Efficacy of Psychotherapies for Borderline Personality Disorder: A Systematic Review and Meta-analysis
Summary (3 min read)
Introduction
- Efficacy of Psychotherapy for borderline personality disorder: A systematic review and meta-analysis.
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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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Frequently Asked Questions (11)
Q2. What databases were used for the search terms for BPD?
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.
Q3. Why were the commonly cited approaches underrepresented?
Frequently cited approaches, such as schema-focused therapy, were underrepresented, mainly because they were mostly studied in head-to-head trials.
Q4. What were the effective psychotherapies at posttest?
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).
Q5. Why did the authors effacing subtle differences between orientations?
Owing to the small number of trials, the authors grouped therapies in broader categories, effacing subtler differences between orientations.
Q6. What was the common method of calculating the effect size?
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.
Q7. What did the authors consider as nonsignificant effects for borderline-relevant outcomes?
Trials with low RoB for at least 3 of the 4 domains considered generated nonsignificant effects for borderline-relevant outcomes.
Q8. What was the approach used to delineate the therapy and control conditions?
Given the diversity and complexity of therapy orientations, the authors used an inclusive approach in delineating the psychotherapy and control conditions.
Q9. What type of studies focused on DBT followed by psychodynamic approaches?
Most trials focused on DBT followed by psychodynamic approaches, and both types generated significant, small between-group effect sizes, with low heterogeneity for DBT.
Q10. What is the effect of a manualized protocol on treatment outcomes?
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.
Q11. What was the exclusion criteria for concurrent medication use?
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.