A comparison of UK and US guidelines for drug treatment in borderline personality disorder.

The UK and USA differ considerably in their guidance regarding the use of drug treatment for borderline personality disorder, but generally agree over the use of psychological treatment. The 2009 UK guidelines from the National Institute for Health and Clinical Excellence (NICE) do not recommend any form of drug treatment except in a crisis with the intention of ceasing such treatment shortly afterwards. The US guidelines from the American Psychiatric Association (APA), published in 2001, are much more positive and suggest that there is a place for selective serotonin reuptake inhibitors (SSRIs), mood stabilizers and antipsychotic drugs as adjunctive treatments in borderline personality disorder. The guidelines are summarized and two main reasons for the differences identified. First, the separation of the borderline personality group into those with 'affective dysregulation', 'impulsive behaviour dyscontrol' and 'cognitive-perceptual' symptoms in the US guidelines was felt by the guideline development group for the NICE guideline to be a post hoc classification not supported by any other evidence. Second, the threshold of evidence necessary for making recommendations was much higher for the UK than the US guideline. Both guidelines recognize that we need more substantial trials, preferably independent of the pharmaceutical industry, before we can have any real confidence in our recommendations.