Current and emerging medications for borderline personality disorder: is pharmacotherapy alone enough?

ABSTRACT

Introduction: The treatment of borderline personality disorder (BPD) remains an open question for clinicians. There is scarce evidence available and the guidelines’ conclusions diverge. Together with these factors, the complexity of BPD generates uncertainty in day-to-day practice. This narrative review aims to provide an overview of advances in BPD treatment and posit a critical opinion based on clinical evidence and practice.

Areas covered: The authors review the clinical trials concerning the efficacy of the main classes of drugs in BPD: antidepressants, mood stabilizers, first-, second-, and third-generation antipsychotics, and other agents (opiate antagonists, clonidine, oxytocin, omega-3 fatty acids). They also include in this review studies on combinations of drugs and psychotherapies.

Expert opinion: An individualized, tailored pharmacotherapy for BPD that targets the prominent symptom clusters can improve relevant aspects of the clinical picture. However, no medication is indicated to treat the global psychopathology of BPD. Polypharmacy should be avoided or strictly limited. To date, pharmacotherapy alone does not suffice to manage the complexity of BPD. Combining medication with psychotherapy may improve specific BPD symptom dimensions. In particular, it may help those aspects that respond slowly or not at all to monotherapy.

KEYWORDS:

• Borderline personality disorder
• pharmacotherapy
• psychotherapy
• combined therapy
• antidepressants
• mood stabilizers
• antipsychotics

Article highlights

• Many psychotropic agents have been tested for the treatment of BPD symptom domains.

• In most cases, the studies are open-label trials or affected by severe limitations. There is little evidence of efficacy.

• Evidence supports the use of mood stabilizers, second-generation antipsychotics, and omega-3 fatty acids to treat BPD.

• Combining drugs with psychotherapy demonstrates better results than single therapies on several core symptoms of BPD.

• Data on the tolerability of psychotropic agents in BPD are scarce. Specific examinations of each drug’s adverse effects are needed.

This box summarizes key points contained in the article.

Acknowledgments

The Authors acknowledge Dr Marco Bosia for his editorial assistance.

Declaration of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

The authors were supported by the program ‘Dipartimento di eccellenza’ from the Ministry of Education, University and Research via the Department of Neuroscience of the University of Turin.