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Suicide in borderline personality disorder: A meta-analysis

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Suicide is the major cause of death among patients with borderline personality disorder; however, the literature on completed suicides in such disorder is inconclusive, as suicide rates vary greatly among cohorts of patients. We searched MedLine, Excerpta Medica and PsycLit from 1980 to 2005 to identify papers dealing with suicide in borderline personality disorder. We also searched the World Health Statistics Annual to ascertain the suicide rate in the age groups for specific years and country. We selected eight studies comprising 1179 patients with a diagnosis of borderline personality disorder. Of these patients, 94 committed suicide. Results obtained for each study were processed together to calculate the mean figure for each year of suicides for 100,000 individuals suffering from borderline personality disorder. Our meta-analysis shows that suicide among patients with borderline personality disorder is more frequent when compared with the general population. All study analyses reported that patients with borderline personality disorder committed suicide more often than their counterparts in the general population. Suicide seems more alarming in the first phases of follow-up than during chronic phases of illness.
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REVIEW ARTICLE
Suicide in borderline personality disorder:
A meta-analysis
MAURIZIO POMPILI, PAOLO GIRARDI, AMEDEO RUBERTO, ROBERTO TATARELLI
Pompili M, Girardi P, Ruberto A, Tatarelli R. Suicide in borderline personality disorder: A
meta-analysis. Nord J Psychiatry 2005;59:319
/324. Oslo. ISSN 0803-9488.
Suicide is the major cause of death among patients with borderline personality disorder;
however, the literature on completed suicides in such disorder is inconclusive, as suicide rates
vary greatly among cohorts of patients. We searched MedLine, Excerpta Medica and PsycLit
from 1980 to 2005 to identify papers dealing with suicide in borderline personality disorder. We
also searched the World Health Statistics Annual to ascertain the suicide rate in the age groups
for specific years and country. We selected eight studies comprising 1179 patients with a
diagnosis of borderline personality disorder. Of these patients, 94 committed suicide. Results
obtained for each study were processed together to calculate the mean figure for each year of
suicides for 100,000 individuals suffering from borderline personality disorder. Our meta-
analysis shows that suicide among patients with borderline personality disorder is more frequent
when compared with the general population. All study analyses reported that patients with
borderline personality disorder committed suicide more often than their counterparts in the
general population. Suicide seems more alarming in the first phases of follow-up than during
chronic phases of illness.
Borderline, Meta-analysis, Suicide.
Maurizio Pompili, Department of Psychiatry, Sant’Andrea Hospital, Via di Grottarossa,
1035-1039, 00189 Roma, Italy, E-mail: maurizio.pompili@uniroma1.it or mpompili@mclean.
harvard.edu; Accepted 25 May 2005.
T
he incidence of completed suicide in borderline
personality disorder (BPD) has been unknown
until recently. In two long-term follow-up studies of
borderline patients treated in residential settings,
McGlashan (1) and Stone et al. (2) found that 3%
and 9%, respectively, of borderline go on to complete
suicide.
Patients with BPD represent 9
/33% of all suicides
(3, 4). Mehlum et al. (5) pointed out that a lack of
control of high intensity affects such as depression,
anxiety or anger may increase the tendency towards
suicidal behavior. Thus the notion of BPD as ‘‘the
suicidal personality disorder’’ may be justified. On the
other hand, the self-destructive tendency in subjects with
BPD may not primarily be due to the personality
disorder (PD) syndrome itself, but rather be caused by
some secondary or coexisting Axis I mental disorder,
such as a mood disorder, anxiety disorder or substance
abuse. Or it may be viewed as a result of a complex
interplay between state and trait dimension. Comorbid-
ity with major depression is highly prevalent in BPD (6);
however, the effect of this comorbidity on suicidal
behavior is unclear. Comorbidity with major depressive
episode has been associated with an increased mortality
rate in some (1, 7) but not all (8
/10) studies of suicidal
behavior in BPD. Comorbidity with major depressive
episode has also been associated with an increase in the
seriousness and frequency of suicide attempts among
inpatients with BPD (6). Other studies have found that
comorbidity with major depressive episode is not pre-
dictive of a history of suicide attempts with BPD (11)
and have found no relationship between comorbid
major episode and measures of suicidal intent, lethality
or risk (12). Peterson & Bongar (13) studied patients
with chronic suicidality that made four or more visits
in a year to a psychiatric emergency room; most
often, these patients met criteria for BPD. Paris et al.
(8) found that the strongest clinical predictor of com-
pleted suicide was previous attempts, although very
often these gestures are manipulative. These authors
also observed that higher education was strongly asso-
ciated with completed suicide, which was explained by
the crushed expectations of an educated person with
severe psychopathology.
# 2005 Taylor & Francis DOI: 10.1080/08039480500320025
Crumley (14) has shown a high incidence of BPD in
the adolescents and young adults aged 15 /24 years who
engage in suicidal behavior. Paris & Zweig-Frank
(15) indicated that this diagnosis significantly increases
the risk of eventual suicide. Those at higher risk
appeared to be young, ranging from adolescence into
the third decade (2, 16). The high rates of suicidal
behavior in patients with BPD are reflected by the
inclusion of recurrent suicidal behavior, gestures, threats
or self-mutilating behavior as diagnostic criteria in
the DSM IV. Also, among patients with BPD, im-
pulsivity, assessed as a diagnostic criterion, is associated
with the number of suicide attempts independent of
comorbid depression or substance use disorder. Soloff
et al. (17) observed that hopelessness predicted the
lifetime number of suicide attempts and the degree of
lethal intent. Hopelessness may contribute to the ser-
iousness of suicidal behavior in BPD, especially in
patients with comorbid depression, by increasing the
number of attempts, the level of subjective intent and
the degree of objective planning. A relation has
been found between increased suicidal behavior and
comorbidity of substance abuse disorder with BPD (3,
11, 18). Links et al. (18) examined the prognostic
significance of comorbid substance abuse in patients
with BPD. The patients were followed prospectively over
a 7-year period. These researchers found that patients
with comorbid substance abuse and BPD perceived
themselves to be at significantly more risk for suicide
than did the comparison groups of patients having
BPD without comorbidity, patients having substance
abuse without BPD and patients having borderline traits
only.
Harris & Barraclough’s (19) comprehensive meta-
analysis on suicide as an outcome for mental disorders
included five studies dealing with suicide in personality
disorders. The five cohorts were mainly heterogeneous
spanning from the mid-1960s to the mid-1980s. These
authors combining the studies found a suicide risk seven
times the expected value.
Data concerning suicide among subjects with
BPD may be difficult to obtain because suicide statistics
are usually reported among many other variables.
Also, cohorts including only borderline patients and
followed up for a certain period of time are few;
this contrasts with the ever increasing availability of
data regarding suicidality among these patients. To our
knowledge, a meta-analytic investigation of suicide
among patients with a diagnosis of BPDs has still to
be performed in the international literature.
Materials and Methods
We conducted careful MedLine, Excerpta Medica
and PsycLit searches to identify papers in English
during the period 1980
/2005. The following search
terms were used: ‘‘suicid*’’ (which comprises suicide,
suicidal, suicidality and other suicide-related terms),
‘‘borderline’’ and ‘‘personality disorder’’. In addition,
each category was cross-referenced with the others
using the MeSH method (medical subject headings).
Study selection allowed the inclusion of only articles
published in peer-reviewed English-language journals.
Suicide of borderline patients is often reported among
cohorts of patients that received a diagnosis of person-
ality disorder. We avoided a systematic review of the
literature prior to 1980 because of diagnostic criteria
heterogeneity. Individuals analyzed in this study received
a diagnosis of BPD according to various diagnostic
criteria, mostly according to DSM-III or IV criteria
and were followed up or were studied retrospectively.
We excluded any study that reported suicide in border-
line patients as part of the analysis of suicidality
among individuals with personality disorders or with
any other psychiatric disorders. We also excluded
studies that mentioned data about suicide but were not
clear about follow-up times, method of statistical
analysis, diagnostic criteria and the number of patients
analyzed.
The World Health Organization publishes the World
Health Statistics Annual, a bulletin with the statistics of
all causes of death ismost countries worldwide. Each
cause of death is divided into age groups, providing for
each group rates and total number of male and female
deaths. Statistics in this bulletin are generally per
100,000 individuals.
For each study selected for our analysis, we searched
the Bulletin of the World Health Organization (WHO),
referring to the year of publication and the country
where the study was performed. We identified suicide
statistics for a specific year and country, and used only
those applicable to the age group indicated in the study.
A comparative analysis was performed in order to
ascertain whether suicide in BPD may be considered a
more frequent phenomenon in comparison to suicide
among the general population.
Results
We selected eight studies comprising 1179 patients.
In this group of patients, 94 had committed suicide.
Follow-up observation ranged from 3 to 27 years. Table
1 provides information about the studies that we used
for our analysis (1, 2, 7, 10, 15, 19
/21). Each study has
been positioned in the table in chronological order.
Table 1 also illustrates the results of our compara-
tive analysis. Fig. 1 shows distribution of suicides
among patients with BPD compared with the general
population of the same age group in accordance with
the country and year of publication of a specific
study.
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320 NORD J PSYCHIATRY×VOL 59 ×NO 5×2005
Table 1. Results of the meta-analysis.
No. of
studies
Author, year of publication and
diagnostic criteria (reference)
Size of
cohort
Follow-up
(years) Suicides
Expected suicides
in a year in 100,000
individuals if they
all suffered from
BPD
b
Expected suicide in a
year in a population
of 100,000
individuals (general
population)
Expected suicide
in a year in a
population of
100,000 males
Expected suicide
in a year in a
population of
100,000 females
Age groups researched
in the WHO Bulletin
in accordance with the
mean age of the
cohorts
1 Pope et al., 1983 (USA)
/ DSM-III (20) 33 3.5 2 1732 10.6 25.20 7.40 25/34
2 Akiskal et al., 1985 (USA) / DSM-III;
Gunderson-Singer (21)
100 3 4 1333 16.1
a
25.20 6.96 25/34
3 McGlashan, 1986 (USA)
/ DSM-III;
Gunderson criteria (1)
81 15 2 165 16.0
a
25.41 6.61 25/34
4 Stone et al., 1987 (USA) / DSM-III;
Kernberg criteria (2)
251 16 19 473 11.2 20.50 4.40 15/24
5 Stone, 1989 (USA) / DSM-III;
Kernberg criteria (7)
299 16.5 27 547 12.0 21.30 4.30 15 /24
6 Modestin and Villinger, 1989
(Switzerland); DSM-III (22)
26 4.6 2 1672 25.2
a
36.60 13.70 35/44
7 Kjelsberg et al., 1991 (Norway),
Gunderson criteria (10)
289 20 21 363 24.9 29.80 11.30 25/34
8 Paris and Zweig-Frank, 2001
(Canada), Gunderson criteria (15)
100 27 17 630 14.1 27.30 7.00 35
/44
Total 1179 105.6 94 6915 130.0
a
Not adjusted for gender.
b
The number of suicides was calculated as suicides/100,000/number of patients in the study/follow up. Mean of suicides in a population suffering from BPD (projection of a population of 100,000
individuals)
/898; standard deviation for a population suffering from BPD (projection of a population of 100,000 individuals)/660; mean of suicides expected in the general population (referring to
100,000 individuals)/16.6; standard deviation for the general population/6.
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UICIDE IN BORDERLINE PERSONALITY DISORDER
NORD J PSYCHIATRY×VOL 59 ×NO 5×2005 321
The results obtained for each study were processed
together to calculate the mean figure for each year of
suicides per 100,000 individuals suffering from BPD.
The mean of suicides expected in a population suffering
from BPD was calculated as follows: a[suicides (study
1)
/suicides (study 2)/ ... suicides (study 8)]/8. A
comparison between mean figure of suicide in patients
with BPD and in the general population has statistical
relevance and allowed us to draw statistically significant
results.
The standard deviation of a population suffering from
BPD has been calculated as follows:
s
ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
P
N
i1
(x
i
¯x)
2
N
s
Discussion
Suicide among patients with BPD is a major issue
and in some studies, the number of suicides is dis-
turbingly high. This is not a new finding, because
BPD, by definition (DSM-IV), is characterized by
‘‘recurrent suicidal behavior, gestures or threats, or
self-mutilating behavior’’. Nevertheless, our meta-
analysis showed that suicide among patients with
BPD is a heterogeneous phenomenon when different
cohorts are compared. Suicide was more frequent in all
cohorts analyzed compared with the general population.
Even more striking is, however, the great difference
among cohorts. It is difficult to recognize background
elements that precipitated suicide in these cohorts in a
given length of time. One possible finding emerging
from our study is the identification that the number of
suicides would appear to be higher in short-term follow-
ups. If this assumption were true, suicide risk would be
higher during the first phases of the taking care rather
than during the chronic phases of the illness.
Comorbidity of psychiatric and personality disorders
is increasingly recognized as a major factor in suicide.
Comorbid disorders, especially those belonging to
DSM-IV Axis I, may play a central role in precipitating
suicide in BPD and should always be indicated in studies
of mortality of these patients.
Our study has a number of limitations. Firstly,
papers included in this meta-analysis may be only a
part of the literature; we only used cohorts available
from studies published in medical journals, which may
exclude data available in other reports. Secondly, the
studies analyzed used different diagnostic criteria; these,
although similar to each other, may represent a source
of bias. One of the main problems of this study is
the heterogeneity of cohorts included in the meta-
analysis, which might be to some degree incompatible
with one another. DSM IV diagnostic criteria for
personality disorders are usually the most common for
1
10
100
1000
10000
12345678
Number of study
Patients with BPD
General population
Tren d
Tren d
Number of suicides (in a year in a population of
100,000 individuals)
Fig. 1. Distribution of suicides among patients with BPD compared with the general population of the same age group in
accordance with the country and year of publication of a specific study. Dashed line, general population; straight line, patients
with BPD.
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322 NORD J PSYCHIATRY×VOL 59 ×NO 5×2005
the assessment of patients. However, other diagnostic
criteria are sometimes preferred, as in the case of the
ICD classification or in the case of the Diagnostic
Interview for Borderlines (23). Also, other relevant
sources for diagnostic criteria are traceable in literature
(24, 25). The comorbidity with affective disorders
makes it difficult to ascertain whether suicidality is
caused by an Axis I or Axis II disorder, or both. Cohorts
analyzed generally had a variable ratio of male and
female as well as suicides in a given cohort presented
variable ratio of males and females. Also, some studies
do not provide clear data on the gender of patients
belonging to the cohort, which impairs a correct
comparison with the general population. We, therefore,
decided to compare the mean of the male and female
suicides in a given age group of the general population
for those studies with no clear indication on the gender
of suicide victims. This may reduce the role of gender in
the characterization of suicides, especially if cohorts
were made only or in a great proportion of males or
females. Also, follow-up time may play an important
role for reaching conclusions in the evaluation of
suicides in a cohort. In our meta-analysis of suicide in
BPD, we used studies with follow-up observation, which
varies greatly from one study to another. We compared
suicide of patients with BPD and those occurring in the
general population for the year of publication of each
study. In most cases, cohorts were analyzed years before
publication, making it difficult to ascertain when exactly
a suicide happened during the follow-up years. Meta-
analysis is a powerful tool that presents numerous
problems, some of them found in this investigation as
well (26).
The purpose of this study was to broaden the
knowledge of the magnitude of completed suicide in
BPD. Paris (27) pointed out that chronic suicidality is a
central feature of BPD; but whereas suicidal thoughts
and attempts are highly prevalent among these patients,
completion is relatively unpredictable. This is the first
meta-analysis of suicide in patients suffering from
BPD. Contrary to the expectation, in our meta-analysis,
suicide rates among patients with BPD are tremendously
heterogeneous. This might be related to various
reasons such as being inpatients or outpatients, comor-
bidity with affective disorders and substance abuse
disorder. Pompili et al. (28) reviewed papers dealing
with suicidality in patients with personality disorders.
These authors found that suicide is extremely repre-
sented among DSM IV cluster B personality disorders,
borderline being the most common disorder related to
suicide, affective disorders and substance abuse. Clearly
more knowledge about the prediction and prevention
of suicide in BPD is needed. In particular, future studies
are needed to clarify further the role of various factors
in mediating suicide risk. In fact, despite intensive
efforts, effective prediction and prevention strategies
have remained elusive, suggesting that our understand-
ing of the interplay of factors that eventuate in suicide in
BPD remains incomplete.
Acknowledgements */The authors thank Ing. Dr Stefano Zorzi for
statistical help and suggestions during the preparation of the
manuscript.
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Maurizio Pompili, M.D., Department of Psychiatry, Sant’ Andrea
Hospital, University of Rome ‘‘La Sapienza’’, Italy and McLean
Hospital, Harvard Medical School, Belmont, Massachusetts, USA.
Paolo Girardi, M.D., Department of Psychiatry, Sant’ Andrea
Hospital, University of Rome ‘‘La Sapienza’’, Italy.
Amedeo Ruberto, M.D., Department of Psychiatry, Sant’ Andrea
Hospital, University of Rome ‘‘La Sapienza’’, Italy.
Roberto Tatarelli, M.D., Department of Psychiatry, Sant’ Andrea
Hospital, University of Rome ‘‘La Sapienza’’, Italy.
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Background Borderline personality disorder is a major mental illness characterized by a sustained relationship instability, impulsive behavior and intense affects. Adherence is a complex behavior, from minor refusals of treatment to inappropriate use of health services or even abandonment of treatment, which can be affected by various factors. Therefore, the present study aimed to investigate the factors affecting pharmacological and non-pharmacological adherence in patients with borderline personality disorder referred to an outpatient referral clinic in Tehran, Iran. Methods The study was a retrospective cohort. The files of patients with borderline personality disorder referred to the outpatient clinic of the Tehran Psychiatric Institute were reviewed as the first step. In the next step, we contacted the patients and asked them to fill out the questionnaires. Data were collected using the Drug Attitude Inventory (DAI) questionnaire and a researcher made questionnaire to determine the attitude of patients toward pharmacological and non-pharmacological treatment and therapeutic adherence. After collecting data, patients’ therapeutic acceptance was divided into three groups: poor, partial, good compliance. The data were analyzed by SPSS software version-22. Results Ninety-four patients were involved in the study and fifty four of them were women. In terms of psychotherapy adherence, patients with higher education and hospital admission history have better compliance. Medication attitudes were negative in 54 patients (57.4%), while 40.4% of them stated that psychotherapy or counselling did not help their condition and showed a negative attitude toward non-pharmacological treatment. Additionally, psychotherapy good adherence of the patients (44.7%) was higher than medication good adherence (31.9%). The most common reasons for discontinuation of treatment were medication side effects (53.1%), dissatisfaction with the therapist (40.3%) and then fear of medication dependence (40%). The results showed no relationship between other demographic factors and treatment adherence. Conclusions Results of the current study show that attitude toward psychotherapy is more positive than pharmacotherapy. In addition, according to the results, working on changeable factors such as patients’ fear of dependence to medication, dissatisfaction with the therapist, and medication side effects may improve patients' treatment adherence.
... BPD is characterized by pervasive instability in the domains of affect regulation, attachment, behavior, and self-image (Lieb, Zanarini, Schmahl, Linehand, & Bohus, 2004). Patients with BPD have highly compromised psychosocial functioning (Gunderson et al., 2011;Mosiolek, Gierus, Koweszko, & Szule, 2018;Zanarini, Frankenburg, Reich, Fitzmaurice, 2010) and frequently manifest suicidal behaviors (Pompili, Girardi, Ruberto, & Tatarelli, 2005). BPD is often associated with early traumatic experiences, which are thought to play an important role in its genesis (Zanarini, 2000). ...
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