A naturalistic study of changes in pharmacological prescription for borderline personality disorder in clinical practice: from APA to NICE guidelines

Abstract

Although no psychotropic agents are specifically licensed for the management of borderline personality disorder (BPD), pharmacological treatment appears to be common. This study aimed to examine the drug prescriptions for patients with BPD in clinical practice, analyze the prescription patterns from the appearance of the American Psychiatric Association guidelines in 2001 until the National Institute for Health and Clinical Excellence guidelines in 2009, and identify the factors associated with such prescription of each type of drug. Naturalistic study on 226 consecutive BPD patients admitted to an outpatient BPD program. Socio-demographic, clinical and pharmacological treatment information was collected; factors associated with drug prescription were examined using logistic regression analyses for dichotomous outcomes measures. Changes in prescription patterns over time were also evaluated. Patients received an average of 2.7 drugs; only 6% were drug-free; 56% were taking ≥3 drugs and 30% ≥4 drugs. Over the past 8 years, prescription of antidepressants has remained stable; there has been a significant reduction in prescription of benzodiazepines and an increase in the use of mood stabilizers and atypical antipsychotics. Comorbidity with Axis I disorders was the main factor associated with drug prescription. Drug prescription and polypharmacy are common in the management of BPD in clinical practice.

The Use of Psychotropic Medication in Patients With Emotionally Unstable Personality Disorder Under the Care of UK Mental Health Services

“…1 In our subgroup of patients with EUPD alone, threequarters were prescribed an antidepressant; three-fifths, an antipsychotic drug; one-third, a benzodiazepine; and onefifth, a z-hypnotic or mood stabilizer. The high prevalence of antidepressant use is consistent with other surveys of prescribing practice [8][9][10] but in contrast with the findings from clinical studies that these drugs are not effective in treating affective symptoms in patients with EUPD 17 and are relatively less effective in treating depression in people with comorbid personality disorder than in those without. 19,20 A higher proportion of our patients with EUPD were prescribed an antipsychotic than the 40% reported by Pascual et al 8 in a naturalistic study of 226 consecutive patients with BPD admitted to an outpatient program, although these investigators noted an increasing prevalence of antipsychotic prescribing over time.…”

“…5,[7][8][9] Polypharmacy was also common with two-thirds of patients with EUPD alone prescribed psychotropic drugs from at least 2 different classes and almost a fifth from at least 4. This is consistent with Zanarini et al, 6 who reported that 11% of those with EUPD were taking 5 or more psychotropic drugs, although these investigators included patients with comorbid mental illness.…”

“…1,8,9,16 Many of the symptoms of EUPD overlap with those of mental illness but may not reach the qualitative or quantitative criteria required for a comorbid diagnosis in that they are not severe enough or do not last long enough. In routine practice, clinicians are likely to differ in their individual thresholds for a diagnosis of a comorbid condition, with, for example, some considering even severe mood lability to be consistent with a diagnosis of EUPD, while others would diagnose comorbid bipolar disorder.…”

Antipsychotics-induced metabolic alterations: Focus on adipose tissue and molecular mechanisms

“…Due to the elevated and increasing worldwide prevalence of neuropsychiatric disorders (10% of adults, according to an 2006 estimation of the World Health Organization (Albrecht, 2006)) the use of antipsychotic drugs has expanded dramatically over the last decade (Alessi-Severini et al, 2012;Bulloch et al, 2012;Comer et al, 2011;Pascual et al, 2010). This increase was also potentiated by the introduction of "second generation" or atypical antipsychotics such as quetiapine, risperidone, olanzapine, clozapine and aripiprazole (Kessler et al, 2003), which in contrast to "first generation" or typical antipsychotics, have a higher clinical efficacy and a lower risk of inducing adverse extrapyramidal symptoms (movement disorders) (Monshat et al, 2010;Shah et al, 2011).…”

Long-Term and Bizarre Self-Injurious Behavior

“…Not only is there insufficient evidence regarding which treatments may be most effective, 9,20 but it is virtually impossible to prevent patients from harming themselves through the ingestion of objects. Current consensus emphasizes the importance of forming a supportive and collaborative therapeutic alliance, validating the patient's feelings, conducting functional analyses of the self-harming episodes, managing reinforcement contingencies, and teaching new skills such as problem-solving or distress tolerance.…”