Psychological therapies for people with borderline personality disorder

This recently updated review sought to assess the beneficial and harmful effects of psychological therapies for people with borderline personality disorder (BPD).

It includes 75 randomised controlled trials (RCTs), conducted in any setting, and involving 4507 participants (predominantly female), with a formal diagnosis of BPD. Mean ages ranged from 14.8 to 45.7 years.

Included RCTs compared the effects of more than 16 different psychotherapeutic interventions (mostly dialectical behavior therapy (DBT) and mentalisation-based treatment (MBT)) with treatment-as-usual (TAU; which included various types of psychotherapy), waiting list, no treatment or active treatments on four primary outcomes: BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects. Treatment duration ranged from one to 36 months.

Results for psychotherapy versus TAU

The review authors found evidence that, compared with TAU, psychotherapy:

  • resulted in clinically relevant reductions in BPD symptom severity (standardised mean difference (SMD) −0.52, 95% confidence interval (CI) −0.70 to −0.33; 22 trials, 1244 participants; moderate-quality evidence);
  • might be more effective at reducing self-harm (SMD −0.32, 95% CI −0.49 to −0.14; 13 trials, 616 participants; low-quality evidence);
  • improved suicide-related outcomes (SMD −0.34, 95% CI −0.57 to −0.11; 13 trials, 666 participants; low-quality evidence);
  • might improve psychosocial functioning (SMD −0.45, 95% CI −0.68 to −0.22; 22 trials, 1314 participants; low-quality evidence); and
  • might result in greater improvements in depressive symptoms (SMD −0.39, 95% CI −0.61 to −0.17; 22 trials, 1568 participants; very low-quality evidence).

They also found evidence that BPD-specific psychotherapy did not reduce attrition. Adverse effects were unclear due to too few data.

Results for psychotherapy versus waiting list or no treatment

The review authors found low-quality evidence that psychotherapy resulted in greater improvements in:

  • BPD symptom severity (SMD −0.49, 95% CI −0.93 to −0.05; 3 trials, 161 participants);
  • psychosocial functioning (SMD −0.56, 95% CI −1.01 to −0.11; 5 trials, 219 participants); and
  • depression (SMD −1.28, 95% CI −2.21 to −0.34, 6 trials, 239 participants).

However, they found no clear evidence of a difference between the groups for self-harm and suicide-related outcomes.

Results for individual treatment approaches

The review authors found low-quality evidence that, compared with TAU:

  • DBT was more effective at reducing BPD severity (SMD −0.60, 95% CI −1.05 to −0.14; 3 trials, 149 participants), self-harm (SMD −0.28, 95% CI −0.48 to −0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD −0.36, 95% CI −0.69 to −0.03; 6 trials, 225 participants); and
  •  MBT might be more effective at reducing self-harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD −0.58, 95% CI −1.22 to 0.05, 4 trials, 333 participants).
Authors' conclusions

The review authors concluded the following.

  • Compared with TAU, BPD-tailored psychotherapy might have beneficial effects on all primary outcomes; however, only the outcome of BPD severity reached the MIREDIF-defined cut-off for a clinically meaningful improvement.
  • Compared with waiting list or no treatment, psychotherapy might improve BPD severity, psychosocial functioning and depression at end of treatment; however, this is low-quality evidence, so the true magnitude of these effects is uncertain. There was no evidence of a difference between the groups for self-harm and suicide-related outcomes.
  • Compared with TAU, there was evidence in favour of DBT for BPD severity, self-harm and psychosocial functioning and, for MBT, on self-harm and suicidality at end of treatment. However, this is low-quality evidence, so the effects are uncertain and could change with the addition of more data.

The evidence is current to March 2019.

Read the full review here on the Cochrane Library.

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