Cited by 655Personality Disorders and PsychopathologyPsychotherapy Techniques and ApplicationsPsychoanalysis and Psychopathology Research

The DOI matches its Crossref record; 70 of the 72 references it cites were found in a registry or an index; none of the 27 sources its claims cite is checked for support yet.

Efficacy of Psychotherapies for Borderline Personality Disorder: A Systematic Review and Meta-analysis

Open access

Cristea, Ioana A., Gentili, Claudio, Cotet, Carmen D., Palomba, Daniela, Barbui, Corrado, Cuijpers, Pim·2017·JAMA Psychiatry

DOI 10.1001/jamapsychiatry.2016.4287

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Abstract

IMPORTANCE: Borderline personality disorder (BPD) is a debilitating condition, but several psychotherapies are considered effective. OBJECTIVE: To conduct an updated systematic review and meta-analysis of randomized clinical trials to assess the efficacy of psychotherapies for BPD populations. DATA SOURCES: Search terms were combined for borderline personality and randomized trials in PubMed, PsycINFO, EMBASE, and the Cochrane Central Register of Controlled Trials (from database inception to November 2015), as well as the reference lists of earlier meta-analyses. STUDY SELECTION: Included were randomized clinical trials of adults with diagnosed BPD randomized to psychotherapy exclusively or to a control intervention. Study selection differentiated stand-alone designs (in which an independent psychotherapy was compared with control interventions) from add-on designs (in which an experimental intervention added to usual treatment was compared with usual treatment alone). DATA EXTRACTION AND SYNTHESIS: Data extraction coded characteristics of trials, participants, and interventions and assessed risk of bias using 4 domains of the Cochrane Collaboration Risk of Bias tool (independent extraction by 2 assessors). Outcomes were pooled using a random-effects model. Subgroup and meta-regression analyses were conducted. MAIN OUTCOMES AND MEASURES: Standardized mean differences (Hedges g) were calculated using all outcomes reported in the trials for borderline symptoms, self-harm, suicide, health service use, and general psychopathology at posttest and follow-up. Differential treatment retention at posttest was analyzed, reporting odds ratios. RESULTS: Thirty-three trials (2256 participants) were included. For borderline-relevant outcomes combined (symptoms, self-harm, and suicide) at posttest, the investigated psychotherapies were moderately more effective than control interventions in stand-alone designs (g = 0.32; 95% CI, 0.14-0.51) and add-on designs (g = 0.40; 95% CI, 0.15-0.65). Results were similar for other outcomes, including stand-alone designs: self-harm (g = 0.32; 95% CI, 0.09-0.54), suicide (g = 0.44; 95% CI, 0.15-0.74), health service use (g = 0.40; 95% CI, 0.22-0.58), and general psychopathology (g = 0.32; 95% CI, 0.09-0.55), with no differences between design types. There were no significant differences in the odds ratios for treatment retention (1.32; 95% CI, 0.87-2.00 for stand-alone designs and 1.01; 95% CI, 0.55-1.87 for add-on designs). Thirteen trials reported borderline-relevant outcomes at follow-up (g = 0.45; 95% CI, 0.15-0.75). Dialectical behavior therapy (g = 0.34; 95% CI, 0.15-0.53) and psychodynamic approaches (g = 0.41; 95% CI, 0.12-0.69) were the only types of psychotherapies more effective than control interventions. Risk of bias was a significant moderator in subgroup and meta-regression analyses (slope β = -0.16; 95% CI, -0.29 to -0.03; P = .02). Publication bias was persistent, particularly for follow-up. CONCLUSIONS AND RELEVANCE: Psychotherapies, most notably dialectical behavior therapy and psychodynamic approaches, are effective for borderline symptoms and related problems. Nonetheless, effects are small, inflated by risk of bias and publication bias, and particularly unstable at follow-up.

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Written from the paper’s full text.

TL;DR

This updated systematic review and meta-analysis of 33 RCTs (2256 adults with BPD) found that psychotherapies produced small posttest benefits over control for borderline-relevant outcomes (all trials g=0.35; 95% CI, 0.20-0.50), with dialectical behavior therapy and psychodynamic approaches effective. Effects were attenuated by risk of bias and publication bias and became unstable/nonsignificant at follow-up after adjustment.

Key findings

Across 33 trials (2256 participants), posttest borderline-relevant outcomes favored psychotherapy: stand-alone designs g=0.32 (95% CI, 0.14-0.51); add-on designs g=0.40 (95% CI, 0.15-0.65); all trials combined g=0.35 (95% CI, 0.20-0.50; 27 trials).
In stand-alone designs, effects were significant for self-harm g=0.32 (95% CI, 0.09-0.54), suicide g=0.44 (95% CI, 0.15-0.74), health service use g=0.40 (95% CI, 0.22-0.58), and general psychopathology g=0.32 (95% CI, 0.09-0.55); treatment retention was not significantly different (OR, 1.32; 95% CI, 0.87-2.00 for stand-alone; OR, 1.01; 95% CI, 0.55-1.87 for add-on).
Only DBT (g=0.34; 95% CI, 0.15-0.53) and psychodynamic approaches (g=0.41; 95% CI, 0.12-0.69) were significantly more effective than control; CBT (g=0.24; 95% CI, -0.01 to 0.49) and other interventions (g=0.38; 95% CI, -0.15 to 0.92) were not.
Follow-up effects were significant across 13 trials (g=0.45; 95% CI, 0.15-0.75), but risk of bias moderated outcomes (slope β=-0.16; 95% CI, -0.29 to -0.03; P=.02), with low-RoB trials (3-4 domains) showing g=0.11 (95% CI, -0.12 to 0.35) versus g=0.48 (95% CI, 0.33-0.64) for 0-2 domains (P=.01); trim-and-fill reduced posttest g from 0.35 to 0.23 (95% CI, 0.07-0.38) and made follow-up nonsignificant (g=0.19; 95% CI, -0.15 to 0.53).

Methods

Systematic review and meta-analysis of RCTs identified from PubMed, PsycINFO, EMBASE, and Cochrane Central Register of Controlled Trials (inception to November 2015) plus reference lists; included adults with diagnosed BPD randomized to psychotherapy exclusively or to a control intervention, excluding adolescent/partially adolescent samples, head-to-head comparisons of BPD-specific therapies, and trials with standardized combined medication protocols.
Included 33 trials (2256 participants; 1169 treatment, 1087 control): 22 stand-alone and 11 add-on designs; DBT (12 trials), psychodynamic (8), CBT (5); control was TAU in 21 trials and manualized in 10; treatment developer was an author in 20 trials.
Random-effects meta-analysis calculated Hedges g for outcome categories at posttest and follow-up, odds ratios for treatment retention, subgroup and meta-regression analyses, Cochrane risk-of-bias assessment across 4 domains, and publication-bias assessment via funnel plots, trim-and-fill, and Egger test.

Limitations

Stated in the paper: some outcome categories or subgroups included few trials; 5 trials lacked data needed for effect-size calculation; most trials were not registered, so selective outcome reporting could not be rated; the search may have missed trials; therapies were grouped into broad categories, effacing subtler differences; schema-focused therapy was underrepresented; and adjunct medication use was neither standardized nor consistently reported.
Stated in the paper: effects were small, inflated by publication bias, and particularly unstable at follow-up; effects were no longer sustained in trials with low risk of bias.
Evident from the text: heterogeneity was moderate to high across many analyses (e.g., 70% for all-trial follow-up borderline-relevant outcomes and 79% for add-on follow-up), and several key findings rested on small numbers of trials, making some estimates tentative.

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Integrity signals

Registry

Crossref · 10.1001/jamapsychiatry.2016.4287

Cites

70 of 70 references verified0 citation errors · 0 not checkable

Statistics

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Claims the paper makes

0 of 27 cited sources checked · 0 supported · 0 flagged

A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“and 1.01; 95% CI, 0.55-1.87for add-on designs).”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Abstract
Strength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passes
- Rests on an assumption: Treatment retention is a valid indicator of treatment acceptability or effectiveness.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“with no differences between design types.”
- Also stated in: § All Trials · plain
  “There were no significant differences between the 2 design types on any of the symptom outcome categories or on treatment retention.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Abstract
Load-bearingStrength:plain· not yet calibratedn = 2,256
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Thirty-three trials (2256 participants) were included.”
- Also stated in: § Selection and Inclusion of Studies · plain
  “Consequently, 33 trials (2256 participants) met our inclusion criteria, and 28 of them had enough data for calculating effect sizes (eFigure 1 in the”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Abstract
Load-bearingStrength:plain· not yet calibratedn = 2,256
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“while CBT (g = 0.24; 95% CI, -0.01 to 0.49 [5 trials]) and other interventions (g = 0.38; 95% CI, -0.15 to 0.92 [6 trials]) were not.”
- Also stated in: § Discussion · plain
  “Surprisingly, CBT was not superior to control conditions.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Subgroup Analyses
Load-bearingStrength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
- The authors state this as an assumption: Grouping different psychotherapies into broad categories yields meaningful and comparable efficacy estimates.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“while CBT (g = 0.24; 95% CI, -0.01 to 0.49 [5 trials]) and other interventions (g = 0.38; 95% CI, -0.15 to 0.92 [6 trials]) were not.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Subgroup Analyses
Load-bearingStrength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
- The authors state this as an assumption: Grouping different psychotherapies into broad categories yields meaningful and comparable efficacy estimates.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“psychodynamic approaches (g=0.41;95% CI, 0.12-0.69)”
- Also stated in: § Subgroup Analyses · plain
  “The DBT (g=0.34;95% CI, 0.15-0.53[9 trials]) and psychodynamic approaches (g=0.41;95% CI, 0.12-0.69[7 trials]) were more effective than control interventions”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Abstract
Load-bearingStrength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
- The authors state this as an assumption: Grouping different psychotherapies into broad categories yields meaningful and comparable efficacy estimates.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Risk of bias was a significant moderator in subgroup and meta-regression analyses (slope β = -0.16;95% CI,”
- Also stated in: § Meta-regression Analyses · plain
  “Risk of bias (the number of criteria with low RoB) had a significant negative association with outcomes at posttest (slope β = -0.16;95% CI, -0.29 to -0.03; P = .02)(eFigure 5 in the Supplement).”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Abstract
Load-bearingStrength:plain· not yet calibratedCausal:correlational· not yet calibratedn = 2,256
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
- Rests on an assumption: The Cochrane risk-of-bias domains and the summed overall score adequately capture bias in psychotherapy trials.

Show all 60 claims

It may state two separate claims as one. 26
Probably not a substantial claim. 8

A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Thirteen trials reported borderline-relevant outcomes at follow-up (g = 0.45; 95% CI, 0.15-0.75).”
- Also stated in: § All Trials · plain
  “Combining both design types yielded a significant effect (g = 0.45; 95% CI, 0.15-0.75[13 trials]), with high heterogeneity (70%).”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Abstract
Load-bearingStrength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Studies were identified through searches in 4 bibliographical databases”
- Also stated in: § Identification and Selection of Studies · plain
  “We also checked the reference lists of earlier meta-analyses.22,23”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Identification and Selection of Studies
Strength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passes
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
In the paper
“One meta-analysis 22 of DBT for BPD reported moderate effects for borderline-relevant outcomes, suicidality, and self-harm.However, analysis restricted to randomized clinical trials (RCTs) showed reduced effects, with nonsignificance for suicidality and self-harm.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > B
What the sources say
- Not checked yetcites [22]
Strength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passes
It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Trial risk of bias (RoB) was evaluated within 4 domains of the Cochrane Collaboration Risk of Bias tool, 26 which assesses sources of bias in RCTs.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Risk of Bias and Data Extraction
Strength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passes
Probably not a substantial claim. The paper’s conclusions may not depend on it.
- Rests on an assumption: The Cochrane risk-of-bias domains and the summed overall score adequately capture bias in psychotherapy trials.
None of the sources cited for this claim have been checked yet.
In the paper
“Previous metaanalyses of psychotherapeutic treatments for BPD have been scarce and used focused criteria for assessing effectiveness, avoiding combining treatments.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > B
What the sources say
- Not checked yetcites [22]
- Not checked yetcites [23]
Load-bearingStrength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“Moreover, because the study collection dates of the 2 previous meta-analyses 22,23 preceded 2012, new trials or follow-ups of older trials published since then should be considered.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > B
What the sources say
- Not checked yetcites [22]
- Not checked yetcites [23]
Load-bearingStrength:hedged· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
In the paper
“One meta-analysis 60 of treatment completion in BPD reported high treatment completion rates (approximately 75%) but with substantial betweenstudy heterogeneity.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Discussion
What the sources say
- Not checked yetcites [60]
Strength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passes
It may state two separate claims as one.
In the paper
“However, included studies were both observational and controlled trials, randomized or not.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Discussion
What the sources say
- Not checked yetcites [60]
Strength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passes
It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“Instead, they pooled absolute rates for the former, a procedure that is discouraged because it can lead to extremely high levels of heterogeneity.61”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Discussion
What the sources say
- Not checked yetcites [60]
- Not checked yetcites [61]
Strength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passes
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

31 of 31

The paper relies on this without support.
Most trials that showed effectiveness had the treatment developer directly involved.
“However, most trials demonstrating effectiveness were conducted with the direct participation of the treatment developer.”
The authors state this as an assumption.
Grouping different psychotherapies into broad categories yields meaningful and comparable efficacy estimates.
“Conversely, because effectiveness differences between therapies appear to be limited and because variations of the same intervention are to be expected in diverse implementation settings, we believe that a broader effectiveness evaluation grouping therapies into theoretically intelligible categories is germane.”
The paper relies on this without support.
The control conditions across included trials are sufficiently comparable to be pooled as a single control category.
“No constraints were placed on the control group, which could include (but was not restricted to) TAU or other treatments not specifically developed for BPD.”
The paper relies on this without support.
The Cochrane risk-of-bias domains and the summed overall score adequately capture bias in psychotherapy trials.
“Trial risk of bias (RoB) was evaluated within 4 domains of the Cochrane Collaboration Risk of Bias tool, 26 which assesses sources of bias in RCTs.”
The paper relies on this without support.
Treatment retention is a valid indicator of treatment acceptability or effectiveness.
“Treatment retention was computed as the comparative dropout rates between the intervention and control groups.”

5 of 5

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Each contradiction between two passages listed here was confirmed by an independent check.

Follow-up heterogeneity is called high below the paper's stated threshold
Minor
The methods identify 75% as the threshold for high heterogeneity, but the results describe follow-up heterogeneity of 70% as high. The stand-alone follow-up result is likewise called high at 62%.

1 of 1

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Hedges LV, Olkin I. Statistical Methods for Meta-Analysis. Orlando, FL: Academic Press; 1985.

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Authors: Cristea, I. A., Gentili, C., Cotet, C. D., Palomba, D., Barbui, C., & Cuijpers, P.
Affiliations: University of Padua (IT)
Department of Clinical Psychology and Psychotherapy, Babes-Bolyai University, Cluj-Napoca, Romania
University of Verona (IT)
Amsterdam Public Health (NL)
Corresponding author: Cristea, Ioana A.
ORCID: Cristea, Ioana A.
Gentili, Claudio
Palomba, Daniela
Barbui, Corrado
Cuijpers, Pim
Venue: JAMA Psychiatry
Publisher: American Medical Association (AMA)
Published: 2017-04-01
Volume: 74
Issue: 4
Pages: 319
ISSN: 2168-622X (ISSN-L)
DOI: 10.1001/jamapsychiatry.2016.4287
OpenAlex: W2592963919
Semantic Scholar: 464a03e120510e87d9085d8a94d7e412e2f34bbd
Cited by: 655
References: 72
Citations by year: 2026: 48 · 2025: 57 · 2024: 64 · 2023: 60 · 2022: 76 · 2021: 86 · 2020: 102 · 2019: 80 · 2018: 59 · 2017: 22
FWCI: 10.99
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: JAMA Psychiatry (publishedVersion)
PubMed (publishedVersion)
VU Research Portal (publishedVersion, other-oa)
Padua Research Archive (University of Padova) (submittedVersion)
Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
Funders: National Authority for Scientific Research and Innovation
Università degli Studi di Padova
Autoritatea Natională pentru Cercetare Stiintifică
Topics: Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
Keywords: borderline personality disorder, psychotherapy efficacy, dialectical behavior therapy, transference-focused psychotherapy, self-harm, suicide, borderline symptoms, treatment retention, health care utilization, general psychopathology, risk of bias, subgroup analysis, meta-regression, risk of bias in meta-analysis
MeSH terms: Suicide Prevention, Behavior Therapy, Borderline Personality Disorder, Humans, Psychotherapy, Suicide, Randomized Controlled Trials as Topic, Self-Injurious Behavior, Treatment Outcome, Psychotherapy, Psychodynamic

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Efficacy of Psychotherapies for Borderline Personality Disorder: A Systematic Review and Meta-analysis

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