No significant difference between olanzapine and placebo for improvement in borderline personality disorder symptoms

ED FROM Schulz SC, Zanarini MC, Bateman A, et al. Olanzapine for the treatment of borderline personality disorder: variable dose 12-week randomised double-blind placebo-controlled study. Br J Psychiatry 2008;193:485–92. Correspondence to: Dr S Charles Schulz, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN 55454, USA; scs@umn.edu Source of funding: Eli Lilly. c Additional notes are published online only at http://ebmh.bmj. com/content/vol12/ issue3 C O M M EN TA R Y B orderline personality disorder (BPD) is a serious and frequent psychiatric disorder. It affects 1– 2% of the general population and is characterised by an early onset enduring and pervasive pattern of instability in affect regulation, impulse control and interpersonal relationships. Despite the prevalence and clinical significance of this disorder, the efficacy of pharmacotherapy is controversial. Previous studies have shown that antipsychotics, antidepressants and mood stabilisers may provide a mild degree of symptom relief but whether pharmacotherapy is effective against the stable core traits of BPD is a matter of dispute. So far, no medication has a specific indication for use in this disorder. Schulz and colleagues, who evaluated the efficacy of olanzapine in individuals with BPD in a 12 week randomised controlled trial, highlighted no additional benefit of olanzapine over placebo in terms of overall symptoms improvement. The study was successful in randomly assigning more than 300 patients, a considerable sample size in a field where patients are very reluctant to participate in clinical trials. However, the study exclusion criteria were very strict: a concurrent psychiatric disorder or substance abuse disorder was not allowed, and actively suicidal patients could not be enrolled. Moreover, use of other psychotropic drugs was not permitted and all such medications had to be discontinued prior to randomisation. Clearly, these aspects leave uncertainty as to whether these patients truly represent those seen in practice. In fact, patients with BPD generally meet criteria for other psychiatric disorders, including affective and anxiety disorders, posttraumatic stress disorders, eating disorders, substance misuse disorders and other personality disorders. Additionally, in clinical practice, one of the first goals of any interventions is to keep patients in treatment, but this was not considered a primary outcome in this study, despite the fact that more than 48% of patients receiving olanzapine and more than 38% of those receiving placebo discontinued the study prematurely. In conclusion, this negative study is in line with the hypothesis that pharmacotherapy can exert only a modest effect on core traits of BPD and that antipsychotics may only have a role in the treatment of state symptoms during periods of acute decompensation. Michela Nosè, MD, PhD Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Italy Competing interests: None. 1. Binks CA, Fenton M, McCarthy L, et al. Pharmacological interventions for people with borderline personality disorder. Cochrane Database Syst Rev 2006;1:CD005653. 2. Nosè M, Cipriani A, Biancosino B, et al. Efficacy of pharmacotherapy against core traits of borderline personality disorder. Meta-analysis of randomized controlled trials. Int Clin Psychopharmacol 2006;21:345–53. Therapeutics EBMH August 2009 Vol 12 No 3 89