L’analyse des prescriptions de psychotropes dans le trouble de personnalité borderline montre un recours massif aux psychotropes, majoritairement en polythérapie et délivrés au long cours. Ce constat est en contradiction avec (1) les résultats de nombreux essais randomisés contrôlés qui n’apportent pas d’argument solide pour une efficacité clinique sur les objectifs thérapeutiques prioritaires du trouble de personnalité borderline, (2) des études populationnelles de registre qui montrent un risque augmenté de réhospitalisation, tentative de suicide voire décès associé aux antidépresseurs, antipsychotiques et benzodiazépines, et (3) les recommandations thérapeutiques dans le trouble de personnalité borderline qui proposent de limiter les psychotropes à un usage ponctuel, en réponse à des situations aiguës associées à des symptômes sévères. Notre article tente d’analyser certains déterminants individuels (impliquant patients et prescripteurs) et structurels (formation des psychiatres, organisation du système de soins) de la surmédicamentation du trouble de personnalité borderline en France. Il propose des pistes pour la limiter notamment le renforcement des stratégies non médicamenteuses, la déprescription et l’usage potentiel du placebo honnête.

Therapeutic recommendations for borderline personality disorder emphasize the importance of offering, as first-line treatment, structured psychotherapies aimed at improving emotional regulation skills and reducing self-harming behaviors. Psychopharmacological recommendations suggest limiting psychotropic drugs to short-term use in case of acute situations associated with severe symptoms. However, analysis of psychotropic prescriptions for borderline personality disorder shows widespread use of psychotropic drugs (96% have received at least one psychotropic drug), mostly in combination therapy (50% take three or more psychotropic drugs, 19% to 26% take four or more) and prescribed on a long-term basis. This finding contradicts therapeutic recommendations and contradicts (1) the results of numerous randomized controlled trials that fail to provide solid evidence of clinical efficacy on the main therapeutic goals for borderline personality disorder, (2) population-based studies that show an increased risk of rehospitalization, suicide attempts, and even death associated with use of antidepressants, antipsychotics, and benzodiazepines. This risk was only reduced by the use of certain psychostimulants.

We analyze some individual (involving patients and prescribers) and structural (psychiatrist training, healthcare system organization) factors of the over-medicalization or over-medication of borderline personality disorder in France. We discuss the fact that the fragility of the concept of borderline personality disorder could explain its very high comorbidity with mood, anxiety, or psychotic disorders, with a risk of overdiagnosis justifying the overmedication described above. We also discuss how the training of psychiatrists, with its greater emphasis on psychopharmacology and less on psychotherapy, may facilitate easier and quicker reliance on medication despite non-pharmacological interventions that should be offered as first line treatment. More structural aspects in France also explain the lower use of psychotherapy, which is insufficiently reimbursed compared to other countries. We also question some cognitive biases among psychiatrists in their application of the principles of “evidence-based medicine”: the confidence they place in prescribing medication may lead them to overestimate its benefits while neglecting the iatrogenic effects of their prescriptions. Finally, we discuss relational issues surrounding the prescription of medication from the patients’ perspective, which may contribute to this overuse.

We propose ways to limit this overmedication: strengthening psychotherapy training for psychiatrists, improving access to non-pharmacological interventions, deprescribing psychotropic drugs, and the use of open-label placebos. We stress that deprescribing psychotropic drugs requires careful protocols in order to minimizing the withdrawal effects induced by too rapid medication tapering, in particular in patients with long-term use of psychotropics such as patients with borderline personality disorder. Those protocols are insufficiently known from psychiatrists. Regarding open-label placebo, this strategy aims to meet prescription demand while minimizing adverse effects and strengthening the ethical transparency of prescribing. This therapeutic option has shown significant clinical efficacy in distinct somatic and psychic conditions. It may also contribute to the clinical improvement of patients by recognizing and mobilizing the non-specific components of the therapeutic relationship (expectations, trust, alliance, meaning given to treatment).

Rethinking the role of medication in the borderline personality disorder does not mean disqualifying psychiatry, but rather strengthening it by anchoring it in a more judicious and ethical use of its tools. If one of the basic principles of medicine is “primum non nocere” (first, do no harm), in the case of BPD, this principle could be rephrased as “primum non prescribere, secondum deprescribere” (first, do not prescribe, second, deprescribe), proposing a more rewarding “skills, no pills” strategy.