Effectiveness of pharmacotherapy for severe personality disorders: meta-analyses of randomized controlled trials.
BACKGROUND
There has been little systematic attempt to validate current pharmacologic treatment algorithms and guidelines for severe personality disorder.


OBJECTIVE
We evaluated studies on the effectiveness of psychoactive drugs on specific symptom domains for borderline and/or schizotypal personality disorder.


METHODS
The literature was searched for placebo-controlled randomized clinical trials (PC-RCTs) on the effectiveness of psychopharmacologic drugs in personality disorder patients. The PubMed, PsychINFO, PiCarta, Cochrane, and Web of Science databases were searched using the search terms borderline personality, schizotypal personality, personality disorder, cluster A, cluster B, treatment, drug, pharmacotherapy, antipsychotic, antidepressant, mood stabilizer, effect, outcome, review, and meta-analysis for studies published between 1980 and December 2007, and references were identified from bibliographies from articles and books.


METHODS
Placebo-controlled randomized clinical trials on the efficacy of antipsychotics, antidepressants, and mood stabilizers regarding cognitive-perceptual symptoms, impulsive-behavioral dyscontrol, and affective dysregulation (with subdomains depressed mood, anxiety, anger, and mood lability) were selected in patients with well defined borderline and/or schizotypal personality disorder. Studies whose primary emphasis was on the treatment of Axis I disorders were excluded. Meta-analyses were conducted using 21 retrieved studies.


RESULTS
Antipsychotics have a moderate effect on cognitive-perceptual symptoms (5 PC-RCTs; standardized mean difference [SMD]=0.56) and a moderate to large effect on anger (4 PC-RCTs; SMD=0.69). Antidepressants have no significant effect on impulsive-behavioral dyscontrol and depressed mood. They have a small but significant effect on anxiety (5 PC-RCTs; SMD=0.30) and anger (4 PC-RCTs; SMD=0.34). Mood stabilizers have a very large effect on impulsive-behavioral dyscontrol (6 PC-RCTs; SMD=1.51) and anger (7 PC-RCTs; SMD=1.33), a large effect on anxiety (3 PC-RCTs; SMD=0.80), but a moderate effect on depressed mood (5 PC-RCTs; SMD=0.55). Mood lability as an outcome measure was seldomly assessed. Mood stabilizers have a more pronounced effect on global functioning (3 PC-RCTs; SMD=0.79) than have antipsychotics (5 PC-RCTs; SMD=0.37). The effect of antidepressants on global functioning is negligible.


CONCLUSIONS
Drug therapy tailored to well-defined symptom domains can have a beneficial effect on patients with severe personality disorder. The findings from this study raise questions on current pharmacologic algorithms.
Treatment Center for Personality Disorders, Symfora Group, Centers for Mental Healthcare, Amersfoort, The Netherlands. tjm.ingenhoven@symfora.nl
Theo
T
Ingenhoven
Patricia
P
Lafay
Thomas
T
Rinne
Jan
J
Passchier
Hugo
H
Duivenvoorden
D000339:Affect / Q000187:drug effects; D000786:Anger / Q000187:drug effects*; D000928:Antidepressive Agents / Q000627:therapeutic use; D018692:Antimanic Agents / Q000627:therapeutic use; D014150:Antipsychotic Agents / Q000627:therapeutic use; D001007:Anxiety / Q000188:drug therapy; D003071:Cognition / Q000187:drug effects; D003863:Depression / Q000188:drug therapy; D006801:Humans; D007175:Impulsive Behavior / Q000188:drug therapy; D019964:Mood Disorders / Q000188:drug therapy; D010554:Personality Disorders / Q000188:drug therapy*; D016032:Randomized Controlled Trials as Topic
D000928:Antidepressive Agents; D018692:Antimanic Agents; D014150:Antipsychotic Agents