TORONTO – In patients hospitalized for borderline personality disorder (BPD) and other complex psychiatric disturbances, symptoms of depression and emotional dysregulation continue to progressively improve over several weeks. But at 1 week, the improvement is minimal, which is an issue given that the average psychiatric hospitalization in the United States is only 5 to 7 days.
“So more time [in the hospital] may be something that we have to lobby for,” Dr. John M. Oldham said during a talk at the American Psychiatric Association (APA) annual meeting.
Dr. Oldham showed preliminary results from the Menninger Clinic’s Hospital-Wide Outcomes Project as part of a longer discussion on the current state of personality disorders research. Dr. Oldham is chief of staff and senior vice president at Menninger in Houston. He also is an internationally recognized specialist in personality disorders and a past president of the APA. There is a “fair drumbeat” in the literature and in clinical circles suggesting long hospitalizations should be avoided in BPD patients, because the illness tends to be associated with regression.
“Well, I think that’s good advice, if you can get away with it,” Dr. Oldham said. Unfortunately, some patients will need longer term hospitalization for refractory symptoms, persistent or severe suicidality, self-destructiveness, or nonadherence to treatment, among other indications.
At the Menninger Clinic, all patients are administered structured psychiatric interviews (e.g., the Structured Clinical Interview for DSM-IV Axis I Disorders [SCID-I] and the Structured Clinical Interview for DSM-IV Axis II Disorders [SCID-II] at admission, as well as a battery of self-report tests that provide objective data on clinical symptoms, level of functioning, interpersonal relationships, and treatment progress and process (working relationships with treatment team members and treatment engagement). Symptom and functional assessments are repeated every 2 weeks during hospitalization. Patients are asked to complete a similar battery of self-report measures 2 weeks after discharge and then every 3 months after that for 18 months. More than 1,600 patients have participated in the study since it began in 2008.
“We have an unusual, unique opportunity to do this work, because our average length of stay at the Menninger Clinic for an inpatient is 45 days, which is very unusual in hospital psychiatry these days,” Dr. Oldham said.
“There’s only one way we can do it, and that is that 80% of our patients are self-pay, so [we’re looking at] a layer of a higher socioeconomic bracket because the insurance companies will not pay for longer care.”
The hope of the Menninger investigators is to use their data to make the case that for some patients – and many of the Menninger patients “have not been able to get better with the usual available treatment” – that it’s cost effective to treat these difficult cases for significantly longer periods in hospital.
Progressively reduced symptoms
The Menninger data so far include 255 patients with BPD and 1,129 patients without BPD, and these numbers are steadily increasing. Dr. Oldham explained that the many of the 1,129 non-BDP patients have complex conditions that are generally a mood disorder and an underlying personality disorder and “almost always” a substance abuse issue, too.
In preliminary data shown by Dr. Oldham, the self-administered Patient Health Questionnaire-9 (PHQ-9) depression severity scale is high in both groups on admission, ranking as “severe” in the BPD group and “moderate” in the non-BPD arm.
At 1 week – the length of a usual hospitalization – the BPD patients have dropped to moderate on the scale, and the non-BDP patients to mild, but after 6 weeks, both groups have dropped further on the scale such that the BPD patients have only mild symptoms and the non-BDP patients are approaching normal levels of depressed affect.
“At the 1-week mark … you can see that the patient is a little bit better but not that much,” Dr. Oldham reported.
Also, in the same sample of patients and using a validated scale measuring difficulty in emotional regulation, both BPD and non-BPD patients are very emotionally dysregulated on admission, albeit BPD patients more so.
After several weeks, the non-borderline patients are in the normal range and the BPD patients are “still not in the normal range, but they are doing much better.”
“Even though almost all of our patients get better, there are some patients who don’t respond even at this level of intensive treatment,” Dr. Oldham concluded, saying that his group also is looking at biomarkers, neuroimaging data, genomics, and the microbiome in an attempt to gain a better understanding of major psychiatric disorders.