Borderline personality disorder (BPD) is a mental health condition that affects how people think, feel and relate to others. It can be deeply distressing for the person experiencing it, for their loved ones and the professionals trying to help. Although people often disagree about the label for this condition, what truly matters is ensuring people access evidence-based help when they need it most.
Many people don’t realise this, but no medication is officially approved to treat BPD in the UK, US or Europe (Gartlehner, 2021, NICE, 2009). Instead, the main treatment recommended by experts is psychological therapy (NICE, 2009).
But here’s the real-world twist: despite these recommendations, psychiatric medications are commonly prescribed, often across several types of drugs. These include antidepressants, antipsychotics, sedatives, and mood stabilisers (Paton, 2015). A large European study of over 2,000 hospitalised patients with BPD found that nine out of ten patients were on medication, with more than half taking three or more drugs at once (Bridler, 2015). Similar findings have been observed across different settings, where over 50% of people with BPD were prescribed three or more psychiatric medications (Tennant, 2023). Even long-term, data confirms that people with BPD are consistently more likely than those with other personality disorders to take multiple psychiatric drugs (Zanarini, 2015).
At the same time, some newer research suggests there may be short-term benefits from certain medications. For example, a Finnish population study, recently summarised in a Mental Elf Blog, found that antipsychotics were linked with lower rates of suicide attempts and violent behaviour in people with personality disorders (Herttua, 2023).
So, why is prescribing in BPD so common? And what does it tell us about mental health in practice?
A recent study led by Joshua Confue and colleagues (2025) explored this question. Their findings provide an important glimpse into how mental health care for BPD actually works and where it might need to improve.
While psychological therapies are treatment recommended in guidelines, it is common for people with a BPD diagnosis to be prescribed medication.
Methods
The researchers did a systematic review, a type of study looking at all the relevant research on a topic to draw conclusions. They searched for studies published since 1994 and focused on why medications are prescribed for adults with BPD, including patients with other co-existing mental health conditions (comorbidity).
They examined several major research databases, covering a broad range of study types, including both numbers-driven research and studies that explore people’s experiences. This combination helps capture the complexity of prescribing medication for BPD, which involves both clinical data and human factors.
From 102 studies identified initially, 13 studies from different countries were included in the analysis. It is possible that smaller studies not published in mainstream journals and databases were not captured.
Results
The 13 studies varied in sample size, from 9 to 550 participants.
People with BPD were more likely to be prescribed medications if:
- They were older
- They had other mental health conditions (usually depression or anxiety)
- They had been hospitalised in the past
- They were seen as posing a risk to themselves or others.
In other words, prescribing wasn’t just about BPD, it was often about what else was going on.
In some studies, more than 50% of patients were prescribed three or more psychiatric medications.
Studies that looked into the experiences of professionals prescribing medications and patients gave a more detailed picture of the reasons behind the numbers. However, only two studies looked at patient perspectives.
The researchers suggest that doctors often feel pressure to act, especially in crisis situations. Prescribing can feel like “doing something” in the face of patient suffering.
They also suggest that some patients may expect medications, and not prescribing them can strain the therapeutic relationship.
Finally, the review team suggest that national guidelines are difficult to apply in the context of real-world complexity as limited access to therapies or constrained service time can increase reliance on medication.
Professionals said that national guidelines were hard to implement in real world complex scenarios.
Conclusions
The authors concluded that although clinical guidance advises against routine medication use for BPD, prescribing is common and influenced by multiple factors. These include patient factors such as age, other conditions and presenting symptoms but also clinician emotion, relationships between clinicians and patients, and systemic pressures.
This review highlights the reasons behind the disconnect between evidence-based recommendations and the clinical reality, but also recognises that limited research exists on the factors at play.
Overall, while further research is required, this review provides a promising foundation for understanding prescribing behaviours in BPD and developing strategies to improve outcomes for these patients.
There is a disconnect between evidence-based recommendations and clinical reality, but limited research exists on the factors at play.
Strengths and limitations
This is one of the first systematic reviews to bring together evidence on what drives prescribing decisions in BPD. That alone makes it an important contribution, because despite high rates of medication use in practice, the reasons behind this have rarely been synthesised in a structured way.
A big strength of this review is the way it combines very different types of evidence. Instead of focusing only on numbers, the authors brought together statistical studies and qualitative research that included patient and clinician perspectives. This gives a richer picture of why prescribing happens.
The authors found that comorbidity plays a role in prescribing decisions. However, because of the nature of the studies included, it is not always possible to determine whether medications were prescribed for BPD symptoms or for co-existing conditions such as depression or anxiety.
Following international standards (PRISMA) ensured the review was conducted transparently and systematically. Nevertheless, only thirteen studies met inclusion criteria, and most had relatively small sample sizes. This limits how confidently the findings can be applied to all patients with BPD.
Diverse evidence provides insight, but small study numbers limit how widely the conclusions can be applied.
Implications for practice
This review highlights that prescribing in borderline personality disorder is rarely a straightforward, guideline-driven decision. Instead, it is shaped by a mix of clinical, relational, and organisational factors.
Certain patient demographics such as age, comorbidity, and symptom profile are important when making prescribing decisions. However, expectations of care and relationships between professionals and patients also affect the likelihood of people with BPD receiving medications. Many clinicians reported prescribing to ease distress, to maintain trust, or because they felt helpless when other options weren’t available. This points to a practical truth: improving prescribing in BPD isn’t only about following guidelines, it’s about strengthening the therapeutic relationship and making sure both patients and professionals feel supported. Where long-term therapies are difficult to access, prescribing may become a default.
Given the high prevalence of prescribing despite limited evidence of benefit, there is a need to systematically monitor, and study potential drawbacks, side effects, or long-term problems of these medications in people with BPD.
As BPD often co-exists with other mental health conditions (Shah, 2018), some prescriptions may target co-occurring conditions like depression or anxiety rather than BPD itself. Understanding this helps explain part of the picture.
In the clinical world, it is important that:
- Clinicians are transparent with patients about why medications are prescribed, including what medication can and cannot do, so expectations are realistic.
- Clinicians can reflect on prescribing choices. Is medication is being used for symptoms, to preserve the relationship, or because of pressure?
- Healthcare services prioritise continuity of care as patients value consistency and trust, which can sometimes reduce reliance on prescribing as a “holding” measure.
- Therapy is accessible, because without it, both patients and clinicians may feel left with few alternatives.
Prescribing in BPD sits at the intersection of evidence, human relationships, and system constraints. Recognising this complexity can help move practice away from automatic prescribing, towards care that is more thoughtful, transparent, and patient-centred.
Prescribing in BPD sits at the intersection of evidence, human relationships, and system constraints.
Links
Primary paper
Confue J, Maidment I, Jones S, Jones M (2025) Factors that influence prescribing in borderline personality disorder: a systematic review. Personality and Mental Health 19(2): e70014.
Other references
Bridler, R., Häberle, A., Müller, S. T., Cattapan, K., Grohmann, R., Toto, S., Kasper, S., & Greil, W. (2015). Psychopharmacological treatment of 2195 in-patients with borderline personality disorder: A comparison with other psychiatric disorders. European Neuropsychopharmacology, 25(6), 763–772.
Gartlehner G, Crotty K, Kennedy S et al (2021) Pharmacological treatments for borderline personality disorder: a systematic review and meta-analysis. CNS Drugs 35: 1053-67.
National Institute for Health and Care Excellence (2009) Borderline personality disorder: recognition and management. NICE Clinical Guideline CG78.
Paton, C., Crawford, M. J., Bhatti, S. F., Patel, M. X., & Barnes, T. R. (2015). The use of psychotropic medication in patients with emotionally unstable personality disorder under the care of UK mental health services. The Journal of clinical psychiatry, 76(4), e512–e518.
Shah R, Zanarini MC (2018) Comorbidity of borderline personality disorder: current status and future directions. Psychiatr Clin North Am 41:583–593.
Tennant, M., Frampton, C., Mulder, R., & Beaglehole, B. (2023). Polypharmacy in the treatment of people diagnosed with borderline personality disorder: Repeated cross-sectional study using New Zealand’s national databases. BJPsych Open, 9(6), e200.
Zanarini, M. C., Frankenburg, F. R., Reich, D. B., Harned, A. L., & Fitzmaurice, G. M. (2015). Rates of psychotropic medication use reported by borderline patients and axis II comparison subjects over 16 years of prospective follow-up. Journal of Clinical Psychopharmacology, 35(1), 63–67.