Cochrane review of psychotherapy for bpd

Background

People affected by borderline personality disorder (BPD) often have difficulties with controlling their impulses and emotions. They may have a poor self-image, experience rapid changes in mood, harm themselves and find it hard to engage in harmonious interpersonal relationships. Different types of psychological treatments (‘talking treatments’) have been developed to help people with BPD. The effects of these treatments must be investigated to decide how well they work and if they can be harmful.

Objective

This review summarises what we currently know about the effect of psychotherapy in people with BPD.

Methods

We compared the effects of psychological treatments on people affected by BPD who did not receive treatment or who continued their usual treatment, were on a waiting list or received active treatment.

Findings

We searched for relevant research articles, and found 75 trials (4507 participants, mostly female, mean age ranging from 14.8 to 45.7 years). The trials examined a wide variety of psychological treatments (over 16 different types). They were mostly conducted in outpatient settings, and lasted between one and 36 months. Dialectical behaviour Therapy (DBT) and Mentalisation-Based Treatment (MBT) were the therapies most studied.

Psychotherapy compared with usual treatment

Psychotherapy reduced the severity of BPD symptoms and suicidality and may reduce self-harm and depression whilst also improving psychological functioning compared to usual treatment. DBT may be better than usual treatment at reducing BPD severity, self-harm and improving psychosocial functioning. Similarly, MBT appears to be more effective than usual treatment at reducing self-harm, suicidality and depression. However, these findings were all based on low-quality evidence and therefore we are uncertain whether or not these results would change if we added more trials. Most trials did not report adverse effects, and those that did, found no obvious unwanted reactions following psychological treatment. The majority of trials (64 out of 75) were funded by grants from universities, authorities or research foundations. Four trials reported that no funding was received. For the remaining trials (7), funding was not specified.

Psychotherapy versus waiting list or no treatment

Psychotherapy was more effective than waiting list at improving BPD symptoms, psychosocial functioning, and depression, but there was no clear difference between psychotherapy, and waiting list for outcomes of self-harm, and suicide-related outcomes.

Conclusions

In general, psychotherapy may be more effective than usual treatment in reducing BPD symptom severity, self-harm, suicide-related outcomes and depression, whilst also improving psychosocial functioning. However, only the decrease in BPD symptom severity was found to be at a clinically important level. DBT appears to be better at reducing BPD severity, self-harm, and improving psychosocial functioning compared to usual treatment and MBT appears more effective than usual treatment at reducing self-harm and suicidality. However, we are still uncertain about these findings as the quality of the evidence is low.

People with borderline personality disorder often have difficulties controlling their emotions and impulses, and find it hard to keep relationships. They can experience feelings of emptiness, suffer quick changes in mood and they may harm themselves. Problems coping with abandonment and a rapidly changing view of other people can form part of their difficulties. All of these things make it hard for them to engage with any treatment they may be offered. Those who are able to engage often find it hard to stick with the treatment and leave before the end. Certain types of psychological treatment (‘talking therapies’) have been developed in recent years to help people with this disorder. This review summarises what is currently known about the effects of these treatments. It updates a review published in the Cochrane Database of Systematic Reviews (CDSR) in 2006 and it was superseded by a new review (with the same title) in the CDSR in 2020.

We found 28 studies that had involved a total of 1804 people with borderline personality disorder. These studies examined various psychological treatments. Some of these are called ‘comprehensive’ treatments because the person talks one-to-one with a professional for at least part of the time. Other treatments are called ‘non-comprehensive’ because they do not involve this one-to-one work.

A number of studies have been carried out on one particular type of comprehensive treatment, called Dialectical Behaviour Therapy. For this treatment, there were sufficient studies for us to pool the results and draw conclusions. The results indicate Dialectical Behaviour Therapy is helpful for people with borderline personality disorder. Effects included a decrease in inappropriate anger, a reduction in self-harm and an improvement in general functioning.

There were generally too few studies to allow firm conclusions to be drawn about the value of all the other kinds of psychotherapeutic interventions evaluated. However, single studies show encouraging findings for each treatment that was investigated, both ‘comprehensive’ and ‘non-comprehensive’ types. More research is needed.

Abstract

Objectives

To review the effectiveness of psychological therapies for adolescents with borderline personality disorder (BPD) or BPD features.

Methods

We included randomized clinical trials on psychological therapies for adolescents with BPD and BPD features. Data were extracted and assessed for quality according to Cochrane guidelines, and summarized as mean difference (MD) with 95% confidence intervals (CI) for continuous data and as Odds ratios (OR) with 95% CI for dichotomous data. Risk of bias was assessed using Cochrane’s risk of bias tool for each domain. When possible, we pooled trials into meta-analyses, and used Trial Sequential Analysis (TSA) to control for random errors. Quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE).

Results

10 trials on adolescents with BPD or BPD features were included. All trials were considered at high risk of bias, and the quality of the evidence was rated as “very low”. We did TSA on the primary outcome and found that the required information size was reached. The risk of random error was thus discarded.

Conclusion

Only 10 trials have been conducted on adolescents with BPD or BPD features. Of these only few showed superior outcomes of the experimental intervention compared to the control intervention. No adverse effects of the interventions were mentioned. Attrition rates varied from 15–75% in experimental interventions. The overall quality was very low due to high risk of bias, imprecision and inconsistency, which limits the confidence in effect estimates. Due to the high risk of bias, high attrition rates and underpowered studies in this area, it is difficult to derive any conclusions on the efficacy of psychological therapies for BPD in adolescence. There is a need for more high quality trials with larger samples to identify effective psychological therapies for this specific age group with BPD or BPD features.

Citation: Jørgensen MS, Storebø OJ, Stoffers-Winterling JM, Faltinsen E, Todorovac A, Simonsen E (2021) Psychological therapies for adolescents with borderline personality disorder (BPD) or BPD features—A systematic review of randomized clinical trials with meta-analysis and Trial Sequential Analysis. PLoS ONE 16(1): e0245331. https://doi.org/10.1371/journal.pone.0245331

Editor: Michael Kaess, University of Bern, SWITZERLAND

Received: June 5, 2020; Accepted: December 28, 2020; Published: January 14, 2021

Copyright: © 2021 Jørgensen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting information files.

Funding: TrygFonden (grant number 115638), Psychiatric Research Unit Region Zealand, the Health Scientific Research Fund of Region Zealand, and Department of Health and Medical Sciences, University of Copenhagen.

Competing interests: The authors have read the journal’s policy and have the following competing interests: MSJ is associated with the M-GAB trial and trained in Dialectical behavior therapy and psychodynamic therapy. OJS is associated with the M-GAB trial, trained in child and adolescent psychoanalytic play therapy and trained in group psychoanalysis. JSW is a board-certified behavior therapist and trained in Dialectical behavior therapy. ES is associated with the M-GAB trial and trained in group psychoanalysis. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Introduction

Borderline personality disorder (BPD) is a severe mental disorder characterized by a pervasive pattern of instability in affect, impulse control, interpersonal relationships and behavior [1,2]. BPD manifests during childhood or adolescence, and we now know that BPD can be validly diagnosed in adolescence [3–5]. In spite of this, many clinicians have been reluctant in diagnosing personality disorders in youth. This delay in diagnosing personality disorders in youth heightens the risk of ineffective or even iatrogenic treatments (psychotherapeutic and/or psycho-pharmacological), and could be a risk factor of decreases in psychosocial functioning over time [4,6]. In order to take action to prevent the development of this disorder, an increasing amount of randomized clinical trials (RCTs) have been conducted on early detection and treatments for adolescents with BPD or BPD features.

Reviews on psychological therapies for BPD have focused on patients who fulfilled diagnostic threshold for BPD and therefore have excluded patients who presented with BPD features (at a subthreshold level). This means that clinicians and researchers are left uninformed about the evidence base and the quality of evidence of RCTs on psychological therapies for BPD pathology in adolescence. The aim of this review was thus to assess the effectiveness of psychological therapies for adolescents with BPD or BPD features.

Methods

This review was conducted according to a published protocol [7] in close collaboration with the Cochrane review of psychological therapies for BPD, and therefore the method section will resemble that seen in the Cochrane review [8], but the participants, interventions, comparisons and outcomes will be different. We will present additional data that was excluded from the Cochrane review on psychological therapies for BPD (due to the requirement of a full criteria BPD diagnosis) with analyses that focus on trials for adolescents with BPD or BPD features.

Study selection

We considered RCTs of psychotherapeutic treatments for adolescents with BPD or BPD features eligible for inclusion. Trials were included irrespective of language, and publication year, type or status.

Types of participants

Patients were eligible if they had a formal diagnosis of BPD according to the Diagnostic of Statistical Manual of Mental Disorders (DSM), Third Edition (DSM-III) [9], Third Edition Revised (DSM-III-R) [10], Fourth Edition (DSM-IV) [11], Fourth Edition Text Revision (DSM-IV-TR) [12], and Fifth Edition (DSM-5) [1], and also if they presented with BPD features at any level (i.e. any trial that specifically targeted BPD symptoms at a threshold or subthreshold level as an overall aim of the trial).

We included trials involving subsamples of BPD patients providing data on these patients were available separately. We included adolescent participants with BPD or BPD features, with or without any comorbid psychiatric conditions. We excluded trials that focused on mental impairment, organic brain disorder, dementia or other severe neurologic/neurodevelopmental diseases [7].

Types of interventions

This review included the same types of experimental and comparator interventions as the Cochrane review [7,8]. Experimental interventions included any well-defined, theory-driven psychotherapeutic treatment. We included all types of psychotherapy, regardless of theoretical orientation or treatment setting. We included any kind of treatment setting: inpatient, outpatient or partially hospitalized. We included the following types of interventions: 1) individual psychotherapy, 2) group psychotherapy, 3) family therapy and 4) any combination of individual, family and/or group psychotherapy.

We included the following comparator interventions: 1) control interventions (e.g., standard care, treatment as usual [TAU] or waitlist or no treatment), and 2) specific psychotherapeutic interventions that were well-defined and theory-driven, e.g., general psychiatric management [13]. Concomitant treatments were included if they were applied to both treatment conditions.

Types of outcome measures

Outcomes were self-rated by patients or observer-rated by clinicians.

We analyzed all outcomes at end of treatment (EOT) and at any potential follow-up periods.

If a trial included several measures of the same outcome, we only included one instrument per outcome to avoid double counting of participants. We preferred the observer-rated instruments over the self-rated.

Primary outcome.

For the primary outcome we chose BPD severity. This includes any measure of BPD symptoms, features or severity.

Secondary outcomes

1. Psychopathological syndromes included all psychopathological syndromes (except BPD) such as depression, anxiety, psychoticism etc. If the trials included more than one measure of psychopathological syndromes, we included the most morbid syndrome for this review (for example, psychotic disorders over depression, but depression over anxiety).
2. Impulsivity covered self-harm, non-suicidal self-injury (NSSI), suicide attempts and externalizing behaviors
3. Substance or alcohol abuse included substance abuse or dependence (all substances) or alcohol abuse or dependence.
4. Functioning included global functioning, occupational functioning and interpersonal functioning.
5. Quality of life included all measures on quality of life.
6. Attrition included number of patients lost after randomization in each intervention due to any reason
7. Adverse events included unfavorable outcomes that occur during or after psychological therapies but not necessarily caused by it. Adverse events are divided into severe adverse events (any event that leads to death, is life-threatening, requires inpatient hospitalization or prolongation of existing hospitalization, results in persistent or significant disability, and any medical even that may have jeopardized the participant’s health or requires intervention to prevent it), and non-serious adverse events (all other adverse events) [8].

Search methods for identification of trials

We searched in the electronic databases and trial registers listed below:

1. Cochrane Central Register of Controlled Trials (CENTRAL; current issue), in the Cochrane Library, which includes the Cochrane Developmental, Psychosocial and Learning Problems Specialised Register
2. MEDLINE Ovid (1948 onwards)
3. Embase Ovid (1980 onwards)
4. CINAHL EBSCOhost (Cumulative Index to Nursing and Allied Health Literature; 1980 onwards)
5. PsycINFO Ovid (1806 onwards)
6. ERIC EBSCOhost (Education Resources Information Center; 1966 onwards)
7. BIOSIS Previews Web of Science Clarivate Analytics (1969 onwards)
8. Web of Science Core Collection Clarivate Analytics (1900 onwards)
9. Sociological Abstracts ProQuest (1952 onwards)
10. LILACS (Latin American and Caribbean Health Science Information database; lilacs.bvsalud.org/en)
11. OpenGrey (www.opengrey.eu)
12. Copac National, Academic and Specialist Library Catalogue (COPAC; copac.jisc.ac.uk)
13. ProQuest Dissertations and Theses A&I (1743 onwards)
14. DART Europe E-Theses Portal (www.dart-europe.eu/basicsearch.php)
15. Networked Digital Library of Theses and Dissertations (NDLTD; www.ndltd.org)
16. Australian New Zealand Clinical Trials Registry (ANZCTR; www.anzctr.org.au/BasicSearch.aspx)
17. ClinicalTrials.gov (clinicaltrials.gov)
18. EU Clinical Trials Register (www.clinicaltrialsregister.eu/ctr-search/search)
19. ISRCTN Registry (www.isrctn.com)
20. UK Clinical Trials Gateway (www.ukctg.nihr.ac.uk/#popoverSearchDivId)
21. WHO International Clinical Trials Registry Platform (ICTRP; who.int/ictrp/en)

In depth details on the data sources and search criteria are available in the Cochrane systematic review [7,8].

Data collection and analysis

We made this review according to the Cochrane Handbook for Systematic reviews of Interventions [14], and analyses were performed using Review Manager 5.3 (RevMan)—the Cochrane Collaboration’s statistical software.

Data extraction and quality assessment

Data were extracted as a part of the Cochrane Review [7,8]. Six review authors independently extracted data for this review and assessed risk of bias according to Cochrane’s tool for assessing risk of bias [14]. The following risk of bias domains were assessed and subsequently determined in pairs of two data extractors: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective outcome reporting, and other sources of bias. For each domain, the data extractors assigned the included trials to one of three categories (low risk of bias, unclear risk of bias or high risk of bias), according to guidelines provided in the Cochrane Handbook for Systematic Reviews of Interventions [14]. We considered trials with one or more unclear or high risk of bias domains as high risk of bias trials. We resolved disagreements by discussion or use of an arbiter if needed. Trial authors were contacted in case we needed supplementary data or information.

We assessed and graded the quality of the evidence according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). The GRADE approach was used to construct a ’Summary of findings’ table where all review outcomes were presented. The GRADE approach evaluates the quality of a body of evidence in terms of risk of bias, directness of the evidence, heterogeneity of the data, precision of effect estimates, and risk of publication bias [15]. The overall GRADE-evaluation indicates to which extent one can be confident in the effect estimates.

Data synthesis and statistical analysis

For continuous data, we compared the mean score between the two groups to give a mean difference (MD). This is presented with 95% confidence intervals (CIs). When there were different outcome measures used on the same construct, we estimated the standardized MD (SMD). We calculated standardized mean differences (SMDs) using end-scores on the basis of end of treatment results and follow-up data, respectively. If the trials did not report means and standard deviations but reported other values such as t-tests and P values, we tried to transform these into standard deviations. Dichotomous data were summarized as Odds ratios (OR) with 95% CIs. We calculated study estimates on the basis of end of treatment results and did separate analyses for different therapies as well as for follow-up data. Whenever there were incomplete reports or missing data on outcomes stated as having been assessed, we contacted the trial authors.

We performed the statistical analysis according to recommendations in the latest version of the Cochrane Handbook for Systematic Reviews of Interventions [16]. Meta-analyses were carried out even if there was concern about heterogeneity. If the heterogeneity was very high in the meta-analysis, we downgraded the quality by using the GRADE tool [15]. When carrying out the meta-analysis, we used the inverse variance method to give more precise estimates from trials with less variance (mostly larger trials) more weight. We used the random-effects model for meta-analysis since we expected some degree of clinical heterogeneity to be present in most cases and the fixed effect model when presenting singe trial results. If data pooling seemed feasible, we pooled the primary trials effects and calculated their 95% CIs.

Diversity-adjusted required information size and Trial Sequential Analysis

Trial Sequential Analysis (TSA) is a methodology that combines a required information size (RIS) calculation for a meta-analysis with the threshold for statistical significance [17–19]. TSA is used to quantify the statistical reliability of the data in cumulative meta-analysis adjusting P values for sparse data and for repetitive testing on accumulating data thus controlling the risks of type I and type II errors [17–19]. We calculated the diversity-adjusted required information size (DARIS, i.e. number of participants required to detect or reject effects in meta-analyses), and used TSA for our primary outcome at end of treatment. If the TSA did not find a significant finding before the RIS was reached (no Z curve crossing of the trial sequential monitoring boundaries), we could conclude that either more trials were needed to reject or accept an intervention effect or the anticipated effect could be rejected. If the cumulated Z curve enters the futility area, the anticipated intervention effect can be rejected.

Discussion

We conducted this systematic review to examine the effectiveness of psychological therapies for adolescents with BPD or BPD features. We assessed 563 full-text papers and included 10 trials consisting of 775 adolescents with BPD or BPD features for this review. To our knowledge this is the most comprehensive systematic review and meta-analysis on psychological therapies for adolescents with BPD or BPD features.

The duration of the trials ranged from 19 weeks [24] to 12 months [20,23]. Most were conducted in outpatient clinics in the US, Europe, or Australia. Nine of the trials had at least one category with high risk of bias, and one had no high risk of bias but two categories with unclear risk of bias [22]. In total, we thus assessed all trials as having high risk of bias, which could lead to systematic errors, i.e. overestimating benefits and underestimating harms. These findings do not equate to wrong conclusions with regards to the findings in the included studies or that psychological therapies for adolescents with BPD or BPD features do not work, but reviews such as these are needed to support and inform clinical practice with regards to the evidence base.

In accordance with the Cochrane Handbook for Systematic Reviews of Interventions [16], we performed meta-analyses on our primary outcome BPD severity at EOT. On the primary outcome, no statistical significant differences were found between the experimental interventions or control interventions in our two meta-analyses of MBT and ERT. TSAs showed that the cumulated Z curve entered the futility area, and therefore any anticipated intervention effect can be rejected at this point of time. Single study results on the primary outcome BPD severity included a statistical significant difference between DBT and EUC at EOT (but not in the follow-up period) [24,52,53], and no statistically significant differences between the experimental and control interventions in the remaining trials [22,29].

For the secondary outcomes, we only found two instances where the experimental intervention was statistically significant different from control interventions: 1) DBT-A was superior at EOT in reducing self-harm. However, this superiority vanished at six months follow-up in McCauley et al.’s trial [26], and after three years in Mehlum et al.’s trial [53], and 2) a single trial of PiM was superior to WL/TAU in increasing global level of functioning [25].

Implications for early intervention for BPD

A recent systematic review with meta-analysis on seven trials of psychotherapies for adolescents with subclinical and BPD concluded that psychotherapies for adolescents with BPD pathology are effective for BPD-specific symptomatology, externalizing and internalizing symptoms, particularly in the short term, and also reduce the frequency of NSSI [55]. Furthermore, they concluded that the risk of bias in the included studies was generally low, and the studies were rated as being of very high quality [55]. These conclusions were based on pooled results from all experimental treatments compared to all control interventions regardless of theoretical orientation and length. There are, however, major limitations to this review. First, pooling of all experimental interventions should only be done when subgroup analysis of clinical heterogeneity can be conducted. Since there are less than ten trials within this field, this pooling of experimental interventions versus controls should be avoided [16]. Furthermore, there was no published protocol, some trials were left out, there was no use of tools to rate quality, there were overly optimistic risk of bias ratings, and lastly also issues regarding clinical heterogeneity [56]. These limitations can mislead clinicians and researchers with regards to the evidence base. Therefore, a systematic review that thoroughly addressed these limitations was warranted. We believe this review addresses the before mentioned limitations, which led to considerable different conclusions regarding the effectiveness of the included studies, the risk of bias assessments as well as ratings of the quality of the evidence.

Diagnosing BPD in youth has been controversial, and therefore there is a scarcity of RCTs on psychological therapies for this age group with BPD. For that reason, it is of uttermost importance to outline the quality of the evidence and the risk of bias in a transparent fashion. BPD is a severe mental disorder associated with enduring difficulties in achieving functional remission (especially vocational recovery), and this constitutes a costly feature of BPD that is remarkable stable without targeted intervention [4,6,57,58]. In a Danish register based study of 67,075 individuals diagnosed with BPD, the BPD group had 32% lower odds of being in work/under education after nine years as well as more impairment in long-term vocational outcome than other PDs, as well as lower labor-market attachment than other disorders (except for schizophrenia, schizotypal and delusional disorders and substance use disorders) [58]. Similar results have been found in a recent nation-wide study of Danish patients with early onset of BPD (<19 years), where BPD patients already at age 20 had reached a statistically significant lower educational level (including lower primary school grades), and were 22 times more likely to be unemployed compared to controls [59]. Furthermore, total health care costs were more than eight times higher in the BPD group [59]. This functional disability has been a key incentive to treat BPD in adolescence where the disorder is still in its early stages (including subthreshold presentations), and where BPD traits are more flexible and malleable [60].

The trials included in this review, show that we still have some way to go before we can identify effective components of early intervention. RCTs on BPD interventions generally focus on reducing BPD symptoms and especially “acute” symptoms of BPD (such as self-harm), despite the fact that these symptoms naturally remit in the transition period from adolescence to adulthood with a symptomatic switch towards symptoms of chronic dysphoria, interpersonal difficulties and persistent functional disability [4,61,62]. Patients with BPD have pointed to functional recovery as a priority of treatment [63], and therefore a focus on functional recovery has been proposed as the most important outcome of intervention and research within this field [6]. This focus on “acute symptoms” of BPD leaves vital questions on early intervention research unanswered: was the observed symptomatic reduction in the trials due to effectiveness of treatment or merely natural remission? Due to the scarcity of follow-up studies, we also do not know of the long-term effectiveness of treatment and whether it had an impact on functional outcomes.

Limitations and strengths

The results of this review are mostly based on single trials results that include a relatively small number of participants, differing control interventions, and with a high degree of heterogeneity in the few pooled trials. This heterogeneity limits the ability to generalize the findings of this review. First and foremost, many of the RCTs aim at early detection and early prevention of BPD, but the included samples vary in terms of inclusion criteria. For instance, number of BPD criteria necessary for inclusion vary from two criteria up to five (diagnostic threshold). This marked difference in sample characteristics makes it difficult to differentiate between early intervention and regular BPD treatment, where the aim of treatment is to treat BPD and associated conditions and social disability. Secondly, the minimum age of the participants in the included trials varied from 12 (3 trials), to 14 (5 trials), to 15 (2 trials), whereas the maximum age varied from 17 (3 trials), to 18 (3 trials), to 19 (3 trials), and one trial included participants up to 25 [29]. We decided to include the latter trial, despite the fact that it consisted of participants that were not adolescents, because it was a small pilot trial consisting of sixteen participants with a mean age of 18.4 years. Lastly, the experimental treatments varied in content, format and length, and the control treatments varied in intensity and whether they were manualized or poorly defined and non-manualized.

All trials were assessed to be of high risk of bias thus raising concern of overestimating benefits and underestimating harm. We used GRADE to rate the quality of the evidence and the GRADE assessments led to downgrading the quality of the evidence to “very low quality” due to within-trial risk of bias, publication bias, imprecision and inconsistency. This means that we have very little confidence in the effect estimate [15].

We wanted to assess for publication biases, but since there were only 10 trials on adolescents with BPD or BPD features, we could not use funnel plots for comparisons nor perform Egger’s statistical test for small-study effects [64] as recommended in the Cochrane Handbook for Systematic Reviews of Interventions [16]. Therefore, we cannot reject the possibility that there might be publication bias.

Another limitation is the lack of knowledge of possible adverse or iatrogenic effects of psychological therapies for adolescents with BPD. We saw varying attrition rates, but reasons for attrition were seldom stated, which leaves us undecided of possible adverse effects.

Our review has a number of strengths: it was conducted as a Cochrane review following the instructions from the Cochrane Handbook [16]. A protocol was published prior to conducting the review [7]. The literature search was systematic and comprehensive, and we contacted authors in cases of missing information. Additionally, we conducted TSA on the primary outcome in cases where meta-analyses were possible, and found that the cumulated Z curve entered the futility area, and therefore that any anticipated intervention effect could be rejected at this point. We believe that our approach has led to the best possible gathering of relevant studies on adolescents with BPD or BPD features.

Conclusions and future directions

In the majority of the trials, no superiority of the experimental intervention was found over control interventions on primary and secondary outcomes. Furthermore, the results of the included trials should be interpreted with caution due to high risk of bias and very low quality of evidence. The trials were characterized by high degrees of heterogeneity. In order to push this field forward, there needs to be more consensus on study designs that allow for comparisons. Given the enormous impact BPD and BPD features have, the case of adolescents with BPD or BPD features deserves more attention in order to avoid inauspicious developments. Importantly, the findings of this review do not equate to ineffectiveness of psychological treatments for this age group with BPD. In the majority of the trials, symptomatology decreased and functioning increased in the experimental arm as well as in the control arm, but it is unclear whether these improvements were caused by effectiveness of treatment, natural improvement or regression toward the mean. Effective treatments need to be developed and evaluated in high quality trials with larger sample sizes. Future trials should also include well-defined control interventions and include follow-up assessments to determine the long-term effectiveness of treatment. BPD severity was chosen as the primary outcome of this review due to the state in the field. However, this field would also benefit from a shift of focus to functional outcomes, and by including outcomes that were raised as important by patients and people with lived experience.

Acknowledgments

We wish to give a special thank you to Trine Lacopiddan Kæstel for her important work in conducting the searches. Also a special thank you to all the co-authors on the review on psychological therapies for BPD for their great work: Birgit A. Völlm, Mickey T. Kongerslev, Jessica T. Mattivi, Christian P. Sales, Henriette Edemann Callesen, Signe S. Nielsen, Maja Lærke Kielsholm, Klaus Lieb, and the Cochrane Developmental, Psychosocial and Learning Problems Group for providing help and support.

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