Psychological therapies for people with borderline personality disorder.
Level 1 - systematic review of randomized trials
Systematic review and meta-analysis of randomized controlled trials
PubMed 32368793 · doi:10.1002/14651858.CD012955.pub2
What was done
Authors conducted a Cochrane systematic review and meta-analysis searching multiple databases up to March 2019 for randomized controlled trials (RCTs) evaluating psychological therapies for individuals with a formal diagnosis of borderline personality disorder (BPD). Comparators included treatment-as-usual (TAU), waiting list, no treatment, or other active treatments across any age or setting. Primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. Risk of bias and certainty of evidence were assessed using Cochrane tools and GRADE, with statistical reliability evaluated via Trial Sequential Analysis.
What was found
The review included 75 RCTs with 4,507 participants (predominantly female; mean ages 14.8 to 45.7 years; treatment duration 1 to 36 months). Compared to TAU: - BPD symptom severity decreased: SMD -0.52 (95% CI -0.70 to -0.33; 22 trials, 1,244 participants; moderate-quality evidence), meeting the minimal clinically relevant difference (MIREDIF) on the Zanarini Rating Scale (MD -3.6 points vs MIREDIF -3.0). - Self-harm improved (SMD -0.32, 95% CI -0.49 to -0.14; 13 trials, 616 participants; low-quality evidence), but did not reach the MIREDIF on the Deliberate Self-Harm Inventory (MD -0.82 vs MIREDIF -1.25). - Suicide-related outcomes improved (SMD -0.34, 95% CI -0.57 to -0.11; 13 trials, 666 participants; low-quality evidence), but did not meet MIREDIF on the Suicidal Attempt Self Injury Interview (MD -0.11 vs MIREDIF -0.17). - Psychosocial functioning improved (SMD -0.45, 95% CI -0.68 to -0.22; 22 trials, 1,314 participants; low-quality evidence), but missed MIREDIF on the Global Assessment of Functioning (MD -2.8 vs MIREDIF -4.0). - Depressive symptoms showed uncertain reduction (SMD -0.39, 95% CI -0.61 to -0.17; 22 trials, 1,568 participants; very low-quality evidence). - Psychotherapy did not reduce attrition compared to TAU, and adverse event data were insufficient. Subgroup analyses showed no clear evidence that any single psychotherapy modality (such as DBT or MBT) was superior to another.
Why it matters
This review establishes that specialized psychotherapies provide statistically significant benefits for BPD symptoms over treatment-as-usual, but highlights that effect sizes for self-harm, suicidality, and functional recovery remain modest and below established thresholds for clear clinical relevance. It also finds no definitive evidence favoring one specific psychological modality over others.
Limits
Most included trials were small, and the evidence base was predominantly rated as low or very low quality due to risk of bias and imprecision, with only overall symptom reduction reaching moderate quality. Adverse effects were underreported across trials. Participants were predominantly female, limiting generalizability to male patients, and long-term follow-up beyond the end of treatment was not clearly established.
Cited by
- supports The gold standard treatment for borderline personality disorder is a long course of psychotherapy, such as Dialectical Behavior Therapy (DBT) over approximately a year.