Although borderline personality disorder (BPD) has been studied more than any other personality disorder, the role of extended hospitalization for adults with BPD is a point of contention among mental health clinicians. Meanwhile, there is a strong consensus that psychotherapy with adjunctive pharmacotherapy as needed is the main evidence-based approach for BPD. This view likely is a result of evidence from high-quality randomized controlled trials supporting the efficacy of outpatient treatment for this patient population, although there is a scarcity of data pertaining to inpatient treatment for individuals with BPD.
The American Psychiatric Association Practice Guideline for the Treatment of Patients With Borderline Personality Disorder suggests that extended hospitalization be considered for patients with BPD under specific circumstances; for example, those with persistent and severe suicidality or comorbid substance abuse or dependence.3 However, this recommendation “appears based on clinical wisdom, to prevent further deterioration or death, rather than based on evidence that extended hospitalization is an effective intervention for individuals diagnosed with BPD,” according to a study published in January 2018 in the Journal of Affective Disorders.
Some experts have even stated that patients with BPD should rarely or never be hospitalized because of the potential for deterioration in functioning, although concerns about iatrogenic effects are not supported by scientific evidence. The importance of elucidating this issue is underscored by estimates that BPD prevalence ranges from 15% to 25% in inpatient settings.2 In addition, BPD is “characterized by emotion dysregulation, impulsivity, self-injurious behavior, and suicidal behavior all of which contribute to the highest emergency and inpatient service utilization of any psychiatric disorder,” the current authors noted.
To further investigate, they explored various outcomes among 245 patients with BPD receiving 2 to 8 weeks of inpatient care at a psychiatric hospital compared with 220 matched patients without BPD who received inpatient care for the same amount of time at the same hospital.
Patients with BPD and non-BPD patients were assigned to the same units and care staff and received the same psychosocial interventions. Treatment was based on a mentalization model intended to reduce symptoms and improve social cognition and emotion regulation.
Participants received an average of 59.4 hours per week of multimodal interventions, including “general psychiatric and medical care, continuous nursing care, medication management to reduce adverse polypharmacy, addictions services, health promotion, physical exercise, individual and group psychotherapy, psychoeducational groups, family work, and leisure-time social/recreational activities,” as described in the paper.
The average length of stay was 40.7 days (standard deviation, 13.9 days) for the entire sample. The 2 patient groups showed similarities in subjective well-being and symptoms of depression and anxiety from intake to discharge (P ≥.232).
The results revealed the following observations:
- Large-effect-size improvements in depression, anxiety, suicidal ideation, and functional disability among patients with BPD (Cohen’s d ≥ 1.0) and non-BPD patient reference sample (Cohen’s d ≥.80).
- Clinical deterioration and adverse events in no more than 1.1% of BPD and non-BPD patients on any outcome, with no difference found across cohorts.
- No influence of BPD diagnosis on the trajectory of continuous depression severity
- An association between trait emotion dysregulation and initial depression severity.
Surprisingly, rates of nonsuicidal self-injury and suicidal behavior, which are diagnostic criteria for BPD, were low. No patient in either group attempted suicide, and the prevalence of nonsuicidal self-injury was 3% for BPD and 1% for the reference group, with no overall differences (χ2=2.7; P =.10). Although the study did not explore underlying mechanisms, the authors propose the low rates may have been attributable to the locked setting, the suicide alert system, and the peer support system in place at the study site.
In addition, although mechanisms of change were beyond the scope of this investigation, certain characteristics of the study setting may have also contributed to the large-effect-size improvements found in BPD inpatients. First, the program offered a “contained and secure environment in which self-defeating and self-destructive behaviors (such as alcohol and drug abuse) were minimized, and medication adherence for both groups was approximately 99% for all standing psychotropic [drugs].” Second, the intensive, mentalization-based approach may be especially suitable for this patient group, as it focused on emotion dysregulation, which is a core BPD feature.
Contrary to long-held beliefs about the utility of extended inpatient treatment for this patient population, the present findings “indicate that extended inpatient treatment can result in significant and clinically meaningful symptomatic and functional improvement in BPD patients without iatrogenic effects,” the authors wrote.
Although this treatment approach may seem to be cost-prohibitive, the authors argued that “this level of care (especially for adults with multiple failed hospitalizations and high degree of psychiatric severity) is less expensive than what third party payors deem to be acceptable costs associated with many medical procedures,” including organ transplantations that cost more than $1 million dollars in the first year of care alone.5 “In light of the high risk of suicide-related behaviors among adults suffering from BPD, the cost prohibitive argument must also be put to an empirical test,” they concluded.
Psychiatry Advisor interviewed Francis M. Mondimore, MD, associate professor of psychiatry and behavioral sciences at Johns Hopkins School of Medicine and director of the Mood Disorders Clinic at Johns Hopkins Bayview Medical Center, Baltimore, Maryland, regarding his take on the topic.
Psychiatry Advisor: What are your thoughts about the findings of this article, and how do they reconcile with your experience with the inpatient treatment of patients with BPD?
Dr Mondimore: The authors present the case for treating patients with BPD on an extended-stay unit with a multidisciplinary staff trained in mentalization, an intervention specifically designed to treat this condition. The results support the efficacy of this intervention. The results of the study are not at all surprising to me. However, the recommendations that the authors are attempting to rebut, that clinicians should strive to avoid hospitalizing patients with BPD, are absolutely true for the vast majority of patients with BPD in the United States. This reason for this is that the specialized program described is vanishingly rare in the United States and is unavailable to most patients.
The modal psychiatric unit in the United States has a length of stay that I would estimate is less than one-fifth that of the unit or units where the study was conducted and is staffed primarily with staff, including psychiatrist staff, who have no specialized training in the treatment of BPD. Because of the brief average length of stay, many patients on these units are acutely ill with psychotic illnesses (schizophrenia, psychotic bipolar disorder, and schizoaffective disorder) and require high-intensity behavioral management and pharmacotherapy. As a consequence, the interventions that staff on these units are trained in and most comfortable with are not helpful in the treatment of patients with BPD.
Most patients with BPD are admitted to units with many psychotic patients, where “take-downs” and therapeutic seclusion of patients are a nearly daily occurrence. The need for attention and reassurance that patients with BPD need becomes a low priority for staff, who often respond to what they perceive as “attention-seeking” behavior with unhelpful “negative reinforcement” interventions such as “one-to-one” monitoring and restricting the patient to the unit, [which means] the patient cannot participate in occupational and recreational therapy sessions.
Needless to say, several days on such units is very counterproductive for these patients, who do indeed tend to regress rather than stabilize. This certainly reflects my experience with them on inpatient units.
Psychiatry Advisor: What are the main takeaways for clinicians?
Dr Mondimore: Patients with BPD benefit from long-term stays on units staffed with professionals who are specialized in the treatment inventions that have proven to be helpful for these patients. Unfortunately, such units are available to only a tiny proportion of the patients who would benefit from them. I noted that one-third of the patients in the study were “self-pay”; that is, they or their family had the financial means to pay their hospital bill out-of-pocket. With a 6-week average stay and an average per diem cost of $1000/day in many psychiatric units, plus physician fees, this means that one-third of the patients in this study could afford to pay around $50,000 for their treatment. Obviously, very few patients are in this position, which partially explains why there are so few of these units in the United States.
Psychiatry Advisor: What should be the focus of future research in this area?
Dr Mondimore: Can lower-cost interventions, such as day-hospital or intensive out-patient treatment, be equally beneficial for patient with BPD? Here at Hopkins Bayview, we have an intensive outpatient program with a focus on treating severe personality disorders by staff who have extensive training and experience in dialectical behavioral therapy, another specialized treatment for BPD. I suspect that this approach is equally effective, at a much lower cost.