Borderline Personality Disorder Symptoms and Treatment Seeking Over the Past 12 Months: An Investigation Using the National Comorbidity Survey-Replication (NCS-R)
To the Editor: Borderline personality disorder is associated with elevated health care utilization.1 However, the degree to which those with borderline personality disorder access mental health care or alternative treatment is unclear. Currently, only limited research on treatment seeking in borderline personality disorder in an epidemiologic sample has been completed, which compared treatment seeking in borderline personality disorder to that in other personality disorders and found no significant differences.2 However, that study did not examine specific treatments or treatment satisfaction, and it may have used overly conservative estimates of borderline personality disorder, potentially reducing power.2 We examined specific treatment-seeking behavior and satisfaction with some treatments in those with elevated borderline personality disorder symptoms over the previous 12 months using the National Comorbidity Survey-Replication (NCS-R) Part II (N = 5,692).3
Method. Borderline personality disorder symptoms were assessed with the International Personality Disorder Examination4 screening questionnaire, and those endorsing 5 or more criteria were classified as having elevated borderline personality disorder symptoms. Axis I or "neither diagnosis" comparison groups were also created and included those with < 5 borderline personality disorder symptoms. All respondents indicated whether or not they received treatment in the last year for "problems with your emotions or nerves or your use of alcohol or drugs." Services included visiting traditional providers such as a nonpsychiatric physician (MD) or a social worker or a mental health specialist such as a psychiatrist or psychologist. Nontraditional providers included "spiritual advisor," "nontraditional healer," mental health hotline, self-help support group, Internet support group, use of herbal medicine, and consultation of a "telephone psychic." Satisfaction with services was rated from 1 (very satisfied) to 5 (very dissatisfied), and whether the participant "felt helped" was rated from 1 (a lot) to 4 (not at all); to produce odds ratios, these scales were dichotomized so that ratings of 1 and 2 were coded as "satisfied" or "felt helped." Logistic regression analyses were conducted using COMPLEX function of MPlus to account for sophisticated sampling procedures.5 Age, sex, race/ethnicity, education level, marital status, occupational status, and family income were included as covariates.
Results. Approximately 50% of those with a diagnosis of borderline personality disorder symptoms sought treatment over the last year (Table 1); 29% sought treatment from traditional sources, 36% sought treatment from nontraditional sources, and only 17% sought treatment from a mental health specialist. Only 14% saw a psychiatrist in the last year, and only 7% saw a psychologist. They used more types of treatments (mean = 0.93, SD = 1.27) than those with an Axis I (mean = .77, SD = 1.08) or no diagnosis (mean = 0.37, SD = .77; F1, 5683 = 412.24, P < .001, ηΡ2 = .11). They had increased odds, relative to both comparison groups, of seeking treatment of any kind, seeing a mental health specialist, seeking traditional treatment, and seeking nontraditional treatment. Respondents with borderline personality disorder had increased odds of seeing a psychiatrist, nonpsychiatric physician, or psychologist and being prescribed medication relative to those with no diagnosis. They also pursued more nontraditional treatments, with increased odds of using a mental health hotline, consulting a telephone psychic or nontraditional healer, attending a support group, and using herbal medicine. Of those with borderline personality disorder who sought any kind of treatment, 30% sought traditional treatment only, 42% sought nontraditional treatment only, and 28% consulted both traditional and nontraditional sources. Seventy percent of those with borderline personality disorder symptoms who sought treatment engaged in nontraditional treatment, making it the most commonly used type (χ22 = 15.15, P < .01). Although over 50% were generally satisfied and found most treatments helpful, they were less satisfied than controls with nonpsychiatric physicians, psychiatrists, and spiritual advisors and reported physicians as less helpful.
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Despite higher rates of mental health care treatment seeking, few with elevated borderline personality disorder symptoms received traditional mental health treatment in the previous year. The finding that only 17% of those with symptoms visited a psychiatrist or psychologist indicates that more effort is needed to reduce barriers to appropriate treatment. Over 70% of those with borderline personality disorder symptoms seeking services did so in a nontraditional setting, pursuing services from the Internet, via telephone, and from the community at large. This suggests that those with borderline personality disorder symptoms may utilize nontraditional services more than those with other psychiatric disorders.6 Most with borderline personality disorder symptoms were generally satisfied with services received, although less so for services of physicians, psychiatrists, and spiritual advisors, in contrast to previous findings that suggest low treatment satisfaction in this population.7,8 Findings should be considered in light of the limitations of using a self-report measure of borderline personality disorder.
References
1. Bender DS, Dolan RT, Skodol AE, et al. Treatment utilization by patients with personality disorders. Am J Psychiatry. 2001;158(2):295-302. PubMed doi:10.1176/appi.ajp.158.2.295
2. Lenzenweger MF, Lane MC, Loranger AW, et al. DSM-IV personality disorders in the national comorbidity survey replication. Biol Psychiatry. 2007;62(6):553-564. PubMed doi:10.1016/j.biopsych.2006.09.019
3. Kessler RC, Merikangas KR. The National Comorbidity Survey Replication (NCS-R): background and aims. Int J Methods Psychiatr Res. 2004;13(2):60-68. PubMed doi:10.1002/mpr.166
4. Loranger AW, Sartorius N, Andreoli A, et al. The International Personality Disorder Examination: The World Health Organization/Alcohol, Drug Abuse, and Mental Health Administration international pilot study of personality disorders. Arch Gen Psychiatry. 1994;51(3):215-224. PubMed doi:10.1001/archpsyc.1994.03950030051005
5. Muthén B, Muthén L. Mplus User’s Guide. 6th ed. Los Angeles, CA: Muthén & Muthén; 2008.
6. Wang PS, Lane M, Olfson M, et al. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):629-640. PubMed doi:10.1001/archpsyc.62.6.629
7. Kelstrup A, Lund K, Lauritsen B, et al. Satisfaction with care reported by psychiatric inpatients. Relationship to diagnosis and medical treatment. Acta Psychiatr Scand. 1993;87(6):374-379. PubMed doi:10.1111/j.1600-0447.1993.tb03390.x
8. Miller JD, Pilkonis PA, Mulvey EP. Treatment utilization and satisfaction: examining the contributions of Axis II psychopathology and the Five-Factor Model of personality. J Pers Disord. 2006;20(4):369-387. PubMed doi:10.1521/pedi.2006.20.4.369
Author affiliations: Department of Psychology, Rutgers, The State University of New Jersey, New Brunswick (Dr Selby); and Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, and Department of Psychiatry, Harvard Medical School, Boston, Massachusetts (Dr McHugh).
Potential conflicts of interest: The authors are aware of no conflicts with the content of this manuscript; nonetheless, Dr McHugh would like to report receipt of royalties from Oxford University Press.
Funding/support: Funding was provided, in part, by a Brain and Behavior Research Foundation Early Investigator NARSAD Grant (PI: Dr Selby). The National Comorbidity Survey Replication was supported by the National Institute of Mental Health (U01-MH60220) with supplemental support from the National Institute on Drug Abuse, the Substance Abuse and Mental Health Services Administration (SAMHSA), the Robert Wood Foundation (Grant 044708), and the John W. Alden Trust.
Disclaimer: The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of any sponsoring organizations, agencies, or US Government. A complete list of NCS publications and the full text of all NCS-R instruments can be found at http://www.hcp.med.harvard.edu/ncs/. The NCS-R is carried out in conjunction with the World Health Organization World Mental Health (WMH) Survey Initiative.
Additional information: The original data set is available at http://www.icpsr.umich.edu/icpsrweb/CPES/.
J Clin Psychiatry 2013;74(10):1026-1028 (doi:10.4088/JCP.12l08232).
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