Efficacy and safety of pharmacological treatments in borderline personality disorder: A systematic review and network meta-analysis.

Patients with borderline personality disorder (BPD) are over-represented in psychiatric services, and their suicide mortality is markedly higher than that of the general population. This network meta-analysis evaluated and compared the efficacy and safety of pharmacological treatments for symptoms of BPD. A systematic search of Medline®, Web of Science®, and Google Scholar® identified randomised clinical trials comparing active drugs with placebo or another agent between 15 January and 12 February 2024. Standardised mean differences were estimated using random-effects pairwise and network meta-analyses. The level of evidence (LoE) for significant drug-placebo comparisons was rated using GRADE NMA guidance. Thirty-five trials including 2551 participants assessed 26 treatments against placebo: 18 had low, five moderate, and 12 high risk of bias. Topiramate (200-250 mg/day, 8-10 weeks), lamotrigine (50-200 mg/day, 8 weeks), and aripiprazole (15 mg/day, 8 weeks) most effectively reduced hostility, aggressiveness, and anger, and improved anger control. Carbamazepine (200-1200 mg/ day, 6 weeks) and asenapine (5-10 mg/day, 12 weeks) improved impulsivity and emotional dysregulation, respectively. Topiramate, lamotrigine, and aripiprazole demonstrated high, moderate, and moderate LoE for hostility and anger reduction. Carbamazepine and asenapine demonstrated low and very low LoE for impulsivity and emotional dysregulation. Conversely, alprazolam, methylphenidate, haloperidol, and valproate had only low-certainty evidence in unselected BPD samples and should not be prioritised. Prescription should be limited to specific, individualised indications, such as panic, comorbid ADHD, or transient psychotic features, following cautious clinical appraisal.