Prescribing in Personality Disorder
Dr.Sanjeevan Somasunderam
Consultant Psychiatrist,
MAP East team,
Croydon
CONTENT
• NICE Guidelines
• The Dilemma in prescribing mood stabilisers/antipsychotics
• Relevant research papers and findings/problems with research
• Polypharmacy/Washout
• Summary and Conclusions
NICE GUIDELINES
• Drug treatment should not be used specifically for borderline personality
disorder or for the individual symptoms or behaviour associated with the
disorder (for example, repeated self-harm, marked emotional instability,
risk-taking behaviour and transient psychotic symptoms)
• Too unequivocal/dogmatic
• No definitive/robust evidence either way
• Does not reflect clinical practice in secondary care though there is variation
in clinical practice
• May encourage a lack of curiosity of potential co-morbidities in staff
• Emerging evidence of underdiagnosed ADHD and Bipolar Affective
Disorder(type 2,and sub-syndromal) within E.U.P.D patient group
The Dilemma in prescribing mood
stabilisers/anti-psychotics
• Issues of risk/benefit considering risk of O.D and toxicity of medication
• Influence of the availability of timely psychological therapies(effect on
prescribing)
• Patient pressure
• Initiating a cycle of medication trials and potential to lead to
polypharmacy/ ‘irrational’ polypharmacy
• Lack of a standardised clinical approach
• Diagnostic counter-transference and effect on prescribing patterns
Relevant research papers and findings/problems with
research
• Medication prescribed to people with personality disorder: The
influence of patient factors and treatment setting. Acta Psychiatrica
Scandinavica 2011 Crawford et al
• Polypharmacy or medication washout: An old tool revisited
Neuropsychiatric Disease and treatment. 2011 Hoffman et al
• Are mood stabilisers helpful in treatment of borderline personality
disorder? BMJ 2014 Crawford et al
• Depression and borderline personality disorder. MJA 2012 Beatson et al
• Antipsychotics,Antidepressants,Anticonvulsants and placebo on
Symptom dimension of borderline personality Disorder. Journal of
clinical psychopharmacology Oct 2011 Vita et al * Meta-Analysis Of
Randomized Controlled and Open-Label Trials
• Comparison of Low and Moderate dosages of Extended-release
Quetiapine in Borderline Personality Disorder: A
Randomised,Double-Blind,Placebo-Controlled Trial. The American
Journal of Psychiatry 2014: Black et al *
Patient factors and treatment setting
• Potential for polypharmacy is greater(in EUPD)
• Clinicians may fail to recognise P.D and use treatment for Axis 1
condition that is not there
• When response is poor, increase doses/’irrational’ polypharmacy
• Service provider with the highest level of prescribing was the one that
did not have a specialist unit(psychotherapy)
• In the univariate analysis, patients with anti-social personality disorder
were less likely to receive psychotropic medications than other groups
of P.D(despite high levels of Axis 1 disorders in this group)
• It has been argued that counter-transference involved by people with
P.D is important in determining the treatment that people receive.
Polypharmacy or medication washout
• Washout as a clinical tool is rarely done today
• ‘Rational’ vs ‘Irrational’ polypharmacy
• Reasons for polypharmacy may be mutifactorial,increase availability of
medications targeting specific symptoms and receptors
• Inadequacies in our current diagnostic nomenclature based as it is on
descriptive psychiatry
• Question arises as to whether the risk of adding another medication is
less than the risk of washout
• Can provide valuable information about which medications are actually
beneficial
• Allow 5-7 half lives as a rule of thumb for clearance,?need for in-patient
washout
• ‘Irrational’ polypharmacy when clinicians are afraid of changing the
status quo by altering a medication that maybe only partially effective
• ‘Rational’ polypharmacy: ‘mini-experiments’ drawing on good
pharmacological decisions,avoid several benzo’s,several anti-psychotics
• Difficulty finding RCT’s on polypharmacy(expensive and driven by
pharma)
• Low-rate of washout failure(suggests that they were not truly treatment
resistive)
• Risks of polypharmacy appear greater than the risks associated with
washout
Are mood stabilisers helpful in treatment of
Borderline Personality Disorder? BMJ 2014
• Cochrane Systematic review 2009:results of randomised trials of mood
stabilisers in Borderline P.D,small trials,short follow-up
• Diverse range of outcome measures were used,limiting the scope for
meta-analysis
• Difficulty finding ‘pure’ E.U.P.D cases
• Study participants had less severe problems than those in secondary
care
• Recommendations include,no routine use of mood stabilisers for BPD
• Possible potential,evidence from pragmatic trials among people using
secondary care is lacking and no data on long term clinical and cost
effectiveness exist
• Consider side-effect profile,drug interactions,previous Hx of adherence
and self-harm using prescribed drugs and women of child bearing age
• Patients to be told of uncertain benefit,risks/’off-license’ use and will be
discontinued after 3-6 months if Sx don’t improve
• A decision to stop meds may trigger feelings of abandonment,but this is
not a sound basis for continuing treatments that are ineffective.
Depression and borderline personality disorder.
MJA 2012 Beatson et al
• Major depressive Disorder(MDD) commonly co-exits with BPD
• MDD co-occurring with BPD does not respond as well to anti-depressant medication
• MDD is not a significant predictor of outcome for BPD,but BPD is a significant
predictor of outcome for MDD
• One study ,BPD patients( twice as likely to receive anti-convulsants,x6 for mood
stabilsers,x10 anti-psychotics and x2 anti-depressants cf MDD alone)
Antipsychotics,Anti-depressants,Anticonvulsants,and Placebo on the
Symptom Dimensions of Borderline Personality Disorder-Vita 2011
• Sx Dimensions of 1)Affective Dysregulation 2)Impulsive-Behavioural
Dyscontrol 3)Cognitive-perceptual Sx
• No previous quantitative review of open label studies was available and
no attempt to compare the results from RCT’s and open-label trials.
• 3 separate sets of meta-analysis for 1)RCT’s 2)Open studies 3) RCT’s and
open trials combined.Also analysed the effect of placebo on Sx
dimensions.
• For Affective Dysregulation,highest efficacy with Anti-Convulsants,then
less for anti-depressants and minimal,although significant for SGA’s
.
• Open-label studies showed yielded the same results for anticonvulsants and SGA’s.
• For Impulse-behavioural dyscontrol,RCT’s demonstrated the highest
effect-size for anti-convulsants and a lower effect size for both FGA’s
and SGA’s,no evidence of efficacy for anti-depressants.
• Open label-studies,anti-depressants were also shown to be
effective(but very small number of open studies(n=3)
• For Cognitive-perceptual Sx dimension,in both RCT’s and opentrials,only anti-psychotics proved to be effective,the existing literature
does not indicate any significant efficacy for anti-convulsants and antidepressants
B: Impulsive-behavioural
Dyscontrol
C:Cognitive-perceptual
• A more pronounced effect of anti-convulsants’ on affective
dysregulation and should be considered 1st line for impulsivebehavioural dyscontrol and affective dysregulation
• Anti-psychotics appear to effective for the treatment of all core Sx of
BPD,insufficient data on FGA’s vs SGA’s.
• Several limitations of the study,quality of the primary studies,huge
heterogeneity of clinical features,treatment settings,outcome variables
and assessment instruments adopted by the different studies.
• Relatively small and qualitatively heterogenous literature that could be
included in the present analysis prevents definitive conclusions being
drawn form the results and limits their interpretation.
• Meta-analysis on largest available database of RCT’s and open-label
trials,when possible on a pooled data set of both RCT’s and open studies
does demonstrate a positive effect of drug treatments on the core Sx of
BPD.
• Also differences in efficacy between different drug classes on each Sx
domain.
• Future research should use a more homogenous set of better described
outcome measures and assessment instruments
• Further outcome measures other than symptomatological,that
is,biological,neurocognitive,and psychosocial should be
addressed,especially in long-term naturalistic studies.
• ?A SLaM group to look into this
SUMMARY
• NICE Guidance not particularly helpful
•
More helpful to consider Symptom Dimensions of E.U.P.D
• 1)Affective Dysregulation 2)Impulsive-behavioural dyscontrol
3)Cognitive-perceptual Symptoms
• Most interesting papers are from Antonio Vita and Black(Quetiapine)
,though it does highlight the ongoing problem with research in this
group
• There is some evidence re:effectiveness of mood stabilisers in
1)Affective dysregulation and 2)Impulsive-behavioural dyscontrol
• Strategies of Washout to be considered when polypharmacy occurs
• Concepts of ‘rational’ polypharmacy and ‘irrational’ polypharmacy
• Awareness of potentially underdiagnosed disorders in this
group(ADHD/F31)
• Awareness of Diagnostic Counter-transference,patient factors
• Prescribing of Mood stabilisers and anti-psychotics appears
haphazard/not focussed.
• The need for a standardised approach from SLaM Consultants/teams
• Formation of Prescribing groups within the M.A.P C.A.G.