Borderline personality disorder (BPD) is a common and debilitating mental health condition, yet medication options remain limited according to a new systematic review published in CNS Drugs.
The study found minimal evidence supporting the benefits of medication for BPD beyond some improvement in individual symptoms.
No drugs have been approved for BPD and there is a lack of high-quality research on pharmaceutical treatments.
Key facts:
- Systematic review assessed 21 clinical trials on medications for BPD, including 1,768 patients. Only 9 of 87 medications of interest were studied.
- Evidence does not support medications alone to reduce severity of BPD. Low-quality evidence found some benefits for specific symptoms like anger and aggression.
- Antipsychotics, anticonvulsants and antidepressants failed to consistently improve BPD. They had modest effects on some associated symptoms.
- Adverse events were more common with antipsychotics compared to placebo. Other harms were similar between drugs and placebo.
- Authors conclude medication efficacy is limited for BPD and evidence quality is low. More research is needed, especially on real-world functioning.
Source: CNS Drugs
Searching for Effective Medications for BPD
Borderline personality disorder is estimated to affect 0.4% to 3.9% of the population.
It involves unstable relationships, distorted self-image, impulsivity and intense emotions.
Patients struggle to maintain work, relationships and experience elevated risks of suicide.
Up to 96% of those seeking treatment are prescribed medication, often several concurrently.
But no pharmaceutical treatments have been officially approved for BPD.
Clinical practice guidelines provide mixed opinions on using drugs off-label.
Researchers conducted an exhaustive search for studies on medications for BPD.
Out of 87 agents in use, they found just 21 trials on 9 drugs over the past 20 years.
The evidence was graded as low to very low quality overall.
“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,” concluded study authors from RTI International and Medical University of South Carolina.
This reveals a concerning lack of research on medications given to many BPD patients.
According to lead author Dr. Gerald Gartlehner, higher quality studies are needed to guide medical practice.
Review Assessed Antipsychotics, Anticonvulsants and Antidepressants for Borderline Personality Disorder
The systematic review covered three main classes of psychotropics:
- Antipsychotics – Assessments of olanzapine, quetiapine, aripiprazole and ziprasidone
- Anticonvulsants – Trials of divalproex, lamotrigine and topiramate
- Antidepressants – Only fluoxetine was studied
In placebo-controlled trials, these drugs failed to consistently decrease the overall severity of BPD based on validated rating scales.
Benefits for associated symptoms were limited.
For instance, the antipsychotic aripiprazole improved anger and quetiapine reduced aggression versus placebo.
Anticonvulsants helped some patients with anger, aggression and mood instability. But the evidence for individual agents relied on single studies with design flaws.
“Low- and very-low-certainty evidence indicates that anticonvulsants can improve anger, aggression, and affective lability, however, the evidence is mostly limited to single studies,” noted the authors.
When it came to side effects, antipsychotics were linked to more adverse events than placebo.
Other safety outcomes and comparisons between medications were inconclusive due to limited data.
Lack of Research on Real-World Outcomes
Beyond the dearth of clinical trials, another issue highlighted by the review was the lack of patient-centered outcomes.
No studies looked at the effects of medication on social functioning, employment, hospitalizations or other measures meaningful to those living with BPD.
Most trials focused only on short-term changes in psychiatric rating scale scores or symptoms.
Further research needs to determine if medications make a tangible difference in patients’ lives.
Longer-term studies are also needed to clarify the risks and benefits of pharmaceutical treatment for BPD.
Patients are often prescribed psychotropic combinations for months or years. But included trials lasted just 8-52 weeks on average.
Targeted research in adolescents, minorities and other subgroups would help guide practice for specific populations.
Current evidence comes mainly from studies of white adults, the majority female.
Non-Drug Therapies Should Be First-Line
In the absence of quality medication research, some guidelines advise psychotherapy as the preferred first-line treatment for BPD patients.
Dialectical behavior therapy, mentalization-based therapy and transference-focused psychotherapy have the strongest evidence base.
But medications are still commonly used as adjunctive treatments.
For acute crises like suicidal depression, short-term drugs may help along with therapy.
The review authors conclude medications have a very limited role on their own in BPD treatment.
“Future research needs to conduct unbiased, adequately powered trials that take potential differences in subgroups into consideration,” stated researchers.
Until then, non-drug options should be the primary approach for borderline personality disorder.
References
- Study: Pharmacological treatments for borderline personality disorder: a systematic review and meta-analysis
- Authors: Gerald Gartlehner et al. (2021)
