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RESULTS
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).
DISCUSSION
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.
REFERENCES
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Norden, MJ: Fluoxetine in Borderline Personality Disorder. Prog Neuropsychopharmacol Biol Psychiatry 1989;13(6):885-93
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Markovitz, P: Fluoxetine in the Rx of the Borderline Personality Disorder and Schizotypal Personality Disorder. Am J Psychiatry 1991; 148(8):1064-7
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Cornelius, J; Soloff, Paul: Fluoxetine Trial in Borderline Personality Disorder. Psychopharmacology Bulletin 1990 Vol 26(1) 151-154
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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
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Heller, L: Life at the Border - Understanding and Recovering From the Borderline Personality Disorder, West Palm Beach, FL, Dyslimbia Press, Inc. 1992
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Cowdry, RW: Psychopharmacology of Borderline Personality Disorder - A Review. J Clin Psychiatry 48:8 (suppl) August 1987
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