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Evidence Tables for Additional Studies Reviewed

Appendix G

Repetitive Transcranial Magnetic Stimulation Versus Sham

Study characteristics and main results of rTMS compared with sham
Author (year) and/or trial nameStudy characteristicsParticipants, N; interventions; durationStudy population, including main inclusion and exclusion criteriaSample demographicsPrimary outcome; main results; attritionRisk of bias
Cailhol et al. (2014)
Design: Double-blinded RCT
Setting: Outpatient, single center
Country: France
Funding: University Hospital of Toulouse
N = 9
G1 (4): Sham rTMS
G2 (5): rTMS frequency: 10 Hz, 80% of motor threshold, total 2,000 pulses per session; 10 sessions
Duration: 2 weeks
Inclusion: Ages 20–45 years; DSM-IV and DIB-R criteria for BPD
Exclusion: Bipolar I disorder, alcohol dependency, current MDE or PTSD; contraindication to rTMS
Mean age, years (SD): NR
Female: 89%
Race/ethnicity: NR
Primary outcome: BPDSI at 3 months
No significant differences in BPDSI, MADRS, SCL-90, GAS
Incidence of AEs: NR
Withdrawal due to AEs: NR
Attrition: 0%
Differential attrition: 0%
Moderate
AE = adverse event; BPD = borderline personality disorder; BPDSI = Borderline Personality Disorder Severity Index; DIB-R = Diagnostic Interview for Borderlines–Revised; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; G1 = Group 1; G2 = Group 2; GAS = Global Assessment Scale; Hz = hertz; MADRS: Montgomery-Åsberg Depression Scale; MDE = major depressive episode; N = sample size; NR = not reported; PTSD = posttraumatic stress disorder; RCT = randomized controlled trial; rTMS = repetitive transcranial magnetic stimulation; SCL-90 = Symptom Checklist–90; SD = standard deviation.

Abandonment Psychotherapy Versus Treatment as Usual

Study characteristics and main results of AP compared with TAU
Author (year) and/or trial nameStudy characteristicsParticipants, N; interventions; durationStudy population, including main inclusion and exclusion criteriaSample demographicsPrimary outcome; main results; attritionRisk of bias
Andreoli et al. (2016)
Design: RCT
Setting: Outpatient, single center
Country: Switzerland
Funding: NR
N = 170
G1 (30): TAU: intensive community treatment
G2 (70): Manualized AP: Two sessions per week delivered by nurses with experience in management of patients with BPD, plus antidepressant medications
Duration: 3 months
Inclusion: Ages 18–60 years; DSM-IV BPD and MDD diagnoses
Exclusion: DSM-IV psychotic disorder, bipolar I disorder, SUD, or intellectual disability; inability to speak French
Mean age, years (SD): 32 (10.1)
Female: 84%
Race/ethnicity: NR
Primary outcome: Suicidal relapse, rehospitalization, clinical remission (GAS > 60) at 3 months
G2 significantly more effective than G1 to reduce suicidal relapse (12.9% vs. 40.0%, P <0.005) and rehospitalization (14.3% vs. 36%, P <0.01), to achieve 50% reduction in Ham-D (65.7% vs. 33.3%, P <0.005), and improve GAS (62.7 vs. 36.7, P <0.01)
Incidence of AEs:
 G1: 100% (30/30)
 G2: 100% (70/70)
Withdrawal due to AEs: NR
Attrition: 12%
Differential attrition:
 G1: 37% (11/30)
 G2: 6% (4/70)
Moderate
AE = adverse event; AP = abandonment psychotherapy; BPD = borderline personality disorder; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; G1 = Group 1; G2 = Group 2; GAS = Global Assessment Scale; Ham-D = Hamilton Rating Scale for Depression; MDD = major depressive disorder; N = sample size; NR = not reported; RCT = randomized controlled trial; SD = standard deviation; SUD = substance use disorder; TAU = treatment as usual.

Schema-Focused Therapy Versus Treatment as Usual

Study characteristics and main results of SFT compared with TAU
Author (year) and/or trial nameStudy characteristicsParticipants, N; interventions; durationStudy population, including main inclusion and exclusion criteriaSample demographicsPrimary outcome; main results; attritionRisk of bias
Farrell et al. (2009)
Design: RCT
Setting: Outpatient, multicenter
Country: United States
Funding: Government, NIMH
N = 32
G1 (16): TAU: Weekly individual psychotherapy in community
G2 (16): SFT plus TAU: 30 weekly group sessions, each lasting 90 minutes; combination of emotional awareness training, BPD psychoeducation, distress management training, and schema-focused change work; sessions consisted of discussing homework from previous session, presenting new information, a question-and-answer session, experiential or cognitive work, and homework assignment
Duration: 8 months
Follow-up: 6 months
Inclusion: Females; age 18–65 years; met criteria for BPD from DIPD-R and BSI; in individual psychotherapy of  6 months duration and stable
Exclusion: Axis I diagnosis of psychotic disorder or presence of psychosis; below-average IQ (89) on Shipley Institute of Living Scale
Mean age, years (SD):
 G1: 36 (8.08)
 G2: 35 (9.30)
Female: 100%
Race/ethnicity: NR
Primary outcome: NR
G2 significantly more effective than G1 at 14-month follow-up (6 months after end of treatment) for BPD diagnosis (measured by DIB-R; 0% vs. 83%, P < 0.001), BPD symptoms (measured by BSI; 15.75 vs. 33.08, P < 0.001), global severity of psychiatric symptoms (measured by SCL-90; 0.96 vs. 1.93, P < 0.001), and improved global functioning (measured by GAF; 66.19 vs. 48.25, P < 0.001)
Attrition: 12.5% (4/32)
 G1: 25% (4/16)
 G2: 0% (0/16)
Moderate
       
Leppänen et al. (2016)
Design: RCT
Setting: Outpatient, multicenter
Country: Finland
Funding: NR
N = 71
G1 (47): TAU; treatment in accordance with current practices of Oulu city mental health care services; treatments vary widely, from supportive weekly psychotherapy sessions to visits every few weeks and from occasional appointments for medication control to home rehabilitation
G2 (24): SFT-based psychoeducational group integrated into individual therapy: 45- to 60-minute individual therapy sessions once a week, a total of forty 90-minute psychoeducational group sessions (approximately once a week), and materials for patients to practice therapy exercises at home
Duration: 12 months
Inclusion: Age ≥ 20 years; fulfilled SCID-II criteria for BPD; severe symptoms of BPD, including parasuicidal behavior (e.g., cutting, other forms of self-harm, impulsive overdosing of medicines); attempted suicide; considerable emotional instability affecting social and professional life; previous unsuccessful treatments (one or more)
Exclusion: Schizophrenia spectrum diseases/psychoses, bipolar disorder (type I), neuropsychiatric disorder, severe substance abuse problem, Axis I disorders diagnosed according to SCID-I, or presence of neuropsychiatric disorder
Mean age, years (SD):
 G1: 32 (8.8)
 G2: 32 (8.3)
Female: 86%
Race/ethnicity: NR
Primary outcome: Borderline symptoms on BPDSI-IV
No difference between groups on BPD outcomes
Attrition: 26.8% (19/71)
 G1: 31.9% (15/47)
 G2: 16.7% (4/24)
High
       
Hilden et al. (2021)
Design: RCT
Setting: Outpatient, single center
Country: Finland
Funding: Helsinki University Hospital
N = 42
G1 (14): TAU; psychiatrist visits and 45-minute therapy sessions once monthly; both pharmacotherapy and some form of psychosocial support or psychotherapy for most patients
G2 (28): SFT; 20 weekly 90-minute sessions
Duration: 20 weeks
Inclusion: Adults; BPD using DSM-IV SCID-II criteria (included those who had previously received treatment)
Exclusion: Psychotic symptoms, suicide risk, principal diagnosis of uncontrollable SUD, or illness or symptoms affecting participation; those undergoing specific psychotherapy
Mean age, years (SD):
 G1: 27 (3.7)
 G2: 31 (8.8)
Female: 83%
Race/ethnicity: NR
Primary outcome: Intra-individual change in borderline personality symptoms
No difference between groups on BPD outcomes
Attrition: 16.7% (7/42)
 G1: 14.3% (2/14)
 G2: 17.97% (5/28)
Moderate
BPD = borderline personality disorder; BPDSI-IV = Borderline Personality Disorder Severity Index-IV; BSI = Borderline Syndrome Index; DIB-R = Diagnostic Interview for Borderlines–Revised; DIPD-R = Diagnostic Interview for Personality Disorders–Revised; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; G1 = Group 1; G2 = Group 2; GAF = Global Assessment of Functioning; IQ = intelligence quotient; N = sample size; NIMH = National Institute of Mental Health; NR = not reported; RCT = randomized controlled trial; SCID-I = Structured Clinical Interview for DSM-IV Axis I Disorders; SCID-II = Structured Clinical Interview for DSM-IV Axis II Disorders; SCL-90 = Symptom Checklist–90; SD = standard deviation; SFT = schema-focused therapy; SUD = substance use disorder; TAU = treatment as usual.

Schema-Focused Therapy Versus Schema-Focused Therapy With Extra Phone Support

Study characteristics and main results of SFT alone compared with SFT with extra phone support
Author (year) and/or trial nameStudy characteristicsParticipants, N; interventions; durationStudy population, including main inclusion and exclusion criteriaSample demographicsPrimary outcome; main results; attritionRisk of bias
Nadort et al. (2009)
Design: RCT
Setting: Outpatient, multicenter
Country: The Netherlands
Funding: Other, public benefit organization
N = 62
G1 (30): 45-minute sessions of SFT twice a week in year 1 and once a week in year 2
G2 (32): 45-minute sessions of SFT twice a week along with extra phone support outside office hours
Duration: 18 months
Inclusion: Ages 18–60 years; DSM-IV BPD diagnosis; BPDSI-IV score > 20
Exclusion: Psychotic disorders, bipolar disorder, DID, ASPD, or ADHD; addiction of such severity that clinical detoxification was indicated; psychiatric disorders secondary to medical conditions
Mean age, years (SD):
 G1: 32.13 (9.01)
 G2: 31.81 (9.24)
Female: 96.8%
Race/ethnicity: NR
Primary outcome: BPDSI-IV at 18 months
No significant differences between G1 and G2 on BPD severity and burden as well as outcomes of global psychological problems, quality of life, and dysfunction
Incidence of AEs: NR
Withdrawal due to AEs:
 G1: 0% (0/30)
 G2: 3% (1/32; suicide after treatment allocation, but before treatment additional crisis support was provided)
Attrition: 21%
Differential attrition:  10 percentage points
Moderate
ADHD = attention-deficit/hyperactivity disorder; AE = adverse event; ASPD = antisocial personality disorder; BPD = borderline personality disorder; BPDSI-IV = Borderline Personality Disorder Severity Index-IV; DID = dissociative identity disorder; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; G1 = Group 1; G2 = Group 2; N = sample size; NR = not reported; RCT = randomized controlled trial; SD = standard deviation; SFT = schema-focused therapy.

Cognitive Rehabilitation Versus Psychoeducation

Study characteristics and main results of CR compared with psychoeducation
Author (year) and/or trial nameStudy characteristicsParticipants, N; interventions; durationStudy population, including main inclusion and exclusion criteriaSample demographicsPrimary outcome; main results; attritionRisk of bias
Pascual et al. (2015)
Design: RCT
Setting: Outpatient, multicenter
Country: Spain
Funding: Government, Centro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III, Fondo de Investigación Sanitaria
N = 70
G1 (36): CR; twice-weekly group sessions
G2 (34): Psychoeducation; weekly group sessions
Duration: 16 weeks
Inclusion: Ages 18–45 years; outpatient; BPD diagnosis according to DSM-IV-TR and evaluated by SCID-II and DIB-R; CGI-BPD > 4; GAF < 65
Exclusion: Severe physical conditions that could affect neuropsychological performance; IQ < 85; MDD or substance misuse within past 6 months; schizophrenia, severe psychotic disorder, or bipolar disorder; previous participation in any psychoeducation or cognitive rehabilitation
Mean age, years (SD):
 G1: 32 (6.04)
 G2: 33 (8.8)
Female: 74.3%
Race/ethnicity: NR
Primary outcome: Psychosocial functioning at 6 months
No significant difference between G1 and G2 on psychosocial functioning including on BSL-23, FAST, BIS, Ham-A, or MADRS at 6 months
Incidence of AEs: NR
Withdrawal due to AEs: NR
Attrition: 40%
Differential attrition: < 10 percentage points
High
AE = adverse event; BIS = Barratt Impulsiveness Scale; BPD = borderline personality disorder; BSL-23 = Borderline Symptom List–23; CGI-BPD = Clinical Global Impression Scale for Borderline Personality Disorder; CR = cognitive rehabilitation; DIB-R = Diagnostic Interview for Borderlines–Revised; DSM-IV-TR = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision; FAST = Functioning Assessment Scale Test; G1 = Group 1; G2 = Group 2; GAF = Global Assessment of Functioning; Ham-A = Hamilton Rating Scale for Anxiety; IQ = intelligence quotient; MADRS = Montgomery-Åsberg Depression Rating Scale; MDD = major depressive disorder; N = sample size; NR = not reported; RCT = randomized controlled trial; SCID-II = Structured Clinical Interview for DSM-IV Axis II Disorders; SD = standard deviation.

Cognitive Therapy Versus Rogerian Supportive Therapy

Study characteristics and main results of CT compared with RST
Author (year) and/or trial nameStudy characteristicsParticipants, N; interventions; durationStudy population, including main inclusion and exclusion criteriaSample demographicsPrimary outcome; main results; attritionRisk of bias
Cottraux et al. (2009)
Design: RCT
Setting: Outpatient, multicenter
Country: France
Funding: Other
N = 65
G1 (32): Weekly individual RST for 6 months then biweekly individual RST for 6 months
G2 (33): Weekly individual CT for 6 months then biweekly individual RST for 6 months
Duration: 1 year
Inclusion: DSM-IV BPD diagnosis (confirmed by DIB-R score of  8)
Exclusion: Age < 18 or > 60 years; living too far from centers; psychotic disorders with current delusions; significant drug or alcohol addiction in foreground; antisocial behaviors; not following psychotherapy at time of the study
Mean age, years (SD):
 G1: 32.6 (8.3)
 G2: 34.3 (10.2)
Female: 76.9%
Race/ethnicity: NR
Primary outcome: Combined response (score  3 on CGI and Hopelessness score < 8) at 24 weeks
No significant differences between G1 and G2 on CGI-I, Hopelessness scale, Ham-D, or BAI at 24 weeks
G2 significant improvement in BDI scores at 24 weeks (13.0 vs. 21.7, P =0.01)
Harms: NR
Attrition:
 Week 24: 22%
 Week 104: 68%
Differential attrition:  10 percentage points
Moderate
BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; BPD = borderline personality disorder; CGI = Clinical Global Impression Scale; CGI-I = Clinical Global Impression–Improvement; CT = cognitive therapy; DIB-R = Diagnostic Interview for Borderlines–Revised; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; G1 = Group 1; G2 = Group 2; Ham-D = Hamilton Rating Scale for Depression; N = sample size; NR = not reported; RCT = randomized controlled trial; RST = Rogerian supportive therapy; SD = standard deviation.

Motive-Oriented Therapeutic Relationship Versus General Psychiatric Management

Study characteristics and main results of MOTR compared with GPM
Author (year) and/or trial nameStudy characteristicsParticipants, N; interventions; durationStudy population, including main inclusion and exclusion criteriaSample demographicsPrimary outcome; main results; attritionRisk of bias
Kramer et al. (2011)
Design: RCT
Setting: Outpatient, single center
Country: Switzerland
Funding: NR
N = 25
G1 (14): 10 session TAU with manual-based psychiatric and psychotherapeutic approach
G2 (11): 10 sessions of MOTR along with TAU
Duration: Seven therapy sessions
Inclusion: Ages 16–60 years; DSM-IV BPD diagnosis; speaks fluent French
Exclusion: Organic disorder or persistent substance abuse or dependence that might affect brain function; psychotic disorder implying pronounced break in reality testing, including schizophrenia, delusional disorder, and bipolar I disorder; acute risk of suicide; severe cognitive impairment
Mean age, years (SD): 31 (10.59)
Female: 77%
Race/ethnicity: NR
Primary outcome: Psychotherapeutic results on OQ–45 after seven therapy sessions
No significant differences between G1 and G2 on psychotherapeutic results after seven therapy sessions
Attrition: 42%
Differential attrition:
 G1: 57% (8/14)
 G2: 18% (2/11)
High
       
Kramer et al. (2014)
Design: RCT
Setting: Outpatient, single center
Country: Switzerland
Funding: Government, Swiss National Science Foundation
N = 85
G1 (43): 10 sessions of GPM
G2 (42): 10 sessions of GPM plus MOTR use of plan analysis
Duration: 3 months
Inclusion: Ages 18–65 years; DSM-IV BPD diagnosis
Exclusion: DSM-IV psychotic disorders, intellectual disability, or substance abuse
Mean age, years (SD):
 G1: 31 (11.00)
 G2: 35 (9.97)
Female: 68.9%
Race/ethnicity: NR
Primary outcome: Psychotherapeutic results on OQ-45 at 3 months
G2 significantly greater improvement on OQ-45 at 3 months (76.0 vs. 86.1, P < 0.01)
No significant differences between G1 and G2 on IIP and BSL at 3 months
Attrition: 29%
Differential attrition:  10 percentage points
Moderate
BPD = borderline personality disorder; BSL = Borderline Symptom List; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; G1 = Group 1; G2 = Group 2; GPM = general psychiatric management; IIP = Inventory of Interpersonal Problems; MOTR = motive-oriented therapeutic relationship; N = sample size; NR = not reported; OQ-45 = Outcome Questionnaire–45; RCT = randomized controlled trial; SD = standard deviation; TAU = treatment as usual.

Psychoanalytic-Interactional Therapy Versus Psychodynamic Therapy by Experts

Study characteristics and main results of PIT compared with E-PDT
Author (year) and/or trial nameStudy characteristicsParticipants, N; interventions; durationStudy population, including main inclusion and exclusion criteriaSample demographicsPrimary outcome; main results; attritionRisk of bias
Leichsenring et al. (2016)
Design: RCT
Setting: Inpatient, single center
Country: Germany
Funding: Other
N = 168
G1 (46): WL/TAU; 80% of patients continued usual treatment and remainder did not receive any treatment during WL period
G2 (64): PIT; one or two weekly individual sessions and three weekly group therapy sessions; art or body therapy and consultations with a social worker (on needs basis)
G3 (58): E-PDT; one or two weekly sessions of non-manualized individual therapy and three weekly sessions of group therapy; art or body therapy and consultations with a social worker (on needs basis)
Mean duration, days (SD):
G1: 89.69 (105.31)
G2: 106.7 (41.71)
G3: 76.78 (21.07)
Inclusion: Ages 18–65 years; Cluster B personality disorder diagnosis according to SCID-II (DSM-IV)
Exclusion: Psychotic and acute substance-related disorders, acute (uncontrollable) risk of suicide, or organic mental disorders; severe medical conditions (according to ICD-10)
Mean age, years (SD):
 G1: 31 (9.4)
 G2: 29 (8.7)
 G3: 30 (9.1)
Female: 69%
Race/ethnicity: NR
Primary outcome: BPI, GSI of SCL-90-R at end of treatment (duration varies by treatment)
G2 and G3 significantly more effective than G1 for improving BPD outcomes (measured by BPI [G2 vs. G1: 18.76 vs. 26.39, P = 0.004; G3 vs. G1: 19.41 vs. 26.39, P = 0.0004]), depression (BDI [G2 vs. G1: 17.44 vs. 27.80, P = 0.0001; G3 vs. G1: 15.20 vs. 27.80, P = 0.0001]), and global functioning (GSI of SCL-90-R [G2 vs. G1: 0.99 vs. 1.65, P = 0.0001; G3 vs. G1: 0.96 vs. 1.65, P = 0.0001])
No significant differences between active arms (G2 and G3) and G1 for anxiety (BAI)
Incidence of AEs: NR
Withdrawal due to AEs: NR
Attrition: 18.0% (22/122)
Differential attrition:  10 percentage points
High
AE = adverse event; BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; BPD = borderline personality disorder; BPI = Borderline Personality Inventory; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; E-PDT = psychodynamic therapy by experts in personality disorder; G1 = Group 1; G2 = Group 2; G3 = Group 3; GSI = Global Severity Index; ICD-10 = International Classification of Diseases, 10th Revision; N = sample size; NR = not reported; PIT = psychoanalytic interactional therapy; RCT = randomized controlled trial; SCL-90-R = Symptom Checklist–90–Revised; SCID-II = Structured Clinical Interview for DSM-IV Axis II Disorders; SD = standard deviation; TAU = treatment as usual; WL = wait-list.

Mechanism-Based Group Psychotherapy Versus Nonspecific Supportive Psychotherapy

Study characteristics and main results of mechanism-based group psychotherapy compared with nonspecific supportive psychotherapy
Author (year) and/or trial nameStudy characteristicsParticipants, N; interventions; durationStudy population, including main inclusion and exclusion criteriaSample demographicsPrimary outcome; main results; attritionRisk of bias
Herpertz et al. (2020)
Design: RCT
Setting: Outpatient, single center
Country: Germany
Funding: Other, German Research Foundation
N = 59
G1 (29): Mechanism-based anti-aggression psychotherapy; highly manualized program starting with one individual 1-hour session followed by 6 weeks of group therapy with two 1.5-hour sessions per week (a total of 18 hours)
G2 (30): Nonspecific supportive psychotherapy similar to DBT with same dosage as G1
Duration: 6 months
Inclusion: Ages 18–55 years; outpatients meeting  4 BPD criteria according to IPDE
Exclusion: Additional non-study psychotherapy; pregnancy; epilepsy; bipolar I disorder, schizophrenia, or current substance abuse or addiction as well as change in medication in past 3 weeks
Mean age, years (SD):
 G1: 33 (8.8)
 G2: 30 (9.5)
Female: 64%
Race/ethnicity: NR
Primary outcome: MOAS at 6 months
No difference between groups at end of treatment
G2 significantly greater improvement in overt aggression on the MOAS at 6 months (10.60 vs. 22.95, P = 0.02)
Incidence of AEs:
 G1: 6.9% (2/29)
 G2: 0% (0/30)
Withdrawal due to AE:
 G1: 3.4% (1/29)
 G2: 0% (0/30)
Attrition: 24%
Differential attrition:  10 percentage points
 G1: 31% (9/29)
 G2: 17% (5/30)
High
AE = adverse event; BPD = borderline personality disorder; DBT = dialectical behavior therapy; G1 = Group 1; G2 = Group 2; IPDE = International Personality Disorder Examination; MOAS = Modified Overt Aggression Scale; N = sample size; NR = not reported; RCT = randomized controlled trial; SD = standard deviation.

Other Psychotherapy Versus Treatment as Usual

Study characteristics and main results of other psychotherapy compared with TAU
Author (year) and/or trial nameStudy characteristicsParticipants, N; interventions; durationStudy population, including main inclusion and exclusion criteriaSample demographicsPrimary outcome; main results; attritionRisk of bias
Amianto et al. (2011)
Design: RCT
Setting: Outpatient, single center
Country: Italy
Funding: Government, other
N = 35
G1 (17): TAU: Supervised team management
G2 (18): Supervised team management plus sequential brief Adlerian psychodynamic psychotherapy
Duration: 12 months
Inclusion: Ages 20–50 years; DSM-IV-TR BPD diagnosis; heavy use of MHS throughout prior year
Exclusion: Acute comorbid Axis I disorder requiring hospitalization; current SUD; intellectual disability; previous psychotherapy interventions
Mean age, years (SD): 40 (9.4)
Female: 49%
Race/ethnicity: NR
Primary outcome: High mental health use (more than six emergency interventions in prior year)
No significant differences between G2 and G1 in CGI, SCL-90, and GAF at 12 months
Attrition: 5.7% (2/35)
 G1: 5.9% (1/17)
 G2: 5.6% (1/18)
Moderate
       
Gratz et al. (2014)
Design: RCT
Setting: Outpatient, single center
Country: NR
Funding: Government, NIMH
N = 61
G1 (30): TAU; ongoing outpatient treatment, with most participants (> 70%) receiving supportive or dynamic individual therapy and others (19%) receiving CBT
G2 (31): ERGT; Weekly 90-minute group sessions over 14 weeks (six patients per group)
Duration: 14 weeks
Inclusion: Females; age 18–60 years; threshold or subthreshold diagnosis of BPD; history of repeated deliberate self-harm, with one or more episodes in past 6 months; having an individual therapist, psychiatrist, or case manager; diagnostic interview for DSM-IV
Exclusion: Diagnoses of primary psychotic disorder, bipolar I disorder, or current (past month) SUD
Mean age, years (SD):
 G1: 33 (0.9)
 G2: 33 (11.0)
Female: 100%
Race/ethnicity:
 Racial/ethnic minority: 21%
Primary outcome: NR
G2 significantly more effective than G1 for improving self-harm (measured using SHI; 16.05 vs. 29.40, P < 0.05), emotion dysregulation (DERS; 95.27 vs. 113.62, P < 0.05), BPD severity (ZAN-BPD; 4.35 vs. 12.03, P < 0.05), and quality of life (QLI; 0.31 vs. - 0.50, P < 0.05)
No significant differences between G2 and G1 on measures of BPD-related severity and symptoms (measured by composite of IIP, BEST, AAQ, BDI, and SDS)
Attrition: 13.1% (8/61)
 G1: 10% (3/30)
 G2: 16.1% (5/31)
Moderate
       
Reneses et al. (2013)
Design: RCT
Setting: Outpatient, multicenter
Country: Spain
Funding: Government, Ministry
N = 53
G1 (28): TAU; conventional treatment without specific additional psychotherapy for 6 months, psychopharmacological treatment in accordance with standard applied in hospital clinic
G2 (25): PRFP along with conventional care: 20 face-to-face, 45-minute, consecutive weekly PRFP sessions plus conventional outpatient psychiatric treatment
Duration: 12 months
Inclusion: Ages 18–50 years; clinical diagnosis of BPD using DSM-IV-TR and SCID-II; clinical situation of outpatient treatment
Exclusion: Active suicide risk symptoms, violent or unmanageable heteroaggressive behaviors; comorbidity with diagnosis of eating behavior disorder on Axis I, toxic dependence disorder, or current severe physical disease; interrupting patients’ psychotherapy for more than four consecutive sessions without justification or for more than six sessions in any case
Mean age, years (SD): 34 (7.5)
Female: 71%
Race/ethnicity: NR
Primary outcome: Severity of general symptoms (GSI of SCL-90-R) and impulsivity (BIS, SASS)
G2 significantly more effective than G1 for improving BPD severity (measured by ZAN-BPD; 13.0 vs. 19.1, P < 0.001) and symptoms (SCL-90 [1.2 vs. 1.7, P < 0.001]; MADRS total [15.9 vs. 22.8, P < 0.001]; BIS [52.5 vs. 68.2, P < 0.01]; and SASS [35.4 vs. 27.6, P < 0.001])
No significant differences between G2 and G1 for STAI state score or CGI
Attrition: 13% (7/53)
 G1: 14% (4/28)
 G2: 12% (3/25)
High
       
Leichsenring et al. (2016)
Design: RCT
Setting: Inpatient, single center
Country: Germany
Funding: Other
N = 168
G1 (46): WL/TAU; 80% of patients continued usual treatment and remainder did not receive any treatment during WL period
G2 (64): PIT; one or two weekly individual sessions and three weekly group therapy sessions; art or body therapy and consultations with a social worker (on needs basis)
G3 (58): E-PDT; one or two weekly sessions of non-manualized individual therapy and three weekly sessions of group therapy; art or body therapy and consultations with a social worker (on needs basis)
Mean duration, days (SD):
G1: 89.69 (105.31)
G2: 106.7 (41.71)
G3: 76.78 (21.07)
Inclusion: Ages 18–65 years; Cluster B personality disorder diagnosis according to SCID-II (DSM-IV)
Exclusion: Psychotic and acute substance-related disorders, acute (uncontrollable) risk of suicide, or organic mental disorders; severe medical conditions (according to ICD-10)
Mean age, years (SD):
 G1: 31 (9.4)
 G2: 29 (8.7)
 G3: 30 (9.1)
Female: 69%
Race/ethnicity: NR
Primary outcome: BPI, GSI of SCL-90-R at end of treatment (duration varies by treatment)
G2 and G3 significantly more effective than G1 for improving BPD outcomes (measured by BPI [G2 vs. G1: 18.76 vs. 26.39, P = 0.004; G3 vs. G1: 19.41 vs. 26.39, P = 0.0004]), depression (BDI [G2 vs. G1: 17.44 vs. 27.80, P = 0.0001; G3 vs. G1: 15.20 vs. 27.80, P = 0.0001]) and global functioning (GSI of SCL-90-R [G2 vs. G1: 0.99 vs. 1.65, P = 0.0001; G3 vs. G1: 0.96 vs. 1.65, P = 0.0001])
No significant differences between active arms (G2 and G3) and G1 for anxiety (BAI)
Incidence of AEs: NR
Withdrawal due to AEs: NR
Attrition: 18.0% (22/122)
Differential attrition:  10 percentage points
High
AAQ = Acceptance and Action Questionnaire; AE = adverse event; BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; BEST = Borderline Evaluation of Severity Over Time; BIS = Barrat Impulsivity Scale; BPD = borderline personality disorder; BPI = Borderline Personality Inventory; CBT = cognitive-behavioral therapy; CGI = Clinical Global Impression; DERS = Difficulties in Emotion Regulation Scale; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; DSM-IV-TR = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision; ERGT = emotion regulation group therapy; E-PDT = psychodynamic therapy by experts in personality disorders; G1 = Group 1; G2 = Group 2; G3 = Group 3; GAF = Global Assessment of Functioning; GSI = Global Severity Index; ICD-10 = International Classification of Diseases, 10th Revision; IIP = Inventory of Interpersonal Problems; MADRS = Montgomery-Åsberg Depression Rating Scale; MHS = mental health services; N = sample size; NIMH = National Institute of Mental Health; NR = not reported; PIT = psychoanalytic-interactional therapy; PRFP = psychic representation focused psychotherapy; QLI = Quality of Life Inventory; RCT = randomized controlled trial; SASS = Social Adaptation Self-evaluation Scale; SCID-II = Structured Clinical Interview for DSM-IV Axis II Disorders; SCL-90 = Symptom Checklist–90; SCL-90-R = Symptom Checklist–90 Revised; SD = standard deviation; SDS = Sheehan Disability Scale; SHI = Self-Harm Inventory; STAI = State-Trait-Anxiety Inventory; SUD = substance use disorder; TAU = treatment as usual; WL = wait-list; ZAN-BPD = Zanarini Rating Scale for Borderline Personality Disorder.

Service Delivery Approaches

Study characteristics and main results of service delivery approaches
Author (year) and/or trial nameStudy characteristicsParticipants, N; interventions; durationStudy population, including main inclusion and exclusion criteriaSample demographicsPrimary outcome; main results; attritionRisk of bias
Bartak et al. (2011)
Design: Prospective cohort study
Setting: University hospital and mental health care centers
Country: The Netherlands
Funding: None
N = 245
G1 (59): Outpatient individual or group psychotherapy sessions for up to two sessions per week
G2 (99): At least one session per week of psychotherapy in day-hospital but slept at home
G3 (87): Stayed at institution for 5 days per week and received different forms of psychotherapy
Duration: 18 months
Inclusion: Participants with Cluster B personality disorders diagnosed with DSM-IV Personality
Exclusion: Organic cerebral impairment, intellectual disability, or schizophrenia
Based on N analyzed:
Mean age, years (SD): 31 (8.5)
Female: 71%
Race/ethnicity: NR
77% with BPD
Primary outcome: GSI at 18 months
No significant differences in GSI and EQ-5D
Incidence of AEs: NR
Withdrawal due to AEs: NR
Attrition: 16%
Differential attrition:  10 percentage points
Moderate
       
Laporte et al. (2018)
Design: Prospective cohort
Setting: Outpatient, multicenter
Country: Canada
Funding: McGill University
N = 681
G1 (479): 12 weekly sessions of individual therapy and 12 of group therapy
G2 (138): Extended care clinic with weekly sessions of two types of group therapy, weekly sessions of individual therapy, and pharmacological management
Duration:
G1: 12 weeks
G2: 6–24 months
Inclusion: DSM-5 BPD diagnosis;  8 on DIB-R for current BPD
Exclusion: NR
Mean age, years (SD):
 G1: 27 (7.8)
 G2: 36 (10.4)
Female: 93%
Race/ethnicity: NR
Primary outcome: NR
Significant reductions in both groups but no reporting on between-group comparisons
Incidence of AEs: NR
Withdrawal due to AEs: NR
Attrition: 32%
Differential attrition:
 G1: 29% (137/479)
 G2: 43% (59/138)
High
Sinnaeve et al. (2018)
Design: RCT
Setting: Community mental health centers
Country: The Netherlands
Funding: GGZ Rivierduinen
N = 84
G1 (42): Standard, outpatient DBT
G2 (42): Step-down DBT consisting of 3 months of residential DBT plus 6 months of outpatient DBT
Duration:
G1: 12 months
G2: 9 months
Inclusion: DSM-IV BPD diagnosis; ages 18–45 years;  24 on the BPDSI-IV and one or more episodes of SIB
Exclusion: Chronic psychotic disorder, bipolar I disorder, intellectual disability, or SUD requiring detoxification; involuntary psychiatric treatment
Mean age, years (SD):
 G1: 26 (7.5)
 G2: 26 (6.2)
Female: 95%
Race/ethnicity: NR
Primary outcome: NR
Significant reductions in both groups but no reporting on between-group comparisons
Incidence of AEs: NR
Withdrawal due to AEs: NR
Attrition: 44%
Differential attrition:  10 percentage points
High
       
Smits et al. (2020; 2022)
Design: RCT
Setting: Outpatient, multicenter
Country: The Netherlands
Funding: ZonMw
N = 114
G1 (70): MBT, day-hospital setting
G2 (44): MBT, IOP setting
Duration: 18 months
Inclusion: BPD diagnosis; age  18 years
Exclusion: ASD, chronic psychotic disorder, or organic brain disorder, intellectual disability (IQ < 80), or ASPD with history of physical violence
Mean age, years (SD):
 G1: 31 (10.6)
 G2: 30 (9.2)
Female: 83%
Race/ethnicity: NR
Primary outcome: GSI of BSI at 18 months
Significant improvements on all outcomes (GSI, SSHI, PAI-BOR, EQ-5D, IIP, SIPP) at 18 months and no significant between-group difference except on IIP and SIPP
No significant differences between groups at 36 months
Incidence of AEs: NR
Withdrawal due to AEs: NR
Attrition: 78% at 18 months
Differential attrition: 18%
High
AE = adverse event; ASD = autism spectrum disorder; ASPD = antisocial personality disorder; BPD = borderline personality disorder; BPDSI-IV = Borderline Personality Disorder Severity Index-IV; BSI = Brief Symptom Inventory; DBT = dialectical behavior therapy; DIB-R = Diagnostic Interview for Borderlines–Revised; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; DSM-5 =  Diagnostic and Statistical Manual of Mental Disorders, 5th Edition; EQ-5D = European Quality of Life–5 Dimension; G1 = Group 1; G2 = Group 2; G3 = Group 3; GSI =  Global Severity Index; IIP = Inventory of Interpersonal Problems; IOP = intensive outpatient; IQ = intelligence quotient; MBT = mentalization-based treatment; N = sample size; NR = not reported; PAI-BOR = Personality Assessment Inventory-Borderline Features Scale; RCT = randomized controlled trial; SD = standard deviation; SIB = self-injurious behavior; SIPP = Severity Indices of Personality Problems; SSHI = Suicide and Self-Harm Inventory; SUD = substance use disorder.

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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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