Magazine article Clinical Psychiatry News

Dueling Borderline Guidelines Spark Debate in U.K

Magazine article Clinical Psychiatry News

Dueling Borderline Guidelines Spark Debate in U.K

Article excerpt

EDINBURGH -- British psychiatrists are scratching their heads over two fresh sets of sharply conflicting guidelines on the use of medications in borderline personality disorder.

On the one hand, the National Institute for Health and Clinical Excellence (NICE), which advises the National Health Service, reviewed 28 randomized controlled trials and found them sorely lacking and unconvincing. The NICE guidelines reached this unequivocal conclusion: "Do not use drug treatment specifically for borderline personality disorder or for the individual symptoms or behaviour associated with it" (BMJ 2009; 338: b93).

Yet a Cochrane systematic review of the evidence base conducted at roughly the same time resulted in a raft of recommendations for a variety of drugs targeting the specific core symptom domains of borderline personality disorder [BPD] (Br. J. Psychiatry 2010; 196: 4-12).

"We've got two well-respected bodies reviewing virtually exactly the same evidence, employing very similar methodologies, and drawing quite markedly different conclusions," Dr. Jeremy Hall said at the meeting.

So, what's going on here? "I think it's really a question of whether you see the glass as being half empty or half full," said Dr. Hall of the University of Edinburgh.

NICE concluded that there is insufficient evidence to robustly recommend any medication for BPD. The Cochrane review concluded that there are small studies showing encouraging evidence of efficacy against some symptom domains, although not for the disorder as a whole, he explained.

The dueling guidelines have sparked much debate among U.K. psychiatrists. Regardless of which camp one falls into, however, there can be no doubt that the literature on medications for BPD is seriously deficient.

The randomized trials are small, nearly all fewer than 50 patients. They're of short duration, with a mean length of only 12 weeks, even though borderline personality disorder is often a chronic condition. There are no standardized outcome measures, making comparisons across studies particularly challenging. Moreover, many of the trials excluded patients with comorbidities.

"Really, what we need as clinicians are results that are generalizable to the population that we see--and the population we see largely has comorbid conditions," Dr. …

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