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Treatment with ADHD medications is associated with reduced risk of suicide in patients with borderline personality disorder (a nationwide Swedish study)

Jul 18, 2023 | Other Medical Disciplines

Approximately 5% to 10% of individuals diagnosed with borderline personality disorder (BPD) will eventually die by suicide, and the lifetime prevalence of suicidal ideation and attempts in these patients is 84% to 94%. In this study, researchers from Finland and Sweden used nationwide Swedish patient registries to investigate the comparative effectiveness of several commonly used pharmacological treatments (antipsychotics, antidepressants, mood stabilizers, benzodiazepines, and ADHD medications) on the risk of attempted or completed suicides in patients with BPD. The results showed that the use of attention-deficit/hyperactive disorder (ADHD) medications was consistently associated with a reduced risk of suicide. On the contrary, the use of antidepressants, antipsychotics, or mood stabilizers was not associated with a reduced risk of suicide in patients with BDP. Furthermore, the use of benzodiazepines was associated with a marked increase in suicide risk.

The authors noted that psychotherapy, especially dialectical behavior therapy, is effective in reducing suicidal behavior. However, due to limited access to psychotherapeutic treatments, most patients diagnosed with BPD are treated with pharmacotherapy. 

Previous large observational studies that investigated the effectiveness of antipsychotics on suicidal behavior in patients with personality disorders, including BPD, like a nationwide Danish registry study of 79,253 individuals (42,987 patients with BPD) found that suicidal behavior was 32% lower during antipsychotic treatment than in periods without antipsychotic treatment. The authors, noted that the fact that patients with comorbid psychotic disorders were not excluded from the study could influence these results.

Over one-third of individuals with BPD have comorbid ADHD symptoms. The existing evidence suggests that ADHD medications are associated with a decreased risk of suicide in patients with ADHD. Patients diagnosed with BPD are often treated with benzodiazepines, despite augmented impulsivity and aggression-related issues that may facilitate suicidal behavior.

About the study

The authors used Swedish electronic nationwide patient registries. The study included individuals who were diagnosed with BPD according to the International Statistical Classification of Diseases, 10th Revision (ICD-10, code F60.3) between January 1, 2006, and June 30, 2021, representing an unselected nationwide sample of 22,601 diagnosed patients with BPD. The mean age of patients was 29.2 years, ranging from 16 to 65 years. The study excluded individuals diagnosed with comorbid nonaffective psychotic disorders (codes F20-F29), bipolar disorder (code F31), psychotic depression (code F32.3), or personality disorders other than BPD (codes F60-61 except F60.3). The mean follow-up was 6.9 years, and the maximum was 16 years.

The majority of patients were women (84.3%), single, and without children (57.7%). Comorbidities reported in this cohort of BDP patients were substance use disorder in 33.7%, depression in 56.6%, anxiety disorder in 71.4%, and ADHD in 17.2%.

Results

During the follow-up of 16 years (mean follow-up was 6.9 years), 32.4% of the sample, (8513 patients diagnosed with BDP) had attempted suicide, and 316 patients completed suicide. The median time from diagnosis of BPD to the first hospitalization for attempted suicide was 271 days (ranging from 55 to 895 days), and from diagnosis of BPD to completion of suicide was 1300 days (ranging from 412 to 2605 days).

Most patients were treated with antidepressants (81.5%) at some point during the follow-up. Sertraline was the most common, used in 28.7% of BDP patients. At some point during follow-up, 56.0% of the patients were taking benzodiazepines.

41.1% of BDP patients were treated with antipsychotics. The most common antipsychotic drug was quetiapine used in 24.2% of patients. 31.7% of BDP patients were treated with mood stabilizers. The most common mood stabilizer was lamotrigine, used in 24.0% of patients. 24.4% of BDP patients were treated with ADHD medications. The most common ADHD medication was methylphenidate, used in 18.8% of patients.

Treatment with ADHD medications, especially stimulant compounds, was associated with a decreased risk of attempted or completed suicide. Importantly, a decrease of 48% in the probability of suicide completion in patients with BPD was attributable to treatment with ADHD medications. The lowest risk of attempted or completed suicide was found for lisdexamphetamine.

Treatment with other pharmacotherapies (antidepressants, antipsychotics, mood stabilizers, or benzodiazepines) was not associated with a reduced risk of suicide. Importantly, treatment with antidepressants or antipsychotics was associated with an increased risk of attempting or completing suicide. Of all antidepressants, paroxetine was associated with the highest risk of attempting or completing suicide. Of all antipsychotics, zuclopenthixol was associated with the highest risk of attempting or completing suicide.

Treatment with benzodiazepines, among all investigated pharmacotherapies, was associated with the highest risk of attempting or completing suicide. These findings remained unchanged even when the first 30 or 60 days of exposure for every medication were omitted.

The authors noted that the limitations of this study were the lack of specific clinical parameters, such as the severity of BPD symptoms and indications for pharmacotherapy, and the lack of information regarding concomitant psychotherapy, such as dialectical behavioral therapy.

Results

This study demonstrated that, compared with nonuse periods, treatment with ADHD medication was associated with a reduced risk of attempted or completed suicide, possibly due to diminished impulsivity. Treatment with antidepressants, antipsychotics, or mood stabilizers did not reduce suicidal behavior in patients with BPD. Furthermore, treatment with benzodiazepines was consistently associated with an increased risk of attempting or completing suicide.

The authors proposed that treatment with ADHD medications should be the preferred option for individuals diagnosed with BPD, ADHD symptoms, and suicidal behavior. In contrast, benzodiazepines should be used with caution in patients diagnosed with BPD due to their association with an increased risk of suicide.

The article was published in JAMA.

 

Journal Reference

Lieslehto J et al. Comparative Effectiveness of Pharmacotherapies for the Risk of Attempted or Completed Suicide Among Persons With Borderline Personality Disorder. JAMA Netw Open. 2023;6(6): e2317130. (Open Access) https://jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.17130

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