Posted by Phillipa on January 27, 2010, at 20:14:07
Seems a new study reveals pyschotheraphy choice for borderline personality. Interestingly omega 3's were helpful. Phillipa
From Medscape Medical News
Drug Therapy Effective for Core Symptoms of Borderline Personality Disorder but Not Overall Severity
Deborah Brauser
January 27, 2009 Drug therapy may not be effective in treating the overall severity of borderline personality disorder (BPD), according to results from a systematic review and meta-analysis of 27 randomized trials published in the January issue of the British Journal of Psychiatry.However, evidence from the analysis shows that medications, especially mood stabilizers and second-generation psychotics, were successful in treating the core symptoms and associated psychopathological aspects of the disorder.
"Pharmacotherapy should therefore be targeted at specific symptoms," write Klaus Lieb, MD, chair of the Department of Psychiatry and Psychotherapy at the University Medical Centre in Mainz, Germany, and colleagues.
In an interview with Medscape Psychiatry, Dr. Lieb added that the development of disorder-specific psychotherapeutic approaches means that "BPD patients are no longer considered 'untreatable'."
"Rather surprising, or against common clinical practice, is our finding that antidepressant, especially [selective serotonin reuptake inhibitor (SSRI)] treatment for BPD is not supported by our up-to-date, high-level evidence. There might be indications for usage if an accordant comorbidity is present, but this question cannot be answered from our review," reported Dr. Lieb.
It is estimated that the lifetime prevalence of BPD is 5.9%. Clinical hallmarks include emotional dysregulation, impulsive aggression, and repeated self-injury, and it often co-occurs with mood, anxiety, substance use, and other personality disorders. In addition, suicidal behavior reportedly occurs in up to 84% of patients with BPD.
Current Data
According to the authors, in treatment settings "pharmacological interventions are increasingly commonly used to treat different facets of the pathology spectrum, such as affective instability, dissociative states, or cognitive-perceptual symptoms."
However, they point out that "many patients with [BPD] receive pharmacologic treatment, but there is uncertainty about the usefulness of such therapies."
For the study, Dr. Lieb and his team analyzed the effects of drug therapy on BPD. They conducted a Cochrane Collaboration review of studies performed up to 2008 and selected 27 randomized comparison trials of first-generation antipsychotics, second-generation antipsychotics, mood stabilizers, antidepressants, and omega-3 fatty acids in a total of 1714 patients with BPD.
The study authors note that the American Psychiatric Association (APA) Practice Guidelines are based on searches of literature published up to 1998, whereas their analysis included 16 additional trials published after that date.
"Our aim was to identify and systematically integrate all up-to-date evidence of randomized controlled trials [RCTs] in this area to allow for well-informed decision making when planning drug treatment for each patient," said Dr. Lieb.
The primary outcome measures were overall disorder severity and specific core symptoms, whereas associated psychiatric disease was a secondary measure.
No Effect of Antidepressants
Results showed beneficial effects of drug treatment for all major core symptom clusters of BPD as well as for associated psychopathological conditions. The most beneficial effects were found for the mood stabilizers topiramate, lamotrigine, and valproate semisodium and the second-generation antipsychotics aripiprazole and olanzapine.
"However, the robustness of [the] findings is low, since they are based mostly on single, small studies," report the study authors.
In addition, there was little evidence of efficacy found for antidepressant treatment. Only amitriptyline showed a significant reduction in depressive pathological conditions. No significant effect for any of the outcome measures was found for mianserin, the SSRIs fluoxetine and fluvoxamine, or the monoamine oxidase inhibitor sulfate.
For omega-3 fatty acids, significant reductions were found in suicidality and depressive symptoms.
The study authors note that no evidence of effectiveness was found for any of the drug treatments for BPD symptoms of avoidance of abandonment, long-term feelings of emptiness, identity disturbance, and dissociation. "This may ... reflect that these symptoms may not be treatable by pharmacotherapeutic interventions but rather by psychotherapy."
Limitations of the analysis included the strict exclusion criteria of the studies reviewed, such as patients who were extremely suicidal or had comorbid schizophrenia, bipolar disorder, or alcohol or drug dependence. "As comorbid Axis I disorders are highly prevalent in people with [BPD], especially mood disorders (96.9%) and substance use disorders (62.1%), their exclusion may render applicability difficult," write the study authors.
In addition, with the exception of 3 trials, study participants did not receive concomitant psychotherapy. "There is a need to investigate possible additive effects of pharmacotherapy to psychotherapy and vice versa in the future."
The study authors write that their conclusions have been drawn cautiously because of these imitations. "However, considering this evidence together with clinical experience, antidepressants such as SSRIs cannot further be recommended as first-choice treatment for affective dysregulation and impulsive-behavioral symptoms, nor can low-dose antipsychotics be advised for cognitive-perceptual symptoms as earlier recommended by the [APA] Practice Guidelines."
Dr. Lieb said that he would like to see further studies on long-term treatment effects. "The average duration of RCTs included in our review was 12 weeks, which does not reflect the reality of clinical settings with patients taking medication over years." In addition, he reported that a parallel review of psychotherapies for BPD is "currently under way."
This study was supported by grants from the German Federal Ministry of Education and Research, the research committee of the University Medical Centre in Freiburg, and the German Research Foundation. The study authors have disclosed no relevant financial relationships.
Br J Psychiatry. 2010;196:4-12.
poster:Phillipa
thread:935176
URL: http://www.dr-bob.org/babble/20100122/msgs/935176.html