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

Abstract

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.

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References

  1. 1.

    Weissman MM (1993) The epidemiology of personality disorders: a 1990 update. J Pers Disord 7:44–62

    Google Scholar 

  2. 2.

    Samuels JF, Nestadt G, Romanoski AJ, Folstein MF, McHugh PR (1994) DSM-III personality disorders in the community. Am J Psychiatry 151(7):1055–1062

    CAS  PubMed  Article  Google Scholar 

  3. 3.

    Sadock BJ, Sadock VA, Ruiz P (2015) Synopsis of psychiatry, 11th ed. Wolters Kluwer, alphen aan den rijn, pp 742–762

    Google Scholar 

  4. 4.

    Perry JC, Banon E, Ianni F (1999) Effectiveness of psychotherapy for personality disorders. Am J Psychiatry 156(9):1312–1321. https://doi.org/10.1176/ajp.156.9.1312

    CAS  PubMed  Article  Google Scholar 

  5. 5.

    Stone MH (1993) Long-term outcome in personality disorders. Br J Psychiatry 162:299–313

    CAS  PubMed  Article  Google Scholar 

  6. 6.

    Bukh JD, Andersen PK, Kessing LV (2016) Personality and the long-term outcome of first-episode depression: a prospective 5-year follow-up study. J Clin Psychiatry 77(6):e704–e710

    PubMed  Article  Google Scholar 

  7. 7.

    Association AP (2013) Diagnostic and statistical manual of mental disorders. American Psychiatric Association, Washington

    Google Scholar 

  8. 8.

    Organization WH (1992) International classification of mental and behavioral disorders (ICD-10). Geneva, Switzerland

  9. 9.

    Bjorkenstam E, Bjorkenstam C, Holm H, Gerdin B, Ekselius L (2015) Excess cause-specific mortality in in-patient-treated individuals with personality disorder: 25-year nationwide population-based study. Br J Psychiatry 207(4):339–345

    PubMed  Article  Google Scholar 

  10. 10.

    Chesney E, Goodwin GM, Fazel S (2014) Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry 13(2):153–160. https://doi.org/10.1002/wps.20128

    PubMed  PubMed Central  Article  Google Scholar 

  11. 11.

    Grigoletti L, Perini G, Rossi A, Biggeri A, Barbui C, Tansella M, Amaddeo F (2009) Mortality and cause of death among psychiatric patients: a 20-year case-register study in an area with a community-based system of care. Psychol Med 39(11):1875–1884

    CAS  PubMed  Article  Google Scholar 

  12. 12.

    Eaton WW, Roth KB, Bruce M, Cottler L, Wu L, Nestadt G, Ford D, Bienvenu OJ, Crum RM, Rebok G, Anthony JC, Munoz A (2013) The relationship of mental and behavioral disorders to all-cause mortality in a 27-year follow-up of 4 epidemiologic catchment area samples. Am J Epidemiol 178(9):1366–1377

    PubMed  PubMed Central  Article  Google Scholar 

  13. 13.

    Nordentoft M, Wahlbeck K, Hallgren J, Westman J, Osby U, Alinaghizadeh H, Gissler M, Laursen TM (2013) Excess mortality, causes of death and life expectancy in 270,770 patients with recent onset of mental disorders in Denmark, Finland and Sweden. PLoS One 8(1):e55176

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  14. 14.

    Allebeck P, Allgulander C, Fisher LD (1988) Predictors of completed suicide in a cohort of 50,465 young men: role of personality and deviant behaviour. BMJ 297(6642):176–178

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  15. 15.

    Cheng AT, Mann AH, Chan KA (1997) Personality disorder and suicide. A case-control study. Br J Psychiatry 170:441–446

    CAS  PubMed  Article  Google Scholar 

  16. 16.

    Cailhol L, Pelletier E, Rochette L, Laporte L, David P, Villeneuve E, Paris J, Lesage A (2017) Prevalence, mortality, and health care use among patients with cluster B personality disorders clinically diagnosed in quebec: a provincial cohort study, 2001–2012. Can J Psychiatry 62(5):336–342

    PubMed  PubMed Central  Article  Google Scholar 

  17. 17.

    Arsenault-Lapierre G, Kim C, Turecki G (2004) Psychiatric diagnoses in 3275 suicides: a meta-analysis. BMC Psychiatry 4:37. https://doi.org/10.1186/1471-244X-4-37

    PubMed  PubMed Central  Article  Google Scholar 

  18. 18.

    Crump C, Sundquist K, Winkleby MA, Sundquist J (2013) Mental disorders and risk of accidental death. Br J Psychiatry 203(3):297–302

    PubMed  Article  Google Scholar 

  19. 19.

    Fazel S, Wolf A, Fiminska Z, Larsson H (2016) Mortality, rehospitalisation and violent crime in forensic psychiatric patients discharged from hospital: rates and risk factors. PLoS One 11(5):e0155906

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  20. 20.

    Black DW, Baumgard CH, Bell SE, Kao C (1996) Death rates in 71 men with antisocial personality disorder. A comparison with general population mortality. Psychosomatics 37(2):131–136

    CAS  PubMed  Article  Google Scholar 

  21. 21.

    Fok ML, Stewart R, Hayes RD, Moran P (2014) Predictors of natural and unnatural mortality among patients with personality disorder: evidence from a large UK case register. PLoS One 9(7):e100979

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  22. 22.

    Hoye A, Jacobsen BK, Hansen V (2013) Sex differences in mortality of admitted patients with personality disorders in North Norway–a prospective register study. BMC Psychiatry 13:317

    PubMed  PubMed Central  Article  Google Scholar 

  23. 23.

    Penzenstadler L, Kolly S, Rothen S, Khazaal Y, Kramer U (2018) Effects of substance use disorder on treatment process and outcome in a ten-session psychiatric treatment for borderline personality disorder. Subst Abuse Treat Prev Policy 13(1):10. https://doi.org/10.1186/s13011-018-0145-6

    PubMed  PubMed Central  Article  Google Scholar 

  24. 24.

    Trull TJ, Sher KJ, Minks-Brown C, Durbin J, Burr R (2000) Borderline personality disorder and substance use disorders: a review and integration. Clin Psychol Rev 20(2):235–253

    CAS  PubMed  Article  Google Scholar 

  25. 25.

    Kienast T, Stoffers J, Bermpohl F, Lieb K (2014) Borderline personality disorder and comorbid addiction: epidemiology and treatment. Dtsch Arztebl Int 111(16):280–286. https://doi.org/10.3238/arztebl.2014.0280

    PubMed  PubMed Central  Article  Google Scholar 

  26. 26.

    Chen CC, Kuo CJ, Tsai SY (2001) Causes of death of patients with substance dependence: a record-linkage study in a psychiatric hospital in Taiwan. Addiction 96(5):729–736. https://doi.org/10.1080/09652140020039099

    CAS  PubMed  Article  Google Scholar 

  27. 27.

    Kuo CJ, Liao YT, Chen WJ, Tsai SY, Lin SK, Chen CC (2011) Causes of death of patients with methamphetamine dependence: a record-linkage study. Drug Alcohol Rev 30(6):621–628

    PubMed  Article  Google Scholar 

  28. 28.

    Kuo CJ, Tsai SY, Liao YT, Conwell Y, Lin SK, Chang CL, Chen CC, Chen WJ (2011) Risk and protective factors for suicide among patients with methamphetamine dependence: a nested case-control study. J Clin Psychiatry 72(4):487–493

    PubMed  Article  Google Scholar 

  29. 29.

    Pan CH, Jhong JR, Tsai SY, Lin SK, Chen CC, Kuo CJ (2014) Excessive suicide mortality and risk factors for suicide among patients with heroin dependence. Drug Alcohol Depend 145:224–230

    PubMed  Article  Google Scholar 

  30. 30.

    Tsai SY, Kuo CJ, Chen CC, Lee HC (2002) Risk factors for completed suicide in bipolar disorder. J Clin Psychiatry 63(6):469–476

    PubMed  Article  PubMed Central  Google Scholar 

  31. 31.

    Kuo CJ, Tsai SY, Lo CH, Wang YP, Chen CC (2005) Risk factors for completed suicide in schizophrenia. J Clin Psychiatry 66(5):579–585

    PubMed  Article  Google Scholar 

  32. 32.

    Lin SK, Hung TM, Liao YT, Lee WC, Tsai SY, Chen CC, Kuo CJ (2014) Protective and risk factors for inpatient suicides: a nested case-control study. Psychiatry Res 217(1–2):54–59

    PubMed  Article  Google Scholar 

  33. 33.

    American Psychiatric Association (1987) Diagnostic and statistical manual of mental disorders, 3rd edn. Revised. American Psychiatric Association, Washington

    Google Scholar 

  34. 34.

    American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders, 4th edn. American Psychiatric Association, Washington

    Google Scholar 

  35. 35.

    World Health Organization (1978) International classification of diseases, ninth revision, clinical modification (ICD-9-CM), vol 1. WHO, Geneva

    Google Scholar 

  36. 36.

    Lee ET (1992) Statistical methods for survival data analysis. Wiley, New York

    Google Scholar 

  37. 37.

    Breslow NE, Day NE (1987) Statistical methods in cancer research. Volume II–The design and analysis of cohort studies. IARC Sci Publ 82:1–406

  38. 38.

    Roberts E, Wessely S, Chalder T, Chang CK, Hotopf M (2016) Mortality of people with chronic fatigue syndrome: a retrospective cohort study in England and Wales from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Clinical Record Interactive Search (CRIS) Register. Lancet 387(10028):1638–1643

    PubMed  Article  Google Scholar 

  39. 39.

    Bjorkenstam C, Bjorkenstam E, Gerdin B, Ekselius L (2015) Excess cause-specific mortality in out-patients with personality disorder. Br J Psych Open 1(1):54–55

    Article  Google Scholar 

  40. 40.

    Bjorkenstam C, Ekselius L, Berlin M, Gerdin B, Bjorkenstam E (2016) Suicide risk and suicide method in patients with personality disorders. J Psychiatr Res 83:29–36

    PubMed  Article  PubMed Central  Google Scholar 

  41. 41.

    Ostergaard MLD, Nordentoft M, Hjorthoj C (2017) Associations between substance use disorders and suicide or suicide attempts in people with mental illness: a Danish nation-wide, prospective, register-based study of patients diagnosed with schizophrenia, bipolar disorder, unipolar depression or personality disorder. Addiction 112(7):1250–1259

    PubMed  Article  Google Scholar 

  42. 42.

    Nyhlen A, Fridell M, Backstrom M, Hesse M, Krantz P (2011) Substance abuse and psychiatric co-morbidity as predictors of premature mortality in Swedish drug abusers: a prospective longitudinal study 1970–2006. BMC Psychiatry 11:122

    PubMed  PubMed Central  Article  Google Scholar 

  43. 43.

    Bogdanowicz KM, Stewart R, Broadbent M, Hatch SL, Hotopf M, Strang J, Hayes RD (2015) Double trouble: Psychiatric comorbidity and opioid addiction-all-cause and cause-specific mortality. Drug Alcohol Depend 148:85–92

    PubMed  Article  Google Scholar 

  44. 44.

    Hung GC, Cheng CT, Jhong JR, Tsai SY, Chen CC, Kuo CJ (2015) Risk and protective factors for suicide mortality among patients with alcohol dependence. J Clin Psychiatry 76(12):1687–1693

    PubMed  Article  Google Scholar 

  45. 45.

    Kuo CJ, Tsai SY, Liao YT, Conwell Y, Lee WC, Huang MC, Lin SK, Chen CC, Chen WJ (2012) Elevated aspartate and alanine aminotransferase levels and natural death among patients with methamphetamine dependence. PLoS One 7(1):e29325

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  46. 46.

    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

    PubMed  Article  Google Scholar 

  47. 47.

    De Hert M, Cohen D, Bobes J, Cetkovich-Bakmas M, Leucht S, Ndetei DM, Newcomer JW, Uwakwe R, Asai I, Moller HJ, Gautam S, Detraux J, Correll CU (2011) Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry 10(2):138–151

    PubMed  Article  Google Scholar 

  48. 48.

    Lohman MC, Whiteman KL, Yeomans FE, Cherico SA, Christ WR (2017) Qualitative analysis of resources and barriers related to treatment of borderline personality disorder in the United States. Psychiatr Serv 68(2):167–172

    PubMed  Article  Google Scholar 

  49. 49.

    Moran P (1999) The epidemiology of antisocial personality disorder. Soc Psychiatry Psychiatr Epidemiol 34(5):231–242

    CAS  PubMed  Article  Google Scholar 

  50. 50.

    Khalili M, Rahimi-Movaghar A, Shadloo B, Mojtabai R, Mann K, Amin-Esmaeili M (2018) Global scientific production on illicit drug addiction: a two-decade analysis. Eur Addict Res 24(2):60–70

    PubMed  Article  Google Scholar 

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Acknowledgements

The authors thank Yin Chi Chen, BS, with the Department of General Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital, for data management and help with the statistical analyses. Ms. Chen declares that she has no competing interests. The authors thank Formosa Medical Editors for assistance with manuscript preparation.

Funding

This research was supported by grants from the Ministry of Science and Technology, Taiwan (NSC 102-2628-B-532-001-MY3 and MOST 105-2314-B-532-006-MY3) and Taipei City Hospital (10001-62-005, 10501-62-015, and 10601-62-002). The funding sources had no involvement in the study design, data collection, analysis, interpretation of data, writing of the report, or the decision to submit the paper for publication.

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K and CCC conceived and designed the study. CCC acquired the data. K performed the statistical analysis. C provided administrative and material support. CCC, WYC, and K drafted the manuscript. T and PHC made critical revisions to the manuscript for important intellectual content, and K and CCC supervised the study.

Corresponding author

Correspondence to Chiao-Chicy Chen.

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The authors declare that they have no competing interests.

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Kuo, C., Chen, W., Tsai, S. et al. Excessive mortality and causes of death among patients with personality disorder with comorbid psychiatric disorders. Soc Psychiatry Psychiatr Epidemiol 54, 121–130 (2019). https://doi.org/10.1007/s00127-018-1587-x

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Keywords

  • Cause of death
  • Comorbidity
  • Personality disorder
  • Standard mortality ratio
  • Substance use disorder