Comorbid personality pathology contributes greatly to overall psychopathology in secondary psychiatric care. It should be both recognised and managed.

This serial cross-sectional survey indicated that use of the EssenCES alone might be a good practical measure of treatment progress/responsivity. A longitudinal study would be an important next step in establishing the extent to which it would be useful in this regard.

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

BackgroundClozapine is an atypical antipsychotic medicine which can cause significant side-effects. It is often prescribed off-license in severe cases of borderline personality disorder contrary to national treatment guidelines. Little is known about the experiences of those who take clozapine for borderline personality disorder. We explored the lived-experience of women in secure inpatient care who were prescribed clozapine for borderline personality disorder.FindingsAdult females (N = 20) participated in audio-taped semi-structured interviews. Transcripts were subject to thematic analysis. The central themes related to evaluation, wellbeing, understanding and self-management; for many, their subjective wellbeing on clozapine was preferred to prior levels of functioning and symptomatology, sometimes profoundly so. The negative and potentially adverse effects of clozapine were explained as regrettable but relatively unimportant.ConclusionsWhen psychological interventions are, at least initially, ineffective then clozapine treatment is likely to be evaluated positively by a group of women with borderline personality disorder in secure care despite the potential disadvantages.

Introduction: The social climate of a unit is an important feature in treatment outcomes (Moos 1974). The Essen Climate Evaluation Schema (EssenCES; Schalast et al 2008) has been developed specifically for forensic settings but research in secure settings for women has been limited. Objectives: To compare staff and patient perception of social climate and it's relationship to therapeutic alliance, motivation to change and level of disturbance across levels of security within a women's secure care pathway. Aims: To assess the implications for therapeutic milieu and service development. Method: Questionnaire survey of staff and patients in 2 medium and 2 low secure units using; EssenCES (Shalast et al 2008); California Psychotherapy Alliance Scale (Mormar et al 1986); and Patient Motivation Inventory (PMI; Gudjonsson et al 2007). Comparisons are made across levels of security, treatment programme, therapeutic alliance, patient motivation and disturbed behaviour. Results: Social climate varied between levels of security and was also found to co vary with perceived therapeutic alliance and patient motivation to change. Differences between staff and patient ratings along with treatment implications are discussed. Conclusion: Measuring the social climate in a secure women's service is an important part of a wider assessment of the therapeutic milieu that has practical implications for the ongoing development of therapy services.