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Crisis interventions for adults with borderline personality disorder

Research output: Contribution to journalArticlepeer-review

Jonathan Monk-Cunliffe, Rohan Borschmann, Alice Monk, Joanna O'Mahoney, Claire Henderson, Rachel Phillips, Jonathan Gibb, Paul Moran

Original languageEnglish
Article numberCD009353
JournalCochrane Database of Systematic Reviews
Volume2022
Issue number9
DOIs
Published26 Sep 2022

Bibliographical note

Funding Information: PM is a Consultant Psychiatrist and clinical academic working in the field of borderline personality disorders and holds an honorary clinical contract with Avon & Wiltshire Partnership Trust (UK). PM reports grants from the Medical Research Council and the National Institute for Health Research (NIHR); both paid to Bristol Medical School, University of Bristol (UK). PM also reports being a named co-investigator on an NIHR grant awarded to Prof Crawford at Imperial College London (UK). Funding Information: RB is funded by an Australian National Health and Medical Research Council (NHMRC) Emerging Leadership-2 Investigator Grant (GNT2008073) Funding Information: We wish to thank the Cochrane Developmental, Psychosocial and Learning Problems (CDPLP) Review Group, specifically Geraldine Macdonald (Co-ordinating Editor), Joanne Duffield (Managing Editor), Sarah Davies (Deputy Managing Editor) and Margaret Anderson (Information Specialist). We also wish to acknowledge the assistance of Oriana Borschmann, who helped with study translation during the original version of this review. RB and JO were funded by a Medical Research Council grant for the original version of this review. The CRG Editorial Team are grateful to the following reviewers for their time and comments: Mike Crawford, Imperial College London (UK); Brian Duncan (USA); and Dr Mark Freestone, Wolfson Institute of Population Health, Queen Mary University of London (UK); and to Julia Turner for copyediting the review. Funding Information: RB, CH, JO and PM were involved in the Borschmann 2013 (JOSHUA) study included in this review; the study was supported by a Medical Research Council (MRC) trial platform grant (ID: 85397), and took place at South London and Maudsley NHS Foundation Trust and King's College London Institute of Psychiatry, Psychology and Neuroscience (UK). The funder had no control over the study design, methods, data analysis and reporting. Funding Information: Funding source: the trial was supported by a Medical Research Council. Authors were partly funded by the NIHR Specialist Biomedical Research Centre for Mental Health at the South London and Maudsley NHS Foundation Trust and King's College London. Funding Information: Funding source: the study was supported by grants from the Mats Paulsson Foundation, the Swedish Research Council, the Swedish National Self-Injury Project, regional research funds (Södra Regionvård-snämnden), the Söderström-Königska Foundation, the Ellen and Henrik Sjöbring Foundation, the OM Persson Foundation and the Maggie Stephens Foundation. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Publisher Copyright: Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

King's Authors

Abstract

Background: People diagnosed with borderline personality disorder (BPD) frequently present to healthcare services in crisis, often with suicidal thoughts or actions. Despite this, little is known about what constitutes effective management of acute crises in this population and what type of interventions are helpful at times of crisis. In this review, we will examine the efficacy of crisis interventions, defined as an immediate response by one or more individuals to the acute distress experienced by another individual, designed to ensure safety and recovery and lasting no longer than one month. This review is an update of a previous Cochrane Review examining the evidence for the effects of crisis interventions in adults diagnosed with BPD. Objectives: To assess the effects of crisis interventions in adults diagnosed with BPD in any setting. Search methods: We searched CENTRAL, MEDLINE, Embase, nine other databases and three trials registers up to January 2022. We also checked reference lists, handsearched relevant journal archives and contacted experts in the field to identify any unpublished or ongoing studies. Selection criteria: Randomised controlled trials (RCTs) comparing crisis interventions with usual care, no intervention or waiting list, in adults of any age diagnosed with BPD. Data collection and analysis: We used standard methodological procedures expected by Cochrane. Main results: We included two studies with 213 participants. One study (88 participants) was a feasibility RCT conducted in the UK that examined the effects of joint crisis plans (JCPs) plus treatment as usual (TAU) compared to TAU alone in people diagnosed with BPD. The primary outcome was self-harm. Participants had an average age of 36 years, and 81% were women. Government research councils funded the study. Risk of bias was unclear for blinding, but low in the other domains assessed. Evidence from this study suggested that there may be no difference between JCPs and TAU on deaths (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.06 to 14.14; 88 participants; low-certainty evidence); mean number of self-harm episodes (mean difference (MD) 0.30, 95% CI −36.27 to 36.87; 72 participants; low-certainty evidence), number of inpatient mental health nights (MD 1.80, 95% CI −5.06 to 8.66; 73 participants; low-certainty evidence), or quality of life measured using the EuroQol five-dimension questionnaire (EQ-5D; MD −6.10, 95% CI −15.52 to 3.32; 72 participants; very low-certainty evidence). The study authors calculated an Incremental Cost Effectiveness Ratio of GBP −32,358 per quality-adjusted life year (QALY), favouring JCPs, but they described this result as "hypothesis-generating only" and we rated this as very low-certainty evidence. The other study (125 participants) was an RCT conducted in Sweden of brief admission to psychiatric hospital by self-referral (BA) compared to TAU, in people with self-harm or suicidal behaviour and three or more diagnostic criteria for BPD. The primary outcome was use of inpatient mental health services. Participants had an average age of 32 years, and 85% were women. Government research councils and non-profit foundations funded the study. Risk of bias was unclear for blinding and baseline imbalances, but low in the other domains assessed. The evidence suggested that there is no clear difference between BA and TAU on deaths (RR 0.49, 95% CI 0.05 to 5.29; 125 participants; low-certainty evidence), mean number of self-harm episodes (MD −0.03, 95% CI −2.26 to 2.20; 125 participants; low-certainty evidence), violence perpetration (RR 2.95, 95% CI 0.12 to 71.13; 125 participants; low-certainty evidence), or days of inpatient mental health care (MD 0.70, 95% CI −14.32 to 15.72; 125 participants; low-certainty evidence). The study suggested that BA may have little or no effect on the mean number of suicide attempts (MD 0.00, 95% CI −0.06 to 0.06; 125 participants; very low-certainty evidence). We also identified three ongoing RCTs that met our inclusion criteria. The results will be incorporated into future updates of this review. Authors' conclusions: A comprehensive search of the literature revealed very little RCT-based evidence to inform the management of acute crises in people diagnosed with BPD. We included two studies of two very different types of intervention (JCP and BA). We found no clear evidence of a benefit over TAU in any of our main outcomes. We are very uncertain about the true effects of either intervention, as the evidence was judged low- and very low-certainty, and there was only a single study of each intervention. There is an urgent need for high-quality, large-scale, adequately powered RCTs on crisis interventions for people diagnosed with BPD, in addition to development of new crisis interventions.

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