Comparing SSRI Treatment and DBT for Managing Suicidality in Patients With Borderline Personality Disorder

TRANSLATING RESEARCH INTO PRACTICE

Rajesh R. Tampi, MD, MS, DFAPA, DFAAGP, Column Editor

A monthly column dedicated to reviewing the literature and sharing clinical implications.

The diagnostic criteria for borderline personality disorder (BPD) include, among other things, recurrent suicidal or self-harm behaviors. Prior research has demonstrated the efficacy of dialectical behavioral therapy (DBT) in reducing the suicidality and nonsuicidal self-injury (NSSI) associated with BPD. BPD is highly comorbid with major depressive disorder (MDD), for which selective serotonin reuptake inhibitors (SSRIs) are the first-line medication class. Previous randomized controlled trials (RCTs) examining pharmacologic management of BPD have focused on general BPD symptom outcomes. This is the first RCT to compare SSRIs with DBT specifically for the management of suicidality and NSSI in BPD.

The Study

Brodsky BS, Galfalvy H, Mann JJ, Grunebaum MF, Stanley B. Dialectical behavior therapy versus serotonin reuptake inhibitor treatment for suicidal behavior in borderline personality disorder: a randomized controlled trial. Am J Psychiatry. 2025;182(12):1083-1092.

Study Funding

This study was funded in part through National Institute of Mental Health R01 grants.

Study Objective

To compare the efficacy of 6 months of DBT vs SSRI treatment for suicidality and NSSI in participants with BPD with or without comorbid MDD.

Methodology

Inclusion criteria for this RCT consisted of a diagnosis of BPD, suicidal ideation in the past week, and at least 1 episode of NSSI, suicide attempt, or suicide-related behavior in the past 6 months. Exclusion criteria included a diagnosis of bipolar I disorder, psychotic disorders, or intellectual disability; any conditions requiring acute inpatient care; receipt of effective treatment elsewhere; and history of nonresponse to an adequate trial of fluoxetine. Participants on medication had a medication taper and subsequent 2-week washout period before starting the study.

Participants aged 18 to 55 years were randomly assigned to either the DBT group (n = 42) or SSRI and clinical management group (SSRI/M; n = 42) for 6 months. The DBT group involved weekly individual DBT sessions with a clinical psychologist, weekly skills groups, and between-session phone coaching. SSRI/M participants received 30-minute psychiatry appointments at least every 2 weeks with psychoeducation and general support. SSRI/M treatment was fluoxetine 20 to 40 mg daily; intolerance or lack of response at 4 weeks prompted a switch to citalopram. A similar protocol was used for switching to paroxetine (20-30 mg daily) for citalopram nonresponse or intolerance. In the follow-up phase (3- and 6-month assessments following 6 months of treatment), participants switched to open, unspecified treatments.

The primary outcome studied was the number of suicide-related events (SREs; defined as attempts, aborted or interrupted attempts, or suicidal ideation resulting in an emergency department visit or psychiatric hospitalization) during the 6-month treatment period. This was analyzed using Poisson regression models. Secondary outcome measures included the time to first SRE (using a log-rank test for survival analysis), incidence of MDD episodes, and (using validated rating scales) severity of depressed mood and BPD symptoms, including NSSI. Intent-to-treat analysis was used.

Study Results

Participants included in this study were 92% women and 57% White, with a mean age of 29.3 years. Comorbid psychiatric diagnoses were relatively equally allocated, with 68% of participants having MDD. Most had a history of past SREs (95%) and/or NSSI (93%). Both treatment arms had similar rates of loss to follow-up.

There were fewer SREs during the treatment phase in the DBT arm (Poisson rate ratio relative risk [RR], 0.29; P = .016), a primary outcome result upheld by survival analysis, as well as a subgroup analysis of those with comorbid MDD. However, during the 6 months of follow-up after the treatment phase, there was no significant difference in the number of participants in each group with at least 1 SRE (26% in the DBT arm, 16% in the SSRI/M arm; P = .467) or those with at least 1 suicide attempt (P = .577). The number of suicide attempts during the treatment phase was lower in the DBT arm (RR, 0.32; P = .048), though time to attempt did not differ significantly between the groups (P = .089). Suicidal Ideation Severity Scale scores also improved similarly in both groups.

Although the total number of treatment-phase NSSI episodes was significantly lower in the DBT arm than in the SSRI/M arm (RR, 0.69; P = .008), the odds of avoiding any treatment-phase NSSI episodes did not differ significantly between the groups (P = .595). Additionally, the groups did not differ significantly on the percentage of participants with NSSI episodes during the follow-up phase.

Self-report (Beck Depression Inventory) and clinician-rated (Hamilton Depression Rating Scale [HAM-D]) depression scores declined similarly in both treatment groups, with an average 6-point reduction in HAM-D score over the treatment phase. However, the rate of current MDD was significantly higher (26% vs 3%) at the end of the treatment phase in the DBT arm. BPD symptom scores (Zanarini Rating Scale) also decreased comparably in both treatment groups. Impulsiveness scores decreased in the DBT group but not in the SSRI/M group.

The SSRI/M treatment arm showed better overall clinical improvement (measured with the Clinical Global Impressions-Improvement scale) after 2 months of treatment, but this improvement did not differ significantly between the groups at later treatment intervals (4 and 6 months). Finally, emotion dysregulation decreased significantly in both groups, but this decrease was more than twice as fast in the DBT group.

Conclusions

DBT treatment resulted in fewer SREs and NSSI episodes than SSRI/M treatment over this RCT’s 6-month treatment phase. This superiority was not sustained at 6-month follow-up after the treatment phase. Although SSRI/M treatment was associated with greater remission rate from comorbid MDD, DBT treatment was associated with greater reduction in impulsiveness and emotion dysregulation.

Practical Applications

The study's findings further support the use of DBT as an effective first-line treatment for BPD. Medications such as SSRIs are often used to treat comorbid MDD and were effective in doing so in this study. Clinicians should pursue evidence-based psychotherapy treatments for patients with BPD; systems must evolve to provide crucial access to high-quality psychotherapy in clinical practice.

Bottom Line

The study findings suggest that 6 months of DBT are superior to SSRI treatment in reducing suicidal thoughts and behaviors and NSSI in individuals with BPD—even in a population with a high rate of MDD comorbidity. However, further studies are required to determine whether this superiority endures over time.

Dr Hilsenrath is a third-year psychiatry resident at Creighton University in Omaha, Nebraska. Dr Chambers is a second-year psychiatry resident at Creighton University. Dr Abid is a first-year psychiatry resident at Creighton University. Dr Dickan is a fourth-year psychiatry resident at Creighton University. Dr Schuster is an assistant professor of psychiatry at Creighton University School of Medicine. Dr Mullen is an assistant professor of psychiatry at Saint Louis University School of Medicine in Missouri. Dr Tampi is professor and chair of the Department of Psychiatry at Creighton University School of Medicine and Catholic Health Initiatives Health Behavioral Health Services. He is also an adjunct professor of psychiatry at Yale School of Medicine in New Haven, Connecticut, and a member of the Psychiatric Times editorial board.

Reference

Brodsky BS, Galfalvy H, Mann JJ, Grunebaum MF, Stanley B. Dialectical behavior therapy versus serotonin reuptake inhibitor treatment for suicidal behavior in borderline personality disorder: a randomized controlled trial. Am J Psychiatry. 2025;182(12):1083-1092.