Brief psychological interventions for borderline personality disorder. A systematic review and meta-analysis of randomised controlled trials

Acceptability and feasibility of a short-term group therapy for people with borderline personality disorder symptoms

OBJECTIVE

This study evaluated the acceptance, feasibility and safety of a short-term group program for adults (18 years and older) and youth (16 to 18 years) with borderline personality disorder (BPD) symptoms. Termed Road Maps, the content and development were informed by common treatment factors identified from evidence-based therapies for BPD.

METHOD

Two-hundred and eight people consented to participate in the research trial and completed baseline measures. Intervention participants rated the acceptability and subjective experience of the group. Attrition rates informed feasibility, and serious adverse events were tracked to identify potential harms.

RESULTS

Participant post-group ratings of the group's acceptability and subjective experience were above average across both adult and youth populations. Attrition rate after commencement of group was 38% for adults and 27% among youth. The incidence rate of emergency department presentations was reduced by 41% in the 6 months post-group, relative to 6 months pre-group.

CONCLUSIONS

The current study provides preliminary support for the acceptability and feasibility of a short-term group therapy program for people with a diagnosis of BPD. Road Maps may be a useful intermediate intervention in a broader model of stepped care. Australian New Zealand Clinical Trials Registry, https://www.anzctr.org.au/ACTRN12622000849796.aspx, (ACTRN12622000849796).

Clinical effectiveness and cost-effectiveness of Structured Psychological Support for people with probable personality disorder in mental health services in England: study protocol for a randomised controlled trial

INTRODUCTION

Evidence-based psychological treatments for people with personality disorder usually involve attending group-based sessions over many months. Low-intensity psychological interventions of less than 6 months duration have been developed, but their clinical effectiveness and cost-effectiveness are unclear.

METHODS AND ANALYSIS

This is a multicentre, randomised, parallel-group, researcher-masked, superiority trial. Study participants will be aged 18 and over, have probable personality disorder and be treated by mental health staff in seven centres in England. We will exclude people who are: unwilling or unable to provide written informed consent, have a coexisting organic or psychotic mental disorder, or are already receiving psychological treatment for personality disorder or on a waiting list for such treatment. In the intervention group, participants will be offered up to 10 individual sessions of Structured Psychological Support. In the control group, participants will be offered treatment as usual plus a single session of personalised crisis planning. The primary outcome is social functioning measured over 12 months using total score on the Work and Social Adjustment Scale (WSAS). Secondary outcomes include mental health, suicidal behaviour, health-related quality of life, patient-rated global improvement and satisfaction, and resource use and costs. The primary analysis will compare WSAS scores across the 12-month period using a general linear mixed model adjusting for baseline scores, allocation group and study centre on an intention-to-treat basis. In a parallel process evaluation, we will analyse qualitative data from interviews with study participants, clinical staff and researchers to examine mechanisms of impact and contextual factors.

ETHICS AND DISSEMINATION

The study complies with the Helsinki Declaration II and is approved by the London-Bromley Research Ethics Committee (IRAS ID 315951). Study findings will be published in an open access peer-reviewed journal; and disseminated at national and international conferences.

TRIAL REGISTRATION NUMBER

ISRCTN13918289.

Recovery-focused self-help intervention using vodcasts for patients with personality disorder: feasibility randomised controlled trial

BACKGROUND

Availability of long-term psychological interventions for personality disorders is limited because of their high intensity and cost. Research in evidence-based, low-intensity interventions is needed.

AIMS

This study aimed to examine the feasibility, acceptability and potential impact of a low-intensity, digital guided self-help (GSH) intervention that is focused on emotion regulation, recovery-oriented and provides in-the-moment delivery for patients with personality disorders.

METHOD

We conducted a single-blind feasibility trial. A total of 43 patients with a personality disorder were recruited and randomly assigned to either a GSH arm (n = 22) or a treatment-as-usual arm (n = 21). The GSH intervention included a series of short videos offering psychoeducation and support, personalised feedback using text messages, and supportive telephone calls, for 4 weeks in addition to treatment as usual. Outcomes of emotional disturbance, emotion dysregulation, self-harm behaviours and decentring ability were measured at baseline, 4 weeks (end of intervention) and 8 weeks (follow-up).

RESULTS

All patients who attended the first session continued until the last session. There was an interaction effect between time and group on anxiety (P = 0.027, Δη2 = 0.10), where the GSH group showed a significant reduction in anxiety at follow-up (P = 0.003, d = 0.25). The GSH group increased in decentring ability at the end of intervention (P = 0.007, d = -0.65), and the decrease in self-harm behaviours continued until follow-up (P = 0.02, d = 0.57).

CONCLUSIONS

The results suggest that a personalised digital GSH with a focus on recovery could reduce anxiety and self-harm behaviours at short-term follow-up.

Evaluation of a skills-based peer-led art therapy online-group for people with emotion dysregulation

OBJECTIVE

We developed and piloted a novel art-based online skills program led by a peer mental health professional with lived experience of complex mental health, including Borderline Personality Disorder (BPD). Key challenges of living with BPD and emotion dysregulation were addressed through artmaking informed by a dialectical framework and skills, to evaluate acceptability and efficacy.

METHOD

A structured, manualised 2-hour weekly arts-based skills program was piloted for people with BPD over 18 weeks. Evaluation included both quantitative and qualitative measures at commencement and completion.

RESULTS

Thirty-eight participants enrolled in the program (89.5% identified she/her pronouns, average age 33.6 years), and 31 completed (82% retention). Multilevel modelling analysis of the primary outcome variable Difficulties in Emotion Regulation Scale (DERS) demonstrated a large improvement over time (effect size Cohen's d = 1.77). Qualitative thematic analysis found participants had improved capacity to regulate emotions and tolerate distress, improved connection with others, enhanced understanding of the self, and higher hope for living well. We found that artmaking facilitated processes and helped the expression of difficult emotions, symbolise challenging relationships, and facilitate greater self-understanding. Participants reported high levels of satisfaction, and 77.4% reported that the program had increased wellbeing.

CONCLUSION

This novel artmaking program for emotion dysregulation and BPD was acceptable and potentially effective. Peer facilitation using arts-based skills is a modality of therapy for further investigation.

Brief psychological interventions for anxiety and depression in a secondary care adult mental health service: an evaluation

Due to continuing pressures on the UK National Health Service’s mental health services, there has been increased interest in the development of brief psychological interventions (BPIs). These interventions are usually defined as including selected components of established psychological interventions, delivered over fewer sessions, and by staff with less specialised training (paraprofessionals). Cognitive behavioural therapy (CBT)-based BPIs for anxiety and depression have been found to be helpful for clients with mild to moderate mental health problems. This project evaluates the introduction of BPIs for anxiety and depression in a secondary care adult mental health service, with clients experiencing moderate to severe mental health difficulties. The service developed CBT-based manuals for anxiety (anxiety management) and depression (behavioural activation) BPIs. The BPIs were delivered by mental health workers without core therapeutic training, who were offered training and group supervision by psychologists in the team. Measures of anxiety (GAD-7), depression (PHQ-9), wellbeing (SWEMWBS) and functioning (WSAS) were completed at the start and end of treatment. The data reported from a 2-year period suggest that BPIs are associated with reductions in symptoms of anxiety and low mood, and improvements in wellbeing and functioning. Whilst this is a small-scale initial evaluation, the results are promising for the potential benefit of BPIs for clients in secondary care settings. Given that this new way of working has possible additional benefits such as improving access to psychological treatment and cost-effectiveness, further research in the area is warranted and encouraged.

Key learning aims

(1)

A service evaluation of short-term mentalisation based treatment for personality disorder

BACKGROUND

People with personality disorder experience long waiting times for access to psychological treatments, resulting from a limited availability of long-term psychotherapies and a paucity of evidence-based brief interventions. Mentalisation-based treatment (MBT) is an efficacious therapeutic modality for personality disorder, but little is known about its viability as a short-term treatment.

AIMS

We aimed to evaluate mental health, client satisfaction and psychological functioning outcomes before and after a 10-week group MBT programme as part of a stepped-care out-patient personality disorder service.

METHOD

We examined routinely collected pre-post treatment outcomes from 176 individuals (73% female) aged 20-63 years, attending a dedicated out-patient personality disorder service, who completed MBT treatment. Participants completed assessments examining mentalising capacity, client satisfaction, emotional reactivity, psychiatric symptom distress and social functioning.

RESULTS

Post-MBT outcomes suggested increased mentalising capacity (mean difference 5.1, 95% CI 3.4-6.8, P < 0.001) and increased client satisfaction with care (mean difference 4.3, 95% CI 3.3-5.2, P < 0.001). Post-MBT emotional reactivity (mean difference -6.3, 95% CI -8.4 to -4.3, P < 0.001), psychiatric symptom distress (mean difference -5.2, 95% CI -6.8 to -3.7, P < 0.001) and impaired social functioning (mean difference -0.7, 95% CI -1.2 to -0.3, P = 0.002) were significantly lower than pre-treatment. Improved mentalising capacity predicted improvements in emotional reactivity (β = -0.56, P < 0.001) and social functioning (β = -0.35, P < 0.001).

CONCLUSIONS

Short-term MBT as a low-intensity treatment for personality disorder was associated with positive pre-post treatment changes in social and psychological functioning. MBT as deployed in this out-patient service expands access to personality disorder treatment.

Personality Disorders and Their Relation to Treatment Outcomes in Cognitive Behavioural Therapy for Depression: A Systematic Review and Meta-analysis

Background

Previous reviews indicate that depressed patients with a comorbid personality disorder (PD) tend to benefit less from psychotherapies for depression and thus personality pathology needs to be the primary focus of treatment. This review specifically focused on studies of Cognitive Behavioural Therapy (CBT) for depression examining the influence of comorbid PD on post-treatment depression outcomes.

Methods

This was a systematic review and meta-analysis of studies identified through PubMed, PsychINFO, Web of Science, and Scopus. A review protocol was pre-registered in the PROSPERO database (CRD42019128590).

Results

Eleven eligible studies (N = 769) were included in a narrative synthesis, and ten (N = 690) provided sufficient data for inclusion in random effects meta-analysis. All studies were rated as having “low” or “moderate” risk of bias and there was no significant evidence of publication bias. A small pooled effect size indicated that patients with PD had marginally higher depression severity after CBT compared to patients without PD (g = 0.26, [95% CI: 0.10, 0.43], p = .002), but the effect was not significant in controlled trials (p = .075), studies with low risk of bias (p = .107) and studies that adjusted for intake severity (p = .827). Furthermore, PD cases showed symptomatic improvements across studies, particularly those with longer treatment durations (16–20 sessions).

Conclusions

The apparent effect of PD on depression outcomes is likely explained by higher intake severity rather than treatment resistance. Excluding these patients from evidence-based care for depression is unjustified, and adequately lengthy CBT should be routinely offered.