The use of psychotropic medication in patients with emotionally unstable personality disorder under the care of UK mental health services

Sociodemographic and clinical factors associated with prescription of first- versus second-generation long-acting antipsychotics in incarcerated adult males

Information on patterns of prescription of long-acting injection (LAI) antipsychotics among people who are incarcerated is lacking. Therefore, we aimed to evaluate prescribing rates for first-generation antipsychotic (FGA)-LAI versus second-generation antipsychotic (SGA)-LAI and to identify the factors associated with the prescription of one of the two classes of LAI. A cross-sectional study was conducted among incarcerated adult males hosted in Monza detention center between January 2013 and April 2023. Socio-demographic and clinical data were retrospectively collected. Descriptive and univariate statistics as well as logistic regression analyses were performed. Data were available for 135 consecutive incarcerated adult males with different mental disorders who received a LAI as part of their treatment. 75.6% of our sample was treated with FGA-LAIs, with haloperidol as the most commonly prescribed drug, followed by zuclopentixol and aripiprazole. Diagnosis of bipolar disorder and concomitant administration of antidepressants were statistically significant predictors of SGA-LAI prescription. Some patients' characteristics may influence prescription patterns in prison. Further longitudinal studies with larger samples should confirm these findings.

Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies

Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

Interventions to improve the sleep quality of adults with personality disorder: A systematic review

Poor quality sleep is common for people who have a diagnosis of personality disorder (PD). Core cognitive and behavioral features of PD may cause and perpetuate poor sleep, but to date, no review has collated the evidence on the efficacy of interventions to improve sleep quality for people with PD. Structured searches for interventional studies among adults with PD and reporting validated measures of sleep quality were conducted up to November 2022 in multiple databases. Single-case reports were excluded. Study quality was assessed with standardized risk of bias tools. Unreported data was sought systematically from authors. This review was pre-registered with an international prospective register of systematic reviews (PROSPERO) (CRD42021282105). Of the 3503 identified studies, nine met inclusion criteria, representing a range of psychological, pharmaceutical, and other interventions and outcome measures. Meta-analytic methods were not feasible because of the serious risk of bias in all studies, and results were therefore synthesized narratively. There is limited and low-quality evidence of the effects of a variety of interventions to improve the sleep quality of people living with PD. Further research might consider specifically including people diagnosed with PD in trials of sleep interventions and using sleep outcome measures in trials of established PD treatments.

Rethinking Clozapine: Lights and Shadows of a Revolutionary Drug

The current literature globally highlights the efficacy of Clozapine in several psychiatric disorders all over the world, with an FDA indication for reducing the risk of repeated suicidal behavior in patients with schizophrenia or schizoaffective disorder. A growing field of research is also stressing a possible broader beneficial effect of Clozapine in promoting neuroprotection and neurotrophism. However, this drug is linked to several life-threatening side effects, such as agranulocytosis, myocarditis and seizures, that limit its use in daily clinical practice. For this work, a search was performed on PubMed using the terms "Clozapine indications", "Clozapine adverse effects", "Clozapine regenerative effects", and "Clozapine neuroplasticity" with the aim of reviewing the scientific literature on Clozapine's treatment indications, adverse effects and potential regenerative role. The results confirmed the efficacy of clozapine in clinical practice, although limited by its adverse effects. It appears crucial to raise awareness among clinicians about the potential benefits of using Clozapine, as well educating medical personnel about its risks and the early identification of possible adverse effects and their management.

Preliminary data from a 4-year mirror-image and multicentre study of patients initiating paliperidone palmitate 6-monthly long-acting injectable antipsychotic: the Paliperidone 2 per Year study

Background

Paliperidone palmitate 6-monthly (PP6M) is the first long-acting antipsychotic injectable (LAI) to allow for only two medication administrations per year, though there is presently limited insight into its effectiveness and potential added value in real clinical practice conditions.

Objectives

To present our ongoing study and draw its preliminary data on patient characteristics initiating PP6M and adherence during the first year of treatment.

Methods

The paliperidone 2 per year (P2Y) study is a 4-year, multicentre, prospective mirror-image pragmatic study taking place at over 20 different sites in Europe. The mirror period covers 2 years either side of the PP6M LAI initiation. Retrospective data for the previous 2 years are collected for each patient from the electronic health records. Prospective data are recorded at baseline, 6, 12, 18 and 24 months of drug administration and also cover information on concomitant psychiatric medication, relapses, hospital admissions, side effects, discontinuation and its reasons. Meanwhile, here we present preliminary data from the P2Y study at basal and 6-month period (first and second PP6M administration).

Results

At the point of PP6M initiation, the most frequent diagnosis was schizophrenia (69%), the clinical global impression scale mean score was 3.5 (moderately markedly ill) and the rate of previous hospital admissions per patient and year was 0.21. PP6M was initiated after a median of 3-4 years on previous treatment: 146 (73%) from paliperidone palmitate 3-monthly, 37 (19%) from paliperidone palmitate 1-monthly and 17 (9%) from other antipsychotics. The mean dose of the first PP6M was 1098.9 mg. The retention rate at 6 months and 1 year of treatment on PP6M in our cohort was 94%.

Conclusion

Patient and clinician preference for LAIs with longer dosing intervals was the main reason for PP6M initiation/switching resulting in high treatment persistence. Future data are needed to evaluate the full impact of PP6M in clinical practice.

Efficacy and Safety of Aripiprazole in Borderline Personality Disorder: A Systematic Review

Aripiprazole is an atypical antipsychotic medication, and its use in treating borderline personality disorder (BPD) is debatable because it is not FDA-approved for treating BPD. This study aimed to investigate the efficacy and safety of aripiprazole in patients with BPD. On July 2, 2021, the protocol (CRD42021256647) was registered in PROSPERO. PubMed, Scopus, Web of Science, Ovid-Medline, Embase, PsycINFO, and Cochrane (CENTRAL) were searched without regard for language or publication date. We also searched trial registries on ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. Randomized clinical trials with adult patients diagnosed with BPD met the inclusion criteria. The Cochrane risk of bias for randomized trials (RoB-2) method was used to assess the quality of the included studies. We included two previously published randomized clinical trials. There were 76 patients with BPD, with 38, 12, and 26 assigned to the aripiprazole, olanzapine, and placebo groups, respectively. Most patients (88.16%) were females, with ages ranging from 22.1 to 28.14 yr. Aripiprazole has been proven to reduce anxiety, depression, anger, hostility, clinical severity, and obsessive-compulsive behavior, insecurity, melancholy, anxiety, aggressiveness/hostility, phobic anxiety, paranoid thinking, psychoticism, and somatization. The adverse effects were headache, insomnia, restlessness, tremor, and akathisia. The risk of bias was considerable in both trials, which is somewhat problematic considering that prejudice can lead to incorrect outcomes and conclusions. Aripiprazole has demonstrated encouraging outcomes in the treatment of patients with BPD. More randomized controlled studies are needed.

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.

Overdose and off-label psychotropic prescribing in patients with borderline personality disorder: A retrospective series

OBJECTIVE

Borderline personality disorder (BPD) is common and poses many clinical challenges. Despite limited evidence of effectiveness, psychotropic medications are often prescribed. We aimed to characterise overdose presentations in patients with BPD.

METHOD

This is a retrospective observational series of patients with BPD presenting to a tertiary hospital following an overdose from January 2019 to December 2020. Medical records were reviewed to determine baseline characteristics, overdose details, clinical features, treatment, and disposition.

RESULTS

There were 608 presentations in 370 people (76% female), median age 28 years (range 16-75 years). The majority (331[89%]) of patients were prescribed at least one psychotropic medication, with 129 (35%) being prescribed three or more different psychotropic agents. Of the total prescribed psychotropics, 520/1459 (36%) were for off-label indications. The majority of agents (860/1487[58%]) taken in overdose were prescribed. The commonest drug classes taken in overdose were benzodiazepines (241[16%]) and antipsychotics (229[15%]). Severe toxicity occurred in 99 (16%) cases with either coma (GCS<9) or hypotension (systolic BP <90 mmHg). The commonest agent associated with severe toxicity was quetiapine 39/99 (39%).

CONCLUSIONS

Psychotropic polypharmacy is common in BPD, often with off-label indications. Prescribed medications are commonly taken in overdose. Quetiapine is over-represented both in off-label prescribing and associated harm.

Associations between antipsychotics and risk of violent crimes and suicidal behaviour in personality disorder

BACKGROUND

Despite uncertain benefits, people with personality disorder are commonly treated with antipsychotic medication.

OBJECTIVE

To investigate the association between antipsychotics and violent crimes and suicidal behaviour in individuals with personality disorder.

METHODS

We used nationwide Danish registries to identify all individuals with diagnosed personality disorder aged 18-64 years during 2007 to 2016. Antipsychotics were recorded in dispensed prescriptions, and individuals were followed up for police-recorded suspicions for violent crimes and healthcare presentations of suicidal behaviour. We applied a within-individual design where outcome rates for individuals with personality disorder during medicated periods were compared with rates during non-medicated periods.

FINDINGS

The cohort included 166 328 people with diagnosed personality disorder, of whom 79 253 were prescribed antipsychotics, presented at least one outcome and were thus included in the within-individual analyses. Compared with periods when individuals were not on antipsychotic medication, violent crime suspicions were 40% lower (incident rate ratio (IRR) 0.60, 95% CI 0.55 to 0.63) in men and 10% lower (IRR 0.90, 95% CI 0.79 to 1.01) in women, while rates of suicidal behaviour were 32% lower both in men (IRR 0.68, 95% CI 0.66 to 0.71) and in women (IRR 0.68, 95% CI 0.65 to 0.70). In subgroup analyses, the magnitude of the association varied across specific personality disorders for criminal outcomes but less for suicidal behaviour, with largest association in dissocial personality disorder for violent criminality (IRR 0.53, 95% CI 0.47 to 0.59).

CONCLUSIONS

Treatment with antipsychotics was associated with reduced risks for violent crime suspicions and suicidal behaviour among individuals with personality disorder.

CLINICAL IMPLICATIONS

Potential effects of antipsychotics on suicidal behaviour and violence should be taken into account when considering treatment options for people with personality disorders.

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.

Cannabis-Based Medicinal Products in the Management of Emotionally Unstable Personality Disorder (EUPD): A Narrative Review and Case Series

Emotionally unstable personality disorder (EUPD) is a common mental health disorder, manifesting with a range of chronic and debilitating symptoms, including impaired social functioning, unstable mood, and risky impulsive or self-injurious behaviour. Whilst the exact aetiology has not been fully elucidated, implicated factors seem to include genetic factors, environmental causes such as trauma, and neurotransmitter deficits. The literature suggests that impaired functioning of the endocannabinoid system in key brain regions responsible for emotional processing and stress response may underlie the manifestation of EUPD symptoms. The National Institute for Health and Care Excellence (NICE) 2009 guidelines state that “no drugs have established efficacy in treating or managing EUPD”, and yet, patients are commonly prescribed medication which includes antipsychotics, antidepressants, and mood stabilisers. Here we present a case series of seven participants diagnosed with EUPD and treated with cannabis-based medicinal products (CBMPs). Participants were given an initial assessment and followed up one month after CBMPs prescription. Improvement in symptoms was assessed by the completion of ratified rating scales by the participant and psychiatrist. Our results indicate that CBMPs were effective and well tolerated, as six participants reported a noticeable improvement in their symptoms and functioning. Although promising, further research is needed to ascertain the long-term tolerability, efficacy, and dosing strategy for CBMPs in EUPD.

Early Intervention for Personality Disorder

Both the DSM-5 Section III Alternative Model for Personality Disorders and the ICD-11 have introduced a genuinely developmental approach to personality disorder. Among young people with personality disorder, compelling evidence demonstrates a high burden of disease, substantial morbidity, and premature mortality, as well as response to treatment. Yet, early diagnosis and treatment for the disorder have struggled to emerge from its identity as a controversial diagnosis to a mainstream focus for mental health services. Key reasons for this include stigma and discrimination, lack of knowledge about and failure to identify personality disorder among young people, along with the belief that personality disorder must always be addressed through lengthy and specialized individual psychotherapy programs. In fact, evidence suggests that early intervention for personality disorder should be a focus for all mental health clinicians who see young people and is feasible by using widely available clinical skills.

"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.

Prescribing of antipsychotics among people with recorded personality disorder in primary care: a retrospective nationwide cohort study using The Health Improvement Network primary care database

OBJECTIVES

To investigate the extent of antipsychotic prescribing to people with recorded personality disorder (PD) in UK primary care and factors associated with such prescribing.

DESIGN

Retrospective cohort study.

SETTING

General practices contributing to The Health Improvement Network UK-wide primary care database, 1 January 2000-31 December 2016.

PARTICIPANTS

46 210 people registered with participating general practices who had a record of PD in their general practice notes. 1358 (2.9%) people with missing deprivation information were excluded from regression analyses; no other missing data.

MAIN OUTCOME MEASURES

Prescriptions for antipsychotics in general practice records and length of time in receipt of antipsychotic prescriptions.

RESULTS

Of 46 210 people with recorded PD, 15 562 (34%) were ever prescribed antipsychotics. Among the subgroup of 36 875 people with recorded PD, but no recorded severe mental illness (SMI), 9208 (25%) were prescribed antipsychotics; prescribing was lower in less deprived areas (adjusted rate ratio (aRR) comparing least to most deprived quintile: 0.56, 95% CI 0.48 to 0.66, p<0.001), was higher in females (aRR:1.25, 95% CI 1.16 to 1.34, p<0.001) and with a history of adverse childhood experiences (aRR:1.44, 95% CI 1.28 to 1.56, p<0.001). Median time prescribed antipsychotics was 605 days (IQR 197-1639 days). Prescribing frequency has increased over time.

CONCLUSIONS

Contrary to current UK guidelines, antipsychotics are frequently and increasingly prescribed for extended periods to people with recorded PD, but with no history of SMI. An urgent review of clinical practice is warranted, including the effectiveness of such prescribing and the need to monitor for adverse effects, including metabolic complications.

The State of Overmedication in Borderline Personality Disorder: Interpersonal and Structural Factors

Purpose of review

a)This review paper describes the state of prescribing practice in Borderline Personality Disorder (BPD), wherein medications are prescribed far more than either evidence or practice guideline would recommend. First, we describe the frequencies of medication use and polypharmacy in people with BPD.

Recent findings

b)In subsequent sections, we elaborate two main categories of factors that lead to overmedication of people with BPD: the interpersonally mediated and the structural. We consider interpersonally mediated factors to arise from communications of patients in distress and the well-meaning efforts of their prescribers to provide relief for certain overwhelming affective states. We are particularly focused on patterns of countertransference in prescribing that are directly linked to specific aspects of BPD pathology. We consider structural factors to arise from the complexities of medical and medicolegal systems and the contemporary patterns of financing medical care; we postulate that these complexities often compel prescribers to start medications, with associated disincentives for decreasing or discontinuing those medications over time.

Summary

c)More research is needed to understand how to best use medications in BPD, for example in targeted combination with psychotherapeutic and psychosocial interventions. However, current practice often departs markedly from the evidence. We recommend the dissemination of accessible, generalist BPD-treatment models in outpatient and inpatient practice; increased early detection of BPD; and increased diagnostic disclosure. We also recommend for individual providers and systems to implement prospective treatment plans that draw from BPD-specific psychosocial models. This approach can employ tiers of interventions to minimize reactive prescribing by anticipating high affect and offering BPD patients steadily empathic evidence-supported care.

Who is prescribed valproate and how carefully is this treatment reviewed in UK mental health services? Data from a clinical audit

BACKGROUND

The licensed indications for valproate are narrow, yet this medication is commonly prescribed in mental health services.

OBJECTIVES

To explore the target symptoms/behaviours for which valproate is prescribed and how well the efficacy and tolerability of this treatment are monitored in routine clinical practice.

DESIGN

An audit-based quality improvement (QI) programme in UK mental health services.

METHODS

Information on valproate prescribing was collected from clinical records using a bespoke data collection tool.

RESULTS

Sixty-four NHS mental health Trusts/healthcare organisations submitted data on valproate treatment for 5320 patients. Valproate was clearly prescribed for a licensed indication in 1995 (38%) patients, off-label in 1987 (37%) while the indication was uncertain/not available in 1338 (25%). Of the 919 patients started on valproate treatment within the past year, between a half and two-thirds had each of the relevant baseline physical health checks documented. In 539 (59%) of these patients, valproate was prescribed for an unlicensed indication; the prescription was recognised as off-label in 363 (67%), 20 (6%) of whom were documented as having had this explained to them. Of 631 patients prescribed valproate for between 3 months and a year, early on-treatment assessments of response and side effects were documented in 441 (70%) and 332 (53%), respectively. Of 4401 patients treated for more than a year, annual on-treatment reviews of clinical response and side effects were documented in 2771 (63%) and 2140 (49%), respectively.

CONCLUSION

Our data suggest the majority of prescriptions for valproate in mental health services are not for a licensed indication. Furthermore, patients rarely receive an explanation that their valproate prescription is off-label, perhaps partly because the licensed indications are not widely understood by prescribers. Given the very limited evidence for efficacy for the off-label uses of valproate, failure to routinely conduct early on-treatment and annual reviews of the benefits and side effects of this medication may result in patients remaining on ineffective and poorly tolerated treatment by default.

The clinical effectiveness and cost effectiveness of clozapine for inpatients with severe borderline personality disorder (CALMED study): a randomised placebo-controlled trial

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.

Short-term and 1-year outcome of patients' with borderline personality admitted to a short-term recovery-oriented residential service

OBJECTIVES

Given the paucity of literature, this study investigated whether a prevention and recovery care (PARC) service supported recovery in patients with borderline personality disorder (BPD).

METHOD

This retrospective study included patients with BPD who had their first (index) admission to North West PARC between 2011 and 2016. Patient medical records and the state-wide database were the sources of information.

RESULTS

Of the 67 patients included, over 70% attended group activities. All patients achieved their recovery goals, either fully or partially. Compared to admission, the frequency of substance use and the Health of the Nation Outcome Scale (HoNOS) scores at discharge were significantly less. A significantly smaller number of patients needed inpatient treatment during the 12 months following their PARC admission.

CONCLUSION

The PARC service appears to promote clinical and psychosocial recovery in patients with BPD.

Borderline personality disorder

Borderline personality disorder (BPD) is a mental disorder with a high burden on patients, family members, and health-care systems. The condition was previously regarded as untreatable, but progress in understanding and management has resulted in earlier diagnosis and better treatment outcomes. A coherent syndrome of BPD typically onsets during adolescence (after age 12 years). BPD is often preceded by or co-develops with symptoms of internalising disorders (depression and anxiety), externalising disorders (conduct problems, hyperactivity, and substance use), or both. BPD is associated with various poor outcomes, including low occupational and educational attainment, lack of long-term relationships, increased partner conflict, sexual risk-taking, low levels of social support, low life satisfaction, and increased service use. Psychotherapy is the main treatment for BPD; drug treatment is only indicated for comorbid conditions that require medication, or during a crisis if psychosocial interventions are insufficient. Awareness of BPD by non-specialists, as well as specialists, is key to appropriate early intervention.

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

OBJECTIVE

Although no psychotropic drugs have been officially approved for the treatment of borderline personality disorder (BPD), medications are routinely prescribed for these patients. The primary aim of this study was to evaluate changes in the pharmacological management of patients with BPD treated in an outpatient specific unit in Spain over the past 20 years, while a secondary aim was to identify the factors associated with the prescription.

METHODS

Observational and cross-sectional study of all patients with a primary diagnosis of BPD (n = 620) consecutively admitted to a BPD outpatient program in Barcelona, Spain, from 2001 through 2020. We examined trends in the prescription of antidepressants, benzodiazepines, mood stabilizers, and antipsychotics. For the analysis, prescription data were grouped into four 5-year periods (2001-2005, 2006-2010, 2011-2015, and 2016-2020). Logistic regression models were performed to identify sociodemographic and clinical variables associated with pharmacological prescription and polypharmacy.

RESULTS

The percentage of patients receiving pharmacotherapy decreased over time. Antidepressant prescription rates remained high and stable over time (74% of patients), while benzodiazepine use decreased significantly during the study period (from 77 to 36%) and second-generation antipsychotic (SGA) use increased from 15 to 32%. Psychiatric comorbidity was the main factor associated with pharmacological treatment (odds ratio 2.5, 95% confidence interval 1.5-4.2) and polypharmacy, although a high percentage of patients without comorbidity were also taking medications.

CONCLUSIONS

Over the past 20 years, the pharmacological treatment of BPD outpatients has undergone important changes, most notably the decrease in benzodiazepines and increase in SGAs. The findings of this study demonstrate that pharmacotherapy is much more prevalent in patients with BPD than recommended in most clinical guidelines.

Off-Label Use of Second-Generation Antipsychotics in Borderline Personality Disorder: A Survey of Italian Psychiatrists

The guidelines for borderline personality disorder (BPD) treatment suggest non-pharmacological treatment as the first option, but second-generation antipsychotics (SGAs) are among the overprescribed medications. This study aimed to explore Italian psychiatrists' attitudes toward off-label use of SGAs in BPD. A randomly selected sample of Italian psychiatrists completed a questionnaire regarding off-label prescription of SGAs. Most respondents reported the off-label use of SGAs. Among the reasons supporting the prescription of SGAs, the presence of strong published data was the most determining factor (51.5%). The SGA olanzapine is considered the most appropriate, followed by quetiapine and aripiprazole. Although off-label prescription of SGAs represents a common clinical practice in accordance with a worldwide trend, the use of long-acting injection formulations was considered inappropriate by 69% of psychiatrists in our sample. Our results reiterate the discrepancy between everyday clinical practice and international recommendations, and show how relevant the literature is in off-label drug prescription.

Comparing psychotropic medication prescribing in personality disorder between general mental health and psychological services: retrospective cohort study

BACKGROUND

Although no drugs are licensed for the treatment of personality disorder, pharmacological treatment in clinical practice remains common.

AIMS

This study aimed to estimate the prevalence of psychotropic drug use and associations with psychological service use among people with personality disorder.

METHOD

Using data from a large, anonymised mental healthcare database, we identified all adult patients with a diagnosis of personality disorder and ascertained psychotropic medication use between 1 August 2015 and 1 February 2016. Multivariable logistic regression models were constructed, adjusting for sociodemographic, clinical and service use factors, to examine the association between psychological services use and psychotropic medication prescribing.

RESULTS

Of 3366 identified patients, 2029 (60.3%) were prescribed some form of psychotropic medication. Patients using psychological services were significantly less likely to be prescribed psychotropic medication (adjusted odds ratio 0.48, 95% CI 0.39-0.59, P<0.001) such as antipsychotics, benzodiazepines and antidepressants. This effect was maintained following several sensitivity analyses. We found no difference in the risk for mood stabiliser (adjusted odds ratio 0.79, 95% CI 0.57-1.10, P = 0.169) and multi-class psychotropic use (adjusted odds ratio 0.80, 95% CI 0.60-1.07, P = 0.133) between patients who did and did not use psychological services.

CONCLUSIONS

Psychotropic medication prescribing is common in patients with personality disorder, but significantly less likely in those who have used psychological services. This does not appear to be explained by differences in demographic, clinical and service use characteristics. There is a need to develop clear prescribing guidelines and conduct research in clinical settings to examine medication effectiveness for this population.

Pharmacological Treatments for Borderline Personality Disorder: A Systematic Review and Meta-Analysis

BACKGROUND

Borderline personality disorder (BPD) is a debilitating psychiatric disorder that affects 0.4-3.9% of the population in Western countries. Currently, no medications have been approved by regulatory agencies for the treatment of BPD. Nevertheless, up to 96% of patients with BPD receive at least one psychotropic medication.

OBJECTIVES

The objective of this systematic review was to assess the general efficacy and the comparative effectiveness of different pharmacological treatments for BPD patients.

METHODS

We conducted systematic literature searches limited to English language in MEDLINE, EMBASE, the Cochrane Library, and PsycINFO up to April 6, 2021, and searched reference lists of pertinent articles and reviews. Inclusion criteria were (i) patients 13 years or older with a diagnosis of BPD, (ii) treatment with anticonvulsive medications, antidepressants, antipsychotic medications, benzodiazepines, melatonin, opioid agonists or antagonists, or sedative or hypnotic medications for at least 8 weeks, (iii) comparison with placebo or an eligible medication, (iv) assessment of health-relevant outcomes, (v) randomized or non-randomized trials or controlled observational studies. Two investigators independently screened abstracts and full-text articles and graded the certainty of evidence based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. For meta-analyses, we used restricted maximum likelihood random effects models to estimate pooled effects.

RESULTS

Of 12,062 unique records, we included 21 randomized controlled trials (RCTs) with data on 1768 participants. Nineteen RCTs compared pharmacotherapies with placebo; two RCTs assessed active treatments head-to-head. Out of 87 medications in use in clinical practice, we found studies on just nine. Overall, the evidence indicates that the efficacy of pharmacotherapies for the treatment of BPD is limited. Second-generation antipsychotics, anticonvulsants, and antidepressants were not able to consistently reduce the severity of BPD. Low-certainty evidence indicates that anticonvulsants can improve specific symptoms associated with BPD such as anger, aggression, and affective lability but the evidence is mostly limited to single studies. Second-generation antipsychotics had little effect on the severity of specific BPD symptoms, but they improved general psychiatric symptoms in patients with BPD.

CONCLUSIONS

Despite the common use of pharmacotherapies for patients with BPD, the available evidence does not support the efficacy of pharmacotherapies alone to reduce the severity of BPD.

REGISTRATION

PROSPERO registration number, CRD42020194098.

Psychopharmacological treatment in borderline personality disorder: A pilot observational study in a real-world setting

Psychotherapy is the cornerstone of treatment for borderline personality disorder (BPD) while pharmacotherapy should be considered only as an adjunctive intervention. In clinical practice, however, most of BPD patients only receive medication. The aim of the study is to first describe pharmacological treatment in BPD patients in Italy and secondly to evaluate if comorbidity or illness severity are associated with the prescription of different class compounds. Data on pharmacological treatment and clinical evaluation of 75 BPD patients were collected in 5 clinical settings. The association between comorbidity and medication was assessed. Moreover, we evaluated the association between pharmacotherapy and severity, defined by a cluster analysis aimed at detecting different groups of patients. Most of the participants (82.7%) were characterized by polypharmacy, with a mean of 2.4 medications per person. Interestingly, the prescription didn't seem to depend on/be based on the severity of the disorder and was only partially determined by the presence of comorbidity. In conclusion, our findings are similar to what described in other clinical studies, supporting the idea that medication management for BPD is only partially coherent with international guidelines. This pilot study confirms the need for more rigorous studies to gain greater understanding of this topic and diminish the gap between guidelines and the real clinical world.

Impact of co-morbid personality disorder on quality of inpatient mental health services for people with anxiety and depression

INTRODUCTION

Concerns have been raised about the quality of inpatient care received by patients with a diagnosis of personality disorder.

OBJECTIVES

The aim of this study was to examine the quality of care received by inpatients with an anxiety or depressive disorder, comparing subgroups with or without a co-morbid personality disorder.

METHOD

We used a retrospective case-note review of 3 795 patients admitted to inpatient psychiatric wards in England, utilizing data from the National Clinical Audit of Anxiety and Depression. Data were gathered on all acute admissions with an anxiety or depressive disorder over a 6-month period, for a number of measures reflecting quality of care derived from national standards. Association of coexisting personality disorder with quality of care was investigated using multivariable regression analyses.

RESULTS

Four hundred sixteen (11.0%) of the patients had a co-co-morbid diagnosis of personality disorder. Patients with personality disorder were less likely to have been asked about prior responses to treatment in their initial assessment (odds ratio (OR) = 0.67, 95% confidence interval (CI) 0.50 to 0.89, p = 0.007). They were less likely to receive adequate notice in advance of their discharge (OR = 0.87, 95% CI 0.65 to 0.98, p = 0.046). They were more likely to be prescribed medication at the point of discharge (OR = 1.52, 95% CI 1.02 to 2.09, p = 0.012) and less likely to have been provided with information about the medicines they were taking (OR = 0.86, 95% CI 0.69 to 0.94, p = 0.048). In addition, the carers of patients with co-morbid personality disorder were less likely to have been provided with information about available support services (OR = 0.73, 95% CI 0.51 to 0.93, p = 0.045).

CONCLUSION

We found evidence of poorer quality of care for patients with co-morbid personality disorder who were admitted to psychiatric hospital for treatment of anxiety or depressive disorders, highlighting the need for improved clinical care in this patient group.

Psychotropic medication use among personality disordered young adults. A follow-up study among former adolescent psychiatric inpatients

OBJECTIVE

To analyze the use of prescribed psychotropic medication in subjects with personality disorder (PD) diagnosed in early adulthood.

METHODS

The study population consisted of former adolescent psychiatric inpatients (N=508). 63 had a diagnosis of PD, including with borderline PD (BPD) (N=38) and other PD (OPD) (N=25). DSM IV-based psychiatric diagnoses in adolescence were based on the Schedule for Affective Disorder and Schizophrenia for School-Age Children Present and Lifetime (K-SADS-PL). The information on in-or outpatient hospital treatments until the end of 2016 were extracted from the National Care Register for Health Care. Lifetime data on purchases of physician-prescribed psychotropic medications was obtained from the Social Insurance Institution of Finland.

RESULTS

98.4% (N=62) of subjects with PD had purchased at least one type of psychotropic medication during the follow-up period. The use of non-opioid analgesics and antipyretics was over twice as common among subjects with BPD than subjects with OPD (57.9% vs.28.0%, p=0.020). Anxiolytic use was 1.5 times more common among subjects with BPD than subjects with OPD (65.8% vs. 40.0%, p=0.044) CONCLUSIONS: Psychotropic medication use was common among subjects with PD. The use of non-opioid analgesics, antipyretics and anxiolytics was more common among subjects with BPD.

The phenomenology of auditory verbal hallucinations in emotionally unstable personality disorder and post-traumatic stress disorder

Objective:

To explore the phenomenology of auditory verbal hallucinations (AVHs) in a clinical sample of young people who have a ‘non-psychotic’ diagnosis.

Methods:

Ten participants aged 17–31 years with presentation of emotionally unstable personality disorder or post-traumatic stress disorder and frequent AVHs were recruited and participated in a qualitative study exploring their subjective experience of hearing voices. Photo-elicitation and ethnographic diaries were used to stimulate discussion in an otherwise unstructured walking interview.

Results:

‘Non-psychotic’ voices comprised auditory qualities such as volume and clarity. Participants commonly personified their voices, viewing them as distinct characters with which they could interact and form relationships. There appeared to be an intimate and unstable relationship between participant and voice, whereby voices changed according to the participants’ mood, insecurities, distress and circumstance. Equally, participants reacted to provocation by the voice, leading to changes in mood and circumstance through emotional and physical disturbances. In contrast to our previous qualitative work in psychosis, voice hearing was not experienced with a sense of imposition or control.

Conclusions:

This phenomenological research yielded in-depth and novel accounts of ‘non-psychotic’ voices which were intimately linked to emotional experience. In contrast to standard reports of voices in disorders such as schizophrenia, participants described a complex and bi-directional relationship with their voices. Many other features were in common with voice hearing in psychosis. Knowledge of the phenomenology of hallucinations in non-psychotic disorders has the potential to inform future more successful management strategies. This report gives preliminary evidence for future research.

What are the barriers to, and enablers of, working with people with lived experience of mental illness amongst community and voluntary sector organisations? A qualitative study

There is increasing emphasis on psychological and social approaches to managing and treating mental illness, including a growing evidence base on the effectiveness of community-based social interventions including arts and heritage activities, library programmes, volunteering schemes, nature-based activities and community groups. However, there is a gap in understanding of what the barriers to, and enablers of, working with individuals with mental illness might be for the community and voluntary sector. A qualitative approach was used involving focus groups with non-profit organisations delivering social activities within communities across the United Kingdom. Behaviour Change Theory, the COM-B model and the Theoretical Domains Framework, were employed as the theoretical framework, to develop interventions to address the barriers raised. Representatives of the organisations reported being motivated by the mental health needs of others, and by seeing the benefits of participation. Further motivations included expanding inclusion, and economic motivation to ensure sustainability. Strengths identified included offering innovative, responsive services that were distinct from conventional mental health services. Running these services demanded new and potentially challenging skills, such as understanding statutory responsibilities, and being able to train and support staff. Further challenges included maintaining boundaries between their roles as community organisations and clients' mental health needs and avoiding burn-out. Ability to deliver this work was enhanced by support of peer organisations and opportunities to share practice. However, funding was often short term, and complex to obtain, which could destabilise organisations' sustainability. Lack of transparency around the process, differences in language between the community and health sectors, and confusion around commissioning pathways undermined the potential opportunity offered by social prescribing policy. Interventions to address these barriers were identified, including long term funding to support core costs, training on engaging with the commissioning process, around mental health support and safeguarding, and developing mentoring schemes and local co-operatives of organisations for developing partnerships with the health sector.

Pharmacotherapy for Borderline Personality Disorder: an Update of Published, Unpublished and Ongoing Studies

PURPOSE OF THE REVIEW

We aim to identify the most recent evidence of randomised controlled trials evaluating continued drug treatments in people with a diagnosis of BPD, review the most recent findings, highlight trends in terms of currently ongoing studies and comment on the overall body of evidence.

RECENT FINDINGS

We identified seven new RCTs, plus newly available data for an older RCT. Only three of these RCTs have been published in full text, while we found study data posted at trial registry platforms for the others. The new findings do not support fluoxetine as a treatment option for suicide and self-harm prevention. A large effectiveness study did not detect beneficial effects of lamotrigine in routine care. The prevalent use of medications in BPD is still not reflected or supported by the current evidence. More research is needed regarding the most commonly used substances and substance classes, i.e. SSRIs, and quetiapine, but also with respect to people presenting with distinct comorbid conditions.

Collaborative Deprescribing in Borderline Personality Disorder: A Narrative Review

After participating in this activity, learners should be better able to:• Assess medication management in patients with borderline personality disorder (BPD)• Evaluate the role of deprescribing as an active intervention in patients with BPD treated with polypharmacy ABSTRACT: Psychopharmacology in borderline personality disorder (BPD) is complicated by comorbid disorders, substance use, sensitivity to side effects, risk of self-harm through medication misuse, and intense but transient symptoms. Patients' relationships with medications may range from tenuous to highly enmeshed, and may profoundly influence the response to treatment. For these reasons, awareness of current evidence and flexible approaches are particularly relevant to prescribing in BPD. In this narrative review, we illustrate the current status of medication management in BPD by focusing on polypharmacy. We use a single vignette to explore the limitations of prescribing multiple medications and the factors contributing to polypharmacy. With the same vignette, and using the framework of deprescribing, we describe how medication regimens can be reduced to a necessary minimum. Deprescribing, originally developed in geriatric medicine, is an active intervention that involves a risk-benefit analysis for each medication, keeping in mind the patient's medical and psychiatric status and his or her preferences and values. Deprescribing lends itself well to use in psychiatry and especially in BPD because of its emphasis on the patient's preferences and on repeated conversations to revisit and update decisions. In addition to elaborating on the deprescribing framework, we provide recommendations for conducting these critical discussions about medications in BPD, with particular attention to the patient's relationship to the medication. Finally, we summarize our recommendations and strategies for implementing flexible and responsive medication management for patients with BPD. We suggest areas of future research, including testing the efficacy of targeted intermittent medication treatments.

A pill for every ill?

Purpose

National guidelines in the UK for emotionally unstable personality disorder and antisocial personality disorder (PD) do not recommend treatment with medication, suggesting instead psychotherapy. There is little evidence that medication has benefit from the literature. Despite this, many patients with PDs are prescribed medications. This study aims to quantify medication prescriptions within the therapeutic community for those with PD and assess if treatment led to changes in prescription.

Design/methodology/approach

An audit tool was designed in Microsoft Excel; 30 most recent patients discharged from the authors’ service since November 2018 were identified. Their discharge summaries were scrutinised for changes in medication comparing the beginning of treatment to the end. These were then analysed in terms of changes in class of medication and dose as well as total number of medications prescribed.

Findings

In total, 31 patients’ notes were scrutinised. Then, 25 patients were prescribed psychiatric medication at the start of their treatment, 24 had medications changed falling to 17 at the end of treatment. Antidepressants were the most commonly prescribed medications. By class, antidepressant prescriptions fell by 35 per cent, antipsychotics by 43 per cent, anxiolytics by 40 per cent. The prescription of mood stabilisers and Z drugs remained the same.

Originality/value

The assessment of medication changes during psychotherapeutic treatment within a therapeutic community is unique in the literature. Understanding and hypothesising the dynamics involved within this process has also received little attention in research. This study highlights the potential from which further research into this neglected but pertinent area could be conducted.

Structured Psychological Support for people with personality disorder: feasibility randomised controlled trial of a low-intensity intervention

BACKGROUND

National guidance cautions against low-intensity interventions for people with personality disorder, but evidence from trials is lacking.

AIMS

To test the feasibility of conducting a randomised trial of a low-intensity intervention for people with personality disorder.

METHOD

Single-blind, feasibility trial (trial registration: ISRCTN14994755). We recruited people aged 18 or over with a clinical diagnosis of personality disorder from mental health services, excluding those with a coexisting organic or psychotic mental disorder. We randomly allocated participants via a remote system on a 1:1 ratio to six to ten sessions of Structured Psychological Support (SPS) or to treatment as usual. We assessed social functioning, mental health, health-related quality of life, satisfaction with care and resource use and costs at baseline and 24 weeks after randomisation.

RESULTS

A total of 63 participants were randomly assigned to either SPS (n = 33) or treatment as usual (n = 30). Twenty-nine (88%) of those in the active arm of the trial received one or more session (median 7). Among 46 (73%) who were followed up at 24 weeks, social dysfunction was lower (-6.3, 95% CI -12.0 to -0.6, P = 0.03) and satisfaction with care was higher (6.5, 95% CI 2.5 to 10.4; P = 0.002) in those allocated to SPS. Statistically significant differences were not found in other outcomes. The cost of the intervention was low and total costs over 24 weeks were similar in both groups.

CONCLUSIONS

SPS may provide an effective low-intensity intervention for people with personality disorder and should be tested in fully powered clinical trials.

Pharmacotherapy of borderline personality disorder: what has changed over two decades? A retrospective evaluation of clinical practice

BACKGROUND

The purpose of this study was to assess the pharmacological treatment strategies of inpatients with borderline personality disorder between 2008 and 2012. Additionally, we compared pharmacotherapy during this period to a previous one (1996 to 2004).

METHODS

Charts of 87 patients with the main diagnosis of borderline personality disorder receiving inpatient treatment in the University Medical Center of Goettingen, Germany, between 2008 and 2012 were evaluated retrospectively. For each inpatient treatment, psychotropic drug therapy including admission and discharge medication was documented. We compared the prescription rates of the interval 2008-2012 with the interval 1996-2004.

RESULTS

94% of all inpatients of the interval 2008-2012 were treated with at least one psychotropic drug at time of discharge. All classes of psychotropic drugs were applied. We found high prescription rates of naltrexone (35.6%), quetiapine (19.5%), mirtazapine (18.4%), sertraline (12.6%), and escitalopram (11.5%). Compared to 1996-2004, rates of low-potency antipsychotics, tri-/tetracyclic antidepressants and mood stabilizers significantly decreased while usage of naltrexone significantly increased.

CONCLUSIONS

In inpatient settings, pharmacotherapy is still highly prevalent in the management of BPD. Prescription strategies changed between 1996 and 2012. Quetiapine was preferred, older antidepressants and low-potency antipsychotics were avoided. Opioid antagonists are increasingly used and should be considered for further investigation.

Psychopharmacological treatment of patients with borderline personality disorder: comparing data from routine clinical care with recommended guidelines

Objectives: Borderline personality disorder (BPD) is a life-threatening mental disorder. Guideline recommendations for pharmacological treatment of patients with BPD vary widely. The objective of the present study was to investigate pharmacotherapy of BPD patients in a routine clinical care setting. Methods: Data on the pharmacological treatment of 110 patients (90% female) with BPD (F- 60.3), treated in an inpatient psychiatric-psychosomatic clinic in Austria were assessed. Results: Results show that clinicians frequently prescribe psychotropic medications to patients with BPD, in many cases multiple medications. The most commonly prescribed substance groups were antipsychotics, mood stabilisers and antidepressants. The most commonly prescribed individual drugs were Quetiapine, Lamotrigine and Setraline. There was no significant difference in the different types or overall number of medications prescribed to BPD patients with vs. without comorbid diagnoses. Pharmacotherapy was not related to comorbidity. Conclusions: The present study shows that in routine clinical care settings psychotropic medications are frequently prescribed to patients with BPD, very often resulting in polypharmacy. A positive association between the number of medications and the effectiveness of the inpatient treatment program, as well as the absence of a relationship between number of medications and comorbidity contradicts the often suggested iatrogenic effect of polypharmacy. Key points Guidelines for pharmacotherapy of borderline personality disorders lack consensus Yet, clinicians frequently prescribe psychotropic medications to BPD patients Types/number of medications prescribed to patients with vs. without comorbidities are similar Larger treatment effects are observed for patients with greater numbers of medications Further knowledge is needed about how and why clinicians prescribe medications.

Improved mental health among LABILE study participants: A qualitative exploration

Results of the LABILE trial showed no difference between people with BPD who were prescribed lamotrigine and those on placebo. However, most study participants experienced sustained improvement in their mental health during the trial. We conducted a thematic analysis of qualitative data from interviews with 47 LABILE study participants to identify factors that may have contributed to this improvement. We identified three main themes: initial reasons and expectations regarding trial participation, patients' experiences of the trial and areas of change. Reasons for participating in the trial included a search for consistent and stable professional care as well as altruistic motives. Improvements in symptoms over the course of the trial were explained by several factors including consistency provided by the research team, salience of the social context and the availability of alternative support networks. While participants appreciated the autonomy provided by the voluntary nature of the trial, they felt that improvements stemmed from the 'structure' brought about by their actively engaging in the study. This study highlights the importance of clear and transparent communication when treating people with BPD. Mental health professionals should ensure that services for people with BPD are consistent and structured. © 2019 John Wiley & Sons, Ltd.

Lamotrigine for people with borderline personality disorder: a RCT

BACKGROUND

No drug treatments are currently licensed for the treatment of borderline personality disorder (BPD). Despite this, people with this condition are frequently prescribed psychotropic medications and often with considerable polypharmacy. Preliminary studies have indicated that mood stabilisers may be of benefit to people with BPD.

OBJECTIVE

To examine the clinical effectiveness and cost-effectiveness of lamotrigine for people with BPD.

DESIGN

A two-arm, double-blind, placebo-controlled individually randomised trial of lamotrigine versus placebo. Participants were randomised via an independent and remote web-based service using permuted blocks and stratified by study centre, the severity of personality disorder and the extent of hypomanic symptoms.

SETTING

Secondary care NHS mental health services in six centres in England.

PARTICIPANTS

Potential participants had to be aged ≥ 18 years, meet diagnostic criteria for BPD and provide written informed consent. We excluded people with coexisting psychosis or bipolar affective disorder, those already taking a mood stabiliser, those who spoke insufficient English to complete the baseline assessment and women who were pregnant or contemplating becoming pregnant.

INTERVENTIONS

Up to 200 mg of lamotrigine per day or an inert placebo. Women taking combined oral contraceptives were prescribed up to 400 mg of trial medication per day.

MAIN OUTCOME MEASURES

Outcomes were assessed at 12, 24 and 52 weeks after randomisation. The primary outcome was the total score on the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD) at 52 weeks. The secondary outcomes were depressive symptoms, deliberate self-harm, social functioning, health-related quality of life, resource use and costs, side effects of treatment and adverse events. Higher scores on all measures indicate poorer outcomes.

RESULTS

Between July 2013 and October 2015 we randomised 276 participants, of whom 195 (70.6%) were followed up 52 weeks later. At 52 weeks, 49 (36%) of those participants prescribed lamotrigine and 58 (42%) of those prescribed placebo were taking it. At 52 weeks, the mean total ZAN-BPD score was 11.3 [standard deviation (SD) 6.6] among those participants randomised to lamotrigine and 11.5 (SD 7.7) among those participants randomised to placebo (adjusted mean difference 0.1, 95% CI -1.8 to 2.0; p = 0.91). No statistically significant differences in secondary outcomes were seen at any time. Adjusted costs of direct care for those prescribed lamotrigine were similar to those prescribed placebo.

LIMITATIONS

Levels of adherence in this pragmatic trial were low, but greater adherence was not associated with better mental health.

CONCLUSIONS

The addition of lamotrigine to the usual care of people with BPD was not found to be clinically effective or provide a cost-effective use of resources.

FUTURE WORK

Future research into the treatment of BPD should focus on improving the evidence base for the clinical effectiveness and cost-effectiveness of non-pharmacological treatments to help policy-makers make better decisions about investing in specialist treatment services.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN90916365.

FUNDING

Funding for this trial was provided by the Health Technology Assessment programme of the National Institute for Health Research (NIHR) and will be published in full in Health Technology Assessment; Vol. 22, No. 17. See the NIHR Journals Library website for further project information. The Imperial Biomedical Research Centre Facility, which is funded by NIHR, also provided support that has contributed to the research results reported within this paper. Part of Richard Morriss' salary during the project was paid by NIHR Collaboration for Leadership in Applied Health Research and Care East Midlands.

A Life Span Perspective on Borderline Personality Disorder

PURPOSE OF REVIEW

To provide an update of a life span perspective on borderline personality disorder (BPD). We address the life span course of BPD, and discuss possible implications for assessment, treatment, and research.

RECENT FINDINGS

BPD first manifests itself in adolescence and can be distinguished reliably from normal adolescent development. The course of BPD from adolescence to late life is characterized by a symptomatic switch from affective dysregulation, impulsivity, and suicidality to maladaptive interpersonal functioning and enduring functional impairments, with subsequent remission and relapse. Dimensional models of BPD appear more age neutral and more useful across the entire life span. There is a need for age-specific interventions across the life span. BPD symptoms and impairments tend to wax and wane from adolescence up to old age, and presentation depends on contextual factors. Our understanding of the onset and early course of BPD is growing, but knowledge of BPD in late life is limited. Although the categorical criteria of DSM allow for reliable diagnosis of BPD in adolescence, dimensional models appear both more age neutral, and useful up to late life. To account for the fluctuating expression of BPD, and to guide development and selection of treatment across the life span, a clinical staging model for BPD holds promise.

Pharmacological interventions for people with borderline personality disorder

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the beneficial and harmful effects of pharmacological treatment for adolescents and adults with borderline personality disorder (BPD).

Dissociative states in borderline personality disorder and their relationships to psychotropic medication

BACKGROUND

According to recent data, dissociation may play an important role in borderline personality disorder (BPD), nevertheless specific influences of psychotropic medication on dissociative symptoms in BPD and their therapeutic indications are largely unknown. The purpose of this study was to assess relationships of dissociative symptoms in BPD patients with levels of psychotropic medication and compare these results with a subgroup of patients with schizophrenia.

MATERIALS AND METHODS

In this study, we investigated 52 BPD patients and compared the results with a control group of 36 schizophrenia patients. In all participants, we assessed actual day doses of antipsychotic medication in chlorpromazine equivalents and antidepressant medication in fluoxetine equivalents. Dissociative symptoms were measured by Dissociative Experiences Scale (DES), and other psychopathological symptoms were measured using Health of the Nation Outcome Scales.

RESULTS

Results indicate that dissociative symptoms measured by DES were significantly correlated with antipsychotic medication (Spearman R=0.45, P<0.01) in chlorpromazine equivalents and antidepressant medication in fluoxetine equivalents (0.36, P<0.01). These relationships between medication and dissociative symptoms were not found in the control group of schizophrenia patients.

CONCLUSION

The results suggest that levels of antipsychotic medication and antidepressant medication are significantly associated with dissociative symptoms in BPD but not in schizophrenia.

Pharmacotherapy of borderline personality disorder: replacing confusion with prudent pragmatism

PURPOSE OF REVIEW

The article aims to examine trends in the pharmacological treatment of borderline personality disorder (BPD) and shed more light on the attendant controversies.

RECENT FINDINGS

Although specialized, BPD-centred psychotherapy is considered first-line treatment for BPD and no psychotropic drug has been licensed for BPD, medications are frequently prescribed in the management of this condition. Various classes of psychopharmacological agents are used for BPD and there is a prominent polypharmacy. Use of antidepressants for BPD has been decreasing somewhat and use of mood stabilizers and second-generation antipsychotics has been increasing. Although there is a general agreement that little evidence of efficacy of medications exists for BPD, clinicians are either advised to almost completely avoid pharmacotherapy for BPD or use a 'targeted' approach, administering specific medications for the specific symptoms of BPD. This has created some confusion in clinical practice and contributed to a variety of prescribing practices for BPD.

SUMMARY

Well designed studies of the efficacy of pharmacological agents in BPD are needed. Clinicians should use medications for BPD with caution, usually short term and mainly for symptom relief. They should frequently review a need for ongoing pharmacotherapy and make every effort to avoid polypharmacy.

Changes over the last 15 years in the psychopharmacological management of persons with borderline personality disorder

OBJECTIVE

To describe the pharmacological management of borderline personality disorder (BPD) in Spain from 2001 through 2016, the factors associated with prescriptions, and changes in pharmacotherapy over this time period.

METHODS

Retrospective, cross-sectional, observational study conducted in a sample of 457 patients with BPD consecutively admitted to a specialist BPD Program between January 2001 and November 2016. Data on sociodemographic and clinical variables, as well as pharmacological treatment upon the admission to the programme, were used to describe pharmacological prescriptions, the factors associated with these medications, and changes in prescription over the last 15 years.

RESULTS

Most (88.4%) patients were on pharmacological treatment, with 53.8% of persons taking ≥3 medications. No significant changes in these percentages were observed over the study period. The use of tricyclic antidepressants and benzodiazepines decreased, while the use of atypical antipsychotics increased. Axis I comorbidity was the main factor associated with pharmacological treatment and polypharmacy.

CONCLUSIONS

This study provides further evidence confirming the worldwide overuse of prescription medications for BPD and shows that there has been a shift in the prescription pattern in the last 15 years. These results suggest that real clinical practice only partially adheres to clinical treatment guidelines.

A Focused Systematic Review of Pharmacological Treatment for Borderline Personality Disorder

BACKGROUND

Medicines are routinely prescribed to treat borderline personality disorder (BPD) despite a relative lack of high-quality evidence and in breach of some treatment guidelines. An earlier Cochrane review of pharmacotherapy in BPD underlined the lack of evidence, encouraged the replication of earlier studies, but also emphasised the pressing need for more randomised placebo-controlled trials, and for those studies to employ broadened inclusion criteria.

METHOD

The authors searched bibliographic databases, reference lists of articles and trials registers. Records were screened to identify those that met the inclusion criteria. Full-text articles were screened and assessed for eligibility. On-going trials of pharmacotherapy in BPD were also identified.

RESULTS

Fifteen new studies of pharmacotherapy for BPD were identified since the earlier review. Eight of those examined second generation antipsychotics, two investigated mood stabilisers, three investigated antidepressants and two studied the effectiveness of opioid antagonists. Results for the effectiveness of antipsychotics appeared to be mixed. There has been little recent evidence to support the use of mood stabilisers. There is a lack of new placebo-controlled, randomised controlled trials investigating antidepressants and limited new evidence to support the use of opioid antagonists.

CONCLUSIONS

The review revealed that there remains a dearth of high-quality research evidence to help patients, carers and clinicians make sound and safe evidence-based decisions about medicines to treat BPD.

Pharmacological treatment of borderline personality disorder: a retrospective observational study at inpatient unit in Italy

OBJECTIVE

Borderline personality disorder (BPD) is a high prevalence personality disorder. Pharmacotherapy is commonly used, however, a minority of studies investigated patterns of prescription for BPD, particularly in inpatients unit. We aimed to describe the clinical features and the prescribing practice for BPD patients, and to investigate the possible advantages of a single class of medications or of combined drug treatments in terms of length of stay in hospital.

METHODS

This is a retrospective observational study evaluating 109 BPD inpatients from June 2011 to June 2013.

RESULTS

There was evidence of an extensive use of drugs: benzodiazepines/hypnotics (85.2%), antipsychotics (78.7%), mood stabilizers (70.4%) and antidepressants (31.5%). Polypharmacy was common (83.5%). A longer length of stay in hospital was associated with the prescription of antipsychotic and/or antidepressant medication, while a shorter hospitalization was associated with the use of a mood stabilizer.

CONCLUSIONS

The rates of prescription of different classes of drugs reported in our sample and in similar 'naturalistic' studies highlight a heterogeneous pattern of prescriptions for BPD. Mood stabilizers showed a more favourable profile in terms in length of stay in hospital than antipsychotic and/or antidepressant. Our results reiterate the discrepancy between international recommendations and everyday clinical practice.