Psychiatrists’ motives for compulsory care of patients with borderline personality disorder – a questionnaire study

Antoinette Lundahl,Niklas Juth,Johan Hellqvist,Gert Helgesson

doi:10.1177/14777509211040190

Antoinette Lundahl, Niklas Juth + Show 2 more

Open Access

https://doi.org/10.1177/14777509211040190

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Journal: Clinical Ethics	Publication Date: Aug 31, 2021
Citations: 1	License type: CC BY 4.0

Affiliation: Karolinska Institutet

Abstract

IntroductionBorderline personality disorder patients are often subjected to inpatient compulsory care due to suicidal behaviour. However, inpatient care is usually advised against as it can have detrimental effects, including increased suicidality.AimTo investigate what motives psychiatrists have for treating borderline personality disorder patients under compulsory care.Materials and MethodsA questionnaire survey was distributed to all psychiatrists and registrars in psychiatry working at mental health emergency units or inpatient wards in Sweden. The questionnaire contained questions with fixed response alternatives, with room for comments, about the respondents’ motives for practising compulsory care of borderline personality disorder patients. The responses were analysed quantitatively with descriptive statistics, and comments were analysed with qualitative descriptive content analysis.ResultsThe psychiatrists’ views were divided on when it was justified to treat borderline personality disorder patients under compulsory care, as were their views on borderline personality disorder patients’ decision competence. When there was an assessed risk of harm, 53% were positive to compulsory care of decision-competent borderline personality disorder patients and another 31% because they considered the patients to be decision incompetent in such situations. Adding the risk of harm caused many respondents to alter their assessment of the patient from decision competent to decision incompetent.ConclusionThe large variations in doctors’ opinions indicate that the care of borderline personality disorder patients is arbitrary. Further, the assessed risk of harm increases the use of compulsory care, even though such care is advised against in clinical guidelines, has questionable legal support, and could lead to an increased suicide risk over time.

Highlights

Borderline personality disorder patients are often subjected to inpatient compulsory care due to suicidal behaviour
For borderline personality disorder (BPD) patients in crisis with the risk of self-harm, 84% were positive to use compulsory care – either because they considered the patients to be decision incompetent or because the risk of harm trumped that the patients were decision competent
This indicates that striving for risk reduction is considered more important than respect for autonomy in such situations and that the increased risk of harm can be interpreted as a sign of decision incompetence

Summary

Introduction

Borderline personality disorder patients are often subjected to inpatient compulsory care due to suicidal behaviour. Guidelines advise that hospitalization, monitoring, restraints, and, in general, overtaking of autonomy should be avoided or used with caution.[7,8] A recent study has even indicated that crisis-service utilization, such as emergency-room visits and previous inpatient admissions, results in an increased risk for future suicide in patients with BPD – a negative side effect of such care.[6] At the same time, BPD patients are overly represented when it comes to inpatient care and compulsory inpatient care.[9,10]

Results

Discussion

Conclusion