Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials

Abstract

The current evidence from randomised controlled trials suggests that drug treatment, especially with mood stabilisers and second-generation antipsychotics, may be effective for treating a number of core symptoms and associated psychopathology, but the evidence does not currently support effectiveness for overall severity of borderline personality disorder. Pharmacotherapy should therefore be targeted at specific symptoms.

Borderline personality disorder: current drug treatments and future prospects

“…In this study, little evidence was found for the value of several commonly prescribed antidepressants in BPD, including SSRIs, mianserin and the monoamine oxidase inhibitor, phenelzine. The only antidepressant medication shown to have a positive effect on BPD symptoms outside episodes of major depression was amitriptyline, a tricyclic antidepressant [Lieb et al 2010]. However the use of amitriptyline in BPD, a condition associated with a substantial risk of impulsive selfharm, is limited by its severe toxicity in overdose.…”

“…However, the common occurrence of adverse side effects in this class of medications means that they are often preferred for the treatment of acute relapses only [Díaz-Marsá et al 2008;Newton-Howes and Tyrer, 2003;Benedetti et al 1998;Teicher et al 1989]. The most commonly studied antipsychotic, olanzapine, has been found to reduce impulsivity, hostility, affective instability and psychotic symptoms in BPD [Lieb et al 2010;Soler et al 2005;Zanarini et al 2004;Bogenschutz and Nurnberg, 2004;Hallmayer, 2003], although it is associated with metabolic side effects, which may limit its tolerability [Reynolds and Kirk, 2010;Kantrowitz and Citrome, 2008]. A more limited literature supports the use of aripiprazole and haloperidol in BPD, the latter especially for symptoms of anger [Lieb et al 2010].…”

“…Although most qualitative, narrative reviews suggest that there is a promising role for medications in the treatment of BPD [Saunders and Silk, 2009;Abraham and Calabrese, 2008;Bellino et al 2008;Díaz-Marsá et al 2008;Grootens and Verkes, 2005;Lieb et al 2004;Markovitz, 2004;Raj, 2004;Zanarini, 2004;Newton-Howes and Tyrer, 2003;Links et al 2001;Soloff, 2000;Dimeff et al 1999;Coccaro, 1998], several recent large-scale metaanalyses of these psychotropic agents in BPD have highlighted a number of limitations in the currently available evidence regarding the pharmacological treatment of BPD [Lieb et al 2010;Mercer et al 2009;Binks et al 2006;Nose et al 2006].…”

“…However, the evidence base for the usage of these treatments remains generally limited [Lieb et al 2010], and further progress will require: (a) larger trials of existing agents; (b) the development of novel, specific drugs to use in BPD. The latter will involve a critical appraisal of possible underlying biological contributions to the development of the disorder.…”

“…Despite this, pharmacotherapy has been recommended as an adjunctive, symptom-targeted component of treatment [Oldham et al 2004;American Psychiatric Association, 2001]. Previous meta-analyses have concluded that pharmacotherapy could exert a beneficial effect on certain core traits of BPD [Lieb et al 2010;Mercer et al 2009;Binks et al 2006;Nose et al 2006] and there is a growing body of evidence that different classes of agents, such as antidepressants, mood stabilizers, antipsychotics and neuroleptics, can be used in the treatment of specific symptoms [Abraham and Calabrese, 2008;Binks et al 2006;Nose et al 2006]. Polypharmacy is common [Lieb et al 2004;Zanarini et al 2001] but the use of multiple drugs is not evidence based, and is likely to reflect the failure of any one agent to provide adequate symptom amelioration.…”