Controversy continues on response to treatment

Rawalpindi : The controversy continues on the use of mood stabilizers and response to treatment for people with a Borderline Personality Disorder (BPD) as there is much uncertainty about the evidence base for the use of psychotropic medication for people diagnosed with BPD.

Psychological treatments such as Dialectical Behaviour Therapy and Cognitive Analytical Therapy are backed by well-established evidence, and are the principal mode of treatment for this disorder. In clinical practice, however, medication is widely prescribed on an ad hoc basis for the symptoms of BPD with limited evidential support.

This was expressed by a leading mental health professional from UK Dr. David Mumford in a meeting of the interest group launched along with a series of Interest Groups for mental health professionals by Center for Global Mental Health Pakistan in the first week of August this year. The aim of launching of these interest groups was to bring interested professionals onto a common platform to discuss and learn about matters related to pertinent issues in the field.

Dr. Mumford said for many years, there has been optimism among some clinicians that mood stabilizers would prove to be effective in reducing the mood instability, impulsivity and self-harming behaviour associated with BPD. Two small-scale randomized controlled trials using lamotrigine have showed promising results. This evidence has been cited in the handbook of the British Association for Psychopharmacology, but has not been sufficient to alter NICE guidelines which do not support the use of any medication (except short-term sedation) for the specific symptoms of BPD, he said.

Data presented from an audit of his own clinical practice (N=23) showed a statistically significant benefit of lamotrigine over quetiapine in treating mood instability.

He said a recent large multicentre double-blind randomized controlled trial in the UK (the LABILE study) has shown no benefit from lamotrigine compared with placebo, added to usual treatment for BPD. The subjects in this trial were 276 patients being treated in secondary mental health care from six centres in the UK, he said.

This leaves the treatment of BPD with mood stabilizers in continuing uncertainty. As the LABILE study admits, ‘It is possible that lamotrigine treatment reduces the symptoms of BPD among people who have less complex mental health problems, higher level of social functioning and lower levels of substance misuse than those we recruited to the LABILE trial’, he explained.

Meanwhile clinicians have to do their best for their patients, while abiding by the Hippocratic principle ‘First do no harm’, he said. Every BPD patient is different, so each use of medication is a clinical experiment. The clinician should monitor closely both benefits and side-effects and titrate the dose appropriately. If no benefit is evident after a reasonable length of trial, the medication must be discontinued, said Dr. David.

Director CGMH Pakistan Professor Fareed Minhas thanked Dr. Mumford for his talk in the meeting and shared the initial plans for a comprehensive handbook on Borderline Personality Disorder. This would be a multi author book, with a blend of young and experienced, mental health professional within the interest group, he said. He added the book would be edited jointly by Professor Mowadat Rana, Dr Sadia Muzaffar and Dr. Ayesha Minhas while Dr. David Mumford will co-author the chapter on the use of medication, particularly mood stabilizers, highlighting the present uncertain state of knowledge.