction-center
 Plan: integrated MBT- DD treatment
 Program:



inpatient detox
5 days a week day-hospital (PH)
outpatient treatment
 Including system-oriented interventions
 Research
Mentalization Based Treatment for Dual Diagnosis
Bjorn Philips, Karolinska Institute, Zweden Initiated in 2009
MAT for opiate dependence
 Regular visits to outpatient clinic for medication and
urine specimens
 Contact with physician, nurse and contact person
 Psychosocial support
MAT + MBTDD





MBT complement to MAT
MBT accordant to manual
Weekly group session
Weekly individual session
18 months of treatment
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
MBT for caregivers: MBT-C
 A mentalizing parental program for high-risk parents
and their children
 Population: caregivers with severe BPD and their
children up to seven years
 Goal: promoting reflective parenting by enhancing the
caregiver’s mentalizing with respect to him/herself,
the child and the relationship
 The interventions on caregiver-child interactions are
based on principles from Minding the baby (Slade)
Plan MBT-C
 Program:
 Course explicit mentalizing (8-10 sessions)
 Course explicit mentalizing for caregivers (6-8
sessions)
 IOP MBT (1 gpt and 1 individual session)
 Interventions on caregiver-child interaction: homevisitations and routine videotaping of caregiverchild interactions
 Research:
 MBT-C versus TAU
 Hypothesis: enhancing the caregiver’s
mentalizing capacity results in less
psychopathology in the children
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
MBT for BPD - ASPD
 Bateman and Fonagy (2008): abnormalities in mentalizing are a
significant problem in ASPD.
 Intensity is iatrogenic
 Target population:




BPD
ASPD
history of severe physical agression
midrange level of psychopathy
 Program (1.5 year with FU)


One group session every two weeks
One individual session
 Research
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
Other new MBT Developments
 Adolescents (MBT-a, Viersprong, NL)
 Families (MBFT), (Viersprong, NL)
 MBT expertise center (UK & NL)
 Children/parents (MBKT, NPi, NL)
 Severe eating disorders (GGZ-MB, NL)
 Severe psychosomatic disorders
(Eikenboom, NL)
Objectives of MBFT
 Help families shift from non-mentalizing to mentalizationbased discussions and interactions, building a basis of trust
and attachment between children and parents.
 Promote parents’sense of competence in helping their
children develop the skill of mentalizing.
 Practice the skills of mentalizing, communication and
problem solving in the specific areas in which mentalizing
has been inhibited.
 Initiate activities and contexts within the family, with
peers, in school, and in the community which reinforce
mentalizing, communication skills and mutually supportive
solutions to problems
Conclusions
 A summary of the evidence
 MBT does work for severe borderline patients
 The effects are lasting
 MBT shows considerable cost savings after
treatment
 MBT-IOP also seems effective
 MBT is also promising for addiction
 Internationally many new developments
www.vispd.nl/presentations
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