Effect of 3 Forms of Early Intervention for Young People With Borderline Personality Disorder: The MOBY Randomized Clinical Trial

An Approach to Providing Timely Mental Health Services to Diverse Youth Populations

Importance

Accessing mental health care is challenging for youths, especially those facing intersectional disadvantages, but whether enhancing youth services increases reach and timeliness has rarely been investigated. ACCESS Open Minds (ACCESS-OM) transformed services at urban, rural, and Indigenous sites in Canada using 5 principles (early identification, rapid access, appropriate care, no age-based transitions from 11-25 years, and youth and family engagement).

Objective

To evaluate whether the number of youths referred (hypothesis 1), offered evaluation appointments within 72 hours of referral (hypothesis 2), and receiving services within 30 days of the first appointment (hypothesis 3) increased over the course of ACCESS-OM's implementation.

Design, Setting, and Participants

This cohort study included youths (aged 11-25 years) at 11 sites referred between March 2016 and December 2020. Data were analyzed from April 2022 to April 2024.

Exposure

Existing primary and/or community services implemented ACCESS-OM's core components: broad-spectrum mental health services, outreach, youth-friendly walk-in spaces, open systems accepting referrals from multiple sources, and response-time benchmarks (72 hours to evaluation and 30 days to start treatment).

Main Outcomes and Measures

Outcomes were the referral rate and the probability of being offered a first evaluation within 72 hours and receiving services within 30 days. Dates of referral and/or help-seeking, first offered appointment, first evaluation, and first services received were recorded. Multilevel negative binomial regression was used for hypothesis 1, and time-to-event analyses followed by multilevel accelerated failure time (AFT) models were used for hypotheses 2 and 3.

Results

A total of 7889 youths were referred; 4519 (mean [SD] age, 19.3 [3.4] years; 2440 [54%] cisgender women; 1049 [23.21%] Indigenous; 991 [21.93%] Visible Minority [Arab, Black, Chinese, Filipino, Japanese, Korean, Latin American, South Asian, Southeast Asian, West Asian, other ethnicity, and multiple ethnicities]; and 1525 [49.10%] White) were evaluated before March 2020. Each 6-month progression after implementation was associated with a 10% increase in referral rates (IRR, 1.10; 95% CI, 1.07-1.13). The probability of being offered an initial appointment (χ22 = 20.30; P < .001) and receiving services (χ22 = 4.48; P = .01) after any given delay differed significantly over the 3 years. In adjusted AFT models, each 6-month progression was associated with a 3% decrease in time to offered evaluation (time ratio [TR], 0.97; 95% CI, 0.95-0.99) and first services (TR, 0.97; 95% CI, 0.94-1.00). Moderate to severe mental health problems were associated with longer delays to offered first appointments (TR, 1.14; 95% CI, 1.06-1.24) and services (TR, 1.11; 95% CI, 1.01-1.22).

Conclusions and Relevance

As hypothesized, after ACCESS-OM implementation, more youths sought help, and the timeliness of initial response and services improved over time. These findings suggest that core principles, benchmarks, and implementation supports are valuable in organizing youth mental health care. Future efforts should make benefits equitable for those with severe problems.

Psychotherapies for the treatment of personality disorders: the state of the art

PURPOSE OF REVIEW

To provide an update of systematic reviews, meta-analyses and recent clinical outcome studies for personality disorder (PD) in order to investigate the state of the art of the evidence of psychotherapy for personality disorders.

RECENT FINDINGS

Few outcome studies in patients with Cluster A and Cluster C PD have been conducted, which limits the conclusions which can be drawn. Most recently published research has been conducted with borderline PD. There is limited evidence that dialectical behavior therapy (DBT), mentalization based therapy and schema therapy are more effective than treatment as usual. There is no convincing evidence that long and intensive therapy is more effective than short and less intensive therapy. Drop-out is rather high for patients with borderline PD. Group therapy results in more drop-outs than individual therapy.

SUMMARY

There is a clear need of studies evaluating whether psychotherapies developed for PDs are more effective than CBT for patients with Cluster C PD. Given that studies with patients with Cluster B PD suggest that longer treatment of DBT and mentalization-based treatment is not more effective than shorter treatment this needs to be studied with other evidence-based therapies as well. Serious efforts are needed to evaluate therapies for patients with Cluster A PDs.

The Relevance of Generalist Approaches to Early Intervention for Personality Disorder

Significant gains have been made in the treatment of personality disorder among young people. However, effect sizes for evidence-based treatments have been modest, and emerging evidence suggests the potential of generalist approaches to improve outcomes in this population. The aim of this review was to highlight how generalist approaches such as good psychiatric management for adolescents (GPM-A) hold promise for early intervention for personality disorders among young people. The authors discuss recent advances in clinical understanding of the diagnosis and treatment of personality disorder among youths and demonstrate how these advances align with GPM-A. Specifically, the authors show how several of GPM-A's guiding principles-most notably the need for access, common-factor approaches, and a focus on interpersonal hypersensitivity and restoring general functioning-align with these advances. This review suggests that GPM-A provides a timely and promising framework for innovating early interventions for personality disorder among young people.

Age dependent effects of early intervention in borderline personality disorder in adolescents

BACKGROUND

Psychological treatments for young people with sub-threshold or full-syndrome borderline personality disorder (BPD) are found to be effective. However, little is known about the age at which adolescents benefit from early intervention. This study investigated whether age affects the effectiveness of early intervention for BPD.

METHODS

N = 626 participants (M age = 15 years, 82.7% female) were consecutively recruited from a specialized outpatient service for early intervention in BPD in adolescents aged 12- to 17-years old. DSM-IV BPD criteria were assessed at baseline, one-year (n = 339) and two-year (n = 279) follow-up.

RESULTS

Older adolescents presented with more BPD criteria (χ2(1) = 58.23, p < 0.001) and showed a steeper decline of BPD criteria over the 2-year follow-up period compared with younger adolescents (χ2(2) = 13.53, p = 0.001). In an attempt to disentangle effects of early intervention from the natural course of BPD, a parametrized regression model was used. An exponential decrease (b = 0.10, p < 0.001) in BPD criteria was found when starting therapy over the 2-year follow-up. This deviation from the natural course was impacted by age at therapy commencement (b = 0.06, p < 0.001), although significant across all ages: older adolescents showed a clear decrease in BPD criteria, and young adolescents a smaller decrease.

CONCLUSIONS

Early intervention appears effective across adolescence, but manifests differently: preventing the normative increase of BPD pathology expected in younger adolescents, and significantly decreasing BPD pathology in older adolescents. The question as to whether developmentally adapted therapeutic interventions could lead to an even increased benefit for younger adolescents, should be explored in future studies.

An analysis of real-time suicidal ideation and its relationship with retrospective reports among young people with borderline personality disorder

INTRODUCTION

This study aimed to analyze the real-time variability of suicidal ideation intensity and the relationship between real-time and retrospective reports of suicidal ideation made on the Beck Scale for Suicidal Ideation (BSS), among young people with borderline personality disorder (BPD).

METHODS

Young people (15-25-year olds) with BPD (N = 46), recruited from two government-funded mental health services, rated the intensity of their suicidal ideation six times per day for 7 days before completing the BSS.

RESULTS

For 70% of participants, suicidal ideation changed in intensity approximately five times across the week, both within and between days. BSS ratings were most highly correlated with the highest real-time ratings of suicidal ideation. However, this was not significantly different from the relationship between the BSS and both the average and most recent ratings. Median ratings of suicidal ideation intensity were higher on the BSS compared with an equivalent question asked in real time.

CONCLUSION

Findings suggest that young people with BPD experience high levels of fluctuation in their intensity of suicidal ideation across a week and that retrospective reports of suicidal ideation might be more reflective of the most intense experience of suicidal ideation across the week.

Evaluating changes in functioning and psychological distress in visitors of the @ease youth mental health walk-in centres

BACKGROUND

Highly accessible youth initiatives worldwide aim to prevent worsening of mental health problems, but research into outcomes over time is scarce.

AIMS

This study aimed to evaluate outcomes and support use in 12- to 15-year-old visitors of the @ease mental health walk-in centres, a Dutch initiative offering free counselling by trained and supervised peers.

METHOD

Data of 754 visitors, collected 2018-2022, included psychological distress (Clinical Outcomes in Routine Evaluation 10 (CORE-10)), social and occupational functioning (Social and Occupational Functioning Assessment Scale (SOFAS)), school absenteeism and support use, analysed with change indicators (first to last visit), and mixed models (first three visits).

RESULTS

Among return visitors, 50.5% were female, 79.4% were in tertiary education and 36.9% were born outside of The Netherlands (one-time visitors: 64.7%, 72.9% and 41.3%, respectively). Moreover, 29.9% of return visitors presented with suicidal ideations, 97.1% had clinical psychological distress levels, and 64.1% of the latter had no support in the previous 3 months (one-time visitors: 27.2%, 90.7% and 71.1%, respectively). From visit 1 to 3, psychological distress decreased (β = -3.79, 95% CI -5.41 to -2.18; P < 0.001) and social and occupational functioning improved (β = 3.93, 95% CI 0.51-7.36; P = 0.025). Over an average 3.9 visits, 39.6% improved reliably and 28.0% improved clinically significantly on the SOFAS, which was 28.4% and 8.8%, respectively, on the CORE-10, where 43.2% improved in clinical category. Counselling satisfaction was rated 4.5/5.

CONCLUSIONS

Reductions in psychological distress, improvements in functioning and high counselling satisfaction were found among @ease visitors, forming a basis for future research with a control group.

A Brief Cognitive Analytic Therapy-Informed Approach for Young People That Have Self-Injured (CATCH-Y): A Case Series

BACKGROUND

Non-suicidal self-injury (NSSI) presents an increasingly prevalent problem for young people; however, there remains a scarce evidence base for effective, scalable treatments for adolescents. This study aimed to assess the feasibility and acceptability of a brief, cognitive analytic therapy (CAT)-informed intervention for young people who engage in NSSI (CATCH-Y).

METHODS

A case series design recruited 13 young people who met the inclusion and exclusion criteria to participate in the five-session intervention. Eligible participants were aged 13-17 years (M = 15.15, SD = 1.28) and had engaged in NSSI at least once in the previous 6 months. Feasibility and acceptability were measured via recruitment, retention, qualitative feedback and missing data. The secondary outcome measures of personal recovery and motivation were administered pre- and post-assessment, with measures of depressive symptoms and urges to self-injure.

RESULTS

The intervention was found to be largely feasible and acceptable with high rates of recruitment, retention and pre-/post-assessment data completeness. Measures showed preliminary support for positive change in rates of NSSI, urges to self-harm, low mood and personal recovery, although results were mixed. Completion rates for remote assessments were low.

CONCLUSIONS

The findings of this study support further evaluation of the CATCH-Y intervention on a larger scale. In-person assessments may be preferable to remote to ensure good completion rates.

A randomised controlled trial of a psychoeducational group intervention for family and friends of young people with borderline personality disorder features

OBJECTIVE

Preliminary evidence indicates that interventions designed to support family and friends ('carers') of young people with early-stage borderline personality disorder effectively improve carer outcomes. None of these interventions have been tested in a randomised controlled trial.

METHOD

This clustered, partially nested, randomised controlled trial was conducted at Orygen, Melbourne, Australia. Carers of young people (aged 15-25 years) with borderline personality disorder features were randomly assigned as a unit in a 1:1 ratio, balanced for young person's sex and age, to receive a 15-day intervention comprising: (1) the three-session, in-person, Making Sense of BPD (MS-BPD) multi-family group programme, plus two self-directed online psychoeducational modules (MS-BPD + Online, n = 38), or (2) the two self-directed online psychoeducational modules alone (Online, n = 41). The primary outcome was 'negative experiences of care', measured with the Experience of Caregiving Inventory, at the 7-week endpoint.

RESULTS

A total of 79 carers were randomised (pool of 281, 197 excluded, 94 declined) and 73 carers (51 females [69.9%], Mage = 43.8 years [standard deviation, SD = 12.9], MS-BPD + Online n = 35 [47.9%], Online n = 38 [52.1%]) provided follow-up data and were included in the intent-to-treat analysis. The intent-to-treat (and per protocol) analyses did not find any significant differences between the groups on the primary (d = -0.32; 95% confidence interval = [-17.05, 3.97]) or secondary outcomes. Regardless of treatment group, caregivers improved significantly in their personality disorder knowledge.

CONCLUSION

Delivering MS-BPD in conjunction with an online psychoeducational intervention was not found to provide additional benefit over and above access to an online intervention alone. In accordance with national guidelines, carer interventions should be routinely offered by youth mental health services as part of early intervention programmes for borderline personality disorder. Further research is warranted into which interventions work for whom, carers' preferences for support and barriers to care.

Therapeutic and Preventive Interventions in Adolescents with Borderline Personality Disorder: Recent Findings, Current Challenges, and Future Directions

BACKGROUND

Borderline personality disorder (BPD) has long suffered from overshadowing in adolescents and hopelessness from the psychiatrists themselves. Comprehensive guidelines for this age group are lacking.

AIMS

This narrative review aims to describe current recommendations for BPD and recent empirical evidence on effective treatments (both pharmacological and non-pharmacological) and preventive approaches. Innovative approaches, based on recent and original research on BPD adolescents, are also discussed.

RESULTS

Very low-certainty evidence has supported that medication has a positive effect on core BPD symptoms in adolescents. Medication prescribed for suicidal crises or associated disorders should be included in a global therapeutic plan, including efficacy reassessment, treatment duration, and a security plan. The overall benefit of structured psychotherapy for adolescents with BPD (cognitive behavioral therapy, mentalization-based therapy, dialectic behavioral therapy, and group therapy) is more important for self-harm behaviors than other BPD symptoms. Their specific efficacy, although difficult to distinguish from the overall non-specific effect of integrative care.

CONCLUSIONS

structured care of young BPD individuals should be based on the following principles: (1) setting the frame of care, including recognition of the diagnosis, and sharing information with patients and families about symptoms, prognosis, and putative psychological mechanisms involved; and (2) promoting comprehensive approaches, including both specific and non specific therapy, ecological interventions, community care, and preventive interventions in at-risk groups.

Differential Diagnosis of ICD-11 Personality Disorder and Autism Spectrum Disorder in Adolescents

The International Classification of Diseases 11th Revision (ICD-11) introduces fundamentally new diagnostic descriptions for personality disorder and autism spectrum disorder. Instead of the traditional categorical taxonomies, both personality disorder and autism spectrum disorder are described as being on a continuum. Accumulating research has pointed out that, in some cases, adolescents with autism spectrum disorder are at risk of being confused with having a personality disorder, which particularly applies to female adolescents. Case reports describe how adult autistic women struggled with social and identity roles as children and adolescents, using compensatory strategies such as social imitation and other types of camouflaging. Furthermore, some adolescents with autism display emotion dysregulation and self-injury. The ICD-11 recognizes that features of autism spectrum disorder may resemble features of personality disorder, but the two diagnoses have not yet been formally compared to one another. The present article therefore sought to outline and discuss the overlap and boundaries between the ICD-11 definitions of personality disorder and autism spectrum disorder and propose guiding principles that may assist practitioners in differential diagnosis with female adolescents. We specifically highlight how aspects of the self and interpersonal functioning along with emotional, cognitive, and behavioral manifestations may overlap across the two diagnoses. Restricted, repetitive, and inflexible patterns of behavior, interests, and activities are core features of autism spectrum disorder, which may be masked or less pronounced in female adolescents. Collecting a developmental history of the early presence or absence of autistic features is vital for a conclusive diagnosis, including features that are typically camouflaged in females. A number of future directions for research and clinical practice are proposed.

Bringing personality disorder in from the cold: Why personality disorder is a fundamental concern for youth mental health

OBJECTIVE

Personality disorder (PD) has its peak incidence between puberty and young adulthood. By any measure, it is among the most severe mental health problems occurring in young people, uniquely predicting debilitating current problems and acting as a 'gateway' to diverse and serious future problems. Yet, PD still struggles for legitimacy and parity of access to services, including early intervention.

CONCLUSION

Addressing PD is fundamental to youth mental health, and early intervention for PD has reached 'proof of concept'. Yet, reform is hindered by bigotry and sectarianism. Successful early intervention calls for a shift in the culture of services, countering damaging myths, addressing bigotry, and fostering hope. Such reforms are well within the reach of youth mental health.

Which psychotherapy is most effective and acceptable in the treatment of adults with a (sub)clinical borderline personality disorder? A systematic review and network meta-analysis

A broad range of psychotherapies have been proposed and evaluated in the treatment of borderline personality disorder (BPD), but the question which specific type of psychotherapy is most effective remains unanswered. In this study, two network meta-analyses (NMAs) were conducted investigating the comparative effectiveness of psychotherapies on (1) BPD severity and (2) suicidal behaviour (combined rate). Study drop-out was included as a secondary outcome. Six databases were searched until 21 January 2022, including RCTs on the efficacy of any psychotherapy in adults (⩾18 years) with a diagnosis of (sub)clinical BPD. Data were extracted using a predefined table format. PROSPERO ID:CRD42020175411. In our study, a total of 43 studies (N = 3273) were included. We found significant differences between several active comparisons in the treatment of (sub)clinical BPD, however, these findings were based on very few trials and should therefore be interpreted with caution. Some therapies were more efficacious compared to GT or TAU. Furthermore, some treatments more than halved the risk of attempted suicide and committed suicide (combined rate), reporting RRs around 0.5 or lower, however, these RRs were not statistically significantly better compared to other therapies or to TAU. Study drop-out significantly differed between some treatments. In conclusion, no single treatment seems to be the best choice to treat people with BPD compared to other treatments. Nevertheless, psychotherapies for BPD are perceived as first-line treatments, and should therefore be investigated further on their long-term effectiveness, preferably in head-to-head trials. DBT was the best connected treatment, providing solid evidence of its effectiveness.

Dropout from psychological treatment for borderline personality disorder: a multilevel survival meta-analysis

BACKGROUND

Dropout from psychotherapy for borderline personality disorder (BPD) is a notorious problem. We investigated whether treatment, treatment format, treatment setting, substance use exclusion criteria, proportion males, mean age, country, and other variables influenced dropout.

METHODS

From Pubmed, Embase, Cochrane, Psycinfo and other sources, 111 studies (159 treatment arms, N = 9100) of psychotherapy for non-forensic adult patients with BPD were included. Dropout per quarter during one year of treatment was analyzed on participant level with multilevel survival analysis, to deal with multiple predictors, nonconstant dropout chance over time, and censored data. Multiple imputation was used to estimate quarter of drop-out if unreported. Sensitivity analyses were done by excluding DBT-arms with deviating push-out rules.

RESULTS

Dropout was highest in the first quarter of treatment. Schema therapy had the lowest dropout overall, and mentalization-based treatment in the first two quarters. Community treatment by experts had the highest dropout. Moreover, individual therapy had lowest dropout, group therapy highest, with combined formats in-between. Other variables such as age or substance-use exclusion criteria were not associated with dropout.

CONCLUSION

The findings do not support claims that all treatments are equal, and indicate that efforts to reduce dropout should focus on early stages of treatment and on group treatment.

A theory of change for one-on-one peer support for older adolescents and young adults

Peer support has become increasingly available as a formal mental health service. However, high quality research and implementation of peer support has been hampered over the years by the lack of theory that clarifies peer support roles and explains exactly how these roles foster positive outcomes for peer support users. Observers have noted that theory is particularly sparse in regard to peer support for older adolescents and young adults, and they have called for theory that not only clarifies roles and mechanisms of impact, but also identifies how peer support for young people might differ from peer support for older adults This qualitative study brought young people with experience providing and using peer support together in small group discussions focused on understanding the activities and outcomes of peer support. This information was used to develop a theory of change that outlines key activities that constitute a one-on-one peer support role for young people, and describes how and why carrying out these activities should lead to positive outcomes. The theory highlights the characteristics of a successful "peerness-based relationship," and proposes that the development of this kind of relationship mediates other positive outcomes from peer support. The article concludes with a discussion of how this theory can usefully inform the development and specification of peer support roles, training and supervision, and other organizational supports.

Early Intervention for Personality Disorder

Both the DSM-5 Section III Alternative Model for Personality Disorders and the ICD-11 have introduced a genuinely developmental approach to personality disorder. Among young people with personality disorder, compelling evidence demonstrates a high burden of disease, substantial morbidity, and premature mortality, as well as response to treatment. Yet, early diagnosis and treatment for the disorder have struggled to emerge from its identity as a controversial diagnosis to a mainstream focus for mental health services. Key reasons for this include stigma and discrimination, lack of knowledge about and failure to identify personality disorder among young people, along with the belief that personality disorder must always be addressed through lengthy and specialized individual psychotherapy programs. In fact, evidence suggests that early intervention for personality disorder should be a focus for all mental health clinicians who see young people and is feasible by using widely available clinical skills.

Improving treatment outcomes for adolescents with borderline personality disorder through a socioecological approach

BACKGROUND

There is a dearth of studies evaluating treatment efficacy for adolescents diagnosed with borderline personality disorder. The few available randomized controlled trials that have been conducted show modest results and treatments appear to have equivalent effects. The current paper draws on (a) the lessons learnt from the last 50 years of psychotherapy research in general and (b) recent advances in mentalization-based understanding of why treatment works, which together point to the importance of following a socioecological approach in the treatment of personality problems in adolescence - a developmental period that insists on a treatment approach that goes beyond the therapist-client dyad.

CASE PRESENTATION

Here, we describe such an approach, and offer a clinical case example with a young 16-year old girl diagnosed with borderline personality disorder, to illustrate what a shift toward a more socioecological approach would entail.

CONCLUSIONS

The clinical impact of the socioecological approach and the potential benefits as illustrated in the current case illustration, offers a framework that justifies and allows for the expansion of service delivery for youth with borderline personality disorder beyond dyadic therapist-client work.