Academic journal article New Zealand Journal of Psychology

The Impact of Brief Planned Admissions on Inpatient Mental Health Unit Utilisation for People with a Diagnosis of Borderline Personality Disorder

Academic journal article New Zealand Journal of Psychology

The Impact of Brief Planned Admissions on Inpatient Mental Health Unit Utilisation for People with a Diagnosis of Borderline Personality Disorder

Article excerpt

People with a diagnosis of Borderline Personality Disorder (BPD) are high users of inpatient mental health facility resources, often having both frequent and lengthy admissions. However, lengthy admissions are often regarded as sub-optimal and may be contra-indicated. This study assessed the impact of a Brief Planned Admission (BPA) approach on inpatient mental health resource use by people with a diagnosis of BPD. Inpatient service use (admissions per year and inpatient days per year) before and after introduction of BPA approach was determined for clients with a diagnosis of BPD for whom the BPA approach was used in one inpatient unit. These results were compared to a matched sample of clients of a similar inpatient unit in which BPAs were not used. The BPA group showed a dramatic decrease in days of hospitalisation per year after the introduction of BPAs compared to the control group. Both groups showed a small decrease in the number of post-BPA admissions per year, with no significant difference between the two. While relatively little outcome information is available, some data suggests that use of BPAs did not diminish the outcome or engender client dissatisfaction. These results suggest that use of BPAs may be an effective strategy for reducing sub-optimal use of inpatient resources by people with BPD, and is acceptable to both clients and staff.

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Clients diagnosed with borderline personality disorder (BPD) are frequent consumers of mental health services (Surber, et al., 1987), and have been found to be high users of inpatient facilities (Kent, Fogarty, & Yellowlees, 1995; Williams et al., 1998). Clients with BPD account for approximately 15% of acute admissions to psychiatric units and have higher rates of mental health utilisation compared with most other mental health consumers (Swartz, et al., 1990). Clients with a diagnosis of BPD are likely to have longer hospital admissions than most other groups (Williams et al., 1998). Krawitz and Watson (2000) described a group of "high service using" BPD clients who had an average annual hospitalisation 139.2 days/client year. Perry (1997) reported a sample of BPD clients with an average hospitalisation of 56.6days/client per year. BPD clients are also less likely to successfully remain in the community for an extended period after discharge (i.e., experience the "revolving door" phenomenon) (Williams et al., 1998).

Despite their high rate of hospitalisation, studies have found that for those diagnosed with BPD, extended hospitalisation may be iatrogenic (Krawitz & Watson, 2000), and is associated with a number of risks (Miller, 1989; Nehls, 1994). These includes an increase in self-harm behaviour, power struggles with staff, increased dependency on mental health services, reduction of taking responsibility for own behaviour, and the "revolving door" problem. The focus on crisis management that frequently is the 'strength of inpatient facilities can reinforce maladaptive and recovery-inhibiting behaviours rather than promoting an effective outcome (Krawitz & Watson, 2000). To avoid such difficulties, Williams (1998), in her personal account of having BPD, strongly recommended that hospitalisation be for no more than 48 hours, and focus on reducing symptoms related to a current crisis. Thus, while short hospital stays may be a valuable management strategy in conjunction with comprehensive community outpatient management services, extended stays are frequently counterproductive.

One approach consistent with the research above and which provides an alternative to long stay care is the use of Brief Planned Admissions (BPAs) (Bryson et al., 1998; Nehls, 1994; Silk et al., 1994). The underlying philosophy is for the client to view hospitalisation as a partnership between the client and the staff, aimed at a quick return to the community. BPAs aim to empower clients to be in charge of their treatment, avoid power struggles with clinicians, and for hospitalisations to be a form of intensive respite and time-out, as opposed to a place of 'treatment'. …

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