Review of Benefits and Harms, Patient Preferences, Other Practice Guidelines, and Quality Measurement Considerations
Appendix F
Use of Guidelines to Enhance Quality of Care
Clinical practice guidelines can help enhance quality by synthesizing available research evidence and delineating recommendations for care on the basis of the available evidence. In some circumstances, practice guideline recommendations will be appropriate to use in developing quality measures. Guideline statements can also be used in other ways, such as educational activities or electronic decision support, to enhance the quality of care that patients receive. Furthermore, when availability of services is a major barrier to implementing guideline recommendations, improved tracking of service availability and program development initiatives may need to be implemented by health organizations, health insurance plans, federal or state agencies, or other regulatory programs.
Typically, guideline recommendations that are chosen for development into quality measures will advance one or more aims of the Institute of Medicine’s (2001) report Crossing the Quality Chasm by facilitating care that is safe, effective, patient-centered, timely, efficient, and equitable. To achieve these aims, quality measures (Watkins et al. 2015) are needed that span the continuum of care (e.g., prevention, screening, assessment, treatment, continuing care), address the different levels of the health system hierarchy (e.g., system-wide, organization, program/department, individual clinicians), and include measures of different types (e.g., process, outcome, patient-centered experience). Emphasis is also needed on factors that influence the dissemination and adoption of evidence-based practices (Drake et al. 2008; Greenhalgh et al. 2004; Horvitz-Lennon et al. 2009a).
Often, quality measures will focus on gaps in care or on care processes and outcomes that have significant variability across specialties, health care settings, geographical areas, or patients’ demographic characteristics. Administrative databases, registries, and data from electronic health record (EHR) systems can help to identify gaps in care and key domains that would benefit from performance improvements (Acevedo et al. 2015; Patel et al. 2015; Watkins et al. 2016). Nevertheless, for some guideline statements, evidence of practice gaps or variability will be based on anecdotal observations if the typical practices of psychiatrists and other health professionals are unknown. Variability in the use of guideline-recommended approaches may reflect appropriate differences that are tailored to the patient’s preferences, treatment of co-occurring illnesses, or other clinical circumstances that may not have been studied in the available research. On the other hand, variability may indicate a need to strengthen clinician knowledge or to address other barriers to adopting best practices (Drake et al. 2008; Greenhalgh et al. 2004; Horvitz-Lennon et al. 2009a). When performance is compared among organizations, variability may reflect a need for quality improvement initiatives to improve overall outcomes but could also reflect case-mix differences such as socioeconomic factors or the prevalence of co-occurring illnesses.
Conceptually, quality measures can be developed for purposes of accountability, for internal or health system–based quality improvement, or both. Accountability measures require clinicians to report their rate of performance of a specified process, intermediate outcome, or outcome in a specified group of patients. Because these data are used to determine financial incentives or penalties based on performance, accountability measures must be scientifically validated, have a strong evidence base, fill gaps in care, and be broadly relevant and meaningful to patients, clinicians, and policy makers. Development of such measures is complex and requires development of the measure specification and pilot testing (Center for Health Policy/Center for Primary Care and Outcomes Research and Battelle Memorial Institute 2011; Fernandes-Taylor and Harris 2012; Iyer et al. 2016; Pincus et al. 2016; Watkins et al. 2011). The purpose of the measure specification is to create detailed, clearly written, and precise instructions on the calculation of the measure so that, when implemented, the measure will be consistent, reliable, and effective in addressing quality in a specific target population (Centers for Medicare and Medicaid Services 2023). In contrast, internal or health system–based quality improvement measures are typically designed by and for individual providers, health systems, or payers. They typically focus on measurements that can suggest ways for clinicians or administrators to improve efficiency and delivery of services within a particular setting. Internal or health system–based quality improvement programs may or may not link performance with payment, and, in general, these measures are not subject to strict testing and validation requirements.
Regardless of the purpose of the quality measure, it must be possible to define the applicable patient group (i.e., the denominator) and the clinical action or outcome of interest that is measured (i.e., the numerator) in validated, clear, and quantifiable terms. The measure also needs to be feasible. More specifically, the health system’s or clinician’s performance on the measure must be readily ascertained from chart review, patient-reported outcome measures, registries, or administrative data. In addition, use of the measure should yield improvements in quality of care to justify any clinician burden (e.g., documentation burden) or related administrative costs (e.g., for manual extraction of data from charts, for modifications of EHRs to capture required data elements).
Documentation of quality measures can be challenging, and, depending on the practice setting, can pose practical barriers to meaningful interpretation of quality measures based on guideline recommendations. For example, when recommendations relate to patient assessment or treatment selection, clinical judgment may need to be used to determine whether the clinician has addressed the factors that merit emphasis for an individual patient. In other circumstances, standardized instruments can facilitate quality measurement reporting, but it is difficult to assess the appropriateness of clinical judgment in a validated, standardized manner. Furthermore, utilization of standardized assessments remains low (Fortney et al. 2017), and clinical findings are not routinely documented in a standardized format. Many clinicians appropriately use free text prose to describe symptoms, response to treatment, discussions with family, plans of treatment, and other aspects of care and clinical decision-making. Reviewing these free text records for measurement purposes would be impractical, and it would be difficult to hold clinicians accountable to such measures without advances in natural language processing technology and further increases in EHR use among mental health professionals.
Possible unintended consequences of any measures would also need to be addressed in testing the measure specifications within a variety of practice settings. For example, in many health care systems, multiple clinicians are involved in the care of a patient, and it is misleading if performance on the measure is attributed to the performance of a single clinician or group of clinicians. As another challenge, if the measure specification requires precise wording for the measure to be met, clinicians may begin to document using standardized language that does not accurately reflect what has occurred in practice. If multiple discrete fields are used to capture information, data will be easily retrievable and reportable, but oversimplification is a possible unintended consequence of measurement, and documentation burden is likely to be high (Johnson et al. 2021). Just as guideline developers must balance the benefits and harms of a particular guideline recommendation, developers of performance measures must weigh the potential benefits, burdens, and unintended consequences of optimizing quality measure design and testing.
Assessment and Determination of Treatment Plan
Statement 1 – Initial Assessment
APA recommends (1C) that the initial assessment of a patient with possible borderline personality disorder include the reason the individual is presenting for evaluation; the patient’s goals and preferences for treatment; a review of psychiatric symptoms, including core features of personality disorders and common co-occurring disorders; a psychiatric treatment history; an assessment of physical health; an assessment of psychosocial and cultural factors; a mental status examination; and an assessment of risk of suicide, self-injury, and aggressive behaviors, as outlined in APA’s Practice Guidelines for the Psychiatric Evaluation of Adults, 3rd Edition.
Benefits
Assessment of current and prior symptoms and previous treatment are beneficial for verifying that BPD is present and for identifying its severity and longitudinal course. Knowledge of the patient’s current symptoms and functioning provides important baseline data for assessing the severity of the clinical presentation and effects of subsequent interventions. Assessment of risk factors, including risk of suicide, self-injury, and aggressive behaviors, is essential to developing a plan of treatment and determining an optimal treatment setting. Similarly, identification of co-occurring disorders and determination of the patient’s goals and preferences for treatment will aid in the development of a comprehensive treatment plan.
Harms1
The harms of a detailed initial assessment are not well studied but are expected to be small, if any. It is possible that time used to focus on a detailed assessment could reduce time available to address other issues of importance to the patient or of relevance to diagnosis and treatment planning. Some individuals may have difficulty concentrating or may become frustrated if asked multiple questions during the evaluation. This could interfere with the therapeutic relationship between patient and clinician.
Patient Preferences
Although there is no specific evidence on patient preferences related to assessment in individuals with BPD, clinical experience suggests that most patients are cooperative with and accepting of these types of questions as part of an initial assessment.
Balancing of Benefits and Harms
The potential benefits of this guideline statement were viewed as far outweighing the potential harms. This recommendation is also consistent with the APA’s Practice Guidelines for the Psychiatric Evaluation of Adults, 3rd Edition (American Psychiatric Association 2016a). The level of research evidence is rated as low because there is minimal research on the benefits and harms of assessing these aspects of history and examination as part of an initial assessment of a patient with BPD. Nevertheless, expert opinion suggests that conducting such assessments as part of the initial psychiatric evaluation improves diagnosis and treatment planning in individuals with BPD. For additional details, see the aforementioned practice guidelines. For additional discussion of the research evidence, see Appendix C, Statement 1.
Differences of Opinion Among Writing Group Members
There were no differences of opinion. The writing group voted unanimously in favor of this recommendation.
Review of Available Guidelines from Other Organizations
Other organizations’ practice guidelines typically assume that an evaluation has occurred and that a diagnosis of BPD has been made. The National Institute for Health and Care Excellence (NICE; 2009) guideline also notes the importance of assessing comorbid mental disorders, social problems, psychosocial and occupational functioning, coping strategies, strengths and vulnerabilities, risks to self and others, and needs for psychological treatment, social care and support, occupational rehabilitation or development, and assistance addressing needs of dependent children.
Quality Measurement Considerations
A detailed initial assessment of individuals with possible BPD is essential to verifying a diagnosis and establishing a comprehensive, patient-centered treatment plan. Nevertheless, it would be challenging to incorporate this recommendation into a performance-based quality measure given the breadth of content areas being assessed and the difficulty in ascertaining evaluation details from clinical charts or administrative data. However, quality-related efforts at the local level could assess whether EHR templates include prompts for documenting key elements of the assessment and whether such aspects of the evaluation are typically completed, while still allowing flexibility in the documentation of findings.
Statement 2 – Quantitative Measures
APA suggests (2C) that the initial psychiatric evaluation of a patient with possible borderline personality disorder include a quantitative measure to identify and determine the severity of symptoms and impairments of functioning that may be a focus of treatment.
Benefits
Use of a quantitative measure as part of the initial evaluation can have a number of benefits by establishing baseline information on the patient’s symptom severity and associated impairment. As compared with a clinical interview, use of a quantitative measure may improve the consistency with which this information is obtained. When administered through paper-based or electronic self-report, use of quantitative measures may allow routine questions to be asked more efficiently. When used on a longitudinal basis, quantitative measures can minimize recall bias and help to determine whether treatment is having its intended effect or whether a shift in the treatment plan is needed to address symptoms, treatment-related side effects, level of distress, functioning impairments, or potential for harm to the patient or others. Ongoing use of quantitative assessments may also foster identification of residual symptoms or impairments and facilitate communication among treating clinicians.
Harms
The harms of using a quantitative measure include the time required for administration and review. Overreliance on quantitative measures may lead to overlooking other aspects of the patient’s symptoms and clinical presentation. Patients may also provide inaccurate information about their symptoms, such as minimizing symptom severity or frequency, leading to an underestimation of severity of illness. Reliance on inaccurate information can have a negative impact on clinical decision-making, including recommendations for treatment. Some patients may view quantitative measures as impersonal or may feel frustrated by having to complete detailed questionnaires, resulting in possible straining of patient-clinician rapport. Changes in the workflow of clinical practices and adjustments in staffing may be needed to incorporate quantitative measures into routine care. Modification of EHRs or use of other technologies may also be required to facilitate capture of quantitative measure data.
Patient Preferences
Clinical experience suggests that most patients are cooperative with and accepting of quantitative measures as part of an initial or subsequent assessment. Most patients will be able to appreciate the ways in which the use of quantitative measures will benefit them. For example, in the testing of the DSM-5 Cross-Cutting Symptom Measure as part of the DSM-5 field trials, quantitative measures were found to be acceptable to patients (Clarke et al. 2014; Moscicki et al. 2013), and only a small fraction of individuals felt that measurement of symptoms would not be helpful to their treating clinician (Moscicki et al. 2013). The fact that the clinician is using a systematic approach to address the patients’ symptoms and functioning may send a positive message that could improve the therapeutic relationship. Especially in developed countries, patients are used to and expect digital, computerized information exchange, including for health-related monitoring and communication. For these patients, the use of quantitative measures within the context of an EHR, mobile application, or other computerized technology may be more convenient.
Balancing of Benefits and Harms
The potential benefits of this guideline statement were viewed as likely outweighing the potential harms. Quantitative measures of BPD symptoms have been used primarily in research settings, and no specific scale for rating BPD symptoms can be recommended over another. Nonetheless, expert opinion suggests that the use of quantitative measures in the assessment of patients with BPD could enhance clinical decision-making and improve treatment outcomes. This statement is also consistent with Guideline VII, “Quantitative Assessment,” in APA’s Practice Guidelines for the Psychiatric Evaluation of Adults, 3rd Edition (American Psychiatric Association 2016a). Although quantitative measures have been used for reporting purposes as well as research, the level of research evidence for this recommendation is rated as low because it remains unclear whether routine use of these scales in clinical practice improves overall outcomes. For additional discussion of the research evidence, see Appendix C, Statement 2.
Differences of Opinion Among Writing Group Members
There were no differences of opinion. The writing group voted unanimously in favor of this recommendation.
Review of Available Guidelines From Other Organizations
Other organizations’ practice guidelines do not comment on the use of a quantitative measure, per se. However, several guidelines suggest that assessment include use of a structured or semistructured clinical interview that focuses on diagnosis of personality disorders (Simonsen et al. 2019).
Quality Measurement Considerations
As a suggestion, this guideline statement is not appropriate for use as a performance-based quality measure or for incorporation into electronic decision support.
Statement 3 – Treatment Planning
APA recommends (1C) that a patient with borderline personality disorder have a documented, comprehensive, and person-centered treatment plan.
Benefits
Development and documentation of a comprehensive, person-centered treatment plan ensures that the clinician has considered available treatment options in the context of individual patient needs, with a goal of improving overall outcome. It may also assist in forming a therapeutic relationship, eliciting patient preferences, permitting education about possible treatments, setting expectations for treatment, and establishing a framework for shared decision-making. Documentation of a treatment plan also promotes accurate communication among all those caring for the patient and can serve as a reminder of prior discussions about treatment.
Harms
The potential harms from this recommendation relate to the time spent in discussion and documentation of a comprehensive treatment plan that may reduce the opportunity to focus on other aspects of the evaluation.
Patient Preferences
Clinical experience suggests that patients are cooperative with and accepting of efforts to establish treatment plans, particularly when they are patient centered.
Balancing of Benefits and Harms
The potential benefits of this guideline statement were viewed as far outweighing the potential harms. The level of research evidence is rated as low because no information is available on the harms of a comprehensive, person-centered treatment plan. There is also minimal research on whether developing and documenting a specific treatment plan improves outcomes as compared with assessment and documentation as usual. However, indirect evidence, including expert opinion, supports the benefits of comprehensive treatment planning. For additional discussion of the research evidence, see Appendix C, Statement 3.
Differences of Opinion Among Writing Group Members
There were no differences of opinion. The writing group voted unanimously in favor of this recommendation.
Review of Available Guidelines from Other Organizations
The NICE guideline recommends development of comprehensive multidisciplinary care plans that include crisis planning, short-term treatment aims, approaches to management of comorbidities, and identification of long-term goals (National Institute for Health and Care Excellence 2009). The NICE and National Health and Medical Research Council guidelines also describe general aspects of treatment of BPD patients that are of relevance to treatment planning (National Health and Medical Research Council 2012; National Institute for Health and Care Excellence 2009).
Quality Measurement Considerations
It is not known whether psychiatrists and other mental health professionals typically document a comprehensive and person-centered treatment plan, and there is likely to be variability. A quality measure could be developed to assess for the presence or absence of text in the medical record that would reflect treatment planning; however, clinical judgment would still be needed to determine whether a documented treatment plan is comprehensive and adapted to individual needs and preferences. Manual review of charts to evaluate for the presence of such a person-centered treatment plan would be burdensome and time-consuming to implement. Nevertheless, EHR note templates could include prompts to foster documentation of a patient-centered treatment plan, and local programs could engage in quality-related initiatives to improve aspects of treatment planning.
Statement 4 – Discussion of Diagnosis and Treatment
APA recommends (1C) that a patient with borderline personality disorder be engaged in a collaborative discussion about their diagnosis and treatment, which includes psychoeducation related to the disorder.
Benefits
Use of psychoeducation in patients with BPD has not been associated with a benefit in small non-representative research studies, but expert opinion suggests that disclosure of diagnosis and associated psychoeducation are beneficial to patients.
Harms
The harms of psychoeducation are likely to be minimal on the basis of results from clinical trials in other psychiatric disorders that show no differences in the rate of harms experienced by individuals treated with psychoeducation as compared with usual care. It is possible that some individuals will not wish to know or would become upset by learning of their diagnosis, but this risk can be mitigated by collaborative and empathic discussion that includes the benefits of treatment.
Patient Preferences
Disclosure and discussion of a diagnosis of BPD is typically preferred by patients (Sulzer et al. 2016), and patients feel that it helps them be more informed about treatment options (Proctor et al. 2021). In addition, clinical experience suggests that most patients are interested in receiving information about their diagnosis and potential treatments as part of their care as well as being accepting of more formal and systematic approaches to psychoeducation. However, some patients may not wish to participate in psychoeducation or may experience logistical barriers (e.g., time, access to transportation, childcare, costs) in attending psychoeducation sessions.
Balancing of Benefits and Harms
The potential benefits of this guideline statement were viewed as far outweighing the potential harms. Although patient preferences may differ, any minimal harms of psychoeducation or disclosure of diagnostic information seem to be outweighed by potential benefits of understanding BPD and its treatment. For additional discussion of the research evidence, see Appendix C, Statement 4.
Differences of Opinion Among Writing Group Members
There were no differences of opinion. The writing group voted unanimously in favor of this recommendation.
Review of Available Guidelines from Other Organizations
Two guidelines from other organizations also emphasize the importance of disclosing the diagnosis of BPD to the patient and providing psychoeducation, with a particular emphasis on the availability of effective treatment (National Health and Medical Research Council 2012; National Institute for Health and Care Excellence 2009).
Quality Measurement Considerations
This guideline statement may not be appropriate for a performance-based quality measure because of the diversity of psychoeducational approaches and services. In addition, providing information about the diagnosis of BPD and its treatment will likely span multiple visits. Furthermore, documentation of diagnostic disclosure and psychoeducation will typically occur in free text notes, which are difficult to track for quality measurement purposes. Reminders about psychoeducation are also not well suited to incorporation into EHR clinical decision support. However, health organizations and health plans may wish to implement quality improvement efforts to increase diagnostic disclosure and psychoeducation among individuals with BPD.
Psychosocial Interventions
Statement 5 – Psychotherapy
APA recommends (1B) that a patient with borderline personality disorder be treated with a structured approach to psychotherapy that has support in the literature and targets the core features of the disorder.
Benefits
Use of psychotherapy in the treatment of BPD is associated with improvements in functioning and reductions in BPD severity, general psychopathology, depression, impulsivity, and suicidal and other self-harming behaviors, although different psychotherapies show different patterns of treatment benefits (moderate strength of research evidence).
Harms
The harms of psychotherapy in the treatment of BPD are not well reported in the literature. However, the harms of an effective psychotherapy delivered by a well-trained and well-supervised psychotherapist appear to be small. In contrast, the use of a psychotherapy that lacks demonstrated benefits in BPD could prevent individuals from receiving effective psychotherapy in a timely fashion, thereby influencing prognosis. Other harms of psychotherapy have been noted in individual circumstances when an evidence-based therapy is not delivered in a rigorous and systematic fashion. Such harms may result from boundary violations, alienation from support systems, apparent recollection of false memories, and undue dependency on psychotherapy, among other iatrogenic harms. In patients who have experienced prior trauma, intense or premature exploration of these experiences can increase patient distress, exacerbate symptoms, and disrupt the therapeutic relationship.
Patient Preferences
Clinical experience suggests that most patients are accepting of psychotherapy as part of a treatment plan. A meta-analysis of patient treatment preferences among individuals with a psychiatric disorder suggests a preference for psychotherapy over pharmacotherapy, with this preference being more pronounced among females and younger individuals (McHugh et al. 2013). However, patients also may have concerns about treatment cost or geographical availability that would influence their choice of psychotherapeutic approaches. In addition, some patients may prefer one type of psychotherapy over another based on personal experience or knowledge about a specific approach. Other patient and clinician factors may affect the therapeutic relationship and may also influence patient preferences.
Balancing of Benefits and Harms
The potential benefits of this statement were viewed as far outweighing the potential harms. For additional discussion of the research evidence, see Appendix C, Statement 5. It was recognized that several psychotherapies have demonstrated efficacy in BPD. The harms of these treatments are not well studied but seem small when treatment is provided by well-trained professionals using a rigorous evidence-based therapy. However, no single psychotherapy can be recommended over other effective psychotherapies in BPD. In addition, efficacies overlap among treatments, and the effects of treatment vary for different outcomes. Furthermore, patient preferences for specific therapies may differ, and additional research evidence may influence our knowledge of effective psychotherapies for this condition. Thus, in balancing of benefits and harms, the guideline statement focuses on the use of an effective evidence-based psychotherapy for BPD rather than a specific psychotherapeutic modality.
Differences of Opinion Among Writing Group Members
There were no differences of opinion. The writing group voted unanimously in favor of this recommendation.
Review of Available Guidelines from Other Organizations
Other organizations’ practice guidelines recommend use of structured psychotherapies that are intended to treat BPD (Canadian Agency for Drugs and Technologies in Health 2018; Finnish Medical Society Duodecim 2020; National Health and Medical Research Council 2012; Simonsen et al. 2019). Outpatient treatment frequencies of up to two sessions per week and adapted to the patient’s needs are recommended (National Health and Medical Research Council 2012; National Institute for Health and Care Excellence 2009; Simonsen et al. 2019). Although the specific choice of a psychotherapy may depend on a number of factors including patient preference (National Health and Medical Research Council 2012; National Institute for Health and Care Excellence 2009), psychotherapies that are specifically recommended are dialectical behavior therapy (Canadian Agency for Drugs and Technologies in Health 2018; Finnish Medical Society Duodecim 2020; Herpertz et al. 2007; Simonsen et al. 2019), mentalization-based treatment (Canadian Agency for Drugs and Technologies in Health 2018; Finnish Medical Society Duodecim 2020; Herpertz et al. 2007; Simonsen et al. 2019), schema-focused therapy (Canadian Agency for Drugs and Technologies in Health 2018; Finnish Medical Society Duodecim 2020; Herpertz et al. 2007; Simonsen et al. 2019), and transference-focused psychotherapy (Herpertz et al. 2007; Simonsen et al. 2019). In females, dialectical behavior therapy is also recommended if treatment goals for BPD include reductions in self-harm (National Health and Medical Research Council 2012; National Institute for Health and Care Excellence 2009) or reductions in anger, anxiety, or depression (National Health and Medical Research Council 2012).
Quality Measurement Considerations
This guideline statement may not be appropriate for a performance-based quality measure because of the diversity of effective psychotherapeutic approaches and variations in the availability of psychotherapies. Measurement of psychotherapy utilization using structured EHR or claims data would require codes for specific types of therapy, but Current Procedural Terminology (CPT) codes refer to psychotherapy in general terms. In addition, patients may be receiving psychotherapies that include a mix of effective elements rather than rigid adherence to a specific psychotherapeutic approach, which would make it hard to specify use of a single modality. For these same reasons, reminders about psychotherapy would be difficult to incorporate into an EHR. In addition, most individuals with BPD are receiving some form of psychotherapy, and a gap in quality would need to be documented before pursuing additional quality measure development. Nevertheless, individual organizations and health plans may wish to implement programs to ensure that effective psychotherapies are being used to treat individuals with BPD.
Pharmacotherapy
Statement 6 – Clinical Review before Medication Initiation
APA recommends (1C) that a patient with borderline personality disorder have a review of co-occurring disorders, prior psychotherapies, other nonpharmacological treatments, past medication trials, and current medications before initiating any new medication.
Benefits
A review of co-occurring disorders, prior psychotherapies, other nonpharmacological treatments, past medication trials, and current medications has not been studied but is likely to be beneficial in assuring that the current treatment regimen is optimized prior to instituting a new medication. Such a review also increases awareness of possible medication interactions with the addition of a new medication and may raise the possibility of discontinuing other medications or shifting the psychotherapeutic approach.
Harms
The harms of reviewing co-occurring disorders, prior psychotherapies, other nonpharmacological treatments, past medication trials, and current medications prior to starting a new medication have not been studied but are expected to be small, if any. Nevertheless, it is possible that time used to conduct such a review could delay medication initiation or reduce time available to address other issues of importance to the patient or of relevance to treatment planning.
Patient Preferences
Although there is no specific evidence on patient preferences related to conducting such a review before starting a new medication, clinical experience suggests that most patients are cooperative with and accepting of careful consideration and discussion of treatment options.
Balancing of Benefits and Harms
The potential benefits of this guideline statement were viewed as far outweighing the potential harms. The level of research evidence is rated as low because there is minimal research on the benefits and harms of assessing these aspects of history prior to initiating a new medication. Nevertheless, expert opinion suggests that conducting such an assessment would enhance treatment planning and appropriateness of medication use in individuals with BPD. For additional details, see APA’s Practice Guidelines for the Psychiatric Evaluation of Adults, 3rd Edition (American Psychiatric Association 2016a). For additional discussion of the research evidence, see Appendix C, Statement 6.
Differences of Opinion Among Writing Group Members
There were no differences of opinion. The writing group voted unanimously in favor of this recommendation.
Review of Available Guidelines from Other Organizations
The NICE guideline does not specify the type of review that was needed prior to instituting a medication but does note the importance of ensuring that medication is not begun in lieu of more appropriate interventions (National Institute for Health and Care Excellence 2009).
Quality Measurement Considerations
Reviewing co-occurring disorders, prior psychotherapies, other nonpharmacological treatments, past medication trials, and current medications prior to starting a new medication is likely to be beneficial to patients. Nevertheless, it would be challenging to incorporate this recommendation into a performance-based quality measure given the breadth of content areas being assessed and the difficulty in ascertaining evaluation details from clinical charts or administrative data. However, quality-related efforts at the local level could assess whether EHR templates include prompts for documenting key elements of the assessment and whether such aspects of the evaluation are typically completed, while still allowing flexibility in the documentation of findings.
Statement 7 – Pharmacotherapy Principles
APA suggests (2C) that any psychotropic medication treatment of borderline personality disorder be time-limited, aimed at addressing a specific measurable target symptom, and adjunctive to psychotherapy.
Benefits
Benefits of psychotropic medications in studies of BPD are modest (low strength of evidence) and inconsistent. Therapeutic benefits may be present for some patients that were not found in aggregated data from clinical trials, but the limitations of the evidence suggest that psychotropic medications should be used judiciously in BPD, with a reliance on psychotherapy as a primary therapeutic modality. A focus on time-limited treatment that addresses a specific measurable target symptom is beneficial to ensuring that treatment response will be assessed and the time of exposure to medication is minimized and dependent on clinical response.
Harms
The harms of psychotropic medication in the treatment of BPD are, in part, dependent on the side effect profile of the specific medication. In addition, patients may view psychotropic medications as a way to address intense feelings and emotions without engaging in the essential process of psychotherapy. The focus on time-limited treatment that addresses a specific measurable target symptom could potentially reduce long-term or nonspecific use of a medication in a patient who may otherwise benefit from it.
Patient Preferences
Clinical experience suggests that most patients would prefer to minimize use of psychotropic medications due to adverse effects, costs, and other factors. Many patients, particularly women and younger individuals, prefer psychotherapy to medications (McHugh et al. 2013). However, in some circumstances, patients may request medications to address specific symptoms or general experiences of distress. Some patients may also prefer one medication over another medication on the basis of prior treatment experiences or other factors.
Balancing of Benefits and Harms
The potential benefits of this guideline statement were viewed as likely outweighing the potential harms. Although the recommended approach has not been specifically studied, the harms of using psychotropic medications in a time-limited, symptom-focused manner seem small compared with the benefits. Also, the benefits of psychotherapy clearly outweigh the benefits of psychotropic medications, and the harms of psychotherapy are likely to be less than those of pharmacotherapy, particularly when the psychotherapy is evidence-based and conducted by well-trained and well-supervised psychotherapists. For additional discussion of the research evidence, see Appendix C, Statements 5 and 7.
Differences of Opinion Among Writing Group Members
There were no differences of opinion. The writing group voted unanimously in favor of this recommendation.
Review of Available Guidelines from Other Organizations
Guidelines from other organizations also note that psychotropic medications should be used as adjuncts to psychotherapy and that use should be time-limited (National Health and Medical Research Council 2012; National Institute for Health and Care Excellence 2009; Simonsen et al. 2019). The British BPD guideline recommends that the use of sedatives be time-limited (National Institute for Health and Care Excellence 2009), whereas other guidelines recommend avoiding the use of benzodiazepines in individuals with BPD (Finnish Medical Society Duodecim 2020; Herpertz et al. 2007; Simonsen et al. 2019). Several guidelines note that use should be symptom-focused (Herpertz et al. 2007; National Health and Medical Research Council 2012; National Institute for Health and Care Excellence 2009) or intended to address co-occurring disorders (Simonsen et al. 2019).
Quality Measurement Considerations
This guideline statement would be difficult to incorporate into a meaningful performance-based quality measure. Although adjunctive use of psychotropic medications could be documented, it would be challenging to extract information from clinical documentation on whether medication was time-limited and symptom-focused in its use. By the same token, this statement would not be appropriate for use in clinical decision support in EHRs.
Statement 8 – Pharmacotherapy Review
APA recommends (1C) that a patient with borderline personality disorder receive a review and reconciliation of their medications at least every 6 months to assess the effectiveness of treatment and identify medications that warrant tapering or discontinuation.
Benefits
The benefits of a review and reconciliation of medications include ensuring that a complete list of medications is maintained and that potential medication interactions are identified. In addition, such a review can identify medications that may warrant dosage reduction or discontinuation as well as medications for which dosage optimization is needed or laboratory monitoring is indicated (e.g., serum levels, metabolic studies).
Harms
The harms of medication review and reconciliation have not been studied but are likely to be small and related to time requirements.
Patient Preferences
No information is available on patient preferences related to medication review and reconciliation, but clinical experience suggests that patients are accepting and appreciative of review and discussion of treatment.
Balancing of Benefits and Harms
The potential benefits of this guideline statement were viewed as far outweighing the potential harms, although evidence is limited. In addition, medication reconciliation and deprescribing, where indicated, are recommended best practices in hospital as well as outpatient settings (Institute for Safe Medication Practice 2023; The Joint Commission 2022).
Differences of Opinion Among Writing Group Members
There were no differences of opinion. The writing group voted unanimously in favor of this recommendation.
Review of Available Guidelines from Other Organizations
Two other guidelines recommend periodic review of pharmacotherapies in patients with BPD with goals of tapering and discontinuing unneeded medications and avoiding polypharmacy (National Institute for Health and Care Excellence 2009; Simonsen et al. 2019).
Quality Measurement Considerations
As a recommended best practice in hospital as well as outpatient settings, medication reconciliation is already incorporated into other quality-related measures in the United States (Institute for Safe Medication Practice 2023; The Joint Commission 2022). The addition of a measure that is specific to BPD would not be indicated.
Footnote
1Harms may include serious adverse events; less serious adverse events that affect tolerability; minor adverse events; negative effects of the intervention on quality of life; barriers and inconveniences associated with treatment; and other negative aspects of the treatment that may influence decision-making by the patient, the clinician, or both. Harms may also include opportunity costs for the clinician who may have to forgo another clinical activity that would be more beneficial for the patient.
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The American Psychiatric Association Practice Guideline for the Treatment of Patients With Borderline Personality Disorder
November 2024
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