Personality disorder, socioeconomic factors and psychiatric hospital admissions: assessing the evidence

The aim of this study is to identify whether there are relationships between key socioeconomic factors and psychiatric inpatient admissions for people with a personality disorder diagnosis. Evidence suggests that there are disproportionately high numbers of people with a personality disorder diagnosis in psychiatric inpatient settings (Evans et al., 2017). Difficult social circumstances have a longstanding and well-documented relationship with negative mental health outcomes (Marmot, 2010), but little is known about whether this association extends to people with a personality disorder diagnosis. This research seeks to understand whether socioeconomic factors are implicated in psychiatric hospital admissions for people with a personality disorder diagnosis. Analysis using the 2014 Adult Psychiatric Morbidity Survey will achieve these aims by enabling an exploration of the relationship between key socioeconomic factors, mental health conditions and mental health outcomes, each of which are available as indicators in the dataset.

People with a diagnosis of personality disorder currently experience a mortality gap of twenty years compared to the general population, almost one in ten will commit suicide and 50-70% of psychiatric inpatients have this diagnosis (Fok et al., 2012; Appleby et al., 2018; Dale et al., 2016; Evans et al., 2017). Economic costs resulting from healthcare service use and unemployment for people with personality disorders are estimated at over £7.9 billion annually with a projected rise to £12.3 billion by 2026 (McCrone et al., 2008). Specialist community service provision has been improving over time but remains patchy, and people with a personality disorder diagnosis are frequent users of accident and emergency, psychiatric inpatient, and primary care services (Evans et al., 2017).

To date, research has focused on individual treatment interventions but has not explored the potential impact of upstream social determinants on the health and healthcare use of people with a personality disorder diagnosis. Socioeconomic deprivation has longstanding links with poorer mental and physical health (Marmot, 2010), and for people with a diagnosis of personality disorder, who may already be socially excluded and unable to access appropriate support, difficult social circumstances have the potential to worsen symptoms. More evidence is needed to determine how socioeconomic factors affect psychiatric hospital admissions for people with personality disorders.

Using the APMS will offer an opportunity to study these relationships using a nationally representative dataset for the first time. This study will therefore contribute to the currently limited evidence base on personality disorders, with the aim of improving policy and clinical practice for people with this diagnosis.

All individuals who participated in the APMS were consenting adults living in England and Wales and, as such, the processing of their data for the purposes described here should not come as unexpected.

The greater understanding of these relationships and the potential for more effective healthcare interventions generated via the study findings means that it is in the public interest, as such the University of York intend to process personal data under Articles 6 (1) (e) and Article 9 (2) (j) of the GDPR for the purpose of carrying out this research. Furthermore, it is in keeping with the University of York’s ‘public task’ which states ‘the objects of the University shall be to advance learning and knowledge by teaching and research, and to enable students to obtain the advantages of University education’. As such, the basis for dissemination of this data falls under Sections 261(1) and 261(2)(b)(ii) of the Health and Social Care Act 2012.

The research is funded by a University of York/Wellcome Trust post-doctoral research fellowship. The funders will have no influence over the analysis or findings.

The University of York is the sole Data Controller who also processes the data for the purposes described in this Agreement.

There will be no flow of data from the University of York to NHS Digital.

The 2014 APMS data set is held on behalf of NHS Digital by the UK Data Service (UKDS) (www.ukdataservice.ac.uk) and the UKDS is responsible for dissemination under direction by NHS Digital. The University of York will receive the pseudonymised APMS data set. There is no facility to select individual variables. The University of York will be able to download the data set from UKDS for the period specified within the Data Sharing Agreement and must securely destroy all local copies of the data set when the Agreement expires and notify NHS Digital in line with standard procedures. This 2014 version of the data set available has been redacted on Disclosure Control Procedure advice to minimise the likelihood of individuals being able to identify anyone taking part in the survey.

UKDS will transfer the pseudonymised APMS data to University of York. No other organisations will be involved in the flow of data

Data obtained in pseudonymised form will be stored on the University of York secure computer network. It will be accessed only by those involved in carrying out the research, all of whom are substantively employed by the University of York and have received adequate data protection and confidentiality training.

This research will involve both descriptive and multivariate analyses to determine whether associations exist between socioeconomic factors and psychiatric hospital admissions. Analysis will be undertaken for respondents with a personality disorder diagnosis only, alongside comparative analysis with respondents who report other mental health conditions - for example, psychosis, depression - and no mental health condition. As hospital admissions could to some extent be a function of health service capacity, for example, availability of beds, other indicators of a mental health crisis including previous self-harm or suicidality will also be used as outcome variables.

The full, pseudonymised 2014 dataset will be required due to the exploratory nature of the analysis. To avoid any potential risk of re-identification, all published results will be at the aggregate level and only used to draw population-level inferences. The data will not be linked as there are no identifiers to link on.

Data have been requested for three years to enable analysis to take place in the first instance, an extension may be requested at this point to allow for further analysis to take place if required.

Findings will be submitted to peer-reviewed journals as one or more research papers, examples of which include the British Journal of Psychiatry and Social Science and Medicine. It is anticipated that the articles will be written in early 2021 and published mid-to-late 2021. The findings will also be presented at several events planned for March and April 2021 at the University of York, designed to raise awareness about the experiences of people with a personality disorder diagnosis. The findings will also be discussed with health and social care services and used to inform the development of care pathways. The study results may also be submitted for presentation at academic conferences. To avoid any potential risk of re-identification, all published results will be at the aggregate level and only used to draw population-level inferences.

It is anticipated that the research will contribute to evidence on the socioeconomic risk and protective factors for psychiatric hospital admissions in people with a diagnosis of personality disorder. Understanding of the factors that precipitate mental health crisis in people with personality disorders is currently very limited and this study will therefore inform policy, clinical practice and the development of effective interventions. In turn, the evidence will seek to support reductions in the number of psychiatric hospital admissions, which are disruptive and upsetting for individuals and their families, in addition to being costly for health services when compared to effective community-based interventions. Findings will be shared with policy and healthcare stakeholders and people with lived experience of this diagnosis in 2021. The research will additionally be used to inform future personality disorder research priorities.

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