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Crawford MJ, Leeson VC, Evans R, Barrett B, McQuaid A, Cheshire J, Sanatinia R, Lamph G, Sen P, Anagnostakis K, Millard L, Qurashi I, Larkin F, Husain N, Moran P, Barnes TRE, Paton C, Hoare Z, Picchioni M, Gibbon S. The clinical effectiveness and cost effectiveness of clozapine for inpatients with severe borderline personality disorder (CALMED study): a randomised placebo-controlled trial. Ther Adv Psychopharmacol 2022; 12:20451253221090832. [PMID: 35510087 PMCID: PMC9058570 DOI: 10.1177/20451253221090832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/11/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Data from case series suggest that clozapine may benefit inpatients with borderline personality disorder (BPD), but randomised trials have not been conducted. METHODS Multicentre, double-blind, placebo-controlled trial. We aimed to recruit 222 inpatients with severe BPD aged 18 or over, who had failed to respond to other antipsychotic medications. We randomly allocated participants on a 1:1 ratio to receive up to 400 mg of clozapine per day or an inert placebo using a remote web-based randomisation service. The primary outcome was total score on the Zanarini Rating scale for Borderline Personality Disorder (ZAN-BPD) at 6 months. Secondary outcomes included self-harm, aggression, resource use and costs, side effects and adverse events. We used a modified intention to treat analysis (mITT) restricted to those who took one or more dose of trial medication, using a general linear model fitted at 6 months adjusted for baseline score, allocation group and site. RESULTS The study closed early due to poor recruitment and the impact of the COVID-19 pandemic. Of 29 study participants, 24 (83%) were followed up at 6 months, of whom 21 (72%) were included in the mITT analysis. At 6 months, 11 (73%) participants assigned to clozapine and 6 (43%) of those assigned to placebo were still taking trial medication. Adjusted difference in mean total ZAN-BPD score at 6 months was -3.86 (95% Confidence Intervals = -10.04 to 2.32). There were 14 serious adverse events; 6 in the clozapine arm and 8 in the placebo arm of the trial. There was little difference in the cost of care between groups. INTERPRETATION We recruited insufficient participants to test the primary hypothesis. The study findings highlight problems in conducting placebo-controlled trials of clozapine and in using clozapine for people with BPD, outside specialist inpatient mental health units. TRIAL REGISTRATION ISRCTN18352058. https://doi.org/10.1186/ISRCTN18352058.
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Affiliation(s)
- Mike J Crawford
- Division of Psychiatry, Imperial College London, The Commonwealth Building, The Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | | | - Rachel Evans
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor, UK
| | | | | | - Jack Cheshire
- Department of Forensic Psychiatry, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
| | | | - Gary Lamph
- School of Nursing, University of Central Lancashire, Preston, UK
| | - Piyal Sen
- Department of Forensic Psychiatry, Elysium Healthcare, Milton Keynes, UK
| | | | - Louise Millard
- St Andrew's Academic Centre, St Andrew's Healthcare, Northampton, UK
| | - Inti Qurashi
- Ashworth Hospital, Mersey Care NHS Foundation Trust, Liverpool, UK
| | - Fintan Larkin
- Acute Mental Health Services, West London NHS Trust, London, UK
| | - Nusrat Husain
- Division of Psychology & Mental Health, University of Manchester, Manchester, UK
| | - Paul Moran
- Centre for Academic Mental Health, University of Bristol, Bristol, UK
| | | | - Carol Paton
- Division of Psychiatry, Imperial College London, London, UK
| | - Zoe Hoare
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor, UK
| | - Marco Picchioni
- Department of Forensic and Neurodevelopmental Science, Kings College London, London, UK
| | - Simon Gibbon
- Department of Forensic Psychiatry, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
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