Skip to main content

Advertisement

SpringerLink
Log in

The impact of co-morbid personality disorder on use of psychiatric services and involuntary hospitalization in people with severe mental illness

  • Original Paper
  • Published:
Social Psychiatry and Psychiatric Epidemiology Aims and scope Submit manuscript

Abstract

Purpose

To examine the impact of co-morbid personality disorder (PD), on inpatient and community-based service use and risk of involuntary hospitalization, amongst patients with severe mental illness (SMI).

Methods

We identified SMI cases (schizophrenia, schizoaffective and bipolar disorder) with and without co-morbid PD, and PD cases, aged ≥18 years, in a large secondary mental healthcare case register. Using multivariable logistic regression, we examined the association between co-morbid PD and high level of inpatient and community-based service use (defined as the top decile of service use), and involuntary hospitalization, respectively, adjusting for socio-demographics, clinical symptoms and social functioning.

Results

Severe mental illness patients with co-morbid PD (SMI-PD) (n = 961) had more severe symptoms and social functioning problems compared to SMI patients without PD (n = 10,963) and patients who had PD but no concurrent SMI (n = 2,309). A greater proportion of SMI-PD patients were high inpatient service users (22.4 vs. 10.1 %). This association was attenuated but remained significant, after adjustment (fully adjusted odds ratio, OR 2.31, 95 % CI 1.88–2.84). The association between SMI-PD and high community-based service use was confounded by symptoms and social functioning. Compared to patients with SMI, SMI-PD patients were significantly more likely to experience involuntary hospitalization (fully adjusted OR 1.56, 95 % CI 1.31–1.85).

Conclusions

In SMI patients, co-morbidity with PD is robustly associated with both high use of inpatient psychiatric services and an increased likelihood of involuntary hospitalization. Patients with SMI and co-morbid PD are likely to require tailored interventions that target both the underlying personality pathology as well as the Axis I disorder.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Zimmerman M, Rothschild L, Chelminski I (2005) The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry 162(10):1911–1918. doi:10.1176/appi.ajp.162.10.1911

    Article  PubMed  Google Scholar 

  2. Moran P, Walsh E, Tyrer P, Burns T, Creed F, Fahy T (2003) Does co-morbid personality disorder increase the risk of suicidal behaviour in psychosis? Acta Psychiatr Scand 107(6):441–448

    Article  PubMed  CAS  Google Scholar 

  3. Moran P, Walsh E, Tyrer P, Burns T, Creed F, Fahy T (2003) Impact of comorbid personality disorder on violence in psychosis: report from the UK700 trial. Br J Psychiatry 182:129–134

    Article  PubMed  Google Scholar 

  4. Fok M, Hotopf M, Stewart R, Hatch S, Hayes R, Moran P (2013) Personality disorder and self-rated health: a population-based cross-sectional survey. J Personal Disord. doi:10.1521/pedi_2013_27_119

    Google Scholar 

  5. Fok ML, Hayes RD, Chang CK, Stewart R, Callard FJ, Moran P (2012) Life expectancy at birth and all-cause mortality among people with personality disorder. J Psychosom Res 73(2):104–107. doi:10.1016/j.jpsychores.2012.05.001

    Article  PubMed  Google Scholar 

  6. Keown P, Holloway F, Kuipers E (2005) The impact of severe mental illness, co-morbid personality disorders and demographic factors on psychiatric bed use. Soc Psychiatry Psychiatr Epidemiol 40(1):42–49. doi:10.1007/s00127-005-0842-0

    Article  PubMed  Google Scholar 

  7. Tyrer P, Simmonds S (2003) Treatment models for those with severe mental illness and comorbid personality disorder. Br J Psychiatry Suppl 44:S15–S18

    Article  PubMed  Google Scholar 

  8. Hodgson RE, Lewis M, Boardman AP (2001) Prediction of readmission to acute psychiatric units. Soc Psychiatry Psychiatr Epidemiol 36(6):304–309

    Article  PubMed  CAS  Google Scholar 

  9. Valenstein M, Copeland LA, Blow FC, McCarthy JF, Zeber JE, Gillon L, Bingham CR, Stavenger T (2002) Pharmacy data identify poorly adherent patients with schizophrenia at increased risk for admission. Med Care 40(8):630–639. doi:10.1097/01.Mlr.0000021003.43524.64

    Article  PubMed  Google Scholar 

  10. Lay B, Lauber C, Rössler W (2006) Prediction of in-patient use in first-admitted patients with psychosis. Eur Psychiatry 21(6):401–409

    Article  PubMed  Google Scholar 

  11. Tulloch AD, Fearon P, David AS (2008) The determinants and outcomes of long-stay psychiatric admissions—a case-control study. Soc Psychiatry Psychiatr Epidemiol 43(7):569–574. doi:10.1007/s00127-008-0332-2

    Article  PubMed  Google Scholar 

  12. Salize HJ, Dressing H (2004) Epidemiology of involuntary placement of mentally ill people across the European Union. Br J Psychiatry 184:163–168

    Article  PubMed  Google Scholar 

  13. Kallert TW, Glockner M, Schutzwohl M (2008) Involuntary vs. voluntary hospital admission. A systematic literature review on outcome diversity. Eur Arch Psychiatry Clin Neurosci 258(4):195–209. doi:10.1007/s00406-007-0777-4

    Article  PubMed  Google Scholar 

  14. Stewart R, Soremekun M, Perera G, Broadbent M, Callard F, Denis M, Hotopf M, Thornicroft G, Lovestone S (2009) The South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLAM BRC) case register: development and descriptive data. BMC Psychiatry 9:51. doi:10.1186/1471-244x-9-51

    Article  PubMed  PubMed Central  Google Scholar 

  15. Hayes RD, Chang CK, Fernandes A, Begum A, To D, Broadbent M, Hotopf M, Stewart R (2012) Associations between symptoms and all-cause mortality in individuals with serious mental illness. J Psychosom Res 72(2):114–119. doi:10.1016/j.jpsychores.2011.09.012

    Article  PubMed  Google Scholar 

  16. Hayes RD, Chang CK, Fernandes AC, Begum A, To D, Broadbent M, Hotopf M, Stewart R (2012) Functional status and all-cause mortality in serious mental illness. PLoS ONE 7(9):e44613. doi:10.1371/journal.pone.0044613

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  17. World Health Organisation (2000) Manual of the international statistical classification of diseases and related health problems 10th revision (ICD-10)

  18. Cunningham H, Maynard D, Bontcheva K, Tablan V, Aswani N, Roberts I (2011) Text Processing with GATE (Version 6). University of Sheffield Department of Computer Science

  19. Orrell M, Yard P, Handysides J, Schapira R (1999) Validity and reliability of the Health of the Nation Outcome Scales in psychiatric patients in the community. Br J Psychiatry 174:409–412

    Article  PubMed  CAS  Google Scholar 

  20. Pirkis JE, Burgess PM, Kirk PK, Dodson S, Coombs TJ, Williamson MK (2005) A review of the psychometric properties of the Health of the Nation Outcome Scales (HoNOS) family of measures. Health Qual Life Outcomes 3:76. doi:10.1186/1477-7525-3-76

    Article  PubMed  PubMed Central  Google Scholar 

  21. Hunter R, Cameron R, Norrie J (2009) Using patient-reported outcomes in schizophrenia: the Scottish Schizophrenia Outcomes Study. Psychiatr Serv 60(2):240–245

    Article  PubMed  Google Scholar 

  22. Wing J, Curtis RH, Beevor A (1999) Health of the Nation Outcome Scales (HoNOS)–glossary for HoNOS score sheet. Br J Psychiatry 174:432–434. doi:10.1192/bjp.174.5.432

    Article  PubMed  CAS  Google Scholar 

  23. Stata Corporation: College Station T (2009) Stata Statistical Software, Release 11

  24. Barbato N, Hafner RJ (1998) Comorbidity of bipolar and personality disorder. Aust N Z J Psychiatry 32(2):276–280

    Article  PubMed  CAS  Google Scholar 

  25. Bahorik AL, Eack SM (2010) Examining the course and outcome of individuals diagnosed with schizophrenia and comorbid borderline personality disorder. Schizophr Res 124(1–3):29–35. doi:10.1016/j.schres.2010.09.005

    Article  PubMed  Google Scholar 

  26. Fan AH, Hassell J (2008) Bipolar disorder and comorbid personality psychopathology: a review of the literature. J Clin Psychiatr 69(11):1794–1803

    Article  Google Scholar 

  27. Moran P, Hodgins S (2004) The correlates of comorbid antisocial personality disorder in schizophrenia. Schizophr Bull 30(4):791–802

    Article  PubMed  Google Scholar 

  28. Hull JW, Yeomans F, Clarkin J, Li C, Goodman G (1996) Factors associated with multiple hospitalizations of patients with borderline personality disorder. Psychiatr Serv 47(6):638–641

    PubMed  CAS  Google Scholar 

  29. Haywood TW, Kravitz HM, Grossman LS, Cavanaugh JL, Davis JM, Lewis DA (1995) Predicting the revolving-door phenomenon among patients with schizophrenic, schizoaffective, and affective-disorders. Am J Psychiatry 152(6):856–861

    PubMed  CAS  Google Scholar 

  30. Olfson M, Mechanic D, Boyer CA, Hansell S, Walkup J, Weiden PJ (1999) Assessing clinical predictions of early rehospitalization in schizophrenia. J Nerv Ment Dis 187(12):721–729

    Article  PubMed  CAS  Google Scholar 

  31. Kent S, Yellowlees P (1995) The relationship between social-factors and frequent use of psychiatric-services. Aust N Z J Psychiatry 29(3):403–408. doi:10.3109/00048679509064947

    Article  PubMed  CAS  Google Scholar 

  32. Postrado LT, Lehman AF (1995) Quality of life and clinical predictors of rehospitalization of persons with severe mental illness. Psychiatr Serv 46(11):1161–1165

    PubMed  CAS  Google Scholar 

  33. Bender DS, Dolan RT, Skodol AE, Sanislow CA, Dyck IR, McGlashan TH, Shea MT, Zanarini MC, Oldham JM, Gunderson JG (2001) Treatment utilization by patients with personality disorders. Am J Psychiatry 158(2):295–302

    Article  PubMed  CAS  Google Scholar 

  34. Kasen S, Cohen P, Skodol AE, First MB, Johnson JG, Brook JS, Oldham JM (2007) Comorbid personality disorder and treatment use in a community sample of youths: a 20-year follow-up. Acta Psychiatr Scand 115(1):56–65. doi:10.1111/j.1600-0447.2006.00842.x

    Article  PubMed  CAS  Google Scholar 

  35. Hayward M, Slade M, Moran PA (2006) Personality disorders and unmet needs among psychiatric inpatients. Psychiatr Serv 57(4):538–543. doi:10.1176/appi.ps.57.4.538

    Article  PubMed  Google Scholar 

  36. Magallon-Neri EM, Canalda G, De la Fuente JE, Forns M, Garcia R, Gonzalez E, Castro-Fornieles J (2012) The influence of personality disorders on the use of mental health services in adolescents with psychiatric disorders. Compr Psychiatry 53(5):509–515. doi:10.1016/j.comppsych.2011.08.005

    Article  PubMed  Google Scholar 

  37. Volavka J, Citrome L (2011) Pathways to aggression in schizophrenia affect results of treatment. Schizophr Bull 37(5):921–929. doi:10.1093/schbul/sbr041

    Article  PubMed  PubMed Central  Google Scholar 

  38. National Institute for Health and Care Excellence (2009) Borderline personality disorder: the NICE Guideline on Treatment and Management (CG78). National Institute for Health and Care Excellence, London

  39. Cutting J, Cowen PJ, Mann AH, Jenkins R (1986) Personality and psychosis: use of the standardized assessment of personality. Acta Psychiatr Scand 73(1):87–92

    Article  PubMed  CAS  Google Scholar 

  40. Pilgrim J, Mann A (1990) Use of the ICD-10 version of the standardized assessment of personality to determine the prevalence of personality disorder in psychiatric in-patients. Psychol Med 20(4):985–992

    Article  PubMed  CAS  Google Scholar 

  41. Keown P, Holloway F, Kuipers E (2002) The prevalence of personality disorders, psychotic disorders and affective disorders amongst the patients seen by a community mental health team in London. Soc Psychiatry Psychiatr Epidemiol 37(5):225–229. doi:10.1007/s00127-002-0533-z

    Article  PubMed  Google Scholar 

  42. Newton-Howes G, Tyrer P, Anagnostakis K, Cooper S, Bowden-Jones O, Weaver T (2010) The prevalence of personality disorder, its comorbidity with mental state disorders, and its clinical significance in community mental health teams. Soc Psychiatry Psychiatr Epidemiol 45(4):453–460. doi:10.1007/s00127-009-0084-7

    Article  PubMed  Google Scholar 

  43. Leontieva L, Gregory R (2013) Characteristics of patients with borderline personality disorder in a state psychiatric hospital. J Pers Disord 27(2):222–232. doi:10.1521/pedi_2013_27_078

    Article  PubMed  Google Scholar 

  44. Hesse M, Moran P (2010) Screening for personality disorder with the standardised assessment of personality: abbreviated scale (SAPAS): further evidence of concurrent validity. BMC Psychiatry 10:10. doi:10.1186/1471-244X-10-10

    Article  PubMed  PubMed Central  Google Scholar 

  45. Henderson C, Flood C, Leese M, Thornicroft G, Sutherby K, Szmukler G (2004) Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial. Br Med J 329(7458):136A–138A. doi:10.1136/bmj.38155.585046.63

    Article  Google Scholar 

Download references

Acknowledgments

The development of the SLAM BRC Case Register has been funded by two Capital Awards from the UK National Institute for Health Research (NIHR) and is further supported through the BRC Nucleus funded jointly by the Guy’s and St Thomas’ Charity and South London and Maudsley Special Trustees. MF is undertaking this research with funding by a project grant from the Maudsley Charity. CKC and RS are part-funded by NIHR BRC at South London and Maudsley NHS Foundation Trust and King’s College London. RH is supported by a Medical Research Council (MRC) Population Health Scientist Fellowship. On behalf of all authors, the corresponding author states that there is no conflict of interest.

Author information

Authors and Affiliations

  1. Health Services & Population Research Department, Institute of Psychiatry, King’s College London, London, UK

    Marcella Lei-Yee Fok & Paul Moran

  2. Department of Psychological Medicine, Institute of Psychiatry, King’s College London, London, UK

    Robert Stewart & Richard D. Hayes

Authors
  1. Marcella Lei-Yee Fok
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Robert Stewart
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Richard D. Hayes
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Paul Moran
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Paul Moran.

Additional information

R. D. Hayes and P. Moran are joint senior authors.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Fok, M.LY., Stewart, R., Hayes, R.D. et al. The impact of co-morbid personality disorder on use of psychiatric services and involuntary hospitalization in people with severe mental illness. Soc Psychiatry Psychiatr Epidemiol 49, 1631–1640 (2014). https://doi.org/10.1007/s00127-014-0874-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00127-014-0874-4

Keywords

Search

Navigation