It is indeed helpful to see an important and complex issue related to the management of the borderline personality disorder (BPD) being addressed by Crawford et al . The authors present an eloquent argument as to why mood stabilizers, and indeed even psychotropics, should be avoided as far as possible . It is interesting to note that the authors also very pertinently point that such patients can be ‘demanding’ and ‘clinicians may feel under pressure to prescribe drugs’; “additionally, patients with BPD have high rates of deliberate self-harm and a rate of suicide that is 20 times that of the general population” .
I have been working as a Consultant for 15 years, and after having spent nearly half that time in the NHS as a General Adult Consultant Psychiatrist managing such patients in both community and inpatient settings, I am of the opinion that the non-pharmacological recommendations provided by the authors as alternatives to use of psychotropics (especially mood stabilizers) is easier said than done.
Beneficial effects for both comprehensive psychotherapies and non-comprehensive psychotherapeutic interventions for patients with BPD are acknowledged as per the most recent Cochrane review . However, this needs to be seen in perspective of the ground reality existing for availability and delivery of psychological therapies in the UK. Even though mental health services are exempt from the 18-week maximum waiting time for access to services as per NHS Constitution, there is data to indicate that roughly 1 in 5 people wait for over one year, and 1 in 2 have to wait for at least 3 months . Additionally, under the Improving Access to Psychological Therapies (IAPT) survey, it was also seen that amongst people who were using talking therapies, 58% were not offered a choice in the type of therapies received, and 75% were not given a choice where they received it . If one extrapolates these findings to patients with BPD, this will not be in keeping with the broad principles of care laid down for managing these patients as per the NICE Guidance .
Additionally, the authors have highlighted the inordinately high use of psychotropics for managing patients with BPD from various NHS Trusts . A similar finding has been reported from other countries like Germany  where pharmacotherapy tends to be play a major role in the management of BPD; one major reason postulated being that prescribing psychiatrists do not feel confident with the choice of psychological treatment over medication . Though not clearly documented, but a similar reason could operate in the UK too.
It is well known that patients with BPD tend to be prone to rejection and have an inherent tendency to fragment and/or ‘sabotage’ their own care with high rates of disengagement [1,4,6]. Additionally, majority of the professionals (most commonly mental health nurses) dealing with these patients tend to harbor negative feelings and attitudes for self (uncomfortable, anxious, challenged, manipulated) and towards them (dangerous, powerful, more difficult to take care of, unrelenting, time-consuming etc.) with behavioral responses of social distancing, being less helpful, expressing less empathy, and expressing anger .
Keeping in view the interplay of the above mentioned factors, the ground reality of managing patients with BPD (especially those who threaten or demonstrate self-harm, and are deemed to be at a high potential risk for suicide) is extremely challenging and demanding, and it is not easy to demonstrate complete fidelity in translating theoretical evidence (or ‘lack of it’ in the case of BPD) into direct clinical care.
Hence, the pragmatic management of patients with BPD will probably continue to show use of psychotropics (including mood stabilizers) on an empirical basis and as a stop-gap arrangement till appropriate pragmatic and/or controlled research evidence becomes available. More importantly, the implementation of NICE guidance regarding psychotherapy for BPD , and addressing the issues related to the ground realities identified above may be an equally, if not more, important way forward for clinicians in managing patients with BPD.
 Crawford MJ, MacLaren T, Reilly JG. Are mood stabilizers helpful in treatment of borderline personality disorder? BMJ 2014; 349: g5378.
 Stoffers JM, Vollm BA, Rucker G, Timmer A, Huband N, Lieb K. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2012; Aug 15;8:CD005652. doi: 10.1002/14651858.CD005652.pub2.
 Department of Health. Annual Report of the Chief Medical Officer 2013, Public Mental Health Priorities: Investing in the Evidence. Department of Health, London, pp 207.
 National Institute for Health and Clinical Excellence. Borderline personality disorder: treatment and management. NICE, 2009.
 Knappich M, Hogz-Sagstetter S, Schwerthoffer D, Leucht S, Rentrop M. Pharmacotherapy in the treatment of patients with borderline personality disorder: results of a survey among psychiatrists in private practices. Int Clin Psychopharmacol 2014; 29: 224-228.
 Gupta N. The conundrum of emotionally unstable personality disorders. IJSP 2012; 28: 36-42.
 Sansone RA, Sansone LA. Responses of mental health clinicians to patients with borderline personality disorder. Innov Clin Neurosci 2013; 10: 39-43.
Competing interests: No competing interests