Interventions to improve the sleep quality of adults with personality disorder: A systematic review.

Poor quality sleep is common for people who have a diagnosis of personality disorder (PD). Core cognitive and behavioral features of PD may cause and perpetuate poor sleep, but to date, no review has collated the evidence on the efficacy of interventions to improve sleep quality for people with PD. Structured searches for interventional studies among adults with PD and reporting validated measures of sleep quality were conducted up to November 2022 in multiple databases. Single-case reports were excluded. Study quality was assessed with standardized risk of bias tools. Unreported data was sought systematically from authors. This review was pre-registered with an international prospective register of systematic reviews (PROSPERO) (CRD42021282105). Of the 3503 identified studies, nine met inclusion criteria, representing a range of psychological, pharmaceutical, and other interventions and outcome measures. Meta-analytic methods were not feasible because of the serious risk of bias in all studies, and results were therefore synthesized narratively. There is limited and low-quality evidence of the effects of a variety of interventions to improve the sleep quality of people living with PD. Further research might consider specifically including people diagnosed with PD in trials of sleep interventions and using sleep outcome measures in trials of established PD treatments.

Evaluation of bi-directional causal association between depression and cardiovascular diseases: a Mendelian randomization study.

BACKGROUND: Depression and cardiovascular disease (CVD) are associated with each other but their relationship remains unclear. We aim to determine whether genetic predisposition to depression are causally linked to CVD [including coronary artery disease (CAD), myocardial infarction (MI), stroke and atrial fibrillation (AF)]. METHODS: Using summary statistics from the largest genome-wide association studies (GWAS) or GWAS meta-analysis of depression (primary analysis: n = 500 199), broad depression (help-seeking behavior for problems with nerves, anxiety, tension or depression; secondary analysis: n = 322 580), CAD (n = 184 305), MI (n = 171 875), stroke (n = 446 696) and AF (n = 1 030 836), genetic correlation was tested between two depression phenotypes and CVD [MI, stroke and AF (not CAD as its correlation was previously confirmed)]. Causality was inferred between correlated traits by Mendelian Randomization analyses. RESULTS: Both depression phenotypes were genetically correlated with MI (depression: rG = 0.169; p = 9.03 × 10-9; broad depression: rG = 0.123; p = 1 × 10-4) and AF (depression: rG = 0.112; p = 7.80 × 10-6; broad depression: rG = 0.126; p = 3.62 × 10-6). Genetically doubling the odds of depression was causally associated with increased risk of CAD (OR = 1.099; 95% CI 1.031-1.170; p = 0.004) and MI (OR = 1.146; 95% CI 1.070-1.228; p = 1.05 × 10-4). Adjustment for blood lipid levels/smoking status attenuated the causality between depression and CAD/MI. Null causal association was observed for CVD on depression. A similar pattern of results was observed in the secondary analysis for broad depression. CONCLUSIONS: Genetic predisposition to depression may have positive causal roles on CAD/MI. Genetic susceptibility to self-awareness of mood problems may be a strong causal risk factor of CAD/MI. Blood lipid levels and smoking may potentially mediate the causal pathway. Prevention and early diagnosis of depression are important in the management of CAD/MI.

Views on psychotherapy research among members of the Medical Psychotherapy Faculty of the Royal College of Psychiatrists.

AIMS AND METHOD: Research drives innovation and improved practice in psychotherapy. We describe views of members of the Faculty of Medical Psychotherapy of the Royal College of Psychiatrists (RCPsych) regarding their knowledge, experience and perspectives on psychotherapy research. We sent questionnaires to the Faculty membership emailing list. RESULTS: In total, 172 psychiatrists from all levels of training returned fully complete responses. Respondents considered knowledge of psychotherapy research to be important to clinical work. Many have qualifications and experience in research but lack current opportunities for research involvement and would welcome the Faculty doing more to promote psychotherapy research. Perceived obstacles to research involvement included lack of competence, competing demands and wider organisational factors. CLINICAL IMPLICATIONS: The lack of research opportunities for medical psychotherapists may lead to their underrepresentation in psychotherapy research and a less medically informed research agenda. Providing support at academic, RCPsych and National Health Service organisational levels will allow more clinically relevant research not only in psychotherapy but in other psychiatric disciplines as well.

Diagnostic conversion to bipolar disorder in unipolar depressed patients in Hong Kong: A 20-year follow-up study.

BACKGROUND: Bipolar (BP) disorder, especially BP depression is common and yet remains enigmatic until the emergence of mania. The rates and risk factors of conversion from unipolar (UP) depression to BP disorder reported vary. OBJECTIVE: To study the long-term conversion rate from UP depression to BP disorder of an inpatient sample and identify the associated risk factors. METHODS: This is a retrospective longitudinal study conducted in 2017 based on review of medical records of patients admitted to a regional hospital in Hong Kong with diagnosis of major depressive disorder during the period from 1988 to 2000. RESULTS: A total of 19.5% of subjects had diagnostic shift from UP depression to BP disorder at follow-up, with a mean conversion time of 10.8 years and about 1% shift annually in the first 10 years. Risk factors include family history of mental illness, young age at onset, repeated admissions, psychotic symptoms and use of electroconvulsive therapy. More unconverted UP subjects (9.0%) committed suicide than those converted to BP (3.5%). LIMITATIONS: The study is limited by its retrospective design. CONCLUSIONS: Conversion from UP depression to BP disorder is dictated by its biological characteristics and clinical severity. Vigilance should be held in the first decade after onset when most conversion takes place.

Comparing psychotropic medication prescribing in personality disorder between general mental health and psychological services: retrospective cohort study.

BACKGROUND: Although no drugs are licensed for the treatment of personality disorder, pharmacological treatment in clinical practice remains common. AIMS: This study aimed to estimate the prevalence of psychotropic drug use and associations with psychological service use among people with personality disorder. METHOD: Using data from a large, anonymised mental healthcare database, we identified all adult patients with a diagnosis of personality disorder and ascertained psychotropic medication use between 1 August 2015 and 1 February 2016. Multivariable logistic regression models were constructed, adjusting for sociodemographic, clinical and service use factors, to examine the association between psychological services use and psychotropic medication prescribing. RESULTS: Of 3366 identified patients, 2029 (60.3%) were prescribed some form of psychotropic medication. Patients using psychological services were significantly less likely to be prescribed psychotropic medication (adjusted odds ratio 0.48, 95% CI 0.39-0.59, P<0.001) such as antipsychotics, benzodiazepines and antidepressants. This effect was maintained following several sensitivity analyses. We found no difference in the risk for mood stabiliser (adjusted odds ratio 0.79, 95% CI 0.57-1.10, P = 0.169) and multi-class psychotropic use (adjusted odds ratio 0.80, 95% CI 0.60-1.07, P = 0.133) between patients who did and did not use psychological services. CONCLUSIONS: Psychotropic medication prescribing is common in patients with personality disorder, but significantly less likely in those who have used psychological services. This does not appear to be explained by differences in demographic, clinical and service use characteristics. There is a need to develop clear prescribing guidelines and conduct research in clinical settings to examine medication effectiveness for this population.

Risk of First General Hospital Admissions for Self-Harm Among People With Personality Disorder: A Retrospective Cohort Study.

For individuals with a personality disorder (PD), it is unknown whether additional psychiatric conditions increase their risk of self-harm. The authors therefore conducted a retrospective cohort study, using data from secondary mental health care, to identify self-harm admissions. Adults with diagnosed PD, followed up over a 6-year period, were involved (N = 7,475). Cox regression was used to model the risk of self-harm admissions, with comorbid depression, substance use disorders (SUD), severe mental illness (SMI), anorexia nervosa (AN), and bulimia nervosa (BN) as primary exposures; sociodemographics were considered as confounders. In multivariable analyses, comorbid SUD (adjusted HR = 1.66; 95% CI [1.45, 1.90]), depressive disorder (1.25; [1.09, 1.44]), AN (1.63; [1.10, 2.39]), and BN (1.65; [1.09, 2.51]) were positively associated with increased risks of hospitalization due to self-harm. However, a negative association was found for comorbid SMI. The findings highlight the importance of assessing and treating comorbid psychiatric disorders in PD.

Predicting high-cost care in a mental health setting.

BACKGROUND: The density of information in digital health records offers new potential opportunities for automated prediction of cost-relevant outcomes. AIMS: We investigated the extent to which routinely recorded data held in the electronic health record (EHR) predict priority service outcomes and whether natural language processing tools enhance the predictions. We evaluated three high priority outcomes: in-patient duration, readmission following in-patient care and high service cost after first presentation. METHOD: We used data obtained from a clinical database derived from the EHR of a large mental healthcare provider within the UK. We combined structured data with text-derived data relating to diagnosis statements, medication and psychiatric symptomatology. Predictors of the three different clinical outcomes were modelled using logistic regression with performance evaluated against a validation set to derive areas under receiver operating characteristic curves. RESULTS: In validation samples, the full models (using all available data) achieved areas under receiver operating characteristic curves between 0.59 and 0.85 (in-patient duration 0.63, readmission 0.59, high service use 0.85). Adding natural language processing-derived data to the models increased the variance explained across all clinical scenarios (observed increase in r2 = 12-46%). CONCLUSIONS: EHR data offer the potential to improve routine clinical predictions by utilising previously inaccessible data. Of our scenarios, prediction of high service use after initial presentation achieved the highest performance.

Use of Natural Language Processing to identify Obsessive Compulsive Symptoms in patients with schizophrenia, schizoaffective disorder or bipolar disorder.

Obsessive and Compulsive Symptoms (OCS) or Obsessive Compulsive Disorder (OCD) in the context of schizophrenia or related disorders are of clinical importance as these are associated with a range of adverse outcomes. Natural Language Processing (NLP) applied to Electronic Health Records (EHRs) presents an opportunity to create large datasets to facilitate research in this area. This is a challenging endeavour however, because of the wide range of ways in which these symptoms are recorded, and the overlap of terms used to describe OCS with those used to describe other conditions. We developed an NLP algorithm to extract OCS information from a large mental healthcare EHR data resource at the South London and Maudsley NHS Foundation Trust using its Clinical Record Interactive Search (CRIS) facility. We extracted documents from individuals who had received a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder. These text documents, annotated by human coders, were used for developing and refining the NLP algorithm (600 documents) with an additional set reserved for final validation (300 documents). The developed NLP algorithm utilized a rules-based approach to identify each of symptoms associated with OCS, and then combined them to determine the overall number of instances of OCS. After its implementation, the algorithm was shown to identify OCS with a precision and recall (with 95% confidence intervals) of 0.77 (0.65-0.86) and 0.67 (0.55-0.77) respectively. The development of this application demonstrated the potential to extract complex symptomatic data from mental healthcare EHRs using NLP to facilitate further analyses of these clinical symptoms and their relevance for prognosis and intervention response.

The Bipolar II Depression Questionnaire: A Self-Report Tool for Detecting Bipolar II Depression.

Bipolar II (BP-II) depression is often misdiagnosed as unipolar (UP) depression, resulting in suboptimal treatment. Tools for differentiating between these two types of depression are lacking. This study aimed to develop a simple, self-report screening instrument to help distinguish BP-II depression from UP depressive disorder. A prototype BP-II depression questionnaire (BPIIDQ-P) was constructed following a literature review, panel discussions and a field trial. Consecutively assessed patients with a diagnosis of depressive disorder or BP with depressive episodes completed the BPIIDQ-P at a psychiatric outpatient clinic in Hong Kong between October and December 2013. Data were analyzed using discriminant analysis and logistic regression. Of the 298 subjects recruited, 65 (21.8%) were males and 233 (78.2%) females. There were 112 (37.6%) subjects with BP depression [BP-I = 42 (14.1%), BP-II = 70 (23.5%)] and 182 (62.4%) with UP depression. Based on family history, age at onset, postpartum depression, episodic course, attacks of anxiety, hypersomnia, social phobia and agoraphobia, the 8-item BPIIDQ-8 was constructed. The BPIIDQ-8 differentiated subjects with BP-II from those with UP depression with a sensitivity/specificity of 0.75/0.63 for the whole sample and 0.77/0.72 for a female subgroup with a history of childbirth. The BPIIDQ-8 can differentiate BP-II from UP depression at the secondary care level with satisfactory to good reliability and validity. It has good potential as a screening tool for BP-II depression in primary care settings. Recall bias, the relatively small sample size, and the high proportion of females in the BP-II sample limit the generalization of the results.

Validation of the standardised assessment of personality--abbreviated scale in a general population sample.

BACKGROUND: Personality disorder (PD) is associated with important health outcomes in the general population. However, the length of diagnostic interviews poses a significant barrier to obtaining large scale, population-based data on PD. A brief screen for the identification of people at high risk of PD in the general population could be extremely valuable for both clinicians and researchers. AIM: We set out to validate the Standardised Assessment of Personality - Abbreviated Scale (SAPAS), in a general population sample, using the Structured Clinical Interviews for DSM-IV Personality Disorders (SCID-II) as a gold standard. METHOD: One hundred and ten randomly selected, community-dwelling adults were administered the SAPAS screening interview. The SCID-II was subsequently administered by a clinical interviewer blind to the initial SAPAS score. Receiver operating characteristic analysis was used to assess the discriminatory performance of the SAPAS, relative to the SCID-II. RESULTS: Area under the curve for the SAPAS was 0.70 (95% CI = 0.60 to 0.80; p < 0.001), indicating moderate overall discriminatory accuracy. A cut point score of 4 on the SAPAS correctly classified 58% of participants. At this cut point, the sensitivity and specificity were 0.69 and 0.53 respectively. CONCLUSION: The SAPAS operates less efficiently as a screen in general population samples and is probably most usefully applied in clinical populations.

Predictors of natural and unnatural mortality among patients with personality disorder: evidence from a large UK case register.

BACKGROUND: People with personality disorder have reduced life expectancy, yet, within this population, little is known about the clinical predictors of natural and unnatural deaths. We set out to investigate this, using a large cohort of secondary mental health patients with personality disorder. METHODS: We identified patients with an ICD-10 diagnosis of personality disorder, aged ≥15 years in a large secondary mental healthcare case register. The case register was linked to national mortality tracing. Using Cox regression, we modelled the effect of a number of pre-specified clinical variables on all-cause, natural cause and unnatural cause mortality. FINDINGS: 2,440 patients were identified. Eighty-five deaths (3.5% of cohort) occurred over a 5-year observation period, of which over 50% were from natural causes. All-cause mortality was associated with alcohol or drug use (adjusted Hazard Ratio [aHR] 2.3; 95% CI 1.3-4.1), physical illness (aHR 1.9; 95% CI 1.0-3.6), and functional impairment (aHR 1.9; 95% CI 1.0-3.6). Natural cause mortality was associated with mild problems of alcohol or drug use (aHR 3.4; 95% CI 1.5-7.4), and physical illness (aHR 2.4; 95% CI 1.0-5.6). Unnatural cause mortality was associated only with severe alcohol or drug use (aHR 3.1; 95% CI 1.3-7.3). INTERPRETATION: Alcohol and drug use, physical illness, and functional impairment are predictors of mortality in individuals with personality disorder. Clinicians should be aware of the existence of problems in these domains, even at mild levels, when assessing the needs of patients with personality disorder.

The impact of co-morbid personality disorder on use of psychiatric services and involuntary hospitalization in people with severe mental illness.

PURPOSE: To examine the impact of co-morbid personality disorder (PD), on inpatient and community-based service use and risk of involuntary hospitalization, amongst patients with severe mental illness (SMI). METHODS: We identified SMI cases (schizophrenia, schizoaffective and bipolar disorder) with and without co-morbid PD, and PD cases, aged ≥18 years, in a large secondary mental healthcare case register. Using multivariable logistic regression, we examined the association between co-morbid PD and high level of inpatient and community-based service use (defined as the top decile of service use), and involuntary hospitalization, respectively, adjusting for socio-demographics, clinical symptoms and social functioning. RESULTS: Severe mental illness patients with co-morbid PD (SMI-PD) (n = 961) had more severe symptoms and social functioning problems compared to SMI patients without PD (n = 10,963) and patients who had PD but no concurrent SMI (n = 2,309). A greater proportion of SMI-PD patients were high inpatient service users (22.4 vs. 10.1 %). This association was attenuated but remained significant, after adjustment (fully adjusted odds ratio, OR 2.31, 95 % CI 1.88-2.84). The association between SMI-PD and high community-based service use was confounded by symptoms and social functioning. Compared to patients with SMI, SMI-PD patients were significantly more likely to experience involuntary hospitalization (fully adjusted OR 1.56, 95 % CI 1.31-1.85). CONCLUSIONS: In SMI patients, co-morbidity with PD is robustly associated with both high use of inpatient psychiatric services and an increased likelihood of involuntary hospitalization. Patients with SMI and co-morbid PD are likely to require tailored interventions that target both the underlying personality pathology as well as the Axis I disorder.

Personality disorder and self-rated health: a population-based cross-sectional survey.

Little is known about the impact of personality disorder (PD) on the health of people living in the community. The authors set out to examine the association between PD and general health, using a cross-sectional survey of a representative community sample in London, UK. A total of 1,698 adults aged 16 years or over from 1,075 randomly selected households were recruited and interviewed face-to-face by trained interviewers. Using multivariable logistic regression, the authors examined the cross-sectional association between PD screen status, as assessed by the Standardised Assessment of Personality-Abbreviated Scale (SAPAS), and self-rated health, adjusting for demographic and health covariates. Of the participants, 14.5% screened positively for PD. A greater proportion of those scoring positively for PD reported poor self-rated health, compared to screen negative participants (41.3% versus 15.0%). This association was reduced, but remained significant, after adjustment for potential confounders (unadjusted odds ratio (OR) = 3.99, 95% CI [2.93, 5.42]; fully adjusted OR = 1.53, 95% CI [1.02, 2.29]. Of note, subthreshold symptoms of PD were significantly associated with poor self-rated health (unadjusted OR per unit SAPAS score increment = 1.53, 95% CI [1.40, 1.67]; fully adjusted OR = 1.19, 95% CI [1.07, 1.33]. Furthermore, people screening positive for PD were more likely to report multiple (three or more) long-standing illnesses. The authors conclude that in the general population, individuals who are at high risk for PD are independently at increased risk of poor general health.

Life expectancy at birth and all-cause mortality among people with personality disorder.

OBJECTIVE: It is well established that serious mental illness is associated with raised mortality, yet few studies have looked at the life expectancy of people with personality disorder (PD). This study aims to examine the life expectancy and relative mortality in people with PD within secondary mental health care. METHODS: We set out to examine this using a large psychiatric case register in southeast London, UK. Mortality was obtained through national mortality tracing procedures. In a cohort of patients with a primary diagnosis of PD (n=1836), standardised mortality ratios (SMRs) and life expectancies at birth were calculated, using general population mortality statistics as the comparator. RESULTS: Life expectancy at birth was 63.3 years for women and 59.1 years for men with PD-18.7 years and 17.7 years shorter than females and males respectively in the general population in England and Wales. The SMR was 4.2 (95% CI: 3.03-5.64) overall; 5.0 (95% CI: 3.15-7.45) for females and 3.5 (95% CI: 2.17-5.47) for males. The highest SMRs were found in the younger age groups for both genders. CONCLUSION: People with PD using mental health services have a substantially reduced life expectancy, highlighting the significant public health burden of the disorder.

Incidence and persistence of sleep complaints in a community older population.

OBJECTIVES: To investigate factors associated with incidence and persistence of sleep complaints in an older population, with particular focus on the role of depression, subclinical depression and physical health status as predictors. METHOD: An analysis was carried out of data from the Gospel Oak Study: a community survey of 656 residents within a geographic catchment area in north London, aged 65 and over who were followed up after 1 year. Subjective sleep complaint was ascertained using a single question at baseline and follow-up. Independent variables included age, sex, marital status, social class, number of physical illnesses, disability, social support deficit and depression (according to SHORT-CARE: both a categorical measure and a scale based score). RESULTS: Baseline prevalence of sleep complaint was 44.7%. Incidence after 1 year was 21.4%, and persistence was 66.3%. After adjustment, female sex and depression predicted incidence of sleep complaint whereas only depression caseness predicted persistence of complaint. The population attributable fractions of depression caseness for incidence and persistence of sleep complaint were 37.4 and 23.4%, respectively. Positive but weaker associations were found between sub-case depressive symptoms and these outcomes. CONCLUSIONS: Depression was the strongest predictor of incidence and persistence of sleep complaints in this older sample. However, overall it accounted only for a minority of instances of incident/persistent symptoms.

Modified and unmodified electroconvulsive therapy: a comparison of attitudes between psychiatrists in Beijing and Hong Kong.

OBJECTIVE: Unmodified electroconvulsive therapy (ECT) is still widely practiced in many psychiatric institutions in China. The study reported herein aimed to explore the attitudes of psychiatrists in Beijing toward unmodified and modified ECT and compare them with those of psychiatrists in Hong Kong, where only modified ECT has been used during the past 40 years. METHOD: One hundred five psychiatrists of a university-affiliated psychiatric hospital in Beijing and all psychiatrists (n = 238) currently practicing in Hong Kong were invited to complete a questionnaire exploring their attitudes toward unmodified and modified ECT. RESULTS: The Beijing respondents had significantly more experience with unmodified ECT than their Hong Kong counterparts. Although 56% of the Beijing respondents preferred modified to unmodified treatment, 81% of them regarded unmodified ECT as safe and associated with minimal morbidity and mortality. Patient choice, financial status, and safety considerations were the main factors that dictated the choice of mode of ECT in Beijing. CONCLUSIONS: It seems that unmodified ECT still has a role as an effective psychiatric treatment in developing countries such as China. Any initiative to replace unmodified with modified treatment should take into account economic conditions, the sociocultural context, and the psychiatric traditions of the particular regions of the country.

Shoplifting in the mentally ill: the role of bipolar affective disorder and mental retardation.

This study explores shoplifting behaviour in mentally ill patients, and evaluates the association between shoplifting and different mental illnesses in a local Chinese population. A comparison is made between shoplifting offenders and a matched control group of non-offenders among the psychiatric patients registered at a university department of psychiatry. Major depression, bipolar affective disorder (BAD) and mental retardation (MR) are the most common diagnoses among mentally ill shoplifters, while patients with a diagnosis of BAD or MR are at higher risk of committing an offence than patients with other diagnoses. Bipolar affective disorder has not been described as a risk factor for shoplifting behaviour in the psychiatric literature. Such a possibility should be seriously considered in the psychiatric assessment of shoplifting cases.