Similar benefits with dialectical behaviour therapy or general psychiatric management for people with borderline personality disorder
Question: What are the long-term outcomes for people with borderline personality disorder (BPD) who receive outpatient dialectical behaviour therapy (DBT) or general psychiatric management for 1 year?
Patients: In all, 180 adults aged between 18 and 60 years with a diagnosis of BPD (DSM-IV criteria; mean age 30.4 years, 86.1% women, 65% unemployed). Participants were eligible if they had at least two suicidal or non-suicidal self-injurious episodes in the previous 5 years with at least one episode in the previous 3 months. Exclusion criteria included: Substance dependence in the preceding 30 days, diagnosis of psychiatric disorder or bipolar I disorder, delirium, dementia or mental retardation, medical condition precluding psychiatric medications, serious medical condition requiring hospitalisation within the following year.
Setting: Toronto, Canada; 2003−2006 (treatment period).
Intervention: Outpatient DBT versus general psychiatric management for 1 year. DBT was delivered according to treatment manuals and general psychiatric management consisted of psychodynamic psychotherapy, case management and pharmacotherapy. Therapy was delivered by trained therapists for both approaches who attended weekly supervision meetings. There were no restrictions for either group for concomitant pharmacotherapy use.
Outcomes: Primary outcomes: self-reported frequency and severity of suicidal and non-suicidal self-injurious behaviours (Suicide Attempt Self-Injury Interview). Secondary outcomes included: healthcare utilisation (Treatment History Interview), general symptom distress, depression, anger, overall quality of life, interpersonal functioning, borderline psychopathology, remission from BPD (defined as meeting no more than two criteria for BPD for 1 year), overall functioning.
Patient follow-up: 73% at 18 months, 71% at 24 months, 66% at 30 months and 61% at 36 months; 48% completed all four follow-up assessments.
Design: Randomised controlled trial.
Blinding: Single blinded (outcome assessors blinded).
Follow-up period: 3 years (including 1-year treatment period).
Both treatment groups had shown a reduction in the rate of suicide attempts at the end of treatment, from 39.3% at baseline to 10.1% after DBT and from 37.5% at baseline to 6.6% after general psychiatric management. This reduction was maintained at 2-year post-treatment follow-up (p=0.64). The rates of suicide attempts did not differ between the groups at 2-year post-treatment follow-up (p=0.83). Both treatment groups had also shown a reduction in rate of non-suicidal self-injurious attempts at the end of treatment, from 84.3% to 47.8% with DBT and from 87.5% to 44.7% with general psychiatric management. The reduced rates of non-suicidal self-injurious behaviours observed during the treatment phase were also maintained by both groups at 2-year follow-up (p=0.07) with rates similar between groups (p=0.80). At 2-year follow-up, 57% of those who received DBT and 68% of those who received general psychiatric management were in remission from BPD, the difference between the groups in remission post-treatment was not significant.
People with BPD who received 1 year of DBT or generalised psychiatric management sustain improvements in the frequency and severity of suicidal and non-suicidal self-injurious behaviours at 2-year post-treatment follow-up, but there are no differences between the two groups.
Sources of funding: The Canadian Institute for Health Research.
The treatment efficacy for manualised, emotion-focused psychotherapies for borderline personality disorder (BPD) is well documented. The accumulation of these studies has provided hope for what was once considered an intractable, life-threatening condition. Despite these advances, questions about these treatments remain, including the longevity of the outcomes, the extent to which treatments impact multiple domains of functioning, and the degree to which specialised BPD therapies are unique or operate under a common set of therapeutic ingredients. This study has extended prior work by examining the benefits of two specialised BPD treatments (ie, dialectical behaviour therapy and general psychiatric management) over a 3-year period including 2 years of naturalistic follow-up. The equivalence in follow-up outcomes across treatments and primary and secondary outcomes is consistent with the original treatment study. Although not tested directly, the study highlights that effective treatments for BPD require a specialised, comprehensive team approach. Each treatment condition involved manualised interventions, training in suicide management, multiple treatment modalities and weekly supervision meetings. The extent to which each component is necessary, or contributes to the outcomes is unclear. A components analysis for improved feasibility of implementation would be the next logical step in this research.
The study also showed a large percentage of sustained unemployment and psychiatric disability, despite achieving over 50% diagnostic remission of BPD in both treatments at 1-year follow-up and 2-year follow-up. The fact that a high percentage of participants were not working or off disability is not surprising given that neither treatment explicitly targeted these outcomes nor was it a hypothesised goal of the original study. It also seems unlikely that symptom remission would be sufficient to compel participants into the workforce without an explicit therapeutic focus on these goals.1 Instead, the results highlight the continued need for psychotherapeutic care following symptom remission if additional client goals are to be achieved.