Telehealth Partial Hospital Level of Care and Borderline Personality Disorder: Reply to Renn et al

See letter by Renn et al and article by Zimmerman et al

J Clin Psychiatry 2021;82(5):21lr14037a

To cite: Zimmerman M, Terrill D, Ward M, et al. Telehealth partial hospital level of care and borderline personality disorder: reply to Renn et al. J Clin Psychiatry. 2021;82(5):21lr14037a.
To share: https://doi.org/10.4088/JCP.21lr14037a

© Copyright 2021 Physicians Postgraduate Press, Inc.

^aDepartment of Psychiatry and Human Behavior, Brown Medical School, and Department of Psychiatry, Rhode Island Hospital, Providence, Rhode Island
*Corresponding author: Mark Zimmerman, MD, 146 West River St, Providence, RI 02904 (mzimmerman@lifespan.org).

To the Editor: We thank Renn, Chu, and Zaslavsky for their comment¹ on our study comparing the safety, effectiveness, and acceptability of telehealth and in-person partial hospital level of care.² We understand their concerns about providers’ hesitancy to provide telehealth treatment to patients with more severe psychopathology such as psychotic disorders and personality disorders because concern about safely treating acutely ill patients who were at high risk for self-harm was one of the motivations for conducting our study. Our group discussed at length the safety precautions we believed necessary to mitigate risk because at least half of our patients report the presence of suicidal ideation during the week prior to admission into our program, and more than one-quarter of the patients in our program are diagnosed with borderline personality disorder. We also treat patients with psychosis, though fewer than 5% of the patients in our program are diagnosed with a psychotic disorder.

While reviews of the research literature suggest that telehealth treatment is generally acceptable, feasible, and comparable to in-person mental health services, most studies have been on patients with single disorders, and many studies exclude patients with suicidal thoughts. We are not aware of any published studies of telehealth treatment of patients with borderline personality disorder, perhaps because of concerns about the risk of self-harm and suicidal behavior.

The diagnostic features of borderline personality disorder include intense fluctuating emotions, impulsivity, unstable relationships, excessive anger, self-injury, and suicidality.³ Patients with borderline personality disorder are high utilizers of mental health services and are frequently hospitalized because of safety concerns.^4–6 Clinicians’ concerns about the risk of self-harm and suicidality may well contribute to the hesitancy described by Renn et al¹ to treat patients with personality disorders by telehealth. As inpatient hospitalization is not a solution for long-term suicide prevention in BPD, and can inadvertently often lead to additional negative outcomes,⁷ partial hospital programs represent an ideal alternative for structured activity, risk management, and psychological treatment.

In a follow-up analysis to our initial study, we compared the safety, effectiveness, and acceptability of virtual and in-person partial hospital care of patients with borderline personality disorder.⁸ The virtual treatment group included 64 patients with BPD who were treated for the first time in the Rhode Island Hospital partial hospital program. The in-person group included 117 patients with BPD who were treated 1 year earlier during the same months of the year. Both treatment groups reported a significant reduction in symptoms from admission to discharge and reported a significant improvement in functioning, coping ability, positive mental health, and general well-being. A large effect size of treatment was found in both treatment groups, and there was little difference in the effect sizes found in the telehealth and in-person groups.

We plan to continue delivering partial hospital level of care virtually for the foreseeable future. As we noted in our original article,² several patients whom we treated virtually indicated that medical illness and transportation difficulties would have precluded in-person treatment even if there were no pandemic. Thus, telehealth treatment increases access to care.

Telehealth medicine may also increase access to expert care. Clinical programs with experience and expertise in treating borderline personality disorder may be able to expand the availability of treatment beyond their immediate geographical area by utilizing a telehealth platform. To be sure, licensing and regulatory issues will require attention.

Renn et al¹ called attention to providers’ perceptions of the appropriateness of telehealth for certain patient populations including personality disorders. Mental health professionals’ negative attitudes toward patients with borderline personality disorder have been repeatedly reported in surveys conducted over the past 40 years.^9–14 Thus, perceptions have been difficult to change. For those clinicians who are concerned about treating patients with borderline personality disorder, we welcome the referral of these patients to our partial hospital program.

Published online: August 17, 2021.
Potential conflicts of interest: None.
Funding/support: None.