Borderline Personality Disorder With Depression Raises Risk of Suicide Attempts in Mood Disorder Patients

Marked differences in the lifetime prevalence and severity of suicidal ideation and behavior among patients with major depressive episodes, diagnosis of bipolar disorder (BD), or presence of comorbid borderline personality disorder (BPD) were observed in a study published in Frontiers in Psychiatry.

Suicidal behavior is highly prevalent in BD and BPD, and the suicidal process can be theorized as potentially progressing from ideation to attempt or death. Researchers investigated the current and lifetime prevalence and risk factors of suicide attempts amo­­­ng patients with major depressive episodes in major depressive disorder (MDD) or BD, with or without comorbid BPD.

This observational cohort study conducted in Helsinki, Finland enrolled 124 psychiatric outpatients with major depressive episodes aged 18 to 50 years. Patients were then stratified into 3 principal diagnosis subgroups using structured interviews: MDD with no BPD (n=50); BD (n=43); and BPD with major depressive episodes (n=31). The severity of patients’ suicidal ideation and behavior was examined with the Columbia Suicide Severity Rating Scale. Categories for both the severity of BPD symptoms and BD mixed features were classified as no or mild suicidal ideation; severe ideation without attempts; and suicide attempts.

There were no significant differences between the 3 patient subgroups in age, gender, age, hopelessness, severity of depression, level of functioning or perceived social support. Although the majority of the patients were treated with pharmacotherapy (79%), they differed in use of antipsychotics, used by 10%, 30%, and 16%; mood stabilizers, used by 4%, 26%, and 10%, and antidepressants, used by 74%, 56%, and 87% of the MDD, BD, and BPD subgroups, respectively.

The lifetime prevalence of suicide attempts differed significantly (P <.001), with attempts reported by 16% of the MDD, 30% of the BD, and 60% of the BPD subgroups. Notably, the lifetime prevalence of suicide attempts was over 90% in patients with comorbid BD and BPD. There were also significant differences between the subgroups for suicidal behavior and nonsuicidal self-injury (P <.001). When investigating risk factors for suicidal ideation and attempts, multinomial logistic regression models revealed that hopelessness was independently correlated with previous attempts and severe suicidal ideation, whereas increased severity of depressive symptoms, younger age, and features of BPD were correlated with an increased risk of previous attempts.

Furthermore, severity of recent suicidal ideation was significantly correlated to borderline personality disorder severity (Pearson correlation, 0.383; P <.001), which remained significant among BPD (Pearson correlation, 0.586; P <.001) and non-BPD patients (Pearson correlation, 0.278; P =.012).

Limitations of the study included the small sample size, retrospective evaluations, and deliberate focus on proximal, rather than temporally distal, risk factors.

The researchers concluded that “severity of BPD features is a central modifiable risk factor for suicidal behavior and ideation among mood disorder patients. Thus, measuring this severity reliably should be implemented in future suicidological research. Clinically, assessment of borderline features may advance evaluation of suicide risk, and their treatment help suicide prevention.”

Reference

Soderholm JJ, Socada JL, Rosenstrom T, Ekelund J, Isometsa ET. Borderline personality disorder with depression confers significant risk of suicidal behavior in mood disorder patients-a comparative study (published online April 21, 2020). Front Psychiatry. doi: 10.3389/fpsyt.2020.00290.