Ambulance attendances for personality disorders involving alcohol and other drugs, and suicidal thoughts and behaviours
What's the issue?
Borderline personality disorder (BPD) is a mental illness in which a person displays a pattern of instability in relationships, self-image, emotions and behaviours such as impulsivity.
Some people living with BPD may self-manage their experiences through harmful ways such as non-suicidal self-injury (NSSI), harmful prescription or illicit drug use, harmful use of alcohol, and may experience suicidal ideation.
Previous research has shown that a majority (60–90%) of people diagnosed with BPD have a history of NSSI, experience suicidal thoughts, and make multiple suicide attempts. Findings of international studies indicate that up to 10% of people diagnosed with personality disorder die by suicide.1
A previous 2020 study by the lead author examined data from a coronial audit conducted in Victoria, which showed more than 7% of all people who died by suicide had a diagnosis of BPD. Among these cases, 25% had presented to an emergency department (ED) within the six weeks prior to their death by suicide. Hospital presentations for suicidal thoughts and behaviours were most common by ambulance.
Ambulance services are often the first to provide care to people experiencing suicidal distress. An estimated 10% of ambulance attendances are for mental health-related presentations.
The researchers of this study aimed to:
a) Evaluate the use of ambulance services in Victoria, Australia, by people diagnosed with personality disorder over a 6.5-year period
b) Examine the frequency of ambulance re-attendance due to personality disorder-related presentations.
What was done?
Researchers examined data from the National Ambulance Surveillance System (NASS) between January 2012 to May 2019. The data was coded and linked to Electronic Patient Care Records (in collaboration with Turning Point) based on patient name, date of birth and gender to identify repeat patients of ambulance services.
Ambulance users were classified as having a BPD if it was recorded by the paramedic when attending an incident, or others present at the scene provided the information to ambulance personnel.
To determine if there was a higher rate of ambulance callout and ambulance re-attendance for people living with BPD, the researchers compared BPD against three subgroups and matched them for comparison. The comparison groups were:
(a) depression and anxiety disorders
(b) serious mental illness
(c) combined all mental health conditions.
What was found?
NOTE – This translation highlights findings specific to drug and alcohol use specific results.
Researchers examined 551,400 ambulance attendances that related to mental health, alcohol, and other drug, or suicidal thoughts. Analysis found:
- Of those with personality disorders, 75% were female. Women made up 55% of those with all other mental disorders.
- Those with personality disorders had an average age of 30.8 years, compared to 41.2 years of age for those with classified as having other mental disorders.
- Of ambulance attendances, 75% took place in metropolitan areas.
- BPD was recorded in 10,397 (1.9%) attendances.
- Other personality disorders were recorded in 13,099 (2.4%) attendances.
- Researchers examined and adjusted for re-attendances. There were 9,632 individual person records identified. BPD was noted in 52.8% of these cases.
- The 9,632 patients with a personality disorder required a total of 76,929 ambulance attendances between January 2012 and May 2019.
- Presentation for NSSI and suicidal behaviours was higher in individuals categorised as living with BPD (56.2%) compared to other mental disorders (30.2%).
- There was no difference in the proportion of attendances involving alcohol and drugs between those with personality disorders or other mental disorders.
- Suicide attempts involving the use of alcohol and other drugs were higher in those categorised ‘all other mental disorders’ compared to the BPD group.
- A greater proportion of ambulance attendances for people with personality disorders involved transport to hospital and police co-attendance.
Note - The ambulance attendances coded in NASS are only for presentations related to alcohol or drug, mental health, and self-injurious thoughts and behaviours. Presentations involving death by suicide were not included.
Why are the findings important?
Ambulance attendances for people living with a personality disorder required a total of 76,929 ambulance attendances during the study period. This is a significant number of callouts and can place strain on service delivery and resourcing. People living with BPD were more likely to require ambulance re-attendance and require police support.
The impacts for individuals experiencing a mental health crisis requiring an ambulance has significant impacts on both the individual and their carers.
The research found no difference in the proportion of attendances involving alcohol and drugs between those with personality disorders or other mental disorders, however suicide attempts involving the use of alcohol and other drugs (AOD) were higher in individuals requiring ambulances and being categorised ‘all other mental disorders’. These findings again highlight a link between AOD use and mental health crisis. Early intervention strategies addressing both mental health, and alcohol and other drug use may support the prevention of distress and suicide.
Given that patients who rely on ambulance services have complex needs and high service engagement, there is a strong case for adopting management plans that are visible throughout the public health system that focus on all aspects of health, including AOD use.
Notes
- 1
McGlashan TH. The Chestnut Lodge follow-up study: III. Long-term outcome of borderline personalities. Arch Gen Psychiatry. 1986;43(1):20-30. doi:10.1001/archpsyc.1986.01800010022003.