Association of pharmacological treatments and real-world outcomes in borderline personality disorder

Abstract

Objective: Most patients with borderline personality disorder (BPD) receive psychopharmacological treatment, but clinical guidelines on BPD lack consensus on the role of pharmacotherapy. We investigated the comparative effectiveness of pharmacological treatments for BPD. Methods: We identified patients with BPD with treatment contact during 2006–2018 using Swedish nationwide register databases. By leveraging within-individual design, in which each individual was used as their own control to eliminate selection bias, we assessed the comparative effectiveness of pharmacotherapies. For each medication, we calculated the hazard ratios (HRs) for the following outcomes: (1) psychiatric hospitalization and (2) hospitalization owing to any cause or death. Results: We identified 17,532 patients with BPD (2649 men; mean [SD] age = 29.8 [9.9]). Treatment with benzodiazepines (HR = 1.38, 95% CI = 1.32–1.43), antipsychotics (HR = 1.19, 95% CI = 1.14–124), and antidepressants (HR = 1.18, 95% CI = 1.13–1.23) associated with increased risk of psychiatric rehospitalization. Similarly, treatment with benzodiazepines (HR = 1.37, 95% CI = 1.33–1.42), antipsychotics (HR = 1.21, 95% CI = 1.17–1.26), and antidepressants (HR = 1.17, 95% CI = 1.14–1.21) was associated with a higher risk of all-cause hospitalization or death. Treatment with mood stabilizers did not have statistically significant associations with the outcomes. Treatment with ADHD medication was associated with decreased risk of psychiatric hospitalization (HR = 0.88, 95% CI = 0.83–0.94) and decreased risk of all-cause hospitalization or death (HR = 0.86, 95% CI = 0.82–0.91). Of the specific pharmacotherapies, clozapine (HR = 0.54, 95% CI = 0.32–0.91), lisdexamphetamine (HR = 0.79, 95% CI = 0.69–0.91), bupropion (HR = 0.84, 95% CI = 0.74–0.96), and methylphenidate (HR = 0.90, 95% CI = 0.84–0.96) associated with decreased risk of psychiatric rehospitalization. Conclusions: ADHD medications were associated with a reduced risk of psychiatric rehospitalization or hospitalization owing to any cause or death among individuals with BPD. No such associations were found for benzodiazepines, antidepressants, antipsychotics, or mood stabilizers.