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In patients with borderline personality disorder (BPD), attention deficit-hyperactive disorder (ADHD) medication was the only pharmacological treatment associated with a lower risk of suicidal behavior, according to a comparative effectiveness study of a Swedish nationwide cohort.

Of more than 22,000 patients with BPD, ADHD medication treatment was associated with a decrease in the risk of attempted or completed suicide compared with no use of these medications (HR 0.83, 95% CI 0.73-0.95, false discovery rate [FDR]-corrected P=0.001), reported Johannes Lieslehto, MD, PhD, of the University of Eastern Finland in Kuopio, and co-authors.

On the other hand, certain pharmacological therapies were associated with an elevated risk of suicidal behavior, they noted in .

For example, treatment with benzodiazepines was associated with the highest risk of attempted or completed suicide (HR 1.61, 95% CI 1.45-1.78, FDR-corrected P<0.001). Treatment with antidepressants (HR 1.38, 95% CI 1.25-1.53, FDR-corrected P<0.001) and antipsychotics (HR 1.18, 95% CI 1.07-1.30, FDR-corrected P<0.001) were also both associated with a higher risk of suicidal behavior.

Treatment with mood stabilizers did not have a statistically significant association with suicidal behavior (HR 0.97, 95% CI 0.87-1.08, FDR-corrected P=0.99).

Lieslehto and team also noted the outcomes remained similar after controlling for potential protopathic bias.

"Individuals with BPD often receive pharmacological treatment with the intention to treat suicidal behavior. However, there is very little evidence supporting the use of pharmacotherapy in BPD," Lieslehto told 番茄社区app. "Our findings suggest that ADHD medication should be the preferred choice for individuals with BPD with ADHD symptoms and suicidal behavior."

"Treatment with benzodiazepines was consistently associated with a high risk of suicidal behavior," he added. "Consequently, it would be prudent for healthcare professionals to refrain from prescribing benzodiazepines to patients with BPD."

Lieslehto said that it was not clear whether ADHD treatments should be considered for patients with BPD but without ADHD symptoms, and that more research will be needed to understand the specific benefits related to ADHD medication for this patient population, especially since patients with BPD frequently have severe comorbidities. A randomized controlled trial would be needed to better understand whether ADHD medications should be used for BPD patients without ADHD comorbidity, he noted.

For this comparative effectiveness research study, the researchers analyzed nationwide Swedish register databases of inpatient care, specialized outpatient care, sickness absences, and disability pensions to identify patients ages 16 to 65 with registered treatment contact for BPD from 2006 to 2021.

They used a within-individual Cox regression model to eliminate selection bias, which meant each patient was used as their own control. This modeling "eliminates time-invariant factors (e.g., genetic differences) and reduces the impact of BPD severity and comorbidities," they wrote.

The modeling also allowed them to adjust only for time-specific factors, such as time since onset of illness, temporal order of treatments, and other concomitant pharmacotherapies.

The researchers also conducted sensitivity analyses to control for protopathic bias by omitting the first 1 or 2 months of medication exposure from the analyses.

The study included 22,601 patients. Mean age was 29.2, 84.3% were female, and 87.7% were born in Sweden. During the 16-year follow-up, 8,513 hospitalizations occurred due to attempted suicide and 316 completed suicides were observed.

Lieslehto and team noted that they lacked specific clinical parameters, including the severity of BPD symptoms and indications for pharmacotherapy, which may have significance for suicidal behaviors.

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