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Purpose People with personality disorders have significantly reduced life expectancy and increased rates of cardiovascular disease compared to members of the general population. Given that more people die annually of cardiovascular disease across the globe than from any other cause, it is important to identify the evidence for interventions aimed at improving cardiovascular health among people with personality disorders. Methods Systematic literature review. PsycINFO, MEDLINE and EMBASE were searched using NICE Healthcare Data- bases, as well as CENTRAL and trial registries. We sought to identify randomised controlled trials of interventions pertaining to adults with a primary diagnosis of personality disorder, where the primary outcome measure was cardiovascular health before and after the intervention. Results A total of 1740 records were identified and screened by two independent reviewers. No papers meeting the inclu- sion criteria were identified. Conclusions This systematic review did not identify any randomised controlled trials testing interventions aimed at improv- ing the cardiovascular health of people with personality disorders. Research in this area could have important public health implications, spanning the fields of psychiatry and general medicine. Keywords Personality disorders · Cardiovascular health · Systematic review Background review aims to include people with any type of personality disorder, much of the relevant epidemiological research has Personality disorders (PDs) are complex mental health prob- been conducted in people with Cluster B PDs, and specifi- lems, with an overall estimated prevalence in western Euro- cally borderline personality disorder (BPD). pean countries of approximately 6% [1], affecting as many People with PD have a lower average life expectancy than as 40% of those in contact with secondary mental health the general population, with figures ranging from 18 years services [2]. The Diagnostic and Statistical Manual of Men- fewer in a London-based retrospective cohort study [4] to as tal Disorders (DSM) classification of personality disorders many as 27.5 years for people with severe PD in a Scottish into three clusters is widely used; Cluster A includes the cohort [5]. This loss of life years cannot simply be attrib- paranoid, schizoid and schizotypal categories, Cluster B uted to excess rates of suicide [6, 7]. A recent review of the includes the antisocial, borderline, histrionic and narcissis- literature relating to physical health problems experienced tic categories, and Cluster C includes the avoidant, depend- by people with PD has summarised associations with pain ent and obsessive–compulsive categories [3]. Although this conditions, obesity and chronic illnesses including CVDs [8]. The authors of this review found that, compared to con- trols, people diagnosed with Cluster B PDs were at increased * Katherine Hall risk of experiencing syncope, seizures and arthritis, as well kh9743@my.bristol.ac.uk as elevated levels of health concern in general [8]. It was also noted that people with PD experience faster annual Population Health Sciences, University of Bristol, Bristol, UK rates of health decline (by 50%) from adolescence to their mid-30 s compared to controls [8]. These health problems Imperial College London, London, UK Vol.:(0123456789) 1 3 898 Social Psychiatry and Psychiatric Epidemiology (2019) 54:897–904 are associated with increased health service utilisation com- as well as higher rates of obesity [9, 25]. Interestingly and pared to the general population [9, 10]. Other research has perhaps intuitively, rates of smoking, alcohol consumption found differences in hospitalisation rates among people with and lack of regular exercise have been found to be higher in borderline PD compared to controls which were especially non-recovered patients with BPD compared to those who apparent in relation to cardiac and gynaecological condi- had recovered [9]. An Australian cross-sectional study of tions [11]. young community-dwelling adults (n = 1520) also found According to the World Health Organization (WHO), strong independent associations between Cluster B PDs and more people die annually from cardiovascular diseases smoking [26]. (CVDs) across the globe than from any other cause. CVDs The WHO, like many national-level organisations, include coronary heart disease, cerebrovascular disease emphasises that most CVDs can be prevented by address- and peripheral arterial disease [12]. In addition to the well- ing behavioural risk factors such as tobacco smoking, poor known occurrence of psychiatric co-morbidities in people diet, obesity and lack of exercise [12]. These factors, as well with PD [13], the disproportionately high burden of physi- as elevated blood glucose levels and hyperlipidaemia, are cal health problems, such as CVDs, is becoming increas- recognised as being causally linked to CVD [27]. However, ingly recognised as contributory to the stark reduction in life it cannot be assumed that the usual CVD risk reduction strat- expectancy in this group [4, 14–16]. Moreover, the finding egies are generalisable to people with PD; in this group, that physical illnesses predict death by suicide illustrates compared to the general population, important differences the critical interplay between poor physical health and sui- regarding patterns of healthcare utilisation [28], treatment cide among people with PD [13, 17, 18]. Evidence for an adherence [29], and co-morbidities [30] must all be con- association between PD and CVDs comes from various sidered. We chose to carry out this systematic review as population-based epidemiological studies, which, for BPD, targeted interventions in this area are likely to provide an demonstrate adjusted odds ratios for CVD ranging from 1.47 important avenue to narrow the health and life expectancy to 7.2 [19–21]. In a UK household survey (n = 8580), Moran gap faced by people with PDs. et al. found that people with a PD were almost twice as likely to report a history of stroke, and around 1.4 times as likely to report a history of ischaemic heart disease compared to the Objectives general population, after adjustment for age, sex, socioeco- nomic status, hypertension, diabetes, smoking and alcohol 1. To assess whether any interventions designed to improve use [21]. Similar figures come from the National Epidemio- the cardiovascular health or cardiovascular risk factors logic Survey on Alcohol and Related Conditions (NESARC) in people diagnosed with PDs have been developed and (n = 34,653), conducted in the United States, in which older evaluated using randomised controlled trials (RCTs). adults with any PD were 1.26 times more likely to report 2. To assess whether any such interventions are efficacious. a history of coronary heart disease than controls [22]. The longitudinal Baltimore study, in which 244 people with PD were followed up over a 23-year period, found that Cluster B Methods disorders were consistently associated with increased CVD incidence, and that their presence predicted CVD mortality Search strategy and selection criteria [20]. Furthermore, in a small sample of women with BPD (n = 47), common carotid artery ultrasound scanning demon- This systematic review was conducted in accordance with strated greater intima-media thickness (compared to healthy the Preferred Reporting Items for Systematic Reviews and controls), an early marker for atherosclerosis and subsequent Meta-Analyses (PRISMA) guidelines [31]. CVD risk [23]. We searched for RCTs of interventions aimed at improv- When considering the psychopathology associated with ing cardiovascular disease or improving cardiovascular risk PD, the susceptibility to certain cardiovascular risk factors is factors in people with a primary diagnosis of PD. perhaps unsurprising. People with BPD, with its association with early life adversity and tendency towards impulsivity, Inclusion criteria have been found to have an increased risk of metabolic syn- drome and dysregulated glucose and lipid metabolism [24], Trials were eligible for inclusion if they met the following criteria: [1] used random allocation to assign participants to the intervention and control groups; [2] all participants were adults (aged 18–65 years) with a primary diagnosis of The authors do note that the increased presentation to cardiology any type of PD, irrespective of the diagnostic criteria used. departments may be confounded by the co-occurrence of anxiety dis- orders in patients with BPD. 1 3 Social Psychiatry and Psychiatric Epidemiology (2019) 54:897–904 899 We set out to include studies of any intervention aimed at Table 1 Results of database and Database Results trial registry searches improving cardiovascular disease or improving cardiovascu- PsycINFO 379 lar risk factors. This would include studies aimed at promot- MEDLINE 618 ing smoking cessation, increasing levels of physical activity, EMBASE 538 reducing weight or body mass index (BMI), improving diet, CENTRAL 479 improving blood pressure, blood glucose or blood lipid lev- Trial registries 31 els. Studies aimed at increasing physical health monitoring Total 2045 or access to physical healthcare which may improve cardio- vascular health would also be included. Outcomes Data collection and analysis Primary outcome Selection of studies Cardiovascular health, measured by 10-year CVD risk, cardiovascular mortality, number of cardiovascular events Covidence, a web-based software platform designed to such as myocardial infarction or stroke, or any relevant streamline the production of systematic reviews, was used measure of cardiovascular health quoted by the study. to facilitate the selection of studies [33]. Electronic records Secondary outcomes identified from our search were imported to Covidence via Endnote X8 [34]. Two review authors (KH and KB) inde- 1. Measures of cardiovascular risk factors such as change pendently screened all records identified from the search to in smoking status, change in levels of physical activity, identify potentially relevant papers for full-text review. Any change in weight or BMI, change in diet, blood pressure, disagreements were resolved by discussion among the two blood glucose or blood lipid levels. review authors; had this not been possible, it would have 2. Leaving the study early for any reason including inef- been further discussed with the senior author (PM). ficacy of treatment, adverse events and death. Data extraction and management Databases In the event of relevant studies being identified, the two The following electronic databases were searched using review authors planned to extract data from the included NICE HDAS (Healthcare Databases Advanced Search): studies onto standardised forms. PsycINFO, MEDLINE and EMBASE. The search terms used for PsycINFO are provided in “Appendix”. To limit Assessment of risk of bias in included studies the results to RCTs, the Cochrane Highly Sensitive Search Strategies for identifying randomised trials were employed The two review authors planned to assess the risk of bias for each of PsycINFO, MEDLINE and EMBASE databases independently, using the Cochrane Risk of Bias tool [35]. [32]. No date, language, document type or publication status Risk of bias level and trial quality would then have been limitations were applied to the search. noted in a ‘Summary of findings’ table. In addition, the Cochrane Central Register of Controlled Trials (CENTRAL) was searched via the Cochrane Library. The following clinical trials registries were also searched to Results identify any unpublished or ongoing trials: World Health Organisation International Clinical Trials Registry Platform Description of studies (ICTRP), ISRCTN Registry, EU Clinical Trials Register (EudraCT) and ClinicalTrials.gov. The reference lists of any From our searches, 2045 electronic records were identified included papers would also have been examined. (Table 1). Three hundred and five duplicates were removed by Covidence, leaving 1740 records for screening. One paper was obtained for full-text screening but was excluded after discussion between the three authors (KH, KB and PM) as, although a proportion of the study population had a diag- nosis of PD, results for this group were not differentiated from the included individuals with other diagnoses. This Full search strategies for each database are available from the authors upon request. published RCT, conducted by Knapen et al., described how 1 3 900 Social Psychiatry and Psychiatric Epidemiology (2019) 54:897–904 Fig. 1 PRISMA flow diagram Records idenfied through Addional records idenfied database searching through other sources (n = 2014) (n = 31) Records a�er duplicates removed (n = 1740) Records screened Records excluded (n = 1740) (n = 1739) Full-text arcle(s) Full-text arcle(s) assessed for eligibility excluded (n = 1) (n = 1) Reason: wrong study populaon Studies included in the qualitave or quantave synthesis (n = 0) 199 patients (70 of whom had a diagnosis of PD) were ran- compared to the association between CVD and other serious domly allocated to either a general programme of psychomo- mental illnesses (SMI) [37]. tor therapy (control) or a personalised psychomotor fitness In contrast to the paucity of trials in patients with PD, we programme (intervention), each lasting for 16 weeks. The have identified 10 systematic reviews investigating interven- intervention group showed an increase in cardiorespiratory tions to improve the cardiovascular health or cardiovascular fitness, but no subgroup analysis for the patients with PD risk profile of people with SMI [38– 47]. Moreover, most of was reported, or made available on request from the authors these reviews did not include people with PD. We believe [36]. that excluding these people, who are at very high risk of With regards to the trial registries search, no ongoing CVD, is not only scientifically unsound but also represents trials were identified which focused on people with PDs. As a lost opportunity for developing an evidence base in a a result, no RCTs were eligible for inclusion in this review. neglected field of health research. This process has been summarised in a PRISMA flow dia- Physical health appears to be under-assessed and under- gram (Fig. 1). treated in people with PD [48]. Sanatinia et al. (2015) found that a lower proportion of those in a random sample of peo- ple with PDs had documented evidence of smoking status, Discussion blood glucose and blood lipid levels compared to people with schizophrenia. Moreover, people with PD were less We have argued that the modifiable risk factors associated likely to be offered smoking cessation advice than those with with the development of CVD constitute an important tar- schizophrenia [48]. get for narrowing the life expectancy gap between people Research in people with SMI may offer guidance on with PD and the general population. The lack of identified future productive trials for people with PD. If we take smok- trials in this area may partly be explained by the fact that ing as an example, several trials (n = 26) relate to smok- the association between PD and CVD is less widely known ing cessation in people with SMI, as shown by the recent 1 3 Included Eligibility Idenficaon Screening Social Psychiatry and Psychiatric Epidemiology (2019) 54:897–904 901 review by Peckham et al. [39]. It is noteworthy that peo- peer health navigator scheme [56]. These interventions may ple with PD were excluded from this review. These trials be of interest when planning future work in those with PD. often test relatively brief interventions, such as motivational interviewing. For example, Metse et al. conducted a cluster RCT of 754 adult psychiatric inpatients, 17.8% of whom Conclusion had ‘personality and other disorders’ but with no further differentiation than this. They investigated the effect of a There is a conspicuous gap in the literature on interventions brief motivational interview and self-help material whilst in designed to improve the cardiovascular health of people with hospital, followed by a 4-month pharmacological and psy- PD, despite the significantly increased prevalence of CVDs chosocial intervention upon discharge. No significant effect and mortality in this population. The lack of studies in this was found on measures of prolonged abstinence at either 6 field is particularly accentuated when compared to the extent or 12 months, but intervention group participants were more of recent and ongoing research into physical health interven- likely than controls to have reduced cigarette consumption tions for people with other types of psychiatric disorders, by 50% [49]. This suggests that there could be grounds for such as psychotic or affective illnesses. testing the effectiveness of a brief motivational intervention It is important to strive for parity of healthcare within for smoking cessation among people with PD specifically. psychiatric practice and this is particularly the case for peo- The mode of treatment delivery is also important to con- ple with PD, who are so often still excluded from main- sider for people with PD, many of whom may lead turbulent stream healthcare. Our review shows that they are also and chaotic lives. It has already been established that the excluded from trials evaluating the effectiveness of cardio- telephone is a feasible and acceptable mode of delivering vascular interventions. We believe that this is magnifying a interventions for people with PD, such as the use of tel- serious public health problem, impacting both the quality of ephone coaching in the context of dialectical behavioural life of individuals with PDs and adversely affecting produc- therapy (DBT) [50]. Telephone-delivered smoking cessation tivity in the context of wider health economics. We would has been trialled in people with psychosis; for example, in a argue that people with PD should be included in future trials RCT involving 235 smokers with psychotic disorders, Baker of cardiovascular interventions. Such research could help to et al. (2018) found that both an individual ‘healthy lifestyle inform improvements in general health and mortality rates intervention’ (consisting of motivational interviewing and for people with this common and complex mental health cognitive behavioural therapy over 6 months) and telephone- disorder. delivered smoking cessation support achieved significant Acknowledgements Thanks to Stephen Walker, Avon and Wiltshire reductions in cardiovascular disease risk and smoking rates Partnership Trust Librarian, and Sarah Herring, University of Bristol across a 36-month follow-up period [51]. Such telephone- Medical Subject Librarian, for their help in developing the search strat- based interventions do not yet appear to have been trialled egies for this systematic review. to improve cardiovascular risk factors in people with PD. However, the telephone could be a potentially promising Compliance with ethical standards delivery platform for a brief intervention designed to pro- mote smoking cessation among people with PD. Ben-Porath This study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University (2004) hypothesises that telephone coaching in the context of Bristol. The views expressed in this publication are those of the of DBT and self-harm provides a framework for encouraging author(s) and not necessarily those of the NHS, the National Institute patients to seek help in ‘more adaptive ways’ than their usual for Health Research or the Department of Health and Social Care. coping mechanisms [50]; this may well be applicable in the context of smoking in people with PD. Conflict of interest The authors declare that they have no conflict of interest. Smoking cessation is one example, but inspiration may be derived from a variety of approaches. Other trials in people Open Access This article is distributed under the terms of the Crea- with mental illness have aimed to reduce weight or waist tive Commons Attribution 4.0 International License (http://creat iveco circumference, for example by attempting to change the mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- ‘obesogenic environment’ of inpatient facilities, with some tion, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the positive results in the short term though not the longer term Creative Commons license, and indicate if changes were made. [52]. Another example is the WebMOVE initiative in those with SMI, which consists of computerised weight-manage- ment with peer coaching, which contributed to a reduction in BMI in the intervention group [53]. 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Published: Mar 30, 2019
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