Selective Serotonin Reuptake-Inhibitors for Symptom-Based Treatment of Borderline Personality Disorders in Older Adults: An International Delphi Study (original) (raw)

The main goal of this study was to reach consensus amongst international experts on the suitability of SSRIs for the treatment of older adults with BPD. The experts agreed on the statements that SSRIs are indicated for treatment of affective instability and as a second choice for impulsive behavior in older adults with BPD. Preferred SSRIs in older adults are citalopram and sertraline, but no consensus was reached on optimal dose. Based on the 11 statements for which consensus was reached, we composed a flowchart with treatment recommendations, which is shown in Figure 2.

Available placebo controlled RCTs show conflicting results when it comes to the effectiveness of SSRIs in treating affective instability in adults [28,29]. They could be effective for mood swings [28], anger [30], irritability [31], and anxiety [32]. According to the experts in this Delphi study, among older adults with BPD SSRIs are effective in treating affective instability. This is supported by the demonstrated effectiveness of SSRIs in de treatment of late life depression [16,17].

The experts also concluded that SSRIs are not preferred as first choice for treating impulsive behavior, but they can be used as a second choice (item 7). In adults, SSRIs have demonstrated to be effective in treating impulsive behavior and aggression, mostly in men with BPD [28,30]. The experts agreed on the statement that it is unclear whether gender has an effect on pharmacotherapy in older adults with BPD.

The experts reached consensus on citalopram and sertraline being first choice SSRIs for older adults with BPD. The fact that citalopram and sertraline are SSRIs with few interactions with other medications is a relevant factor in older adults, who are exposed to polypharmacy frequently [5].

However, at the end of this Delphi study some statements did not reach consensus, such as the statement on the dosage of sertraline and citalopram. Sertraline appears to be as safe as a placebo for the risk of dizziness, which makes it very preferable for older adults [33]. More caution might be required when using citalopram. The Food and Drug Administration (FDA) issued a safety communication which proclaimed that daily dosages of citalopram should no longer exceed 40mg because of the risk of prolonged QT interval [34]. Even though this was not supported by a cohort study in veterans [35] frequent monitoring of patients at risk of prolonged QT interval is a requirement.

There was also no consensus reached on the treatment of suicidality with an SSRI. The study by Stone et al. [36] showed SSRIs could have a protective effect for suicidal ideation but it has no effect on suicidal behavior.

This Delphi study generally encourages more research, for example to clarify dosing strategies in older adults with PDs; starting dose, optimal therapeutic dose, maximum dose, but also when to increase the dose of SSRIs. Most importantly, the first steps are made for treatment recommendations of older adults with BPD by use of an SSRI.

Limitations

In adherence to the findings, some limitations of the study must be considered. The Delphi method is a study design based on expert opinion and therefore has limited level of evidence. However, since no studies have yet been performed on the use of SSRIs in the treatment of BPD in older adults, it is a valid approach to explore this new area of interest. In the first and second rounds there was much inclination towards the answer ‘neither agree nor disagree’. Before the third round began the experts were asked to minimize the use of this answer. If this had been done from round 1 onwards, a consensus could have possibly been reached on statements that did not pass before. Although Delphi studies are most commonly performed with two or three rounds, it may have been useful to carry out a fourth round to achieve more consensus. Unfortunately, this was not possible in the reserved timeframe for this study. The subjects on which no consensus has been reached are leads for further research.

Conclusions and Recommendations

The results of this study suggest a valuable role for SSRIs in the treatment of affective symptoms, and to a lesser extent impulsive behavior, in older adults with BPD. Sertraline or citalopram are suggested to be the first choice medica-tion, but should be prescribed with some caution. Treatment recommendations have been suggested (presented in a flowchart), but still have to be investigated in clinical practice. To test both effectiveness and tolerability of SSRIs in older adults with BPD we propose a single case experimental design, because it takes into account the heterogeneity of the population of older adults. This should eventually be investigated for other psychotropics too, such as antipsychotics and anticon-vulsants. Evidence based pharmacotherapy is essential for an effective and safe treatment of the various symptoms of BPD in older adults.