Modest, Transient Effect of Psychotherapy for BPD

March 07, 2017

Psychotherapies developed specifically for the treatment of borderline personality disorder (BPD) show modest effects that tend to lose superiority compared to usual treatment, a new meta-analysis suggests.

"Various independent psychotherapies demonstrated efficacy for borderline-relevant symptoms, self-harm, suicide, health service use, and general psychopathology in bipolar personality disorder," the researchers, with first author Ioana Cristea, PhD, an associate professor in the Department of Clinical Psychology and Psychotherapy at Babes-Bolyai University in Cluj-Napoca, Romania, write.

"However," they add, "the effects were small, inflated by publication bias, and particularly unstable for follow-up."

The findings were published online March 1 in  JAMA Psychiatry .

High Rate of Self-harm

The meta-analysis included 33 randomized controlled trials in which a specialized psychotherapy was compared with a control condition in the treatment of adults with BPD.

In post-test study results, psychotherapies were moderately more effective than control interventions for combined BPD outcomes, including symptoms, self-harm, and suicide (Hedges g = .32 for stand-alone and g = .40 for add-on designs).

These outcomes are important, because more than 75% of patients with BPD are believed to engage in deliberate self-harm, the authors note.

The studies had follow-up periods of up to 2 years. Thirteen of the trials reported outcomes relevant to BPD (g = .45). Results indicated that only dialectical behavior therapy and psychodynamic approaches, each designed specifically for the treatment of BPD, were more efficacious than control interventions (g = 0.34 and g = 0.41, respectively).

However, in well-designed trials that were less prone to bias, many of the differences dissipated, the authors note.

The analysis distinguished studies comparing specialized psychotherapies to treatment as usual. Specialized psychotherapies were employed either as monotherapy or as an adjunct to standard treatments. Results showed no differences between the stand-alone and add-on approaches in any outcomes.

Importantly, the findings also showed no significant differences in terms of treatment retention (odds ratio [OR], 1.32 for stand-alone trial designs; OR, 1.01 for add-on designs) for specialized vs control therapies.

No Superior Durability

"One of the chief findings of the paper is we found no evidence that treatment retention was higher for specific psychotherapies than for control interventions, directly contradicting systematic claims from individual trials," Dr Cristea told Medscape Medical News.

"I think this is particularly germane for both clinical and methodological reasons. It shows that what was believed to be the advantage of tailored psychotherapies for borderline personality ― uniquely improving treatment retention ― might for a large part be due to single trials having used inconsistent and sometimes idiosyncratic ways of defining what is a dropout."

The analysis also showed no greater benefits with increased treatment intensity, including increased treatment duration and exposure.

Surprisingly, cognitive-behavioral therapy also showed no greater effectiveness compared to control conditions. The approach was only described in five trials, and the heterogeneity of those studies was low, the investigators point out.

The analysis also showed efficacy in some control interventions that involved participation of the study team in treatment or with a manualized protocol when the therapies were specifically tailored for BPD.

However, Dr Cristea noted that the control interventions included an eclectic mix of psychotherapeutic strategies.

"Hence, a clear case that can definitely be made is one for structured and manualized interventions," she said.

Dr Cristea noted that separate meta-analyses of pharmacologic treatments for BPD have shown generally modest effects.

"It's all worth pointing out that many of the pharmacological trials do not report outcomes for core symptoms or problems associated with borderline (like self-harm or suicide) and instead look at the effects of pharmacological treatments on associated problems like depression or aggression, which might be of more moderate intensity, more manageable and diffuse, and easier to treat than, for instance, self-harm," she said.

In the current analysis, use of adjunctive medication was neither standardized nor consistently reported, which hampered the assessment of the effects, Dr Cristea added.

Highly Debilitating Condition

Although long considered "hard to reach," patients with BPD have shown promising improvement in recent decades in response to specialized therapies, and the meta-analysis helps put the evidence of those approaches into perspective, Peter Fonagy, PhD, of University College London, United Kingdom, and colleagues write in an accompanying editorial.

"The [current study] represents a new and major leap forward in this regard, as it heralds the coming of an age of research on the effectiveness of psychotherapy for borderline personality disorder.

"While these findings provide further support for cautious optimism in relation to the role of specialized psychotherapy (and psychotherapy more generally) in treating borderline personality disorder, the meta-analysis also highlights important limitations and concerns that the field needs to urgently address," Dr Fonagy and colleagues write.

They note that greater improvements through specialized therapies that were observed in some, but not all, studies may reflect the fact some studies used more structured therapeutic approaches.

"Consistent with this, we have argued that for borderline personality disorder, the treatment characteristics of coherence, consistency, and continuity, marked in specialized treatments, are critical because they provide cognitive structure for a patient group that lacks in metacognitive organization."

They add that the many unanswered questions about the nature of the disorder itself complicates the determination of the best treatment approaches.

"If borderline personality disorder is largely an indicator of vulnerability to personality disorder diagnoses, then perhaps we are wrong to think about borderline personality disorder as a disorder; rather, we could conceive of its core symptoms as indications of a relative lack of capacity to withstand adversity," they write.

The meta-analysis ultimately makes it "clear that much remains to be done in terms of the development, evaluation, and implementation in routine clinical care of effective psychotherapy for this highly debilitating condition."

The study authors have disclosed no relevant financial relationships. The editorialists are developers of a specialist psychotherapy for BPD (mentalization-based therapy) and receive payment for training and supervision. Dr Fonagy is recipient of a senior investigator award from the National Institute for Health Research (NIHR) and was in part supported by the NIHR Collaboration for Leadership in Applied Health Research and Care North Thames at Barts Health NHS Trust.

JAMA Psychiatry . Published March 1, 2017. Full textEditorial

 

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