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IN THIS ISSUE:
May 2010

Citalopram and Escitalopram Overdoses
Overdoses with both citalopram (Celexa and others) and escitalopram (Lexapro) can cause serious toxicity.

Borderline Personality Disorder: A Role for Medication?
Antipsychotics, including aripiprazole (Abilify) and olanzapine (Zyprexa), as well as mood stabilizers, such as topiramate (Topamax) and lamotrigine (Lamictal), alleviate some symptoms of borderline personality disorder, but the effects of antidepressants on this condition are variable.

Morphine to Prevent PTSD
Early treatment with morphine following an injury may reduce the risk of posttraumatic stress disorder (PTSD).

Risperidone-Induced Hyperprolactinemia Lowers BMD in Boys
Both risperidone (Risperdal and others), through its effects on prolactin concentrations, and selective serotonin reuptake inhibitors (SSRIs) can lower bone mineral density in boys.

Priapism with Antipsychotics
Antipsychotic medications with a high affinity for the α1-adrenal receptor, such as chlorpromazine (Thorazine), quetiapine (Seroquel), and ziprasidone (Geodon), may be more likely to cause priapism than those with a low affinity.

In Brief
Spouses of People with Dementia Have Higher Risk of Depression; Modafinil (Provigil) Effective for Treating Fatigue in HIV+ Patients

Borderline Personality Disorder: A Role for Medication?

May 2010

Borderline personality disorder (BPD) is usually treated with psychotherapy, and studies of medications for this condition—including anticonvulsants, antidepressants, and antipsychotics—have been limited (BTP 2009;32:13). The drug most studied for BPD is olanzapine (Zyprexa). Last November, we described a small trial1 that found lamotrigine (Lamictal) to be significantly superior to placebo in improving affective instability and impulsivity among patients with BPD (BTP 2009;32:46) Recently, Lieb and coauthors conducted a Cochrane systematic review of randomized controlled trials of pharmacotherapy for BPD, which was an update of a similar review conducted in 2001.2 Since the earlier review, newer antipsychotics and mood stabilizers have become the primary foci of research on this disorder, as first-generation antipsychotics have receded in importance. The authors reviewed 27 trials, which comprised first- and second-generation antipsychotics, mood stabilizers, antidepressants, and omega-3 fatty acids as the medications.

Symptoms involving the interpersonal pathology pattern typical of BPD were significantly affected by aripiprazole (Abilify), valproate (Depakote and others), and topiramate (Topamax). Medications most effective in alleviating affective dysregulation were haloperidol (Haldol and others), aripiprazole, olanzapine, and three mood stabilizers—topiramate, lamotrigine, and valproate. Impulsive-behavioral dyscontrol symptoms were improved by the first-generation antipsychotic flupentixol decanoate,* aripiprazole, topiramate, lamotrigine, and omega-3 fatty acids. Olanzapine's effects on self-injurious and suicidal behaviors were inconsistent.

The effects of antidepressants on the behaviors and symptoms of BPD are variable. The antidepressant amitriptyline (Elavil and others) significantly alleviates only the depressive pathology of BPD. There is no evidence of benefit against any BPD symptoms from selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), or the tetracyclic mianserin.*

Few systematic trials assessed differential efficacy between any two medication treatments. One exception was a study comparing phenelzine (Nardil) with haloperidol. Phenelzine was significantly superior to haloperidol in reducing affective and general psychiatric pathology and in ameliorating the overall level of functioning of BPD patients.

Several BPD symptoms were unaffected by any of the medications studied: abandonment fears, chronic feelings of emptiness, identity disturbance, and dissociation.

BPD is common and highly disabling. It is very distressing to the patients who suffer from it and usually to their loved ones. Treatments are imperfect. The mainstay for most patients will be a psychotherapeutic approach, such as dialectical behavioral therapy, augmented as needed by the selective use of medication.

*Not available in the United States.

1Reich DB, Zanarini MC, Bieri KA: A preliminary study of lamotrigine in the treatment of affective instability in borderline personality disorder. Int Clin Psychopharmacol 2009;24:270-275.

2Lieb K, Völlm B, Rücker G, Timmer A, Stoffers JM: Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials. Br J Psychiatry 2010;196:4-12.