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Cited by 302Personality Disorders and PsychopathologyBipolar Disorder and TreatmentSchizophrenia research and treatment

Pharmacological interventions for borderline personality disorder

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Stoffers, Jutta, Völlm, Birgit A, Rücker, Gerta, Timmer, Antje, Huband, Nick, Lieb, Klaus·2010·Cochrane Database of Systematic Reviews
DOI 10.1002/14651858.cd005653.pub2PMC PMC4169794
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Abstract

BACKGROUND: Drugs are widely used in borderline personality disorder (BPD) treatment, chosen because of properties known from other psychiatric disorders ("off-label use"), mostly targeting affective or impulsive symptom clusters. OBJECTIVES: To assess the effects of drug treatment in BPD patients. SEARCH STRATEGY: We searched bibliographic databases according to the Cochrane Developmental, Psychosocial and Learning Problems Group strategy up to September 2009, reference lists of articles, and contacted researchers in the field. SELECTION CRITERIA: Randomised studies comparing drug versus placebo, or drug versus drug(s) in BPD patients. Outcomes included total BPD severity, distinct BPD symptom facets according to DSM-IV criteria, associated psychopathology not specific to BPD, attrition and adverse effects. DATA COLLECTION AND ANALYSIS: Two authors selected trials, assessed quality and extracted data, independently. MAIN RESULTS: Twenty-eight trials involving a total of 1742 trial participants were included. First-generation antipsychotics (flupenthixol decanoate, haloperidol, thiothixene); second-generation antipsychotics (aripirazole, olanzapine, ziprasidone), mood stabilisers (carbamazepine, valproate semisodium, lamotrigine, topiramate), antidepressants (amitriptyline, fluoxetine, fluvoxamine, phenelzine sulfate, mianserin), and dietary supplementation (omega-3 fatty acid) were tested. First-generation antipsychotics were subject to older trials, whereas recent studies focussed on second-generation antipsychotics and mood stabilisers. Data were sparse for individual comparisons, indicating marginal effects for first-generation antipsychotics and antidepressants.The findings were suggestive in supporting the use of second-generation antipsychotics, mood stabilisers, and omega-3 fatty acids, but require replication, since most effect estimates were based on single studies. The long-term use of these drugs has not been assessed.Adverse event data were scarce, except for olanzapine. There was a possible increase in self-harming behaviour, significant weight gain, sedation and changes in haemogram parameters with olanzapine. A significant decrease in body weight was observed with topiramate treatment. All drugs were well tolerated in terms of attrition.Direct drug comparisons comprised two first-generation antipsychotics (loxapine versus chlorpromazine), first-generation antipsychotic against antidepressant (haloperidol versus amitriptyline; haloperidol versus phenelzine sulfate), and second-generation antipsychotic against antidepressant (olanzapine versus fluoxetine). Data indicated better outcomes for phenelzine sulfate but no significant differences in the other comparisons, except olanzapine which showed more weight gain and sedation than fluoxetine. The only trial testing single versus combined drug treatment (olanzapine versus olanzapine plus fluoxetine; fluoxetine versus fluoxetine plus olanzapine) yielded no significant differences in outcomes. AUTHORS' CONCLUSIONS: The available evidence indicates some beneficial effects with second-generation antipsychotics, mood stabilisers, and dietary supplementation by omega-3 fatty acids. However, these are mostly based on single study effect estimates. Antidepressants are not widely supported for BPD treatment, but may be helpful in the presence of comorbid conditions. Total BPD severity was not significantly influenced by any drug. No promising results are available for the core BPD symptoms of chronic feelings of emptiness, identity disturbance and abandonment. Conclusions have to be drawn carefully in the light of several limitations of the RCT evidence that constrain applicability to everyday clinical settings (among others, patients' characteristics and duration of interventions and observation periods).

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  • During the publication years 1991 to 2011, the understanding of the relative efficacy of medications in BPD changed; SSRIs once regarded as first-line lack corresponding evidence, whereas mood stabilisers and second-generation antipsychotics are supported by some evidence.

    “During the time-span that the included trials cover (that is, publication years range from 1991 to 2011), the understanding of the relative efficacy of medications in BPD has changed.For example, SSRIs that were once regarded the first-line treatment for BPD (compare APA guidelines: APA 2001; Rush 2005) for the treatment of various symptom clusters lack corresponding evidence, whereas mood stabil”

    From Psychological therapies for people with borderline personality disorder. (2012) · cites this paper as Stoffers 2010

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  • There were favourable results for psychotherapy plus placebo over psychotherapy plus drug, especially with regard to self-harming and dissociative behaviour.

    “In contrast, there were indeed favourable results for psychotherapy plus placebo over psychotherapy plus drug, especially with regard to self-harming and dissociative behaviour.”

    From Psychological therapies for people with borderline personality disorder. (2012) · cites this paper as Stoffers 2010

    The Results (Concomitant psychotherapeutic treatment; page unavailable) identify trials in which both groups received dialectical behavioural therapy. The Results (Effects of interventions; page unavailable) report outcomes favouring placebo over olanzapine for self-mutilating behaviour and over fluoxetine for dissociation, but both estimates were non-significant. The sentence presents these limited, uncertain findings as a general favourable result for psychotherapy plus placebo over psychotherapy plus drug. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • The findings of the pharmacotherapy review were not conclusive in terms of a clear superiority of combined treatments.

    “The findings were not conclusive in terms of a clear superiority of combined treatments.”

    From Psychological therapies for people with borderline personality disorder. (2012) · cites this paper as Stoffers 2010

  • The pharmacotherapy review (Stoffers 2010) included three trials testing psychotherapy plus drug against psychotherapy plus placebo.

    “the pharmacotherapy review (Stoffers 2010) included three trials testing psychotherapy plus drug against psychotherapy plus placebo (Simpson 2004;Soler 2005;Linehan 2008).”

    From Psychological therapies for people with borderline personality disorder. (2012) · cites this paper as Stoffers 2010

  • There is some evidence for positive effects of medication in the domains of mood stabilization and impulsivity.

    “there is some evidence for positive effects of medication in the domains of mood stabilization and impulsivity [33]”

    From European guidelines for personality disorders: past, present and future (2019) · cites this paper as [33]

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Research works printed but not linked: 11

  1. * Linehan MM McDavid JD Brown MZ Sayrs JHR Gallop RJ Olanzapine plus dialectical behavior therapy for women with high irritability who meet criteria for borderline personality disorder: a double-blind, placebocontrolled pilot study published ahead of print: Journal of Clinical Psychiatry 6th 5 2008 e1 e7 pii: ej07m03158 18466045
  2. Montgomery SA Montgomery DB Janyanthi Rani S Roy DH Shaw PJ McAuley R Maintenance therapy in repeat suicidal behaviour: a placebo controlled trial. Proceedings of the 10th international congress for suicide prevention and crisis intervention Ottawa 1979 227 9
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  4. Schulz SC Zanarini M Detke H Trzaskoma Q Lin D DeBerdt W Olanzapine for the treatment of borderline personality disorder: a flexible-dose 12-week randomized double-blind placebo-controlled study International Journal of Neuropsychopharmacology 2006 9 Suppl.1 S191
  5. Schulz SC Zanarini MC Detke HC Trzaskoma Q Lin D DeBerdt W Olanzapine for the treatment of borderline personality disorder: A flexible-dose, 12-week, randomized, double-blind, placebo-controlled study Proceedings of the Association of European Psychiatrsts 15th European Congress of Psychiatry Madrid (Spain) 2007 March 17-21
  6. Pascual JC Soler J Barrachina J Campins J Puigdemont D Alvarez E Olanzapine plus dialectical behavior therapy of patients with BPD Proceedings of the 157th annual meeting of the American Psychiatric Association 2004 May 1-6
  7. Zanarini MC Schulz SC Detke HC Tanaka Y Zhao F Lin D A dose comparison of olanzapine for the treatment of borderline personality disorder: a 12-week randomized, double-blind, placebo-controlled study Proceedings of the Association of European Psychiatrists 15th European Congress of Psychiatry Madrid (Spain) 2007 March 17-21
  8. * Soloff PH George A Nathan RS Schulz PM Ulrich RF Perel JM Progress in pharmacotherapy of borderline disorders. A double-blind study of amitriptyline, haloperidol, and placebo Archives of General Psychiatry 1986 43 7 691 7 3521532
  9. American Psychiatric Association Diagnostic and statistical manual of mental disorders 1980 American Psychiatric Association Washington, DC 3rd Edition
  10. Higgins JPT Green S Cochrane Handbook for Systematic Review of Interventions Version 5.0.0 [updated February 2008] 2008 The Cochrane Collaboration Available from www.cochrane-handbook.org. The Cochrane Collaboration
  11. The Nordic Cochrane Centre The Cochrane Collaboration Review Manager (RevMan). 5.0 2008 The Nordic Cochrane Centre, The Cochrane Collaboration Copenhagen

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Authors
Stoffers, J., Völlm, B. A., Rücker, G., Timmer, A., Huband, N., & Lieb, K.
Affiliations
  • & Department of Psychiatry and Psychotherapy; Department of Psychiatry and Psychotherapy, Freiburg; Mainz Germany
  • Institute of Mental Health; Section of Forensic Mental Health; University of Nottingham, Duncan Macmillan House Porchester Road Nottingham UK NG3 6AA
  • University Medical Center Freiburg (DE)
  • Helmholtz Munich (DE)
  • University of Nottingham (GB)
  • University Medical Center of the Johannes Gutenberg University Mainz (DE)
ORCID
Venue
Cochrane Database of Systematic Reviews
Publisher
Wiley
Published
2010-06-16
Issue
6
Pages
CD005653-CD005653
ISSN
  • 1361-6137 (ISSN-L)
  • 1465-1858
DOI
10.1002/14651858.cd005653.pub2
PMC
PMC4169794
OpenAlex
W1929053668
Cited by
302
References
119
Citations by year
2026: 10 · 2025: 8 · 2024: 23 · 2023: 11 · 2022: 19 · 2021: 15 · 2020: 37 · 2019: 21 · 2018: 18 · 2017: 20 · 2016: 22 · 2015: 21 · 2014: 20 · 2013: 19 · 2012: 21
FWCI
2.47
Type
journal article
Language
en
Open access
Locations
  • Cochrane Database of Systematic Reviews (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • Site cant be reached (submittedVersion)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
  • Health Sciences › Medicine › Psychiatry and Mental health › Bipolar Disorder and Treatment
  • Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
Keywords
borderline personality disorder, pharmacotherapy, off-label drug use, atypical antipsychotics, typical antipsychotics, mood stabilizers, antidepressants, omega-3 fatty acids, olanzapine, topiramate, adverse drug reactions, self-harm, impulsivity, affective symptoms, treatment discontinuation, long-term drug effects
MeSH terms
Antidepressive Agents, Borderline Personality Disorder, Humans, Antipsychotic Agents, Fatty Acids, Omega-3, Randomized Controlled Trials as Topic

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