How to Identify Suicide Risk in Borderline Personality Disorder
How can clinicians use this study's findings to identify patients with borderline personality disorder at higher risk of completed suicide?
Clinicians caring for patients with borderline personality disorder often need practical ways to distinguish chronic suicidality from factors linked to eventual suicide death. In this 24-year prospective cohort, the clearest baseline signal for completed suicide was a more extensive prior psychiatric hospitalization history.
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Confirm the patient has borderline personality disorder
Apply this workflow to patients with borderline personality disorder, as the suicide predictor analyses were restricted to the BPD group. The study cohort consisted of adult psychiatric inpatients with rigorously diagnosed BPD, so use the findings within that diagnostic context.
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Review the number of prior psychiatric hospitalizations
Elicit and document how many psychiatric hospitalizations occurred before the current index of care. In this study, number of prior hospitalizations before index admission was the only significant baseline predictor of completed suicide in patients with BPD, with a hazard ratio of 1.62 and P = .037.
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Do not over-rely on other baseline factors that were not significant here
This analysis examined sex, education, numbers of past self-injury episodes and suicide attempts, caretaker self-destructive behavior, and histories of major depression, any substance use disorder, and antisocial personality disorder. None of those other examined baseline variables significantly predicted completed suicide in this cohort.
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Maintain heightened vigilance early in follow-up
Interpret a heavy prior hospitalization burden as a marker for increased need for ongoing suicide surveillance, particularly earlier in treatment-seeking. The study found that the steepest increases in suicide incidence occurred in younger participants and concluded that suicide risk appears especially elevated in the initial stages of treatment-seeking before stabilizing over time.
Clinical Considerations
- The suicide outcome was relatively rare, which limited power to detect predictor effects and between-group differences.
- The study did not produce a multivariate suicide model because only one baseline predictor was significant.
- These findings came from a sample of initially hospitalized patients with BPD, so generalizability to non-inpatient or untreated populations is uncertain.
- Patients with bipolar I disorder were excluded at baseline, and the effect of that exclusion on mortality estimates is unknown.
Bottom Line
In borderline personality disorder, a greater number of prior psychiatric hospitalizations was the only baseline factor in this study that significantly identified higher risk of completed suicide.
