Avoiding Polypharmacy in the Treatment of Borderline Personality Disorder

SAN DIEGO—Data suggest there is little evidence concerning the effectiveness of any medication or medication class in patients with borderline personality disorder. Weak effectiveness of medications in this patient population can lead clinicians to try harder to find the best medication, which translates to multiple medications and polypharmacy, according to Victor Hong, MD, Clinical Instructor of Psychiatry, University of Michigan Health System, Ann Arbor. Dr. Hong discussed how to avoid polypharmacy in the treatment of borderline personality disorder during a session at the 28th Annual U.S. Psychiatric and Mental Health Congress. 

Benefits and Limitations

Dr. Hong reviewed the benefits and limitations in psychopharmacologic treatment of patients with borderline personality disorder. “The benefits in psychopharmacologic treatment of patients with borderline personality disorder are that they can sometimes be helpful in regulating mood, decreasing anxiety and stress-associated psychotic systems, and reducing the impact of impulsivity of patients,” he said. “However, one must balance these possible gains with the limitations that borderline personality disorder patients can be exquisitely sensitive to side effects, and no medications have been found to be significantly or consistently effective.” 

Furthermore, when patients with borderline personality disorder become attached to a medication, they find it hard to give up the medication. “Patients must know that the reliance on medication for the treatment of borderline personality disorder without concomitant psychosocial treatments is a setup for failure,” added Dr. Hong. 

He also discussed what pharmacological trials reveal about borderline personality disorder medications. Results from 24 randomized, controlled trials did not demonstrate any solid evidence for pharmacological efficacy. These randomized, controlled trials involved numerous different medications and medication classes, involved small sample sizes, and were short-term trials. 

“As such, the evidence is limited regarding the efficacy of any medication in treating borderline personality disorder,” he said. “It has been demonstrated through meta-analyses that perhaps atypical antipsychotics are most helpful in the treatment of global symptoms of borderline personality disorder, and that antidepressants can be helpful but only if a patient is in the midst of a bona fide major depressive episode.” 

How Polypharmacy Happens

A number of factors contribute to polypharmacy, including the emphasis on the idea that with the right medication or combination of medications, an individual’s “chemical imbalance” can be corrected or fixed. “This is something that is detailed often in the media without the balanced view that medications can be helpful, but that especially for borderline personality disorder, effective treatments are largely psychosocial in nature,” said Dr. Hong. 

Diagnostic inaccuracy is another factor contributing to polypharmacy, such as symptoms of borderline personality disorder that can be misinterpreted as treatment resistance or symptoms of depression, panic attacks, and psychosis. “Misdiagnosis or missed diagnosis of borderline personality disorder is also a factor, as prescribers can try numerous medications for other indications that may or may not be effective in borderline personality disorder,” explained Dr. Hong. “Furthermore, prescribers are often responding to psychological pain that their patients report, and they often feel they have to do something to help their patients.” 

Dr. Hong emphasized the importance of discussing medications with patients and/or family members. “The importance of having a candid, up-front discussion about medications in borderline personality disorder lies in the concept of psychoeducation,” he said, noting that patients and their families need to know that there is limited evidence for medications in borderline personality disorder. 

Patients and families should also understand that medications have numerous side effects and that medications are considered adjunctive treatments at best in borderline personality disorder. In addition, clinicians should carefully explain which medication will be prescribed and communicate that prescribers will try to minimize rather than maximize the number of medications patients take at one time. 

Guarding Against Polypharmacy

Dr. Hong concluded the session by outlining strategies for managing medications in patients with borderline personality disorder to avoid polypharmacy. Clinicians need to start with a single medication that is dosed correctly. They need to allow enough time to assess if the medication is having an effect. If the medication is not effective, they should stop the medication and replace with a different medication rather than augment. 

“One important concept is realizing how easy it is to fall into the practice of polypharmacy and to recognize the pitfalls,” he said. “If clinicians are able to recognize this, we can be more intentional in being disciplined in using only one medication at a time at a proper dose, trying it long enough to determine its efficacy, and not adding on medications while the patient is in crisis.” 

“It is sometimes a negotiation with the patient about the pros and cons of using multiple medications, and the more organized you can be in your own thought process, the better you are able to communicate your concerns to the patient,” he added.  Finally, patients need to be reminded that psychotherapy and improvements in one’s relationships and work functioning are far more effective than medications in reducing symptomatology in borderline personality disorder. 

— Eileen Koutnik-Fotopoulos 

Reference

1. Hong V, Silk K. Avoiding polypharmacy in the treatment of borderline personality disorder. Session presented at the U.S. Psychiatric and Mental Health Congress; September 13, 2015; San Diego, CA.