Influence of therapist competence and quantity of cognitive behavioural therapy on suicidal behaviour and inpatient hospitalisation in a randomised controlled trial in borderline personality disorder: further analyses of treatment effects in the BOSCOT study

Abstract

Objectives: We investigated the treatment effects reported from a high-quality randomized controlled trial of cognitive behavioural therapy (CBT) for 106 people with borderline personality disorder attending community-based clinics in the UK National Health Service - the BOSCOT trial. Specifically, we examined whether the amount of therapy and therapist competence had an impact on our primary outcome, the number of suicidal acts, using instrumental variables regression modelling.

Design: Randomized controlled trial. Participants from across three sites (London, Glasgow, and Ayrshire/Arran) were randomized equally to CBT for personality disorders (CBTpd) plus Treatment as Usual or to Treatment as Usual. Treatment as Usual varied between sites and individuals, but was consistent with routine treatment in the UK National Health Service at the time. CBTpd comprised an average 16 sessions (range 0-35) over 12 months.

Method: We used instrumental variable regression modelling to estimate the impact of quantity and quality of therapy received (recording activities and behaviours that took place after randomization) on number of suicidal acts and inpatient psychiatric hospitalization.

Results: A total of 101 participants provided full outcome data at 2 years post randomization. The previously reported intention-to-treat (ITT) results showed on average a reduction of 0.91 (95% confidence interval 0.15-1.67) suicidal acts over 2 years for those randomized to CBT. By incorporating the influence of quantity of therapy and therapist competence, we show that this estimate of the effect of CBTpd could be approximately two to three times greater for those receiving the right amount of therapy from a competent therapist.

Conclusions: Trials should routinely control for and collect data on both quantity of therapy and therapist competence, which can be used, via instrumental variable regression modelling, to estimate treatment effects for optimal delivery of therapy. Such estimates complement rather than replace the ITT results, which are properly the principal analysis results from such trials.

Figure 1

Time to first suicidal act, omitting the first 180 days post randomization.

Figure 2

Time to first Inpatient hospitalization – in the first 180 days.

Figure 3

Boxplots of Cognitive Therapist Rating Scale by Therapist. Data shown are minimum and maximum (dotted box), interquartile range (yellow box), median (solid dot), and mean (open dot).

Figure 4

Mean number of suicidal acts (in the previous 6-month period) by randomized treatment group.

Figure 5

Suicidal acts per year by number of sessions taken.

Figure 6

Suicidal acts per year by therapist competence.

Figure 7

Suicidal acts by therapist competence and sessions attended.