COMMENTARY

Pharmacotherapy for Borderline Personality Disorder

Leslie Citrome, MD, MPH

Disclosures

February 10, 2010

Pharmacotherapy for Borderline Personality Disorder: Cochrane Systematic Review of Randomised Trials

Lieb K, Vollm B, Rücker G, Timmer A, Stoffers JM
Br J Psychiatry. 2010;196:4-12

Summary

This is an updated "Cochrane" review of the pharmacotherapy for borderline personality disorder. The authors identified 27 reports of completed randomized controlled studies that examined medications such as antipsychotics, anticonvulsants, and antidepressants -- as well as a dietary supplement -- for outcomes related to affective dysregulation, cognitive-perceptual symptoms, impulsive-behavioral dyscontrol, interpersonal problems, and associated pathology. Not all outcomes were assessed in each study. The data supplement available online is indispensable to determine which drug was tested against which outcome for how long a period. The authors conclude that anticonvulsants and second-generation antipsychotics may be effective for treating a number of core symptoms and associated psychopathology, but that antidepressants are generally not worthwhile in the treatment of this disorder. The latter finding has important implications for practice -- the authors specifically state that serotonin-specific reuptake inhibitors cannot be recommended as first-choice treatment for affective dysregulation and impulsive-behavioral symptoms in borderline personality disorder.

Viewpoint

Borderline personality disorder is challenging to manage effectively. Some schools of thought suggest that these patients ought not to receive medication and that only psychotherapeutic approaches are indicated. This is unnecessarily restrictive and the authors of the review make the case for medication treatment targeted at defined specific symptoms. An important limitation to the currently available research is that although patients with borderline personality disorder often have other comorbid psychiatric conditions, common exclusion criteria for the studies reviewed include comorbid psychotic disorder, bipolar disorder, current major depressive disorder, and substance-related disorders. Moreover, patients with current suicidal ideation were not eligible for almost half of the included trials. Other limitations include the short durations of the clinical trials (mean 84 days), and the lack of use of disorder-specific assessment instruments. Thus currently available research on the medication treatment of borderline personality disorder is not easily generalizable to the "real world" borderline patients managed in the clinic.

Abstract

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