Journal of Personality Disorders, 28(3), 358-364, 2014 © 2014 The Guilford Press BIPOLAR DISORDER, BPD, AND SUICIDE ATTEMPTS ZIMMERMAN ET AL.
COMORBID BIPOLAR DISORDER AND BORDERLINE PERSONALITY DISORDER AND HISTORY OF SUICIDE ATTEMPTS Mark Zimmerman, MD, Jennifer Martinez, BA, Diane Young, PhD, Iwona Chelminski, PhD, Theresa A. Morgan, PhD, and Kristy Dalrymple, PhD
Both bipolar disorder and borderline personality disorder are associated with elevated rates of attempted suicide; however, no studies have examined whether there is an independent, additive risk for suicide attempts in patients diagnosed with both disorders. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, 3,465 psychiatric outpatients were interviewed with semistructured interviews. Compared to the bipolar patients without borderline personality disorder, the patients diagnosed with both bipolar and borderline personality disorder were significantly more likely to have made a prior suicide attempt. The patients with borderline personality disorder and bipolar disorder were nonsignificantly more likely than the borderline patients without bipolar disorder to have made a prior suicide attempt. Bipolar disorder and borderline personality disorder were each associated with an increased rate of suicide attempts. The co-occurrence of these disorders conferred an additive risk, although the influence of borderline personality disorder was greater than that of bipolar disorder.
Bipolar disorder and borderline personality disorder are life-threatening disorders. Both disorders are associated with elevated rates of completed and attempted suicide (Black, Blum, Pfohl, & Hale, 2004; Goodwin & Jamison, 2007; Novick, Swartz, & Frank, 2010; Oldham, 2006; Pompili, Girardi, Ruberto, & Tatarelli, 2005). Approximately 20% of patients diagnosed with either bipolar disorder or borderline personality disorder are diagnosed with the other (Paris, Gunderson, & Weinberg, 2007; Zimmerman & Morgan, in press). Thus, diagnostic co-occurrence is not rare. We are not aware of any studies that have examined whether there is an additive, independent risk for suicide attempts in patients diagnosed with both disorders.
This article was accepted under the editorship of Robert F. Krueger and John Livesley. From the Department of Psychiatry and Human Behavior, Brown Medical School, and the Department of Psychiatry, Rhode Island Hospital, Providence. Address correspondence to Mark Zimmerman, MD, 146 West River St,. Providence, RI 02904; E-mail: [email protected]
358
BIPOLAR DISORDER, BPD, AND SUICIDE ATTEMPTS 359
Suicidal behavior is a component of a diagnostic criterion for both borderline personality disorder and the depressive phase of bipolar disorder. While some studies have compared suicide attempts in bipolar patients with and without a personality disorder (Garno, Goldberg, Ramirez, & Ritzler, 2005; Ucok, Karaveli, Kundakci, & Yazici, 1998), only two studies have specifically examined whether suicide attempts are more frequent in bipolar patients with borderline personality disorder. Carpiniello, Lai, Pirarba, Sardu, and Pinna (2011) studied 57 euthymic outpatients with bipolar I or bipolar II disorder, 18 of whom were diagnosed with borderline personality disorder and 11 of whom were diagnosed with another personality disorder. The bipolar patients with borderline personality disorder made significantly more suicide attempts than the patients with no personality disorder or other personality disorders, and these latter two groups did not differ. Neves, Malloy-Diniz, and Correa (2009) evaluated 239 patients with bipolar I or bipolar II disorder, 95% of whom were hospitalized or recently discharged from the hospital. The bipolar patients with borderline personality disorder made four times as many suicide attempts as the bipolar patients without borderline personality disorder. These two studies each found that borderline personality disorder was associated with an increased frequency of suicide attempts in patients with bipolar disorder. We are not aware of any study that has examined whether the presence of bipolar disorder in patients with borderline personality disorder is associated with an elevated rate of suicide attempts, and no study has included patients without bipolar disorder to examine whether bipolar disorder and borderline personality disorder confer independent, additive risks for suicide attempts. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we tested the hypothesis that patients with both bipolar disorder and borderline personality disorder would have a higher rate of suicide attempts than patients with either disorder alone. METHOD
The Rhode Island MIDAS project represents an integration of research methodology into a community-based outpatient practice affiliated with an academic medical center (Zimmerman, 2003). A comprehensive diagnostic evaluation is conducted when a patient comes for treatment. This private practice group predominantly treats individuals with medical insurance (including Medicare but not Medicaid) on a fee-for-service basis, and it is distinct from the hospital’s outpatient residency training clinic, which predominantly serves lower income, uninsured, and medical assistance patients. Data on referral source were recorded for the last 1,600 patients enrolled in the study. Patients were most frequently referred from primary care physicians (29.9%), psychotherapists (16.1%), and family members or friends (18.8%). The Rhode Island Hospital institutional review committee approved the research protocol, and all patients provided informed, written consent.
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Patients were interviewed by a diagnostic rater who administered a modified version of the Structured Clinical Interview for DSM-IV (SCID; First, Spitzer, Gibbon, & Williams, 1995) and the borderline personality disorder section of the Structured Interview for DSM-IV Personality (SIDP-IV; Pfohl, Blum, & Zimmerman, 1997). A history of suicide attempts was inquired for during the SCID interview. During the course of the MIDAS project, the assessment battery has been modified at times. We introduced the assessment of borderline personality disorder near the beginning of the study (after approximately 100 patients had been enrolled). From a total of 3,600 patients evaluated in the MIDAS project, 3,465 were evaluated with the SIDP-IV borderline personality disorder module and form the basis of this report. The 3,465 patients included 1,381 (39.9%) men and 2,084 (60.1%) women who ranged in age from 18 to 85 years (mean = 38.6, SD = 13.3). About onethird of the subjects were married (40.4%, n = 1,399); the remainder were single (32.1%, n = 1,112), divorced (14.2%, n = 493), separated (5.3%, n = 182), widowed (1.7%, n = 58), or living with someone as if in a marital relationship (6.4%, n = 221). More than 60% of the patients attended school beyond high school (61.6%, n = 2,133), although less than one-third graduated from a 4-year college (30.5%, n = 1,058). The racial composition of the sample was 90.9% (n = 3,150) White, 4.2% (n = 146) Black, 2.5% (n = 87) Hispanic, 1.0% (n = 35) Asian, and 1.4% (n = 47) from another or a combination of these racial backgrounds. The most frequent current DSM-IV diagnoses were major depressive disorder (42.4%, n = 1,527), social phobia (27.9%, n = 1,006), generalized anxiety disorder (20.5%, n = 738), and panic disorder (17.1%, n = 615). The diagnostic raters were highly trained and monitored throughout the project to minimize rater drift. The diagnostic raters included PhD-level psychologists and research assistants with college degrees in the social or biological sciences. Research assistants received 3 to 4 months of training during which they observed at least 20 interviews by senior raters, and they were observed and supervised in their administration of more than 20 evaluations. During their training on the MIDAS project, the psychologists first observed an experienced interviewer administer five interviews, and then they were observed by an experienced interviewer in their administration of 15 to 20 evaluations. During the course of training, the senior author met with each rater to review the interpretation of every item on the SCID. Also during training, every interview was reviewed on an item-by-item basis by the senior rater who observed the evaluation, and by the senior author, who reviewed the case with the interviewer. At the end of the training period, the raters were required to demonstrate exact, or near exact, agreement with a senior diagnostician on five consecutive evaluations. Throughout the MIDAS project, ongoing supervision of the raters consisted of weekly diagnostic case conferences involving all members of the team. In addition, every case was reviewed by the senior author. Reliability was examined in 65 patients. A joint-interview design was used in which one rater observed another conducting the interview, and both raters independently made their ratings. Of relevance to the present report,
BIPOLAR DISORDER, BPD, AND SUICIDE ATTEMPTS 361
the reliabilities for diagnosing bipolar disorder (k = 0.75) and borderline personality disorder (k = 1.0) were excellent. RESULTS
Two hundred sixty-three patients were diagnosed with bipolar I (n = 117) or bipolar II disorder (n = 146). There was no difference in the rate of suicide attempts between patients diagnosed with bipolar I and bipolar II disorder (39.3% vs. 34.2%, χ2 = 0.72, p = .40); therefore these groups were combined. Slightly more than 10% of the sample (n = 375) was diagnosed with borderline personality disorder. Approximately one-fourth of the patients with bipolar disorder were diagnosed with borderline personality disorder (26.2%, n = 69). More than one third of the patients with bipolar disorder had made a previous suicide attempt (36.5%, n = 96), and 20% (n = 55) had made more than one prior suicide attempt. Nearly half of the patients with borderline personality disorder had made a suicide attempt (48.8%, n = 183), and onefourth (25.9%, n = 97) had made more than one attempt. Compared to the bipolar patients without borderline personality disorder, the patients diagnosed with both bipolar and borderline personality disorder were twice as likely to have made a prior suicide attempt (58.0% vs. 28.9%, χ2 = 18.6, p < .001) and to have made multiple suicide attempts (33.3% vs. 16.5%, χ2 = 8.7, p < .01). Similarly, the patients with borderline personality disorder and bipolar disorder were more likely, albeit nonsignificantly, than the borderline patients without bipolar disorder to have made a prior suicide attempt (58.0% vs. 46.7%, χ2 = 2.8, p = .09) and to have made multiple suicide attempts (33.3% vs. 24.2%, χ2 = 2.5, p = .12). To put these rates into a broader perspective, only 14.3% (n = 415) of the 2,895 patients who were not diagnosed with either borderline personality disorder or bipolar disorder had made a prior suicide attempt, significantly lower than the suicide attempt rate in each group (bipolar disorder: χ2 = 87.3, p < .001; borderline personality disorder: χ2 = 263.9, p < .001). We repeated the analyses controlling for age and gender and the results remained the same. DISCUSSION
In the present study, slightly more than one third of the patients with bipolar disorder had previously attempted suicide. This rate is nearly identical to the rate computed across 24 studies of bipolar disorder (Novick et al., 2010). Likewise, consistent with prior studies, there was no difference between bipolar I disorder and bipolar II disorder in the suicide attempt rate (Novick et al., 2010). Nearly 50% of the patients with borderline personality disorder had previously made a suicide attempt, consistent with the high rate reported in other studies, although also lower than the 60%–80% rate that is typically found (Black et al., 2004; Oldham, 2006). The frequency of suicidal behavior would be expected to be higher in a study of psychiatric inpatients,
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and a history of psychiatric hospitalizations is significantly associated with suicide attempts (Links, Kolla, Guimond, & McMain, 2013; Wedig et al., 2012). Approximately one fourth of the patients in the study reported a history of psychiatric hospitalization. The results of the present study suggest that bipolar disorder and borderline personality disorder were each associated with an increased rate of suicide attempts. The co-occurrence of these disorders conferred an additive risk, although the influence of borderline personality disorder was greater than that of bipolar disorder. Nearly 60% of the patients with both diagnoses had previously attempted suicide, and more than one third had made multiple attempts. The percentage of patients with both diagnoses who attempted suicide was four times higher than the percentage of psychiatric outpatients without either disorder. During the past decade, a debate has arisen as to whether borderline personality disorder should be considered as part of a bipolar spectrum. Several reviews of this issue have been conducted, and they have reached different conclusions (Antoniadis, Samakouri, & Livaditis, 2012; Belli, Ural, & Akbudak, 2012; Nemeroff et al., 2002; Smith, Muir, & Blackwood, 2004). The present study suggests that it is important to diagnose both conditions when they are present because they identify a cohort of patients who are at particularly high risk for suicide attempts, and thus may be at particularly high risk for suicide. If borderline personality disorder is considered a type of bipolar disorder, then it would be redundant to diagnose both disorders, and this could reduce recognition of an important comorbid disorder in bipolar patients that is associated with an elevated suicide risk. A limitation of the study was that it was conducted in a single outpatient practice in which the majority of patients were White, female, and had health insurance. Replication of the results in samples with different demographic characteristics is warranted. The present findings were based on the retrospective report of suicide attempts in patients seeking outpatient treatment. The depressed state could have biased the assessment; however, this bias should have been similar across diagnostic groups. Moreover, there is research support for the validity of personality disorder assessment in depressed patients (Morey et al., 2010). To the degree that both bipolar disorder and borderline personality disorder are associated with an increased risk of completed suicide, the magnitude of the risk of these disorders for suicide attempts overall is likely underestimated in a retrospective study such as the present one. Ideally, the results of this retrospective study should be replicated in a prospective, follow-up study. However, in the present study, nearly 3,500 patients were evaluated to obtain an adequately sized sample of patients with both diagnoses. A prospective study of this issue may be cost prohibitive. Suicide attempts, similar to comorbidity, are likely associated with treatment seeking; thus the results should be replicated in communitybased epidemiological studies. While the present results suggest that the cooccurrence of bipolar disorder and borderline personality disorder confers some additive risk of attempting suicide, it is uncertain whether the risk for
BIPOLAR DISORDER, BPD, AND SUICIDE ATTEMPTS 363
completed suicide is also elevated in patients with both diagnoses. We did not examine the impact of other comorbid disorders on suicide attempt rates. We focused on the interface between bipolar and borderline personality disorder because the relationship between these two disorders has been debated. Some authors have suggested that borderline personality disorder should be subsumed under the bipolar rubric (Akiskal, 2004; Perugi, Toni, Travierso, & Akiskal, 2003), thereby questioning the validity of the borderline diagnosis. In the personality disorder field, suicidal behavior has been most commonly discussed as a feature of borderline personality disorder rather than other personality disorders, and a previous study of patients with bipolar disorder did not find an increased rate of suicide attempts in patients with other types of personality disorders (Carpiniello et al., 2011). REFERENCES Akiskal, H. S. (2004). Demystifying borderline personality: Critique of the concept and unorthodox reflections on its natural kinship with the bipolar spectrum. Acta Psychiatrica Scandinavica, 110, 401–407. Antoniadis, D., Samakouri, M., & Livaditis, M. (2012). The association of bipolar spectrum disorders and borderline personality disorder. Psychiatric Quarterly, 83, 449–465. Belli, H., Ural, C., & Akbudak, M. (2012). Borderline personality disorder: Bipolarity, mood stabilizers and atypical antipsychotics in treatment. Journal of Clinical Medicine Research, 4, 301–308. Black, D. W., Blum, N., Pfohl, B., & Hale, N. (2004). Suicidal behavior in borderline personality disorder: Prevalence, risk factors, prediction, and prevention. Journal of Personality Disorders, 18, 226–239. Carpiniello, B., Lai, L., Pirarba, S., Sardu, C., & Pinna, F. (2011). Impulsivity and aggressiveness in bipolar disorder with co-morbid borderline personality disorder. Psychiatry Research, 188, 40–44. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1995). Structured Clinical Interview for DSM-IV Axis I Disorders–Patient edition (SCID-I/P, version 2.0). New York: Biometrics Research Department, New York State Psychiatric Institute. Garno, J. L., Goldberg, J. F., Ramirez, P. M., & Ritzler, B. A. (2005). Bipolar disorder with comorbid cluster B personality disorder features: Impact on suicidality. Journal of Clinical Psychiatry, 66, 339–345. Links, P. S., Kolla, N. J., Guimond, T., & McMain, S. (2013). Prospective risk factors for suicide attempts in a treated sample of patients with borderline personality disorder. Canadian Journal of Psychiatry, 58, 99–106.
Morey, L. C., Shea, M. T., Markowitz, J. C., Stout, R. L., Hopwood, C. J., Gunderson, J. G., et al. (2010). State effects of major depression on the assessment of personality and personality disorder. American Journal of Psychiatry, 167, 528–535. Neves, F. S., Malloy-Diniz, L. F., & Correa, H. (2009). Suicidal behavior in bipolar disorder: What is the influence of psychiatric comorbidities? Journal of Clinical Psychiatry, 70, 13–18. Novick, D. M., Swartz, H. A., & Frank, E. (2010). Suicide attempts in bipolar I and bipolar II disorder: A review and meta-analysis of the evidence. Bipolar Disorders, 12, 1–9. Oldham, J. M. (2006). Borderline personality disorder and suicidality. American Journal of Psychiatry, 163, 20–26. Paris, J., Gunderson, J., & Weinberg, I. (2007). The interface between borderline personality disorder and bipolar spectrum disorders. Comprehensive Psychiatry, 48, 145–154. Perugi, G., Toni, C., Travierso, M. C., & Akiskal, H. S. (2003). The role of cyclothymia in atypical depression: Toward a data-based reconceptualization of the borderline-bipolar II connection. Journal of Affective Disorders, 73, 87–98. Pfohl, B., Blum, N., & Zimmerman, M. (1997). Structured Interview for DSM-IV Personality. Washington, DC: American Psychiatric Press. Pompili, M., Girardi, P., Ruberto, A., & Tatarelli, R. (2005). Suicide in borderline personality disorder: A meta-analysis. Nordic Journal of Psychiatry, 59, 319–324. Smith, D. J., Muir, W. J., & Blackwood, D. H. (2004). Is borderline personality disorder part of the bipolar spectrum? Harvard Review of Psychiatry, 12, 133–139.
364 Ucok, A., Karaveli, D., Kundakci, T., & Yazici, O. (1998). Comorbidity of personality disorders with bipolar mood disorders. Comprehensive Psychiatry, 39, 72–74. Wedig, M. M., Silverman, M. H., Frankenburg, F. R., Reich, D. B., Fitzmaurice, G., & Zanarini, M. C. (2012). Predictors of suicide attempts in patients with borderline personality disorder over 16 years of prospective follow-up. Psychological Medicine, 43, 1–10.
ZIMMERMAN ET AL. Zimmerman, M. (2003). Integrating the assessment methods of researchers in routine clinical practice: The Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project. In M. First (Ed.), Standardized evaluation in clinical practice (Vol. 22, pp. 29–74). Washington, DC: American Psychiatric Publishing. Zimmerman, M., & Morgan, T. A. (in press). The relationship between borderline personality disorder and bipolar disorder. Dialogues in Clinical Neuroscience.
This article has been cited by: 1. Trehani M. Fonseka, Brenda Swampillai, Vanessa Timmins, Antonette Scavone, Rachel Mitchell, Katelyn A. Collinger, Benjamin I. Goldstein. 2015. Significance of borderline personality-spectrum symptoms among adolescents with bipolar disorder. Journal of Affective Disorders 170, 39-45. [CrossRef] 2. Kei Yoshimatsu, Brian Palmer. 2014. Depression in Patients with Borderline Personality Disorder. Harvard Review of Psychiatry 22, 266-273. [CrossRef]
COMORBID BIPOLAR DISORDER AND BORDERLINE PERSONALITY DISORDER AND HISTORY OF SUICIDE ATTEMPTS Mark Zimmerman, MD, Jennifer Martinez, BA, Diane Young, PhD, Iwona Chelminski, PhD, Theresa A. Morgan, PhD, and Kristy Dalrymple, PhD
Both bipolar disorder and borderline personality disorder are associated with elevated rates of attempted suicide; however, no studies have examined whether there is an independent, additive risk for suicide attempts in patients diagnosed with both disorders. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, 3,465 psychiatric outpatients were interviewed with semistructured interviews. Compared to the bipolar patients without borderline personality disorder, the patients diagnosed with both bipolar and borderline personality disorder were significantly more likely to have made a prior suicide attempt. The patients with borderline personality disorder and bipolar disorder were nonsignificantly more likely than the borderline patients without bipolar disorder to have made a prior suicide attempt. Bipolar disorder and borderline personality disorder were each associated with an increased rate of suicide attempts. The co-occurrence of these disorders conferred an additive risk, although the influence of borderline personality disorder was greater than that of bipolar disorder.
Bipolar disorder and borderline personality disorder are life-threatening disorders. Both disorders are associated with elevated rates of completed and attempted suicide (Black, Blum, Pfohl, & Hale, 2004; Goodwin & Jamison, 2007; Novick, Swartz, & Frank, 2010; Oldham, 2006; Pompili, Girardi, Ruberto, & Tatarelli, 2005). Approximately 20% of patients diagnosed with either bipolar disorder or borderline personality disorder are diagnosed with the other (Paris, Gunderson, & Weinberg, 2007; Zimmerman & Morgan, in press). Thus, diagnostic co-occurrence is not rare. We are not aware of any studies that have examined whether there is an additive, independent risk for suicide attempts in patients diagnosed with both disorders.
This article was accepted under the editorship of Robert F. Krueger and John Livesley. From the Department of Psychiatry and Human Behavior, Brown Medical School, and the Department of Psychiatry, Rhode Island Hospital, Providence. Address correspondence to Mark Zimmerman, MD, 146 West River St,. Providence, RI 02904; E-mail: [email protected]
358
BIPOLAR DISORDER, BPD, AND SUICIDE ATTEMPTS 359
Suicidal behavior is a component of a diagnostic criterion for both borderline personality disorder and the depressive phase of bipolar disorder. While some studies have compared suicide attempts in bipolar patients with and without a personality disorder (Garno, Goldberg, Ramirez, & Ritzler, 2005; Ucok, Karaveli, Kundakci, & Yazici, 1998), only two studies have specifically examined whether suicide attempts are more frequent in bipolar patients with borderline personality disorder. Carpiniello, Lai, Pirarba, Sardu, and Pinna (2011) studied 57 euthymic outpatients with bipolar I or bipolar II disorder, 18 of whom were diagnosed with borderline personality disorder and 11 of whom were diagnosed with another personality disorder. The bipolar patients with borderline personality disorder made significantly more suicide attempts than the patients with no personality disorder or other personality disorders, and these latter two groups did not differ. Neves, Malloy-Diniz, and Correa (2009) evaluated 239 patients with bipolar I or bipolar II disorder, 95% of whom were hospitalized or recently discharged from the hospital. The bipolar patients with borderline personality disorder made four times as many suicide attempts as the bipolar patients without borderline personality disorder. These two studies each found that borderline personality disorder was associated with an increased frequency of suicide attempts in patients with bipolar disorder. We are not aware of any study that has examined whether the presence of bipolar disorder in patients with borderline personality disorder is associated with an elevated rate of suicide attempts, and no study has included patients without bipolar disorder to examine whether bipolar disorder and borderline personality disorder confer independent, additive risks for suicide attempts. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we tested the hypothesis that patients with both bipolar disorder and borderline personality disorder would have a higher rate of suicide attempts than patients with either disorder alone. METHOD
The Rhode Island MIDAS project represents an integration of research methodology into a community-based outpatient practice affiliated with an academic medical center (Zimmerman, 2003). A comprehensive diagnostic evaluation is conducted when a patient comes for treatment. This private practice group predominantly treats individuals with medical insurance (including Medicare but not Medicaid) on a fee-for-service basis, and it is distinct from the hospital’s outpatient residency training clinic, which predominantly serves lower income, uninsured, and medical assistance patients. Data on referral source were recorded for the last 1,600 patients enrolled in the study. Patients were most frequently referred from primary care physicians (29.9%), psychotherapists (16.1%), and family members or friends (18.8%). The Rhode Island Hospital institutional review committee approved the research protocol, and all patients provided informed, written consent.
360
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Patients were interviewed by a diagnostic rater who administered a modified version of the Structured Clinical Interview for DSM-IV (SCID; First, Spitzer, Gibbon, & Williams, 1995) and the borderline personality disorder section of the Structured Interview for DSM-IV Personality (SIDP-IV; Pfohl, Blum, & Zimmerman, 1997). A history of suicide attempts was inquired for during the SCID interview. During the course of the MIDAS project, the assessment battery has been modified at times. We introduced the assessment of borderline personality disorder near the beginning of the study (after approximately 100 patients had been enrolled). From a total of 3,600 patients evaluated in the MIDAS project, 3,465 were evaluated with the SIDP-IV borderline personality disorder module and form the basis of this report. The 3,465 patients included 1,381 (39.9%) men and 2,084 (60.1%) women who ranged in age from 18 to 85 years (mean = 38.6, SD = 13.3). About onethird of the subjects were married (40.4%, n = 1,399); the remainder were single (32.1%, n = 1,112), divorced (14.2%, n = 493), separated (5.3%, n = 182), widowed (1.7%, n = 58), or living with someone as if in a marital relationship (6.4%, n = 221). More than 60% of the patients attended school beyond high school (61.6%, n = 2,133), although less than one-third graduated from a 4-year college (30.5%, n = 1,058). The racial composition of the sample was 90.9% (n = 3,150) White, 4.2% (n = 146) Black, 2.5% (n = 87) Hispanic, 1.0% (n = 35) Asian, and 1.4% (n = 47) from another or a combination of these racial backgrounds. The most frequent current DSM-IV diagnoses were major depressive disorder (42.4%, n = 1,527), social phobia (27.9%, n = 1,006), generalized anxiety disorder (20.5%, n = 738), and panic disorder (17.1%, n = 615). The diagnostic raters were highly trained and monitored throughout the project to minimize rater drift. The diagnostic raters included PhD-level psychologists and research assistants with college degrees in the social or biological sciences. Research assistants received 3 to 4 months of training during which they observed at least 20 interviews by senior raters, and they were observed and supervised in their administration of more than 20 evaluations. During their training on the MIDAS project, the psychologists first observed an experienced interviewer administer five interviews, and then they were observed by an experienced interviewer in their administration of 15 to 20 evaluations. During the course of training, the senior author met with each rater to review the interpretation of every item on the SCID. Also during training, every interview was reviewed on an item-by-item basis by the senior rater who observed the evaluation, and by the senior author, who reviewed the case with the interviewer. At the end of the training period, the raters were required to demonstrate exact, or near exact, agreement with a senior diagnostician on five consecutive evaluations. Throughout the MIDAS project, ongoing supervision of the raters consisted of weekly diagnostic case conferences involving all members of the team. In addition, every case was reviewed by the senior author. Reliability was examined in 65 patients. A joint-interview design was used in which one rater observed another conducting the interview, and both raters independently made their ratings. Of relevance to the present report,
BIPOLAR DISORDER, BPD, AND SUICIDE ATTEMPTS 361
the reliabilities for diagnosing bipolar disorder (k = 0.75) and borderline personality disorder (k = 1.0) were excellent. RESULTS
Two hundred sixty-three patients were diagnosed with bipolar I (n = 117) or bipolar II disorder (n = 146). There was no difference in the rate of suicide attempts between patients diagnosed with bipolar I and bipolar II disorder (39.3% vs. 34.2%, χ2 = 0.72, p = .40); therefore these groups were combined. Slightly more than 10% of the sample (n = 375) was diagnosed with borderline personality disorder. Approximately one-fourth of the patients with bipolar disorder were diagnosed with borderline personality disorder (26.2%, n = 69). More than one third of the patients with bipolar disorder had made a previous suicide attempt (36.5%, n = 96), and 20% (n = 55) had made more than one prior suicide attempt. Nearly half of the patients with borderline personality disorder had made a suicide attempt (48.8%, n = 183), and onefourth (25.9%, n = 97) had made more than one attempt. Compared to the bipolar patients without borderline personality disorder, the patients diagnosed with both bipolar and borderline personality disorder were twice as likely to have made a prior suicide attempt (58.0% vs. 28.9%, χ2 = 18.6, p < .001) and to have made multiple suicide attempts (33.3% vs. 16.5%, χ2 = 8.7, p < .01). Similarly, the patients with borderline personality disorder and bipolar disorder were more likely, albeit nonsignificantly, than the borderline patients without bipolar disorder to have made a prior suicide attempt (58.0% vs. 46.7%, χ2 = 2.8, p = .09) and to have made multiple suicide attempts (33.3% vs. 24.2%, χ2 = 2.5, p = .12). To put these rates into a broader perspective, only 14.3% (n = 415) of the 2,895 patients who were not diagnosed with either borderline personality disorder or bipolar disorder had made a prior suicide attempt, significantly lower than the suicide attempt rate in each group (bipolar disorder: χ2 = 87.3, p < .001; borderline personality disorder: χ2 = 263.9, p < .001). We repeated the analyses controlling for age and gender and the results remained the same. DISCUSSION
In the present study, slightly more than one third of the patients with bipolar disorder had previously attempted suicide. This rate is nearly identical to the rate computed across 24 studies of bipolar disorder (Novick et al., 2010). Likewise, consistent with prior studies, there was no difference between bipolar I disorder and bipolar II disorder in the suicide attempt rate (Novick et al., 2010). Nearly 50% of the patients with borderline personality disorder had previously made a suicide attempt, consistent with the high rate reported in other studies, although also lower than the 60%–80% rate that is typically found (Black et al., 2004; Oldham, 2006). The frequency of suicidal behavior would be expected to be higher in a study of psychiatric inpatients,
362
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and a history of psychiatric hospitalizations is significantly associated with suicide attempts (Links, Kolla, Guimond, & McMain, 2013; Wedig et al., 2012). Approximately one fourth of the patients in the study reported a history of psychiatric hospitalization. The results of the present study suggest that bipolar disorder and borderline personality disorder were each associated with an increased rate of suicide attempts. The co-occurrence of these disorders conferred an additive risk, although the influence of borderline personality disorder was greater than that of bipolar disorder. Nearly 60% of the patients with both diagnoses had previously attempted suicide, and more than one third had made multiple attempts. The percentage of patients with both diagnoses who attempted suicide was four times higher than the percentage of psychiatric outpatients without either disorder. During the past decade, a debate has arisen as to whether borderline personality disorder should be considered as part of a bipolar spectrum. Several reviews of this issue have been conducted, and they have reached different conclusions (Antoniadis, Samakouri, & Livaditis, 2012; Belli, Ural, & Akbudak, 2012; Nemeroff et al., 2002; Smith, Muir, & Blackwood, 2004). The present study suggests that it is important to diagnose both conditions when they are present because they identify a cohort of patients who are at particularly high risk for suicide attempts, and thus may be at particularly high risk for suicide. If borderline personality disorder is considered a type of bipolar disorder, then it would be redundant to diagnose both disorders, and this could reduce recognition of an important comorbid disorder in bipolar patients that is associated with an elevated suicide risk. A limitation of the study was that it was conducted in a single outpatient practice in which the majority of patients were White, female, and had health insurance. Replication of the results in samples with different demographic characteristics is warranted. The present findings were based on the retrospective report of suicide attempts in patients seeking outpatient treatment. The depressed state could have biased the assessment; however, this bias should have been similar across diagnostic groups. Moreover, there is research support for the validity of personality disorder assessment in depressed patients (Morey et al., 2010). To the degree that both bipolar disorder and borderline personality disorder are associated with an increased risk of completed suicide, the magnitude of the risk of these disorders for suicide attempts overall is likely underestimated in a retrospective study such as the present one. Ideally, the results of this retrospective study should be replicated in a prospective, follow-up study. However, in the present study, nearly 3,500 patients were evaluated to obtain an adequately sized sample of patients with both diagnoses. A prospective study of this issue may be cost prohibitive. Suicide attempts, similar to comorbidity, are likely associated with treatment seeking; thus the results should be replicated in communitybased epidemiological studies. While the present results suggest that the cooccurrence of bipolar disorder and borderline personality disorder confers some additive risk of attempting suicide, it is uncertain whether the risk for
BIPOLAR DISORDER, BPD, AND SUICIDE ATTEMPTS 363
completed suicide is also elevated in patients with both diagnoses. We did not examine the impact of other comorbid disorders on suicide attempt rates. We focused on the interface between bipolar and borderline personality disorder because the relationship between these two disorders has been debated. Some authors have suggested that borderline personality disorder should be subsumed under the bipolar rubric (Akiskal, 2004; Perugi, Toni, Travierso, & Akiskal, 2003), thereby questioning the validity of the borderline diagnosis. In the personality disorder field, suicidal behavior has been most commonly discussed as a feature of borderline personality disorder rather than other personality disorders, and a previous study of patients with bipolar disorder did not find an increased rate of suicide attempts in patients with other types of personality disorders (Carpiniello et al., 2011). REFERENCES Akiskal, H. S. (2004). Demystifying borderline personality: Critique of the concept and unorthodox reflections on its natural kinship with the bipolar spectrum. Acta Psychiatrica Scandinavica, 110, 401–407. Antoniadis, D., Samakouri, M., & Livaditis, M. (2012). The association of bipolar spectrum disorders and borderline personality disorder. Psychiatric Quarterly, 83, 449–465. Belli, H., Ural, C., & Akbudak, M. (2012). Borderline personality disorder: Bipolarity, mood stabilizers and atypical antipsychotics in treatment. Journal of Clinical Medicine Research, 4, 301–308. Black, D. W., Blum, N., Pfohl, B., & Hale, N. (2004). Suicidal behavior in borderline personality disorder: Prevalence, risk factors, prediction, and prevention. Journal of Personality Disorders, 18, 226–239. Carpiniello, B., Lai, L., Pirarba, S., Sardu, C., & Pinna, F. (2011). Impulsivity and aggressiveness in bipolar disorder with co-morbid borderline personality disorder. Psychiatry Research, 188, 40–44. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1995). Structured Clinical Interview for DSM-IV Axis I Disorders–Patient edition (SCID-I/P, version 2.0). New York: Biometrics Research Department, New York State Psychiatric Institute. Garno, J. L., Goldberg, J. F., Ramirez, P. M., & Ritzler, B. A. (2005). Bipolar disorder with comorbid cluster B personality disorder features: Impact on suicidality. Journal of Clinical Psychiatry, 66, 339–345. Links, P. S., Kolla, N. J., Guimond, T., & McMain, S. (2013). Prospective risk factors for suicide attempts in a treated sample of patients with borderline personality disorder. Canadian Journal of Psychiatry, 58, 99–106.
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