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Search Strategies, Study Selection, and Search Results

Appendix B
The methods for this systematic review follow the Agency for Healthcare Research and Quality (AHRQ) Methods Guide for Effectiveness and Comparative Effectiveness Reviews (available at https://effectivehealthcare.ahrq.gov/products/collections/cer-methods-guide) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist (Moher et al. 2015). The final protocol of this review was registered on PROSPERO (Registration #: CRD42020194098). All methods and analyses were determined a priori.

Literature Searches

Initial searches were conducted on June 7, 2018, by APA staff using MEDLINE (PubMed), EMBASE, the Cochrane Library (Wiley), and PsychInfo (EBSCO). Subsequent searches were conducted by RTI. Searches differed in exact search strings; however, to ensure optimal recall, the RTI searches were reviewed in detail to ensure that the revised search strategy still detected all studies that met inclusion criteria of the original search. These searches were also conducted in MEDLINE, EMBASE, the Cochrane Library, and PsychINFO from January 1, 2018, to June 15, 2020. Additional overlapping update searches of MEDLINE and PsycINFO were run in April and September 2021. Our search strategies used a variety of terms, medical subject headings (MeSH), and major headings, and were limited to English-language and human-only studies.
To minimize retrieval bias, we manually searched reference lists of landmark studies and background articles on this topic for relevant citations that electronic searches might have missed.

Doctor Evidence Original Search Strategy

Search Date: June 7, 2018

PubMed search strategy for borderline personality disorder
Search ID#QueryResults
#1
(“Borderline Personality Disorder”[Mesh]) OR (borderline [tiab] AND personality [tiab])
8,962
#2
(“animals”[MeSH Terms] OR animal [tiab] OR animals [tiab] OR rat [tiab] OR rats [tiab] OR mouse [tiab] OR mice [tiab] OR rodent [tiab] OR rodents [tiab]) NOT (“humans”[MeSH Terms] OR humans [tiab] OR human [tiab])
4,419,530
#3
#1 NOT #2
8,957
 
Limit to English
7,983
EMBASE search strategy for borderline personality disorder
SearchQueryResults
#1
exp *borderline state/ or (borderline and personality).ti. or (borderline and personality).ab.
11,073
#2
limit #1 to (article or article in press or conference paper)
7,571
#3
#2 not ((exp animal/ or nonhuman/) not exp human/)
7,564
#4
#2 not ((animal or animals or rat or rats or mouse or mice or rodent or rodents) not (humans or human)).ti,ab.
7,548
#5
#3 or #4
7,569
#6
limit #5 to yr = “1883–2002”
2,765
#7
limit #5 to yr = “2002–Current”
4,929
#8
remove duplicates from #6
2,740
#9
remove duplicates from #7
4,739
#10
#8 or #9
7,337
#11
limit #10 to English language
6,356
Cochrane Library search strategy for borderline personality disorder
SearchQueryResults
#1
MeSH descriptor: [Borderline Personality Disorder] explode all trees
390
#2
borderline and personality:ti,ab,kw (Word variations have been searched)
684
#3
#1 or #2
684
#4
#3 not (pubmed or embase):an
145 in trials; 6 in Cochrane reviews; 9 in other reviews
PsycINFO search strategy for borderline personality disorder
SearchQueryLimiters/ExpandersResults
S1
MM “Borderline Personality Disorder”
 
5,220
S2
DE “Borderline Personality Disorder”
 
7,857
S3
MA “borderline personality disorder”
 
4,192
S4
TI “borderline personality” OR AB “borderline personality” OR SU “borderline personality” OR KW “borderline personality”
 
11,400
S5
S1 OR S2 OR S3 OR S4
 
11,400
S6
(MM “Animals” OR DE “Animals” OR DE “Vertebrates” OR DE “Amphibia” OR DE “Birds” OR DE “Fishes” OR DE “Mammals” OR DE “Pigs” OR DE “Reptiles” OR DE “Rats” OR DE “Rodents” OR DE “Mice”)
 
329,022
S7
TI “animals” OR TI “animal” OR TI “mouse” OR TI “mice” OR TI “rodent” OR TI “rodents” OR TI “rat” OR TI “rats” OR SU “animals” OR SU “animal” OR SU “mouse” OR SU “mice” OR SU “rodent” OR SU “rodents” OR SU “rat” OR SU “rats” OR KW “animals” OR KW “animal” OR KW “mouse” OR KW “mice” OR KW “rodent” OR KW “rodents” OR KW “rat” OR KW “rats” OR AB “animals” OR AB “animal” OR AB “mouse” OR AB “mice” OR AB “rodent” OR AB “rodents” OR AB “rat” OR AB “rats”
 
426,155
S8
 
Limiters—Population Group: Animal
385,743
S9
S6 OR S7 OR S8
 
459,805
S10
 
Limiters—Population Group: Human
3,780,890
S11
TI “humans” OR TI “human” OR AB “humans” OR AB “human” OR SU “humans” OR SU “human” OR KW “humans” OR KW “human”
 
1,585,426
S12
S10 OR S11
 
3,888,530
S13
S9 NOT S12
 
310,376
S14
S5 NOT S13
 
11,398
S15
 
Limiters—Publication Type: All Journals
3,518,961
S16
S14 AND S15
 
9,386
S17
LA English
 
4,207,720
S18
S16 AND S17
 
8,116

RTI Updated Search Strategy

Search Date: June 15, 2020

PubMed search strategy for borderline personality disorder
SearchQueryResults
#1
“Borderline Personality Disorder”[Mesh] OR “Borderline Disorder”[ti] OR “Borderline Personality Disorder”[tiab] OR “borderline-patient”[ti] OR “borderline patient”[ti] OR “borderline-patients”[ti] OR “borderline patients”[ti]
8,693
#2
#1 AND (“2018/01/01”[Date—Publication]: “3000”[Date—Publication])
1,202
#3
#2 AND English[lang]
1,161
EMBASE search strategy for borderline personality disorder
SearchQueryResults
#1
(‘borderline state’/de OR ‘borderline disorder’:ti OR ‘borderline-patient’:ti OR ‘borderline patient’:ti OR ‘borderline-patients’:ti OR ‘borderline patients’:ti OR ‘borderline personality disorder’:ti,ab,kw) AND [2018-2020]/py AND [english]/lim
1,777
#2
‘borderline personality disorder’:ti,kw AND [english]/lim AND [1-1-2018]/sd
990
#3
#1 OR #2
1,924
Cochrane Library search strategy for borderline personality disorder
SearchQueryResults
#1
(“Borderline Disorder” OR “Borderline Personality Disorder” OR “borderline-patient” OR “borderline patient” OR “borderline-patients” OR “borderline patients”):ti,ab,kw OR [mh “Borderline Personality Disorder”]
851
#2
#1 with Cochrane Library publication date from Jan 2018 to present, in Cochrane Reviews, Cochrane Protocols, Trials, Clinical Answers, Editorials and Special collections
412
PsycINFO (via ProQuest) search strategy for borderline personality disorder
SearchQueryResults
S1
if(“Borderline Personality Disorder”) OR mjsub(“Borderline Personality Disorder”) OR mainsubject(“Borderline Personality Disorder”) OR ti(“Borderline Personality Disorder” OR “Borderline Disorder” OR “borderline-patient” OR “borderline patient” OR “borderline-patients” OR “borderline patients”) OR ab(“Borderline Personality Disorder”)
Additional limits—Date: After January 01 2018; Language: English
986

Search Date: April 6, 2021

PubMed search strategy for borderline personality disorder
SearchQueryResults
#1
“Borderline Personality Disorder”[Mesh] OR “Borderline Disorder*”[ti] OR “Borderline Personality Disorder*”[tiab] OR “borderline patient”[ti] OR “borderline patients”[ti]
9,260
#2
#1 NOT (“Animals”[Mesh] NOT “Humans”[Mesh])
9,258
#3
(#2) AND ((“2020”[Date—Publication]: “3000”[Date—Publication])) Filters: English
744
PsycINFO (via ProQuest) search strategy for borderline personality disorder
SearchQueryResults
S1
DE “Borderline Personality Disorder”
8,991
S2
borderline W1 (disorder# OR patient#)
13,511
S3
S1 OR S2
13,511
S4
S3 (Limiters – Publication Year 2020 – 2021; Language: English)
510

Search Date: September 24, 2021

PubMed search strategy for borderline personality disorder
SearchQueryResults
#1
“Borderline Personality Disorder”[Mesh] OR “Borderline Disorder*”[ti] OR “Borderline Personality Disorder*”[tiab] OR “borderline patient”[ti] OR “borderline patients”[ti]
9,488
#2
#1 NOT (“Animals”[Mesh] NOT “Humans”[Mesh])
9,486
#3
(#2) AND ((“2020”[Date—Publication]: “3000”[Date—Publication])) Filters: English
949
PsycINFO (via ProQuest) search strategy for borderline personality disorder
SearchQueryResults
S1
DE “Borderline Personality Disorder”
9,216
S2
borderline W1 (disorder# OR patient#)
13,784
S3
S1 OR S2
13,784
S4
S3 (Limiters – Publication Year 2020 – 2021; Language: English)
749

Criteria for Inclusion/Exclusion of Studies in the Review

The criteria for inclusion and exclusion of studies are designed to identify research that can answer the key questions. The criteria are based on the population, intervention/exposure, comparator, outcomes, time frames, country and clinical settings, and study design (PICOTS).
Inclusion and exclusion criteria
CriteriaIncludeExclude
Participants/population
Age  13
Age < 13
 
Diagnosed with BPD as defined by DSM-IV, DSM-IV-TR, DSM-5 (Section II or Section III), or ICD-10
Individuals with borderline traits without a specific diagnosis
 
For mixed population studies, BPD must account for  75% of the total population
Diagnosed with BPD as defined by DSM-III-R
 
Subgroups of interest:
Studies in which the primary research focus is a different diagnosis with co-occurring BPD in a subset (< 75% of the total population)
 
Co-occurring mental disorder
 
 
Age
 
 
Gender
 
 
Race/ethnicity
 
 
Genotypes (related to treatment selection, treatment response, or adverse effects)
 
Intervention(s)/exposure(s)
Yoga
Complementary/alternative treatments not listed for inclusion
 
Exercise
Somatic therapies
 
Peer-support interventions
Bioenergetic analysis
 
Psychosocial support
Body psychotherapy
 
Safety planning
Core energetics
 
Service delivery approaches:
Hakomi
 
Stepped-care
Somatic experiencing
 
Collaborative care
Pharmacotherapies
 
Measurement-based care
Acetazolamide
 
Treatment setting comparisons
Ethosuximide
 
Face-to-face sessions
Felbamate
 
Group sessions
Fosphenytoin
 
Online programs
Lacosamide
 
Therapeutic community
Methsuximide
 
Video
Pentobarbital
 
Progressive muscle relaxation
Perampanel
 
Somatic therapies:
Primidone
 
Electroconvulsive therapy (ECT)
Rufinamide
 
Repetitive transcranial magnetic stimulation (rTMS)
Droperidol
 
Transcranial alternating current stimulation (tACS)
Nalmefene
 
Transcranial direct current stimulation (tDCS)
Butabarbital
 
Transcranial magnetic stimulation (TMS)
Secobarbital
 
Pharmacotherapies
 
 
Anticonvulsant “mood stabilizers”:
 
 
Carbamazepine
 
 
Divalproex sodium
 
 
Gabapentin
 
 
Lamotrigine
 
 
Levetiracetam
 
 
Oxcarbazepine
 
 
Phenytoin
 
 
Pregabalin
 
 
Tiagabine
 
 
Topiramate
 
 
Valproate
 
 
Valproic acid
 
 
Vigabatrin
 
 
Zonisamide
 
 
Antidepressants:
 
 
Amitriptyline
 
 
Amoxapine
 
 
Bupropion
 
 
Citalopram
 
 
Clomipramine
 
 
Desipramine
 
 
Desvenlafaxine
 
 
Doxepin
 
 
Duloxetine
 
 
Escitalopram
 
 
Fluoxetine
 
 
Fluvoxamine
 
 
Imipramine
 
 
Isocarboxazid
 
 
Maprotiline
 
 
Mirtazapine
 
 
Milnacipran
 
 
Nefazodone
 
 
Nortriptyline
 
 
Paroxetine
 
 
Phenelzine
 
 
Protriptyline
 
 
Sertraline
 
 
Selegiline
 
 
Tranylcypromine
 
 
Trazodone
 
 
Trimipramine
 
 
Venlafaxine
 
 
Vilazodone
 
 
Vortioxetine
 
 
Antipsychotics:
 
 
Aripiprazole
 
 
Asenapine
 
 
Chlorpromazine
 
 
Clozapine
 
 
Fluphenazine
 
 
Haloperidol
 
 
Iloperidone
 
 
Loxapine
 
 
Lurasidone
 
 
Olanzapine
 
 
Paliperidone
 
 
Perphenazine
 
 
Pimozide
 
 
Prochlorperazine
 
 
Quetiapine
 
 
Risperidone
 
 
Thioridazine
 
 
Thiothixene
 
 
Trifluoperazine
 
 
Ziprasidone
 
 
Benzodiazepines:
 
 
Alprazolam
 
 
Clobazam
 
 
Clonazepam
 
 
Clorazepate
 
 
Chlordiazepoxide
 
 
Diazepam
 
 
Estazolam
 
 
Flurazepam
 
 
Lorazepam
 
 
Midazolam
 
 
Oxazepam
 
 
Quazepam
 
 
Temazepam
 
 
Triazolam
 
 
Opioid agonists and antagonists:
 
 
Buprenorphine
 
 
Naloxone
 
 
Naltrexone
 
 
Sedative-hypnotic medications:
 
 
Eszopiclone
 
 
Melatonin
 
 
Ramelteon
 
 
Suvorexant
 
 
Tasimelteon
 
 
Zaleplon
 
 
Zolpidem
 
 
Other pharmacotherapies:
 
 
Clonidine
 
 
Lithium
 
 
Prazosin
 
 
Psychotherapies:
 
 
Acceptance and commitment therapy (ACT)
 
 
Client-centered therapy
 
 
Cognitive analytic therapy (CAT)
 
 
Cognitive-behavioral therapy (CBT)
 
 
Cognitive rehabilitation
 
 
Cognitive therapy (CT)
 
 
Comprehensive validation therapy
 
 
Dialectical behavior therapy (DBT)
 
 
Dual-focused schema therapy
 
 
Dynamic deconstructive psychotherapy (DDP)
 
 
Emotion regulation group intervention
 
 
Emotion regulation training (ERT)
 
 
Good psychiatric management (GPM)
 
 
Group analytic psychotherapy
 
 
Humanistic and integrative psychotherapy
 
 
Individual psychotherapy
 
 
Interpersonal group psychotherapy
 
 
Interpersonal psychotherapy (IPP)
 
 
Interpersonal therapy (IPT)
 
 
Manual-assisted cognitive therapy (MACT)
 
 
Mentalization-based therapy (MBT)
 
 
Mindfulness-based cognitive therapy (MBCT)
 
 
Motive-oriented therapeutic relationship (MOTR)
 
 
Nidotherapy
 
 
Problem-solving therapy
 
 
Psychoanalytic therapy (psychoanalysis)
 
 
Psychodynamic interpersonal therapy (PIT)
 
 
Psychodynamic therapy
 
 
Psychodynamic/psychoanalytic psychotherapy
 
 
Psychoeducation
 
 
Psychotherapy focused on psychic representation
 
 
Rogerian supportive therapy
 
 
Schema-focused cognitive therapy
 
 
Schema-focused therapy
 
 
Schema-focused psychotherapy (SFP)
 
 
Sequential brief Adlerian psychodynamic psychotherapy
 
 
Supervised team management
 
 
Supportive therapy
 
 
System-based psychotherapy
 
 
Systemic therapy
 
 
Systems Training for Emotional Predictability and Problem Solving (STEPPS)
 
 
Transference-focused psychotherapy (TFP)
 
Comparator(s)/control
Interventions listed above for inclusion
Interventions listed as excluded above for interventions/exposures
 
Placebo
 
 
Treatment as usual
 
 
Wait-list control
 
 
Community treatment by experts
 
 
General psychiatric management
 
 
Standard group treatment
 
 
Standard psychiatric care
 
 
Structured clinical management
 
Outcomes
Pre-specified outcomes and outcome measures
Outcomes not listed, imaging markers, physiological markers, and biomarkers
 
A. BPD symptoms/diagnostic criteria
Outcomes that were not pre-specified, e.g., during post-hoc, exploratory analyses
 
 1. Frantic efforts to avoid real or imaginary abandonment
 
 
 2. Pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
 
 
  a. Inventory of Interpersonal Problems (IIP)
 
 
  b. Distorted self-image
 
 
 3. Identity disturbances: markedly and persistent unstable self-image or sense of self
 
 
  a. Distorted self-image
 
 
 4. Impulsivity
 
 
  a. Impulsivity
 
 
  b. Impulsive/behavioral
 
 
  c. Risk taking behaviors
 
 
  d. Lack of restraint
 
 
  e. Barratt Impulsiveness Scale (BIS-11)
 
 
  f. Multi-Impulsivity Scale (MIS)
 
 
 5. Recurrent suicidal behavior, gestures, or threats; or self-mutilating behavior
 
 
  a. Nonsuicidal self-injury
 
 
  b. Suicide attempts
 
 
  c. Suicide
 
 
  d. Suicidal ideation
 
 
  e. Self-destructive behavior
 
 
  f. Beck Scale for Suicide Ideation (BSS)
 
 
  g. Self-Harm Behavior Survey
 
 
  h. Suicidal Behaviors Questionnaire (SBQ) and SBQ-R
 
 
  i. Parasuicide History Interview (PHI)
 
 
  j. Borderline Personality Disorder Severity Index (BPDSI) Parasuicidality Subscale
 
 
  k. Columbia Suicide Severity Rating Scale (C-SSRS)
 
 
  l. Deliberate Self-Harm Inventory (DSHI)
 
 
  m. Self-Injurious Thoughts and Behaviors Interview-Self-Report
 
 
 6. Affective instability, due to a marked reactivity of mood
 
 
  a. Irritability
 
 
  b. Mood swings
 
 
  c. Difficulties in Emotion Regulation Scale (DERS)
 
 
  d. Affective dysregulation
 
 
 7. Chronic feelings of emptiness
 
 
 8. Inappropriate intense anger or difficulty controlling anger
 
 
  a. Aggression
 
 
  b. Anger
 
 
  c. Hostility
 
 
  d. Aggressive behavior
 
 
  e. Antisocial behavior
 
 
  f. Spielberger State-Trait Anger Expression Inventory (STAXI)
 
 
  g. Spielberger State-Trait Anger Scale (STAS)
 
 
  h. Acting Out Scale (AOS)
 
 
  i. Aggression Questionnaire (AQ)
 
 
  j. Anger, Irritability, and Assault Questionnaire (AIAQ)
 
 
  k. Overt Aggression Scale (OAS)
 
 
  l. Buss Durkee Hostility Inventory (BDHI)
 
 
 9. Transient, stress-related paranoid ideation, or severe dissociative symptoms
 
 
  a. Dissociation
 
 
B. Scales for BPD
 
 
 1. Borderline Personality Disorder Severity Index (BPDSI)
 
 
 2. Zanarini Rating Scale (ZAN-BPD)
 
 
C. Other symptoms commonly found in individuals with BPD, but not part of the diagnostic criteria
 
 
 1. Depression and Anxiety
 
 
  a. Spielberger State-Trait Anxiety Inventory (STAI)
 
 
  b. Symptom Checklist-90 (SCL-90)
 
 
  c. Beck Anxiety Inventory (BAI)
 
 
  d. Beck Depression Inventory (BDI)
 
 
  e. Beck Hopelessness Scale (BHS)
 
 
  f. Hamilton Rating Scale for Anxiety (Ham-A)
 
 
  g. Hamilton Rating Scale for Depression (Ham-D)
 
 
  h. Hospital Anxiety and Depression Scale (HADS)
 
 
  i. Montgomery-Åsberg Depression Rating Scale (MADRS)
 
 
  j. Patient Health Questionnaire (PHQ-9)
 
 
  k. Brief Symptom Inventory (BSI)
 
 
  l. Generalized Anxiety Disorder 7-item scale (GAD-7)
 
 
  m. Patient Health Questionnaire–Adolescent
 
 
  n. Patient Health Questionnaire: Somatic, Anxiety, and Depressive Symptoms
 
 
D. Functioning Scales
 
 
 1. Global Adjustment Scale
 
 
 2. Global Assessment of Functioning (GAF)
 
 
 3. Quality of Life
 
 
 4. Global Social Adjustment (GSA)
 
 
 5. Global Severity Index (GSI)
 
 
 6. Number of years with employment
 
 
 7. Social Adjustment Scale (SAS)
 
 
 8. Social and Occupational Functioning Assessment Scale
 
 
 9. Social Functioning Questionnaire (SFQ)
 
 
 10. Social History Interview (SHI)
 
 
 11. Social Problem-Solving Inventory
 
 
 12. World Health Organization—Disability Assessment Schedule (WHO-DAS)
 
 
E. Adverse events (AEs)
 
 
 1. Rate of any AEs
 
 
 2. Overall serious treatment-related AE rate
 
 
 3. Specific serious treatment-related AEs
 
 
 4. Study withdrawal due to AE
 
 
 5. Study withdrawal for any reason
 
Timing
Treatment duration  8 weeks
Treatment duration < 8 weeks
Setting/context
Very high Human Development Index (HDI) countries*
All other countries
Study design
RCTs phase 2 | 3 | 4
Single-arm dose-finding trials
 
Nonrandomized clinical trials (N 50):
Observational, noncomparative
 
 Phase 1 | 2 | 3 | 4
Case reports/series
 
Observational studies, comparative (N ≥50)
Prognostic course/factor studies
 
 Cross-sectional
Modeling studies
 
 Prospective cohort
Pre-clinical
 
 Retrospective cohort
Narrative reviews
 
 Nonconcurrent cohort
Systematic reviews/meta-analyses (will be used for hand searches)
 
 Case-control
 
 
Pooled analyses of controlled studies
 
BPD = borderline personality disorder; KQ = key question; N = sample size; NA = not applicable; RCT = randomized controlled trial.
*Very high HDI countries: Andorra, Argentina, Australia, Austria, Bahamas, Bahrain, Barbados, Belarus, Belgium, Brunei Darussalam, Bulgaria, Canada, Chile, Croatia, Cyprus, Czechia, Denmark, Estonia, Finland, France, Germany, Greece, Hong Kong, China (SAR), Hungary, Iceland, Ireland, Israel, Italy, Japan, Kazakhstan, Korea (Republic of), Kuwait, Latvia, Liechtenstein, Lithuania, Luxembourg, Malaysia, Malta, Montenegro, Netherlands, New Zealand, Norway, Oman, Poland, Portugal, Qatar, Romania, Russian Federation, Saudi Arabia, Singapore, Slovakia, Slovenia, Spain, Sweden, Switzerland, Taiwan**, United Arab Emirates, United Kingdom, United States, Uruguay.
**The United Nations does not recognize Taiwan (i.e., Republic of China) as a sovereign state and does not include it in the HDI report. However, Taiwan’s government calculated its HDI to be 0.885, based on 2014 data and using the same methodology as the United Nations. This HDI value would place Taiwan among countries in the “very high” human development category and will be included in this report.

Literature Review, Data Abstraction, and Data Management

To ensure accuracy, two reviewers independently reviewed all titles, abstracts, and full-text articles. We used Distiller SR, an online tool to conduct systematic reviews, to screen the literature (DistillerSR, Evidence Partners, Ottawa, Canada). We resolved discrepancies by consensus or by involving a third, senior reviewer.
All results at both title/abstract and full-text review stages were tracked in an EndNote® bibliographic database (Thomson Reuters, New York, NY). Appendix I presents the list of studies excluded (with reasons) at the full-text level.
We designed, pilot tested, and used a structured data abstraction form in DistillerSR to ensure consistency of data abstraction. We abstracted data into categories that included (but were not limited to) the following: study design, eligibility criteria, intervention, methods of outcome assessment, population characteristics, sample size, attrition, results, and adverse event incidence. A second team member verified abstracted study data for accuracy and completeness.

Assessment of Risk of Bias of Individual Studies

To assess the risk of bias of studies, we used the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) (Sterne et al. 2016) for nonrandomized controlled studies, and for randomized controlled trials (RCTs), we used the Cochrane Risk of Bias 2 tool. Two independent reviewers assessed the risk of bias at the study level and also considered rating bias at an outcome level if methodological limitations might affect different outcomes in a different way (e.g., lack of blinding might increase the risk of bias for quality of life but not for overall mortality). We assigned a “high risk of bias” rating to studies that had very serious limitations in design or conduct that might invalidate findings regarding all or individual outcomes. Disagreements between the two reviewers were resolved by discussion and consensus or by consulting a third member of the team. Risk of bias diagrams were generated using the Risk-Of-Bias VISualization (robvis) tool (McGuinness and Higgins 2021; see Appendix E).

Data Synthesis

We summarized all included studies in narrative form and in summary tables that tabulate the important features of the study populations, design, intervention, outcomes, setting, country, and results. If we found three or more similar studies addressing an outcome of interest, we considered quantitative analysis (i.e., meta-analysis) if studies were similar (in population, interventions, comparators, and outcomes). For all analyses, we used random-effects models (restricted maximum likelihood random effects) to estimate pooled effects. To determine whether quantitative analyses were appropriate, we assessed the clinical and methodological heterogeneity of the studies under consideration following established guidance (Gartlehner et al. 2012). If we conducted meta-analyses, we assessed statistical heterogeneity in effects between studies by calculating the chi-squared statistic and the I2 statistic (the proportion of variation in study estimates attributable to heterogeneity). We examined potential sources of heterogeneity using sensitivity analyses. When quantitative analyses were not appropriate (e.g., due to heterogeneity, insufficient numbers of similar studies, or insufficiency or variation in outcome reporting), we synthesized the data qualitatively.

Grading the Certainty of Evidence for Major Comparisons and Outcomes

We graded the certainty of evidence of relevant outcomes based on current Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance (Balshem et al. 2011). Developed to grade the overall certainty of a body of evidence, this approach incorporates five key domains: 1) risk of bias, 2) inconsistency, 3) indirectness, 4) imprecision of the evidence, and 5) reporting bias. It also considers other optional domains that may be relevant for some scenarios. These included plausible confounding that would decrease the observed effect and strength of association (i.e., magnitude of effect) or factors that would increase the strength of association (i.e., dose-response effect). Two reviewers assessed each domain for each selected outcome and resolved differences by consensus discussion. We documented all decisions regarding up- or down-grading the certainty of evidence to ensure transparency. We used GradePro to develop summary of findings tables for the guideline panel.
A2–14 describes the grades of certainty of evidence, which reflect the certainty of the body of evidence regarding a specific outcome.
Definitions of the grades of certainty of evidence
GradeDefinition
High
We are very confident that the estimate of effect lies close to the true effect for this outcome. The body of evidence has few or no deficiencies. We believe that the findings are stable (i.e., another study would not change the conclusions).
Moderate
We are moderately confident that the estimate of effect lies close to the true effect for this outcome. The body of evidence has some deficiencies. We believe that the findings are likely to be stable, but some doubt remains.
Low
We have limited confidence that the estimate of effect lies close to the true effect for this outcome. The body of evidence has major or numerous deficiencies (or both). We believe that additional evidence is needed before concluding either that the findings are stable or that the estimate of effect is close to the true effect.
Very low
We have no evidence, we are unable to estimate an effect, or we have no confidence in the estimate of effect for this outcome. The body of evidence has unacceptable deficiencies, precluding reaching a conclusion.
Source. Adapted from Balshem et al. 2011.

Results of Literature Search and Literature Screening

We screened 3,321 titles and abstracts from our literature searches. This represents 3,206 records from database and hand searches plus 115 studies previously included by a comparable search conducted by Doctor Evidence, of which we excluded 32 references. Overall, we identified 92 studies reported in 111 publications that met inclusion criteria (A2–1).
PRISMA flow chart.
APA = American Psychiatric Association; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

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Go to The American Psychiatric Association Practice Guideline for the Treatment of                 Patients With Borderline Personality Disorder
The American Psychiatric Association Practice Guideline for the Treatment of Patients With Borderline Personality Disorder
November 2024
©American Psychiatric Association Publishing

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