Clinical Summary
Clinical Summary: Deaths by Suicide and Other Causes Among Patients With Borderline Personality Disorder and Personality-Disordered Comparison Subjects Over 24 Years of Prospective Follow-Up
Clinicians often focus on suicide risk in borderline personality disorder, but this study shows that premature death from other causes is even more common over long-term follow-up. For patients with borderline personality disorder, failure to achieve recovery tracked with a striking concentration of both suicide and non-suicide deaths, making medical risk surveillance part of psychiatric care.
Design
The current study is part of the McLean Study of Adult Development, a multifaceted longitudinal study of the course of BPD.
N
A total of 290 adult inpatients meeting rigorous Revised Diagnostic Interview for Borderlines and DSM-III-R criteria for BPD and 72 personality-disordered comparison subjects
Population
all subjects were initially inpatients at McLean Hospital in Belmont, Massachusetts, between June 1992 and December 1995
Duration
over 24 years of prospective follow-up
Key Findings
- Among borderline patients, 14.0% died by non-suicide causes over follow-up, compared with 5.9% who died by suicide.
- Suicide mortality was 5.9% for patients with BPD versus 1.4% for comparison subjects; the between-group difference in time-to-suicide was nonsignificant (HR = 4.42, P = .150).
- Premature death not due to suicide occurred in 14.0% of borderline patients versus 5.5% of comparison subjects; the between-group difference in incidence and time-to-death was nonsignificant (HR = 2.93, P = .144).
- For completed suicide in borderline patients, the only significant baseline predictor was number of hospitalizations before index admission (HR = 1.62, P = .037).
- In multivariate analyses predicting premature death not due to suicide in borderline patients, male sex (HR = 3.56, P = .003) and more prior psychiatric hospitalizations (HR = 2.93, P < .001) remained significant; 87.5% of those who died by suicide and 87.5% of those who died by other causes had never achieved recovery (χ21 = 16.11, P < .0001; n = 16 and n = 24, respectively).
Clinical Bottom Line
In borderline personality disorder, premature non-suicide death exceeded suicide over 24 years, and the patients at highest risk were disproportionately those who never recovered. Long-term management should treat medical morbidity and illness severity as core mortality issues, not secondary concerns.
Practice Implications
- Do not limit mortality prevention in borderline personality disorder to suicide assessment; incorporate ongoing evaluation of cardiovascular risk, substance-related harm, obesity, and accident risk because non-suicide deaths reached 14.0%.
- Use a history of more prior psychiatric hospitalizations as a high-value warning sign: it predicted completed suicide (HR = 1.62, P = .037) and also premature non-suicide death (HR = 2.93, P < .001).
- Pay particular attention to medically vulnerable male patients with borderline personality disorder, as male sex was an independent predictor of premature non-suicide death (HR = 3.56, P = .003).
- Prioritize interventions tied to recovery and modifiable risk burden, including health behaviors, psychiatric medication burden, and referral for substance abuse treatment, because 87.5% of borderline patients who died had never achieved recovery.
