Which psychotherapy is most effective and acceptable in the treatment of adults with a (sub)clinical borderline personality disorder? A systematic review and network meta-analysis

Abstract

A broad range of psychotherapies have been proposed and evaluated in the treatment of borderline personality disorder (BPD), but the question which specific type of psychotherapy is most effective remains unanswered. In this study, two network meta-analyses (NMAs) were conducted investigating the comparative effectiveness of psychotherapies on (1) BPD severity and (2) suicidal behaviour (combined rate). Study drop-out was included as a secondary outcome. Six databases were searched until 21 January 2022, including RCTs on the efficacy of any psychotherapy in adults (⩾18 years) with a diagnosis of (sub)clinical BPD. Data were extracted using a predefined table format. PROSPERO ID:CRD42020175411. In our study, a total of 43 studies (N = 3273) were included. We found significant differences between several active comparisons in the treatment of (sub)clinical BPD, however, these findings were based on very few trials and should therefore be interpreted with caution. Some therapies were more efficacious compared to GT or TAU. Furthermore, some treatments more than halved the risk of attempted suicide and committed suicide (combined rate), reporting RRs around 0.5 or lower, however, these RRs were not statistically significantly better compared to other therapies or to TAU. Study drop-out significantly differed between some treatments. In conclusion, no single treatment seems to be the best choice to treat people with BPD compared to other treatments. Nevertheless, psychotherapies for BPD are perceived as first-line treatments, and should therefore be investigated further on their long-term effectiveness, preferably in head-to-head trials. DBT was the best connected treatment, providing solid evidence of its effectiveness.

Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies

“…There is no evidence that psychotherapy is associated with a higher rate of serious adverse events compared with TAU (risk ratio, RR=0.86, 95% CI: 0.14-5.09; n=4, N=571, p=0.86) 17 . Generic methods of psychotherapy (e.g., general psychiatric management, structured clinical management, client-centered therapy, supervised team management) were found to be inferior to specialized psychotherapies such as DBT, MBT or schema therapy 216 .…”

“…Due to the limited number of RCTs, meta-analyses specifically focusing on between-group effect sizes with ST are not available 229 . The most recent meta-analysis on psychotherapy for BPD included only three RCTs of ST 216 . As noted above, in reducing BPD symptoms, ST was found to be superior to DBT and CBT, but not MBT or TFP 216 .…”

“…The most recent meta-analysis on psychotherapy for BPD included only three RCTs of ST 216 . As noted above, in reducing BPD symptoms, ST was found to be superior to DBT and CBT, but not MBT or TFP 216 . However, these results should be interpreted with caution, due to the limited number of RCTs on which they were based.…”

Complex Posttraumatic Stress Disorder and a Biopsychosocial Model of Borderline Personality Disorder

“…Thus there is good evidence for a number of methods that have somewhat different theoretical root, including dialectical behavior therapy (Linehan, 1993), mentalization-based treatment (Bateman and Fonagy, 2004), and transference-focused psychotherapy (Yeomans et al, 2002). Each of these methods has been supported by clinical trials, but no single therapy has been shown to be superior (Storebø et al, 2018; Setkowski et al, 2023), and all of these have an implicit or explicit adherence to a biopsychosocial model. This suggests that all effective treatments make use of common factors and may not be wholly dependent on underlying theories (Choi-Kain, 2020).…”

Correspondence to Setkowski and colleagues on Best psychotherapies for borderline personality disorder

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Setkowski et al (2023) published an ambitious paper asking, 'Which psychotherapy is most effective…in the treatment of … borderline personality disorder?' They employ network meta-analysis (NMA), a statistical procedure that estimates the comparative effectiveness of interventions never trialed against each other, but against the same comparator, most often 'treatment as usual' (TAU), but also, other interventions that are better matched in dose, focus, and expertise with the treatments of interest.The authors enumerate limitations of their study responsibly, which include first and foremost the heterogeneity of control conditions in studies.

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