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Review: urgent need for RCT evidence on effectiveness of crisis interventions for borderline personality disorder
  1. Andrew Chanen
  1. Orygen Youth Health Research Centre and Centre for Youth Mental Health, The University of Melbourne, Melbourne, Victoria, Australia

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Question

Question: Are crisis interventions effective for adults with borderline personality disorder (BPD) presenting in acute distress?

Outcomes: Primary outcomes were death; sudden, unexpected death and death from natural causes occurring while a seemingly healthy individual was either a participant in, or had recently completed, a randomised trial; self-harm and suicide intention or completed suicide; violence to others; hospital admissions (mental health or general) and quality of life.

Methods

Design: Cochrane systematic review.

Data sources: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In Process & Other Non-indexed Citations, PsycINFO, CINAHL, Social Services Abstracts, Social Care Online, Science Citation Index, Social Science Citation Index, Conference Proceedings Citation Index—Science, Conference Proceedings Citation Index—Social Science and Humanities and ZETOC Conference proceedings were searched in September 2011. Relevant dissertations were identified in WorldCat, Australasian Digital Theses Program, Networked Digital Library of Theses and Dissertations and Theses Canada Portal. Trials were identified in the International Clinical Trials Registry Platform and hand search was performed of the reference lists from relevant literature. In addition, researchers contacted the 10 most published researchers in the field of BPD (as indexed by BioMed Experts) and contacted topic experts about ongoing trials and unpublished data.

Study selection and analysis: Randomised controlled trials (RCTs) and quasi-randomised trials that compared crisis interventions for adults (aged ≥18 years) with BPD with usual care, no intervention or waiting list control. Crisis interventions were defined as ‘an immediate response by one or more individuals to the acute distress experienced by another individual, which is designed to ensure safety and recovery and lasts no longer than 1 month’. Interventions could be provided by ward-based or community-based teams working alongside mental health teams within the NHS, and could take place in a hospital, the community or at home. Interventions could also include the provision of crisis plans or any other service user-held tools to be used in a crisis. Participants could have comorbid mental illness, but could not be registered in studies focusing on a separate mental disorder. Two reviewers assessed the relevance and quality of articles for inclusion.

Main results

Fifteen potentially relevant articles were identified in the search and assessed in full text. Thirteen articles were excluded because the study was not randomised (n=8); had a retrospective study design (n=2); or because the intervention was a complex psychological therapy that lasted for longer than 1 month (n=3). Two ongoing RCTs were identified that met inclusion criteria. The first of these is assessing the impact of joint crisis plans on outcomes in people with BPD, and the second is assessing the impact of a 24 h crisis phone line on suicide attempts in people with BPD. The predicted sample size of these studies is 688 but results are not currently available.

Conclusions

There is currently no available RCT evidence on the most effective way to manage acute crises in people with BPD. Quality RCTs in this area are urgently needed.

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Commentary

Suicidal crises are common in borderline personality disorder (BPD), with up to 70% of patients making suicide attempts and up to 10% completing suicide.1 Evidence-based, specialised interventions for BPD have limited availability and many individuals with BPD do not engage with psychiatric services or are excluded from such services because of overtly discriminatory practices. Consequently, for many people with BPD, their contact with the healthcare system is limited to crisis presentations, lending face validity to Borschmann and colleagues Cochrane review.

The review addresses the role of crisis interventions for individuals with BPD receiving treatment as usual (TAU) or no active intervention. Crisis interventions for BPD are more widespread than is implied in the review, as they are also a routine component of many evidence-based and/or structured psychosocial interventions for BPD. Some of these were identified in this review (eg, Bateman and Fonagy2) and excluded on the grounds of ‘complexity’ and duration.

Excluding studies using certain background interventions seems unjustified and it undermines the objective of studying crisis intervention in ‘any setting’. For this reason, excluding the Bateman study2 seems better justified on the grounds that the crisis intervention component of this intervention was not tested using a ‘dismantling’ design. It does not justify the exclusion of the study by Nadort et al,3 who used a similar design to the included study by Pham-Scottez et al.4 The former added a therapist telephone contact to a structured (‘complex’) intervention, whereas the latter added it to TAU.

Nevertheless, background intervention is important, and conflating TAU with ‘no intervention’ also seems unjustified. TAU is highly variable, and in some settings has significant potential for iatrogenic harm (‘maltreatment as usual’5), especially during crises. This is supported by a recent RCT of a psychotherapeutic intervention for personality disorders reporting deterioration in those receiving TAU.6

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  • Competing interests None.

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