Twenty-Year Trends in the Psychopharmacological Treatment of Outpatients with Borderline Personality Disorder: A Cross-Sectional Naturalistic Study in Spain

Polypharmacy in the treatment of people diagnosed with borderline personality disorder: repeated cross-sectional study using New Zealand's national databases

BACKGROUND

There is insufficient evidence to support the pharmacological treatment of borderline personality disorder. However, previous out-patient cohorts have described high rates of polypharmacy in this group. So far, there have been no national studies that have considered polypharmacy in borderline personality disorder.

AIMS

To describe psychotropic polypharmacy in people with borderline personality disorder in New Zealand.

METHOD

New Zealand's national databases have been used to link psychotropic medication dispensing data and diagnostic data for borderline personality disorder. Annual dispensing data for 2014 and 2019 have been compared.

RESULTS

Fifty percent of people with borderline personality disorder who were dispensed medications had three or more psychotropic medications in 2014. This increased to 55.9% in 2019 (P < 0.001). Those on seven or more psychotropics increased from 8.4 to 10.7% (P < 0.023). Quetiapine was the most dispensed psychotropic medication, being given to 53.8% of people dispensed medication with borderline personality disorder in 2019. Lorazepam dispensing showed the largest increase, going from 15.5 to 26.7% between 2014 and 2019 (P < 0.001).

CONCLUSIONS

There is a large burden of psychotropic polypharmacy in people with borderline personality disorder. This is concerning because of the lack of evidence regarding the efficacy of these medications in this group.

Pharmacological Management of Borderline Personality Disorder and Common Comorbidities

Comorbidity between borderline personality disorder (BPD) and other mental disorders is common. Although no specific pharmacological treatments have been approved for the treatment of BPD, many drugs, including antidepressants such as selective serotonin reuptake inhibitors (SSRIs), mood stabilizers, second-generation antipsychotics, and even benzodiazepines, are routinely prescribed off label. Nonetheless, recommendations for off-label drugs in these patients are highly varied, with a notable lack of agreement among clinical guidelines. The most common reason for pharmacological treatment and polypharmacy in these patients is comorbidity with other psychiatric disorders. In this context, we reviewed major clinical guidelines and the available data on pharmacotherapy in patients with BPD to develop practical recommendations to facilitate decision-making in routine clinical practice, thus helping clinicians to select the optimal therapeutic approach in patients with BPD who have comorbid disorders. This review confirmed that no clear recommendations for the pharmacological treatment are available in clinical guidelines. Therefore, based on the available evidence, we have developed a series of recommendations for pharmacotherapy in patients with BPD who present the four most common comorbidities (affective, anxiety, eating, and drug use disorders). Here, we discuss the recommended treatment approach for each of these comorbid disorders. The prescription of medications should be considered only as an adjunct to BPD-specific psychotherapy. Polypharmacy and the use of unsafe drugs (i.e., with a risk of overdose) should be avoided. Our review highlights the need for more research to provide more definitive guidance and to develop treatment algorithms.

[Towards a pragmatic cohabitation of theoretical and clinical models: The example of "Good Psychiatric Management" in the treatment of borderline personality disorder]

Borderline personality disorder (BPD) is a common disorder in general and clinical populations and is related to potentially severe medical and socio-professional consequences. Treatment of BPD is based on evidence-based psychotherapies (such as Dialectical Behavioral Therapy, Mentalization-Based Therapy, Schema-Focused Therapy or Transference Focused Psychotherapy), which have been shown effective but are poorly available in France. Pharmacological treatments, which are more easily available, are not effective in treating symptoms of the disorder but can be useful in management of comorbidities. In this context, recently called "generalist" models have been developed, which every well-trained psychiatrist can implement in their daily practice, combining practical elements from evidence-based psychotherapies and elements of pharmacological management of symptoms and comorbidities. The purpose of this article is to present one of these models, the Good Psychiatric Management (GPM) and its basic principles and its applications, and to provide one of the first French-speaking resources about this model. In addition, beyond the practical elements proposed by the GPM, we discuss the deeper question that it raises, namely the question of a pragmatic integration of different theoretical and clinical models. Indeed, the treatment of BPD patients is at the junction of different conceptualizations of mental pathology (psychopathological, neurobiological) and different modalities of practice (psychotherapy, biological psychiatry). In a French context, that sometimes separates these two models, and in our opinion GPM constitutes an example of clinical collaboration which shows the interest of the combined role of psychiatrist-psychotherapist.

Pharmacological interventions for people with borderline personality disorder

BACKGROUND

Among people with a diagnosis of borderline personality disorder (BPD) who are engaged in clinical care, prescription rates of psychotropic medications are high, despite the fact that medication use is off-label as a treatment for BPD. Nevertheless, people with BPD often receive several psychotropic drugs at a time for sustained periods.

OBJECTIVES

To assess the effects of pharmacological treatment for people with BPD.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers up to February 2022. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing pharmacological treatment to placebo, other pharmacologic treatments or a combination of pharmacologic treatments in people of all ages with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. Secondary outcomes were individual BPD symptoms, depression, attrition and adverse events.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's risk of bias tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 46 randomised controlled trials (2769 participants) in this review, 45 of which were eligible for quantitative analysis and comprised 2752 participants with BPD in total. This is 18 more trials than the 2010 review on this topic. Participants were predominantly female except for one trial that included men only. The mean age ranged from 16.2 to 39.7 years across the included trials. Twenty-nine different types of medications compared to placebo or other medications were included in the analyses. Seventeen trials were funded or partially funded by the pharmaceutical industry, 10 were funded by universities or research foundations, eight received no funding, and 11 had unclear funding. For all reported effect sizes, negative effect estimates indicate beneficial effects by active medication. Compared with placebo, no difference in effects were observed on any of the primary outcomes at the end of treatment for any medication. Compared with placebo, medication may have little to no effect on BPD symptom severity, although the evidence is of very low certainty (antipsychotics: SMD -0.18, 95% confidence interval (CI) -0.45 to 0.08; 8 trials, 951 participants; antidepressants: SMD -0.27, 95% CI -0.65 to 1.18; 2 trials, 87 participants; mood stabilisers: SMD -0.07, 95% CI -0.43 to 0.57; 4 trials, 265 participants). The evidence is very uncertain about the effect of medication compared with placebo on self-harm, indicating little to no effect (antipsychotics: RR 0.66, 95% CI 0.15 to 2.84; 2 trials, 76 participants; antidepressants: MD 0.45 points on the Overt Aggression Scale-Modified-Self-Injury item (0-5 points), 95% CI -10.55 to 11.45; 1 trial, 20 participants; mood stabilisers: RR 1.08, 95% CI 0.79 to 1.48; 1 trial, 276 participants). The evidence is also very uncertain about the effect of medication compared with placebo on suicide-related outcomes, with little to no effect (antipsychotics: SMD 0.05, 95 % CI -0.18 to 0.29; 7 trials, 854 participants; antidepressants: SMD -0.26, 95% CI -1.62 to 1.09; 2 trials, 45 participants; mood stabilisers: SMD -0.36, 95% CI -1.96 to 1.25; 2 trials, 44 participants). Very low-certainty evidence shows little to no difference between medication and placebo on psychosocial functioning (antipsychotics: SMD -0.16, 95% CI -0.33 to 0.00; 7 trials, 904 participants; antidepressants: SMD -0.25, 95% CI -0.57 to 0.06; 4 trials, 161 participants; mood stabilisers: SMD -0.01, 95% CI -0.28 to 0.26; 2 trials, 214 participants). Low-certainty evidence suggests that antipsychotics may slightly reduce interpersonal problems (SMD -0.21, 95% CI -0.34 to -0.08; 8 trials, 907 participants), and that mood stabilisers may result in a reduction in this outcome (SMD -0.58, 95% CI -1.14 to -0.02; 4 trials, 300 participants). Antidepressants may have little to no effect on interpersonal problems, but the corresponding evidence is very uncertain (SMD -0.07, 95% CI -0.69 to 0.55; 2 trials, 119 participants). The evidence is very uncertain about dropout rates compared with placebo by antipsychotics (RR 1.11, 95% CI 0.89 to 1.38; 13 trials, 1216 participants). Low-certainty evidence suggests there may be no difference in dropout rates between antidepressants (RR 1.07, 95% CI 0.65 to 1.76; 6 trials, 289 participants) and mood stabilisers (RR 0.89, 95% CI 0.69 to 1.15; 9 trials, 530 participants), compared to placebo. Reporting on adverse events was poor and mostly non-standardised. The available evidence on non-serious adverse events was of very low certainty for antipsychotics (RR 1.07, 95% CI 0.90 to 1.29; 5 trials, 814 participants) and mood stabilisers (RR 0.84, 95% CI 0.70 to 1.01; 1 trial, 276 participants). For antidepressants, no data on adverse events were identified.

AUTHORS' CONCLUSIONS

This review included 18 more trials than the 2010 version, so larger meta-analyses with more statistical power were feasible. We found mostly very low-certainty evidence that medication may result in no difference in any primary outcome. The rest of the secondary outcomes were inconclusive. Very limited data were available for serious adverse events. The review supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology. More research is needed to understand the underlying pathophysiologic mechanisms of BPD better. Also, more trials including comorbidities such as trauma-related disorders, major depression, substance use disorders, or eating disorders are needed. Additionally, more focus should be put on male and adolescent samples.

"Skills for pills": The dialectical-behavioural therapy skills training reduces polypharmacy in borderline personality disorder

OBJECTIVE

Polypharmacy and overprescription of off-label medications are common in patients with borderline personality disorder (BPD). The aim of the present naturalistic study was to explore whether the skills training module of dialectical-behavioural therapy (DBT) can reduce polypharmacy in these patients in routine clinical practice.

METHODS

Retrospective, observational study of 377 patients with a primary diagnosis of BPD consecutively admitted to the BPD outpatient unit from 2010 through 2020. All patients were invited to participate in the DBT skills training module (DBT-ST). DBT-ST participants (n = 182) were compared with a control group who did not participate in DBT-ST (n = 195). Pre-post intervention changes in medication load and use of antidepressants, benzodiazepines, mood stabilizers, and antipsychotics were evaluated.

RESULTS

At baseline, most patients (84.4%) were taking at least one medication and 46.9% were on polypharmacy. Compared to controls, patients in the DBT-ST group presented a significant reduction in the number of medications (2.67-1.95 vs. 2.16-2.19; p < 0.001), medication load (4.25-3.05 vs. 3.45-3.48; p < 0.001), use of benzodiazepines (54.4%-27.5% vs. 40%-40.5%; p < 0.001), mood stabilizers (43.4%-33% vs. 36.4%-39.5%; p < 0.001), and antipsychotics (36.3%-29.1% vs. 34.4%-36.9%; p < 0.001).

CONCLUSIONS

These findings suggest that patients with BPD can benefit from the DBT-ST module, which may reduce the medication load, particularly of sedatives. The results suggest that DBT-ST may be useful to treat overmedication in patients with BPD and could help to promote "deprescription" in clinical practice.