Is mentalization‐based therapy effective in treating the symptoms of borderline personality disorder? A systematic review

Probably not a substantial claim: may not pass S3 (load-bearing).

Three studies offered an initial 18-month treatment in a day hospital setting, with an additional 18 months of outpatient maintenance treatment.

“Three studies offered an initial 18‐month treatment in a day hospital setting, with an additional 18 months of outpatient maintenance treatment (Bales et al., 2012, 2015; Bateman & Fonagy, 1999, 2001).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The shortest MBT course was 4 weeks, and the longest duration was up to three years.

“The shortest MBT course was 4 weeks (Brüne et al., 2013; Edel et al., 2017), and the longest duration was up to three years (Kvarstein et al., 2015).”

Probably not a substantial claim: may not pass S3 (load-bearing).

Three studies used MBT-A, mentalization-based therapy specifically adapted for adolescents.

“Three studies used MBT‐A, mentalization‐based‐therapy specifically adapted for adolescents (Bo et al., 2016; Laurenssen, Hutsebaut, et al., 2014; Rossouw & Fonagy, 2012).”

May combine two claims.

The majority of studies specifically recruited participants with a full diagnosis of BPD; only one study did not report this full inclusion criterion (Rossouw & Fonagy, 2012).

“The majority of studies specifically recruited participants with a full diagnosis of BPD; only one study did not report this full inclusion criterion (Rossouw & Fonagy, 2012).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Three studies used adolescent samples; across adult samples, mean ages ranged from 26 to 31.

“Three studies used adolescent samples. Across adult samples, mean ages ranged from 26 to 31.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Attrition rates in BPD samples ranged from 7% to 54%.

“High attrition rates are common in BPD samples: They ranged from 7% to 54%.”

May combine two claims.

Seven baseline and two follow-up studies used SCL-90-R or BSI; all found that MBT significantly reduced overall psychiatric symptoms with effect sizes (d) ranging from 0.59 to 1.79.

“Seven baseline as well as two follow‐up studies used the Symptom Checklist (SCL‐90‐R), or its brief version the BSI, to assess general psychiatric and psychological problems. All studies found that MBT significantly reduced overall psychiatric symptoms with effect sizes (d) ranging from 0.59 to 1.79”

• AssumptionRests on an assumption: The effect sizes reported or calculated across included studies are comparable enough to be synthesized.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The majority of original studies were conducted in day hospital and outpatient settings: four in day hospital, two of which continued outpatient MBT after initial day hospital; three in outpatient; all pilot studies in inpatient settings.

“The majority of the original studies were conducted in day hospital and outpatient settings: Four organized their treatment plans in a day hospital setting (partial hospitalization), two of which continued to offer MBT in an outpatient setting after the termination of the initial day hospital period (Bateman & Fonagy, 1999; Kvarstein et al., 2015). Three other studies were conducted in an”

May combine two claims.

Rossouw and Fonagy (2012) recruited adolescents who self-harmed, unaware that almost 75% of participants would meet BPD diagnostic criteria according to DSM-IV.

“Rossouw and Fonagy (2012) recruited adolescents who self‐harmed, unaware that almost 75% of participants would meet BPD diagnostic criteria according to DSM‐IV.”

• cites Rossouw & Fonagy, 2012Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Only one study offered treatment for 18 months without providing further therapy (Bateman & Fonagy, 2009).

“Only one study offered treatment for 18 months without providing further therapy (Bateman & Fonagy, 2009).”

• cites Bateman & Fonagy, 2009Not checked yet

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May combine two claims.

Seven studies compared MBT to another form of treatment, including supportive group therapy (n=2), standard psychiatric care (n=1), treatment as usual (n=2), traditional psychodynamic treatment, and structured supportive clinical management.

“Seven studies compared MBT to another form of treatment. These include supportive group therapy (SGT) (n = 2), ‘Standard psychiatric care’ (n = 1) or ‘Treatment as usual’ (n = 2) (Bateman & Fonagy, 1999, 2001, 2008; Rossouw & Fonagy, 2012), traditional psychodynamic treatment (Kvarstein et al., 2015), and structured supportive clinical management (SSCM) (Bateman & Fonagy, 2009).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The 14 included studies comprised three randomized control trials, one randomized yet not controlled trial and its 18-month follow-up, one matched control study, three cohort studies, and three pilot studies.

“The studies included three randomized control trials, one of which had two different follow‐up periods (18 months and 8 years post‐treatment) (Bateman & Fonagy, 1999, 2001, 2008, 2009; Rossouw & Fonagy, 2012) , one ‘randomized yet not controlled trial’ and its18‐month follow‐up (Jørgensen et al., 2013, 2014), one matched control study (Bales et al., 2015), three cohort studies (Bales et al., 2012;”

Probably not a substantial claim: may not pass S3 (load-bearing).

The number of participants taking part in the studies ranged from 11 to 345.

“The number of participants taking part in the studies ranged from 11 to 345.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Three studies offered a 12-month mentalization-based programme.

“Three others offered a 12‐month mentalization‐based programme (Bo et al., 2016; Laurenssen, Hutsebaut, et al., 2014; Rossouw & Fonagy, 2012).”

May combine two claims.

Mentalization-based therapy can achieve significant reductions in BPD symptom severity and the severity of comorbid disorders as well as increase quality of life.

“Mentalization‐based therapy can achieve significant reductions in BPD symptom severity and the severity of comorbid disorders as well as increase quality of life.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

A total of 885 participants took part in the eleven baseline studies; at baseline, 684 participants were female (77%) and 201 were male (23%).

“A total of 885 participants took part in the eleven baseline studies; the number subsequently reduced after attrition. At baseline, 684 participants were female (77%) and 201 were male (23%).”

Probably not a substantial claim: may not pass S3 (load-bearing).

All studies were conducted in European countries, either in the United Kingdom or northern European countries (Germany, Netherlands, Denmark, and Norway).

“All studies were conducted in European countries, either in the United Kingdom or northern European countries (Germany, Netherlands, Denmark, and Norway).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Quality assessment scores ranged from 11 to 23, with the highest score awarded to Rossouw and Fonagy (2012) and the lowest to Brüne et al. (2013).

“Scores obtained ranged from 11 to 23, with the highest scoring being awarded to the randomized control trial conducted by Rossouw and Fonagy (2012) while the lowest score of 11 was assigned to a pilot study (Brüne et al., 2013).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Fourteen papers were included in the review, comprising 11 original studies and three follow-up papers.

“Fourteen papers were included in the review which examined the effectiveness of MBT in the context of BPD; these included 11 original studies and three follow‐up papers.”

• AssumptionRests on an assumption: The search strategy and databases used identified all relevant studies of MBT for BPD.

May combine two claims.

Improvements were statistically significant for both groups at 36-month follow-up, although the MBT group had a larger effect size (d = 0.81) than the SGT group (d = 0.67).

“Improvements were statistically significant for both groups at 36‐month follow‐up, although the MBT group had a larger effect size (d = 0.81) than the SGT group (d = 0.67) (Jørgensen et al., 2014).”

• cites Jørgensen et al., 2014Not checked yet

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• AssumptionRests on an assumption: The effect sizes reported or calculated across included studies are comparable enough to be synthesized.

May combine two claims.

Edel et al. (2017) reported significant changes for both participant groups over the course of treatment; patients receiving MBT combined with DBT scored significantly better post-treatment with effect sizes of 0.6 for all three subscales.

“The study reported significant changes for both participant groups over the course of treatment. Across its three subscales, ‘borderline symptoms’, ‘subjective health’, and ‘self‐harm’, patients receiving MBT combined with DBT scored significantly better post‐treatment with effect sizes of 0.6 for all three subscales.”

• cites Edel et al., 2017Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Six studies, including three follow-ups, used the IIP or its shorter versions, the IIP-C, or CIP.

“Six studies, including three follow‐ups, used the Inventory of Interpersonal Problems (IIP) or its shorter versions, the IIP‐C, or CIP”

May combine two claims.

According to the MFQ, all but three patients of Rossouw and Fonagy's sample (TAU+MBT) could be classed as clinically depressed at baseline; at 12-month follow-up, this was reduced to 49% of patients in MBT versus 68% of TAU patients.

“According to the MGQ, all but three patients of their sampled (TAU+MBT) could be classed as clinically depressed at baseline. At 12‐month follow‐up, this was reduced to 49% of patients in MBT versus 68% of TAU patients.”

• cites Rossouw & Fonagy, 2012Not checked yet

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May combine two claims. The quote only partly states this claim.

Patients in the DBT group achieved effect sizes of 0.6, 1.0, and 0.1 for the subscales borderline symptoms, subjective health, and self-harm, respectively.

“Patients in the DBT group achieved effect sizes of 0.6, 1.0, and 0.1 for the subscales, respectively.”

May combine two claims.

A significantly greater reduction in BPD symptoms was found in the MBT group compared to the control group using CI-BPD; no effect sizes were reported.

“A significantly greater reduction in BPD symptoms was found in the MBT group compared to the control group (Rossouw & Fonagy, 2012); however, no effect sizes were reported.”

• cites Rossouw & Fonagy, 2012Not checked yet

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May combine two claims.

Studies comparing MBT to structured clinical management or supportive group therapy found reductions in medication for both groups, although a greater reduction in medication use was reported for MBT participants.

“Studies comparing MBT to structured clinical management or supportive group therapy found reductions in medication for both groups, although a greater reduction in medication use was reported for MBT participants”

• cites Bateman & Fonagy, 2009Not checked yet

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• cites Jørgensen et al., 2013, 2014Not checked yet

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May combine two claims.

Brüne et al. (2013) offered MBT combined with DBT over 4 weeks and reported a significant difference between pre- and post-treatment scores with an effect size of 1.05.

“One study was the pilot study conducted by Brüne et al. (2013) who offered MBT combined with DBT over 4 weeks; a significant difference between pre‐ and post‐treatment scores was reported (p > .05) with an effect size of 1.05.”

• cites Brüne et al., 2013Not checked yet

  Not checked in the free run.

May combine two claims.

One adolescent study reported significant differences in scores between the MBT-A and TAU groups for the RTSHI subscale of self-harm at 12 months, with the MBT-A group engaging in significantly less self-harming behaviour; on the risk taking subscale, no group differences were found.

“One study reported significant differences in scores between the MBT‐A and TAU groups for its subscale of ‘self‐harm’ at 12 months with the MBT‐A group engaging in significantly less self‐harming behaviour; on the second subscale of ‘risk taking’, no group differences were found (Rossouw & Fonagy, 2012).”

• cites Rossouw & Fonagy, 2012Not checked yet

  Not checked in the free run.

May combine two claims.

Compared to comparison treatments (supportive group therapy, standard psychiatric care, and traditional psychodynamic approach), MBT achieved better outcomes and larger effect sizes.

“Compared to the comparison treatments (supportive group therapy, standard psychiatric care, and traditional psychodynamic approach), MBT achieved better outcomes and larger effect sizes”

• AssumptionRests on an assumption: The comparison treatments used in the included studies are well-established treatments for BPD.

May combine two claims.

One study and its follow-up found that both MBT and supportive group therapy patients improved significantly from baseline to post-treatment with equal effect sizes 36 months post-treatment.

“In contrast, one study and its follow‐up found that both MBT and supportive group therapy patients improved significantly from baseline to post‐treatment with equal effect sizes 36 months post‐treatment (Jørgensen et al., 2013, 2014).”

• cites Jørgensen et al., 2013, 2014Not checked yet

  Not checked in the free run.

May combine two claims.

Bales et al. (2015) reported that MBT patients achieved substantially higher scores with large effect sizes than patients in SGT, except on the Relational Functioning subscale where no significant differences between groups were found.

“Bales et al. (2015) further reported that MBT patients achieved substantially higher scores with large effect sizes than patients in SGT, and it was only on the subscale of Relational Functioning subscale where no significant differences between the groups were found.”

• cites Bales et al., 2015Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Depressive symptoms were assessed in eight of the 14 studies.

“Depressive symptoms were assessed in eight of the 14 studies.”

May combine two claims.

Both studies using BPFS-C report significant decreases in borderline symptomatology; neither reported effect sizes.

“Both studies report significant decreases in borderline symptomatology (Bo et al., 2016; Rossouw & Fonagy, 2012). Neither of the studies reported effect sizes.”

May combine two claims.

The STAI was used in two original studies and their follow-ups; all four reported improvements for MBT patients.

“The Spielberger State‐Trait Inventory (STAI) was used in two original studies and their follow‐ups. All four reported improvements for MBT patients”

May combine two claims.

Only Jørgensen et al. (2014) reported effect sizes separately for their MBT and control group; patients achieved comparable effect sizes of 1.11 and 1.21 for SGT and MBT, respectively.

“Of these studies, only Jørgensen et al. (2014) reported effect sizes separately for their MBT and control group. Patients achieved comparable effect sizes of 1.11 and 1.21 for SGT and MBT, respectively.”

• cites Jørgensen et al., 2014Not checked yet

  Not checked in the free run.

May combine two claims.

Changes in BAI scores from baseline to 24 months were statistically significant for the MBT group but not for the SGT group at 18 months post-treatment.

“Changes in BAI scores from baseline to 24 months were statistically significant for the MBT group but not for the SGT group at 18 months post‐treatment (Jørgensen et al., 2013).”

• cites Jørgensen et al., 2013Not checked yet

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May combine two claims. The quote only partly states this claim.

Three studies used SIPP-118; Bales et al. (2012, 2015) found significant improvements with large effect sizes ranging from .081 to 2.08 for MBT patients after 18 and 36 months.

“The studies (Bales et al., 2012, 2015) found significant improvements with large effect sizes ranging from .081 to 2.08 for MBT patients after 18 and 36 months.”

• cites Bales et al., 2012, 2015Not checked yet

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• AssumptionRests on an assumption: The effect sizes reported or calculated across included studies are comparable enough to be synthesized.

May combine two claims.

Kvarstein et al. (2015) reported superior reductions in interpersonal problems for the MBT patients compared to TPT patients, especially for the subscale Mistrust; the effect size for the MBT group was 1.46 compared to 0.67 for the TPT group.

“Kvarstein et al. (2015) reported superior reductions in interpersonal problems for the MBT patients compared to TPT patients, and the difference was especially significant for the subscale ‘Mistrust’; the effect size for the MBT group was reported as 1.46 compared to 0.67 for the TPT group.”

• cites Kvarstein et al., 2015Not checked yet

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May combine two claims.

Some studies emphasized a reduction in parasuicidal behaviour as primary outcomes, while other studies did not include specific measures.

“While some studies emphasized a reduction in parasuicidal behaviour as primary outcomes, other studies did not include specific measures.”

May combine two claims.

The percentages of women in the samples were disproportionately high: Samples were either dominated by female patients or exclusively female.

“The percentages of women in the samples were disproportionately high: Samples were either dominated by female patients or exclusively female.”

May combine two claims.

Borderline-specific features were found to decrease over the course of treatment, including substantial reductions in parasuicidal behaviour.

“Borderline‐specific features were also found to decrease over the course of treatment, including substantial reductions in parasuicidal behaviour.”

The quote only partly states this claim.

MBT significantly reduces levels of anxiety and depression.

“Mentalization‐based therapy was also found to significantly reduce levels of anxiety and depression”

May combine two claims.

The studies included in the review indicate that MBT can achieve significant reductions in BPD symptom severity, the severity of comorbid disorders, and the use of psychotropic medication.

“The studies included in the review indicate that MBT can achieve significant reductions in BPD symptom severity, the severity of comorbid disorders, and the use of psychotropic medication.”

May combine two claims.

In the reviewed studies, the effectiveness of MBT was compared to treatment programmes, such as structured clinical management or psychodynamic treatment, and was found to achieve either superior or equal results.

“In the reviewed studies, the effectiveness of MBT was compared to treatment programmes, such as structured clinical management or psychodynamic treatment, and was found to achieve either superior or equal results.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Three other studies stated in their exclusion criteria that participants could not be receiving any psychological treatment at the same time or could not have previously received treatment.

“three other studies stated in their exclusion criteria that participants could not be receiving any psychological treatment at the same time or could not have previously received treatment”

May combine two claims.

Evidence was collated that MBT leads to reductions in BPD-specific symptoms, such as profound interpersonal problems or suicidal behaviour, and common comorbid disorders, such as depression and anxiety.

“Evidence was collated that MBT leads to reductions in borderline personality disorder‐specific symptoms, such as profound interpersonal problems or suicidal behaviour, and common comorbid disorders, such as depression and anxiety.”

May combine two claims.

MBT can improve general psychiatric well-being, interpersonal functioning, and social adjustment.

“It can also improve general psychiatric well‐being, interpersonal functioning, and social adjustment.”

Classified as probably not a substantial claim. May combine two claims.

Brüne et al. reported that while borderline symptom severity was significantly reduced over the course of the 4-week MBT/DBT intervention, no significant differences were found on the cartoon task that assessed participants' mentalizing skills and prosocial understanding.

“Brüne et al. reported that while borderline symptom severity was significantly reduced over the course of the 4‐week MBT/DBT intervention, no significant differences were found on the cartoon task that assessed participants’ mentalizing skills and prosocial understanding.”

• cites Brüne et al., 2013Not checked yet

  Not checked in the free run.

May combine two claims.

The effect sizes for the reductions of psychiatric symptoms were consistently large for MBT patients and either superior or comparable to the comparison treatments.

“The effect sizes for the reductions of psychiatric symptoms were consistently large for MBT patients and either superior or comparable to the comparison treatments.”

May combine two claims.

This narrative review combined the results of very heterogeneous studies with different outcome measurements, and found that a reduction across all BPD symptoms was achieved.

“This narrative review combined the results of very heterogeneous studies with different outcome measurements, and found that a reduction across all BPD symptoms was achieved”

Probably not a substantial claim: may not pass S3 (load-bearing).

The protocol for this systematic review was registered on PROSPERO (Reference number: CRD42017071091) on 3 July 2017.

“The protocol for this systematic review was registered on PROSPERO (Reference number: CRD42017071091) on 3 July 2017.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

BPD is a complex and multifaceted disorder associated with profound impairment of functioning and a high number of comorbid disorders.

“Borderline personality disorder is a complex and multifaceted disorder that is associated with profound impairment of functioning and a high number of comorbid disorders”

• cites APA, 2013Not checked yet

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• cites Zimmerman & Mattia, 1999Not checked yet

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Classified as probably not a substantial claim.

A patient's symptoms will only improve if they learn to understand and perceive the mental states of other individuals.

“a patient's symptoms will only improve if they learn to understand and perceive the mental states of other individuals”

• cites Bateman & Fonagy, 2010Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

BPD is regarded as difficult to treat.

“is regarded as difficult to treat”

• cites National Institute for Health and Care Excellence, 2009Not checked yet

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• cites Rossouw, 2015Not checked yet

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May combine two claims.

This indicates that MBT is successful at reducing symptoms both related to self-harming behaviours and to symptoms not associated with them.

“which indicates that MBT is successful at reducing symptoms both related to self‐harming behaviours and to symptoms not associated with them.”

May combine two claims.

This reduction may help to improve patients' quality of life as the side effects and adverse consequences of psychotropic drugs are linked with lower quality of life.

“This reduction may help to improve patients’ quality of life as the side effects and adverse consequences of psychotropic drugs are linked with lower quality of life”

• cites Hajji et al., 2014Not checked yet

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• cites Kopp et al., 2011Not checked yet

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Classified as probably not a substantial claim.

The DSM-V diagnostic criteria only require individuals to have five of nine symptoms.

“The DSM‐V diagnostic criteria only require individuals to have five of nine symptoms”

• cites APA, 2013Not checked yet

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May combine two claims.

BPD patient samples generally have very high attrition rates and clinicians often have difficulties keeping them engaged.

“BPD patient samples generally have very high attrition rates and clinicians often have difficulties keeping them engaged”

• cites National Institute for Health and Care Excellence, 2009Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

This might also represent a publication bias as only successful MBT applications may have been translated.

“This might also represent a publication bias as only successful MBT applications may have been translated.”

May combine two claims.

This suggests that undergoing MBT does not necessarily increase patients' mentalizing capacities, but that patients might improve substantially as a result of its format.

“This suggests that undergoing MBT does not necessarily increase patients’ mentalizing capacities, but that patients might improve substantially as a result of its format.”

May combine two claims.

The review only included publications in English, and several articles found in German and Dutch were excluded when English translations could not be accessed (n = 6).

“As the review only included publications in the English, several articles found in German and Dutch were excluded when English translations could not be accessed (n = 6).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Symptoms of BPD are multifaceted and diverse, associated comorbid disorders further complicate treatment.

“Symptoms of BPD are multifaceted and diverse, associated comorbid disorders further complicate treatment”

• cites NICE, 2009Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

BPD usually emerges between puberty and early adulthood.

“BPD usually emerges between puberty and early adulthood”

• cites Chanen, 2015Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Four of the included studies were conducted by Bateman and Fonagy (1999, 2001, 2008, 2009), who developed MBT.

“four of the included studies were conducted by Bateman and Fonagy (1999, 2001, 2008, 2009), who developed MBT.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The process of receiving a diagnosis and treatment is often very slow and patients often do not receive treatment until the disorder has progressed substantially.

“the process of receiving a diagnosis and treatment is often very slow and patients often do not receive treatment until the disorder has progressed substantially”

• cites Bateman et al., 2015Not checked yet

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• cites Gunderson et al., 2011Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

The limitation of author involvement previously identified for the reviews conducted by Binks et al. (2006), Cristea et al. (2017) and Stoffers et al. (2012) therefore remains.

“The limitation of author involvement previously identified for the reviews conducted by Binks et al. (2006), Cristea et al. (2017) and Stoffers et al. (2012) therefore remains.”

• cites Binks et al., 2006Not checked yet

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• cites Cristea et al., 2017Not checked yet

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• cites Stoffers et al., 2012Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

These reductions are further indicators of improvements in quality of life for BPD patients following MBT.

“These reductions are further indicators of improvements in quality of life for BPD patients following MBT.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Fonagy was also the second author on another study included in this review (Rossouw & Fonagy, 2012).

“Fonagy was also the second author on another study included in this review (Rossouw & Fonagy, 2012).”

Probably not a substantial claim: may not pass S3 (load-bearing).

There was some discrepancy between the number of participants included in the RCTs conducted by Bateman & Fonagy in 1999 and, at follow-up, in 2001.

“There was also some discrepancy between the number of participants included in the RCTs conducted by Bateman & Fonagy in 1999 and, at follow‐up, in 2001.”

Probably not a substantial claim: may not pass S3 (load-bearing).

This review was not able to summarize therapy adherence and attendance as few papers reported such data.

“this review was not able to summarize therapy adherence and attendance as few papers reported such data”

Classified as probably not a substantial claim.

DBT has been established as one of the most effective psychotherapeutic treatments for BPD.

“this has been established as one of the most effective psychotherapeutic treatments for BPD”

• cites Bloom et al., 2012Not checked yet

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• cites Cristea et al., 2017Not checked yet

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• cites Lee et al., 2015Not checked yet

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