S-06-01
Severe personality disorders: How organize the clinical framework for community mental health centers
M. Bassi. Dipartimento di Salute Mentale Azienda USL di Bologna, Bologna, Italy
Italian psychiatrists are finding on an increasingly more frequent basis that they must diagnose and treat a particular type of patient. These are not the traditional patients of public mental health services, such as people with psychotic, severe and persistent mental disorders, which these structures have by now been able to pinpoint and to whom they have been able to offer a series of solutions to the problem having to become “responsible” for their care on an intensive or prolonged basis, both in terms of pharmacological and psychosocial treatment. These patients meet with psychiatrists when they are urgently admitted or in the emergency room, whether they are examined at a Community Mental Health Center or in the emergency room of a general hospital in a big city. More frequently, psychiatrists encounter these “new patients” while providing psychiatric consulting services at so-called “borderline areas”. These are patients which have been examined for the first time by services for substance- related disorders, social services for homeless people or health services which are responsible for treating prisoners. The health and social workers which come into contact with these “new patients” soon realize that the difficulties in establishing a relationship in order to help the patient, the impulsivity with frequent return to the negative behavior, and the disturbed, aggressive or frankly antisocial behavior would suggest that these patients should undergo a psychiatric evaluation. In many of these cases, when a request is made for a timely evaluation, psychiatrists find themselves faced with young people, prevalently male, affected by a “impulsive cluster” personality disorder (in the majority of cases a borderline personality disorder or an antisocial personality disorder, which are distinct or in comorbidity), with a history of various duration of substance dependence or abuse, with previous episodes of clear anti-social behavior and consequent problems of a legal or penal nature.
S-06-02
Borderline personality disorder and suicidal attempt: A 3 year follow-up
Y. Bumand, D. Maire. R. Pirrotta, C. Damsa. Geneva, Switzerland
This study was aimed to investigate the long-term outcome of borderline patients with suicidal attempt. Seventy-six patients with DSM IV borderline personality disorder and a self-poisoning severe enough to require intensive medical treatment at the emergency room of the Geneva general Hospital were prospectively follow-up during 3 years. At that occurrence reliable assessment was obtained for 71 of them (93%) on a battery of instruments including GAS scores, suicidal behaviour repetition and service consume. The data indicated fair to good outcome and no suicidal relapse in a large majority of these patients, but a minority of them had persistent patterns of severe suicidal behaviour and poor outcome. In addition, these patients had elevated service consume, high treatment costs and significant work disruption. These results suggest that presence of borderline syndrome has a complex relationship to outcome in those patients requiring emergency medical care for suicidal attempt. The study provides criteria to discriminate borderline patients subgroups requiring low/high dosage of intensive treatment at emergency treatment discharge.
S-06-03
Effective ingredients of psychiatric treatment for borderline patients with suicidal attempt
A. Andreoli, D. Maire, V. D Agostino. Service d'accueil, d'urgences etde liasion psychiatriques, Geneva, Switzerland
To further investigate the effectiveness and cost of combined treatment in borderline patients with suicidal attempt, we investigated four groups of borderline patients that had been assigned to: a) antidepressant medication and supportive case management, b) antidepressant medication and psychodynamic crisis intervention, c) antidepressant medication and psychodynamic psychotherapy, d) treatment as usual. Inclusion criteria were referred to the Geneva general hospital with DSM IV borderline personality disorder and self-poisoning suicidal attempt severe enough to require intensive medical treatment and an age between 20 and 65. The presence of psychotic symptoms, bipolar disorder, severe substance abuse/ dependence and mental retardation were exclusion criteria. Repeated assessment were performed at intake, emergency treatment dis charge (up to one week) and 3-month follow-up. At 3-month follow-up all treatment groups exhibited little drop-out and self damaging behaviour. Those patients with treatment as usual had, however, less adherence to treatment, higher treatment costs and more work disruption. In addition, provision of supplemental psychotherapy (psychodynamic crisis intervention or psychodynamic psychotherapy) was associated with better global functioning and increased adjustment at work. The data indicate that provision of supplemental psychotherapy is cost-effective in borderline patients with suicidal attempt.
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