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Certain medications, including treatments predominately used for attention deficit/hyperactivity disorder (ADHD) result in a decrease in negative outcomes and mortality for patients with borderline personality disorder (BPD).¹

A team, led by Johannes Lieslehto, Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, investigated the comparative effectiveness of pharmacological treatments for patients with borderline personality disorder.

Borderline Personality Disorder

The majority of patients with borderline personality disorder are treated with psychopharmacological treatment. However, the majority of clinical guidelines for the disease lack a consensus for the role of pharmacotherapy.

“In particular, while some recommendations expressly advise against using pharmacotherapy, other guidelines view medication as adjunctive therapy in the treatment of issues like impulsivity, cognitive-perceptual symptoms, or anger,” the authors wrote. “However, the efficacy of pharmacotherapeutic treatments for BPD is unclear.”

In the study, the investigators identified patients with borderline personality disorder with treatment contact between 2006-2018 from Swedish nationwide register databases. The team leveraged within-individual design, where each participant was used as their own control to eliminate selection bias. Here, they assessed the comparative effectiveness of pharmacotherapies.

The patient population frequently suffered from comorbidities, including substance use disorder (33%; n = 5782), depression (47.9%; n = 8391), anxiety disorder (62.3%; n = 10,925), and ADHD (16.6%; n = 2907). In addition, 32.5% (n = 5689) of the patients had attempted suicide previously.

The investigators calculated the hazard ratios (HR) for psychiatric hospitalization and hospitalization owing to any cause or death for each medication.

Overall, there were 17,532 patients with borderline personality disorder included in the study, 2649 of which were men. The mean age of the patient population was 29.8 years.

The investigators sought main outcomes of any psychiatric rehospitalization, which served as a surrogate for treatment failure and hospitalization owing to any reason or death, which served as a proxy for both treatment failure and tolerability of treatments.

The Treatments

The results show treatment with benzodiazepines (HR, 1.38; 95% confidence interval [CI], 1.32-1.43), antipsychotics (HR, 1.19; 95% CI, 1.17-1.26), and antidepressants (HR, 1.17l 95% CI, 1.14-1.21) was linked to a higher risk of increased psychiatric rehospitalizations.

The investigators also found treatment with benzodiazepines (HR, 1.37; 95% CI, 1.33-1.42), antipsychotics (HR, 1.21; 95% CI, 1.17-1.26) and antidepressants (HR, 1.17; 95% CI, 1.14-1.21) was associated with an increased riskof all-cause hospitalization or mortality.

On the other hand, the results show mood stabilizer treatment did not have a statistically significant association with any of the predetermined outcomes and ADHD medications were linked to a lower risk of psychiatric hospitalization (HR, 0.88; 95% CI, 0.83–0.94), as well as a decreased risk of all-cause hospitalization or death (HR, 0.86; 95% CI, 0.82–0.91). 

Finally, clozapine (HR, 0.54; 95% CI, 0.32–0.91), lisdexamphetamine (HR, 0.79; 95% CI, 0.69–0.91), bupropion (HR, 0.84; 95% CI, 0.74–0.96), and methylphenidate (HR, 0.90; 95% CI, 0.84–0.96) were all linked to a decrease in psychiatric rehospitalization.

“ADHD medications were associated with a reduced risk of psychiatric rehospitalization or hospitalization owing to any cause or death among individuals with BPD,” the authors wrote. “No such associations were found for benzodiazepines, antidepressants, antipsychotics, or mood stabilizers.”

References:

Lieslehto, J., Tiihonen, J., Lähteenvuo, M., Mittendorfer‐Rutz, E., Tanskanen, A., & Taipale, H. (2023). Association of Pharmacological Treatments and real‐world outcomes in borderline personality disorder. Acta Psychiatrica Scandinavica. https://doi.org/10.1111/acps.13564