Behavioral Therapy Can Help Reduce Polypharmacy in Borderline Personality Disorder, Study Finds

New study findings indicate that a dialectical-behavioral therapy skills training (DBT-ST) module can benefit patients with borderline personality disorder (BPD) when it comes to the reduction of medication load, specifically sedatives.

BPD is a severe but common disorder and accounts for approximately 20% of psychiatric inpatient populations, researchers explained. The condition is associated with psychosocial and occupational dysfunctions and substantial economic burden. Although there are no drugs specifically approved for BPD, most patients only receive pharmacological treatment as access to psychological therapies is limited.

In addition, “the optimal therapeutic drug for BPD-specific symptoms is controversial, in part due to the scant research on pharmacological management in patients with BPD but also to the lack of consensus pharmacological recommendations in clinical guidelines for BPD,” authors wrote.

Medication use in BPD also carries risks for these patients including addiction potential, serious adverse effects, and a high risk for self-injury. Meanwhile, DBT serves as one of the most effective psychotherapeutic treatments for BDP as it helps patients develop cognitive-behavioral principles to replace maladaptive behaviors with healthier coping skills, authors wrote.

DBT-ST encompasses 4 modules focused on mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation, researchers said. Offering the therapy to patients does not rule out the use of accompanying medications. Importantly, one of the aims of DBT-ST is to taper medication use while increasing the use and proficiency of the module’s trained skills.

In an effort to determine whether use of DBT-ST actually does reduce the use of medications and/or polypharmacy in those with BPD, investigators retrospectively collected and assessed data from 377 patients receiving outpatient care at a single center in Spain between 2010 and 2020.

All individuals included in the study had confirmed diagnoses of BPD, were between ages 18 and 55 years, and had no other neurological diseases or intellectual abilities that could affect psychotherapeutic intervention.

Participants were divided into 2 cohorts: those who elected to undergo DBT-ST (n = 182) and those who did not participate in the intervention (n = 195). “All patients received periodic psychiatric evaluation and follow-up visits, including supervision of pharmacological treatment to prevent excessive use of medications,” authors wrote.

Upon program admission:

• 84.4% of patients were taking at least 1 medication.
• The mean number of medications was 2.4 (range, 0-8), and nearly half of the patients were receiving polypharmacy (≥3 medications).
• 71.9% of the sample were on antidepressants (mostly selective serotonin reuptake inhibitors), 47% on benzodiazepines, 40% on mood stabilizers, and 35% on antipsychotics (mostly second-general antipsychotics).

Patients in the DBT-ST group also had greater clinical severity of BPD at the beginning of the study and were taking more medications on average compared with controls.

Analyses revealed:

• Patients in the DBT-ST cohort experienced a significant decrease in the number of medications prescribed (F [1375] = 69.74; P < .001] and in the medication and sedation load indices (F [1375] = 86.77; P < .001; and F [1375] = 127.56; P < .001, respectively) over the course of the psychotherapeutic intervention compared with controls.
• Participants in the DBT-ST group significantly reduced their use of benzodiazepines (from 54.4% to 27.5%), mood stabilizers (from 43.4% to 33%), and antipsychotics (from 36.3% to 29.1%).
• In the control group, no decrease in medication use was observed in any drug class; for some medications, small increases were observed.
• In both groups, antidepressant prescriptions were either unchanged or increased slightly, perhaps due to the prescribing clinicians’ confidence in the effectiveness of antidepressants.

The rates of patients with BPD taking at least 1 medication and experiencing polypharmacy were similar to those seen in previous studies.

“This prescription practice in the public mental health system in Spain is consistent with clinical practice in other western countries and higher than recommended in some clinical guidelines (eg, United Kingdom and Australian guidelines), which do not recommend prescribing pharmacological agents to treat BPD symptoms, but only to treat comorbid disorders or for short term use during periods of crisis,” researchers explained.

Previous research has also shown DBT-ST can help mediate reductions in suicide, depression, and anger. However, because DBT-ST is a resource-intensive treatment that requires specific clinical training, staffing, and time, it is not always available in public health systems, despite its promising potential, researchers wrote.

The retrospective, nonrandom nature of the study makes it susceptible to potential selection bias; a prospective, double-blind randomized clinical trial is warranted to confirm the current findings.

Researchers also cautioned that the observed decrease in medication “does not necessarily imply better functional outcomes.”

Overall, “findings support the value of a coordinated and synergistic approach between psychopharmacologic and psychotherapeutic interventions in BPD,” they concluded.

“Providing patients with tools to effectively manage distress could reduce the need for these patients to resort to the use of pharmaceuticals as their main approach to reducing distress,” they said.

Reference

Soler J, Casellas-Pujol E, Fernández-Felipe I, Martín-Blanco A, Almenta D, Pascual JC. “Skills for pills”: the dialectical-behavioral therapy skills training module reduces polypharmacy in borderline personality disorder. Acta Psychiatr Scand. Published online January 27, 2022. doi:10.1111/acps.13403