Long-acting injectable aripiprazole in borderline personality disorder: targeting non-adherence and behavioural dysregulation

Background

Borderline personality disorder (BPD) is characterised by affective instability, impulsivity, and recurrent self-harming behaviours, often leading to emergency department attendances, psychiatric hospitalisations and impaired psychosocial functioning. Although no pharmacological treatments are formally approved for BPD, second-generation antipsychotics are widely used in clinical practice to target mood instability, impulsivity, and behavioural dysregulation, with a growing body of literature supporting their role in selected symptom domains. Aripiprazole, has been associated with improvements in emotional regulation and impulsivity. Poor adherence to oral pharmacotherapy is a major contributor to clinical instability in this population. Long-acting injectable (LAI) formulations may improve adherence and provide more stable plasma drug levels, potentially enhancing therapeutic outcomes, but evidence regarding LAI antipsychotics in BPD remains limited.

Aims

To evaluate the impact of LAI aripiprazole on clinical outcomes in patients with BPD and documented non-adherence to oral treatment in a real-world setting.

Methods

A retrospective, naturalistic case series was conducted including 10 outpatients diagnosed with BPD and a history of poor adherence to oral pharmacotherapy, followed in a specialist psychiatric outpatient programme and treated with LAI aripiprazole (aripiprazole maintena). The sample was clinically heterogeneous, with frequent comorbidities including substance use disorders and other psychiatric conditions; approximately half of the patients met criteria for bipolar spectrum disorders. The variables recorded and compared before and after introduction of LAI aripiprazole were number of suicide attempts, frequency of self-harming behaviours, number of psychiatric hospital admissions, number of emergency department attendances, and substance use patterns. Functional change was assessed using the Functioning Assessment Short Test (FAST). Descriptive statistics were calculated, and pre–post differences were explored using non-parametric methods (Wilcoxon signed-rank test), given the small sample size and non-normal distribution of variables.

Results

Comparison of clinical variables before and after initiation of LAI aripiprazole showed substantial overall improvement, although the magnitude of change varied between patients. Suicide attempts, self-harming behaviours, psychiatric hospital admissions, emergency department attendances, and substance use all improved to a greater or lesser extent. FAST scores also improved quantitatively in all patients, supporting a broad functional benefit beyond reduction in acute behavioural dysregulation. Treatment adherence improved markedly, with no missed administrations recorded. LAI aripiprazole was generally well tolerated, and no discontinuations due to adverse effects were observed. Given the small sample size and clinical heterogeneity, statistical findings should be interpreted with caution.

Conclusions

LAI aripiprazole may represent a useful off-label strategy for patients with BPD and persistent non-adherence, with benefits across acute clinical outcomes and overall functioning. The observed improvements included reductions in self-harming behaviours, suicide attempts, acute care utilisation, and substance use, alongside quantitative improvement in FAST scores. These findings are notable given the heterogeneity of the sample and the high prevalence of bipolar spectrum comorbidity. However, variability in adjunctive pharmacological treatments and comorbid conditions may represent confounding factors. These results are hypothesis-generating and support the need for controlled, prospective studies to clarify the potential role of LAI antipsychotics in BPD.

References

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