In 2018 the UK National Health Service (NHS) attempted to clarify this very point with the “
- …test whether or not prescribing lamotrigine in addition to usual treatment reduces symptoms of this condition, improves social functioning and quality of life, reduces the incidence of suicidal behavior, reduces the level of alcohol and substance misuse and lowers the amount of antipsychotic and other psychotropic medication that people are prescribed.
LABILE resulted in over 270 patients with BPD separated into a lamotrigine arm and placebo arm. Each arm received normal treatment as well. Review of the study demonstrate reliable and valid results. Patients were recruited from NHS treatment centers and demonstrated severity across the spectrum of the condition.
To put it simply, in as real world a study as possible, with the largest number of patients yet, lamotrigine did not hold up the initial suggestion of benefit from earlier research. Results between placebo and lamotrigine treatment were equivocal. Levels of depression, the likelihood of self-harming or suicidal behavior and likelihood of problem drug or alcohol use were all comparable across the groups at follow-up. Social functioning was also equivalent across groups.
Additionally, medication compliance was poor for all patients after 12 weeks, with only thirty three percent demonstrating consistency. In a medication where inconsistent/rapid titration can be life-threatening this can be especially concerning. The indication is that lamotrigine, similar to all other medications, does not treat or alleviate BPD symptoms. It adds cost and risk.
A notable risk of lamotrigine is that of Steven’s Johnson Syndrome, a serious and life threatening blistering rash of mucosa and skin. When the medication is titrated too quickly, the risk increases markedly. After a two days of missed medication the 2 week titration schedule for lamotrigine must be started again. Poor compliance with
this medication certainly places patient at greater risk.
On the other hand, there is some reason to conclude hopefully regarding BPD. The interaction with the physician was stabilizing. The indication of having a legitimate treatable condition was validating. However the lamotrigine did not add to this benefit any better than an inert placebo.
BPD warrants treatment. Patients with the disorder have a completed suicide rate greater than fifty times the general population. They utilize emergency and clinic resources to an extensive degree. Anti-depressants fair worse than placebo. Benefits of atypical anti-psychotics match placebo. Sadly, lamotrigine, much like many medications before it, once scrutinized does not meet the hope of its initial small studies and open label trials.
Therefore do not fall into the trap of avoiding the valid and successful treatment of Dialectical Behavior Therapy and Mentalization Based Therapy.
Crawford MJ, Sanatinia R, Barrett B, et al. Lamotrigine for people with borderline personality disorder: a RCT. Southampton (UK): NIHR Journals Library; 2018 Apr. (Health Technology Assessment, No. 22.17.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK493476/