Antidepressivi nel trattamento del disturbo borderline di personalità: revisione dei dati di letteratura

Summary Background Borderline personality disorder (BPD) is a pervasive pattern of instability of interpersonal relationships, affects and identity, as well as poorly controlled impulsivity. BPD causes serious distress and impairment in social, occupational and role functioning, and it is associated with high rates of self-destructive behaviors and suicide. The American Psychiatric Association (APA) treatment guidelines indicate the use of pharmacotherapy to manage state symptoms during periods of acute exacerbations and trait vulnerability, while psychotherapy is required to attain lasting improvements in patients’ personality and overall functioning. Three symptom dimensions are the main targets for pharmacotherapy of borderline personality disorder: affective dysregulation, impulsive-behavioral dyscontrol and cognitive-perceptual symptoms. APA guidelines recommend choosing antidepressant agents, in particular, selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs), and mood stabilizers to treat affective dysregulation and impulsive-behavioral dyscontrol; lowdose antipsychotics are suggested for cognitive-perceptual symptoms. Two psychotherapeutic approaches have been shown in randomized controlled trials to be efficacious, i.e., psychodynamic therapy and dialectical behavior therapy. Cognitive, interpersonal, and support psychotherapies have also been considered. Objective This review aims to report and discuss data from clinical trials, reviews and meta-analyses concerning efficacy and tolerability of antidepressants in the treatment of borderline personality disorder (Tables I, II). Methods Clinical trials, reviews and meta-analyses of antidepressants in patients with borderline personality disorder were identified through careful searches in MedLine and other sources. Results Investigations that considered controlled trials of antidepressant agents mainly focused on SSRIs. These drugs, mainly fluoxetine and fluvoxamine, are indicated as firstline treatments for affective instability (depression, anxiety, and outbursts of anger) and impulsive dyscontrol (impulsive aggression, self-mutilation, and self-damaging behaviors). SSRIs present lower incidence and milder severity of adverse effects than tricyclic antidepressants (TCAs) and MAOIs. Risk of toxicity is also lower. Available controlled studies indicate that MAOIs can be useful in treating borderline personality disorder with main effects on symptoms of atypical depression, anger and impulsivity, but the risk of adverse effects and the difficulties with adherence to required dietary restrictions constitute limitations to their use in clinical practice. TCAs are second-choice drugs in treatment of BPD; these agents can produce effects on mood instability and irritability control, but available results are limited. Clinical experience suggests that TCAs may sometimes be indicated for patients with comorbid severe depressive disorders. However, their risk for toxicity and potential lethality in overdose support the preferential use of SSRIs or related antidepressants. Although more clinical trials are needed, initial data concerning reuptake inhibitors of serotonin and noradrenaline (SNRIs) (duloxetine and venlafaxine) are promising. These antidepressants have been found to be efficacious in reducing impulsivity, anger, affective instability, anxiety, and suicidality. Conclusions Many antidepressive agents with different mechanism of actions have been evaluated in the treatment of patients with borderline personality disorder. However, a part of available studies suffer from serious methodological limitations. Further controlled trials vs. placebo or active agents are required, including larger samples and using longer durations of treatments, in order to confirm current indications for pharmacotherapy of patients with BPD.