ACKNOWLEDGMENTS:
This study was supported financially by a $2500 Education Grant by Pfizer, Inc., manufacturer of sertraline. To the best of my knowledge, I was not given a grant number.
STATISTICAL SIGNIFICANCE:
Due to the small number of patients studied, no statistical analyses (such as p values) are included. The number of patients is not statistically significant.
BACKGROUND:
Little is known about which specific Borderline Personality Disorder symptoms are affected by SSRI’s, and how different medications in the SSRI class compare inn treating the Borderline Personality Disorder. This study compares the effects of fluoxetine with sertraline on four target symptoms: mood swings, chronic anger, emptiness/boredom, and chronic emotional pain.
METHODS:
Four patients were switched from fluoxetine to sertraline. Five patients who had never taken fluoxetine were given a trial of sertraline.
RESULTS:
Those switched from fluoxetine to sertraline experienced worsening of their symptoms and returned to taking fluoxetine. For those who had not previously taken fluoxetine, sertraline was extremely effective for some, mildly effective for others.
CONCLUSIONS:
Both fluoxetine and sertraline are effective in reducing mood swings, chronic anger, emptiness and boredom, emotional pain, and depression. Fluoxetine appears to be superior.
Studies by Norden (1), Markovitz (2), Cornelius (3), and Hull (4) have shown efficacy in treating Borderline Personality Disorder (BPD) patients with fluoxetine.
In my practice, I have over 400 patients. Four symptoms are significantly reduced by fluoxetine: mood swings, chronic anger, emptiness/boredom, and chronic emotional pain (5).
Sertraline is a new SSRI. This study’s purpose is to compare it’s efficacy to fluoxetine. Four patients successfully treated with fluoxetine were switched to sertraline. Six patients who had never taken fluoxetine began treatment with sertraline, five completed the study.
All patients were diagnosed by reviewing the DSM-III-R criteria, carefully emphasizing that this was a lifetime pattern, affecting virtually every aspect of their lives. Those experiencing chronic dysphoria (6), incest crisis, or significant dissociative symptoms were excluded from the study.
Baseline laboratory testing, physical examinations and Zung depression tests were performed.
Patients also filled out a symptoms questionnaire. They rated each symptom as "no problem" which equals a score of 1, "mild problem" - score of 2, "moderately severe" - score of 3, and "very severe" - score of 4. During subsequent visits, they also rated the percentage of symptom relief. This was an exclusively patient rated study.
Mood swings were defined as "inappropriate mood changes, not directly related to life’s events."
Chronic anger was defined as "feeling angry most or all of the time. This chronic anger is not to be confused with the uncontrollable rage a borderline personality disorder patient sometimes experiences."
Emptiness/boredom was defined as "Emptiness is a sensation of feeling empty inside. The boredom is not due to boring life situations, but presents itself in virtually all life situations, including pleasant ones."
Emotional pain was defined as "feeling like your best friend or close relative died."
All patients previously treated with fluoxetine had a wash out period - two for 7 days, one 30 days, one 120 days. Each experienced the period off fluoxetine as very unpleasant.
Patients were begun on 50 mg of sertraline daily, and re-evaluated regularly, either weekly or monthly. If symptom improvement was inadequate, the dose was increased, up to a maximum of 200 mg of sertraline daily. A Zung index and symptom assessment were completed at every visit.
Office visits, the physical examination, laboratory tests, and medication were free to the patient during the study period.
The four patients who were switched from fluoxetine to sertraline eventually took 200 mg of sertraline daily. Sertraline’s relative lack of efficacy caused problems, such as irritability and mood swings, in one case putting the patient’s job at risk. Within three months, they all requested switching back to fluoxetine. The symptoms eventually improved, returning to the baseline fluoxetine experience.
Due to severity of their symptoms while on sertraline, I was unable to get all four patients to give me the symptom assessment scores and Zung indexes prior to resuming fluoxetine. The interim data indicated that their symptoms were worsening, but no final data is available for numerical scoring.
The fluoxetine treated patients were asked to retrospectively describe their symptoms before and after taking fluoxetine (at either 20mg or 40mg). The results: Mood swing scores dropped from an average of 3.75 to 1.25, and average 89% improvement in subjective symptom relief. Chronic anger dropped from 4.0 to 1.25, 90%. Emptiness/boredom dropped from 3.5 to 1.3, 93%. Emotional pain dropped from 3.25 to 1.0, 95%.
Of the five patients who had never previously taken fluoxetine, two had a good response to sertraline - one at 200mg daily, the other at 100mg daily. The other three eventually took 200mg daily. They were switched to fluoxetine, two of them experiencing significant symptom improvement.
The sertraline "responders" had the following scores: Mood swings 3.5 to 1.5, 90%. Chronic anger 3.5 to 1.0, 95%. Emptiness/boredom 3.5to 1.0, 98%. Emotional pain 4.0 to 1.0, 98%. The average Zung depression index dropped from 83 (most severely depressed) to 40 (no longer depressed).
The scores for sertraline "mild-responders" showed modest improvement: Mood swings 4.0 to 3.7, with a 23% reduction in severity. Chronic Anger 4.0 to 2.7, 47%. Emptiness/boredom 4.0 to 3.3, 24%. Emotional pain 4.0 to 3.3, 27%. The average Zung score dropped from 75 to 59 (mildly depressed).
While both sertraline and fluoxetine can be effective in treating the target symptoms from this study, those previously on fluoxetine preferred it to sertraline. The length of the wash out period seemed to make no difference.
While this small study showed sertraline can be effective, previously published studies and my experience with over 400 BPD patients show fluoxetine to be more consistently efficacious than sertraline. Sertraline appears to be a reasonable option for borderlines who are fluoxetine intolerant or refuse to take fluoxetine. High doses of sertraline were required to get similar effects.
Sertraline was effective in reducing or eliminating depression, according to Zung index scores. While depression is commonly associated with patients suffering from the BPD, the target symptoms studied were affected even when the depression persisted.
Much more study is needed, certainly with a larger population allowing for statistical significance. The specific effects of SSRI’s in treating the BPD must be clarified. Other symptoms such as self-mutilation, impulsive and self-destructive behaviors, and suicide attempts must also be studied.
1) Norden, MJ: Fluoxetine in Borderline Personality Disorder. Prog Neuropsychopharmacol Biol Psychiatry 1989;13(6):885-93
2) Markovitz, P: Fluoxetine in the Rx of the Borderline Personality Disorder and Schizotypal Personality Disorder. Am J Psychiatry 1991; 148(8):1064-7
3) Cornelius, J; Soloff, Paul: Fluoxetine Trial in Borderline Personality Disorder. Psychopharmacology Bulletin 1990 Vol 26(1) 151-154
4) Hull, J; Clarkin, J; Alexopoulos, G: Time-series Analysis of Intervention Effects - Fluoxetine Therapy as a Case Illustration. Journal of Nervous and Mental Disease, 1993, N1(Jan), P 48-53
5) Heller, L: Life at the Border - Understanding and Recovering From the Borderline Personality Disorder, West Palm Beach, FL, Dyslimbia Press, Inc. 1992
6) Cowdry, RW: Psychopharmacology of Borderline Personality Disorder - A Review. J Clin Psychiatry 48:8 (suppl) August 1987
February 1994. Copyrighted. Permission granted by Leland M. Heller M.D.
