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Letters

Do Patients With Borderline Personality Disorder in Primary Care Gain Access to Mental Health Services?

Do Patients With Borderline Personality Disorder in Primary Care Gain Access to Mental Health Services?

To the Editor: Borderline personality disorder is characterized by a pervasive pattern of instability, which makes borderline personality disorder patients frequent users of mental health resources.1 The prevalence of borderline personality disorder in primary care is high.2 In our study, we expected to discover high prevalences of patients at high risk of suffering from borderline personality disorder among this population. Secondly, we predicted that, among them, those at high risk of borderline personality disorder would report greater health care utilization than the others.

Method. Twenty French general practitioners belonging to a Continuing Medical Education (CME) program were invited to participate in a cross-sectional study in 2007. The research involved their asking all their patients to fill in a self-report questionnaire assessing the presence of personality disorder via the Personality Diagnostic Questionnaire-Revised,3 as well as providing information regarding previous use of mental health services. Seven general practitioners agreed to hand out the questionnaires to all of their patients during a randomly chosen work day. In order to better understand these findings, we discussed them with the general practitioners involved in the study.

Results. Of the 100 questionnaires distributed by general practitioners, 60 were returned. The final sample was largely female (sex ratio: 3.2), mean age was 39.9 years, 48.3% (n = 29) were living with a partner at the time, and 36.7% (n = 22) were unemployed. According to our results, 45.0% of the sample (n = 27) reported a personality disorder, of which 35% (n = 21) were of Cluster A, 35% (n = 21) of Cluster B, and 33.3% (n = 20) of Cluster C; participants could report meeting several diagnoses. The prevalence of patients at high risk of suffering from borderline personality disorder was 21.7% (n = 13).

Findings reveal that 46.2% of patients (n = 6) at high risk of borderline personality disorder had been previously engaged in psychotherapy, 53.8% (n = 7) had been prescribed psychoactive medication (mainly benzodiazepines), and 15.4% (n = 2) had been admitted at least once to a psychiatric unit. Among patients with a high risk of personality disorder, we found no differences regarding previous use of mental health services between patients reporting a high risk of borderline personality disorder and those at high risk of personality disorders other than borderline personality disorder. Three main difficulties came to light from general practitioners: the difficulties of screening, then the diagnostic and referral difficulties.

The elevated rates of patients at high risk of suffering from borderline personality disorder are in agreement with previous research.3 Nevertheless, the present study did not support our second hypothesis. Our findings highlight the fact that patients at high risk of borderline personality disorder do not make use of mental health care services any more frequently than other primary care patients. It has been suggested that borderline personality disorder patients in primary care and psychiatric settings are more similar than not.4 However, in our sample, the patients suffering from borderline personality disorder encountered in primary care settings benefited from only partial access to psychiatric services.

Regarding tentative solutions, we propose that each health care zone should be allocated a mental health consultant, available to general practitioners. This consultant could organize regular training sessions. Furthermore, this consultant’s role would extend to consultations or a hotline dedicated to assisting with diagnosis or referral of patients to the local health care system. This system avoids creating highly specialized psychiatric consultations that risk becoming rapidly congested.

References

1. Lieb K, Zanarini MC, Schmahl C, et al. Borderline personality disorder. Lancet. 2004;364(9432):453-461. PubMed doi:10.1016/S0140-6736(04)16770-6

2. Gross R, Olfson M, Gameroff M, et al. Borderline personality disorder in primary care. Arch Intern Med. 2002;162(1):53-60. PubMed doi:10.1001/archinte.162.1.53

3. Hyler SE, Skodol AE, Oldham JM, et al. Validity of the Personality Diagnostic Questionnaire-Revised: a replication in an outpatient sample. Compr Psychiatry. 1992;33(2):73-77. PubMed doi:10.1016/0010-440X(92)90001-7

4. Sansone RA, Wiederman MW, Sansone LA, et al. Patterns of self-harm behavior among women with borderline personality symptomatology: psychiatric versus primary care samples. Gen Hosp Psychiatry. 2000;22(3):174-178. PubMed doi:10.1016/S0163-8343(00)00074-8

Lionel Cailhol, MD

l.cailhol@ch-montauban.fr

Rachel Rodgers, PhD

Julie Rieu, MD

Author affiliations: Emergency Psychiatry, CHG Montauban, Montauban (Dr Cailhol); Centre d’ Etudes et de Recherches en Psychopathologie, Université Toulouse-II Le Mirail (Dr Rodgers); and Service de Psychiatrie, CHU, Toulouse (Dr Rieu), France.

Previous presentation: L’ Encephale Congress; January 24-26, 2008; Paris, France.

Potential conflicts of interest: None reported.

Funding/support: None reported.

Published online: February 24, 2011 (doi:10.4088/PCC.09l00844gre).

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