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Efficacy of Psychotherapies for Borderline Personality Disorder: A Systematic Review and Meta-analysis

01 Apr 2017-JAMA Psychiatry (American Medical Association)-Vol. 74, Iss: 4, pp 319-328
TL;DR: Psychotherapies, most notably dialectical behavior therapy and psychodynamic approaches, are effective for borderline symptoms and related problems but effects are small, inflated by risk of bias and publication bias, and particularly unstable at follow-up.
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.

Summary (3 min read)

Introduction

  • Efficacy of Psychotherapy for borderline personality disorder: A systematic review and meta-analysis.
  • You may not further distribute the material or use it for any profit-making activity or commercial gain.

Efficacy of Psychotherapies for Borderline Personality Disorder

  • A Systematic Review and Meta-analysis Ioana A. Cristea, PhD; Claudio Gentili, MD, PhD; Carmen D. Cotet, PhD; Daniela Palomba, MD; Corrado Barbui, MD; Pim Cuijpers, PhD IMPORTANCE.
  • 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).
  • More than 75% of patients with BPD are believed to engage in deliberate self-harm.
  • Previous metaanalyses of psychotherapeutic treatments for BPD have been scarce and used focused criteria for assessing effectiveness, avoiding combining treatments.

Identification and Selection of Studies

  • Studies were identified through searches in 4 bibliographical databases (from database inception to November 2015 in PubMed, PsycINFO, EMBASE, and the Cochrane Central Reg- ister of Controlled Trials) using the search term borderline personality (both text word and Medical Subject Headings term), with a filter for randomized trials (eMethods in the Supplement).
  • Studies were included if they were RCTs in which a psychotherapy was compared with a control condition for adults diagnosed as having BPD.
  • Given the diversity and complexity of therapy orientations, the authors used an inclusive approach in delineating the psychotherapy and control conditions.
  • No constraints were placed on the control group, which could include (but was not restricted to) TAU or other treatments not specifically developed for BPD.
  • Two independent assessors (I.A.C. and C.D.C.) examined the full texts and selected eligible RCTs.

Risk of Bias and Data Extraction

  • Trial risk of bias (RoB) was evaluated within 4 domains of the Cochrane Collaboration Risk of Bias tool,26 which assesses sources of bias in RCTs.
  • Generation of allocation sequence, (2) concealment of allocation to conditions, (3) prevention of knowledge of the allocated intervention to assessors of outcome (masking of assessors), and (4) dealing with incomplete data.
  • For use in meta-regression analyses, the authors computed an overall RoB score for each study by awarding 1 point for each bias source rated as low risk.

Meta-analysis

  • Treatment retention was computed as the comparative dropout rates between the intervention and control groups.
  • 27 Follow-up data more than 2 years from treatment termination or in which the control group also received the experimental treatment were not included.
  • The authors used a software program (Comprehensive MetaAnalysis, version 3; Biostat) for computing and pooling effect sizes, with a random-effects model for pooling effect sizes.
  • The authors calculated the number needed to treat using the formulas by Kraemer and Kupfer.29 Heterogeneity was assessed with the I2 statistic: 0% indicates no observed heterogeneity, and higher values indicate increasing heterogeneity, with 25%, 50%, and 75% defining thresholds for low, moderate, and high.

Selection and Inclusion of Studies

  • The authors screened 1058 abstracts, removed 500 duplicates, and subsequently retrieved 158 full-text articles.
  • Thirty-eight trials examined a psychotherapy, with 5 excluded for comparing 2 versions of the same therapy.
  • For the 5 missing trials,20,33-36 the authors were contacted, but they did not provide the requested data.

Characteristics of Included Studies

  • The 33 trials included 1169 participants in the investigated treatment group and 1087 participants in the control group (eTable 1 in the Supplement).
  • Twenty-two trials had a stand-alone design, and 11 trials had an add-on design.
  • Twelve trials had women-only samples, and this percentage ranged from 0% to 95% in the remainder.
  • The best-represented approaches were DBT (12 trials), psychodynamic therapies (8 trials), and CBT (5 trials).
  • The κ statistics indicated high interrater agreement for RoB estimations (eMethods in the Supplement), which were variable (eFigure 2 in the Supplement).

Adverse Effects

  • There were 2 deaths by suicide in the treatment group and 5 deaths by suicide in the control group.
  • The treatment group and the control group each had 6 all-cause deaths.

Subgroup Analyses

  • These analyses were conducted on the most inclusive outcome category (all borderline-relevant outcomes), combining stand-alone and add-on designs because the authors found no differences among them (Table 2 and eTable 2 in the Supplement).
  • Trials with an ad hoc control group developed as part of the study, trials in which the control intervention was manualized, or trials in which the study team was involved in treating the control group, as well trials with low RoB for 3 or 4 domains, generated nonsignificant between-group effects.
  • Psychotherapies were more effective than control interventions in trials with more RoB than in those with less RoB (0.48 vs 0.11, P = .01).

Favors

  • Shown are standardized posttest effect sizes of comparisons between investigated psychotherapies and control conditions for borderline-relevant outcomes (borderline symptoms, self-harm and parasuicidal behavior, and suicide) for 27 trials.
  • A surprising finding regarded treatment retention, for which the authors found no significant differences between the experimental treatment and control groups.
  • This discrepancy might stem from the fact that individual trials used variable ways of calculating dropout rates, while the authors used a standard ITT method whereby all participants who did not finish treatment after randomization were considered dropouts regardless of whether they started treatment or what their specific reasons were for discontinuing it.
  • The authors can speculate that, at least in part, the differential efficacy of psychotherapies designed for BPD in contrast to usual treatment could be due to the “special attention” granted to the experimental group or indeed to having a manualized, structured treatment.
  • Trial RoB consistently emerged as a moderator of effect sizes in both subgroup and meta-regression analyses.

Limitations

  • Furthermore, most trials had not been registered in clinical trial registries, so the authors could not rate RoB because of selective outcome reporting.
  • While treatment intensity per se did not seem to influence outcomes, there are indications that a control group balanced for the involvement of the study team in treatment or with a manualized protocol is as effective as psychotherapies tailored for BPD.
  • Dr Cristea was also supported by a Visiting Scientist Grant from the University of Padova.

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Efficacy of Psychotherapy for borderline personality disorder: A systematic review and
meta-analysis
Cristea, I.A.; Gentili, C.; Cotet, C.D.; Palomba, D.; Barbui, C.; Cuijpers, Pim
published in
JAMA Psychiatry
2017
DOI (link to publisher)
10.1001/jamapsychiatry.2016.4287
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Publisher's PDF, also known as Version of record
Link to publication in VU Research Portal
citation for published version (APA)
Cristea, I. A., Gentili, C., Cotet, C. D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of Psychotherapy
for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry, 74(4), 319-328.
https://doi.org/10.1001/jamapsychiatry.2016.4287
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Copyright 2017 American Medical Association. All rights reserved.
E fficacy of Psy chother apies for Borderline Personality Disorder
A Systematic Review and Meta-analysis
Ioana A. Cristea, PhD; Claudio Gentili, MD, PhD; Carmen D. Cotet, PhD; Daniela Palomba, MD; Corrado Barbui, MD; Pim Cuijpers, PhD
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.
JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.4287
Published online March 1, 2017.
Editorial
Supplemental content
Author Affiliations: Department of
Clinical Psychology and
Psychotherapy, Babeş-Bolyai
University, Cluj-Napoca, Romania
(Cristea, Cotet); Department of
General Psychology, University of
Padova, Padova, Italy (Cristea, Gentili,
Palomba); Meta-Research Innovation
Center at Stanford, Stanford
University, Stanford, California
(Cristea); Section of Psychiatry,
Department of Neuroscience,
Biomedicine and Movement
Sciences, University of Verona,
Verona, Italy (Barbui); Department of
Clinical Psychology, Amsterdam
Public Health Research Institute, Vrije
Universiteit, Amsterdam, the
Netherlands (Cuijpers).
Corresponding Author: Ioana A.
Cristea, PhD, Department of Clinical
Psychology and Psychotherapy,
Babeş-Bolyai University, 37 Republicii
St, 400015, Cluj-Napoca, Romania
(ioana.cristea@ubbcluj.ro).
Research
JAMA Psychiatry | Original Investigation | META-ANALYSIS
(Reprinted) E1
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Copyright 2017 American Medical Association. All rights reserved.
B
orderline personality disorder (BPD) is a debilitating
mental disorder characterized by severe instability in
affect, identity, interpersonal relationships, and behav-
ioral dysregulation.
1
Alongside a vast array of comorbidities,
parasuicide (ie, nonlethal intentional self-harming behav-
iors) and suicide are commonly associated problems. More than
75% of patients with BPD are believed to engage in deliberate
self-harm.
2
Suicide rates are estimated to be between 8% and
10%,
3,4
almost 50 times higher than in the general population.
5
Borderline personality disorder is the most common person-
ality disorder in clinical populations,
5,6
associated with inten-
sive use of mental health services
7,8
even in the absence of a
full diagnosis.
9
Functional impairment is considerable com-
pared with other personality disorders
10
and is enduring in the
absence of a change in personality psychopathology.
11
Several psychotherapy approaches were specifically de-
veloped for the disorder, most notably dialectical behavior
therapy (DBT),
12
cognitive behavior therapy (CBT),
13
and psy-
chodynamic treatments, such as mentalization-based therapy
14
or transference-focused psychotherapy.
15
Each approach ap-
peared to be more effective than treatment as usual (TAU) for
BPD-related problems, such as suicidality or parasuicidal
behavior.
16-19
Trials of direct comparisons of treatments for BPD
reported few differences among them.
20,21
However, most trials
demonstrating effectiveness were conducted with the direct
participation of the treatment developer. Previous meta-
analyses of psychotherapeutic treatments for BPD have been
scarce and used focused criteria for assessing effectiveness,
avoiding combining treatments. One meta-analysis
22
of DBT
for BPD reported moderate effects for borderline-relevant out-
comes, suicidality, and self-harm. However, analysis re-
stricted to randomized clinical trials (RCTs) showed reduced
effects, with nonsignificance for suicidality and self-harm. An-
other meta-analysis
23
of RCTs for BPD reported only moder-
ate effects for the comparison between DBT and TAU.
Conversely, because effectiveness differences between
therapies appear to be limited and because variations of the
same intervention are to be expected in diverse implementa-
tion settings, we believe that a broader effectiveness evalua-
tion grouping therapies into theoretically intelligible catego-
ries is germane. Heterogeneity, publication bias, and potential
moderators of efficacy (eg, treatment duration and type of psy-
chotherapy) are additional unclear issues. Moreover, because
the study collection dates of the 2 previous meta-analyses
22,23
preceded 2012, new trials or follow-ups of older trials pub-
lished since then should be considered. Therefore, our objec-
tive was to conduct an updated systematic review and meta-
analysis of RCTs to assess the efficacy of psychotherapies
for BPD-relevant outcomes at posttest and, where possible, at
follow-up.
Methods
Identification and Selection of Studies
Studies were identified through searches in 4 bibliographical
databases (from database inception to November 2015 in
PubMed, PsycINFO, EMBASE, and the Cochrane Central Reg-
ister of Controlled Trials) using the search term borderline
personalit y (both text word and Medical Subject Headings
term), with a filter for randomized tr ials (eMethods in the
Supplement). We also checked the reference lists of earlier
meta-analyses.
22,23
Studies were included if they were RCTs in which a psy-
chotherapy was compared with a control condition for adults
diagnosed as having BPD. Given the diversity and complexity
of therapy orientations, we used an inclusive approach in de-
lineating the psychotherapy and control conditions. We used
a customary definition of psychotherapy emphasizing verbal
communication, structured and purposeful therapist-
patient encounters, and the establishment of a therapeutic
relationship.
24,25
No constraints were placed on the control
group, which could include (but was not restricted to) TAU or
other treatments not specifically developed for BPD. Compari-
sons between 2 different psychotherapies specifically devel-
oped for BPD (ie, DBT and transference-focused psycho-
therapy) or between forms of the same psychotherapy (eg, DBT
vs its skills training component) were excluded because of ex-
pectations of similar efficacy. Concomitant medication use was
not an exclusion criterion unless it was prescribed in a stan-
dardized way, as in trials in which individuals were random-
ized to a combination of psychotherapy and either pharma-
cotherapy or placebo. Medication use followed a systematic
protocol, and we could not disentangle its effects from those
of psychotherapy. Studies on even partially adolescent samples
were excluded because BPD diagnosis and treatment pose dis-
tinct challenges for this group. No language restrictions were
applied. One researcher (I.A.C.) screened all records, and full
texts were obtained for RCTs. Two independent assessors
(I.A.C. and C.D.C.) examined the full texts and selected eli-
gible RCTs.
Risk of Bias and Data Extraction
Trial risk of bias (RoB) was evaluated within 4 domains of the
Cochrane Collaboration Risk of Bias tool,
26
which assesses
sources of bias in RCTs. Rated domains included (1) adequate
Key Points
Question What is the efficacy of psychotherapy for borderline
personality disorder?
Findings In this systematic review and meta-analysis of
randomized clinical trials, outcomes of psychotherapies (most
notably dialectical behavior therapy and psychodynamic
approaches) significantly improved borderline-relevant outcomes
(symptoms, self-harm, and suicide) compared with control
interventions. However, differences dissipated in well-designed
and implemented trials or if the control group was balanced for
manualization of treatment or the involvement of the study team
in treatment.
Meaning Psychotherapies specifically designed for borderline
personality disorder have significant yet modest benefits over
treatment as usual, and future independent and well-conducted
trials are needed to clarify the stability and practical relevance of
their effects.
Research Original Investigation Efficacy of Psychotherapies for Borderline Personality Disorder
E2 JAMA Psychiatry Published online March 1, 2017 (Reprinted) jamapsychiatry.com
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generation of allocation sequence, (2) concealment of alloca-
tion to conditions, (3) prevention of knowledge of the allo-
cated intervention to assessors of outcome (masking of asses-
sors), and (4) dealing with incomplete data. This last domain
was assessed as low risk if proper intent-to-treat (ITT) analy-
ses were conducted, meaning that authors used a method for
imputing missing values so that all randomized participants
were included in the analyses. Masking of assessors was rated
as low risk if the trial described proper methods of ensuring
masking or if all relevant outcome measures were self-report
instruments, thus not requiring the direct interaction with an
assessor. For use in meta-regression analyses, we computed
an overall RoB score for each study by awarding 1 point for each
bias source rated as low risk.
Among trials, we distinguished between stand-alone
designs (in which the experimental group received a full
course of an independent BPD psychotherapy and the con-
trol group received TAU or another therapy not specific for
BPD) and add-on designs (in which both groups received
TAU and the experimental group received an additional BPD
therapy). We also extracted characteristics of the partici-
pants, interventions, and studies, including therapy type
(DBT, psychodynamic, CBT, or other); control group (TAU,
supportive therapy, or an ad hoc control, designed as part of
the trial); whether the control group was manualized (ie, fol-
lowed a treatment protocol or manual); involvement or non-
involvement of the study team in treating the control group;
the presence or absence of a treatment developer as an
author of the trial report; therapist supervision for the
experimental group (by the treatment developer or by oth-
ers); and low RoB (studies rated as low risk for ≤2 vs ≥3 RoB
domains). We also extracted the following treatment inten-
sity variables: treatment duration (in months), treatment
exposure (in hours, calculated by multiplying the session
duration for individual or group therapy by the number of
sessions either planned or, if available, attended on average
for the experimental and control groups), and difference in
treatment exposure between the intervention and control
groups (in hours). Risk of bias assessment and data extrac-
tion were performed by 2 independent assessors. Interrater
agreement κ statistics were computed (eMethods in the
Supplement), and disagreement was resolved by discussion
among assessors and with the senior author (P.C.).
Meta-analysis
To capture the breadth and variability of reported outcomes,
we grouped them into the following categories: borderline
relevant (BPD symptom measures, self-harm and parasui-
cide, and suicidal behaviors), borderline symptoms (only
BPD symptom measures), self-harm and parasuicidal behav-
ior, suicidal behavior, health service use (hospitalizations
[whether psychiatric or general], use of emergency services,
use of additional outpatient services, and medication use),
and general psychopathology (general psychopathology,
anxiety, or depression). Treatment retention was computed
as the comparative dropout rates between the intervention
and control groups. Dropouts (eMethods in the Supplement)
were defined as all randomized participants not finishing
treatment, regardless of the reasons. Adverse effects were
defined as participant death by suicide and as death from
any cause after randomization.
The between-group effect size was calculated as the dif-
ference between the intervention and control groups at post-
test and at follow-up (Hedges g), corrected for small sample
sizes.
27
Follow-up data more than 2 years from treatment ter-
mination or in which the control group also received the ex-
perimental treatment were not included. Data across mul-
tiple follow-up points were averaged at the study level for each
outcome category. For treatment retention, odds ratios indi-
cated the odds of maintaining participants in treatment in the
intervention group vs the control group.
If a trial reported data on multiple outcomes in the same
category, the mean effect size was calculated using the pro-
cedures by Borenstein et al
28
so that each trial reported just
one effect size in a category at each time point. Where avail-
able, the means (SDs) were used, but if only dichotomous out-
comes were reported, we used available procedures
28
to com-
pute the standardized mean difference. If a study did not
include sufficient data for effect size calculation, the authors
were contacted, and the study was excluded if they failed to
provide data. Where available, ITT data were preferred. Ef-
fect sizes for dichotomous outcomes were computed, adher-
ing to the ITT principle, by reporting the observed or im-
puted number of patients with an event (eg, self-harm) relative
to the total number of patients randomized to that group.
We used a software program (Comprehensive Meta-
Analysis, version 3; Biostat) for computing and pooling effect
sizes, with a random-effects model for pooling effect sizes. We
calculated the number needed to treat using the formulas by
Kraemer and Kupfer.
29
Heterogeneity was assessed with the
I
2
statistic: 0% indicates no observed heterogeneity, and higher
values indicate increasing heterogeneity, with 25%, 50%, and
75% defining thresholds for low, moderate, and high. We cal-
culated 95% CIs around I
2
statistics
30
using a noncentral χ
2
-
based approach (heterogi module for Stata, version 8; Stata-
Corp LP).
31
Outliers were defined as studies in which the 95%
CI was outside the 95% CI of the pooled studies (on both sides).
For categorical moderators, we conducted subgroup analy-
ses using a mixed-effects model.
28
For continuous modera-
tors, meta-regression analyses used a restricted maximum like-
lihood model with the Knapp-Hartung method.
28
We examined
publication bias through visual funnel plot inspection, the trim-
and-fill procedure
32
(which produces an effect size estimate
after accounting for publication bias), and Egger test for fun-
nel plot asymmetry.
Results
Selection and Inclusion of Studies
We screened 1058 abstracts, removed 500 duplicates, and sub-
sequently retrieved 158 full-text articles. Thirty-eight trials ex-
amined a psychotherapy, with 5 excluded for comparing 2 ver-
sions of the same therapy. Consequently, 33 trials (2256
participants) met our inclusion criteria, and 28 of them had
enough data for calculating effect sizes (eFigure 1 in the Supple-
Efficacy of Psychotherapies for Borderline Personality Disorder Original Investigation Research
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Copyright 2017 American Medical Association. All rights reserved.
ment). For the 5 missing trials,
20,33-36
the authors were con-
tacted, but they did not provide the requested data.
Characteristics of Included Studies
The 33 trials included 1169 participants in the investigated treat-
ment group and 1087 participants in the control group (eTable
1intheSupplement). Seventeen trials targeted patients with
BPD diagnosed using a structured clinical interview, 10 trials
targeted patients with BPD with recent documented self-
harm, and the rest targeted special BPD populations (eg, vet-
erans and individuals with addiction). Twenty-two trials had
a stand-alone design, and 11 trials had an add-on design. Twelve
trials had women-only samples, and this percentage ranged
from 0% to 95% in the remainder. The best-represented ap-
proaches were DBT (12 trials), psychodynamic therapies (8
trials), and CBT (5 trials). Twenty-one trials had TAU as the con-
trol treatment, and the control treatment was manualized in
10 trials. The treatment developer was an author in 20 trials.
In 15 trials, the treatment developer was a therapist or super-
vised therapists directly. Treatment duration ranged from 2.5
to 24 months, and the number of sessions (for individual and
group therapy taken together) ranged from 6 to 312.
The κ statistics indicated high interrater agreement for RoB
estimations (eMethods in the Supplement), which were vari-
able (eFigure 2 in the Supplement). Sixteen trials reported ad-
equate sequence generation, 12 trials properly concealed al-
location, and 20 trials implemented masking of outcome
assessors (2 used self-report measures only). However, for in-
complete outcome data, only 13 trials were rated as low RoB,
and more than half had high RoB. Eleven trials could be rated
as low risk on 3 or 4 domains.
Main Effects at Posttest
Stand-alone Designs
Results showed significant effects for all outcome categories,
ranging from 0.31 (0.04-0.57) for borderline symptoms to 0.44
(0.15-0.74) for suicide outcomes (Table 1). Heterogeneity was
moderate to high with the exception of health service use. For
all borderline-relevant outcomes (eFigure 3 in the Supple-
ment), 17 trials had a Hedges g of 0.32 (95% CI, 0.14-0.51), with
moderate heterogeneity (48%).
Add-on Designs
For borderline-relevant outcomes (Table 1 and eFigure 3 in the
Supplement), 10 trials had a Hedges g of 0.40 (95% CI, 0.15-
0.65), with moderate heterogeneity (50%). Results were not
significant for self-harm and parasuicidal behavior or for health
service use, but the number of trials was small (range, 3-6).
All Trials
Combining both design types for all borderline-relevant out-
comes (combining borderline symptoms, self-harm and para-
Table 1. Main Effects at Posttest and Follow-up of Trials Comparing Experimental Psychotherapy and Control Treatments
for Borderline Personality Disorder
Variable
Stand-alone Design Add-on Design
P Value
b
No. of
Trials
Hedges g
(95% CI)
a
NNT
I
2
(95%
CI), %
No. of
Trials
Hedges g
(95% CI)
a
NNT
I
2
(95%
CI), %
Posttest
Borderline-relevant
outcomes
c
17 0.32
(0.14 to 0.51)
5.56 49
(0 to 69)
10 0.40
(0.15 to 0.65)
4.50 50
(0 to 74)
.63
Borderline symptoms 10 0.31
(0.04 to 0.57)
5.75 62
(3 to 79)
8 0.56
(0.15 to 0.97)
3.25 76
(43 to 87)
.30
Self-harm and parasuicidal
behavior
13 0.32
(0.09 to 0.54)
5.56 55
(0 to 75)
6 0.24
(−0.07 to 0.55)
7.46 41
(0 to 75)
.68
Suicide 10 0.44
(0.15 to 0.74)
4.10 60
(0 to 78)
3 0.35
(0.02 to 0.68)
5.10 10
(0 to 75)
.67
Health service use 13 0.40
(0.22 to 0.58)
4.50 22
(0 to 59)
3 0.16
(−0.13 to 0.46)
11.11 5
(0 to 74)
.17
General psychopathology,
anxiety, and depression
13 0.32
(0.09 to 0.55)
5.56 62
(18 to 78)
10 0.53
(0.24 to 0.82)
3.42 62
(4 to 79)
.25
Follow-up
Borderline-relevant
outcomes
c
7 0.56
(0.17 to 0.95)
3.25 62
(0 to 81)
6 0.35
(−0.15 to 0.85)
5.10 79
(41 to 89)
.51
Borderline symptoms 3 0.34
(−0.13 to 0.81)
5.26 64
(0 to 88)
4 0.43
(−0.41 to 1.26)
4.20 87
(62 to 93)
.85
Self-harm and parasuicidal
behavior
5 0.58
(0.06 to 1.10)
3.14 74
(0 to 88)
4 0.04
(−0.21 to 0.30)
45.45 0
(0 to 68)
.07
Suicide 5 0.34
(−0.06 to 0.74)
5.26 39
(0 to 76)
2 0.31
(−0.04 to 0.66)
5.75 0 .90
Health service use 4 0.30
(−0.10 to 0.70)
5.95 51
(0 to 82)
2 0.06
(−0.32 to 0.44)
29.41 0 .39
General psychopathology,
anxiety, and depression
5 −0.15
(−1.12 to 0.83)
11.90 93
(88 to 96)
5 0.40
(−0.11 to 0.91)
4.50 78
(27 to 89)
.33
Abbreviation: NNT, number needed to treat.
a
According to the random-effects model. A positive effect indicates superiority
of the experimental psychotherapy over control treatments.
b
The P values indicate whether the difference between the effect sizes in the
group of trials with stand-alone vs add-on designs is significant.
c
Borderline-relevant outcomes include borderline symptoms, self-harm and
parasuicidal behavior, and suicide.
Research Original Investigation Efficacy of Psychotherapies for Borderline Personality Disorder
E4 JAMA Psychiatry Published online March 1, 2017 (Reprinted) jamapsychiatry.com
Copyright 2017 American Medical Association. All rights reserved.
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  • ...Fourth, there is a need for large-scale, adequately powered studies of the efficacy and effectiveness of MBT, particularly given the risk of bias and publication bias identified in a recent review of psychological therapies for BPD (Cristea et al. 2017)....

    [...]

  • ...with BPD (Cristea et al. 2017) supports the efficacy of MBT in BPD patients....

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  • ...…differences in efficacy between MBT and other specialized treatments for BPD, or between specialized and bona fide non-specialized treatments (Cristea et al. 2017, Volkert et al. 2019); this is consistent with our emphasis on the importance of coherence, continuity, and consistency in…...

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References
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Reference EntryDOI
11 Jun 2013

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Journal ArticleDOI
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Book
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Frequently Asked Questions (11)
Q1. What procedures were used to determine the effect size of a study?

The authors examined publication bias through visual funnel plot inspection, the trimand-fill procedure32 (which produces an effect size estimate after accounting for publication bias), and Egger test for funnel plot asymmetry. 

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. 

Frequently cited approaches, such as schema-focused therapy, were underrepresented, mainly because they were mostly studied in head-to-head trials. 

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). 

Owing to the small number of trials, the authors grouped therapies in broader categories, effacing subtler differences between orientations. 

The authors used a software program (Comprehensive MetaAnalysis, version 3; Biostat) for computing and pooling effect sizes, with a random-effects model for pooling effect sizes. 

Trials with low RoB for at least 3 of the 4 domains considered generated nonsignificant effects for borderline-relevant outcomes. 

Given the diversity and complexity of therapy orientations, the authors used an inclusive approach in delineating the psychotherapy and control conditions. 

Most trials focused on DBT followed by psychodynamic approaches, and both types generated significant, small between-group effect sizes, with low heterogeneity for DBT. 

While treatment intensity per se did not seem to influence outcomes, there are indications that a control group balanced for the involvement of the study team in treatment or with a manualized protocol is as effective as psychotherapies tailored for BPD. 

Concomitant medication use was not an exclusion criterion unless it was prescribed in a standardized way, as in trials in which individuals were randomized to a combination of psychotherapy and either pharmacotherapy or placebo.