Skip to main content
SpringerLink
Log in

Twenty-Year Trends in the Psychopharmacological Treatment of Outpatients with Borderline Personality Disorder: A Cross-Sectional Naturalistic Study in Spain

  • Original Research Article
  • Published:
CNS Drugs Aims and scope Submit manuscript

Abstract

Objective

Although no psychotropic drugs have been officially approved for the treatment of borderline personality disorder (BPD), medications are routinely prescribed for these patients. The primary aim of this study was to evaluate changes in the pharmacological management of patients with BPD treated in an outpatient specific unit in Spain over the past 20 years, while a secondary aim was to identify the factors associated with the prescription.

Methods

Observational and cross-sectional study of all patients with a primary diagnosis of BPD (n = 620) consecutively admitted to a BPD outpatient program in Barcelona, Spain, from 2001 through 2020. We examined trends in the prescription of antidepressants, benzodiazepines, mood stabilizers, and antipsychotics. For the analysis, prescription data were grouped into four 5-year periods (2001–2005, 2006–2010, 2011–2015, and 2016–2020). Logistic regression models were performed to identify sociodemographic and clinical variables associated with pharmacological prescription and polypharmacy.

Results

The percentage of patients receiving pharmacotherapy decreased over time. Antidepressant prescription rates remained high and stable over time (74% of patients), while benzodiazepine use decreased significantly during the study period (from 77 to 36%) and second-generation antipsychotic (SGA) use increased from 15 to 32%. Psychiatric comorbidity was the main factor associated with pharmacological treatment (odds ratio 2.5, 95% confidence interval 1.5-4.2) and polypharmacy, although a high percentage of patients without comorbidity were also taking medications.

Conclusions

Over the past 20 years, the pharmacological treatment of BPD outpatients has undergone important changes, most notably the decrease in benzodiazepines and increase in SGAs. The findings of this study demonstrate that pharmacotherapy is much more prevalent in patients with BPD than recommended in most clinical guidelines.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Grant BF, Chou SP, Goldstein RB, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2008;69(4):533–45. https://doi.org/10.4088/jcp.v69n0404.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Trull TJ, Jahng S, Tomko RL, et al. Revised NESARC personality disorder diagnoses: gender, prevalence, and comorbidity with substance dependence disorders. J Pers Disord. 2010;24(4):412–26. https://doi.org/10.1521/pedi.2010.24.4.412.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Alvarez-Tomás I, Soler J, Bados A, et al. Long-term course of borderline personality disorder: a prospective 10-year follow-up study. J Pers Disord. 2017;31(5):590–605. https://doi.org/10.1521/pedi_2016_30_269.

    Article  PubMed  Google Scholar 

  4. Stoffers JM, Völlm BA, Rücker G, et al. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2012;2012(8):CD005652. https://doi.org/10.1002/14651858.CD005652.pub2.

    Article  Google Scholar 

  5. Storebø OJ, Stoffers-Winterling JM, Völlm BA, et al. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2020;5(5):CD012955. https://doi.org/10.1002/14651858.CD012955.pub2.

    Article  PubMed  Google Scholar 

  6. Pascual JC, Martín-Blanco A, Soler J, et al. A naturalistic study of changes in pharmacological prescription for borderline personality disorder in clinical practice: from APA to NICE guidelines. Int Clin Psychopharmacol. 2010;25(6):349–55. https://doi.org/10.1097/YIC.0b013e32833e23ed.

    Article  PubMed  Google Scholar 

  7. Martín-Blanco A, Ancochea A, Soler J, et al. Changes over the last 15 years in the psychopharmacological management of persons with borderline personality disorder. Acta Psychiatr Scand. 2017;136(3):323–31. https://doi.org/10.1111/acps.12767.

    Article  PubMed  Google Scholar 

  8. Riffer F, Farkas M, Streibl L, et al. Psychopharmacological treatment of patients with borderline personality disorder: comparing data from routine clinical care with recommended guidelines. Int J Psychiatry Clin Pract. 2019;23(3):178–88. https://doi.org/10.1080/13651501.2019.1576904.

    Article  CAS  PubMed  Google Scholar 

  9. Simonsen S, Bateman A, Bohus M, et al. European guidelines for personality disorders: past, present and future. Borderline Personal Disord Emot Dysregul. 2019;6:9. https://doi.org/10.1186/s40479-019-0106-3.

    Article  PubMed  PubMed Central  Google Scholar 

  10. American Psychiatric Association Practice Guidelines. Practice guideline for the treatment of patients with borderline personality disorder. Am J Psychiatry. 2001;158(10 Suppl):1–52.

    Google Scholar 

  11. Herpertz SC, Zanarini M, Schulz CS, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of personality disorders. World J Biol Psychiatry. 2007;8(4):212–44. https://doi.org/10.1080/15622970701685224.

    Article  PubMed  Google Scholar 

  12. DGPPN. Deutsche Gesellschaft für Psychiatry, Psychotherapie und Nervenheilkunde. Behandlungsleitlinie Persönlichkeitstörungen [German guideline for personality disorders]. Dresden: Steinkopff Verlag; 2009.

  13. CBO Landelijke Stuurgroep Multidisciplinaire Richtlijnontwikkeling in de GGZ. Multidisciplinaire Richtlijn voor de diagnostiek en behandeling van volwassen patiënten met een persoonlijkheidsstorrnis [Dutch multidisciplinary guideline for the diagnosis and treatment of personality disorders]. Utrecht: Trimbos-instituut; 2008.

    Google Scholar 

  14. National Institute for Clinical Excellence (NICE). Borderline personality disorder: treatment and management. Clinical Guideline. London: NICE; 2009.

  15. National Health and Medical Research Council. Clinical Practice Guideline for the Management of Borderline Personality Disorder. Canberra: National Health and Medical Research Council; 2012.

  16. GPC. Grupo de trabajo de la guía de práctica clínica sobre trastorno límite de la personalidad. Fórum de Salud Mental y AIAQS, coordinadores. Guía de práctica clínica sobre trastorno límite de la personalidad. Barcelona: Agència d’Informació, Avaluació i Qualitat en Salut. Servei Català de la Salut. Pla Director de Salut Mental i Addiccions. Departament de Salut. Generalitat de Catalunya; 2011.

  17. Zanarini MC, Frankenburg FR, Reich DB, Harned AL, Fitzmaurice GM. Rates of psychotropic medication use reported by borderline patients and axis II comparison subjects over 16 years of prospective follow-up. J Clin Psychopharmacol. 2015;35(1):63–7. https://doi.org/10.1097/JCP.0000000000000232.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Crawford MJ, Kakad S, Rendel C, et al. Medication prescribed to people with personality disorder: the influence of patient factors and treatment setting. Acta Psychiatr Scand. 2011;124(5):396–402. https://doi.org/10.1111/j.1600-0447.2011.01728.x.

    Article  CAS  PubMed  Google Scholar 

  19. Bridler R, Häberle A, Müller ST, Cattapan K, Grohmann R, Toto S, Kasper S, Greil W. Psychopharmacological treatment of 2195 in-patients with borderline personality disorder: a comparison with other psychiatric disorders. Eur Neuropsychopharmacol. 2015;25(6):763–72. https://doi.org/10.1016/j.euroneuro.2015.03.017.

    Article  CAS  PubMed  Google Scholar 

  20. Paton C, Crawford MJ, Bhatti SF, et al. The use of psychotropic medication in patients with emotionally unstable personality disorder under the care of UK mental health services. J Clin Psychiatry. 2015;76(4):e512–8. https://doi.org/10.4088/JCP.14m09228.

    Article  PubMed  Google Scholar 

  21. Rhee TG, Olfson M, Nierenberg AA, et al. 20-year trends in the pharmacologic treatment of bipolar disorder by psychiatrists in outpatient care settings. Am J Psychiatry. 2020;177(8):706–15. https://doi.org/10.1176/appi.ajp.2020.19091000.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Stoffers-Winterling J, Storebø OJ, Lieb K. Pharmacotherapy for borderline personality disorder: an update of published, unpublished and ongoing studies. Curr Psychiatry Rep. 2020;22(8):37. https://doi.org/10.1007/s11920-020-01164-1.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Gómez-Beneyto M, Villar M, Renovell M, et al. The Diagnosis of Personality Disorder with a modified version of the SCID-II in a Spanish clinical sample. J Pers Disord. 1994;8(2):104–10. https://doi.org/10.1521/pedi.1994.8.2.104.

    Article  Google Scholar 

  24. Barrachina J, Soler J, Campins MJ, et al. Validación de la versión española de la Diagnostic Interview for Bordelines-Revised (DIB-R) [Validation of a Spanish version of the Diagnostic Interview for Bordelines-Revised (DIB-R)]. Actas Esp Psiquiatr. 2004;32(5):293–8.

    CAS  PubMed  Google Scholar 

  25. Hosmer DW, Lemeshow S, Sturdivant RX. Applied logistic regression. 3rd ed. New York: Wiley; 2013.

    Book  Google Scholar 

  26. Pascual JC, Córcoles D, Castaño J, et al. Hospitalization and pharmacotherapy for borderline personality disorder in a psychiatric emergency service. Psychiatr Serv. 2007;58(9):1199–204. https://doi.org/10.1176/ps.2007.58.9.1199.

    Article  PubMed  Google Scholar 

  27. Timäus C, Meiser M, Bandelow B, et al. Pharmacotherapy of borderline personality disorder: what has changed over two decades? A retrospective evaluation of clinical practice. BMC Psychiatry. 2019;19(1):393. https://doi.org/10.1186/s12888-019-2377-z.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Ingenhoven TJ, Duivenvoorden HJ. Differential effectiveness of antipsychotics in borderline personality disorder: meta-analyses of placebo-controlled, randomized clinical trials on symptomatic outcome domains. J Clin Psychopharmacol. 2011;31(4):489–96. https://doi.org/10.1097/JCP.0b013e3182217a69.

    Article  CAS  PubMed  Google Scholar 

  29. Crawford MJ, Sanatinia R, Barrett B, et al. The clinical effectiveness and cost-effectiveness of lamotrigine in borderline personality disorder: a randomized placebo-controlled trial. Am J Psychiatry. 2018;175(8):756–64. https://doi.org/10.1176/appi.ajp.2018.17091006.

    Article  PubMed  Google Scholar 

  30. Gunderson JG, Links PS. Handbook of good psychiatric management for borderline personality disorder. 1st ed. Washington DC: American Psychiatric Publishing; 2014.

    Google Scholar 

  31. Paris J. Why patients with severe personality disorders are overmedicated. J Clin Psychiatry. 2015;76(4): e521. https://doi.org/10.4088/JCP.14com09441.

    Article  PubMed  Google Scholar 

  32. Fineberg SK, Gupta S, Leavitt J. Collaborative deprescribing in borderline personality disorder: a narrative review. Harv Rev Psychiatry. 2019;27(2):75–86. https://doi.org/10.1097/HRP.0000000000000200.

    Article  PubMed  Google Scholar 

  33. Linehan M. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press; 1993.

    Google Scholar 

  34. Burckell L, McMain S. Dialectical behavior therapy adapted to the treatment of concurrent borderline personality disorder and substance use disorders. Clinical Addiction Psychiatry. 2010:207–217.

  35. Nguyen T, Seiler N, Brown E, et al. The effect of Clinical Practice Guidelines on prescribing practice in mental health: a systematic review. Psychiatry Res. 2020;284: 112671. https://doi.org/10.1016/j.psychres.2019.112671.

    Article  PubMed  Google Scholar 

  36. Kurko T, Saastamoinen LK, Tuulio-Henriksson A, et al. Trends in the long-term use of benzodiazepine anxiolytics and hypnotics: a national register study for 2006 to 2014. Pharmacoepidemiol Drug Saf. 2018;27(6):674–82. https://doi.org/10.1002/pds.4551.

    Article  CAS  PubMed  Google Scholar 

  37. Kochi K, Sato I, Nishiyama C, Tanaka-Mizuno S, Doi Y, Arai M, et al. Trends in antipsychotic prescriptions for Japanese outpatients during 2006–2012: a descriptive epidemiological study. Pharmacoepidemiol Drug Saf. 2017;26(6):642–56. https://doi.org/10.1002/pds.4187.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

This study was supported by Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM). The authors thank Bradley Londres for professional English language editing.

Author information

Authors and Affiliations

  1. Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Av. Sant Antoni Mª Claret 167, 08025, Barcelona, Spain

    Juan C. Pascual, Ana Martín-Blanco & Joaquim Soler

  2. Universitat Autònoma de Barcelona (UAB), Barcelona, Spain

    Juan C. Pascual, Ana Martín-Blanco & Joaquim Soler

  3. Institut d’Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Barcelona, Spain

    Juan C. Pascual, Ana Martín-Blanco & Joaquim Soler

  4. Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain

    Juan C. Pascual, Ana Martín-Blanco & Joaquim Soler

Authors
  1. Juan C. Pascual
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ana Martín-Blanco
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Joaquim Soler
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ana Martín-Blanco.

Ethics declarations

Funding

The authors have no funding sources to disclose.

Conflict of interest

Juan C. Pascual, Ana Martín-Blanco, and Joaquim Soler declare they have no conflicts of interest.

Availability of Data and Material

Not applicable.

Code Availability

Not applicable.

Author Contributions

All three authors contributed equally to designing and conducting the study, analyzing the data, and writing this article. All authors approved the final version of the manuscript for submission and agree to be accountable for the work.

Ethics Approval

This study adhered to the principles outlined in the Declaration of Helsinki and was approved by the Clinical Research Ethics Committee at the Hospital de la Santa Creu I Sant Pau.

Consent to Participate

Written consent to participate in this study was not considered necessary as all data were collected retrospectively from routine admission data and were anonymized; however, the authors did check the patients’ medical records to ensure that there was no written objection to the use of this information.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Pascual, J.C., Martín-Blanco, A. & Soler, J. Twenty-Year Trends in the Psychopharmacological Treatment of Outpatients with Borderline Personality Disorder: A Cross-Sectional Naturalistic Study in Spain. CNS Drugs 35, 1023–1032 (2021). https://doi.org/10.1007/s40263-021-00852-7

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40263-021-00852-7

Search

Navigation