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Start slow, simple to avoid polypharmacy among patients with borderline personality disorder

SAN DIEGO — In a presentation at U.S. Psychiatric and Mental Health Congress, Victor Hong, MD, and Kenneth Silk, MD, of the University of Michigan, discussed how psychiatrists could potentially avoid polypharmacy when treating patients with borderline personality disorder.

Polypharmacy, or the use of two or more medications for the same disorder, is common among patients with borderline personality disorder, according to Hong.

Results from the McLean Study of Adult Development, conducted by Zanarini and colleagues, show that at 16 years of follow-up, 36% of patients with borderline personality disorder take three or more medications, 19% take four or more medications and 7% take five or more medications, Hong said.

“So do [these medications] work? The most we can say is that their efficacy is non-specific. Most clinical trials demonstrate a high placebo success rate and a high dropout rate. The trials are typically short and there are no continuation studies, which limits our ability to interpret much from the results,” Hong told Healio.com/Psychiatry. “Borderline personality disorder is a disorder that has chronic, long-standing symptoms, so trials with shorter time frames can’t tell us much about longer-term results. Furthermore, patients with borderline personality disorder tend to be quite sensitive to side effects.”

While there are no FDA-approved medications for personality disorder, meta-analyses show atypical antipsychotics are likely the most effective for treating global symptoms and antidepressants are most effective when treating concurrent depression among patients with borderline personality disorder, according to Hong.

“The idea exists that if we just find the right medication or combination of medications, we can ‘fix’ the problem. In borderline personality disorder, it’s rarely going to be that simple,” Hong said.

Another aspect of polypharmacy among patients with borderline personality disorder is mis-diagnosis, according to Hong.

“If we don’t know exactly what we are treating, it is much easier to fall into prescribing medications that may not be indicated,” he said. “If the symptoms are not classic, then patients may not respond to medications as well as they would for classic depression, anxiety, and psychosis. There is no evidence that if one medication doesn’t work for these symptoms, that two or three or four will.”

In some cases, patients are considered treatment-resistant if they do not respond to medications, which may lead to more prescriptions or more invasive treatments such as electroconvulsive therapy, Hong said.

The first step to avoiding polypharmacy is laying simple and clear groundwork, starting with a single medication at a time and focusing on one symptom cluster, according to Hong. If treatment is ineffective, stop and replace it rather than adding another medication. Further, medications should not be changed when a patient is in acute crisis, Hong added.

“In borderline personality disorder, the mainstay of treatment is psychosocial in nature: case management, psychotherapy and improving patients’ relationships and work lives. Medications should only be considered adjunctive,” he said. – by Amanda Oldt

Disclosure: Hong reports no relevant financial disclosures.

Reference:

Hong V. Avoiding polypharmacy in the pharmacologic treatment of borderline personality disorder. Presented at: U.S. Psychiatric and Mental Health Congress; Sept. 10-13, 2015; San Diego.