BACKGROUND:
Borderline personality disorder (BPD) is a significant cause of morbidity with no approved pharmacological treatment. We assessed treatment trajectories of patients with BPD in real-world clinical practice to help identify treatment gaps.

‍METHODS:
This retrospective, observational, cohort study used de-identified MindLinc electronic health records data from the Holmusk NeuroBlu database (Version 21R2) to analyse the treatment journey of patients with BPD (aged ≥12 years with ≥1 diagnosis of BPD) that were prescribed pharmacological treatment within 14 days of diagnosis (baseline) and had treatment data for ≥12 months.‍

RESULTS:
Of those prescribed pharmacological treatment at baseline, 1461 patients (16.1%) had 12 months of follow-up data. Antidepressants were the most frequently prescribed medication at baseline (80.4%) either alone or in combination with other medication classes, followed by second-generation antipsychotics (SGAs), anxiolytics and mood stabilisers. In the 12 months post-baseline, the most frequently recorded treatment pathway was a switch from 1 antidepressant to another. Sertraline (5.5%), fluoxetine (5%), and citalopram (5%) were the most-prescribed antidepressants; lamotrigine (24.9%), gabapentin (15.4%), and valproate (7.1%) were the most prescribed mood stabilisers; and quetiapine (22.1%) and aripiprazole (19.0%) were the most prescribed SGAs. Polypharmacy (defined as the prescription of ≥1 psychotropic medication) was observed in 83.1% of patients at baseline and increased with follow-up time and age.

‍CONCLUSION:
The high rates of polypharmacy observed suggest that current clinical practices may not fully align with treatment guidelines for BPD, and that patients with BPD experience a considerable treatment burden. Limitations of this study include the absence of psychotherapy data and the use of prescription records without information on treatment adherence. Nonetheless, the diversity of treatment patterns observed reflects the complex symptomatology of BPD and highlights the need to deepen our understanding of its neurobiology to improve pharmacological treatment strategies and translate to meaningful patient outcomes.

‍CLINICAL TRIAL NUMBER:
Not applicable.

BACKGROUND:
Current treatment modalities demonstrate variable effectiveness across patients with borderline personality disorder (BPD). Here, we describe the presenting clinical characteristics of patients with BPD based on approximately 20 years of real-world data.‍

METHODS:
This retrospective, observational study was based on de-identified MindLinc electronic health records of individuals (aged ≥12 years with ≥1 diagnosis of BPD) receiving mental healthcare between 1999 and 2020 across 15 US states using the NeuroBlu database (vRel21R2). Demographic and clinical characteristics at first recorded BPD diagnosis (index date), baseline (index date ±14 days), and in the 12 months prior to diagnosis were described. BPD symptoms were derived by natural language processing (NLP) of unstructured clinician-documented mental state examination (MSE) data.

‍RESULTS:
Across the 13,444 patients analysed at baseline (mean [SD] age 33 [12.8] years; 83.6 % female; 97.5 % with psychiatric comorbidities), the most frequent comorbid psychiatric conditions were major depressive disorder (45.7 %), substance use disorder (34.6 %) and post-traumatic stress disorder (29.2 %). Emotional dysregulation (35.8 %) and suicidal intent/ideation (31.3 %) were the most frequent NLP-derived BPD symptoms. Emotional dysregulation was more common in older patients, whereas suicidal intent/ideation/attempt/self-injury were more prevalent in younger patients. Mean (SD) length of hospitalisation was 2.9 (4.2) days, with 46.5 % of patients requiring ≥1 psychiatric hospitalisation. At diagnosis, 67.7 % of patients were prescribed pharmacological treatment, including antidepressants (51.1 %), second-generation antipsychotics (34.0 %) and anticonvulsants (33.7 %).

‍CONCLUSION:
BPD symptoms varied according to patient characteristics, including age and gender. These insights may enable patient-specific treatment planning in the future and improve therapeutic outcomes.

BACKGROUND:
Anxiety disorders, including the common generalized anxiety disorder (GAD), are among the leading causes of disability globally. Clinical practice guidelines recommend venlafaxine, a serotonin and norepinephrine reuptake inhibitor, as a first-line pharmacological treatment option for GAD.‍

METHODS:
This retrospective cohort study utilized longitudinal real-world data from the US-based database, Holmusk NeuroBlu Data, to explore anxiety severity changes following 30-90 days of venlafaxine prescription in adults with GAD. The main outcome was change from baseline (mean and median) in the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7) score, as well as clinically meaningful change (a difference of ≥4 points).

‍RESULTS:
Of 756 patients with GAD (78.6% female, 78.4% White, mean [standard deviation] age 38.5 [14.4 years]), 71.8% had a diagnosis of comorbid major depressive disorder (MDD) at baseline and 23.0% had another anxiety/phobic disorder. Median (interquartile range [IQR]) GAD-7 scores decreased significantly (P<0.001) from 14.0 (10.0-18.0) at baseline (-30 to +7 days from first venlafaxine prescription) to 9.0 (5.0-14.0) points at follow-up (30-90 days after first venlafaxine prescription), a median (IQR) change of -3.0 (-8.0-0.0), corresponding to a shift from moderate to mild anxiety severity. Stratified by baseline anxiety severity, symptom improvement was more pronounced among patients with greater baseline severity. Overall, 48.1% of patients had a clinically meaningful decrease of ≥4 points in GAD-7 score, while only 7.5% significantly worsened. Altogether, 63.6% of patients continued venlafaxine for ≥90 days after first venlafaxine prescription.

‍CONCLUSION:
In this real-world cohort, improved GAD-7 scores were observed to be associated with venlafaxine prescription.

OBJECTIVES:
To investigate long-acting injectable (LAI) antipsychotic prescribing patterns and their associations with transition and continuation of care and healthcare resource utilisation (HCRU) for patients with schizophrenia in the USA.

‍DESIGN:
A retrospective cohort study.

‍SETTING:
Electronic health record data from adults in the USA with schizophrenia were extracted from the NeuroBlu Database V.21R2.

‍PARTICIPANTS:
Adults (aged ≥18 years) with a schizophrenia diagnosis who initiated LAI antipsychotic treatment during psychiatric inpatient admission. The index date was the date of LAI initiation. Patients who had ≥1 primary, secondary or tertiary ICD-9/10 (International Classification of Diseases) diagnosis of schizophrenia at clinical sites that had both inpatient and outpatient facilities were included.

‍PRIMARY OUTCOME MEASURES:
Transition-of-care (eg, risk of rehospitalisation, number of hospital readmissions, number of outpatient visits post discharge), continuation-of-care (eg, first treatment path after discharge, time to index LAI discontinuation and number of patients who restarted LAIs after discontinuation) and HCRU endpoints (eg, length of stay of index hospitalisation and estimated cost for psychiatric outpatient visits pre-index and post-index) were the primary outcome measures.

‍RESULTS:
A total of 1197 patients were included who initiated an LAI in an inpatient setting. Of 339 patients with ≥3 months pre-index and post-index data, median time to rehospitalisation was 135 days. Patients discharged taking an LAI alone had lower frequency of rehospitalisation (incidence rate ratio (IRR)=0.62 (95% CI, 0.46 to 0.84)), lower risk of longer hospital stays (IRR=0.60 (95% CI, 0.43 to 0.84)), lower risk of becoming rehospitalised (HR=0.49 (95% CI, 0.35 to 0.69)) and lower risk of outpatient visits (IRR=0.50 (95% CI, 0.36 to 0.70)) versus patients co-prescribed an oral antipsychotic (LAI+OA). Patients discharged taking an LAI dosed once every 1-2 months or once every 2 weeks had lower frequency of rehospitalisation (IRR=0.85 (95% CI, 0.64 to 1.14)), lower risk of longer hospital stays (IRR=0.90 (95% CI, 0.70 to 1.15)) and lower risk of becoming rehospitalised versus an LAI dosed once every 2 weeks; risk of becoming rehospitalised was no different (HR=1.00 (95% CI, 0.76 to 1.32)) and risk of outpatient visits was greater (IRR=1.25 (95% CI, 0.96 to 1.63)). During hospitalisation, 73.4% of patients were co-prescribed an OA, most frequently risperidone, with their index LAI. From pre-admission to post-discharge, psychiatric clinic costs significantly increased (US$14 231, p<0.01 post-discharge vs pre-admission) among patients co-prescribed an OA. For patients who were prescribed an LAI alone there was minimal change in costs from pre-admission to post-discharge (p=0.068). At 12 months post-index, 75.3% of patients discontinued LAIs, dosed once every 1-2 months versus LAIs, dosed once every 2 weeks (86.5%) and median days to discontinuation was longer (67 (IQR 60-91) vs 32 (IQR 28-49).

‍CONCLUSIONS:
Patients prescribed a combination of LAI and OA at discharge had a higher risk of rehospitalisation compared with those prescribed LAI alone. Additionally, the study findings suggest that patients are more likely to be prescribed oral risperidone, the most frequently used second-generation OA, which may support an easier transition to an LAI of the same molecule.

OBJECTIVES:
This observational retrospective real-world study examined changes in healthcare resource utilization (HCRU) pre- and post-initiation of aripiprazole once-monthly (AOM 400) in patients with schizophrenia or bipolar I disorder.

‍METHODS:
Electronic health record-derived, de-identified data from the NeuroBlu Database (2013-2020) were used to identify patients ≥18 years with schizophrenia (n = 222) or bipolar I disorder (n = 129) who were prescribed AOM 400, and had visit data within 3, 6, 9, or 12 months pre- and post-initial AOM 400 prescription. Rates of inpatient hospitalization, emergency department visits, inpatient readmissions, and average length of stay were examined and compared over 3, 6, 9, and 12 months pre-/post-AOM 400 using a McNemar test.

‍RESULTS:
Statistically significant differences were seen in both schizophrenia and bipolar I disorder patient cohorts pre- and post-AOM 400 in inpatient hospitalization rates (p < .001 all time points, both cohorts) and 30-day readmission per patient rates (p < .001 all time points, both cohorts). Statistically significant improvement in mean length of stay was observed in both cohorts at all time points, except for at six months in patients with schizophrenia. Emergency department visit rates were significantly lower after AOM 400 initiation for both cohorts at all time points (p < .001).

‍CONCLUSIONS:
A reduction in the rate of hospitalizations, emergency department visits, 30-day readmissions, and average length-of-stay was observed for patients diagnosed with either schizophrenia or bipolar I disorder, which suggests a positive effect of AOM 400 treatment on HCRU outcomes and is supportive of earlier analyses from different data sources.

BACKGROUND:
The paliperidone palmitate 6-month (PP6M) long-acting injectable formulation is currently the longest dosing interval available for schizophrenia treatment.

‍OBJECTIVE:
To compare treatment outcomes between a real-world external comparator arm (ECA; NeuroBlu database) and the PP6M open-label extension (OLE) clinical trial arm.

‍METHODS:
The ECA comprised patients receiving PP 1-month (PP1M) or PP 3-month (PP3M) for ⩾12 months without a relapse. The PP6M OLE arm included patients with PP1M treatment prior to randomization who completed the 12-month double-blind PP6M study on either PP3M or PP6M relapse-free. Inverse probability treatment weighting (IPTW) was used to study time-to-relapse (primary outcome) and change in Clinical Global Impressions-Severity (CGI-S) score (secondary outcome).

‍RESULTS:
At 24 months, 3.9% (7/178) of patients in the PP6M cohort experienced a relapse versus 15.6% (26/167) in the ECA. Time-to-relapse was longer in the PP6M cohort versus the ECA at 12-, 18-, and 24-months across the different weighting methods; median time-to-relapse was not reached in both cohorts. Hazard ratio (HR) for relapse was significantly lower for the PP6M cohort versus the ECA throughout the duration of the study [HR at 24 months: 0.18 (95% CI: 0.08-0.42), p < 0.001]. At 24 months, change in CGI-S score for the PP6M cohort was 0.76 points lower than the ECA (p < 0.001). Results were similar in a sensitivity analysis using propensity score matching (PSM); IPTW resulted in larger sample sizes in balanced dataset than PSM.

‍CONCLUSION:
Consistent findings across weighting and matching methods suggest PP6M efficacy in reducing and delaying relapses and long-term symptom control compared to PP1M/PP3M in usual-care settings. Additional confounds, such as greater illness severity and more frequent comorbidities and comedications in the ECA, were not fully controlled by the applied statistical methods. Future real-world studies directly comparing PP6M with PP3M/PP1M and adjusting for these confounders are warranted.