Adaptation of Interpersonal Psychotherapy to Borderline Personality Disorder: A Comparison of Combined Therapy and Single Pharmacotherapy

Article excerpt

Objective: Combined treatment with interpersonal psychotherapy (IPT) and antidepressants (ADs) has been found more effective than single pharmacotherapy in patients with major depression and concomitant borderline personality disorder (BPD). The aim of our study is to investigate whether combined treatment with a modified version of IPT is still superior to ADs when treating patients with a single diagnosis of BPD.

Method: Fifty-five consecutive outpatients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, diagnosis of BPD were enrolled. They were randomly assigned to 2 treatment arms for 32 weeks: fluoxetine 20 to 40 mg per day plus clinical management; and fluoxetine 20 to 40 mg per day plus IPT adapted to BPD (IPT-BPD). Eleven patients (20%) discontinued treatment owing to noncompliance. Forty-four patients completed the treatment period. They were assessed at baseline, and at week 16 and 32 with: a semi-structured interview for demographic and clinical variables; Clinical Global Impression Scale (CGI-S); Hamilton Depression Rating Scale (HDRS); Hamilton Anxiety Rating Scale (HARS); Social and Occupational Functioning Assessment Scale (SOFAS); BPD Severity Index (BPD-SI); and a questionnaire for quality of life (Satisfaction Profile [SAT-P]). A univariate general linear model was performed with 2 factors: duration and type of treatment. P values of less than 0.05 were considered significant.

Results: Remission rates did not differ significantly between subgroups. Duration, but not type of treatment, had a significant effect on CGI-S, HDRS, SOFAS, and total BPD-SI score changes. Combined therapy was more effective on the HARS; the items: interpersonal relationships, affective instability, and impulsivity of BPD-SI; and the factors: psychological functioning and social functioning of SAT-P.

Conclusions: Combined therapy with adapted IPT was superior to fluoxetine alone in BPD patients, concerning a few core symptoms of the disorder, anxiety, and quality of life.

Can J Psychiatry. 2010;55(2):74-81.

Clinical Implications

* IPT adapted to BPD can be an efficacious model of intervention that responds to the growing demand for manualized and time-limited treatment of BPD patients.

* Pharmacotherapy (selective serotonin reuptake inhibitors) and combined treatment with IPT-BPD are both efficacious in treating BPD patients without Axis I comorbidity.

* Combined treatment with IPT-BPD is more efficacious than single pharmacotherapy on a few core symptoms of BPD, anxiety symptoms, and subjective quality of life.

Limitations

* Owing to the exclusion of patients with Axis I comorbidity, clinical characteristics of our BPD patients can be different from clinical practice.

* Assessment scales did not include an assessment instrument designed to investigate the specific mechanisms of action of IPT on BPD psychopathology.

* This initial trial of IPT-BPD did not include intention-to-treat analyses.

Key Words: borderline personality disorder, interpersonal psychotherapy, combined therapy, fluoxetine

Abbreviations used in this article

AD antidepressant

APA American Psychiatric Association

BPD borderline personality disorder

BPD-SI BPD Severity Index

CGI-S Clinical Global Impression Severity

DSM Diagnostic and Statistical Manual of Mental Disorders

GLM general linear model

HARS Hamilton Anxiety Rating Scale

HDRS Hamilton Depression Rating Scale

IPT Interpersonal psychotherapy

SAT-P Satisfaction Profile

SOFAS Social and Occupational Functioning Assessment Scale

BPD is a prevalent and serious mental disorder characterized by a pervasive pattern of instability in interpersonal relationships, affect regulation, and self-image, as well as marked impulsivity.1 It is associated with impaired social and occupational functioning and high rates of medical and psychiatric services use. …