REVIEW OF: Soler J et al, Acta Psychiatr Scand 2022;145:332–342

STUDY TYPE: Retrospective cohort study

Polypharmacy is common in borderline personality disorder (BPD), despite the underwhelming evidence for this practice. Psychotherapy is first line for this disorder, and there is compelling support for dialectical behavior therapy (DBT), transference-focused therapy, and mentalization-based therapy. This study examines skills training, one component of DBT treatment, and tests whether it can reduce the use of psychotropics in BPD.

The authors examined the charts of 377 patients admitted to a specialized clinical service at a large academic medical center in Barcelona, Spain. All patients on this service had their diagnosis of BPD confirmed using instruments such as the Structured Clinical Interview for DSM and were provided with psychoeducation and medication management. In addition, patients could elect to participate in the DBT skills training (DBT-ST) group. Out of the entire sample, 182 participated, while 195 did not. Both groups were predominantly female, in their late 20s to early 30s, and had multiple psychiatric comorbidities. Symptom severity was higher among DBT-ST participants, and more of these patients were on three or more medications or were prescribed benzodiazepines. The number of medications (2.14–2.66) was not significantly different between groups. 

During the course of treatment, patients who completed DBT-ST decreased the average number of medications they were taking from 2.66 to 1.95, while those in the control group did not see a decrease. Most significantly, the DBT-ST participants had a reduction in benzodiazepine usage, with the percentage of patients using these medications decreasing from 54% to 27%. Antipsychotic and mood stabilizer use were also lower after the intervention among the DBT-ST participants. Antidepressant usage did not change in either group, and functional outcomes (including symptom severity) were not measured.

There are various limitations inherent in any retrospective, uncontrolled study such as this one. Most importantly, patients were not randomly assigned to skills training, but participated based on preference. The decision to start DBT-ST might have reflected a greater motivation to change treatments and a preference for psychotherapy over pharmacotherapy—which could explain the decrease in medication use. 

CARLAT TAKE

Design limitations of this study aside, we are encouraged that an educational therapy—one with a focus on emotion regulation and easy deliverability in a group format—might help patients reduce psychiatric polypharmacy and benzodiazepine use.