The under-recognition of borderline personality disorder has been identified as a significant clinical problem.

A brief screening tool to screen for borderline personality disorder would be very useful in clinical practice. If the person screened positive, a more detailed assessment would be done.

A major barrier to identifying borderline personality disorder in clinical practice is the fact that these persons very commonly have comorbid anxiety, mood, or substance use disorders.

3674 subjects being evaluated at an outpatient psychiatry clinic were evaluated at initial intake.

The mean age of these patients was 39 years and 60% of them were female.

Semi-structured diagnostic interviews were used—the Structured Clinical Interview for the DSM-IV (SCID) and the borderline personality disorder section of the Structured Interview for DSM-IV Personality Disorders (SIDP-IV).

Sensitivity, specificity, positive predictive value, and negative predictive value were determined for each of the nine DSM-IV diagnostic criteria for borderline personality disorder. However, since the study aimed to identify the best approach to screening, the most important characteristic to look at is sensitivity.

The prevalence of borderline personality disorder in these patients was 11%.

As hypothesized by the investigators, the diagnostic criterion that had the highest sensitivity (93%) was Affective Instability.

The DSM-IV-TR criterion describes this as “affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).”

The Affective Instability criterion was present in 93% of subjects with borderline personality disorder (sensitivity). That is, only 7% of persons with borderline personality disorder did not meet the Affective Instability criterion.

If Affective Instability was absent, 99% of those persons did not have borderline personality disorder (negative predictive value).

However, only 38% of persons in whom the Affective Instability criterion was present met DSM-IV-TR criteria for borderline personality disorder (positive predictive value). This could mean that there are causes of Affective Instability other than borderline personality disorder or that many persons with Affective Instability had subthreshold symptoms of borderline personality disorder. 

Which characteristic should we use to judge how useful it is to evaluate the use of the Affective Instability criterion? This depends on what we are aiming to do.  The Affective Instability criterion is not intended to diagnose borderline personality disorder; it is intended as a screening tool to identify everyone (or almost everyone) who might have the disorder. Therefore, as for all screening tools, the most important characteristics are:

In what percentage of persons who really have the disorder is the screening criterion present (Sensitivity)?

In persons in whom the screening criterion is absent, in what percentage is the disorder absent (Negative predictive value).

The combination of high sensitivity (93%) and high negative predictive value (99%) suggest that if all persons undergoing a mental health evaluation were evaluated for the presence or absence of Affective Instability, very few persons with borderline personality disorder would be missed.

A major strength of this study, as for all the work coming from this group, is that the data is from all patients seen in a busy outpatient clinical practice. That is, these patients from the Rhode Island Hospital Methods to Improve Diagnostic Assessment and Services (MIDAS) project are “real world” patients.

We must screen for common, important disorders in all patients just like other clinicians do a review of systems. Borderline personality disorder is certainly one of the disorders that can have very serious adverse effects on the person suffering from it. So, let’s resolve to screen all adult patients for borderline personality disorder. This study provides us guidance about which criterion to use for the purposes of quick screening. If Affective Instability is present, we should set aside time to assess the person for all the other criteria as well.

Do you prescribe monotherapy to most adult patients with ADHD? Do you almost always use long-acting stimulants? When you use combinations of more than one medication, which ones do you use the most? Answer these questions and then compare your practices to those of other clinicians throughout the US.

Knowing what treatments clinicians are using in “real world” patients is helpful for understanding what issues they are facing with their patients.

In contrast to a decade or two ago, Attention-Deficit Hyperactivity Disorder (ADHD) is now recognized as a lifespan disorder, rather than one which persons suffering from it “outgrow.”

However, little is known about real-world pharmacological treatment among adults with ADHD.

This study, looked at the what medications are prescribed to adults with ADHD in the US.

The study was sponsored by Shire Development, LLC.

A large database of persons who had a commercial medical insurance in the US was used.

Adults (18 years of age or older in 2013) who had a diagnosis of ADHD on at least 2 consecutive visits and who received at least one ADHD medication were included in the analysis

Combination therapy was defined as use of two or more ADHD medications together for 30 days or more.

Duration of effect of medication is a key factor in choosing ADHD medications and was used to classify the patterns of medication use.

The study included about 206,000 adults with a diagnosis of ADHD.

The mean age of the patients was 33 years.

Of these patients, 52% were female. That’s interesting, isn’t it? In children, boys are diagnosed much more often than girls.

There were six mutually exclusive treatment groups. Combining generic and branded medications, three treatment patterns were most common:

1. Monotherapy with a long-acting medication—57% of the patients.

2.  Monotherapy with a short-acting medication—31%

3. Combination of a long-acting and a short-acting medication—10%

Combining generic and branded medications, the other three treatment patterns were quite uncommon:

4. Combination of two long-acting medications—1%

5. Combination of two short-acting medications—0.5%

6. Combination of more than two medications—0.5%

The most common prescriptions for long-acting medications used as monotherapy were:

1. Mixed amphetamine salts extended-release (39%)

2. Lisdexamphetamine (32%)

3. Methylphenidate long-acting preparations (20%).

The most common prescriptions for short-acting medications used as monotherapy were:

1. Mixed amphetamine salts—82%

2. Methylphenidate—15%

The most common prescriptions for a long-acting plus a short-acting preparation were:

1. Mixed amphetamine salts extended-release (generic) plus mixed amphetamine salts (generic)—39%

2. Lisdexamfetamine plus mixed amphetamine salts (generic)—17%

3. Methylphenidate long-acting preparation (generic) plus methylphenidate (generic)—13%

The most commonly used combinations of prescriptions for two long-acting medications were:

1. Mixed amphetamine salts (branded) plus mixed amphetamine salts (generic)—14%

2. Lisdexamfetamine plus mixed amphetamine salts (generic)—11%

3. Lisdexamfetamine plus guanfacine extended-release—11%

The most frequently used combinations of two short-acting preparations were:

1. Mixed amphetamine salts (generic) plus clonidine immediate-release—34%

2. Mixed amphetamine salts (generic) plus methylphenidate generic—18%

3. Mixed amphetamine salts (branded) plus mixed amphetamine salts  (generic)—11%

The majority (57%) of adults with ADHD in a commercially-insured US population were treated with monotherapy with a long-acting stimulant. Others (31%) received monotherapy with a short-acting medication.

However, 12% of patients received a prescription for more than one medication for ADHD during the same 30-day period.

Psychopharmacological treatment of ADHD in adults is both an art and a science. Duration of effect is probably the most important factor to consider. However, there is more than one way to achieve all-day coverage, optimized for the time of the day when the person needs more medication.

This study showed that a high percentage of adults with ADHD are treated with monotherapy, but it also showed that there are many other combinations that are used.

Clinicians treating ADHD should become skillful in using various preparations and combinations of preparations.

For any medication, it is hard for clinicians to read even the summaries of the many studies done. Pooled analyses are one way of putting data from many studies together.

However, in the case of this study, there is another reason why it is clinically important. Several studies in both schizophrenia and bipolar disorder had been done that used a wide range of doses. However, the FDA only approved a narrower range of doses. Thus, it is important to know both the efficacy and the adverse effects when cariprazine is used at the FDA-approved doses.

Cariprazine is a dopamine D3/D2 receptor partial agonist that was approved by the FDA in late 2015 for the treatment of schizophrenia and for manic or mixed episodes associated with bipolar I disorder.

Several of the studies of cariprazine used flexible doses, i.e., the dose could be changed during the study. This is a pooled post-hoc analysis to evaluate the safety and tolerability of cariprazine when the most frequently used dose (the modal dose) was within the FDA-approved dose range FDA-approved dose range—schizophrenia 1.5 to 6 mg/day, bipolar mania 3 to 6 mg/day.

Data were pooled for each indication separately. For schizophrenia, four 6-week trials were included. For bipolar disorder three 3-week trials were included.

For safety analyses, patients were grouped into groups based on the modal daily dose as outlined below.

Schizophrenia:

Placebo (n=584)

Cariprazine 1.5 to 3 mg/day (n=539)

Cariprazine 4.5 to 6 mg/day (n=575).

Bipolar disorder:

Placebo (n=442)

Cariprazine 3 to 6 mg/day (n=263).

Cariprazine was statistically significantly more efficacious than placebo in 3 of the 4 clinical trials in patients with schizophrenia.

Cariprazine was statistically significantly more efficacious than placebo in all 3 clinical trials in patients with bipolar disorder.

The most commonly reported treatment-emergent adverse events that occurred in at least 5% of patients and at least twice as often as placebo are shown below.  

Schizophrenia studies: 

Bipolar disorder studies: 

In the FDA-approved dose range, no patient on cariprazine had a QTcB or QTcF interval >500 msec.

The percentages of patients whose cholesterol, triglycerides, or fasting glucose changed from normal to abnormal were similar between cariprazine and placebo.

The percentages of patients who gained 7% of more from their baseline weight (the standard definition of clinically significant weight gain) were as shown below.

Schizophrenia studies:

Placebo 5%, cariprazine 1.5 to 3 mg/day 8%, cariprazine 3 to 6 mg/day 8%.

Bipolar disorder studies:

Placebo 2%, cariprazine 3 to 6 mg/day 1%

Cariprazine has been shown to be efficacious in the FDA-approved dose ranges in patients with acute exacerbation of schizophrenia and bipolar mania.

The commonest adverse events associated with cariprazine were akathisia, extrapyramidal symptoms, tremor, restlessness, and vomiting.

Cariprazine was not associated with worsening of lipid profile or fasting blood glucose, or with prolongation of QTc interval.

Cariprazine has been shown to be efficacious in FDA-approved dose ranges and its adverse effect profile is what is to be expected based on its pharmacological activity as a D3/D2 receptor partial agonist.

Tardive dyskinesia (TD) is one of the most important adverse effects of antipsychotic treatment because it often persists and can be disfiguring and even disabling.

However, there are currently no FDA-approved treatments for TD. Available treatments either do not work well or are extremely expensive (tetrabenazine). Tetrabenazine is FDA-approved only for Huntington’s disease. Also, it has been associated with neurological and psychiatric adverse effects in persons with Huntington’s disease.

Valbenazine is a drug being developed for the treatment of tardive dyskinesia that has completed phase III studies, but is not yet approved by the FDA.

It is a highly selective vesicular monoamine transporter 2 (VMAT2) inhibitor. The vesicular monoamine transporter 2 (VMAT2) is a protein in the presynaptic neuron that regulates monoamine (e.g., dopamine) uptake from the cytoplasm to the synaptic vesicle. With the dopamine thus stored away, dopamine levels in the synapse are reduced, which in turn improves the symptoms of TD. Note: the existing medication tetrabenazine is also a VMAT2 inhibitor.

This was a phase 3 study and was sponsored by the Neurocrine Biosciences, Inc, that is developing this drug.

This was a 6-week, double-blind, placebo-controlled clinical trial

Persons with moderate or severe antipsychotic-induced TD were included.  These persons had schizophrenia, schizoaffective disorder, or a mood disorder.

They were randomized to receive valbenazine 40 mg/day, valbenazine 80 mg/day, or placebo.

The primary outcome measure was the score on the Abnormal Involuntary Movement Scale (AIMS). AIMS assessment was done by central video raters who were blinded to the treatment.

234 subjects were randomized.

86% of the subjects were currently receiving an antipsychotic medication (second-generation or “atypical” antipsychotic 77%; first-generation or “typical” antipsychotic 16%).

The mean AIMS score before treatment was 10.

There was a statistically significantly greater improvement in AIMS score in patients who received either valbenazine 40 mg/day or 80 mg/day compared to those who received placebo.

Better by how much? The estimated mean reduction in AIMS score with valbenazine 80 mg/day was 3.2 points and with 40 mg/day was 1.9 points versus only 0.1 points on placebo. That is a clinically meaningful difference between drug and placebo when you compare the reduction to the baseline AIMS score (mean of 10).

Another way of looking at how much of a benefit there was is Effect Size. An effect size of 0.8 is considered a large effect and for the benefit of valbenazine 80 mg/day vs. placebo, the Effect Size was 0.9.

The Clinical Global Impression showed a lower severity of TD with valbenazine than with placebo, but this difference was not statistically significant (i.e., could have occurred by chance alone). I am not too surprised by this and we can all ponder over why the systematic assessment using the AIMS showed a statistically significant difference while the Clinical Global Impression did not.

What were the adverse effects? There were surprisingly few. Adverse effects that occurred in either of the valbenazine groups at least twice as often as on placebo were:

Akathisia: placebo 1%, valbenazine 40 mg/day 4%, valbenazine 80 mg/day 3%

Arthralgia: placebo 1%, valbenazine 40 mg/day 1%, valbenazine 80 mg/day 4%

Dry mouth: placebo 1%, valbenazine 40 mg/day 6%, valbenazine 80 mg/day 0%

Vomiting: placebo 0%, valbenazine 40 mg/day 0%, valbenazine 80 mg/day 4%

Dyskinesia: placebo 0%, valbenazine 40 mg/day 0%, valbenazine 80 mg/day 4%

Multiple rating scales (PANSS, YMRS, MADRS, CDSS, C-SSRS) were used to assess psychiatric status and it remained stable during the study.

Valbenazine was associated with a significant improvement in TD.

It had very few adverse effects, even when taken with a wide range of concomitant medications, including antipsychotic medications.

It did not appear to worsen psychiatric symptoms, or to lead to depression or suicidality.

It has been very frustrating to clinicians and to patients that we have not had any effective treatments for TD that we could use in clinical practice. Tetrabenazine is very expensive and health insurance doesn’t approve it for TD. Also, tetrabenazine was associated with poor tolerability and with neurological/psychiatric adverse events.

Both the efficacy and the tolerability of valbenazine in such a short-term study are encouraging.

I would definitely like to see longer-term data to see if the TD continues to improve even further and to make sure that the improvement lasts.

For the same reasons that were mentioned for the study of valbenazine discussed above:

Tardive dyskinesia (TD) is one of the most important adverse effects of antipsychotic treatment because it often persists and can be disfiguring and even disabling.

However, there are currently no FDA-approved treatments for TD. Available treatments either do not work well or are extremely expensive (tetrabenazine).  Tetrabenazine is FDA-approved only for Huntington’s disease. Also, it has been associated with neurological and psychiatric adverse effects in persons with Huntington’s disease.

Deutetrabenazine is a new drug in development. It is a selective VMAT2 inhibitor that has been shown to be efficacious in reducing chorea in persons with Huntington’s disease.

Deuterium is a naturally occurring form of hydrogen. Incorporation of deuterium in deutetrabenazine changes the drug’s pharmacokinetic profile and reportedly leads to more-uniform systemic exposure.

This study aimed to evaluate the efficacy, safety, and tolerability of deutetrabenazine as a treatment for TD.

The study was funded by Teva Pharmaceutical Industries, Ltd, that is developing deutetrabenazine as a potential treatment for TD.

This was a 12-week, randomized, double-blind, placebo-controlled study.

Adults with moderate or severe TD were included.

The subjects had been treated with a dopamine receptor antagonist for at least 3 months (1 month for persons 60 years or older).

Abnormal Involuntary Movements Scale (AIMS) assessment was done by a blinded central rater.

The Abnormal Involuntary Movements Scale (AIMS) score was 6 or greater.

The psychiatric disorder and medication were stable prior to entering the study.

Deutetrabenazine was titrated to a tolerated dose that adequately controlled abnormal movements over 6 weeks. The drug was then continued at that dose for another 6 weeks.

117 subjects were randomized. The mean age was 55 years; 52% were females.

Mean duration of TD was 75 months but with a lot of variability. That is, many patients had had the TD for years.

The mean AIMS score was 10.

Patients who received deutetrabenazine showed a greater reduction in AIMS score after 12 weeks of treatment (the primary outcome measure)—an estimated mean reduction of 3 points vs. 1.6 points on placebo.

On the Clinical Global Impression scale, 48% on drug were considered much improved or very much improved versus 40% on placebo. Thus, only 8% more patients who received deutetrabenazine were considered much improved or very much improved. In persons whose baseline AIMS score was 6 or more (i.e., who had more severe TD), this drug-placebo difference was 17%, which would be considered clinically meaningful. However, these differences were not clinically significant, i.e., could have occurred simply be due to chance alone. Thus, systematic, centralized assessment using the AIMS showed a statistically significant difference while the Clinical Global Impression did not.

Treatment-emergent adverse events that occurred at least twice as often on drug as on placebo were:

Insomnia (7% vs. 2%)

Akathisia (5% vs. 0%). However, surprisingly, on systematic examination using the Barnes Akathisia Rating Scale, there was no difference between drug and placebo.

Just for your amusement and to illustrate the problem of assessing and reporting adverse events in clinical trials, treatment-emergent adverse events that occurred at least twice as often on placebo as on drug were:

Dry mouth (10% vs. 3%)

Upper respiratory tract infection (7% vs. 3%)

Rash (2% vs. 5%)

After 12 weeks of treatment, deutetrabenazine was efficacious for the treatment of antipsychotic-induced TD.

The rate of discontinuation of treatment was low and no depression or suicidal ideation were reported. Both of these have been reported with tetrabenazine in persons with Huntington’s disease.

My comments are the same as those for the study of valbenazine for TD that is discussed above:

It has been very frustrating to clinicians and to patients that we have not had any effective treatments for TD that we could use in clinical practice. Tetrabenazine is very expensive and health insurance doesn’t approve it for TD. Also, tetrabenazine was associated with poor tolerability and with neurological/psychiatric adverse events.

Both the efficacy and the tolerability of deutetrabenazine in such a short-term study are encouraging.

I would definitely like to see longer-term data to see if the TD continues to improve even further and to make sure that the improvement lasts.

What is the regulatory status of deutetrabenazine? In May 2016, Teva pharmaceuticals received a Complete Response Letter from the U.S. Food and Drug Administration (FDA) regarding the New Drug Application for deutetrabenazine for the treatment of chorea associated Huntington disease. The FDA has asked Teva to examine blood levels of certain metabolites, but no new clinical trials have been requested. Hopefully Teva will address the FDA concerns and  deutetrabenazine will soon be approved by the FDA for the treatment of Huntington’s chorea. A separate New Drug Application for deutetrabenazine for the treatment of tardive dyskinesia is expected to be submitted after that.