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Supplementary Online Content
Cristea IA, Gentili C, Cotet CD, Palomba D, Barbui C, Cuijpers P. Efficacy of psychotherapies for borderline personality disorder: a systematic review and meta-analysis. JAMA Psychiatry. Published online March 1, 2017. doi:10.1001/jamapsychiatry.2016.4287
eMethods. Supplemental Methods eFigure 1. Flowchart of Selection and Inclusion Process, Following the PRISMA Statement eFigure 2. Risk of Bias Graph: Review Authors’ Judgments About Each Risk of Bias Item Presented as Percentages Across All Included Studies eFigure 3. Standardized Posttest Effect Sizes of Comparisons Between Investigated Psychotherapies and Control Conditions on Borderline Relevant Outcomes for a) Stand-alone Designs and b) Add-on Designs eFigure 4. Standardized Follow-up Effect Sizes of Comparisons Between Investigated Psychotherapies and Control Conditions on Borderline Relevant Outcomes for All Trials eFigure 5. Effects of Trial Risk of Bias (Number of Sources Rated as Low Risk) Posttest Borderline Relevant Outcomes: Meta-regression Analysis eFigure 6. Funnel Plots for Borderline Relevant Outcomes for a) Posttest (With Imputed Trials) and b) Follow-up (With Imputed Trials) eTable 1. Selected Characteristics of Included Studies eTable 2. Classification of Trial Characteristics as Used in the Subgroup and Meta-Regression Analysis This supplementary material has been provided by the authors to give readers additional information about their work.
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eMethods. Supplemental Methods Complete search string Pubmed: “borderline personality” Filter: Clinical trials Date: November 6th 2015; Hits: 230 Risk of bias (RoB) and data extraction Selective outcome reporting was not rated since inspection of the reports of the included trials revealed that only 6 out of 33 reported a trial registration number, 1 had a previously published protocol, and another referred to an unpublished one. Since trial registration is only the first step in looking at information for selective outcome reporting, we would have most likely been in the situation of rating most trials as unclear. The earliest of the six registered trials was conducted in 2008. We also computed Cohen’s Kappa inter-rater agreement for each of the four domains of the Cochrane Risk of Bias tool, prior to resolving disagreements. The Kappa inter-rater agreement coefficients were 0.88 for sequence generation, 0.95 for concealment of allocation, 0.90 for blinding for outcome assessors and 0.83 for dealing with incomplete data, showing high inter-rater agreement even prior to resolving disagreements. Handling of dichotomous data
Dichotomous data was handled staying as true to the intent-to-treat (ITT) principle as possible. For dichotomous symptom outcomes (e.g., number of patients with self-harm, suicide attempts or hospitalizations), we used the imputed or observed number of patients with the event, reported in the original article (e.g., how many participants attempted suicide or were hospitalized in each group). In calculating group rates for the event, we reported this number to the total number of participants randomized in that group. Specifically, in the cases where the authors of the original trial performed imputation themselves to account for missing data, we used their imputed data. However, in the cases where they just provided the observed count for an event (e.g., how many hospitalized or with suicide attempts), we made sure that this number was reported to the number of participants initially randomized in the group in question (and not the number of participants who stayed in treatment or whom the authors for various reasons decided to retain in their analysis).
Drop-outs are a particular case of dichotomous outcome, because in this case it was generally possible to reconstruct patient level data. Drop-outs were defined as any participant who did not finish treatment., regardless of the reasons. We perused the report of the trial for all the information available regarding drop-outs post-randomization (the PRISMA diagram, information in the text and tables) so as to “reconstruct” the exact number of drop-outs. Again, this number was reported to the total number of randomized participants in each group.
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eReferences. List of studies included in the meta-analysis
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2. Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry. 1999;156(10):1563-1569. doi:10.1176/ajp.156.10.1563.
3. Bateman A, Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry. 2009;166(12):1355-1364. doi:10.1176/appi.ajp.2009.09040539.
4. Blum N, St John D, Pfohl B, et al. Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up. Am J Psychiatry. 2008;165(4):468-478. doi:10.1176/appi.ajp.2007.07071079.
5. Bos EH, van Wel EB, Appelo MT, Verbraak MJPM. A randomized controlled trial of a Dutch version of systems training for emotional predictability and problem solving for borderline personality disorder. J Nerv Ment Dis. 2010;198(4):299-304. doi:10.1097/NMD.0b013e3181d619cf.
6. Carter GL, Willcox CH, Lewin TJ, Conrad AM, Bendit N. Hunter DBT project: randomized controlled trial of dialectical behaviour therapy in women with borderline personality disorder. Aust N Z J Psychiatry. 2010;44(2):162-173. doi:10.3109/00048670903393621.
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9. Davidson K, Norrie J, Tyrer P, et al. The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial. J Pers Disord. 2006;20(5):450-465. doi:10.1521/pedi.2006.20.5.450.
10. Doering S, Hörz S, Rentrop M, et al. Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial. Br J Psychiatry. 2010;196(5):389-395. doi:10.1192/bjp.bp.109.070177.
11. Farrell JM, Shaw IA, Webber MA. A schema-focused approach to group psychotherapy for outpatients with borderline personality disorder: a randomized controlled trial. J Behav Ther Exp Psychiatry. 2009;40(2):317-328. doi:10.1016/j.jbtep.2009.01.002.
12. Gratz KL, Gunderson JG. Preliminary data on an acceptance-based emotion regulation group intervention for deliberate self-harm among women with
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borderline personality disorder. Behav Ther. 2006;37(1):25-35. doi:10.1016/j.beth.2005.03.002.
13. Gratz KL, Tull MT, Levy R. Randomized controlled trial and uncontrolled 9-month follow-up of an adjunctive emotion regulation group therapy for deliberate self-harm among women with borderline personality disorder. Psychol Med. 2014;44(10):2099-2112. doi:10.1017/S0033291713002134.
14. Gregory RJ, Chlebowski S, Kang D, et al. A controlled trial of psychodynamic psychotherapy for co-occurring borderline personality disorder and alcohol use disorder. Psychotherapy (Chic). 2008;45(1):28-41. doi:10.1037/0033-3204.45.1.28.
15. Jørgensen CR, Freund C, Bøye R, Jordet H, Andersen D, Kjølbye M. Outcome of mentalization-based and supportive psychotherapy in patients with borderline personality disorder: a randomized trial. Acta Psychiatr Scand. 2013;127(4):305-317. doi:10.1111/j.1600-0447.2012.01923.x.
16. Kamalabadi MJ, Ahmadi SA, Etemadi O, Fatehizadeh M, Bahrami F, Firoozabadi A. A study of the effect of couple dialectical behavioral therapy on symptoms and quality of marital relationships and mental health of Iranian borderline personality couples: A controlled trial. SOURCE Interdisciplinary Journal of Contemporary Research in Business. 3(9):1480-1487.
17. Koons CR, Robins CJ, Lindsey Tweed J, et al. Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy. 2001;32(2):371-390. doi:10.1016/S0005-7894(01)80009-5.
18. Kramer U, Berger T, Kolly S, et al. Effects of motive-oriented therapeutic relationship in early-phase treatment of borderline personality disorder: a pilot study of a randomized trial. J Nerv Ment Dis. 2011;199(4):244-250. doi:10.1097/NMD.0b013e3182125d19.
19. Kramer U, Kolly S, Berthoud L, et al. Effects of motive-oriented therapeutic relationship in a ten-session general psychiatric treatment of borderline personality disorder: a randomized controlled trial. Psychother Psychosom. 2014;83(3):176-186. doi:10.1159/000358528.
20. Leppänen V, Hakko H, Sintonen H, Lindeman S. Comparing Effectiveness of Treatments for Borderline Personality Disorder in Communal Mental Health Care: The Oulu BPD Study. Community Ment Health J. 2016;52(2):216-227. doi:10.1007/s10597-015-9866-4.
21. Linehan MM, Dimeff LA, Reynolds SK, et al. Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug Alcohol Depend. 2002;67(1):13-26.
22. Linehan MM, Armstrong HE, Suarez A, Allmon D, Heard HL. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry. 1991;48(12):1060-1064.
23. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757-766. doi:10.1001/archpsyc.63.7.757.
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24. Linehan MM, Schmidt H, Dimeff LA, Craft JC, Kanter J, Comtois KA. Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. Am J Addict. 1999;8(4):279-292.
25. McMain SF, Links PS, Gnam WH, et al. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. Am J Psychiatry. 2009;166(12):1365-1374. doi:10.1176/appi.ajp.2009.09010039.
26. Munroe-Blum H, Marziali E. A Controlled Trial of Short-Term Group Treatment for Borderline Personality Disorder. Journal of Personality Disorders. 1995;9(3):190-198. doi:10.1521/pedi.1995.9.3.190.
27. Pascual JC, Palomares N, Ibáñez Á, et al. Efficacy of cognitive rehabilitation on psychosocial functioning in Borderline Personality Disorder: a randomized controlled trial. BMC Psychiatry. 2015;15:255. doi:10.1186/s12888-015-0640-5.
28. Priebe S, Bhatti N, Barnicot K, et al. Effectiveness and cost-effectiveness of dialectical behaviour therapy for self-harming patients with personality disorder: a pragmatic randomised controlled trial. Psychother Psychosom. 2012;81(6):356-365. doi:10.1159/000338897.
29. Reneses B, Galián M, Serrano R, et al. A new time limited psychotherapy for BPD: preliminary results of a randomized and controlled trial. Actas Esp Psiquiatr. 2013;41(3):139-148.
30. Soler J, Pascual JC, Tiana T, et al. Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: a 3-month randomised controlled clinical trial. Behav Res Ther. 2009;47(5):353-358. doi:10.1016/j.brat.2009.01.013.
31. Turner RM. Naturalistic evaluation of dialectical behavior therapy-oriented treatment for borderline personality disorder. Cognitive and Behavioral Practice. 2000;7(4):413-419. doi:10.1016/S1077-7229(00)80052-8.
32. Verheul R, Van Den Bosch LMC, Koeter MWJ, De Ridder MAJ, Stijnen T, Van Den Brink W. Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in The Netherlands. Br J Psychiatry. 2003;182:135-140.
33. Weinberg I, Gunderson JG, Hennen J, Cutter CJ. Manual assisted cognitive treatment for deliberate self-harm in borderline personality disorder patients. J Pers Disord. 2006;20(5):482-492. doi:10.1521/pedi.2006.20.5.482.
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eFigure 1. Flowchart of Selection and Inclusion Process, Following the PRISMA Statement
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eFigure 2. Risk of Bias Graph: Review Authors’ Judgments About Each Risk of Bias Item Presented as Percentages Across All Included Studies
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eFigure 3. Standardized Posttest Effect Sizes of Comparisons Between Investigated Psychotherapies and Control Conditions on Borderline Relevant Outcomes for a) Stand-alone Designs and b) Add-on Designs
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eFigure 4. Standardized Follow-up Effect Sizes of Comparisons Between Investigated Psychotherapies and Control Conditions on Borderline Relevant Outcomes for All Trials
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eFigure 5. Effects of Trial Risk of Bias (Number of Sources Rated as Low Risk) Posttest Borderline Relevant Outcomes: Meta-regression Analysis
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eFigure 6. Funnel Plots for Borderline Relevant Outcomes for a) Posttest (With Imputed Trials) and b) Follow-up (With Imputed Trials)
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eTable 1. Selected Characteristics of Included Studies
Study Popula Recra % Fa
Txb Ctrb Nr txc
% md txd
% md ctrd
Th supe
Outcomef Tx (m)g
Nseg FU Typeg
FU (m)g
COh
Amianto, 2011
BPD (SCID) & heavy MHS use
MH outpat (>1 yr tr)
49 SB-APP+ STM
STM 18 100 100 Dev CGI; CGI-BPD; SCL-90-R; clin rec (SH, SU)
11 40 Supp Tx
6, 12
IT
Bateman, 1999
BPD (SCID) & DIB >7
Tx unit in gen psych serv
58 MBT-PH
SPT (outpat)
22 94 89 Dev SSHI; SCL-90-R; BDI; STAI-T; clin rec (SU)
18 312 Tx: Outpat GT Ctr: SPT
6, 12, 18
UK
Bateman, 2009
BPD (SCID) & suicide attempt/ life-threat SH last 6 ms
Spec PD serv
80 MBT (outpat)
SCM 71 78 68 Dev SSHI; SCL-90-R; BDI; clin rec (SH, SU)
18 92 - - UK
Blum, 2008 BPD (SCID)
Psych serv in- & outpat, MHC
83 STEPPS+TAU
TAU 93 65 56 Dev BESO; ZRSB; CGI; SCL-90-R
5 20 Nat 12 US
Bos, 2010 BPD (PDQ-4 & SCID)
Non-acad outpat MHC
82 STEPPS+ Indiv Tx
TAU (Indiv Tx)
45 60 62 Oth BPD-40; BPDSI-IV; SCL-90; CI (SU)
4 23 Tx: STEPPS Ctr: Nat
6 NL
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Carter, 2010 BPD (CI) & >3 SH ep last 12 ms
GPs, psych, MHS
100 DBT TAU+WL
38 - - Oth PHI-2 6 - - - AU
Clarkin, 2007
BPD (IPDE)
MHC, PP, self-ref
92 DBT; TFP
ST 61 70; 52
65 Dev ND ES calc
12 52; 96
- - US
Cottraux, 2009
BPD (MINI) & DIB-R>8
Outpat acad hosp
77 CT RST 33 73 81 Dev SHBCL; CGI; HAMD; BDI; BAI
12 36 Nat 12 FR
Davidson, 2006
BPD (SCID) & inpat psych or AE serv/SH ep last 12 ms
Comm MHC, clin psy & liason psych serv
84 CBT+ TAU
TAU 54 - - Dev ADSHI; BSI; BDI-II; STAI-T; clin rec (SU)
12 16 Nat 6, 12
UK
Doering, 2010
BPD (SCID)
Outpat acad unit
100 TFP ECP 52 62 48 Dev train
SCID; CISSB; BSI; BDI; STAI-T; CRTHI
12 48.5 - - DE
Farrell, 2009 BPD (DIBP-R & BSI) & tx ~6 ms
Psy, th, MHC, acad outpat clin
100 SFT+ TAU
TAU 16 100 100 Dev BDSI; DIB-R; SCL-90
8 30 Nat 6 US
Gratz, 2006 BPD (SCID), DIB-R>8 & 1 SH
BPD hosp unit, PP, self-ref
100 ERG+ TAU
TAU+WL
14 - - - BEST; DSHI; DASS-D; DASS-A
3 14 - - US
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ep last 6 ms
Gratz, 2014 BPD/subth BPD (SCID, DIPD-IV) & 1 SH ep last 6 ms
Comm ad, clinician- & self-ref
100 ERG+ TAU
TAU+WL
31 - - Dev BESOT; ZRSB; DSHI; SHI; BDI-II; DASS-D; DASS-A
3 14 Tx: Nat Ctr: ERG
9 US
Gregory, 2008
BPD (SCID) & alcohol abuse, depend
AE, MHC, rehab, inpat psych unit
80 DDP TAU 15 67 60 Dev BESOT; LPC; BDI; THI
12 48 - - US
Jorgensen, 2013
BPD (SCID)
Psych units, PP, outpat clin
96 MBT ST 74 70 68 Dev train
SCID; GAF-S; SCL-90-R; BDI; BAI; STAI-T
24 152 - - DK
Kalamabadi, 2012
BPD (BPDSI-IV) mar
Psych 0 DBT-C WL 15 - - - ND ES calc
3 14 - - IR
Koons, 2001 BPD (SCID) veteran
VA med cent
100 DBT TAU 14 - - Oth SCID; BSSI; PHI; BHS; BDI; HAMD; HAMA; THI
6 50.9 - - US
Kramer, 2011
BPD (SCID)
Outpat 76 MOTR+TAU
TAU 11 82 86 Oth OQ 2.5 10 - - CH
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Kramer, 2014
BPD (SCID)
Acad outpat psych clin
69 MOTR+GPM
GPM 42 58 61 Oth BSL-23; OQ
3 8.77 - - CH
Leppänen, 2016
BPD (SCID) & severe sympt
MH units
86 SFT+ DBT
TAU 24 - - Oth BPDSI-IV;
12 80 - - FIN
Linehan, 1991
BPD (DSM-III), DIB>7, 2 SH ep last 5 yrs (1 last 8 wk)
Clin ref 100 DBT TAU 24 - - Dev PHI; THI 12 104 Nat (11 pat DBT)
6, 12
US
Linehan, 1999
BPD (SCID, IPDE) & SUD (SCID)
Clin ref 100 DBT TAU 12 8 13 Dev ND ES calc
12 43.1 Nat 4 US
Linehan, 2002
BPD (SCID, IPDE) & heroin addict
MHC, addict clin, HIV NPs
100 DBT CVT+ 12-Step
12 - - Dev ND ES calc
12 59.8 Nat 4 US
Linehan, 2006
BPD (SCID, IPDE), 2 suicide/SH ep last 5 yrs (1 last 8 wk)
- 100 DBT CTBE 60 87 90 - SASII; SBQ; HAMD; THI
12 80.5 Nat 12 US
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Monroe-Blum, 1995
BPD (DIB >7)
Inpat & outpat psych unit
81 IGP TAU 59 - - Dev ND ES calc
8.5 30 Nat 12, 24
CA
McMain, 2009
BPD (SCID), 2 suicide/SH ep last 5 yrs (1 last m)
- 92 DBT GPM 90 - - Dev train
ZRSB; SASII; SCL-90-R; BDI; THI
12 58 Nat 6, 12, 18, 24
CA
Pascual, 2015
BPD (SCID, DIB-R)
Hosp outpat
74 CR PE 36 75 68 - BSL-23; MADRS; HAMA
4 32 Nat 6 ES
Priebe, 2012 PD (SCID) (all but 1 BPD) & > 5 days SH
DBT serv ref
88 DBT TAU 40 - - - ZRSB; CI (SH); BPRS; BSI; CSRI
12 42.2 - - UK
Reneses, 2013
BPD (SCID)
Hosp outpat
70 PFPR+TAU
TAU 25 100 100 - ZRSB; CGI; SCL-90; MADRS; STAI-S
5 20 - - ES
Soler, 2009 BPD (SCID, DIB-R)
Outpat & AE serv
83 DBT-ST SGT 30 83 80 - CGI-BPD; BPRS; SCL-90-R; HAMD; HAMA
3 13 - - ES
Turner, 2000 BPD (SCID, DIB)
AE serv, outpat MHC
79 DBT CCT 12 67 92 - BSSI; SH Likert BPRS; HAMD;
12 49-84
- - US
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BDI; BAI; clin rec (SH, suicide, SU)
Verheul, 2003
BPD (SCID, PDQ)
Addictpsych & MH clin, PP
100 DBT TAU 31 - - Dev train
BPDSI-IV; LPC; THI
12 52 Nat 6 NL
Weinberg, 2006
BPD (DSM-IV, DIB-R) & 1 SH ep last m
Comm ad, hosp clin serv, PD study
100 MACT+TAU
TAU 15 47 60 Dev PHI; SBQ
2 6 Nat 6 US
Note. a Popul, population; Recr, recruitment; Acad, academic; Ad, advertisement; Addict, addiction; AE, accident and emergency; BPD, borderline personality disorder; BSI, Borderline Syndrome Index; CI, clinical interview; Clin, clinic/clinical; Comm, community; Depend, dependence; DIB/DIB-R, Diagnostic Interview for Borderline Personality Disorders (R-Revised); DIBP-R, Diagnostic Interview for Borderline Patients Revised; DIPD-IV, Diagnostic Interview for DSM-IV Personality Disorders DSM-IV, Diagnostic and Statistical Manual IV; Ep, episode; F, female; Gen, general; GP, general practitioner; Hosp, hospital; Inpat, inpatient; Interv, interview; IPDE, International Personality Disorder Examination; Mar, married; MHC, mental health center; MHS, mental health service; Min, minimum; MINI, Mini International Neuropsychiatric Interview; M, month; NP, no profit; Outpat, outpatient; PD, personality disorder; PDQ-4, Personality Diagnostic Questionnaire, DSM-IV; PP, private practice; Psych, psychiatry; Psy, psychologist; Ref, referral; SCID, Structured Clinical Interview for DSM; Serv, service; SH, self-harm; Spec, specialist; Subth, subthreshold; SUD, Substance Use Disorder; Sympt, symptomatology; Ther, therapist; Threat, threatening; Tr, treatment; Tx, psychotherapy; VA, Veteran Affairs; Wk, week; Yr, year. b CBT, Cognitive Behavior Therapy; CCT, Client Centered Therapy; CR, Cognitive Rehabilitation; CT, Cognitive Therapy; CTBE, Community Treatment by Experts; Ctr, control; CVT, Comprehensive Validation Therapy; DBT, Dialectical Behaviour Therapy (ST – Skills Training; C-couples); DDP, Dynamic Deconstructive Psychotherapy; ECP, Expert Community Psychotherapists; ERG, Emotional Regulation Group Intervention; GPM, General Psychiatric Management; IGP, Interpersonal Group Psychotherapy; Indiv, individual; MACT, Manual Assisted Cognitive Treatment; MBT, Mentalization-based treatment (PH – partial hospitalization);
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MOTR, Motive-oriented therapeutic relationship; Outpat, outpatient; PE, Psychoeducation; PFPR, Psychotherapy Focused on Psychic Representation; PMR, Progressive muscle relaxation; RST, Rogersian Supportive Therapy; SB-APP, Sequential Brief Adlerian Psychodynamic Psychotherapy; SCM, Structured Clinical Management; SFT, Schema Focused Therapy; SGT, Standard Group Treatment; SPT, Standard Psychiatric Care; ST, Supportive Therapy (group); STEPPS, Systems Training for Emotional Predictability and Problem Solving; STM, Supervised Team Management; TAU, treatment as usual; TFP, Transference Focused Psychotherapy; Tx, psychotherapy; WL, Waiting list. c Nr, Number randomized; d % md, Proportion of patients taking medication at baseline (if no overall group estimation was give, the estimation used was for the drug class taken by the largest proportion of participants); Tx, psychotherapy; Ctr, control e Th sup, therapist supervision; Dev, developer; Dev train, therapist trained by developer; Oth, other; fADSHI, Acts of Deliberate Self-Harm Inventory; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; BDI-II, Beck Depression Inventory – II; BDSI, Borderline Syndrome Index; BESOT, Borderline Evaluation Scale Over Time; BEST, Borderline Evaluation of Severity over time; BHS, Beck Hopelessness Scale; BPD-40, Borderline Personality Disorder checklist-40; BPDSI-IV, Borderline Personality Disorder Severity Index; BPRS, Brief Psychiatric Rating Scale; BSI, Brief Symtom Inventory (GSI-Global Severity Index; PST- Positive Symptom Total; PSDI-Positive Symptom Distress Index); BSL-23, Borderline Symtom List; BSSI, Beck Scale for Suicide Ideation; CGI/CGI-BPD, Clinical Global Impression (BPD – Modified for Borderline Personality Disorder); CISSB, Cornell Interview for Suicidal and Self-Harming Behavior – Self Report; Clin rec, clinical record; CRTHI, Cornell Revised Treatment History Inventory; CSRI, Client Service Receipt Inventory; DASS, Depression Anxiety Stress Scales; DIB-R, Diagnostic Interview for Borderline Personality Disorders-Revised; DIPD-IV, Diagnostic Interview for DSM-IV Personality Disorders; DSHI, Deliberate Self-Harm Inventory; GAF-S, Global Assessment of Functioning (symptoms); HAMA – Hamilton Rating Scale for Anxiety; HAMD – Hamilton Rating Scale for Depression; LPC, Lifetime Parasuicide Count; MADRS – Montgomery-Asberg Depression Rating Scale; ND ES calc, no data for effect size calculation; OQ, Outcome Questionnaire; PHI, Parasuicide History Interview; PHI-2, Parasuicide History Interview–3 month period; SASII, Suicide Attempt Self-Injury Interview; SBQ, Suicidal Behaviors Questionnaire; SCID – Structured Clinical Interview for DSM; SCL-90-R, Symptom Checklist-90 Revised; SH, Self-harming; SHBCL, Self-harm behaviors checklist; SHI, Self-harm inventory; SSHI, Suicide and Self-Harm Inventory; STAI-S, State Trait Anxiety Inventory – State; STAI-T, State Trait Anxiety Inventory – Trait; SU, service use; THI, Treatment History Interview; ZRSB, Zanarini Rating Scale for Borderline. g Ctr, control; DBT, Dialectical Behaviour Therapy; ERG, Emotional Regulation Group Intervention; FU, follow-up; M, months; Nat, naturalistic; Nse, number of sessions; Outpat GT, Outpatient Groupt Treatment; Pat, patients; SPT, Standard Psychiatric Care; Supp, supportive; STEPPS, Systems Training for Emotional Predictability and Problem Solving; Tx, psychotherapy.
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h AU, Australia; CA, Canada; CH, Switzerland; CO, Country of provenance; DE, Germany; DK, Denmark; ES, Spain; FIN, Finland; FR, France; IR, Iran; IT, Italy; NL, Netherlands; UK, United Kingdom; US, United States of America.
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eTable 2. Classification of Trial Characteristics as Used in the Subgroup and Meta-Regression Analysis Study Design Therapy
typea Ctrl groupa
Ctrl manuala
Study team treating ctrl groupa
Treatment devel trial authora
Therapy superva
RoBa Treatment duration for treatment group (h)
Treatment duration for ctrl group (h)
Difference in treatment duration (h)b
Amianto, 2011
Add-on PDT TAU N Y Y Devel 2 40 40 0
Bateman, 1999
Stand-alone
PDT TAU N N Y Devel 0 470 120 350
Bateman, 2009
Stand-alone
PDT Ad hoc Y Y Y Devel 4 92 84 8
Blum, 2008
Add-on CBT TAU N N Y Devel 2 40 0 40
Bos, 2010 Add-on CBT TAU N N N Other 0 23 9 14 Carter, 2010
Stand-alone
DBT TAU N N N - 3 - - -
Cottraux, 2009
Stand-alone
CBT ST Y Y Y Devel 3 36 36 0
Davidson, 2006
Add-on CBT TAU N N Y Devel 3 16 0 16
Doering, 2010
Stand-alone
PDT TAU N N N Other 3 40.42 18.6 21.82
Farrell, 2009
Add-on Otherc TAU N N Y Other 1 - - 45
Gratz, 2006
Add-on Otherc TAU N N Y - 1 50.4 41.3 9.1
Gratz, 2014
Add-on Otherc TAU N N Y Devel 2 37.8 35 2.78
Gregory, 2008
Stand-alone
PDT TAU N N Y Devel 2 42.84 73.3 -30.46
Jorgensen, Stand- PDT ST Y Y N Other 1 174 72 102
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2013 alone Koons, 2001
Stand-alone
DBT TAU N N N Other 1 66.95 34.4 32.55
Kramer, 2011
Add-on Otherc Ad hoc Y Y Y Other 4 10 10 0
Kramer, 2014
Add-on Otherc Ad hoc Y Y Y Devel 3 8.77 8.86 -0.09
Leppänen, 2016
Stand-alone
Otherc TAU N N N Other 2 100 - -
Linehan, 1991
Stand-alone
DBT TAU N N Y Devel 1 182 - -
Linehan, 2006
Stand-alone
DBT Ad hoc N Y Y - 2 137.5 33 104.5
McMain, 2009
Stand-alone
DBT Ad hoc Y Y N Other 4 84 31 53
Pascual, 2015
Stand-alone
Other Ad hoc Y Y Y - 3 64 32 32
Priebe, 2012
Stand-alone
DBT TAU N N N - 3 42.2 12.1 30.1
Reneses, 2013
Add-on PDT TAU N N Y - 1 - - 15
Soler, 2009
Stand-alone
DBT Ad hoc - Y N - 2 26 26 0
Turner, 2000
Stand-alone
DBT ST Y Y N - 1 - - -
Verheul, 2003
Stand-alone
DBT TAU N N N Other 1 182 26 156
Weinberg, 2006
Add-on CBT TAU N N N Devel 1 - - 6
Note. a CBT, Cognitive Behavior Therapy; ctrl, control; DBT, Dialectical Behaviour Therapy; devel, developer; PDT, Psychodynamic Therapy; RoB, rating of Bias; TAU, treatment as usual; ST, supportive therapy; superv, supervisor.
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b Represents the difference of treatment duration between the therapy and the control group, measured in hours – a positive score indicates treatment duration was longer for the treatment group. c Therapies classified as other included (in this order): Schema Focused Therapy (SFT), Emotion Regulation Group Intervention, Motive-oriented therapeutic relationship, SFT+DBT
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