ADHD meds emerge as preferred option for reducing self-harm risk in BPD

For individuals with bipolar disorder (BPD), attention-deficit/hyperactive disorder (ADHD) medications help lower the risk of suicidal behaviour, according to data from a comparative effectiveness research study.

A 17-percent reduction in the risk of attempted or completed suicide was seen among BPD patients who used vs did not use ADHD meds (hazard ratio [HR], 0.83, 95 percent confidence interval [CI], 0.73–0.95; false discovery rate [FDR]–corrected p=0.001). [JAMA Netw Open  2023;6:e2317130]

“None of the other investigated pharmacotherapies (ie, antipsychotics [HR, 1.18, 95 percent CI, 1.07–1.30; FDR-corrected p<0.001], antidepressants [HR, 1.38, 95 percent CI, 1.25–1.53; FDR-corrected p<0.001], mood stabilizers [HR, 0.97, 95 percent CI, 0.87–1.08; FDR-corrected p=0.99], and benzodiazepines [HR, 1.61, 95 percent CI, 1.45–1.78; FDR-corrected p<0.001]) were associated with favourable outcomes,” reported a team of Sweden-based investigators.

“In fact, treatment with benzodiazepines was consistently associated with an increased risk of attempted and completed suicide,” they added.

The analysis included 22,601 patients with BPD (mean age 29.2 years, 15.7 percent men) who were identified from nationwide Swedish register databases of inpatient care, specialized outpatient care, sickness absences, and disability pensions. Over a mean follow-up of 6.9 years, 8,513 hospitalizations due to attempted suicide and 316 cases of completed suicide were documented.

“To our knowledge, this is the first study to explore the comparative effectiveness of pharmacotherapies on suicidal behaviour in individuals with BPD. Our study adds to the literature by providing insight concerning the use of pharmacotherapy and suicide risk, which is a major clinical challenge for treating BPD,” the investigators said.

Overlapping symptoms

Large epidemiological studies provide evidence that ADHD medication use is associated with a low risk of self-harm in ADHD. [BMJ 2014;348:g3769; Biol Psychiatry 2020;88:452-458]

“According to our results, patients with BPD are at their lowest risk for suicidal behaviour when treated (vs not treated) with ADHD medications, particularly stimulant compounds. The lowest risk of attempted or completed suicide was detected for lisdexamphetamine,” the investigators pointed out.

They also believe that patients with BPD who are receiving ADHD medication treatment likely have comorbid ADHD symptoms, given that the main clinical indication for stimulants is ADHD. Indeed, BPD and ADHD share overlapping symptoms, such as impulsivity and emotion dysregulation, thus creating an opportunity for drugs to target such symptoms in both patient populations. [Borderline Personal Disord Emot Dysregul 2018;5:9; Borderline Personal Disord Emot Dysregul 2019;6:11]

More importantly, ADHD medications have been associated with decreased impulsivity—a crucial predictor of suicidal behaviour among individuals with BPD. [J Am Acad Child Adolesc Psychiatry 2009;48:884-893; JAMA Psychiatry 2021;78:187-194]

“Strikingly, our findings suggest that up to a 48-percent decrease in the probability of suicide completion in patients with BPD is attributable to treatment with ADHD medication. Taken together, our [data] indicate that ADHD medication should be the preferred choice for patients with BPD with ADHD symptoms and suicidal behaviour,” the investigators said.

Benzos commonly prescribed

On the other hand, benzodiazepines are often prescribed to patients with BPD. In the present cohort, more than half of the patients received treatment with benzodiazepines at some point during the follow-up. The use of benzodiazepines in this patient population, according to the investigators, runs counter to the impulsivity-related concerns in BPD. [Acta Psychiatr Scand 2017;136:323-331; Int Clin Psychopharmacol 2014;29:224-228; Dialogues Clin Neurosci 2013;15:213-224]

“During benzodiazepine treatment, the risk of attempted or completed suicide was increased compared with time without benzodiazepine treatment. Alarmingly, treatment with benzodiazepines was related to a fourfold risk increment in suicide completion in patients with BPD,” the investigators said.

“Our findings potentially result from well-reported augmented impulsivity and aggression among patients with BPD during benzodiazepine treatment that may facilitate suicidal behaviour,” they added. [Am J Psychiatry 1985;142:98-100; Arch Gen Psychiatry 1988;45:111-119]