Ioana A Cristea1, Claudio Gentili2, Carmen D Cotet3, Daniela Palomba2, Corrado Barbui4, Pim Cuijpers5. 1. Department of Clinical Psychology and Psychotherapy, Babes-Bolyai University, Cluj-Napoca, Romania2Department of General Psychology, University of Padova, Padova, Italy3Meta-Research Innovation Center at Stanford, Stanford University, Stanford, California. 2. Department of General Psychology, University of Padova, Padova, Italy. 3. Department of Clinical Psychology and Psychotherapy, Babes-Bolyai University, Cluj-Napoca, Romania. 4. Section of Psychiatry, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy. 5. Department of Clinical Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit, Amsterdam, the Netherlands.
Abstract
IMPORTANCE: Borderline personality disorder (BPD) is a debilitating condition, but several psychotherapies are considered effective. OBJECTIVE: To conduct an updated systematic review and meta-analysis of randomized clinical trials to assess the efficacy of psychotherapies for BPD populations. DATA SOURCES: Search terms were combined for borderline personality and randomized trials in PubMed, PsycINFO, EMBASE, and the Cochrane Central Register of Controlled Trials (from database inception to November 2015), as well as the reference lists of earlier meta-analyses. STUDY SELECTION: Included were randomized clinical trials of adults with diagnosed BPD randomized to psychotherapy exclusively or to a control intervention. Study selection differentiated stand-alone designs (in which an independent psychotherapy was compared with control interventions) from add-on designs (in which an experimental intervention added to usual treatment was compared with usual treatment alone). DATA EXTRACTION AND SYNTHESIS: Data extraction coded characteristics of trials, participants, and interventions and assessed risk of bias using 4 domains of the Cochrane Collaboration Risk of Bias tool (independent extraction by 2 assessors). Outcomes were pooled using a random-effects model. Subgroup and meta-regression analyses were conducted. MAIN OUTCOMES AND MEASURES: Standardized mean differences (Hedges g) were calculated using all outcomes reported in the trials for borderline symptoms, self-harm, suicide, health service use, and general psychopathology at posttest and follow-up. Differential treatment retention at posttest was analyzed, reporting odds ratios. RESULTS: Thirty-three trials (2256 participants) were included. For borderline-relevant outcomes combined (symptoms, self-harm, and suicide) at posttest, the investigated psychotherapies were moderately more effective than control interventions in stand-alone designs (g = 0.32; 95% CI, 0.14-0.51) and add-on designs (g = 0.40; 95% CI, 0.15-0.65). Results were similar for other outcomes, including stand-alone designs: self-harm (g = 0.32; 95% CI, 0.09-0.54), suicide (g = 0.44; 95% CI, 0.15-0.74), health service use (g = 0.40; 95% CI, 0.22-0.58), and general psychopathology (g = 0.32; 95% CI, 0.09-0.55), with no differences between design types. There were no significant differences in the odds ratios for treatment retention (1.32; 95% CI, 0.87-2.00 for stand-alone designs and 1.01; 95% CI, 0.55-1.87 for add-on designs). Thirteen trials reported borderline-relevant outcomes at follow-up (g = 0.45; 95% CI, 0.15-0.75). Dialectical behavior therapy (g = 0.34; 95% CI, 0.15-0.53) and psychodynamic approaches (g = 0.41; 95% CI, 0.12-0.69) were the only types of psychotherapies more effective than control interventions. Risk of bias was a significant moderator in subgroup and meta-regression analyses (slope β = -0.16; 95% CI, -0.29 to -0.03; P = .02). Publication bias was persistent, particularly for follow-up. CONCLUSIONS AND RELEVANCE: Psychotherapies, most notably dialectical behavior therapy and psychodynamic approaches, are effective for borderline symptoms and related problems. Nonetheless, effects are small, inflated by risk of bias and publication bias, and particularly unstable at follow-up.
IMPORTANCE: Borderline personality disorder (BPD) is a debilitating condition, but several psychotherapies are considered effective. OBJECTIVE: To conduct an updated systematic review and meta-analysis of randomized clinical trials to assess the efficacy of psychotherapies for BPD populations. DATA SOURCES: Search terms were combined for borderline personality and randomized trials in PubMed, PsycINFO, EMBASE, and the Cochrane Central Register of Controlled Trials (from database inception to November 2015), as well as the reference lists of earlier meta-analyses. STUDY SELECTION: Included were randomized clinical trials of adults with diagnosed BPD randomized to psychotherapy exclusively or to a control intervention. Study selection differentiated stand-alone designs (in which an independent psychotherapy was compared with control interventions) from add-on designs (in which an experimental intervention added to usual treatment was compared with usual treatment alone). DATA EXTRACTION AND SYNTHESIS: Data extraction coded characteristics of trials, participants, and interventions and assessed risk of bias using 4 domains of the Cochrane Collaboration Risk of Bias tool (independent extraction by 2 assessors). Outcomes were pooled using a random-effects model. Subgroup and meta-regression analyses were conducted. MAIN OUTCOMES AND MEASURES: Standardized mean differences (Hedges g) were calculated using all outcomes reported in the trials for borderline symptoms, self-harm, suicide, health service use, and general psychopathology at posttest and follow-up. Differential treatment retention at posttest was analyzed, reporting odds ratios. RESULTS: Thirty-three trials (2256 participants) were included. For borderline-relevant outcomes combined (symptoms, self-harm, and suicide) at posttest, the investigated psychotherapies were moderately more effective than control interventions in stand-alone designs (g = 0.32; 95% CI, 0.14-0.51) and add-on designs (g = 0.40; 95% CI, 0.15-0.65). Results were similar for other outcomes, including stand-alone designs: self-harm (g = 0.32; 95% CI, 0.09-0.54), suicide (g = 0.44; 95% CI, 0.15-0.74), health service use (g = 0.40; 95% CI, 0.22-0.58), and general psychopathology (g = 0.32; 95% CI, 0.09-0.55), with no differences between design types. There were no significant differences in the odds ratios for treatment retention (1.32; 95% CI, 0.87-2.00 for stand-alone designs and 1.01; 95% CI, 0.55-1.87 for add-on designs). Thirteen trials reported borderline-relevant outcomes at follow-up (g = 0.45; 95% CI, 0.15-0.75). Dialectical behavior therapy (g = 0.34; 95% CI, 0.15-0.53) and psychodynamic approaches (g = 0.41; 95% CI, 0.12-0.69) were the only types of psychotherapies more effective than control interventions. Risk of bias was a significant moderator in subgroup and meta-regression analyses (slope β = -0.16; 95% CI, -0.29 to -0.03; P = .02). Publication bias was persistent, particularly for follow-up. CONCLUSIONS AND RELEVANCE: Psychotherapies, most notably dialectical behavior therapy and psychodynamic approaches, are effective for borderline symptoms and related problems. Nonetheless, effects are small, inflated by risk of bias and publication bias, and particularly unstable at follow-up.
Authors: T Munder; C Flückiger; F Leichsenring; A A Abbass; M J Hilsenroth; P Luyten; S Rabung; C Steinert; B E Wampold Journal: Epidemiol Psychiatr Sci Date: 2018-07-30 Impact factor: 6.892
Authors: Sabine C Herpertz; Steven K Huprich; Martin Bohus; Andrew Chanen; Marianne Goodman; Lars Mehlum; Paul Moran; Giles Newton-Howes; Lori Scott; Carla Sharp Journal: J Pers Disord Date: 2017-09-14
Authors: Christopher J Hopwood; Roman Kotov; Robert F Krueger; David Watson; Thomas A Widiger; Robert R Althoff; Emily B Ansell; Bo Bach; R Michael Bagby; Mark A Blais; Marina A Bornovalova; Michael Chmielewski; David C Cicero; Christopher Conway; Barbara De Clercq; Filip De Fruyt; Anna R Docherty; Nicholas R Eaton; John F Edens; Miriam K Forbes; Kelsie T Forbush; Michael P Hengartner; Masha Y Ivanova; Daniel Leising; W John Livesley; Mark R Lukowitsky; Donald R Lynam; Kristian E Markon; Joshua D Miller; Leslie C Morey; Stephanie N Mullins-Sweatt; J Hans Ormel; Christopher J Patrick; Aaron L Pincus; Camilo Ruggero; Douglas B Samuel; Martin Sellbom; Tim Slade; Jennifer L Tackett; Katherine M Thomas; Timothy J Trull; David D Vachon; Irwin D Waldman; Monika A Waszczuk; Mark H Waugh; Aidan G C Wright; Mathew M Yalch; David H Zald; Johannes Zimmermann Journal: Personal Ment Health Date: 2017-12-11