Sex differences in mortality of admitted patients with personality disorders in North Norway--a prospective register study

Mortality in mental health patients of the Emilia-Romagna region of Italy: A registry-based study

Evidence from previous research demonstrated a gap in mortality between patients with mental disorders and the general population. However, a more exhaustive assessment is required to address this public health issue. The aim of this study was to provide comprehensive analysis of mortality examining all causes of death and all psychiatric diagnoses. We conducted a 10-year retrospective cohort study, including all in and out patients registered in the Mental Health Registry of Emilia-Romagna, Italy. Standardized mortality ratios (SMRs) were calculated. The cohort consisted of 137,351 patients 11,236 of whom died during the study period and the overall SMR was 1.99. 85.9 % of excess mortality was attributable to a broad range of natural causes. Diseases of circulatory and respiratory systems as well as neoplasms were the principal contributors to the mortality gap. All psychiatric conditions led to a higher risk of death. The greatest excess was due to neoplasms in depressed and neurotic patients and to cardiovascular diseases in patients with schizophrenia and personality disorders. Our results highlight the need for close collaboration between mental and primary health care services with the aim of reducing excess mortality as a result of medical diseases among all patients suffering from psychiatric condition.

Total and cause-specific mortality in patients with personality disorders: the association between comorbid severe mental illness and substance use disorders

PURPOSE

To investigate the mortality in both in- and outpatients with personality disorders (PD), and to explore the association between mortality and comorbid substance use disorder (SUD) or severe mental illness (SMI).

METHODS

All residents admitted to Norwegian in- and outpatient specialist health care services during 2009-2015 with a PD diagnosis were included. Standardized mortality ratios (SMRs) with 95% confidence intervals (CI) were estimated in patients with PD only and in patients with PD and comorbid SMI or SUD. Cox proportional hazards models were used to estimate adjusted hazard ratios (HRs) with 95% CIs in patients with PD and comorbid SMI or SUD compared to patients with PD only.

RESULTS

Mortality was increased in both in- and outpatients with PD. The overall SMR was 3.8 (95% CI 3.6-4.0). The highest SMR was estimated for unnatural causes of death (11.0, 95% CI 10.0-12.0), but increased also for natural causes of death (2.2, 95% CI 2.0-2.5). Comorbidity was associated with higher SMRs, particularly due to poisoning and suicide. Patients with comorbid PD & SUD had almost four times higher all-cause mortality HR than patients with PD only; young women had the highest HR.

CONCLUSION

The SMR was high in both in- and outpatients with PD, and particularly high in patients with comorbid PD & SUD. Young female patients with PD & SUD were at highest risk. The higher mortality in patients with PD cannot, however, fully be accounted for by comorbidity.

All-Cause Mortality of Hospital-Treated Borderline Personality Disorder: A Nationwide Cohort Study

Patients with borderline personality disorder (BPD) are known to present frequently in emergency rooms, and they have a high rate of suicide. The mortality rate of patients with BPD is still unclear. The Danish Psychiatric Central Research Register and The Danish Register for Causes of Death were used to identify patients with a first-ever diagnosis of BPD (ICD-10: F60.31) from 1995 through 2011 together with time and cause of death. A total of 10,545 patients with a BPD diagnosis were followed for a mean time of 7.98 years. A total of 547 deaths were registered. The standardized mortality ratio of patients with BPD compared to the general population was 8.3 (95% CI [7.6, 9.1]). More than three inpatient admissions per year or a comorbid diagnosis of substance use disorder correlated with a higher mortality rate. The increased mortality rate in patients with BPD treated in secondary care emphasizes that it is a severe mental disorder.

Daily Self-Monitoring of Symptoms and Skills Learning in Patients With Borderline Personality Disorder Through a Mobile Phone App: Protocol for a Pragmatic Randomized Controlled Trial

Background

Patient self-monitoring via mobile phones during psychotherapy can enhance and provide an overview of psychotherapeutic progress by graphically displaying current and previous symptom scores, providing feedback to the patient, delivering psychoeducative material, and providing timely data to the therapist or treatment team.

Objective

This study will aim to assess the effects of using a mobile phone to self-monitor symptoms and acquire coping skills instead of using pen and paper during psychotherapy in patients with borderline personality disorder (BPD). Dialectical behavior therapy will be performed to treat BPD. The primary outcome is the mean time needed to learn coping skills directed at emotion regulation; the secondary outcome is changes in the BPD symptom score as measured by the Zanarini Rating Scale for Borderline Personality Disorder.

Methods

This study is a pragmatic, multicenter randomized controlled trial. Participants were recruited through five public general psychiatric outpatient treatment facilities in Denmark. Patients are randomly assigned, on a 1:1 basis, to either the mobile phone condition (using the Monsenso mDiary mobile app) or pen-and-paper condition. Patients will complete several self-report questionnaires on symptom severity; assessments by trained raters on BPD severity will be performed as well. Survival analysis with a shared frailty model will be used to assess the primary outcome.

Results

Recruitment began in June 2017 and was completed in February 2019 after 80 participants were recruited. The study ended in February 2020. It is expected that the benefits of mobile phone–based self-report compared to the pen-and-paper method will be demonstrated for skill learning speed and registration compliance. To our knowledge, this is the first trial exploring the impact of cloud-based mobile registration in BPD treatment.

Conclusions

This trial will report on the effectiveness of mobile phone–based self-monitoring during psychiatric treatment. It has the potential to contribute to evidence-based clinical practice since apps are already in use clinically.

Trial Registration

ClinicalTrials.gov NCT03191565; https://clinicaltrials.gov/ct2/show/NCT03191565

International Registered Report Identifier (IRRID)

DERR1-10.2196/17737

The course of (comorbid) trauma-related, dissociative and personality disorders: two year follow up of the Friesland study cohort

Background: There is substantial comorbidity between trauma-related disorders (TRDs), dissociative disorders (DDs) and personality disorders (PDs), especially in patients who report childhood trauma and emotional neglect. However, little is known about the course of these comorbid disorders, despite the fact that this could be of great clinical importance in guiding treatment. Objective: This study describes the two-year course of a cohort of patients with (comorbid) TRDs, DDs and PDs and aims to identify possible predictors of course. Possible gender differences will be described, as well as features of non-respondents. Method: Patients (N = 150) referred to either a trauma treatment program or a PD treatment program were assessed using five structured clinical interviews for diagnosing TRDs, DDs, PDs and trauma histories. Three self-report questionnaires were used to assess general psychopathology, dissociative symptoms and personality pathology in a more dimensional way. Data on demographics and received treatment were obtained using psychiatric records. We described the cohort after a two-year follow-up and used t-tests or chi-square to test possible differences between respondents and non-respondents and between women and men. We used regression analysis to identify possible course predictors. Results: A total of 85 (56.7%) of the original 150 patients participated in the follow-up measurement. Female respondents reported more sexual abuse than female non-respondents. Six patients (4.0%; all women) died because of suicide. Levels of psychopathology significantly declined during the follow-up period, but only among women. Gender was the only significant predictor of change. Conclusions: Comorbidity between TRDs, DDs and PDs was more the rule than the exception, pleading for a more dimensional and integrative view on pathology following childhood trauma and emotional neglect. Courses significantly differed between men and women, advocating more attention to gender in treatment and future research.

Using a Mobile Diary App in the Treatment of Borderline Personality Disorder: Mixed Methods Feasibility Study

BACKGROUND

Borderline personality disorder (BPD) is a disorder characterized by difficulties with regulating emotions and impulsive behavior. Long-term monitoring of progress during BPD psychotherapy constitutes a challenge using paper and pencil registration. Hence, a mobile app assessing emotions and progress in treatment may be useful.

OBJECTIVE

The aim of this study was to examine the feasibility of using the mDiary app as an adjunct to dialectical behavior therapy (DBT) for the treatment of BPD.

METHODS

A total of 9 focus group interviews were conducted and analyzed according to the grounded theory approach. Furthermore, the usability of the mDiary app was examined using the System Usability Scale (SUS). The app was implemented in a standard DBT program as an adjunct to DBT. In total, 16 patients (age range 19-41 years) and 23 therapists (age range 25-64 years) from 5 Danish public outpatient psychiatric treatment facilities participated in the study.

RESULTS

Overall, patients were satisfied with the mDiary app, as it was "easy to use" and "always there." Inside-out innovation, meaning new work tasks generated during implementation and communication of modifications needed in the app, was found to influence the perceived usability negatively among the interviewed therapists. The patients rated the usability as high (mean SUS score 81.2, SD 9.9), whereas therapists rated the mDiary app at an average level (mean 68.3, SD 14.3). Older age of the users correlated with lower usability ratings on the SUS score (Pearson r=-0.60).

CONCLUSIONS

The mDiary app was considered as an acceptable and relevant way of registering DBT diary data for both patients and therapists generating increased long-term overview. Older users were overall more reluctant to accept this new technology in clinical practice. Time to align expectations among involved parties needs to be set aside when implementing this new approach to patient monitoring. Here, the focus should be on the realistic use of resources and expected impact on present clinical work.

Excessive mortality and causes of death among patients with personality disorder with comorbid psychiatric disorders

PURPOSE

Excessive mortality has been seen in patients with personality disorder (PD), but it has not been well-studied when patients also have other psychiatric comorbidities. This study investigated the mortality rates and causes of death in an Asian cohort with PD.

METHOD

We enrolled patients ≥ 18 years of age with PD as defined by DSM-IV criteria (N = 1172), who had been admitted to a psychiatric service center in northern Taiwan between 1985 and 2008. By linking with the national mortality database (1985-2008), cases of mortality (n = 156, 13.3%) were obtained. We calculated the standardized mortality ratios (SMRs) to estimate the mortality gap between patients with PD and the general population. Stratified analyses of mortality rates by Axis I psychiatric comorbidity and sex were performed.

RESULTS

Borderline PD (n = 391, 33.4%) was the dominant disorder among the subjects. The SMRs for all-cause mortality of PD alone, PD comorbid with non-substance use disorder(non-SUD), and PD comorbid with SUD were 4.46 (95% CI 1.94-6.98), 7.42 (5.99-8.85), and 15.96 (11.07-20.85), respectively. Among the causes of death, the SMR for suicide was the highest (46.92, 95% CI 34.29-59.56). The SMR for suicide in PD patients with comorbid SUD was unusually high (74.23, 95% CI 33.88-114.58). Women had a significant increase in suicide with an SMR of 59.00 (95% CI 37.89-80.11). Men had significant increase in SMRs for cardiovascular disease and gastrointestinal disease.

CONCLUSIONS

We found significant synergistic effects of PD and SUD on mortality risk. A personality assessment should be mandatory in all clinical settings to prevent premature death and detect SUD early.

Personality disorder: a disease in disguise

Personality disorders (PDs) can be described as the manifestation of extreme personality traits that interfere with everyday life and contribute to significant suffering, functional limitations, or both. They are common and are frequently encountered in virtually all forms of health care. PDs are associated with an inferior quality of life (QoL), poor health, and premature mortality. The aetiology of PDs is complex and is influenced by genetic and environmental factors. The clinical expression varies between different PD types; the most common and core aspect is related to an inability to build and maintain healthy interpersonal relationships. This aspect has a negative impact on the interaction between health-care professionals and patients with a PD. From being discrete and categorical disease entities in previous classification systems, the current concept of PD, reflected in the newly proposed ICD-11, is a dimensional description based on the severity of the disturbed functioning rather than on the type of clinical presentation. Insight about the characteristics of PDs among medical practitioners is limited, which is partly because persons do not seek health care for their PD, but instead for other medical issues which are obscured by their underlying personality problems. What needs to be emphasized is that PDs affect both the clinical presentation of other medical problems, and the outcome of these, in a negative manner and that the integrated effects of having a PD are a shortened life expectancy. Accordingly, PDs need to be recognized in clinical practice to a greater extent than previously.

Personality pathology and intentional self-harm: cross-cutting insights from categorical and dimensional models

This paper reviews current literature on the links between personality pathology and intentional self-harm, including nonsuicidal self-injury (NSSI) and suicidal behaviors. Specifically, this review highlights recent advances stemming from longitudinal, epidemiological, and health registry studies, as well as emerging research on pathological personality traits and intentional self-harm, and integrates current knowledge across dimensional and categorical frameworks to provide recommendations for clinical practice and future research. This review provides strong evidence that personality disorders marked by intense and unstable negative affect, detachment/low extraversion, aggression/hostility, and specific facets of impulsivity may be considered risk factors for suicidal behaviors. Further, there is some evidence of a stronger relation between maladaptive personality traits and suicidal versus non-suicidal intentional self-harm.

Mortality of young offenders: a national register-based follow-up study of 15- to 19-year-old Finnish delinquents referred for forensic psychiatric examination between 1980 and 2010

BACKGROUND

The mortality rate of young offenders is high. Furthermore, mortality in young offenders is associated with psychiatric and substance use disorders. The primary aim of this national register-based follow-up study was to investigate the mortality rate of Finnish delinquents who underwent a forensic psychiatric examination between 1980 and 2010. As delinquency is not a solid entity, we further aimed to compare the risk of premature death among different subgroups of the delinquents; violent versus non-violent offenders, offenders with alcohol use disorders versus those with no such diagnoses, offenders with schizophrenia spectrum disorders versus conduct- and personality-disordered offenders, under-aged versus young adult offenders, and, finally, boys versus girls.

METHODS

We collected the forensic psychiatric examination reports of all 15- to 19-year-old offenders who were born in Finland and had undergone the examination between 1.1.1980 and 31.12.2010 (n = 606) from the archives of the National Institute of Health and Welfare and retrospectively reviewed them. For each delinquent, four age-, gender- and place of birth-matched controls were randomly selected from the Central Population Register (n = 2424). The delinquents and their controls were followed until the end of 2015. The median follow-up time was 23.9 years (interquartile range 15.3-29.5). We obtained the mortality data from the causes of death register. Deaths attributable to a disease or an occupational disease were considered natural, and those attributable to an accident, suicide or homicide were considered unnatural.

RESULTS

By the end of the follow-up period, 22.1% (n = 134) of the delinquents and 3.4% (n = 82) of their controls had died (OR 8.11, 95% CI 6.05-10.86, p < 0.001). Among boys, 22.0% (n = 121) of the delinquents and 3.7% (n = 81) of the controls had died (OR 7.38, 95% CI 5.46-9.95, p < 0.001). Male delinquents' risk of unnatural death was almost 11-fold, of natural death more than twofold, and of unclear death more than fourfold compared to that of their controls. No girls had natural or unclear deaths, but 23.6% (n = 13) of the delinquents and 0.5% (n = 1) of the controls had died due to unnatural causes (OR 67.79, 95% CI 8.63-532.00, p < 0.001). The violent delinquents' risk of premature death was twice that of the non-violent delinquents. The other comparisons demonstrated no statistically significant differences between subgroups.

CONCLUSIONS

Even though the Finnish correction system prefers psychiatric treatment and rehabilitation over criminal sanctions, and the national health care system offers developmental-phase-specific psychiatric care, the mortality rate of delinquents, especially of those with a history of violent offences, is high. The excess mortality of offenders can be regarded as a specific public-health inequity that calls for more effective intervention procedures than those used thus far.

Suicide Rates After Discharge From Psychiatric Facilities: A Systematic Review and Meta-analysis

Importance

High rates of suicide after psychiatric hospitalization are reported in many studies, yet the magnitude of the increases and the factors underlying them remain unclear.

Objectives

To quantify the rates of suicide after discharge from psychiatric facilities and examine what moderates those rates.

Data Sources

English-language, peer-reviewed publications published from January 1, 1946, to May 1, 2016, were located using MEDLINE, PsychINFO, and EMBASE with the search terms ((suicid*).ti AND (hospital or discharg* OR inpatient or in-patient OR admit*).ab and ((mortality OR outcome* OR death*) AND (psych* OR mental*)).ti AND (admit* OR admis* or hospital* OR inpatient* OR in-patient* OR discharg*).ab. Hand searching was also done.

Study Selection

Studies reporting the number of suicides among patients discharged from psychiatric facilities and the number of exposed person-years and studies from which these data could be calculated.

Data Extraction and Synthesis

The meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. A random-effects model was used to calculate a pooled estimate of postdischarge suicides per 100 000 person-years.

Main Outcomes and Measures

The suicide rate after discharge from psychiatric facilities was the main outcome, and the association between the duration of follow-up and the year of the sampling were the main a priori moderators.

Results

A total of 100 studies reported 183 patient samples (50 samples of females, 49 of males, and 84 of mixed sex; 129 of adults or unspecified patients, 20 of adolescents, 19 of older patients, and 15 from long-term or forensic discharge facilities), including a total of 17 857 suicides during 4 725 445 person-years. The pooled estimate postdischarge suicide rate was 484 suicides per 100 000 person-years (95% CI, 422-555 suicides per 100 000 person-years; prediction interval, 89-2641), with high between-sample heterogeneity (I2 = 98%). The suicide rate was highest within 3 months after discharge (1132; 95% CI, 874-1467) and among patients admitted with suicidal ideas or behaviors (2078; 95% CI, 1512-2856). Pooled suicide rates per 100 000 patients-years were 654 for studies with follow-up periods of 3 months to 1 year, 494 for studies with follow-up periods of 1 to 5 years, 366 for studies with follow-up periods of 5 to 10 years, and 277 for studies with follow-up periods longer than 10 years. Suicide rates were higher among samples collected in the periods 1995-2004 (656; 95% CI, 518-831) and 2005-2016 (672; 95% CI, 428-1055) than in earlier samples.

Conclusions and Relevance

The immediate postdischarge period is a time of marked risk, but rates of suicide remain high for many years after discharge. Patients admitted because of suicidal ideas or behaviors and those in the first months after discharge should be a particular focus of concern. Previously admitted patients should be able to access long-term care and assistance.

Prevalence, Mortality, and Health Care Use among Patients with Cluster B Personality Disorders Clinically Diagnosed in Quebec: A Provincial Cohort Study, 2001-2012

BACKGROUND

Cluster B personality disorders (PDs) are prevalent mental health conditions in the general population (1%-6% depending on the subtype and study). Affected patients are known to be heavier users of both mental and medical health care systems than patients with other clinical conditions such as depression.

METHODS

Several rates were estimated using data from the integrated monitoring system for chronic diseases in the province of Quebec, Canada. It provides a profile of annual and period prevalence rates, mortality rates, and years of lost life as well as health care utilisation rates for Quebec residents. All Quebec residents are covered by a universal publicly managed care health plan. It is estimated that the monitoring system includes 99% of Quebec's 8 million inhabitants.

RESULTS

Quebec residents aged 14 years and older were included in the study. The lifetime prevalence of cluster B PDs was 2.6%. The mean years of lost life expectancy were 13 for men and 9 for women compared to the provincial population. The 3 most important causes of death are suicide (20.4%), cardiovascular diseases (19.1%), and cancers (18.6%). In 2011 to 2012, 78% had consulted a general practitioner and 62% a psychiatrist, 44% were admitted to an emergency department, and 22% were hospitalised.

CONCLUSIONS

Considering mortality, cluster B personality disorder is a severe condition, is highly prevalent in the population, and is associated with heavy health care services utilisation, especially in emergency settings.

Excess cause-specific mortality in in-patient-treated individuals with personality disorder: 25-year nationwide population-based study

BACKGROUND

Although personality disorders are associated with increased overall mortality, less is known about cause of death and personality type.

AIMS

To determine causes of mortality in ICD personality disorders.

METHOD

Based on data from Swedish nationwide registers, individuals admitted to hospital with a primary diagnosis of personality disorder between 1987 and 2011 were followed with respect to mortality until 31 December 2011. Standardised mortality ratios (SMRs) with 95% confidence intervals and underlying causes of death were calculated.

RESULTS

All-cause SMRs were increased, overall and in all clusters, for natural as well as unnatural causes of death. The overall SMR was 6.1 in women and 5.0 in men, as high as previously reported for anorexia nervosa, with higher rates in cluster B and mixed/other personality disorders. The SMR for suicide was 34.5 in women and 16.0 in men for cluster B disorders. Somatic and psychiatric comorbidity increased SMRs.

CONCLUSIONS

The SMR was substantially increased for all personality disorder clusters. Thus, there was an increased premature mortality risk for all personality disorders, irrespective of category.

Identifying risk of deliberate self-harm through longitudinal monitoring of psychological distress in an inpatient psychiatric population

BACKGROUND

While cross-sectional correlates of deliberate self-harm, such as psychological distress, have been identified; it is still difficult to predict which individuals experiencing distress will engage in deliberate self-harm, and when this may occur. Therefore, this study aimed to explore the ability of longitudinal measurements of psychological distress to predict deliberate self-harm in a psychiatric population.

METHOD

Participants (N = 933; age range 14-93 (M = 38.95, SD = 14.64; 70% female) were monitored daily in terms of suicidal ideation, depression, anxiety, worthlessness and perceptions of not coping. Latent Growth Curve Analysis was used to check if groups of inpatients reporting suicidal ideation, who shared early change in measures of psychological distress, existed. Logistic regression tested whether different groups were at higher (or lower) risks of deliberate self-harm.

RESULTS

Four groups were found. Of these, Non-Responders (high symptoms, remaining high) were more likely to engage in deliberate self-harm than patients with high, medium and low symptoms which improved over one week. Group membership was a greater predictor of deliberate self-harm than initial distress scores. Females and patients with personality disorders were significantly more likely to be Non-Responders.

CONCLUSIONS

Continuous monitoring and subsequent grouping of inpatients according to their early change in psychological distress provides a novel and practical approach to risk management. A lack of early improvement in psychological distress may indicate a higher risk of deliberate self-harm.

Mortality of firesetters: a follow-up study of Finnish male firesetters who underwent a pretrial forensic examination in 1973-1998

Little is known about mortality among firesetters. However, they hold many risk factors associated with elevated mortality. This study aimed to investigate mortality rates and patterns in the course of a 39-year follow-up of a consecutive sample (n=441) of pretrial male firesetters evaluated in a forensic psychiatric unit in Finland. For each firesetter, four controls matched for age, sex and place of birth were randomly selected from the Central Population Register. Mortality data was obtained from the Causes of Death statistics. By the end of the follow-up period, 48.0% of the firesetters and 22.0% of the controls had died (OR 2.47, 95% CI 2.00-3.05). Altogether, 24.1% of the firesetters and 17.6% of the control subjects had died of natural causes (OR 1.49, 95% CI 1.16-1.92), whereas 20.9% and 3.8% respectively, died an unnatural death (OR 6.71, 95% CI 4.79-9.40). Alcohol-related deaths were more frequent among firesetters than controls. Our findings confirm that fire-setting behavior is associated with high mortality. More attention must be paid to the treatment of suicidality, psychiatric comorbidities and alcohol use disorders within this group both during and after their sentences.