Prescribing medications for people with a personality disorder A service evaluation of a community mental health team Dr Umama Khan, Consultant Psychiatrist Dr Venkatesh Ballagere, Specialist Registrar
Prevalence Prevalence studies suggest that 10-13% of the adult population suffers with personality disorder (National Institute for Mental Health in England, 2003) and this is endorsed by Coid (2003). In primary care, the prevalence of BPD ranges from 4 to 6% (Moran et al., 2000; Gross et al., 2002). In spite of this, BPD appears to be underrecognised by GPs (Moran et al., 2001) Borderline personality disorder is the most prevalent personality disorder in non-forensic mental healthcare settings. In mental healthcare settings, the prevalence of all personality disorder subtypes is high, with many studies reporting a figure in excess of 50%
Current evidence NICE guideline on treatment and management for borderline personality disorder found no evidence for routine use of psychotropic medications Cochrane review came to similar conclusions American Psychiatric Associations (APA guidelines) suggest medications are primarily adjunctive to psychotherapy.
Acute community mental health Team HONOS Cluster 4-8 High prevalence of personality disorder Large Team comprising of nurses, psychologists, counsellors, occupational therapist and support workers.
Method and design Retrospective study of psychotropic medication use in people with personality disorder in the past year. Care Coordinators had sent list of cluster 8 patients 45 case notes were randomly selected. Proforma was adopted from Prescribing Observatory For Mental health UK
Proforma Diagnosis. Subtypes of personality disorders. Co-morbidity. Medications prescribed in the past year including antipsychotics, mood stabilizers, sedatives, antidepressant, the rationale for such prescriptions. Duration of prescribing. Last medical review, whether the target symptoms were addressed during the review.
Results Sub-Types of personality disorder: Emotionally unstable personality disorder, Borderline type Paranoid Personality disorder (2%) Co morbidity: 35% substance misuse disorder 32% affective disorder 21% anxiety disorders 9% eating disorders
Results- Admission to psychiatric ward 14 cases(33%) 9 had co morbidities:1 Bipolar, 1 Anorexia, 1 A.S.D, 4 Substance misuse & drug induced psychotic episode, 2 P.T.S.D Medications vs Therapy: 4 no meds Group, Individual, Family therapy, DBT. 5 meds- No therapy. 3 were on both medications and therapy
Psychological therapies 13 were receiving some form of psychological therapy (31%) 7 were receiving DBT 5 were receiving individual Psychotherapy (psychodynamic). 4 receiving group therapy.
Medications- Antipsychotics 56% were prescribed antipsychotics. Majority were on Quetiapine, dose ranging from 50mgs-550mgs/day, only one patient was on a dose >400mgs. Other antipsychotics prescribed: Aripiprazole, Trifluoperazine, Chlorpromazine, Olanzapine, Flupenthixol and depot injection (one patient)
Medications- Antipsychotics Indications documented: Affective instability in 25% cases Transient psychotic experiences in 16% Anxiety (phobic and panic) in 14%. Distress in 14%. Other reasons were disturbed sleep, aggression/ hostility, PTSD or stress related symptoms. Prescribed more than 4 weeks in all, from 1 month to 3.5 years All were reviewed by a Doctor within the last year. Target symptoms were addressed in only 9 cases (41%)
Medications- Sedatives Benzodiazepines/z-hypnotic/sedative antihistamines: Prescribed in 17 cases (38%) Reason for prescription: Disturbed sleep- 50% Anxiety- 21% Emotional distress- 14% None documented- 14% Prescribed for longer than 4 weeks: in all cases, for 6 months or longer. Target symptoms and side effects were addressed in only 33%.
Medications- Mood stabilisers 20%(9) were on a mood stabilizer Lithium, Sodium Valproate, Carbamazepine or Lamotrigine Indication: Affective, emotional instability- 5 Mood symptoms- 2 Aggression/hostility- 1 Distress- 1 Client's request- 1 All were prescribed for more than 4 weeks, ranging from a few months to 3 years. The target symptoms were addressed in 3 cases (38%)
Other Psychotropic medications 2 were on methadone. Antidepressants- 32 (71%) Non psychotropics 3 on opiates 1 on non opiate analgesic 2 on inhalers for asthma
Recommendations Avoid routine prescribing Explain to patients and carers the reasons for not prescribing Co morbidities should be treated as usual Reasons for medication use should clearly documented Regular medication reviews Not to change medication when patient is in crisis. Benzodiazepines and Z drugs should not be prescribed unless absolutely necessary, and only for the shortest possible period Aim for reducing and stopping any routine prescriptions- of antipsychotics, mood stabilisers and sedatives
Current evidence No psychotropic drug is licensed in the UK for the treatment of borderline personality disorder, although some are licensed for the management of individual symptoms or symptom clusters. Quetiapine: A few open label studies proved efficacy in reducing impulsivity and affective symptoms No previous RCTs. One RCT currently ongoing, (double blind, placebo controlled, 8 weeks trial, Q XR vs placebo, 200-300mgs)
Limitations of guidelines: Dilemma! Guidelines are not a substitute for professional knowledge and clinical judgement. There will always be some service users for whom clinical guideline recommendations are not appropriate There is lack of high-quality research evidence, quality of the methodology, generalisability of research findings and the uniqueness of individuals with borderline personality disorder. The guidelines do not override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual, in consultation with the person with borderline personality disorder or their family/carer.
References http://guidance.nice.org.uk/cg78/guidance/pdf/english http://www.ncbi.nlm.nih.gov/pubmed/20556762 http://psychiatryonline.org/pdfaccess.ashx?resourceid=243177&pdfsource=6 http://www.ncbi.nlm.nih.gov/pubmed/16889446 http://informahealthcare.com/doi/abs/10.1080/13651500510029048?journalcode=jpc http://clinicaltrials.gov/show/nct00880919 http://clinicaltrials.gov/show/nct00880919
Acknowledgement Tracey Green, Mental health pharmacist Cathy Watkins, Medical secretary Care Coordinators from the team Lisa House, Quality advisor and data analyst.