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Research found that 1 in 4 people with personality disorders who do not have a severe mental illness are being prescribed antipsychotics in primary care. Many people are receiving these drugs for more than a year, despite UK guidelines advising against this use of antipsychotics.

People with personality disorders think, feel, behave or relate to others differently from the average person. There is limited evidence that antipsychotics (drugs that reduce anxiety and hallucinations) can help them. Despite this, people with personality disorders are being prescribed these medications in primary care.

This study was based on patient records from primary care. Researchers found that, among people with personality disorders, prescribing of antipsychotics was more common in women, deprived areas, and in those who had had an adverse childhood experience (such as physical abuse). Prescriptions have increased over time.

Treatment guidelines for people with personality disorders do not recommend antipsychotics in those who do not have severe mental illnesses. Antipsychotics can increase the risk of weight gain and diabetes.

More information on personality disorders is available on the NHS website.

What’s the issue?

People with personality disorders have irregular patterns of thinking and may struggle to control their emotions, and to interact with others. As many as 1 in 10 people have a personality disorder; the most common type is borderline personality disorder.

People with a severe mental illness (such as schizophrenia or bipolar disorder) may have psychosis and hold unusual beliefs that are not based on reality. They can benefit from antipsychotic medicines. However, for people with borderline personality disorder, there is only limited evidence that these drugs improve impulsivity, aggression, and poor social skills.

Long-term use of antipsychotics has been linked with conditions affecting people’s metabolism (such as obesity and diabetes) and conditions affecting the heart and blood vessels. UK treatment guidelines do not recommend their use in people with personality disorders who do not have severe mental illnesses.

This study examined how frequently antipsychotics are prescribed in UK primary care for people with personality disorders, and for how long.  

What’s new?

The study included people with personality disorders who were included in a large primary care database, The Health Improvement Network. The researchers looked at anonymised data on 46,000 people with personality disorders, from 744 general practices in the UK, between 2000 and 2016. There was an even split between men and women, the average age was 43, and many were economically disadvantaged.

Overall, 1 in 3 (34%) had been prescribed antipsychotics. Of those who were prescribed antipsychotics, some had a record of severe mental illness, for which antipsychotics are recommended. However, most (59%) people with personality disorders who were prescribed antipsychotics had no record of severe mental illness.

Of the 36,857 people who had personality disorders but no record of severe mental illness:

  • 1 in 4 were prescribed antipsychotics
  • antipsychotics were more likely to be prescribed to women, to those from deprived backgrounds, to those who had an adverse childhood experience, and to those aged between 20 – 34 or over 75
  • antipsychotic prescribing increased (from 9% in 2000, to 19% in 2016)
  • many people received antipsychotics for a long time; the average was more than 1 year (439 days), with 1 in 10 people receiving antipsychotics for 5 years
  • the most commonly prescribed antipsychotics were quetiapine (40%), olanzapine (21%), and risperidone (18%).

Why is this important?

This is the first study to investigate antipsychotic prescriptions for people with personality disorders in UK primary care. Despite UK guidelines advising against antipsychotics in people with personality disorders (without severe mental illness), the practice is common.  

Antipsychotics put people with personality disorders at risk of conditions such as obesity. Prescribing was common among people over 75 who are already at high risk of conditions affecting their heart and blood vessels.

Guidelines recommend that people receiving antipsychotics should have their physical health monitored (for example, checking for weight gain and blood sugar levels). However, because antipsychotics are not recommended for people with personality disorders (without severe mental illness), they are not being monitored. The researchers say everyone receiving antipsychotics should have their health monitored.

The researchers were concerned that people with an adverse childhood experience were more likely to be prescribed antipsychotics. This group may benefit more from talking therapy than from medication, they say.

What’s next?

The study highlights the difference between guidelines and practice. The researchers call for greater awareness of treatment guidelines for people with personality disorders. More appropriate care pathways need to be identified. People with personality disorders need better access to mental health support, they say, especially in areas that are less wealthy.

Further research could examine why antipsychotics are so often prescribed long-term, and why certain groups are more likely to receive them. The researchers say that higher rates of prescribing in more deprived areas could reflect poorer access to psychological therapies or higher levels of distress.

Antipsychotics can have a negative impact on people’s physical health, especially if taken long-term. People taking these drugs need to have their physical health closely monitored, the researchers say.

This research is part of the Pathfinder programme that is assessing better ways to analyse patient records in mental health research. The study included data from 2000 to 2016; more up to date research could explore whether prescribing patterns have changed.

The NIHR is funding research into whether antipsychotics offer benefit to people with a borderline personality disorder, and whether they offer value for money.

You may be interested to read

This NIHR Alert is based on: Hardoon S, and others. Prescribing of antipsychotics among people with recorded personality disorder in primary care: a retrospective nationwide cohort study using The Health Improvement Network primary care database. BMJ Open 2022;2:e053943.

A description of personality disorders by the mental health charity Mind.

An overview of the signs and symptoms of personality disorders from the Rethink Mental Illness group.

NICE guidelines on the treatment of personality disorders.  

Funding: David Osborn and Joseph Hayes are supported by the University College London Hospitals NIHR Biomedical Research Centre and the NIHR Applied Research Collaboration North Thames. This work was supported by the Medical Research Council and the Wellcome Trust.  

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.


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