To determine whether ambulatory psychotherapy targeted to abandonment experiences and fears can reduce suicidality and improve outcome in borderline patients referred to the emergency room with major depressive disorder and self-destructive behavior severe enough to require medical/ surgical treatment and a brief psychiatric hospitalization. A total of 170 subjects were randomized at hospital discharge into three treatment groups: treatment as usual (TAU), abandonment psychotherapy delivered by certified psychotherapists, and abandonment psychotherapy delivered by nurses. Assessments were performed before randomization and at 3-month followup. Continued suicidality and other outcome measures were significantly worse in the treatment-as-usual as compared to both abandonment psychotherapy groups, but there were no differences between the two psychotherapy groups. These results suggest the efficacy of manualized psychotherapy that specifically targets the abandonment fears and experiences that are so common as precipitants to suicidal and self-destructive acts in borderline patients. It does not appear that formal psychotherapy training is associated with better outcomes.

Background:Psychoanalytic psychotherapy was found superior to usual treatment among borderline patients and should be further investigated in subject samples with adequate adherence to effective treatment and careful evaluation of psychotherapy process and its relationship to outcome. According to this rationale we tested the comparative cost-effectiveness of an innovative model of time limited psychoanalytic psychotherapy aimed at working-out conflicting mourning process associated with traumatic abandonment from a romantic partner.Methods:Eighty patients aged 18-60, who had been referred to medical emergency room with self-intoxication, DSMIV-R major depression and DSMIV-R borderline personality disorder were investigated in a 3-month randomized clinical trial. At general hospital discharge consecutive subjects were allocated to time-limited mourning focused psychoanalytic psychotherapy and venlafaxine and psychodynamic crisis intervention and venlafaxine. Reliable evaluations were conducted at intake, treatment discharge and 6-month follow-up on a battery of standardized instruments. Service consume was assessed via the computerized case register of the Geneva state health services system.Results:Intensive psychoanalytic psychotherapy was found a cost-effective treatment choice among borderline patients in a suicidal crisis.Comment:A combination of ambulatory psychoanalytic psychotherapy and venlafaxine protocol is a feasible, safe and cost-effective treatment for acutely suicidal borderline patients.

trial of patient flow and treatment assignment at emergency room discharge over 1-month, we implemented a consensual diagnostic and treatment decision manual. Then, an educational program aimed to improve the understanding of the reliability of treatment decision among the psychiatric staff of the emergency room. In short, a substantial proportion of psychiatric patients with suicide attempt did not receive adequate treatment assignment at discharge and the presence of a clinical diagnosis of borderline personality disorder was a factor of even more unpredictable treatment choice. This is an issue of great need and potential impact since medical decisions often appeared to favour either treatment that are more expensive or treatments that are at increased risk of completed suicide. Further steps of the data analyses aimed to clarify the impact of better quality assurance on the reliability of treatment decision are under scrutiny and will be discussed.

Backgrounds and Aims:We assessed the efficiency and costs of an innovative emergency service focusing on specialized evaluation and intensive treatment for the new acute mental patient.Methods:A computerized register provided continuous evaluation of the impact of the new unit on the global patient flows in a 500.000 inhabitants catchment area during 5 years. Furthermore, we carefully assessed the all population treated at the emergency room and the subpopulation population assigned to crisis intervention at the General hospital at emergency room discharge during 2-months. The efficiency and costs were investigated with: a) pre-post analyses (global flows), b)assessing the reliability of decision processes according to pre-established decision guidelines.Results:Well integrated, diagnostic assessment, acute treatment and crisis intervention for the new acute mental appeared to dramatically improve the efficiency of a large system of community psychiatry services.Comment:The study suggests that the emergency treatment of the new acute mental patient deserves more study.