Predictors of Natural and Unnatural Mortality among Patients with Personality Disorder:Evidence from a Large UK Case register

People with personality disorder have reduced life expectancy, yet, within this population, little is known about the clinical predictors of natural and unnatural deaths. We set out to investigate this, using a large cohort of secondary mental health patients with personality disorder.We identified patients with an ICD-10 diagnosis of personality disorder, aged ≥15 years in a large secondary mental healthcare case register. The case register was linked to national mortality tracing. Using Cox regression, we modelled the effect of a number of pre-specified clinical variables on all-cause, natural cause and unnatural cause mortality.2,440 patients were identified. Eighty-five deaths (3.5% of cohort) occurred over a 5-year observation period, of which over 50% were from natural causes. All-cause mortality was associated with alcohol or drug use (adjusted Hazard Ratio [aHR] 2.3; 95% CI 1.3-4.1), physical illness (aHR 1.9; 95% CI 1.0-3.6), and functional impairment (aHR 1.9; 95% CI 1.0-3.6). Natural cause mortality was associated with mild problems of alcohol or drug use (aHR 3.4; 95% CI 1.5-7.4), and physical illness (aHR 2.4; 95% CI 1.0-5.6). Unnatural cause mortality was associated only with severe alcohol or drug use (aHR 3.1; 95% CI 1.3-7.3).Alcohol and drug use, physical illness, and functional impairment are predictors of mortality in individuals with personality disorder. Clinicians should be aware of the existence of problems in these domains, even at mild levels, when assessing the needs of patients with personality disorder

The Bipolar II depression questionnaire:A self-report Tool for detecting Bipolar II depression

Bipolar II (BP-II) depression is often misdiagnosed as unipolar (UP) depression, resulting in suboptimal treatment. Tools for differentiating between these two types of depression are lacking. This study aimed to develop a simple, self-report screening instrument to help distinguish BP-II depression from UP depressive disorder. A prototype BP-II depression questionnaire (BPIIDQ-P) was constructed following a literature review, panel discussions and a field trial. Consecutively assessed patients with a diagnosis of depressive disorder or BP with depressive episodes completed the BPIIDQ-P at a psychiatric outpatient clinic in Hong Kong between October and December 2013. Data were analyzed using discriminant analysis and logistic regression. Of the 298 subjects recruited, 65 (21.8%) were males and 233 (78.2%) females. There were 112 (37.6%) subjects with BP depression [BP-I = 42 (14.1%), BP-II = 70 (23.5%)] and 182 (62.4%) with UP depression. Based on family history, age at onset, postpartum depression, episodic course, attacks of anxiety, hypersomnia, social phobia and agoraphobia, the 8-item BPIIDQ-8 was constructed. The BPIIDQ-8 differentiated subjects with BP-II from those with UP depression with a sensitivity/specificity of 0.75/0.63 for the whole sample and 0.77/0.72 for a female subgroup with a history of childbirth. The BPIIDQ-8 can differentiate BP-II from UP depression at the secondary care level with satisfactory to good reliability and validity. It has good potential as a screening tool for BP-II depression in primary care settings. Recall bias, the relatively small sample size, and the high proportion of females in the BP-II sample limit the generalization of the results

Views on psychotherapy research among members of the Medical Psychotherapy Faculty of the Royal College of Psychiatrists

Aims and Method: Research drives innovation and improved practice in psychotherapy. We describe views of members of the Faculty of Medical Psychotherapy of the Royal College of Psychiatrists (RCPsych) regarding their knowledge, experience and perspectives on psychotherapy research. We sent questionnaires to the Faculty membership emailing list. Results: In total, 172 psychiatrists from all levels of training returned fully complete responses. Respondents considered knowledge of psychotherapy research to be important to clinical work. Many have qualifications and experience in research but lack current opportunities for research involvement and would welcome the Faculty doing more to promote psychotherapy research. Perceived obstacles to research involvement included lack of competence, competing demands and wider organisational factors. Clinical Implications: The lack of research opportunities for medical psychotherapists may lead to their underrepresentation in psychotherapy research and a less medically informed research agenda. Providing support at academic, RCPsych and National Health Service organisational levels will allow more clinically relevant research not only in psychotherapy but in other psychiatric disciplines as well

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

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

Cox regression analyses of factors associated with all-cause mortality amongst individuals with personality disorder.

†<p>Entered as a continuous variable in all models.</p>a<p>Demographic factors = age, gender, ethnicity, deprivation.</p><p>b Adjusted for demographic factors and all other variables that appear in this table.</p><p>*p<0.05;</p><p>**p<0.01;</p><p>***p<0.001.</p

Cohort characteristics and crude hazard ratios for association with all-cause mortality.

<p>*p<0.05;</p><p>**p<0.01;</p><p>***p<0.001.</p