Assessing the Effectiveness of Treatments of Personality Disorders in the Community

Author(s)Anvesh Jalasutram, MD, Ayse Coskun, MD, Haley Schuster, MD

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Key Takeaways

Community-based psychosocial interventions effectively reduce symptoms of borderline personality disorder, anxiety, depression, and global psychiatric symptoms compared to treatment as usual or waitlist controls.
Cognitive behavior therapy, dialectical behavior therapy, and psychodynamic psychotherapy showed significant efficacy in treating personality disorder symptoms.
The effectiveness of interventions was consistent regardless of type, duration, or intensity, supporting their use in community settings.
Meta-regression analysis found no significant association between intervention type or duration and effectiveness, highlighting the broad applicability of these treatments.

Patients with personality disorders would benefit from therapy regardless of modality, duration, or intensity.

TRANSLATING RESEARCH INTO PRACTICE

Rajesh R. Tampi, MD, MS, DFAPA, DFAAGP, Column Editor

A monthly column dedicated to reviewing the literature and sharing clinical implications.

The treatment of personality disorders is often met with the critique that there is limited access to quality care. This systematic review and meta-analysis included 54 studies with 3716 participants who received treatment in the community for a personality disorder. The aim was to clarify the effectiveness of psychosocial interventions used to treat personality disorders implemented in outpatient and community settings.

The Study

Katakis P, Schlief M, Barnett P, et al. Effectiveness of outpatient and community treatments for people with a diagnosis of ‘personality disorder’: systematic review and meta-analysis. BMC Psychiatry. 2023;23(1):57.

Study Funding

This study was funded by the National Institute for Health and Care Research Policy Research Programme.

Study Objectives

To examine the effectiveness of community psychological and psychosocial interventions in treating personality disorders.

Study Strengths

1. This is a large review that included 54 studies and more than 3700 individuals. Individuals with any personality disorder were included. Individuals not formally diagnosed with a personality disorder but who had comparable needs were also included. Secondary outcomes of depressive, anxiety, and global psychiatric symptoms were included. There were no conflicts of interest reported by the authors.

Study Limitations

1. Most of the studies included were conducted with participants with BPD.

2. Males were underrepresented in most of the studies. Ethnic minority individuals were underrepresented. Most studies had small sample sizes. High heterogeneity was noted in some of the meta-analyses.

Methodology

This meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered on PROSPERO (CRD42019143165). It was based on a subset of high-quality randomized controlled trials (RCTs) derived from a broader scoping review. The systematic search covered MEDLINE, Embase, PsycInfo, CINAHL, HMIC, and ASSIA for English-language RCTs published up to November 23, 2020, focusing on interventions for complex emotional needs (CEN) in community or outpatient settings. The analysis used random-effects models to evaluate primary outcomes (personality disorder symptoms) and secondary outcomes (anxiety, depression, and global psychiatric symptoms). The effects of interventions on the outcomes were compared with treatment as usual or waitlist (TAU/WL). Meta-regression assessed the impact of treatment characteristics, and study quality and publication bias were evaluated. Note that CEN is used interchangeably with personality disorder to address concerns about diagnostic validity and stigma.

Study Results

Regarding personality disorder symptoms, no statistically significant difference was found in any interventions vs active or nonactive controls. However, there was weak evidence in favor of interventions when compared with nonactive controls.

Regarding borderline personality disorder (BPD) symptoms, 23 comparisons were analyzed. Cognitive behavior therapy (CBT; K = 6; g = 0.89; 95% CI, 0.42-1.36; P = .0002; I² =76.85%), psychodynamic psychotherapy (K = 2; g = 0.69; 95% CI, 0.18-1.21; P = .0085; I² = 0%), and dialectical behavior therapy (DBT; K = 5; g = 0.67; 95% CI, 0.32-1.01; P = .0002; I² = 28.07%) significantly reduced BPD symptoms when compared with TAU/WL. Pooled analysis was as follows: K = 17; g = 0.78; 95% CI, 0.56-1.01; P < .0001; I² = 55.4%.

Regarding anxiety symptoms, 16 comparisons were meta-analyzed; CBT (K = 6; g = 0.65; 95% CI, 0.08-1.23; P = .0255; I² = 79.29%) and DBT (K = 2; g = 0.87; 95% CI, 0.28-1.47; P = .004; I² = 0%) significantly reduced anxiety symptoms compared with TAU/WL, whereas psychodynamic psychotherapy did not significantly reduce anxiety symptoms compared with TAU/WL. Pooled analysis was as follows: K = 12; g = 0.58; 95% CI, 0.21-0.95; P = .002; I² = 75.29%. The study results also found that the studied interventions were not more effective when compared with active control interventions.

Regarding depressive symptoms, 23 comparisons were meta-analyzed; CBT (K = 7; g = 0.55; 95% CI, 0.23-0.88; P = .0009; I² = 54.88%), DBT (K = 4; g = 0.53; 95% CI, –0.06 to 1.13; P = .08; I² = 68.39%), and psychodynamic psychotherapy (K = 2; g = 0.54; 95% CI, 0.03-1.05; P = 0.04; I² = 0%) were significantly effective compared with TAU/WL. Pooled analysis was as follows: K = 16; g = 0.57; 95% CI, 0.32-0.83; P < .0001; I² = 67.94%. The study results also found strong evidence that therapeutic interventions are more effective when compared with TAU/WL at 13 to 18 months (K = 2; g = 0.99; 95% CI, 0.42-1.57; P = .0007; I² = 0%) but (marginally statistically significantly) less effective at more than 18 months (K = 3; g = –0.24; 95% CI, –0.48 to 0.01; P = .055; I² = 19.59%).

Regarding global psychiatric symptoms, 36 comparisons were meta-analyzed; CBT (K = 7; g = 0.45; 95% CI, 0.21-0.69; P = .0002; I² = 31.43%), DBT (K = 5; g = 0.36; 95% CI, 0.05-0.67; P = .02; I² = 31.91%), and psychodynamic psychotherapy (K = 4; g = 0.50; 95% CI, 0.14-1.05; P = .86; I² = 34.35%) were more effective than TAU/WL. Pooled analysis was as follows: K = 25; g = 0.50; 95% CI, 0.35-0.66; P < .0001; I² = 48.56%. The study results also found that interventions are equally effective when compared with active control interventions at all time intervals.

Finally, meta-regression analysis was conducted, which revealed no significant association between the type or duration of intervention and intervention effectiveness for any outcome.

Conclusions

This systematic review and meta-analysis included 54 studies. It found that interventions in the community, regardless of type, duration, or intensity, were more effective at treating BPD, anxiety, depression, and global psychiatric symptoms when compared with TAU/WL.

Practical Application

Personality disorders are common across the entire spectrum of psychiatric care and present an important therapeutic target. Findings from this study show us that patients with complex emotional needs would benefit from being provided with community psychological/ psychosocial interventions regardless of treatment duration, modality, or intensity.

Bottom Line

Patients with CEN/personality disorders would benefit from therapy regardless of modality, duration, or intensity, and providers should feel encouraged to engage in brief psychotherapy or make referrals for psychological/psychosocial interventions when appropriate to best serve their patients.

Dr Jalasutram is a second-year psychiatry resident at Creighton University in Omaha, Nebraska. Dr Coskun is a first-year psychiatry resident at Creighton University. Dr Schuster is a fourth-year psychiatry resident at Creighton University. Dr Mullen is an assistant professor of psychiatry at Saint Louis University School of Medicine in Missouri. Dr Tampi is professor and chair of the Department of Psychiatry at Creighton University School of Medicine and Catholic Health Initiatives Health Behavioral Health Services. He is also an adjunct professor of psychiatry at Yale School of Medicine in New Haven, Connecticut, and a member of the Psychiatric Times editorial board.

Reference

1. Katakis P, Schlief M, Barnett P, et al. Effectiveness of outpatient and community treatments for people with a diagnosis of ‘personality disorder’: systematic review and meta-analysis. BMC Psychiatry. 2023;23(1):57.