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Storebø OJ, Stoffers-Winterling JM, Völlm BA, Kongerslev MT, Mattivi JT, Jørgensen MS, Faltinsen E, Todorovac A, Sales CP, Callesen HE, Lieb K, Simonsen E. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2020; 5:CD012955. [PMID: 32368793 PMCID: PMC7199382 DOI: 10.1002/14651858.cd012955.pub2] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers-Winterling 2012). OBJECTIVES To assess the beneficial and harmful effects of psychological therapies for people with BPD. SEARCH METHODS In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication. SELECTION CRITERIA Randomised controlled trials comparing different psychotherapeutic interventions with treatment-as-usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects. DATA COLLECTION AND ANALYSIS At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis. MAIN RESULTS We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation-based treatment (MBT). The comparator interventions included treatment-as-usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months. Psychotherapy versus TAU Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.70 to -0.33; 22 trials, 1244 participants; moderate-quality evidence. This corresponds to a mean difference (MD) of -3.6 (95% CI -4.4 to -2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is -3.0 points). Psychotherapy may be more effective at reducing self-harm compared to TAU (SMD -0.32, 95% CI -0.49 to -0.14; 13 trials, 616 participants; low-quality evidence), corresponding to a MD of -0.82 (95% CI -1.25 to 0.35) on the Deliberate Self-Harm Inventory Scale (range 0 to 34). The MIREDIF of -1.25 points was not reached. Suicide-related outcomes improved compared to TAU (SMD -0.34, 95% CI -0.57 to -0.11; 13 trials, 666 participants; low-quality evidence), corresponding to a MD of -0.11 (95% CI -0.19 to -0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of -0.17 points was not reached. Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD -0.45, 95% CI -0.68 to -0.22; 22 trials, 1314 participants; low-quality evidence), corresponding to a MD of -2.8 (95% CI -4.25 to -1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of -4.0 points was not reached. Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases. A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning. Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD -0.39, 95% CI -0.61 to -0.17; 22 trials, 1568 participants; very low-quality evidence), corresponding to a MD of -2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of -3.0 points was not reached. BPD-specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data. Psychotherapy versus waiting list or no treatment Greater improvements in BPD symptom severity (SMD -0.49, 95% CI -0.93 to -0.05; 3 trials, 161 participants), psychosocial functioning (SMD -0.56, 95% CI -1.01 to -0.11; 5 trials, 219 participants), and depression (SMD -1.28, 95% CI -2.21 to -0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low-quality evidence). No evidence of a difference was found for self-harm and suicide-related outcomes. Individual treatment approaches DBT and MBT have the highest numbers of primary trials, with DBT as subject of one-third of all included trials, followed by MBT with seven RCTs. Compared to TAU, DBT was more effective at reducing BPD severity (SMD -0.60, 95% CI -1.05 to -0.14; 3 trials, 149 participants), self-harm (SMD -0.28, 95% CI -0.48 to -0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD -0.36, 95% CI -0.69 to -0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self-harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD -0.58, 95% CI -1.22 to 0.05, 4 trials, 333 participants). All findings are based on low-quality evidence. For secondary outcomes see review text. AUTHORS' CONCLUSIONS Our assessments showed beneficial effects on all primary outcomes in favour of BPD-tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF-defined cut-off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) . The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low-quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self-harm and suicide-related outcomes. However, compared to TAU, we observed effects in favour of DBT for BPD severity, self-harm and psychosocial functioning and, for MBT, on self-harm and suicidality at end of treatment, but these were all based on low-quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.
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Affiliation(s)
- Ole Jakob Storebø
- Child and Adolescent Psychiatric Department, Region Zealand, Roskilde, Denmark
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | | | - Birgit A Völlm
- Department of Forensic Psychiatry, Center for Neurology, University Rostock, Rostock, Germany
| | - Mickey T Kongerslev
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Jessica T Mattivi
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Mie S Jørgensen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Erlend Faltinsen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Adnan Todorovac
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Christian P Sales
- Duncan MacMillan House, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
- Institute of Mental Health, Department of Psychiatry & Applied Psychology, Nottingham, UK
| | | | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Erik Simonsen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
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Ligier F, Kabuth B, Guillemin F. MEDIACONNEX: a multicenter randomised trial based on short message service to reduce suicide attempt recurrence in adolescents. BMC Psychiatry 2016; 16:251. [PMID: 27435094 PMCID: PMC4952238 DOI: 10.1186/s12888-016-0965-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 07/12/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Suicide attempt among adolescents is a public health problem around the world. The risk of recurrence is high: about 30 % of adolescents. New ways to prevent suicide attempt recurrence being developed for adult suicide attempters include maintaining contact with them, and results are encouraging. METHODS/DESIGN The MEDIACONNEX study will be a simple blinded, parallel-group, multicenter randomised controlled trial. It will compare usual care alone to a program based on usual care plus short message service (SMS) provided to adolescents who attempt suicide and who receive treatment in pediatric and adolescent psychiatry units at hospitals in eastern France. Adolescents will be recruited over an 18-month period. The intervention will be based on the SMS, involving personalized and evolving text messages, sent on days 7 to 14 and months 1, 2, 4 and 6 after the SA. The primary endpoint will be the recurrence of an SA, with an assessment during 12 months. Secondary endpoints will be the evolution of 1) social networks, 2) depression and 3) health-related quality of life, with an assessment at inclusion and at 6 months. DISCUSSION This paper describes the design of MEDIACONNEX, which will assess the effectiveness of an SMS program for adolescent suicide attempters on SA recurrence. This program will be easy to reproduce and inexpensive. TRIAL REGISTRATION The study was registered at ClinicalTrials.gov (no. NCT02762734 ) on March 2016.
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Affiliation(s)
- Fabienne Ligier
- />Université de Lorraine, Université Paris Descartes, EA 4360 APEMAC, Nancy – CHU de Nancy, Hôpital d’enfants, Service de Psychiatrie pour enfants et adolescents, rue du Morvan, 54500 Vandoeuvre-lès-Nancy, France
| | - Bernard Kabuth
- />CHU de Nancy, Hôpital d’enfants, Service de Psychiatrie pour enfants et adolescents, Nancy, France
| | - Francis Guillemin
- />Université de Lorraine, Université Paris Descartes, EA 4360 APEMAC, Nancy - INSERM CIC-EC 1433 – CHU de Nancy, Service d’épidémiologie et évaluation cliniques, Nancy, France
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Hatcher S, Sharon C, House A, Collins N, Collings S, Pillai A. The ACCESS study: Zelen randomised controlled trial of a package of care for people presenting to hospital after self-harm. Br J Psychiatry 2015; 206:229-36. [PMID: 25614531 DOI: 10.1192/bjp.bp.113.135780] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The problem of people presenting to hospitals with self-harm is important because such presentations are common, there is a clear link to suicide and a high premature mortality. However, the best treatment for this population is unclear. AIMS To see whether a package of measures, that included regular postcards and problem-solving therapy, improved outcomes at 1 year compared with usual care in people who presented to hospital with self-harm (the ACCESS study: trial registration Australian and New Zealand Clinical Trials Registry ACTRN12609000641291). METHOD The design of the study was a Zelen randomised controlled trial. The primary outcome was re-presentation to hospital with self-harm within 12 months of the index episode. RESULTS There were no significant differences in the primary outcome and most of the secondary outcomes between the two groups. About half the people offered problem-solving therapy did not receive it, for various reasons. CONCLUSIONS The package as offered had little effect on the proportion of people re-presenting to hospital with self-harm. The dose of problem-solving therapy may have been too small to have an effect and there was a difficulty engaging participants in active treatment.
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Affiliation(s)
- Simon Hatcher
- Simon Hatcher, MBBS, MD, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Cynthia Sharon, MSc, University of Auckland, Auckland, New Zealand; Allan House, MBBS, DM, University of Leeds, Leeds, UK; Nicola Collins, University of Auckland, Auckland, New Zealand; Sunny Collings, MBChB, PhD, University of Otago, Dunedin, New Zealand; Avinesh Pillai, MSc, University of Auckland, Auckland, New Zealand
| | - Cynthia Sharon
- Simon Hatcher, MBBS, MD, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Cynthia Sharon, MSc, University of Auckland, Auckland, New Zealand; Allan House, MBBS, DM, University of Leeds, Leeds, UK; Nicola Collins, University of Auckland, Auckland, New Zealand; Sunny Collings, MBChB, PhD, University of Otago, Dunedin, New Zealand; Avinesh Pillai, MSc, University of Auckland, Auckland, New Zealand
| | - Allan House
- Simon Hatcher, MBBS, MD, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Cynthia Sharon, MSc, University of Auckland, Auckland, New Zealand; Allan House, MBBS, DM, University of Leeds, Leeds, UK; Nicola Collins, University of Auckland, Auckland, New Zealand; Sunny Collings, MBChB, PhD, University of Otago, Dunedin, New Zealand; Avinesh Pillai, MSc, University of Auckland, Auckland, New Zealand
| | - Nicola Collins
- Simon Hatcher, MBBS, MD, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Cynthia Sharon, MSc, University of Auckland, Auckland, New Zealand; Allan House, MBBS, DM, University of Leeds, Leeds, UK; Nicola Collins, University of Auckland, Auckland, New Zealand; Sunny Collings, MBChB, PhD, University of Otago, Dunedin, New Zealand; Avinesh Pillai, MSc, University of Auckland, Auckland, New Zealand
| | - Sunny Collings
- Simon Hatcher, MBBS, MD, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Cynthia Sharon, MSc, University of Auckland, Auckland, New Zealand; Allan House, MBBS, DM, University of Leeds, Leeds, UK; Nicola Collins, University of Auckland, Auckland, New Zealand; Sunny Collings, MBChB, PhD, University of Otago, Dunedin, New Zealand; Avinesh Pillai, MSc, University of Auckland, Auckland, New Zealand
| | - Avinesh Pillai
- Simon Hatcher, MBBS, MD, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Cynthia Sharon, MSc, University of Auckland, Auckland, New Zealand; Allan House, MBBS, DM, University of Leeds, Leeds, UK; Nicola Collins, University of Auckland, Auckland, New Zealand; Sunny Collings, MBChB, PhD, University of Otago, Dunedin, New Zealand; Avinesh Pillai, MSc, University of Auckland, Auckland, New Zealand
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