Intervenciones durante la crisis en adultos con trastorno límite de la personalidad
Resumen
Antecedentes
Las personas diagnosticadas con trastorno límite de la personalidad (TLP) suelen acudir a los servicios sanitarios en crisis, a menudo con pensamientos o acciones suicidas. A pesar de ello, se sabe poco sobre lo que constituye una gestión efectiva de las crisis agudas en esta población y sobre qué tipo de intervenciones son útiles en los momentos de crisis. En esta revisión, se examinará la eficacia de las intervenciones durante la crisis, definidas como una respuesta inmediata por parte de una o más personas a la angustia aguda experimentada por otra persona, diseñadas para garantizar la seguridad y la recuperación y que no duran más de un mes. Esta revisión es una actualización de una revisión Cochrane anterior que examina la evidencia de los efectos de las intervenciones durante la crisis en adultos diagnosticados con TLP.
Objetivos
Evaluar los efectos de las intervenciones durante la crisis en adultos diagnosticados con TLP en cualquier contexto.
Métodos de búsqueda
Se realizaron búsquedas en CENTRAL, MEDLINE, Embase, otras nueve bases de datos y tres registros de ensayos hasta enero de 2022. También se verificaron las listas de referencias, se realizaron búsquedas manuales en los archivos de las revistas pertinentes y se contactó con expertos en la materia para identificar cualquier estudio no publicado o en curso.
Criterios de selección
Ensayos controlados aleatorizados (ECA) que compararan las intervenciones durante la crisis con la atención habitual, ninguna intervención o lista de espera, en adultos de cualquier edad diagnosticados con TLP.
Obtención y análisis de los datos
Se utilizaron los procedimientos metodológicos estándar previstos por Cochrane.
Resultados principales
Se incluyeron dos estudios con 213 participantes.
Un estudio (88 participantes) fue un ECA de viabilidad realizado en el Reino Unido que examinó los efectos de planes de crisis conjuntos (PCC) más el tratamiento habitual (TH) en comparación con el TH solo en personas diagnosticadas con TLP. El desenlace principal fue la autolesión. La media de edad de los participantes era de 36 años y el 81% eran mujeres. Consejos de investigación gubernamentales financiaron el estudio. El riesgo de sesgo fue incierto para el cegamiento, pero bajo en los otros dominios evaluados. La evidencia de este estudio indicó que podría no haber diferencias entre los PCC y el TH en cuanto a las muertes (razón de riesgos [RR] 0,91; intervalo de confianza [IC] del 95%: 0,06 a 14,14; 88 participantes; evidencia de certeza baja); el número medio de episodios de autolesión (diferencia de medias [DM] 0,30; IC del 95%: ‐36,27 a 36.87; 72 participantes; evidencia de certeza baja), el número de noches de hospitalización en salud mental (DM 1,80; IC del 95%: ‐5,06 a 8,66; 73 participantes; evidencia de certeza baja) o la calidad de vida medida con el cuestionario de cinco dimensiones EuroQol (EQ‐5D; DM ‐6,10; IC del 95%: ‐15,52 a 3,32; 72 participantes; evidencia de certeza muy baja). Los autores del estudio calcularon una razón de coste‐efectividad incremental de ‐32,358 libras esterlinas por año de vida ajustado por la calidad (AVAC), que favoreció a los PCC, pero describieron este resultado como "solo generador de hipótesis" y a los efectos de esta revisión se consideró evidencia de certeza muy baja.
El otro estudio (125 participantes) fue un ECA realizado en Suecia sobre el ingreso breve en un hospital psiquiátrico por iniciativa propia (IB) en comparación con el TH, en personas con conductas autolesivas o suicidas y tres o más criterios diagnósticos de TLP. El desenlace principal fue el uso de los servicios de salud mental para pacientes hospitalizados. La media de edad de los participantes era de 32 años y el 85% eran mujeres. Consejos de investigación gubernamentales y fundaciones sin ánimo de lucro financiaron el estudio. El riesgo de sesgo fue incierto para el cegamiento y las desigualdades iniciales, pero bajo en los demás dominios evaluados. La evidencia indica que no hay una diferencia clara entre el IB y el TH en cuanto a las muertes (RR 0,49; IC del 95%: 0,05 a 5,29; 125 participantes; evidencia de certeza baja), el número medio de episodios de autolesión (DM ‐0,03; IC del 95%: ‐2,26 a 2.,20; 125 participantes; evidencia de certeza baja), la perpetración de violencia (RR 2,95; IC del 95%: 0,12 a 71,13; 125 participantes; evidencia de certeza baja) o los días de atención de salud mental como paciente interno (DM 0,70; IC del 95%: ‐14,32 a 15,72; 125 participantes; evidencia de certeza baja). El estudio indicó que el IB podría tener poco o ningún efecto sobre el número medio de intentos de suicidio (DM 0,00; IC del 95%: ‐0,06 a 0,06; 125 participantes; evidencia de certeza muy baja).
También se identificaron tres ECA en curso que cumplían los criterios de inclusión. Los resultados se incorporarán en futuras actualizaciones de esta revisión.
Conclusiones de los autores
Una búsqueda exhaustiva de la literatura reveló muy poca evidencia basada en ECA para informar sobre el control de las crisis agudas en personas diagnosticadas con TLP. Se incluyeron dos estudios de dos tipos de intervención muy diferentes (PCC e IB). No se encontró evidencia clara de un efecto beneficioso en relación con el TH en ninguno de los desenlaces principales de esta revisión. No están claros los verdaderos efectos de ninguna de las dos intervenciones, ya que la evidencia se consideró de certeza baja y muy baja, y solo hubo un único estudio de cada intervención.
Hay una necesidad urgente de ECA de alta calidad, a gran escala y con potencia estadística suficiente sobre las intervenciones durante la crisis en personas diagnosticadas con TLP, además del desarrollo de nuevas intervenciones de tratamiento durante la crisis.
PICO
Resumen en términos sencillos
Intervenciones durante la crisis para personas con trastorno límite de la personalidad
¿Qué es el trastorno límite de la personalidad?
El trastorno límite de la personalidad (TLP) es un trastorno mental complejo y grave que afecta aproximadamente al 2% de la población general. Muchas personas diagnosticadas con TLP tienen relaciones inestables y cambios angustiosos y rápidos en sus emociones, lo que provoca frecuentes crisis. Estas crisis son periodos críticos, ya que podrían conducir a un mayor consumo de medicamentos y alcohol, a un menor contacto con los profesionales sanitarios y a autolesiones, pudiendo poner en peligro la vida.
¿Qué se quería averiguar?
Hasta la fecha, se sabe poco sobre lo que podría ayudar a las personas diagnosticadas con TLP cuando experimentan una crisis aguda. En esta revisión, se quiso determinar si las intervenciones durante la crisis son efectivas para las personas diagnosticadas con TLP mediante el análisis de la evidencia de los ensayos controlados aleatorizados (en los que algunos participantes [grupo de intervención] son asignados al azar para recibir un tratamiento experimental, y los otros [grupo control] son asignados al azar para recibir un tratamiento ficticio [placebo], ningún tratamiento o el tratamiento habitual).
¿Qué se encontró?
Se realizaron búsquedas en bases de datos médicas y se encontraron dos estudios que abordaban esta cuestión.
En un estudio, el grupo de intervención tenía un plan de crisis conjunto (un documento que explicaba sus preferencias de tratamiento para la gestión de futuras crisis, que podían llevar consigo y consultar en caso de crisis). Este documento es similar a un plan de acción para la recuperación del bienestar, pero se redacta con un profesional de la salud mental, en lugar de hacerlo solo la persona. El grupo de intervención también tuvo acceso a la atención habitual, que fue proporcionada por un equipo de salud mental de la comunidad e incluyó el contacto regular con un miembro asignado del equipo. El grupo control solo recibió la atención habitual.
En el otro estudio, el grupo de intervención podía elegir ser ingresado en un hospital de salud mental durante un máximo de tres días en un momento de crisis (ingreso breve), además de recibir la atención habitual. El grupo control solo recibió la atención habitual.
Consejos de investigación gubernamentales y fundaciones sin ánimo de lucro financiaron los estudios.
Resultados principales
En el estudio del plan de crisis conjunto, no hubo evidencia clara de un efecto sobre la muerte, las autolesiones, el tiempo de estancia en un hospital de salud mental ni la calidad de vida. El documento escrito podría ser más coste‐efectivo que el tratamiento habitual, pero los autores del estudio no estaban seguros de ello.
El estudio sobre el ingreso breve no mostró evidencia clara de una diferencia entre el ingreso breve y el tratamiento habitual sobre la muerte, las autolesiones, los intentos de suicidio, la perpetración de violencia ni el ingreso en un hospital de salud mental.
¿Cuáles son las limitaciones de la evidencia?
Se tiene poca confianza en la evidencia, porque no abarca a todas las personas de interés, se basa en un solo estudio y los propios participantes notificaron algunos de los resultados.
Dado que las crisis en las personas diagnosticadas con TLP son periodos angustiosos y potencialmente peligrosos que se asocian con un mayor riesgo de suicidio, se necesitan con urgencia más estudios de investigación para mejorar la base de evidencia en este ámbito. Estos estudios de investigación se deben realizar en forma de ensayos grandes y bien diseñados para que se pueda confiar en el efecto de la intervención.
¿Cuál es el grado de actualización de esta revisión?
Las búsquedas se completaron en enero de 2022.
Authors' conclusions
Summary of findings
| Joint crisis plan plus treatment as usual versus treatment as usual alone | ||||||
| Patient/population: community‐dwelling adults with a diagnosis of borderline personality disorder Settings: all settings Intervention: joint crisis plan plus treatment as usual Comparison: treatment as usual alone | ||||||
| Outcomes | Anticipated absolute effects (95% CI)* | Relative effect (95% CI) | Number of participants (RCTs) | Certainty of the evidence (GRADE) | Comments | |
|---|---|---|---|---|---|---|
| Risk in control group | Risk in intervention group | |||||
| Deatha Timing of outcome assessment: 6 months | n = 1/42 | n = 1/46 | RR 0.91 (0.06 to 14.14)
| 88 (1 RCT) | ⊕⊕⊝⊝ | — |
| Self‐harm: mean number of self‐harm episodes Timing of outcome assessment: 6 months | The mean number in the control group was 20.3
| The mean in the intervention group was 0.30 higher (−36.27 to 36.87)
| — | 72 (1 RCT) | ⊕⊕⊝⊝ | — |
| Suicidality | — | — | — | — | — | Not measured |
| Violence perpetration | — | — | — | — | — | Not measured |
| Hospital admissions: inpatient mental health nights Timing of outcome assessment: 6 months | The mean number in the control group was 4.3
| The mean in the intervention group was 1.80 higher (−5.06 to 8.66)
| — | 73 (1 RCT) | ⊕⊕⊝⊝ | — |
| Quality of life Measured with EQ‐5D: higher scores mean lower quality of life Timing of outcome assessment: 6 months | The mean score in the control group was 53.1
| The mean score in the intervention group was6.10 lower (−15.52 to 3.32)
| — | 72 (1 RCT) | ⊕⊝⊝⊝ | — |
| Cost‐effectiveness Timing of outcome assessment: 6 months | — | — | ICER GBP −32,358 per QALY
| 73 (1 RCT) | ⊕⊝⊝⊝ | Study reports this result as "hypothesis‐generating only"
|
| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| aNumbers presented as raw values for n (events) in study population (intervention and control groups), and not modelled on RR. We have used the number of participants randomised as the denominator, rather than the number with complete follow‐up data, which assumes that those not followed up did not have the outcome. | ||||||
| Brief admission to psychiatric hospital by self‐referral plus treatment as usual versus treatment as usual alone | ||||||
| Patient/population: adults meeting 3 or more diagnostic criteria for borderline personality disorder Settings: all settings Intervention: brief admission by self‐referral plus treatment as usual Comparison: treatment as usual alone | ||||||
| Outcomes | Anticipated absolute effects (95% CI)* | Relative effect (95% CI) | Number of participants (RCTs) | Certainty of the evidence (GRADE) | Comments | |
|---|---|---|---|---|---|---|
| Risk in control group | Risk in intervention group | |||||
| Deatha Timing of outcome assessment: 12 months | n = 2/62
| n = 1/63 | RR 0.49 (0.05 to 5.29)
| 125 (1 RCT) | ⊕⊕⊝⊝ | The individual in the intervention group died before receiving the intervention. |
| Self‐harm: mean number of self‐harm episodes Timing of outcome assessment: 12 months | The mean number in the control group was 4.44
| The mean in the intervention group was 0.03 lower (−2.26 to 2.20)
| — | 125 (1 RCT) | ⊕⊕⊝⊝ | — |
| Suicidality: mean number of suicide attempts over the preceding 2 weeks Timing of outcome assessment: 12 months | The mean score in the control group was 0.03
| The mean in the intervention group was the same (−0.06 to 0.06)
| — | 125 (1 RCT) | ⊕⊝⊝⊝ | — |
| Violence perpetration: number of participants who perpetrated violencea Timing of outcome assessment: 12 months | n = 0/62
| n = 1/63 | RR 2.95 (0.12 to 71.13)
| 125 (1 RCT) | ⊕⊕⊝⊝ | — |
| Hospital admissions: days of inpatient mental health care Timing of outcome assessment: 12 months | The mean number in the control group was 29.44
| The mean in the intervention group was 0.70 higher (−14.32 to 15.72)
| — | 125 (1 RCT) | ⊕⊕⊝⊝ | — |
| Quality of life | — | — | — | — | — | Not measured |
| Cost‐effectiveness | — | — | — | — | — | Not measured |
| *The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval;n: number of events; RCT: randomised controlled trial; RR: risk ratio. | ||||||
| GRADE Working Group grades of evidence | ||||||
| aNumbers presented as raw values for n (events) in study population (intervention and control groups), and not modelled on RR. We have used the number of participants randomised as the denominator, rather than the number with complete follow‐up data, which assumes that those not followed up did not have the outcome. | ||||||
Background
Description of the condition
Borderline personality disorder (BPD) is a complex and severe mental disorder that manifests in a pervasive pattern of instability in interpersonal relationships and self‐image, impulsive behaviour, repeated self‐injury, chronic suicidal thoughts and impaired functioning (APA 2013; Bohus 2021). Approximately 2% of the general population, 10% of psychiatric outpatients and 20% of psychiatric inpatients meet the diagnostic criteria for BPD (APA 2013; Winsper 2020). BPD is diagnosed more frequently in women than in men, although this association is less evident in community samples (Eaton 2018; Stoffers 2012).
The aetiology of BPD is multifactorial, with current theories focusing on the interplay between environmental factors (particularly adverse childhood experiences) and potential genetic factors; there is also emerging research into neurobiological factors (Bohus 2021). People diagnosed with BPD are 13 times more likely to report childhood adversity (Porter 2019). It is thought that these factors affect the development of emotional regulation, identity and social cognition (Bohus 2021; Winsper 2018).
While diagnostic criteria include a heterogeneous set of symptoms (APA 2013; WHO 2016; WHO 2019), experts agree on the core features, which include emotional dysregulation, impulsivity and interpersonal dysfunction (Fonagy 2017; Gunderson 2018). These symptoms contribute to significant psychological suffering and impact on individuals' lives in a number of ways (Zanarini 1998). People with BPD have a range of vocational and social difficulties (Hastrup 2019a; Niesten 2016; Paris 2014), and their carers can feel considerable distress (Bateman 2019). People diagnosed with BPD often experience other mental health problems, particularly anxiety, depression, substance use disorders and self‐harm (Bohus 2021; Leichsenring 2011). Some studies have reported suicide rates of 10% (Paris 2019), and suicide rates in prospective cohorts range from 2% to 6% (Temes 2019). A diagnosis of BPD is also associated with increased all‐cause mortality (Fok 2012; Kjær 2020).
Many people diagnosed with BPD make frequent use of acute psychiatric and primary healthcare services (Cailhol 2015; Coid 2009; Comtois 2016; Sansone 2011), and the overall societal and economic costs of BPD are substantial (Gunderson 2011; Hastrup 2019b; Sansone 2012). Individuals diagnosed with BPD may frequently present to healthcare services in crisis (Stoffers 2010). Factors commonly associated with the onset of a crisis include a clear precipitating event causing distress, an acute reduction in motivation and problem‐solving abilities, and an increase in help‐seeking behaviour (Sansone 2004).
Crises in people diagnosed with BPD are frequently related to suicidal or homicidal thoughts, gestures or actions, and the experience of crisis can be extremely distressing, with a range of precipitating factors (Warrender 2021). To relieve intolerable feelings brought on by a crisis (Zanarini 2013), people may engage in recurrent self‐harm, which can lead to repeat hospitalisation (Bohus 2021; Lieb 2010; NICE 2009).
Description of the intervention
The priority in a crisis for people diagnosed with BPD is to address high‐risk behaviours, including self‐harm, suicide attempts and harm to others (Bohus 2021). Crisis interventions for individuals with other severe mental illness include home‐based care, intensive case management and initial crisis intervention (Dieterich 2017; Murphy 2015). Other options that have been explored include joint crisis plans (JCPs; Henderson 2004), advance treatment statements (Campbell 2009), contact with community mental health teams (Malone 2007), and women's crisis houses (Howard 2010). These measures could also help people diagnosed with BPD. However, there is limited research into crisis interventions for individuals with any severe mental illness; one Cochrane Review from 2015 included a small number of studies and found low‐ to moderate‐certainty evidence (Murphy 2015).
It is possible that people diagnosed with BPD may benefit from interventions similar to those designed for individuals with other severe mental illness. It is also possible that different individuals may benefit from crisis intervention involving several different teams (e.g. home treatment teams, intensive case management teams and community mental health teams). Specific intervention at the time of crisis may help to reduce the distress and risk associated with these events.
For the purposes of this review, we have adopted the following definition of a crisis intervention: 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 (although could be accessed multiple times over an extended period). Given the limited research in the field, the previous version of this review established the definition to distinguish between short‐term crisis interventions and interventions delivered over a longer period of time (e.g. an intervention lasting three months per episode; Borschmann 2012). The definition has since been adopted by other reviews on the topic (Shaikh 2017; Warrender 2021).
We included studies examining any form of crisis‐oriented intervention, conducted either during or outside standard business hours. Interventions may have included any services provided by ward‐based or community‐based teams, with a specific remit to intervene at times of acute distress (such as crisis resolution teams, home treatment teams or crisis intervention teams), working alongside community mental health teams. These interventions may have taken place in hospital, in the community or at home. Interventions may also have included the provision of crisis plans or any other service user‐held tools designed for use in a crisis to ameliorate its effects.
How the intervention might work
There is limited research exploring how crisis interventions work (Murphy 2015). However, effective crisis management requires an understanding of the contributing factors and an attempt to address them (e.g. understanding behaviour, identifying triggers and modifying external factors; Bohus 2021). Given the potentially heterogeneous nature of crisis interventions, different interventions may act in different ways.
Internal factors contributing to effective crisis resolution partly depend on levels of intrinsic and extrinsic motivation, as well as the receptivity of the individual in crisis (Oudeyer 2007). If motivation is sufficiently high, the individual may be capable of re‐evaluating their situation and modifying dysfunctional behaviour, for example through a change in motivation and problem‐solving ability (Sansone 2004).
External factors contributing to effective crisis resolution may include the temporary removal of an individual from a risky or distressing environment (e.g. to hospital for a brief stay), but some experts question whether this approach is helpful in the longer term (Paris 2019). Facilitating immediate access to appropriate services (such as health, housing or legal advice) may also alleviate distress and reduce the risk of impulsive behaviour by addressing social problems (Bohus 2021).
Crisis intervention may facilitate the management of acute distress, helping people to access longer‐term psychological treatment, which has a larger evidence base in the management of BPD (Storebø 2020).
Why it is important to do this review
People diagnosed with BPD frequently present to healthcare services in crisis, but there is limited evidence on how to support them (Borschmann 2012; Murphy 2015; Stoffers 2012). The consequences of people not receiving appropriate crisis intervention are potentially lethal, and cause significant distress to individuals and their families. Furthermore, crises occurring within this population are associated with substantial social and economic costs. The nature and potential impact of these crises justify the need to identify and make use of effective crisis management interventions (NICE 2009).
One Cochrane Review of psychological therapies for people diagnosed with BPD examined the evidence for efficacy of long‐term psychological treatments such as dialectical behaviour therapy (DBT) and mentalisation‐based treatment (MBT), each of which includes a component of crisis management (Storebø 2020). However, the review authors did not assess the efficacy of the crisis management component, as they formed part of a complex intervention. Another Cochrane Review explored the related topic of psychosocial interventions for self‐harm in adults, but was also mainly focused on longer‐term or complex interventions and did not examine crisis interventions specifically (Witt 2021).
This review is an update of a previous Cochrane Review examining the evidence for the effectiveness of crisis interventions in adults diagnosed with BPD (Borschmann 2012). Despite the frequent crises experienced by this population and the associated health risks, the previous review did not identify any randomised controlled trial (RCT)‐based evidence for inclusion, but did identify ongoing studies.
Objectives
To assess the effects of crisis interventions in adults diagnosed with BPD in any setting.
Methods
Criteria for considering studies for this review
Types of studies
We included RCTs and quasi‐RCTs, where participants are allocated through quasi‐random methods such as alternation. We excluded non‐randomised trials.
Types of participants
Adults aged 18 years and older with a primary diagnosis of BPD, whether they received the diagnosis before or within a trial. We also included participants meeting three or more diagnostic criteria for BPD, and acknowledge this is a lower threshold for diagnosis than the five criteria required by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‐5; APA 2013). We took this decision to increase the yield of papers included in the review, although we note that meeting just one or more of the BPD criteria has been associated with increased psychosocial morbidity (Harford 2015; Zimmerman 2012).
We also included individuals with other disorders (e.g. substance misuse disorders) comorbid with BPD, and individuals with other comorbid psychiatric diagnoses, if the primary diagnosis was BPD. We excluded individuals registered in studies focusing on a separate mental disorder (some of whom could also meet the criteria for BPD), as such studies were not primarily about the treatment of BPD.
Types of interventions
All crisis interventions compared with treatment as usual (TAU), no intervention or waiting list. Eligible interventions could last up to one month. We excluded longer‐term complex psychological interventions (e.g. DBT) that could include a crisis management component, as complex psychological interventions were the subject of a previous Cochrane Review (Storebø 2020), and do not constitute stand‐alone crisis interventions. We included interventions delivered by any individual or group of individuals in any setting, such as primary care, community mental health services or inpatient mental health services.
Types of outcome measures
We included any length of follow‐up, and we analysed outcomes after treatment where possible, examining the effect of assignment to the intervention (i.e. the intention‐to‐treat effect).
Primary outcomes
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Death: sudden and unexpected death and death from natural causes in a seemingly healthy individual who is a participant in an RCT or has recently completed an RCT
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Self‐harm and suicidality (including dying by suicide), for example, frequency of self‐harm, number of participants reporting self‐harm or mean score on a suicide risk scale such as the Beck Scale for Suicidal Ideation (BSSI; Beck 1979)
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Violence perpetration, for example, number of participants perpetrating violence or number of incidences of violence
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Hospital admissions (either mental health admission or general admission), for example, number of nights of inpatient care or number of admissions to hospital
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Quality of life assessed on an instrument such as the World Health Organization Quality of Life questionnaire (WHOQOL; WHOQOL 1994), or the EuroQol five‐dimension questionnaire (EQ‐5D; Herdman 2011)
Secondary outcomes
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Satisfaction with services, measured on an instrument such as the Client Satisfaction Questionnaire (CSQ; Larsen 1979)
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Engagement with services, measured on an instrument such as the Service Engagement Scale (SES; Tait 2002)
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Perceived coercion, measured on an instrument such as the Admission Experience Survey (AES; Gardner 1993)
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Social functioning, measured on an instrument such as the Social Functioning Questionnaire (SFQ; Tyrer 2005), or the Work and Social Adjustment Scale (WSAS; Mundt 2002)
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Well‐being and symptom severity, measured on a standardised instrument such as the Warwick‐Edinburgh Mental Wellbeing Scale (WEMWBS; Tennant 2007), or the Zanarini Rating Scale for Borderline Personality Disorder (ZAN‐BPD; Zanarini 2003)
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Cost‐effectiveness, measured by a statistic such as the incremental cost‐effectiveness ratio (ICER)
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Utilisation of services, as recorded in healthcare service records such as hospital, primary or secondary care records
We included the outcome measures death, self‐harm, suicidality, violence perpetration, hospital admissions, quality of life and cost‐effectiveness in summary of findings tables (Schünemann 2022).
Search methods for identification of studies
Electronic searches
We ran searches for this update in May 2021 and again in January 2022. We updated the previous search methods by including additional search terms in the population and intervention sections (Borschmann 2012). We revised the list of electronic sources by replacing some with databases that were previously unavailable, and adding some new ones. Where possible, we limited searches to the period since the last update (2011 onwards). For newly added databases, searches were conducted since database inception. We did not restrict the search by language or type of publication. We reported the changes in Differences between protocol and review. We searched the following electronic databases and trial registers.
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Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 12) in the Cochrane Library, which includes the Cochrane Developmental, Psychosocial and Learning Problems Specialised Register (searched 24 January 2022).
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Ovid MEDLINE (1946 to January week 2 2022).
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Ovid MEDLINE In Process & Other Non‐indexed Citations (24 January 2022).
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Ovid MEDLINE Epub ahead of print (24 January 2022).
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Embase (1974 to 21 January 2022).
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PsycINFO (1806 to January week 3 2022).
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CINAHL (Cumulative Index to Nursing and Allied Health Literature; 1937 to 26 January 2022).
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Social Services Abstracts ProQuest (1979 to 24 January 2022).
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Social Policy and Practice Ovid (1981 to 24 January 2022).
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Web of Science (WoS) Clarivate Core databases (1970 to 26 January 2022).
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LILACS (Latin American and Caribbean Health Sciences Literature; searched 26 January 2022)
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Cochrane Database of Systematic Reviews (CDSR; 2022, Issue 1) in the Cochrane Library (searched 24 January 2022).
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Proquest Dissertations and Theses Global (PQDT) searched 26 January 2022).
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Epistemonikos (epistemonikos.org/en; searched 26 January 2022).
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ClinicalTrials.gov (clinicaltrials.gov; searched 26 January 2022).
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World Health Organization International Clinical Trials Registry Platform (WHO ICTRP; trialsearch.who.int; searched 26 January 2022).
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ISRCTN Registry (www.isrctn.com/; searched 31 January 2022).
The detailed strategies for each database are presented in Appendix 1.
Searching other resources
We scrutinised the reference lists of relevant published reviews to locate additional publications not identified by the database searches (Bozzatello 2020; Paris 2019; Shaikh 2017; Stoffers‐Winterling 2018; Storebø 2020; Town 2011; Warrender 2021; Witt 2021). We then searched the complete archives of the six journals that returned the largest number of relevant citations: American Journal of Psychiatry (up to volume 179 issue 1); British Journal of Psychiatry (up to volume 220 issue 1); Journal of Clinical Psychiatry (up to volume 82 issue 6); Psychological Medicine (up to volume 52 issue 2); Journal of Personality Disorders (up to volume 35 issue 6); and Archives of General Psychiatry (up to volume 69 issue 12), which was renamed JAMA Psychiatry in 2013 (searched to volume 79 issue 1). We contacted some of the most published researchers in the field of BPD (as indexed by Expert Scape), in addition to authors contacted for the previous version of this review (Borschmann 2012), and topic experts Anthony Bateman and Mike Crawford, about ongoing trials and unpublished data. See Appendix 2.
Data collection and analysis
Review authors RB, CH, JO and PM were involved in one of the included studies (Borschmann 2013). The remaining review authors (JMC, AM, JG) performed the eligibility assessment, data extraction, risk of bias assessment and GRADE assessment for this trial.
Selection of studies
Two review authors (JMC and AM) independently screened the titles and abstracts of all records, discarding those that were clearly irrelevant. Next, they retrieved the full‐text reports of potentially eligible records and assessed them against the inclusion and exclusion criteria. When the two review authors did not agree, they consulted a third review author (PM) to reach a consensus. PM was not contacted in relation to Borschmann 2013. We recorded our selection process in detail in a PRISMA diagram (Moher 2009).
Data extraction and management
Using a data extraction form specifically designed for this review, two review authors (JMC and JG) independently extracted data from Borschmann 2013, and another pair of review authors (JMC and JO) independently extracted data from the other included study. We assessed the data collected and compared to original sources. We extracted data related to:
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sample size;
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study design, setting, location;
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year of publication;
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participant information, including age and gender distributions, comorbidities;
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inclusion criteria, exclusion criteria, diagnostic criteria;
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number of intervention groups;
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intervention type, length, setting;
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comparator characteristics;
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assessment of risk of bias;
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primary and secondary outcome measures; and
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methods of statistical analysis.
We discussed any disagreements to reach consensus. We contacted study authors to obtain missing outcome data.
Main comparisons
We planned to compare crisis interventions to TAU or another comparator. Given the clinical heterogeneity of interventions identified, we included the following comparisons:
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JCP plus TAU versus TAU alone
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Brief admission to psychiatric hospital by self‐referral (BA) plus TAU versus TAU alone
Assessment of risk of bias in included studies
Using the Cochrane risk of bias tool RoB 1 (Higgins 2011) two review authors (JMC, AM) independently assessed the risk of bias in Borschmann 2013, and another two review authors (JO, CH) assessed the risk of bias in the other included study. Specifically, we answered the following questions.
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Was the allocation sequence adequately generated?
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Was allocation adequately concealed?
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Were both participants and personnel blinded to which intervention a participant received?
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Were outcome assessors blinded from knowledge of which intervention a participant received?
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Were incomplete outcome data adequately addressed?
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Are reports of the study free of suggestion of selective outcome reporting?
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Was the study apparently free of other problems that could put it at a high risk of bias (including fraud, baseline imbalances or deviations from protocol)?
We gave ratings of low, high or unclear risk of bias for each of the domains described above. Differences in opinions were resolved by discussion.
Measures of treatment effect
We calculated measures of treatment effect for individual studies but could not complete any meta‐analyses due to the clinical heterogeneity of the two included studies. Unused methods are presented in Appendix 3 (Borschmann 2011).
Dichotomous outcomes
For dichotomous outcomes, we calculated risk ratios (RRs) and their 95% confidence intervals (CIs).
Continuous outcomes
For continuous outcomes, we calculated mean differences (MDs) and their 95% CIs.
Count outcomes
We extracted count data in the form in which they were reported, and treated count outcomes of common events (e.g. mean number of self‐harm episodes) as continuous data, calculating MDs with 95% CIs (Borschmann 2011; Higgins 2022).
Timing of outcome assessment
The primary endpoint was after the intervention. If studies reported more than one time point for an intervention, we used the data from the last assessment of this outcome.
Unit of analysis issues
We found no cluster randomised trials and no trials with multiple treatment arms (see Appendix 3; Borschmann 2011).
Dealing with missing data
Where studies used an intention‐to‐treat analysis (analysing participants according to the group they were randomised to), we used the same principle.
We did not impute data for the outcomes death and violence perpetration in our primary analysis. We did complete sensitivity analyses for these outcomes, assuming all participants lost to follow‐up had a negative result (Analysis 1.2; Analysis 2.2; Analysis 2.6). While this is in keeping with our protocol, it does not necessarily model a realistic scenario, given the low prevalence of our outcomes. Further information on incomplete outcome data is reported in the risk of bias section for each study (Borschmann 2013; Westling 2019).
Assessment of heterogeneity
In view of the substantial clinical heterogeneity between the interventions used in the two included studies, it was not appropriate to combine data in meta‐analyses, so we were unable to assess statistical heterogeneity (see Appendix 3; Borschmann 2011).
Assessment of reporting biases
We could not assess reporting bias as planned due to the small number of included studies (see Appendix 3; Borschmann 2011).
Data synthesis
We did not pool the data in a meta‐analysis as there were only two included studies with clinically heterogeneous interventions. Instead, we provided a narrative description of: sample size; age and gender distribution; study design; setting and location; details of the intervention group and control group; direction of effect of the intervention; size of the effect; and consistency of effect (if information in these domains was available for assessment).
Subgroup analysis and investigation of heterogeneity
We could not conduct any of our preplanned subgroup analyses due to the small number of included studies (see Appendix 3; Borschmann 2011).
Sensitivity analysis
We completed sensitivity analyses for the outcomes of death and violence perpetration, assuming all participants lost to follow‐up had a negative result (assuming they died or perpetrated violence). While this is in keeping with our protocol, it does not necessarily model a realistic scenario, given the low prevalence of these outcomes. We could not conduct any of our other preplanned sensitivity analyses due to the small number of included studies (see Appendix 3; Borschmann 2011).
Summary of findings and assessment of the certainty of the evidence
We created summary of findings tables for our two main comparisons: JCP plus TAU versus TAU alone (summary of findings Table 1) and BA plus TAU versus TAU alone (summary of findings Table 2), using data from the last assessment for each outcome.
Two review authors (JMC, AM) independently assessed the certainty of the evidence for outcomes included in the summary of findings tables (death, self‐harm, suicidality, violence perpetration, hospital admissions, quality of life, cost‐effectiveness) using the GRADE approach, which assesses the five GRADE considerations (risk of bias, consistency of effect, imprecision, indirectness and publication bias; Schünemann 2022). We began with the assumption that there was a high certainty of evidence, and downgraded by one level for concerns about any of the GRADE domains, or by two levels if there were significant concerns for any of the domains. This gave one of the following levels of certainty.
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High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
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Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
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Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
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Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
We constructed the summary of findings tables using Review Manager Web (RevMan Web 2022). These tables provide: key information about the best estimate of the magnitude of the effect in relative terms and absolute differences for each relevant comparison of alternative management strategies; the numbers of participants and studies addressing each important outcome; and our ratings of the overall confidence in effect estimates for each outcome (Schünemann 2022).
Results
Description of studies
Results of the search
We did not include any studies in the previous version of this review (Borschmann 2012). Searching of electronic databases, trial registers and other resources generated a total of 2911 records for the update to this review, 960 of which were identified as duplicates. After screening the titles and abstracts of the remaining 1951 records, we excluded 1927 records, and retrieved 24 full‐text reports for further examination. Eleven studies (from 13 reports) were excluded because they did not meet the inclusion criteria (see Excluded studies; Characteristics of excluded studies), and three studies (from four reports) were ongoing (see Characteristics of ongoing studies). We included two studies (from seven reports; see Included studies; Characteristics of included studies). Figure 1 shows the study flow diagram.
PRISMA flow diagram. RCT: randomised controlled trial.
Included studies
We identified two studies that met the inclusion criteria.
Design
Borschmann 2013 and Westling 2019 were both single‐blind RCTs.
Sample size
Borschmann 2013 had a sample size of 88, and Westling 2019 had a sample size of 125.
Setting
Borschmann 2013 was conducted in community mental health teams in London (UK), and Westling 2019 was conducted in four psychiatric healthcare facilities in southern Sweden.
Participants
Borschmann 2013 included community‐dwelling adults with a diagnosis of BPD (measured using the Structured Clinical Interview from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM‐IV‐TR)) who had self‐harmed in the previous 12 months and were under the ongoing care of a community mental health team.
Westling 2019 included adults referred to four psychiatric healthcare facilities, with current episodes of self‐harm or recurrent suicidal behaviour; seven or more days of hospital admission or three or more emergency department visits in the last six months; and three or more diagnostic criteria for BPD The inclusion criterion of three or more diagnostic criteria for BPD is a lower threshold for diagnosis than that required by DSM‐5 (at least five criteria; APA 2013). Therefore, some individuals in this study may not have met the DSM‐5 criteria for BPD.
Age
Participants in Borschmann 2013 had a mean age of 36 years. Participants in Westling 2019 had a mean age of 32 years.
Gender
In Borschmann 2013, 81% of participants were women. In Westling 2019, 85% of participants were women.
Intervention and comparator
In Borschmann 2013, the intervention group (n = 46) received JCPs plus TAU, while the comparison group (n = 42) received TAU only.
The JCP was a written document that indicated the participant's preferences for treatment during future crises, and included topics such as 'Positive things I can do in a crisis' and 'Useful telephone numbers'. The document was produced after a facilitated meeting between the participant, his or her treating mental health professional, any other person the participant invited, and a mental health professional acting as an independent facilitator. The JCP was not legally binding, and differed from a wellness recovery action plan in that a mental health professional was involved in its development (Copeland 2002; Henderson 2008).
TAU in Borschmann 2013 was standard care from the participant's community mental health team. This included the provision for service users to receive written copies of their care plan, including a brief 'crisis contingency plan', in addition to regular contact with a care co‐ordinator or allocated member of the clinical team.
In Westling 2019, the BA group (n = 63) had access to a standardised brief admission to a psychiatric hospital for a maximum of three nights, in addition to TAU, while the comparison group (n = 62) received TAU only.
BA was offered for a period of 12 months. Participants negotiated a contract that applied during the admissions, including goals (e.g. preferred approach from staff and stress‐reducing activities) and responsibilities (e.g. the need to bring and administer medication and not to harm oneself or others).
TAU in Westling 2019 included access to all psychiatric care the participant would have had if they had not participated in the study (including general admission to hospital).
Outcomes
Borschmann 2013 was designed as a feasibility study to assess recruitment to a trial of JCPs, but did intend to be powered to detect a clinically meaningful effect for its primary outcome measure of the occurrence of self‐harming behaviour over the six‐month period following randomisation. However, it did not meet the required sample size and so was underpowered for this outcome. Secondary outcomes included depression, anxiety, engagement and satisfaction with services, quality of life, well‐being and cost‐effectiveness.
In Westling 2019, prespecified primary outcome measures were days admitted to hospital, including voluntary admission, BA, and compulsory admission. It was powered to detect differences for these main outcomes.
We contacted the study authors about missing data relating to the outcome 'satisfaction with services' and received unpublished data, which is included in Analysis 2.8 (Westling 2021 [pers comm]).
Excluded studies
We excluded 13 studies from the previous version of this review, and 11 studies from this update. One study was not an RCT, four studies did not meet the participant inclusion criteria, and six studies did not meet the intervention criteria. From these 24 excluded studies, we selected nine that readers might expect to be included in this review, and reported the details in the Characteristics of excluded studies table.
Ongoing studies
We identified three ongoing studies. See Characteristics of ongoing studies.
Pham‐Scottez 2010 is an ongoing study investigating the impact of a 24‐hour telephone service on suicide attempts in adults diagnosed with BPD. It was identified in the previous version of this review. We attempted to contact the study authors for an update but received no response. NCT04211753 is an RCT examining the effectiveness of a mobile app for managing emotional crisis in people diagnosed with BPD. NCT04779099 is a pilot RCT of a brief psychological intervention for people diagnosed with BPD presenting to the emergency department with suicidal ideation or self‐harm.
Risk of bias in included studies
We carried out the risk of bias assessment according to the methods set out in Assessment of risk of bias in included studies and described in the protocol for this review (Borschmann 2011), using RoB 1 (Higgins 2011). A narrative description of the results is presented below and in the risk of bias tables (Characteristics of included studies), and a graph and summary of the results can be found in Figure 2 and Figure 3.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Allocation
Random sequence generation (selection bias)
We rated risk of bias related to random sequence generation as low for both studies. In Borschmann 2013, the institution's clinical trials unit managed randomisation electronically. Westling 2019 used a random sequence for allocation.
Allocation concealment (selection bias)
We rated risk of bias related to allocation concealment as low for both studies. In Borschmann 2013, participants were unaware of their allocation until after they had been enroled to the trial, and randomisation was managed centrally. In Westling 2019, participants learned their allocation after initial assessments, and were randomised with consecutively numbered, sealed envelopes.
Blinding
Blinding of participants and research staff (performance bias)
We rated risk of performance bias as unclear for both studies. Owing to the nature of the interventions, participants and staff were aware of their allocation, which may have had an impact on outcomes.
Blinding of outcome assessment (detection bias)
We rated risk of detection bias as unclear for both studies. While most outcomes were collected by a researcher masked to treatment allocation, both studies included some self‐reported measures (e.g. quality of life in Borschmann 2013 and frequency of self‐harm in Westling 2019). The fact that participants were unmasked to their group allocation may have introduced bias in the reporting of these outcomes, although Borschmann 2013 did assess masking at the end of the study.
Incomplete outcome data
We rated risk of attrition bias as low: while there were incomplete outcome data in both studies, they were similar between groups and not considered to affect the results (Borschmann 2013; Westling 2019). Both studies also employed intention‐to‐treat analyses.
Selective reporting
We detected no signs of reporting bias for either study, as both reported results in accordance with prespecified and published protocols (Borschmann 2013; Westling 2019). Westling 2019 could not complete their full intended analysis of suicide attempts, but the reasons for this are clear (low numbers of participants completing the outcome reporting in both groups).
Other potential sources of bias
We rated 'other' risk of bias as low for Borschmann 2013, as we identified no other important sources of bias (including fraud, baseline imbalances or deviations from protocol). In Westling 2019, there were baseline imbalances for anxiety disorders and days of compulsory admission, though there were no important differences in overall days of admission or other covariates. We therefore considered that Westling 2019 was at unclear risk of bias from other sources.
Effects of interventions
See: Summary of findings 1 Joint crisis plan plus treatment as usual versus treatment as usual alone; Summary of findings 2 Brief admission to psychiatric hospital by self‐referral plus treatment as usual versus treatment as usual alone
Comparison 1: joint crisis plan plus treatment as usual versus treatment as usual alone
Outcomes for Borschmann 2013 were reported at six months postintervention. See summary of findings Table 1
Primary outcomes
Death
Borschmann 2013 did not explore mortality as a main outcome, but two participants (one from each trial arm) died during follow‐up. The trial authors considered that neither of these deaths were related to the intervention. There was no clear evidence of a difference between JCP plus TAU and TAU alone (RR 0.91, 95% CI 0.06 to 14.14; 88 participants; low‐certainty evidence; Analysis 1.1). Worst case scenario sensitivity analysis (assuming all participants lost to follow‐up had died) also showed no clear difference between JCP plus TAU and TAU alone (RR 1.37, 95% CI 0.53 to 3.52; 88 participants; low‐certainty evidence; Analysis 1.2).
Self‐harm and suicidality
Borschmann 2013 found no clear difference between the groups in the proportion of participants who reported self‐harming (odds ratio (OR) 1.86, 95% CI 0.53 to 6.51) or the frequency of self‐harming behaviour (rate ratio 0.74, 95% CI 0.34 to 1.63). According to the results of our analysis, there may be no difference between JCP plus TAU and TAU alone in terms of mean number of self‐harm episodes at the end of treatment (MD 0.30, 95% CI −36.27 to 36.87; 72 participants; low‐certainty evidence; Analysis 1.3).
Violence perpetration
Borschmann 2013 did not measure violence perpetration.
Hospital admissions
Borschmann 2013 provided no evidence of a clear difference between JCP plus TAU and TAU alone on nights of inpatient mental health care over a six‐month period (MD 1.80, 95% CI −5.06 to 8.66; 73 participants; low‐certainty evidence; Analysis 1.4).
Quality of life
Evidence from Borschmann 2013 suggested that JCP plus TAU may not reduce the EQ‐5D score for quality of life at six months' follow‐up compared to TAU alone (MD −6.10, 95% CI −15.52 to 3.32; 72 participants; very low‐certainty evidence; Analysis 1.5). Lower scores in the EQ‐5D reflect a better quality of life.
Secondary outcomes
Satisfaction with services
Borschmann 2013 provided no evidence of a clear difference between JCP plus TAU and TAU alone on satisfaction measured using the Client Satisfaction Questionnaire (CSQ) at the end of treatment (MD 0.33, 95% CI −0.45 to 1.11; 73 participants; Analysis 1.6). Higher scores in the CSQ reflect higher satisfaction with services.
Engagement with services
Evidence from Borschmann 2013 suggested that JCP plus TAU may not reduce scores in the Service Engagement Scale (SES) at the end of treatment compared with TAU alone (10.88 in control group, 2.25 lower in intervention group; MD −2.25, 95% CI −5.35 to 0.85; 55 participants; Analysis 1.7). Higher scores in the SES reflect greater difficulty in engaging with services.
Perceived coercion
Borschmann 2013 provides evidence that JCP plus TAU may result in slightly higher scores in the Treatment Experience Scale at the end of treatment compared with TAU alone (16 in control group, 1.68 higher in intervention group; MD 1.68, 95% CI 0.27 to 3.09; 73 participants; Analysis 1.8). Higher scores reflect higher perceived coercion.
Social functioning
Evidence from Borschmann 2013 suggested that JCP plus TAU may not reduce scores in the Work and Social Adjustment Scale (WSAS) at the end of treatment compared with TAU alone (26.1 in control group, 0.25 lower in intervention group; MD −0.25, 95% CI −4.16 to 3.66; 72 participants; Analysis 1.9). Higher scores in the WSAS reflect a higher level of impairment.
Well‐being and symptom severity
Borschmann 2013 provided evidence that JCP plus TAU may not increase scores in the Warwick‐Edinburgh Mental Wellbeing Scale (WEMWBS) at the end of treatment compared with TAU alone (35.3 in control group, 0.93 lower in intervention group; MD −0.93, 95% CI −5.97 to 4.11; 71 participants; Analysis 1.10). Higher scores in the WEMWBS reflect a higher level of well‐being.
Cost‐effectiveness
Borschmann 2013 reported total costs over six months of GBP 5308 for the JCP plus TAU group and GBP 5631 for TAU alone. The trial authors calculated an ICER of GBP −32,358 per quality‐adjusted life year (QALY) favouring JCP plus TAU, but they reported this result as hypothesis‐generating only, and we rated this evidence as very low‐certainty.
Utilisation of services
Borschmann 2013 reported a number of different measures of how many contacts participants had with all health, social care and criminal justice sector services. The results suggest that JCP plus TAU may not reduce community mental health contacts (32.2 in control group, 9.7 lower in intervention group; MD −9.70, 95% CI −27.68 to 8.28; 73 participants; Analysis 1.12).
Comparison 2: brief admission to psychiatric hospital by self‐referral plus treatment as usual versus treatment as usual alone
Outcomes for Westling 2019 were reported at 12 months postintervention.
Primary outcomes
Death
Westling 2019 did not explore mortality as a main outcome, but reported deaths as adverse events. During the trial, three participants died by suicide: two were randomised to the control group, and one was randomised to the intervention group. We included the participant who died in the intervention group, although they died before receiving the intervention. There was no clear evidence of a difference between BA plus TAU and TAU alone (RR 0.49, 95% CI 0.05 to 5.29; 125 participants; low‐certainty evidence; Analysis 2.1). Worst case scenario sensitivity analysis (assuming all participants lost to follow‐up had died) produced similar results (RR 0.87, 95% CI 0.36 to 2.12; 125 participants; low‐certainty evidence; Analysis 2.2).
Self‐harm and suicidality
Westling 2019 found that BA plus TAU had little or no effect on the number of self‐harm acts compared to TAU alone (latent growth curve modelling (LGCM) −0.41; z = 1.70; P = 0 .09). Our analysis showed that BA plus TAU had little or no effect on the mean number of self‐harm episodes at the end of treatment compared to TAU alone (4.44 in control group, 0.03 lower in intervention group; MD −0.03, 95% CI −2.26 to 2.20; 125 participants; low‐certainty evidence; Analysis 2.3).
Westling 2019 also found that BA plus TAU may result in little to no difference in the mean number of suicide attempts over the preceding two weeks at the end of treatment compared to TAU alone (0.03 in both groups; MD 0.00, 95% CI −0.06 to 0.06; 125 participants; very low‐certainty evidence; Analysis 2.4). They had planned to perform LGCM for this outcome but were unable to do so, as low numbers of participants completed the outcome at all time points.
Violence perpetration
Westling 2019 did not explore violence as a main outcome but reported it as an adverse event. One individual in the BA group was violent to others in the ward. There was no clear evidence of a difference between BA plus TAU and TAU alone (RR 2.95, 95% CI 0.12 to 71.13; 125 participants; low‐certainty evidence; Analysis 2.5). Worst case scenario sensitivity analysis (assuming all participants lost to follow‐up had perpetrated violence) also showed no clear evidence of a difference between BA plus TAU and TAU alone (RR 0.98, 95% CI 0.42 to 2.31; 125 participants; low‐certainty evidence; Analysis 2.6).
Hospital admissions
Westling 2019 showed that there may be no clear difference between BA plus TAU and TAU alone on days of inpatient mental health care over a six‐month period (29.44 in control group, 0.7 higher in intervention group; MD 0.70, 95% CI −14.32 to 15.72; 125 participants; low‐certainty evidence; Analysis 2.7).
Quality of life
Westling 2019 did not report quality of life.
Secondary outcomes
Satisfaction with services
Westling 2019 reported that BA results in little or no difference in the Client Satisfaction Questionnaire (CSQ) between groups at any time point, but did report a within‐group difference over time for the intervention group, suggesting BA may improve CSQ scores (F (2, 54) = 3.92, P = 0.026). This result comes from unpublished data received in correspondence with the study author (Westling 2021 [pers comm]). Our analysis suggested that BA plus TAU may result in a slightly lower CSQ score at the end of treatment compared to TAU alone (25.88 in control group, 1.2 lower in intervention group; MD −1.20, 95% −1.52 to −0.88; 125 participants; Analysis 2.8). Higher CSQ scores reflect higher satisfaction with services.
Engagement with services
Westling 2019 did not report engagement with services.
Perceived coercion
Westling 2019 did not report perceived coercion.
Social functioning
Westling 2019 reported the World Health Organization Disability Assessment Schedule (WHODAS). This is a measure of disability with six domains, three of which relate to social functioning (Westling 2019 used getting along, domestic responsibilities and participation). LGCM showed little to no difference between groups when these items were used as a covariate.
Well‐being and symptom severity
Westling 2019 reported changes in the Hospital Anxiety and Depression Scores, but did not report symptom measures for people diagnosed with BPD, or measures of well‐being.
Cost‐effectiveness
Westling 2019 did not report cost‐effectiveness.
Utilisation of services
Westling 2019 also found little to no difference between BA plus TAU and TAU alone in the number of admissions to the emergency department (LGCM 0.19; z = 1.54; P = 0.12) and number of days with compulsory admission (LGCM −0.33; z = −1.06; P = 0.29).
Discussion
Summary of main results
We identified two RCTs investigating crisis interventions for people diagnosed with BPD. Borschmann 2013 investigated joint crisis plans (JCPs) and Westling 2019 investigated brief admission to psychiatric hospital by self‐referral (BA). We did not pool the results of the two studies or complete a meta‐analysis, as we considered they were distinct interventions.
Borschmann 2013 compared JCPs plus TAU to TAU alone. They assessed the use of a written document containing a mental health service user's treatment preferences for the management of future crises. They included 88 adults diagnosed with BPD who had self‐harmed in the previous 12 months. They found no evidence of a difference between groups at six‐months' follow‐up for the primary outcomes of this review: death, mean number of self‐harm episodes, nights of inpatient mental health care or quality of life. They reported that JCP may be more cost‐effective than TAU, but noted that this result was hypothesis‐generating only. We graded the certainty of the evidence as being low for all outcomes other than quality of life and cost‐effectiveness, which we assessed as very low‐certainty.
While Borschmann 2013 did not establish efficacy of JCPs, the results did confirm the feasibility of recruiting and retaining people diagnosed with BPD to trials of JCPs, which was the aim of the study. The trial authors highlighted a need for further investigation to determine efficacy because their study was underpowered to detect a clinically meaningful difference in its primary outcomes.
Westling 2019 compared BA plus TAU to TAU alone. Participants had access to standardised brief admission to psychiatric hospital for a maximum of three nights, for a period of 12 months. The trial randomised 125 adults who exhibited current self‐harm or suicidal behaviour, three or more diagnostic criteria for BPD, and recent hospital admission or emergency department attendance. The trial authors found no evidence of a difference between groups at 12 months for the primary outcomes of this review, including death, mean number of self‐harm episodes, mean number of suicide attempts, violence perpetration, or days of inpatient mental health care. We graded the certainty of evidence for these outcomes as low, except for mean number of suicide attempts, which we assessed as very low‐certainty. Westling 2019 did not establish efficacy of BA and the authors recommended further research into the intervention. The study was sufficiently powered to identify differences for its main outcomes, although not for all outcomes included in this review.
Based on the currently available evidence, we were unable to draw any clear conclusions about the efficacy of crisis interventions for people diagnosed with BPD.
We identified three ongoing trials. Pham‐Scottez 2010 has been ongoing since the previous version of this review, but no update was available. The other studies explore a mobile app and a brief psychological intervention in the emergency department (NCT04211753, NCT04779099). In total, these three studies intend to recruit 740 people. We plan to include the results in future updates of this review.
Overall completeness and applicability of evidence
Only two studies met the criteria for inclusion in this review. We believe our review includes the currently available evidence, but due to the small number of relevant trials, there are very significant gaps in the literature.
The participants in both studies came from a subgroup of people with prior self‐harm, and in Westling 2019, all participants also had recent hospital admission or emergency department attendance. This may have excluded individuals experiencing a crisis for the first time, individuals who experience infrequent crises, and those not seeking hospital treatment. It also excludes individuals who experience crises that do not result in self‐harm. Both studies took place in Western Europe, and participants in Borschmann 2013 were predominantly White British. In both studies, most participants were women. We only included studies in adults, and there may be evidence for interventions in adolescents that are relevant to adult populations as well, although we found no studies in adolescents that would have met the other inclusion criteria for this review.
Westling 2019 included individuals with three or more diagnostic criteria for BPD, which is a lower threshold for diagnosis than required by DSM‐5 (at least five criteria; APA 2013). Therefore, we may have included data in our review from individuals who do not meet the DSM‐5 criteria for BPD. We made this decision to increase the yield of papers included in the review, although we note that meeting just one or more of the BPD criteria has been associated with increased psychosocial morbidity (Harford 2015; Zimmerman 2012).
We also included individuals with other disorders (e.g. substance misuse disorders) comorbid with BPD, and individuals with other comorbid psychiatric diagnoses, if the primary diagnosis was BPD. We excluded individuals registered in studies focusing on a separate mental disorder (some of whom also meet the criteria for BPD), as such studies were not primarily about the treatment of BPD.
Our review focused on BPD, but we may have identified more studies if we had explored the broader category of crisis interventions for any personality disorder, which could apply to people diagnosed with BPD (Grenyer 2018).
We used a broad definition of crisis interventions in this review, including different types of intervention (JCP and BA). Other types of crisis interventions are being investigated by ongoing studies. These ongoing studies will eventually contribute to the evidence base, which is currently very slender.
Our inclusion criteria limited interventions to one month because we aimed to assess crisis‐specific interventions. Consequently, we excluded longer‐term psychological therapies that may include a crisis management element (e.g. DBT) but are not specific interventions for crises. One Cochrane Review published in 2020 assessed psychological therapies for people diagnosed with BPD, and found that these therapies (many of which are complex interventions, such as DBT) may reduce self‐harm, which may reflect a reduction in the number of crises (Storebø 2020).
Both of the studies included in our review compared crisis interventions plus TAU to TAU alone. TAU varies significantly between geographic areas, with service provision varying between different settings. TAU may be more helpful for managing crises than no treatment, which was not assessed in either of the included studies.
The two studies had different follow‐up periods, with Borschmann 2013 reporting outcomes at six months and Westling 2019 at 12 months. Given the short‐term nature of crisis interventions, the differences in follow‐up periods may have an important effect on results.
Our review included no studies on the use of medication as a crisis management strategy in people diagnosed with BPD. The broader use of medication in people diagnosed with BPD is covered in a separate Cochrane Review (Stoffers‐Winterling 2018).
Inclusion of non‐RCT evidence would increase the number of studies available for this review, but may not increase the certainty of the evidence.
Certainty of the evidence
We assessed the certainty of the evidence for each outcome using the GRADE approach. We rated the evidence for all outcomes as either low‐ or very low‐certainty. Both studies were conducted in clinical populations that may not be representative of the entire population of people diagnosed with BPD, so we downgraded for indirectness. Only one study was available for each comparison, and the numbers of participants in these were relatively low. The available results had large confidence intervals, so we downgraded for imprecision. We had significant concerns about the precision of the results on the cost‐effectiveness of crisis interventions, and we downgraded the certainty of the evidence by two levels for this reason. Some outcomes were assessed on the basis of self‐reported information, so we downgraded the evidence on these outcomes by one level for risk of bias. Future trials should aim to obtain more information from objective sources.
Potential biases in the review process
RB, CH, JO and PM were involved in one of the included studies (Borschmann 2013). The remaining review authors (JMC, AM, JG) performed the eligibility assessment, data extraction, risk of bias assessment and eligibility assessment for this trial. For Westling 2019, two review authors worked independently to assess eligibility, extract data, assess the risk of bias and assess the certainty of the evidence. We resolved any disagreements by discussion.
We have acknowledged that our eligibility criteria excluded longer‐term therapies that may have components of crisis management, and we have also acknowledged that the inclusion of non‐RCT evidence may have provided further data.
To increase the yield of eligible papers, we included participants meeting three or more diagnostic criteria for BPD, which is a lower threshold for diagnosis than required by DSM‐5 (APA 2013).
Agreements and disagreements with other studies or reviews
This review is an update of a version published in 2012 (Borschmann 2012). The original review identified no studies for inclusion, whereas this update included two studies. However, the low certainty of available evidence means that we were unable to reach any definitive conclusions about the effectiveness of crisis interventions.
There are very few other studies or reviews exploring crisis interventions for people diagnosed with BPD. Shaikh 2017 synthesised the available published evidence on crisis interventions for people diagnosed with BPD in the emergency department, including all observational and interventional studies. The authors acknowledged the lack of RCT evidence, but concluded that psychotherapy may lead to a small reduction in BPD‐related symptoms in these settings. Our review did not include any crisis‐specific psychotherapy interventions. Shaikh 2017 also discussed the use of medication for people diagnosed with BPD who present with significant agitation, but we did not include any studies exploring the use of medication as a crisis intervention. Paris 2019 is a review article about suicidality in people diagnosed with BPD. The review authors concluded that hospital admission was not supported by the evidence, but could be justified in specific circumstances. They suggested focusing on existing evidence‐based psychological treatments. Our review suggested that brief admission to psychiatric hospital by self‐referral has little to no effect on the outcomes we explored.
One Cochrane Review of psychological therapies for people diagnosed with BPD found that self‐harm may improve with psychological work (Storebø 2020). All interventions in that review occurred over a longer period of time than the crisis interventions we explored. Another Cochrane Review, which evaluated psychosocial interventions for self‐harm, found that psychological work may be helpful for reducing self‐harm (Witt 2021). We did not include any longer‐term psychological therapies in this review, but it is possible that psychological work, by reducing self‐harm, also reduces the frequency of crises. We identified one ongoing study exploring the use of a brief psychological intervention in the emergency department (NCT04779099).
Our review is consistent with the findings of Murphy 2015 on crisis interventions for people with severe mental illness, in that we identified a low number of studies on crisis interventions, with low‐certainty evidence.
PRISMA flow diagram. RCT: randomised controlled trial.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Comparison 1: Joint crisis plan (JCP) plus treatment as usual (TAU) versus TAU alone, Outcome 1: Death: number of deaths during study period
Comparison 1: Joint crisis plan (JCP) plus treatment as usual (TAU) versus TAU alone, Outcome 2: Death: number of deaths during study period (worst‐case scenario; sensitivity analysis)
Comparison 1: Joint crisis plan (JCP) plus treatment as usual (TAU) versus TAU alone, Outcome 3: Self‐harm (SH): mean number of SH episodes at 6 months
Comparison 1: Joint crisis plan (JCP) plus treatment as usual (TAU) versus TAU alone, Outcome 4: Mean number of inpatient mental health nights
Comparison 1: Joint crisis plan (JCP) plus treatment as usual (TAU) versus TAU alone, Outcome 5: Quality of life: EQ‐5D score at six months
Comparison 1: Joint crisis plan (JCP) plus treatment as usual (TAU) versus TAU alone, Outcome 6: Satisfaction with services: Client Satisfaction Questionnaire at end of treatment
Comparison 1: Joint crisis plan (JCP) plus treatment as usual (TAU) versus TAU alone, Outcome 7: Engagement with services: Service Engagement Scale at end of treatment
Comparison 1: Joint crisis plan (JCP) plus treatment as usual (TAU) versus TAU alone, Outcome 8: Perceived coercion: Treatment Experience Scale at end of treatment
Comparison 1: Joint crisis plan (JCP) plus treatment as usual (TAU) versus TAU alone, Outcome 9: Social functioning: Work and Social Adjustment Scale at end of treatment
Comparison 1: Joint crisis plan (JCP) plus treatment as usual (TAU) versus TAU alone, Outcome 10: Wellbeing and symptom severity: Warwick‐Edinburgh Mental Wellbeing Scale at end of treatment
| Cost‐effectiveness | ||||
| Study | Incremental Cost‐Effectiveness Ratio | N in intervention group | N in control group | Total number of participants |
|---|---|---|---|---|
| Borschmann 2013 | GBP −32,358 per QALY | 37 | 36 | 73 |
Comparison 1: Joint crisis plan (JCP) plus treatment as usual (TAU) versus TAU alone, Outcome 11: Cost‐effectiveness
Comparison 1: Joint crisis plan (JCP) plus treatment as usual (TAU) versus TAU alone, Outcome 12: Utilisation of services: community mental health contacts over 6 months' follow‐up
Comparison 2: Brief admission to psychiatric hospital by self‐referral (BA) plus treatment as usual (TAU) versus TAU alone, Outcome 1: Death: number of deaths during study period
Comparison 2: Brief admission to psychiatric hospital by self‐referral (BA) plus treatment as usual (TAU) versus TAU alone, Outcome 2: Death: number of deaths during study period (worst‐case scenario; sensitivity analysis)
Comparison 2: Brief admission to psychiatric hospital by self‐referral (BA) plus treatment as usual (TAU) versus TAU alone, Outcome 3: Self‐harm (SH): mean number of SH episodes at 12 months
Comparison 2: Brief admission to psychiatric hospital by self‐referral (BA) plus treatment as usual (TAU) versus TAU alone, Outcome 4: Suicidality: mean number of suicide attempts over preceding 2 weeks at 12 months
Comparison 2: Brief admission to psychiatric hospital by self‐referral (BA) plus treatment as usual (TAU) versus TAU alone, Outcome 5: Violence perpetration: number of participants who perpetrated violence during study period
Comparison 2: Brief admission to psychiatric hospital by self‐referral (BA) plus treatment as usual (TAU) versus TAU alone, Outcome 6: Violence perpetration: number of participants who perpetrated violence during study period (worst case scenario; sensitivity analysis)
Comparison 2: Brief admission to psychiatric hospital by self‐referral (BA) plus treatment as usual (TAU) versus TAU alone, Outcome 7: Mean number of days of inpatient mental health care
Comparison 2: Brief admission to psychiatric hospital by self‐referral (BA) plus treatment as usual (TAU) versus TAU alone, Outcome 8: Satisfaction with services: Client Satisfaction Questionnaire at end of treatment
| Joint crisis plan plus treatment as usual versus treatment as usual alone | ||||||
| Patient/population: community‐dwelling adults with a diagnosis of borderline personality disorder Settings: all settings Intervention: joint crisis plan plus treatment as usual Comparison: treatment as usual alone | ||||||
| Outcomes | Anticipated absolute effects (95% CI)* | Relative effect (95% CI) | Number of participants (RCTs) | Certainty of the evidence (GRADE) | Comments | |
|---|---|---|---|---|---|---|
| Risk in control group | Risk in intervention group | |||||
| Deatha Timing of outcome assessment: 6 months | n = 1/42 | n = 1/46 | RR 0.91 (0.06 to 14.14)
| 88 (1 RCT) | ⊕⊕⊝⊝ | — |
| Self‐harm: mean number of self‐harm episodes Timing of outcome assessment: 6 months | The mean number in the control group was 20.3
| The mean in the intervention group was 0.30 higher (−36.27 to 36.87)
| — | 72 (1 RCT) | ⊕⊕⊝⊝ | — |
| Suicidality | — | — | — | — | — | Not measured |
| Violence perpetration | — | — | — | — | — | Not measured |
| Hospital admissions: inpatient mental health nights Timing of outcome assessment: 6 months | The mean number in the control group was 4.3
| The mean in the intervention group was 1.80 higher (−5.06 to 8.66)
| — | 73 (1 RCT) | ⊕⊕⊝⊝ | — |
| Quality of life Measured with EQ‐5D: higher scores mean lower quality of life Timing of outcome assessment: 6 months | The mean score in the control group was 53.1
| The mean score in the intervention group was6.10 lower (−15.52 to 3.32)
| — | 72 (1 RCT) | ⊕⊝⊝⊝ | — |
| Cost‐effectiveness Timing of outcome assessment: 6 months | — | — | ICER GBP −32,358 per QALY
| 73 (1 RCT) | ⊕⊝⊝⊝ | Study reports this result as "hypothesis‐generating only"
|
| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| aNumbers presented as raw values for n (events) in study population (intervention and control groups), and not modelled on RR. We have used the number of participants randomised as the denominator, rather than the number with complete follow‐up data, which assumes that those not followed up did not have the outcome. | ||||||
| Brief admission to psychiatric hospital by self‐referral plus treatment as usual versus treatment as usual alone | ||||||
| Patient/population: adults meeting 3 or more diagnostic criteria for borderline personality disorder Settings: all settings Intervention: brief admission by self‐referral plus treatment as usual Comparison: treatment as usual alone | ||||||
| Outcomes | Anticipated absolute effects (95% CI)* | Relative effect (95% CI) | Number of participants (RCTs) | Certainty of the evidence (GRADE) | Comments | |
|---|---|---|---|---|---|---|
| Risk in control group | Risk in intervention group | |||||
| Deatha Timing of outcome assessment: 12 months | n = 2/62
| n = 1/63 | RR 0.49 (0.05 to 5.29)
| 125 (1 RCT) | ⊕⊕⊝⊝ | The individual in the intervention group died before receiving the intervention. |
| Self‐harm: mean number of self‐harm episodes Timing of outcome assessment: 12 months | The mean number in the control group was 4.44
| The mean in the intervention group was 0.03 lower (−2.26 to 2.20)
| — | 125 (1 RCT) | ⊕⊕⊝⊝ | — |
| Suicidality: mean number of suicide attempts over the preceding 2 weeks Timing of outcome assessment: 12 months | The mean score in the control group was 0.03
| The mean in the intervention group was the same (−0.06 to 0.06)
| — | 125 (1 RCT) | ⊕⊝⊝⊝ | — |
| Violence perpetration: number of participants who perpetrated violencea Timing of outcome assessment: 12 months | n = 0/62
| n = 1/63 | RR 2.95 (0.12 to 71.13)
| 125 (1 RCT) | ⊕⊕⊝⊝ | — |
| Hospital admissions: days of inpatient mental health care Timing of outcome assessment: 12 months | The mean number in the control group was 29.44
| The mean in the intervention group was 0.70 higher (−14.32 to 15.72)
| — | 125 (1 RCT) | ⊕⊕⊝⊝ | — |
| Quality of life | — | — | — | — | — | Not measured |
| Cost‐effectiveness | — | — | — | — | — | Not measured |
| *The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval;n: number of events; RCT: randomised controlled trial; RR: risk ratio. | ||||||
| GRADE Working Group grades of evidence | ||||||
| aNumbers presented as raw values for n (events) in study population (intervention and control groups), and not modelled on RR. We have used the number of participants randomised as the denominator, rather than the number with complete follow‐up data, which assumes that those not followed up did not have the outcome. | ||||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1.1 Death: number of deaths during study period Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 1.2 Death: number of deaths during study period (worst‐case scenario; sensitivity analysis) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 1.3 Self‐harm (SH): mean number of SH episodes at 6 months Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 1.4 Mean number of inpatient mental health nights Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 1.5 Quality of life: EQ‐5D score at six months Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 1.6 Satisfaction with services: Client Satisfaction Questionnaire at end of treatment Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 1.7 Engagement with services: Service Engagement Scale at end of treatment Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 1.8 Perceived coercion: Treatment Experience Scale at end of treatment Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 1.9 Social functioning: Work and Social Adjustment Scale at end of treatment Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 1.10 Wellbeing and symptom severity: Warwick‐Edinburgh Mental Wellbeing Scale at end of treatment Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 1.11 Cost‐effectiveness Show forest plot | 1 | Other data | No numeric data | |
| 1.12 Utilisation of services: community mental health contacts over 6 months' follow‐up Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 2.1 Death: number of deaths during study period Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 2.2 Death: number of deaths during study period (worst‐case scenario; sensitivity analysis) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 2.3 Self‐harm (SH): mean number of SH episodes at 12 months Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 2.4 Suicidality: mean number of suicide attempts over preceding 2 weeks at 12 months Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 2.5 Violence perpetration: number of participants who perpetrated violence during study period Show forest plot | 1 | Risk Ratio (IV, Fixed, 95% CI) | Totals not selected | |
| 2.6 Violence perpetration: number of participants who perpetrated violence during study period (worst case scenario; sensitivity analysis) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 2.7 Mean number of days of inpatient mental health care Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 2.8 Satisfaction with services: Client Satisfaction Questionnaire at end of treatment Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
