Influences on prescribing in borderline personality disorder: insights from health care professionals: a qualitative interview study

Borderline Personality Disorder (BPD) is a complex psychiatric condition that significantly impacts not only individuals but also wider society. Despite the absence of licensed medication for BPD, there is substantial evidence of high rates of prescribing and polypharmacy within this population. This has raised concerns, given the potential adverse effects of psychotropics. This study aimed to explore the potential factors influencing prescribing decisions in patients with BPD. We conducted semi-structured interviews with healthcare professionals involved in prescribing for individuals with BPD. Participants included doctors, non-medical prescribers, and pharmacists from both primary and secondary care settings. Data was analysed using thematic analysis utilising both inductive and deductive approaches. Twenty interviews were completed, generating five key themes believed to influence prescribing decisions. These themes indicate that prescribing occurs at least in part to manage specific symptoms; address perceived risks; maintain or strengthen the therapeutic relationship; compensate for the lack of alternative treatment options; and respect patient autonomy and choice. Participants highlighted the complexities involved in treating individuals with BPD, indicating that prescribing decisions were often more than simple risk-benefit assessments of the prescribed medication. In particular, they highlighted the challenge of balancing risks while maintaining a therapeutic relationship. Additionally, the findings indicate that a patient's preference for medication may lead prescribers to embrace a greater risk tolerance when prescribing. The study was registered with and received a favourable outcome from the Human Research Authority (IRAS 330510) and was approved at the London - Camberwell St Giles Research Ethics Committee (REC) on the 12th of December 2023.