A Cochrane review [Abstract] 1 included 28 studies (5 comparisons) with a total of 1804 subjects with borderline personality disorder (BPD). Interventions were classified as comprehensive psychotherapies if they included individual psychotherapy as a substantial part of the treatment programme, or as non-comprehensive if they did not. Among comprehensive psychotherapies, dialectical behaviour therapy (DBT), mentalisation-based treatment in a partial hospitalisation setting (MBT-PH), outpatient MBT (MBT-out), transference-focused therapy (TFP), cognitive behavioural therapy (CBT), dynamic deconstructive psychotherapy (DDP), interpersonal psychotherapy (IPT) and interpersonal therapy for BPD (IPT-BPD) were tested against a control condition. Direct comparisons of comprehensive psychotherapies included DBT vs. client-centered therapy (CCT); schema-focused therapy (SFT) vs. TFP; SFT vs. SFT plus telephone availability of therapist in case of crisis (SFT+TA); cognitive therapy (CT) vs. CCT, and CT vs. IPT. Non-comprehensive psychotherapeutic interventions comprised DBT-group skills training only (DBT-ST), emotion regulation group therapy (ERG), schema-focused group therapy (SFT-G), systems training for emotional predictability and problem solving for borderline personality disorder (STEPPS), STEPPS plus individual therapy (STEPPS+IT), manual-assisted cognitive treatment (MACT) and psychoeducation (PE). The only direct comparison of an non-comprehensive psychotherapeutic intervention against another was MACT vs. MACT plus therapeutic assessment (MACT+). Inpatient treatment was examined in one study where DBT for PTSD (DBT-PTSD) was compared with a waiting list control. Data allowed for meta-analytic pooling only for DBT compared with treatment as usual (TAU) for 4 outcomes. There were moderate to large statistically significant effects indicating a beneficial effect of DBT over TAU for anger (SMD -0.83, 95% CI -1.43 to -0.22; 2 RCTs, n = 46), parasuicidality (SMD -0.54, 95% CI -0.92 to -0.16; 3 RCTs; n = 110) and mental health (SMD 0.65, 95% CI 0.07 to 1.24; 2 RCTs, n = 74). There was no indication of superiority of DBT over TAU in terms of keeping participants in treatment (RR 1.25, 95% CI 0.54 to 2.92; 5 RCTs, n = 252). All remaining findings were based on single study estimates of effect. Statistically significant between-group differences for comparisons of psychotherapies against controls were observed for BPD core pathology and associated psychopathology for the following interventions: DBT, DBT-PTSD, MBT-PH, MBT-out, TFP and IPT-BPD. IPT was only indicated as being effective in the treatment of associated depression. No statistically significant effects were found for CBT and DDP interventions on either outcome, with the effect sizes moderate for DDP and small for CBT. For comparisons between different comprehensive psychotherapies, statistically significant superiority was demonstrated for DBT over CCT (core and associated pathology) and SFT over TFP (BPD severity and treatment retention). No data were available for adverse effects of any psychotherapy.
Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment), inconsistency (heterogeneity in patients, interventions, comparisons and outcomes), indirectness (90 % of the patients were women) and imprecise results (limited study size for each comparison).
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