Michael Brodsky, MD

In response to the Veterans Affairs waiting list scandal at the Phoenix Health Care System, President Obama unveiled a sweeping new veterans health initiative. Cornerstones of the initiative included increased funding for mental health services and increased efforts to reduce homelessness for veterans. In a speech in late August to the American Legion announcing the initiative, Mr. Obama called housing for veterans “a basic commitment that we have to uphold.” What the president did not mention is that providing housing is itself an evidence-based mental health treatment, recognized by organizations as diverse as the Substance Abuse and Mental Health Services Administration and the United Nations, that not only reduces homelessness and alleviates poverty but also improves mental and physical health outcomes for patients with high rates of health service use.

Over the last 25 years, health service researchers have recognized the value of housing as a behavioral health intervention. But this was not always the case. Traditionally, homeless patients with mental health and substance issue were transitioned to permanent housing in a series of graduated steps – from the street to homeless shelter, to more transitional living quarters, to group housing settings, and finally to permanent single-family housing. Individuals were assessed for their readiness for a higher level of housing based on their engagement with psychiatric, psychosocial, and abstinence-related programs.

In the late 1980s, first in Los Angeles and later in New York City, housing advocates developed the alternative Housing First model, which has since been adopted widely both in the United States and abroad. In contrast to the traditional model, hallmarks of the Housing First model are 1) immediate access to permanent housing; 2) supportive case management with attention to enhancing linkages to health services and social service agencies; and 3) no requirement for sobriety or treatment adherence, consistent with a harm-reduction approach to substance abuse.

A Housing First approach to chronic homelessness has been shown to reduce use and costs of health services and social services. In one study, Mary E. Larimer, Ph.D., and her colleagues at the University of Washington, Seattle, enrolled 95 alcohol-dependent individuals in a Housing First program and compared them with wait-list controls. Over 12 months, health care expenditures for housed group were $2,449 less per person per month, compared with those maintained on the wait-list, even after subtracting housing expenses. More surprisingly, subjects in the housing group significantly reduced their overall alcohol consumption and the number episodes of intoxication, despite no requirement to reduce drinking in the program (JAMA 2009;301:1439-57).

In another study, T.E. Martinez and M.R. Burt examined the health services use of 236 individuals who received supportive housing in San Francisco between 1994 and 1998 (Psychiatric Serv. 57;922:9). During the 2 years after securing housing, individuals had significantly fewer emergency room visits and hospitalizations than during the 2 years before housing.

Proponents of the Housing First approach have based their advocacy for the program on the cost-effectiveness of supportive housing interventions, rather than wading into any moral or policy debates regarding the right to shelter. In this era of fiscal austerity, such an approach has won adherents from both liberal and conservative policymakers while avoiding traditional areas of policy conflict.

State and local jurisdictions have taken notice of the potential cost savings of supportive housing for the chronically physically and mentally ill. In late 2013, New York State announced plans to use federal funds earmarked for Medicaid Redesign under the Affordable Care Act to construct port of housing and provide accompanying case management. In an editorial in the New England Journal of Medicine, Dr. Nirav R. Shah, the New York state health commissioner and his colleagues wrote, “We envision a [public] system in which spending on social determinants of health such as housing is not only allowable, but recognized as a best practice” (N. Engl.J. Med. 2013;369:2374-7).

Such a shift would likely produce tangible benefits both for the individuals with mental illness directly affected and for the public mental health systems already strained by limited budgets and ever-increasing demand for services.

Dr. Brodsky is an assistant clinical professor of psychiatry at the University of California, Los Angeles, and the medical director of Bridges to Recovery in Pacific Palisades, Calif.

In response to the Veterans Affairs waiting list scandal at the Phoenix Health Care System, President Obama unveiled a sweeping new veterans health initiative. Cornerstones of the initiative included increased funding for mental health services and increased efforts to reduce homelessness for veterans. In a speech in late August to the American Legion announcing the initiative, Mr. Obama called housing for veterans “a basic commitment that we have to uphold.” What the president did not mention is that providing housing is itself an evidence-based mental health treatment, recognized by organizations as diverse as the Substance Abuse and Mental Health Services Administration and the United Nations, that not only reduces homelessness and alleviates poverty but also improves mental and physical health outcomes for patients with high rates of health service use.

Over the last 25 years, health service researchers have recognized the value of housing as a behavioral health intervention. But this was not always the case. Traditionally, homeless patients with mental health and substance issue were transitioned to permanent housing in a series of graduated steps – from the street to homeless shelter, to more transitional living quarters, to group housing settings, and finally to permanent single-family housing. Individuals were assessed for their readiness for a higher level of housing based on their engagement with psychiatric, psychosocial, and abstinence-related programs.

In the late 1980s, first in Los Angeles and later in New York City, housing advocates developed the alternative Housing First model, which has since been adopted widely both in the United States and abroad. In contrast to the traditional model, hallmarks of the Housing First model are 1) immediate access to permanent housing; 2) supportive case management with attention to enhancing linkages to health services and social service agencies; and 3) no requirement for sobriety or treatment adherence, consistent with a harm-reduction approach to substance abuse.

A Housing First approach to chronic homelessness has been shown to reduce use and costs of health services and social services. In one study, Mary E. Larimer, Ph.D., and her colleagues at the University of Washington, Seattle, enrolled 95 alcohol-dependent individuals in a Housing First program and compared them with wait-list controls. Over 12 months, health care expenditures for housed group were $2,449 less per person per month, compared with those maintained on the wait-list, even after subtracting housing expenses. More surprisingly, subjects in the housing group significantly reduced their overall alcohol consumption and the number episodes of intoxication, despite no requirement to reduce drinking in the program (JAMA 2009;301:1439-57).

In another study, T.E. Martinez and M.R. Burt examined the health services use of 236 individuals who received supportive housing in San Francisco between 1994 and 1998 (Psychiatric Serv. 57;922:9). During the 2 years after securing housing, individuals had significantly fewer emergency room visits and hospitalizations than during the 2 years before housing.

Proponents of the Housing First approach have based their advocacy for the program on the cost-effectiveness of supportive housing interventions, rather than wading into any moral or policy debates regarding the right to shelter. In this era of fiscal austerity, such an approach has won adherents from both liberal and conservative policymakers while avoiding traditional areas of policy conflict.

State and local jurisdictions have taken notice of the potential cost savings of supportive housing for the chronically physically and mentally ill. In late 2013, New York State announced plans to use federal funds earmarked for Medicaid Redesign under the Affordable Care Act to construct port of housing and provide accompanying case management. In an editorial in the New England Journal of Medicine, Dr. Nirav R. Shah, the New York state health commissioner and his colleagues wrote, “We envision a [public] system in which spending on social determinants of health such as housing is not only allowable, but recognized as a best practice” (N. Engl.J. Med. 2013;369:2374-7).

Such a shift would likely produce tangible benefits both for the individuals with mental illness directly affected and for the public mental health systems already strained by limited budgets and ever-increasing demand for services.

Dr. Brodsky is an assistant clinical professor of psychiatry at the University of California, Los Angeles, and the medical director of Bridges to Recovery in Pacific Palisades, Calif.

In response to the Veterans Affairs waiting list scandal at the Phoenix Health Care System, President Obama unveiled a sweeping new veterans health initiative. Cornerstones of the initiative included increased funding for mental health services and increased efforts to reduce homelessness for veterans. In a speech in late August to the American Legion announcing the initiative, Mr. Obama called housing for veterans “a basic commitment that we have to uphold.” What the president did not mention is that providing housing is itself an evidence-based mental health treatment, recognized by organizations as diverse as the Substance Abuse and Mental Health Services Administration and the United Nations, that not only reduces homelessness and alleviates poverty but also improves mental and physical health outcomes for patients with high rates of health service use.

Over the last 25 years, health service researchers have recognized the value of housing as a behavioral health intervention. But this was not always the case. Traditionally, homeless patients with mental health and substance issue were transitioned to permanent housing in a series of graduated steps – from the street to homeless shelter, to more transitional living quarters, to group housing settings, and finally to permanent single-family housing. Individuals were assessed for their readiness for a higher level of housing based on their engagement with psychiatric, psychosocial, and abstinence-related programs.

In the late 1980s, first in Los Angeles and later in New York City, housing advocates developed the alternative Housing First model, which has since been adopted widely both in the United States and abroad. In contrast to the traditional model, hallmarks of the Housing First model are 1) immediate access to permanent housing; 2) supportive case management with attention to enhancing linkages to health services and social service agencies; and 3) no requirement for sobriety or treatment adherence, consistent with a harm-reduction approach to substance abuse.

A Housing First approach to chronic homelessness has been shown to reduce use and costs of health services and social services. In one study, Mary E. Larimer, Ph.D., and her colleagues at the University of Washington, Seattle, enrolled 95 alcohol-dependent individuals in a Housing First program and compared them with wait-list controls. Over 12 months, health care expenditures for housed group were $2,449 less per person per month, compared with those maintained on the wait-list, even after subtracting housing expenses. More surprisingly, subjects in the housing group significantly reduced their overall alcohol consumption and the number episodes of intoxication, despite no requirement to reduce drinking in the program (JAMA 2009;301:1439-57).

In another study, T.E. Martinez and M.R. Burt examined the health services use of 236 individuals who received supportive housing in San Francisco between 1994 and 1998 (Psychiatric Serv. 57;922:9). During the 2 years after securing housing, individuals had significantly fewer emergency room visits and hospitalizations than during the 2 years before housing.

Proponents of the Housing First approach have based their advocacy for the program on the cost-effectiveness of supportive housing interventions, rather than wading into any moral or policy debates regarding the right to shelter. In this era of fiscal austerity, such an approach has won adherents from both liberal and conservative policymakers while avoiding traditional areas of policy conflict.

State and local jurisdictions have taken notice of the potential cost savings of supportive housing for the chronically physically and mentally ill. In late 2013, New York State announced plans to use federal funds earmarked for Medicaid Redesign under the Affordable Care Act to construct port of housing and provide accompanying case management. In an editorial in the New England Journal of Medicine, Dr. Nirav R. Shah, the New York state health commissioner and his colleagues wrote, “We envision a [public] system in which spending on social determinants of health such as housing is not only allowable, but recognized as a best practice” (N. Engl.J. Med. 2013;369:2374-7).

Such a shift would likely produce tangible benefits both for the individuals with mental illness directly affected and for the public mental health systems already strained by limited budgets and ever-increasing demand for services.

Dr. Brodsky is an assistant clinical professor of psychiatry at the University of California, Los Angeles, and the medical director of Bridges to Recovery in Pacific Palisades, Calif.

"But at my back I always hear/ Time’s winged chariot hurrying near."

Andrew Marvell (1621-1678), "To His Coy Mistress"

At press time, John Green’s young-adult novel "The Fault in Our Stars" (New York: Penguin Group, 2012) has sold more than 10.7 million copies and has been translated into 46 languages, the Washington Post reports. Although derided by some as maudlin and clichéd, most reviewers have offered high praise for the emotional and clinical realism of the story, and National Public Radio has called the author’s writing style "so compulsively readable that it defies categorization."

Critics have praised Mr. Green for his witty yet rueful dialogue and his incisive, seemingly effortless allusions to Kierkegaard, Shakespeare, Abraham Maslow, and the profound existential dilemmas confronted by the story’s protagonists, two adolescents with cancer. Green knows much about this topic; he previously led a pastoral support group for teens with cancer, and he befriended a particular 16-year-old girl to whom the book is dedicated posthumously.

The story centers on the romance of Hazel, a 16-year-old with metastatic thyroid carcinoma, and Augustus, a survivor of osteosarcoma, whom she meets in a support group for teens at the local church. Theirs is a whirlwind romance, fueled by the exuberance of adolescence conflated with the very real prospect that their lives will be radically foreshortened by a dreaded recurrence or progression of disease. (A movie based on the novel opened across the country this summer.)

Though adults surrounding the couple often regard them with a mixture of pity and sympathy, neither Hazel nor Augustus sentimentalizes their plight, and both are realistic about the likelihood of an unhappy conclusion of their romance. More than once, Hazel warns Augustus to keep his feelings in check because "I am a grenade" whose medical decompensation will someday wreak emotional havoc among those close to her. Faced with the grim possibility of an untimely ending, Hazel and Augustus seek to make the most of the "little infinity" of intimate moments that they have together.

The premise of TFIOS reminded me of the work of the writings of the psychologist Rollo May and the psychiatrist Irvin D. Yalom, who urged psychotherapists to bear in mind the larger existential questions, termed by Dr. Yalom "ultimate concerns," that underlie many of the fears and anxieties that patients bring into our offices. In his magisterial Existential Psychotherapy (New York: Basic Books, 1980), Yalom classifies these concerns in four broad categories: Death, Freedom, Isolation, and Meaninglessness. Somehow, without becoming heavy handed, this novel manages to touch on all of these themes without resorting to excessive sentimentality.

Patients seek out our psychiatric assistance at moments when the burden of their emotional suffering becomes too much to bear. Sometimes, the stressors that lead to a clinical worsening are acute and unforeseen; but more often, the presenting problem offered by patients reverberates with more profound and longstanding doubts and fears. Many of these doubts and fears stem from the existential uncertainties and precarious nature of every human life. There are no guarantees that our patients will find the courage and emotional security to overcome these fears, but we in this field have the privilege to try to lend a hand along the way.

Dr. May and Dr. Yalom urge us to bear in mind the existential realities of our patients’ lives as we listen to their stories and their symptoms. Their time on earth is short, in the grand scheme of things; they struggle to feel that their efforts and challenges and disappointments are in any way meaningful; and ultimately, they (and we) will die alone. The protagonists of TFIOS face these stark truths on a grossly and unfairly accelerated timeline, and they find a way to make the most of the choices that are available to them. True, this is a work of fiction, but fortunately one drawn with more than a modicum of emotional realism. We will serve our patients well if we can find a way – gently – to draw their attention to the tougher realities of their existence, no matter whether their symptoms are anxious, depressed, manic, or psychotic. Then, if possible, we can seek to ease the distress that brought them to our office in the first place, so that they can move forward in their efforts to make the best of their time here.

Dr. Brodsky is assistant clinical professor of psychiatry at the University of California, Los Angeles, and the medical director of Bridges to Recovery in Pacific Palisades, Calif.

"But at my back I always hear/ Time’s winged chariot hurrying near."

Andrew Marvell (1621-1678), "To His Coy Mistress"

At press time, John Green’s young-adult novel "The Fault in Our Stars" (New York: Penguin Group, 2012) has sold more than 10.7 million copies and has been translated into 46 languages, the Washington Post reports. Although derided by some as maudlin and clichéd, most reviewers have offered high praise for the emotional and clinical realism of the story, and National Public Radio has called the author’s writing style "so compulsively readable that it defies categorization."

Critics have praised Mr. Green for his witty yet rueful dialogue and his incisive, seemingly effortless allusions to Kierkegaard, Shakespeare, Abraham Maslow, and the profound existential dilemmas confronted by the story’s protagonists, two adolescents with cancer. Green knows much about this topic; he previously led a pastoral support group for teens with cancer, and he befriended a particular 16-year-old girl to whom the book is dedicated posthumously.

The story centers on the romance of Hazel, a 16-year-old with metastatic thyroid carcinoma, and Augustus, a survivor of osteosarcoma, whom she meets in a support group for teens at the local church. Theirs is a whirlwind romance, fueled by the exuberance of adolescence conflated with the very real prospect that their lives will be radically foreshortened by a dreaded recurrence or progression of disease. (A movie based on the novel opened across the country this summer.)

Though adults surrounding the couple often regard them with a mixture of pity and sympathy, neither Hazel nor Augustus sentimentalizes their plight, and both are realistic about the likelihood of an unhappy conclusion of their romance. More than once, Hazel warns Augustus to keep his feelings in check because "I am a grenade" whose medical decompensation will someday wreak emotional havoc among those close to her. Faced with the grim possibility of an untimely ending, Hazel and Augustus seek to make the most of the "little infinity" of intimate moments that they have together.

The premise of TFIOS reminded me of the work of the writings of the psychologist Rollo May and the psychiatrist Irvin D. Yalom, who urged psychotherapists to bear in mind the larger existential questions, termed by Dr. Yalom "ultimate concerns," that underlie many of the fears and anxieties that patients bring into our offices. In his magisterial Existential Psychotherapy (New York: Basic Books, 1980), Yalom classifies these concerns in four broad categories: Death, Freedom, Isolation, and Meaninglessness. Somehow, without becoming heavy handed, this novel manages to touch on all of these themes without resorting to excessive sentimentality.

Patients seek out our psychiatric assistance at moments when the burden of their emotional suffering becomes too much to bear. Sometimes, the stressors that lead to a clinical worsening are acute and unforeseen; but more often, the presenting problem offered by patients reverberates with more profound and longstanding doubts and fears. Many of these doubts and fears stem from the existential uncertainties and precarious nature of every human life. There are no guarantees that our patients will find the courage and emotional security to overcome these fears, but we in this field have the privilege to try to lend a hand along the way.

Dr. May and Dr. Yalom urge us to bear in mind the existential realities of our patients’ lives as we listen to their stories and their symptoms. Their time on earth is short, in the grand scheme of things; they struggle to feel that their efforts and challenges and disappointments are in any way meaningful; and ultimately, they (and we) will die alone. The protagonists of TFIOS face these stark truths on a grossly and unfairly accelerated timeline, and they find a way to make the most of the choices that are available to them. True, this is a work of fiction, but fortunately one drawn with more than a modicum of emotional realism. We will serve our patients well if we can find a way – gently – to draw their attention to the tougher realities of their existence, no matter whether their symptoms are anxious, depressed, manic, or psychotic. Then, if possible, we can seek to ease the distress that brought them to our office in the first place, so that they can move forward in their efforts to make the best of their time here.

Dr. Brodsky is assistant clinical professor of psychiatry at the University of California, Los Angeles, and the medical director of Bridges to Recovery in Pacific Palisades, Calif.

"But at my back I always hear/ Time’s winged chariot hurrying near."

Andrew Marvell (1621-1678), "To His Coy Mistress"

At press time, John Green’s young-adult novel "The Fault in Our Stars" (New York: Penguin Group, 2012) has sold more than 10.7 million copies and has been translated into 46 languages, the Washington Post reports. Although derided by some as maudlin and clichéd, most reviewers have offered high praise for the emotional and clinical realism of the story, and National Public Radio has called the author’s writing style "so compulsively readable that it defies categorization."

Critics have praised Mr. Green for his witty yet rueful dialogue and his incisive, seemingly effortless allusions to Kierkegaard, Shakespeare, Abraham Maslow, and the profound existential dilemmas confronted by the story’s protagonists, two adolescents with cancer. Green knows much about this topic; he previously led a pastoral support group for teens with cancer, and he befriended a particular 16-year-old girl to whom the book is dedicated posthumously.

The story centers on the romance of Hazel, a 16-year-old with metastatic thyroid carcinoma, and Augustus, a survivor of osteosarcoma, whom she meets in a support group for teens at the local church. Theirs is a whirlwind romance, fueled by the exuberance of adolescence conflated with the very real prospect that their lives will be radically foreshortened by a dreaded recurrence or progression of disease. (A movie based on the novel opened across the country this summer.)

Though adults surrounding the couple often regard them with a mixture of pity and sympathy, neither Hazel nor Augustus sentimentalizes their plight, and both are realistic about the likelihood of an unhappy conclusion of their romance. More than once, Hazel warns Augustus to keep his feelings in check because "I am a grenade" whose medical decompensation will someday wreak emotional havoc among those close to her. Faced with the grim possibility of an untimely ending, Hazel and Augustus seek to make the most of the "little infinity" of intimate moments that they have together.

The premise of TFIOS reminded me of the work of the writings of the psychologist Rollo May and the psychiatrist Irvin D. Yalom, who urged psychotherapists to bear in mind the larger existential questions, termed by Dr. Yalom "ultimate concerns," that underlie many of the fears and anxieties that patients bring into our offices. In his magisterial Existential Psychotherapy (New York: Basic Books, 1980), Yalom classifies these concerns in four broad categories: Death, Freedom, Isolation, and Meaninglessness. Somehow, without becoming heavy handed, this novel manages to touch on all of these themes without resorting to excessive sentimentality.

Patients seek out our psychiatric assistance at moments when the burden of their emotional suffering becomes too much to bear. Sometimes, the stressors that lead to a clinical worsening are acute and unforeseen; but more often, the presenting problem offered by patients reverberates with more profound and longstanding doubts and fears. Many of these doubts and fears stem from the existential uncertainties and precarious nature of every human life. There are no guarantees that our patients will find the courage and emotional security to overcome these fears, but we in this field have the privilege to try to lend a hand along the way.

Dr. May and Dr. Yalom urge us to bear in mind the existential realities of our patients’ lives as we listen to their stories and their symptoms. Their time on earth is short, in the grand scheme of things; they struggle to feel that their efforts and challenges and disappointments are in any way meaningful; and ultimately, they (and we) will die alone. The protagonists of TFIOS face these stark truths on a grossly and unfairly accelerated timeline, and they find a way to make the most of the choices that are available to them. True, this is a work of fiction, but fortunately one drawn with more than a modicum of emotional realism. We will serve our patients well if we can find a way – gently – to draw their attention to the tougher realities of their existence, no matter whether their symptoms are anxious, depressed, manic, or psychotic. Then, if possible, we can seek to ease the distress that brought them to our office in the first place, so that they can move forward in their efforts to make the best of their time here.

Dr. Brodsky is assistant clinical professor of psychiatry at the University of California, Los Angeles, and the medical director of Bridges to Recovery in Pacific Palisades, Calif.

Few clinicians look forward to treating patients with borderline personality disorder, in part because of the assumption that the symptoms and dysfunction associated with the syndrome are likely to prove intractable. A new study in the May issue of the American Journal of Psychiatry challenges those assumptions about the course and prognosis of the disease. Mary C. Zanarini, Ed.D., of McLean Hospital, Belmont, Mass., and her colleagues reported on the longitudinal course of personality disorder over 16 years of follow-up (2012;169:476-83).

The investigators followed 290 inpatients diagnosed with BPD according to DSM-III-R criteria and compared them with 72 inpatients diagnosed with other personality disorders. Subjects were reassessed every 2 years for symptoms of personality pathology as well as for indicators of social and occupational functioning. The authors assessed the study subjects for two end points: remission, defined as no longer meeting diagnostic criteria for BPD; and recovery, defined as meeting operationalized criteria in order to qualify for a Global Assessment of Functioning (GAF) score of 61 or higher. Criteria for this score included the remission of BPD symptoms, the presence of a supportive social or romantic relationship, and the capacity for full-time work as an employee, homemaker, or student.

The results showed that nearly all the subjects in the BPD sample (99%) experienced remission of BPD symptoms for at least a 2-year period. Nearly 80% of borderline patients had a remission of their symptoms lasting 8 years or more. And nearly 90% of all participants completed all interviews for the entire 16-year study.

From the perspective of symptomatology, the prognosis for these inpatients was relatively positive and less chronic and unremitting than many psychiatric clinicians would assume about BPD. Even more encouragingly, only 10% of those with remission of BPD symptoms lasting 8 years experienced a recurrence of BPD symptoms over the course of the study. Once BPD symptoms had remitted for an extended period, they tended to "stay gone."

However, the study’s findings were considerably less encouraging when viewed with the goal of achieving a full functional recovery. Slightly more than half of the BPD subjects attained a full functional recovery lasting 2 years, meaning that nearly half of the sample never reached the point of a functional recovery. What’s more, among those who did achieve recovery, nearly 50% did not sustain social and/or occupational engagement for more than 2 years. In the end, a significant proportion of subjects with BPD eventually came to require federal disability payments.

The key findings from this study are consistent with those of a 10-year follow-up of a different sample of patients with BPD, led by Dr. John G. Gunderson, also of McLean Hospital (Arch. Gen. Psych. 2011;68:827-37).

In that trial, known as the Collaborative Longitudinal Personality Disorders Study, 85% of patients with BPD exhibited a remission of symptoms; only 12% experienced a relapse of symptoms following remission; but, discouragingly, only 36% with BPD were employed full-time at the 10-year mark, and only 41% were found to be in a marital or cohabiting relationship at that point.

What are we to make of these converging findings? On the one hand, Dr. Zanarini’s study provides a sobering reminder that with BPD, as with patients with schizophrenia and with substance dependence, remission of psychiatric symptoms does not equal a return to optimal psychosocial functioning.

As Dr. Joel Paris of McGill University in Montreal points out, these and other longitudinal studies point to the need for a second phase of treatment that extends beyond symptom control to target social and occupational domains (Am. J. Psychiatry 2012;169;445-6).It may be prudent for personality researchers to consider adaptation and modification of the rehabilitation models developed for schizophrenia (Psychiatry 1993;56:238-49) and severe substance dependence (Psychol. Bull. 1995;117:416-33).

On the other hand, there appears to be a substantial case for clinical optimism. Clinicians should feel a measure of reassurance by the knowledge that the most intense period of symptomatology for most young BPD patients can be expected to remit by middle age. Although the course of symptoms, the scope of acting-out behaviors, and the lurking risk of self-harm may be quite intense and destructive, a mounting and increasingly persuasive body of evidence suggests that the affect storms of the illness will often prove to be time-limited.

As Dr. Gunderson wrote in this study, "What is evident appears clinically counterintuitive; patients with BPD improve symptomatically more often, more quickly, and more dramatically than expected and, once better, maintain improvements more enduring than for many other major psychiatric disorders."

Increasingly, affective disorders have been conceptualized as chronic conditions that may require treatment across the lifespan (Br. Med. J. 2001;322:419-21). Evidence from recent papers suggests that even the most feared and intense of the personality disorders may have a disease course considerably shorter than that of unipolar or bipolar depression. This makes clinical sense; few among us would be surprised when an elderly patient develops mood symptoms following years of euthymia, but many of us would be surprised if that elderly person developed a sudden resurgence of cutting, affect storms, and frantic efforts to avoid abandonment. What remains to be seen is whether the research findings about borderline personality disorder can be translated into meaningful advances in the science of treatment and psychosocial rehabilitation of these challenging and significantly impaired patients.

Dr. Brodsky is the medical director of Bridges to Recovery in Pacific Palisades, Calif., as well as the director of psychiatric services at the Venice (Calif.) Family Clinic. He is a member of the teaching faculty of the department of psychiatry at the University of California, Los Angeles. 

Few clinicians look forward to treating patients with borderline personality disorder, in part because of the assumption that the symptoms and dysfunction associated with the syndrome are likely to prove intractable. A new study in the May issue of the American Journal of Psychiatry challenges those assumptions about the course and prognosis of the disease. Mary C. Zanarini, Ed.D., of McLean Hospital, Belmont, Mass., and her colleagues reported on the longitudinal course of personality disorder over 16 years of follow-up (2012;169:476-83).

The investigators followed 290 inpatients diagnosed with BPD according to DSM-III-R criteria and compared them with 72 inpatients diagnosed with other personality disorders. Subjects were reassessed every 2 years for symptoms of personality pathology as well as for indicators of social and occupational functioning. The authors assessed the study subjects for two end points: remission, defined as no longer meeting diagnostic criteria for BPD; and recovery, defined as meeting operationalized criteria in order to qualify for a Global Assessment of Functioning (GAF) score of 61 or higher. Criteria for this score included the remission of BPD symptoms, the presence of a supportive social or romantic relationship, and the capacity for full-time work as an employee, homemaker, or student.

The results showed that nearly all the subjects in the BPD sample (99%) experienced remission of BPD symptoms for at least a 2-year period. Nearly 80% of borderline patients had a remission of their symptoms lasting 8 years or more. And nearly 90% of all participants completed all interviews for the entire 16-year study.

From the perspective of symptomatology, the prognosis for these inpatients was relatively positive and less chronic and unremitting than many psychiatric clinicians would assume about BPD. Even more encouragingly, only 10% of those with remission of BPD symptoms lasting 8 years experienced a recurrence of BPD symptoms over the course of the study. Once BPD symptoms had remitted for an extended period, they tended to "stay gone."

However, the study’s findings were considerably less encouraging when viewed with the goal of achieving a full functional recovery. Slightly more than half of the BPD subjects attained a full functional recovery lasting 2 years, meaning that nearly half of the sample never reached the point of a functional recovery. What’s more, among those who did achieve recovery, nearly 50% did not sustain social and/or occupational engagement for more than 2 years. In the end, a significant proportion of subjects with BPD eventually came to require federal disability payments.

The key findings from this study are consistent with those of a 10-year follow-up of a different sample of patients with BPD, led by Dr. John G. Gunderson, also of McLean Hospital (Arch. Gen. Psych. 2011;68:827-37).

In that trial, known as the Collaborative Longitudinal Personality Disorders Study, 85% of patients with BPD exhibited a remission of symptoms; only 12% experienced a relapse of symptoms following remission; but, discouragingly, only 36% with BPD were employed full-time at the 10-year mark, and only 41% were found to be in a marital or cohabiting relationship at that point.

What are we to make of these converging findings? On the one hand, Dr. Zanarini’s study provides a sobering reminder that with BPD, as with patients with schizophrenia and with substance dependence, remission of psychiatric symptoms does not equal a return to optimal psychosocial functioning.

As Dr. Joel Paris of McGill University in Montreal points out, these and other longitudinal studies point to the need for a second phase of treatment that extends beyond symptom control to target social and occupational domains (Am. J. Psychiatry 2012;169;445-6).It may be prudent for personality researchers to consider adaptation and modification of the rehabilitation models developed for schizophrenia (Psychiatry 1993;56:238-49) and severe substance dependence (Psychol. Bull. 1995;117:416-33).

On the other hand, there appears to be a substantial case for clinical optimism. Clinicians should feel a measure of reassurance by the knowledge that the most intense period of symptomatology for most young BPD patients can be expected to remit by middle age. Although the course of symptoms, the scope of acting-out behaviors, and the lurking risk of self-harm may be quite intense and destructive, a mounting and increasingly persuasive body of evidence suggests that the affect storms of the illness will often prove to be time-limited.

As Dr. Gunderson wrote in this study, "What is evident appears clinically counterintuitive; patients with BPD improve symptomatically more often, more quickly, and more dramatically than expected and, once better, maintain improvements more enduring than for many other major psychiatric disorders."

Increasingly, affective disorders have been conceptualized as chronic conditions that may require treatment across the lifespan (Br. Med. J. 2001;322:419-21). Evidence from recent papers suggests that even the most feared and intense of the personality disorders may have a disease course considerably shorter than that of unipolar or bipolar depression. This makes clinical sense; few among us would be surprised when an elderly patient develops mood symptoms following years of euthymia, but many of us would be surprised if that elderly person developed a sudden resurgence of cutting, affect storms, and frantic efforts to avoid abandonment. What remains to be seen is whether the research findings about borderline personality disorder can be translated into meaningful advances in the science of treatment and psychosocial rehabilitation of these challenging and significantly impaired patients.

Dr. Brodsky is the medical director of Bridges to Recovery in Pacific Palisades, Calif., as well as the director of psychiatric services at the Venice (Calif.) Family Clinic. He is a member of the teaching faculty of the department of psychiatry at the University of California, Los Angeles. 

Few clinicians look forward to treating patients with borderline personality disorder, in part because of the assumption that the symptoms and dysfunction associated with the syndrome are likely to prove intractable. A new study in the May issue of the American Journal of Psychiatry challenges those assumptions about the course and prognosis of the disease. Mary C. Zanarini, Ed.D., of McLean Hospital, Belmont, Mass., and her colleagues reported on the longitudinal course of personality disorder over 16 years of follow-up (2012;169:476-83).

The investigators followed 290 inpatients diagnosed with BPD according to DSM-III-R criteria and compared them with 72 inpatients diagnosed with other personality disorders. Subjects were reassessed every 2 years for symptoms of personality pathology as well as for indicators of social and occupational functioning. The authors assessed the study subjects for two end points: remission, defined as no longer meeting diagnostic criteria for BPD; and recovery, defined as meeting operationalized criteria in order to qualify for a Global Assessment of Functioning (GAF) score of 61 or higher. Criteria for this score included the remission of BPD symptoms, the presence of a supportive social or romantic relationship, and the capacity for full-time work as an employee, homemaker, or student.

The results showed that nearly all the subjects in the BPD sample (99%) experienced remission of BPD symptoms for at least a 2-year period. Nearly 80% of borderline patients had a remission of their symptoms lasting 8 years or more. And nearly 90% of all participants completed all interviews for the entire 16-year study.

From the perspective of symptomatology, the prognosis for these inpatients was relatively positive and less chronic and unremitting than many psychiatric clinicians would assume about BPD. Even more encouragingly, only 10% of those with remission of BPD symptoms lasting 8 years experienced a recurrence of BPD symptoms over the course of the study. Once BPD symptoms had remitted for an extended period, they tended to "stay gone."

However, the study’s findings were considerably less encouraging when viewed with the goal of achieving a full functional recovery. Slightly more than half of the BPD subjects attained a full functional recovery lasting 2 years, meaning that nearly half of the sample never reached the point of a functional recovery. What’s more, among those who did achieve recovery, nearly 50% did not sustain social and/or occupational engagement for more than 2 years. In the end, a significant proportion of subjects with BPD eventually came to require federal disability payments.

The key findings from this study are consistent with those of a 10-year follow-up of a different sample of patients with BPD, led by Dr. John G. Gunderson, also of McLean Hospital (Arch. Gen. Psych. 2011;68:827-37).

In that trial, known as the Collaborative Longitudinal Personality Disorders Study, 85% of patients with BPD exhibited a remission of symptoms; only 12% experienced a relapse of symptoms following remission; but, discouragingly, only 36% with BPD were employed full-time at the 10-year mark, and only 41% were found to be in a marital or cohabiting relationship at that point.

What are we to make of these converging findings? On the one hand, Dr. Zanarini’s study provides a sobering reminder that with BPD, as with patients with schizophrenia and with substance dependence, remission of psychiatric symptoms does not equal a return to optimal psychosocial functioning.

As Dr. Joel Paris of McGill University in Montreal points out, these and other longitudinal studies point to the need for a second phase of treatment that extends beyond symptom control to target social and occupational domains (Am. J. Psychiatry 2012;169;445-6).It may be prudent for personality researchers to consider adaptation and modification of the rehabilitation models developed for schizophrenia (Psychiatry 1993;56:238-49) and severe substance dependence (Psychol. Bull. 1995;117:416-33).

On the other hand, there appears to be a substantial case for clinical optimism. Clinicians should feel a measure of reassurance by the knowledge that the most intense period of symptomatology for most young BPD patients can be expected to remit by middle age. Although the course of symptoms, the scope of acting-out behaviors, and the lurking risk of self-harm may be quite intense and destructive, a mounting and increasingly persuasive body of evidence suggests that the affect storms of the illness will often prove to be time-limited.

As Dr. Gunderson wrote in this study, "What is evident appears clinically counterintuitive; patients with BPD improve symptomatically more often, more quickly, and more dramatically than expected and, once better, maintain improvements more enduring than for many other major psychiatric disorders."

Increasingly, affective disorders have been conceptualized as chronic conditions that may require treatment across the lifespan (Br. Med. J. 2001;322:419-21). Evidence from recent papers suggests that even the most feared and intense of the personality disorders may have a disease course considerably shorter than that of unipolar or bipolar depression. This makes clinical sense; few among us would be surprised when an elderly patient develops mood symptoms following years of euthymia, but many of us would be surprised if that elderly person developed a sudden resurgence of cutting, affect storms, and frantic efforts to avoid abandonment. What remains to be seen is whether the research findings about borderline personality disorder can be translated into meaningful advances in the science of treatment and psychosocial rehabilitation of these challenging and significantly impaired patients.

Dr. Brodsky is the medical director of Bridges to Recovery in Pacific Palisades, Calif., as well as the director of psychiatric services at the Venice (Calif.) Family Clinic. He is a member of the teaching faculty of the department of psychiatry at the University of California, Los Angeles.