A systematic review of the literature

Transcription

1 A systematic review of the literature April 2009 Review of national and international clinical practice guidelines for the management of Borderline Personality Disorder Nimita Arora Adele Weston

2 This report should be referenced as follows: Arora, N and Weston, A. Review of national and international clinical practice guidelines for the management of Borderline Personality Disorder: a systematic review. HSAC Report 2009; 2(2) Health Services Assessment Collaboration (HSAC), University of Canterbury ISBN (online) ISBN (print) ISSN (online) ISSN X (print)

3 i Review Team The review has been undertaken by the Health Services Assessment Collaboration (HSAC). HSAC is a collaboration of the Health Sciences Centre of the University of Canterbury, New Zealand and Health Technology Analysts, Sydney, Australia. The primary reviewer contact for this project is Dr Adele Weston. Nimita Arora is the primary analyst working on this project. Acknowledgements Dr Sarah Norris (HSAC Director) reviewed the final draft. Cecilia Tolan and Lynn Wohlfiel provided administrative support. The review was conducted under the auspices of a contract funded by the New Zealand Ministry of Health. The report was requested by the Mental Health team of the Population Health Directorate. This review, together with two recent Cochrane systematic reviews on pharmacological and psychosocial interventions for borderline personality disorder, will ultimately be used by the New Zealand Ministry of Health and stakeholders to inform policy decision making in conjunction with other information. The content of this review alone does not constitute clinical advice or policy recommendations. Copyright Statement & Disclaimer This report is copyright. Apart from any use as permitted under the Copyright Act 1994, no part may be reproduced by any process without written permission from HSAC. Requests and inquiries concerning reproduction and rights should be directed to the Director, Health Services Assessment Collaboration, Health Sciences Centre, University of Canterbury, Private Bag 4800, Christchurch, New Zealand HSAC takes great care to ensure the accuracy of the information in this report, but neither HSAC, the University of Canterbury, Health Technology Analysts Pty Ltd nor the Ministry of Health make any representations or warranties in respect of the accuracy or quality of the information, or accept responsibility for the accuracy, correctness, completeness or use of this report. The reader should always consult the original database from which each abstract is derived along with the original articles before making decisions based on a document or abstract. All responsibility for action based on any information in this report rests with the reader. This report is not intended to be used as personal health advice. People seeking individual medical advice should contact their physician or health professional. The views expressed in this report are those of HSAC and do not necessarily represent those of the University of Canterbury New Zealand, Health Technology Analysts Pty Ltd, Australia or the Ministry of Health. Review of national and international clinical practice guidelines for the management of BPD: a systematic review

4 ii Contact Details Health Services Assessment Collaboration (HSAC) Health Sciences Centre University of Canterbury Private Bag 4800 Christchurch 8140 New Zealand Tel: Fax: hsac@canterbury.ac.nz Web Site:

5 iii Executive Summary The purpose of this review is to systematically identify and summarise national and international clinical practice guidelines (CPGs) relating to the management of borderline personality disorder (BPD). The review is not limited to interventions, but also includes broader management issues such as diagnosis of the condition, and consideration of the setting in which the treatment is administered. While the report is not intended to be a systematic review of evidence per se, the methodology used to undertake the review was systematic in approach and broadly based upon guidelines published by the NHMRC (2000a, 2000b, 2005). Relevant CPGs were identified through searching international clinical practice guideline clearinghouses, EMBASE and the grey literature. After applying a priori inclusion and exclusion criteria, three guidelines were identified as eligible for inclusion in this review: National Institute for Health and Clinical Excellence (2009) BPD: treatment and management (full guideline) Practice guideline for the treatment of patients with BPD (2001) American Psychiatric Association. American Journal of Psychiatry 158:1-52. Herpertz S, Zanarini M, Schulz C, Siever L, Lieb K, and Moller HJ. (2007) World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of personality disorders. World Journal of Biological Psychiatry 8: Quality assessment of the CPGs was undertaken using the AGREE tool (AGREE collaboration, 2001). Relevant recommendations from the three guidelines were subsequently extracted, compared and qualitatively discussed. While the NICE and APA guidelines are relatively comprehensive and attempt to cover a broad range of issues associated with the management of patients with BPD, the WFSBP guideline is much narrower in scope, focusing on the role of pharmacological interventions. The guidelines generally agree that psychological therapy should be the cornerstone of effective treatment; however they present differing views on the manner in which psychological care should be delivered. While the NICE guideline advocates a multidisciplinary team-based approach to patient care, the APA guideline focuses on the role of psychiatrists. The APA guideline also differs to the NICE guideline in its more permissive attitude towards hospitalisation in the event of a crisis. The final marked point of difference between the three guidelines is their approach to the role of pharmacotherapy in the management of BPD. While the APA and WFSBP guidelines include pharmacological interventions as viable treatment options (especially as an adjunct to psychological treatment), the NICE guideline emphatically recommends against all forms of drug treatment, unless it is in response to a crisis. Finally, the three guidelines were contrasted with the advice included in a discussion paper written by Krawitz and Watson (1999) for the New Zealand Mental Health Commission. It was found that while the Krawitz and Watson discussion paper is now relatively outdated and is not based on a systematic review of the literature, its general principles have more in common with the NICE guideline than the APA guideline.

6 iv Table of Contents Review Team...i Acknowledgements...i Copyright Statement & Disclaimer...i Contact Details...ii Executive Summary...iii Table of Contents...iv List of Tables...vi Introduction...1 Systematic Review of the Literature...3 Literature search...3 Summary of eligible clinical practice guidelines...6 NICE Guidelines...6 APA Guidelines...6 WFSBP Guidelines...7 Quality Assessment of Clinical Practice Guidelines...9 Appraisal of Guidelines Research and Evaluation (AGREE) Instrument...9 Summary of AGREE appraisal...10 NICE Guidelines...10 APA Guidelines...10 WFSBP Guidelines...11 Summary of Recommendations...13 Experience of care...14 Psychological Treatment...16 Pharmacological Treatment...20 Management of crises...29 Configuration of services...32 Young people with BPD...39 Discussion...41 NZ Mental Health Commission (Krawitz & Watson, 1999)...43 References...45 Appendix A...49 PsychINFO and CINAHL searches...49 PsycINFO search strategy...49 CINAHL search strategy...50 Appendix B: AGREE Scores...51 NICE Guidelines (Reviewer 1)...51 NICE Guidelines (Reviewer 2)...55 APA Guidelines (Reviewer 1)...61 APA Guidelines (Reviewer 2)...66

7 v WFSBP Guidelines (Reviewer 1)...71 WFSBP Guidelines (Reviewer 2)...76 Appendix C: Extraction of Recommendations...81 NICE Guidelines...81 APA Guidelines...93 WFSBP Guidelines...97

8 vi List of Tables Table 1: DSM-IV criteria for BPD...1 Table 2: Search strategy for CPGs in BPD...3 Table 3: Exclusion criteria for CPGs...4 Table 4: Included and excluded citations...4 Table 5: Guidelines identified from CPG databases and clearinghouses...5 Table 6: CPGs eligible for inclusion in review...6 Table 7: Domain specific score assigned to each guideline...10 Table 8: Recommendations about experience of care in BPD...15 Table 9: Recommendations about psychological treatment in BPD...17 Table 10: Recommendations about pharmacological treatment in BPD...21 Table 11: Recommendations about the management of crises...29 Table 12: Recommendations about the configuration of services for patients with BPD...33 Table 13: Recommendations about the configuration of services for patients with BPD...40

9 1 Introduction Borderline Personality Disorder (BPD), also known as Emotionally Unstable Personality Disorder, is a condition historically considered to lie between psychosis and neurosis. The condition is characterised by a pervasive pattern of instability in affective regulation, impulse control, interpersonal relationships, and self-image. Causal factors are only partly known, but genetic factors and adverse events during childhood, such as physical and sexual abuse, contribute to the development of the disorder. The nature of the condition is somewhat controversial; however the condition has both a DSM-IV and ICD-10 classification. The DSM-IV criteria for a diagnosis of BPD are presented in Table 1 below: Table 1: Affective criteria Cognitive criteria Behavioural criteria Interpersonal criteria DSM-IV criteria for BPD Inappropriate intense anger or difficulty controlling anger (eg, frequent displays of temper, constant anger, recurrent physical fights) Chronic feelings of emptiness Affective instability due to a marked reactivity of mood (eg, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) Transient stress-related paranoid ideation or severe dissociative symptoms Identity disturbance: striking and persistent unstable self-image or sense of self Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour Impulsivity in at least two areas that are potentially self-damaging that do not include suicidal or self-mutilating behaviour Frantic efforts to avoid real or imagined abandonment that do not include suicidal or self-mutilating behaviour A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation Abbreviations: BPD, Borderline Personality Disorder; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders IV Notes: Adapted by Lieb et al. (2004) Until recently, the prevalence of BPD was estimated to be about 2% of the general population (Swartz et al., 1990); however the results of a 2008 study of 35,000 American adults suggest that the lifetime prevalence is much higher at 5.9% (Grant et al., 2008). It was also previously thought that the diagnosis was several times more common in (especially young) women than in men (DSM-IV-TR 2000); however the same recent study by Grant et al. (2008) found no significant differences in the rates of BPD among men and women. The course of this disorder is quite variable. Whilst short-term outcomes are less favourable, long term follow-up suggests that many patients ultimately cease to meet the criteria for BPD. Nonetheless, the disorder can have serious consequences, with a reported suicide rate of ten percent (Paris, 2002). Patients often need extensive mental health services, and account for 20 percent of psychiatric hospitalisations (Zanarini et al., 2001). BPD is also very damaging to sufferers quality of life with recurrent job losses, interrupted education, and broken marriages commonly experienced. The condition is often misdiagnosed in adolescent patients, due to the fact that their personalities are still forming. BPD is often comorbid with mood disorders, substance-related disorders, eating disorders (usually bulimia), posttraumatic stress disorder, attention-deficit/hyperactivity disorder, and other personality disorders. This can make diagnosis, and assessment of the effectiveness of interventions, problematic. In spite of these complexities, there is a growing belief amongst

10 2 clinicians that BPD is a highly treatable disorder. The last several years have seen the completion of numerous RCTs of psychotherapies for borderline illness, and there is now a sufficient body of research to support the development of evidence-based guidelines for the treatment of BPD. The objective of this report is to provide a systematic review of existing clinical practice guidelines (CPGs) for the treatment of BPD. Quality assessment of eligible CPGs will be undertaken, in this case using the AGREE tool designed specifically for the quality assessment of CPGs (AGREE collaboration, 2001).

11 3 Systematic Review of the Literature Literature search The review methodology used in this review is broadly based upon guidelines published by the NHMRC (2000a, b, 2005); however the systematic review process has been modified so as to be suitable for a review of CPGs. The initial step in the review process was to undertake a comprehensive literature search including EMBASE, the Cochrane Library, PsychINFO, CINAHL and various CPG databases/clearinghouses. The exact terms used and number of citations found in the EMBASE, Cochrane Library, PsychINFO and CINAHL searches are presented in Table 2 below. Full details of the PsychoINFO and CINAHL searches are provided in Appendix A. Table 2: Search strategy for CPGs in BPD Database Search terms Title/ Abstract review EMBASE (08/12/08) Cochrane (08/12/08) PsychINFO and CINAHL ('emotionally unstable personality' OR 'borderline type' OR 'f60.31' OR 'borderland' OR 'bpd' OR 'borderline state'/syn) AND ('clinical practice guidelines'/syn OR 'treatment guidelines' OR 'management guidelines' OR'clinical guidelines' OR 'evidence based guidelines' OR 'consensus guidelines') AND [ ]/py 'BPD' AND 'guideline' 0 0 Refer to Table 1 and Table 2 in Appendix A 80 0 Total a Full text review Abbreviations: BPD, Borderline Personality Disorder; CINAHL, Cumulative Index to Nursing and Allied Health Literature; CPG, Clinical Practice Guideline; EMBASE, Excerpta Medica Database a duplicates were removed manually The searches collectively identified 566 citations which were subsequently reviewed by title and abstract. This list was narrowed down to those citations that presented evidence-based recommendations relevant to BPD. Systematic reviews of evidence that did not make specific recommendations were considered to be ineligible. For example, there are two recent systematic reviews undertaken by the Cochrane Collaboration looking at the efficacy of pharmacological interventions (Binks et al., 2006a) and psychological treatments (Binks et al., 2006b) for BPD. Further eligibility requirements were that CPGs should be relatively recent (i.e. published after 1999), written in English and four or more pages in length. A summary of the exclusion criteria used for the identification of eligible CPGs is presented in Table 3.

12 4 Table 3: Exclusion criteria for CPGs Not BPD Not a CPG Published prior to 1999 Not in English Publications were excluded if the guidance presented did not relate specifically to BPD. Publications were excluded if they were not clinical practice guidelines (e.g. original studies, reviews and systematic reviews of the literature). Only CPGs published after 1999 were eligible for inclusion in this review. Eligible CPGs were restricted to those published in English. < 4 pages CPGs of less than four pates were excluded. Not evidencebased CPGs should be based on the systematic identification and synthesis of the best available scientific evidence. Abbreviations: BPD, Borderline Personality Disorder; CPG, Clinical Practice Guideline Following the title/abstract review, 14 papers were subject to a full text review in which the same exclusion criteria were applied. All citations that were reviewed in full text are listed in Table 4, along with reasons for exclusion or inclusion. Two citations were identified as eligible for inclusion in this review: one guideline produced by the American Psychiatric Association in 2001, and another produced by the World Federation of Societies of Biological Psychiatry (WFSBP) in 2007 (Herpetz et al., 2007). Table 4: Included and excluded citations Citation Included/excluded Included Practice guideline for the treatment of patients with BPD (2001) American Psychiatric Association. American Journal of Psychiatry 158:1-52. Herpertz S, Zanarini M, Schulz C, Siever L, Lieb K, and Moller HJ. (2007) World federation of societies of biological psychiatry (WFSBP) guidelines for biological treatment of personality disorders. World Journal of Biological Psychiatry 8: Excluded Bellino S, Paradiso E, Fenocchio M, and Bogetto F. (2007) Pharmacological treatment of BPD: Guidelines and research findings. Minerva Psichiatrica 48: Durham JD, Arthur Grube RR, and Fuller SH. (2007) BPD. U. S. Pharmacist 32:52-58 (copyright) Jobson Medical Information LLC McGlashan TH. (2002) The BPD practice guidelines: The good, the bad, and the realistic. Journal of Personality Disorders 16: Morana HCP and Camara FP. (2006) International guidelines for the management of personality disorders. Current Opinion in Psychiatry 19: Nissen T. (2000) Psychopharmacological treatment of BPD. Tidsskrift for den Norske Laegeforening 120: Renaud S and Lecomte Y. (2003) Guidelines for the treatment of patients with BPD. Sante mentale au Quebec 28: Stone MH. (2000) Clinical guidelines for psychotherapy for patients with BPD. Psychiatric Clinics of North America 23: Turbott J. (2004) Treatment of BPD. Australasian Psychiatry 12:289. Tyrer P and Duggan C. (2008) NICE guidelines for the treatment of personality disorder. Psychiatry 7: (copyright) 2008 Tyrer P. (2002) Practice guideline for the treatment of BPD: A bridge too far. Journal of Personality Disorders 16: Included Included Not in English Not evidence-based Not a CPG Not evidence-based Not in English Not evidence-based Not evidence-based Not evidence-based Not a CPG Not a CPG

13 5 Table 4: Included and excluded citations (continued) Verheul R and Herbrink M. (2007) The efficacy of various modalities of psychotherapy for personality disorders: A systematic review of the evidence and clinical recommendations. International Review of Psychiatry 19: (copyright) 2007 Informa UK Ltd Woeller W and Tress W. (2005) Psychotherapeutic treatment of personality disorders. Zeitschrift fur Psychosomatische Medizin und Psychotherapie. 51: Not a CPG Not in English Abbreviations: BPD, Borderline Personality Disorder; CPG, Clinical Practice Guideline In addition to the aforementioned search, a search of CPG databases and clearinghouses was undertaken. A full list of searched databases and the guidelines identified in each search is presented in Table 5. Table 5: Database Guidelines identified from CPG databases and clearinghouses Guidelines identified US National Guidelines Clearing House CMA Infobase Guidelines International Network (G-I-N) National Institute for Clinical Excellence NLH National Library of Guidelines (U.K.) New Zealand Guidelines Group Scottish Intercollegiate Guidelines Network Recommended Clinical Practice Guidelines Recommended Clinical Practice Guidelines Abbreviations: BPD, Borderline Personality Disorder Practice guideline for the treatment of patients with BPD (2001) American Psychiatric Association. American Journal of Psychiatry 158:1-52. None Practice guideline for the treatment of patients with BPD (2001) American Psychiatric Association. American Journal of Psychiatry 158:1-52. National Institute for Health and Clinical Excellence (2009) BPD: treatment and management (full guideline) None None None None None Two individual guidelines were identified: a practice guideline produced by the American Psychiatric Association (APA, 2001), and a recently published CPG by National Institute for Health and Excellence (NICE, 2009). Since the APA guideline was also identified in the EMBASE search, there are in total, three guidelines eligible for consideration in this review. These are summarised in Table 6.

14 6 Table 6: Guideline NICE Guideline CPGs eligible for inclusion in review Included documents National Institute for Health and Clinical Excellence (2009) BPD: treatment and management (full guideline) National Institute for Health and Clinical Excellence (2009) BPD (costing report) APA Guideline National Institute for Health and Clinical Excellence (2009) BPD (quick reference guide) Practice guideline for the treatment of patients with BPD (2001) American Psychiatric Association. American Journal of Psychiatry 158:1-52. WFSBP Guideline Oldham JM (2005) Guideline Watch: Practice Guideline for the Treatment of Patients with BPD. Available at: Accessed December 11, 2008 American Psychiatric Association (2006). Treating BPD: a quick reference guide. Available at: Accessed December 11, 2008 Herpertz S, Zanarini M, Schulz C, Siever L, Lieb K, and Moller HJ. (2007) World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of personality disorders. World Journal of Biological Psychiatry 8: Abbreviations: BPD, Borderline Personality Disorder; APA, American Psychiatric Association; NICE, National Institute of Clinical Excellence; WFSBP, World Federation of Societies of Biological Psychiatry Summary of eligible clinical practice guidelines NICE Guidelines The National Institute for Health and Clinical Excellence (NICE) practice guideline entitled BPD: treatment and management was published in January The guideline was designed to provide advice to clinicians and service commissioners on the treatment and management of BPD. A range of evidence-based clinical practice recommendations are made in relation to management of BPD in primary and secondary care, as well as the organisation and planning of services. Where research-based evidence is not available, consensus by experts, patients and carers forms the basis of this guideline. The guideline also makes a number of research recommendations to address gaps in the evidence base. Future revisions of the guideline are planned to incorporate new scientific evidence as it develops. To assist with the implementation of NICE guidance, the guideline is accompanied by a separate costing report and clinical reference guide, both of which are available on the NICE website. APA Guidelines The American Psychiatric Association (APA) published a practice guideline in 2001 for the treatment of patients with BPD. This guideline presents a set of best practice recommendations for the psychiatric community, using a symptom-targeted approach. Based on a systematic review of the literature, psychotherapy was designated as the primary treatment, with pharmacotherapy recommended as an adjunctive, symptom-targeted component of treatment. Where insufficient evidence was available, recommendations were based on clinical consensus. Specific algorithms were developed to guide clinicians in the use of psychotropic medications. These medication algorithms address three clusters of BPD symptoms: Cognitive-perceptual symptoms Affective dysregulation Impulsive-behavioural dyscontrol

15 7 A Guideline Watch summarising significant developments in practice since the publication of the original guideline, was published in March 2005 and is available from the American Psychiatric Association Web site. The website also provides access to a quick reference guide which is intended to assist clinical decision-making by distilling key points from the full guideline. WFSBP Guidelines This guideline, published in January 2007, was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The guideline relates specifically to the biological treatment of personality disorders in primary care settings. The recommendations are based on the results of a systematic review of all available clinical and scientific evidence pertaining to the biological treatment of three personality disorders: borderline, schizotypal and anxious/avoidant personality disorder. The guideline covers disease definition, classification, epidemiology, course and current knowledge on biological underpinnings, and provides an evidence-based overview of clinical management. It deals primarily with biological treatments including antidepressants, neuroleptics, mood stabilizers and other pharmacological agents.

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17 9 Quality Assessment of Clinical Practice Guidelines Appraisal of Guidelines Research and Evaluation (AGREE) Instrument Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances (Field & Lohr 1990). A guideline s main purpose is to achieve better health outcomes by improving the practice of health professionals and providing consumers with better information about treatment options. Given the growing role of CPGs in advising the course of clinical practice, it is imperative that there are well-validated tools available to assess the quality of guidelines and measure their impact on health outcomes. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was developed by a group of researchers from 13 countries to provide a systematic framework for assessing guideline quality. This instrument was thoroughly evaluated and refined and is now a commonly used assessment instrument for CPGs (MacDermid et al., 2004). The AGREE instrument consists of 23 key items which are intended to collectively reflect guideline quality. The items are categorised into the following six domains: Scope and purpose are concerned with the overall aim of the guideline, the specific clinical questions and the target patient population Stakeholder involvement focuses on the extent to which the guideline represents the views of its intended users Rigor of development relates to the process used to gather and synthesize the evidence, and the methods used to formulate the recommendations and to update them Clarity and presentation deal with the language and format of the guideline Applicability pertains to the likely organizational, behavioural and cost implications of applying the guideline Editorial independence is concerned with the independence of the recommendations and acknowledgement of possible conflict of interest from the guideline development group Each item is scored from 1 (complete disagreement) to 4 (complete agreement). The instrument accommodates marking by multiple raters. In this review, each CPG was independently scored by two reviewers, and the results were averaged. A final score for each domain was arrived at using the following method proposed by AGREE: Obtained score minimum possible score Maximum possible score minimum possible score

18 10 Summary of AGREE appraisal A domain-specific score for each guideline was calculated using the above-cited formula, and the results are presented in Table 7 below. Full AGREE evaluations by each rater for each guideline are available in Appendix B of this report. Table 7: Scope and purpose Domain specific score assigned to each guideline Stakeholder involvement Rigour and development Clarity and presentation Applicability NICE a 94.44% 66.67% 78.57% 91.67% 72.22% 83.33% APA b 66.67% 37.50% 71.43% 87.50% 44.44% 75.00% WFSBP c 33.33% 25.00% 42.86% 33.33% 0.00% 75.00% Editorial independence a National Institute for Clinical Excellence (NICE). BPD: Treatment and Management (draft for consultation) b American Psychiatric Association (2001). Practice Guideline for the Treatment of Patients with BPD. American Journal of Psychiatry 158:1-52 c Herpertz S, Zanarini M, Schulz C, Siever L, Lieb K, and Moller HJ. (2007) World federation of societies of biological psychiatry (WFSBP) guidelines for biological treatment of personality disorders. World Journal of Biological Psychiatry 8: NICE Guidelines The results of the evaluation show that the NICE guideline is superior or equivalent to the other CPGs in every domain. This is not surprising given that the NICE guidelines were almost certainly developed according to the methodology promoted by the AGREE collaboration. The CPG is thorough in scope and purpose, with clearly stated objectives, clinical questions and target patient group. The development process for this guideline was rigorous, including input from service users/carers, professional stakeholders, commercial stakeholders, government stakeholders, Primary Care Trusts and patients. While there was considerable time allowed for feedback after the publication of draft guidelines, the CPG was penalised for not having been formally piloted. The systematic review was comprehensive, and the methods used to undertake the search and synthesis of evidence are presented in thorough detail. It was noted that the guidelines could have included better cross-referencing between the final list of recommendations and chapters describing the literature review and formulation of recommendations. The recommendations are relatively specific, however it is unclear which are evidence-based, and which are based on consensus and patient/carer accounts. The NICE guidance would also be more meaningful if it included a grading system to reflect clinical confidence for individual recommendations. The NICE guideline scores strongly in clarity/presentation and applicability, although it lacks key review criteria for monitoring and/or audit purposes. The introduction refers to future revisions of the CPG; however the procedures for carrying out the update are not provided. The CPG was also judged as editorially independent with no conflicts of interest. APA Guidelines The APA guideline was published in the same year as the AGREE instrument (2001) and as such, was developed to comply with a different set of standards. The methods used to develop these guidelines are described in a document available on the APA website, titled Practice Guideline Development Process.

19 11 The guideline is adequate in terms of scope and purpose; however it is not as specific as the NICE guideline and does not present key clinical questions in as much detail. The CPG also failed to adequately involve stakeholders and patients during its development. The systematic review supporting the recommendations in the guideline appears to be thorough, however some methodological details (e.g. inclusion/exclusion criteria for citations) are not provided. The recommendations in the CPG are generally clear, and it is worth noting that some perceived ambiguity reflects the poor evidence base in BPD at the time the CPG was written. As was the case for the NICE guidelines, the CPG also fails to clearly identify which recommendations are evidence-based and which are consensus-based. Unlike the NICE guidelines, the APA recommendations are presented with a grading to denote clinical confidence. Applicability issues are well presented; however the CPG does not provide specific review criteria that could assist in the conduct of an audit to measure the impact of the guidelines. The CPG was also judged as editorially independent with no conflicts of interest. WFSBP Guidelines The WFSBP guidelines scored the most poorly out of the three CPGs. This is partially due to the fact that they were only disseminated via publication in a journal (Herpetz et al., 2007) and were thus restricted in length and scope. Areas such as applicability and stakeholder involvement were particularly lacking in detail. The CPG scored most highly in editorial independence and rigour of development, although some items pertaining to the methodology of the systematic review and synthesis of recommendations were penalised due to a lack of detail.

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21 13 Summary of Recommendations The three guidelines included in the scope of this review adopt different approaches to the presentation of recommendations. The NICE guidelines present recommendations in categories relating to stages of management in BPD, including: General principles for working with people with BPD Recognition and management in primary care Assessment and management by community mental health services Inpatient services Organisation and planning of services As mentioned previously, it is not made clear which recommendations are evidence-based, and which are based on consensus and patient/carer accounts. Nor does the NICE guideline include a grading system to indicate the strength of evidence or level of clinical confidence associated with individual recommendations. The APA guideline presents specific algorithms which are related to the three main symptom categories: cognitive-perceptual symptoms, affective disturbance, and impulsive-behavioural dyscontrol. There is some controversy about whether a symptom-targeted approach is sufficiently evidence based, or may favour the practice of poly-pharmacy frequently observed in BPD (Herpetz et al., 2007). Recommendations are presented in the Section I Executive Summary of Recommendations. Each recommendation is graded according to the level of clinical confidence with which it was made, indicated by a bracketed Roman numeral following the statement. The coding system used to grade the recommendations is presented below: [I] Recommended with substantial clinical confidence [II] Recommended with moderate clinical confidence [III] May be recommended on the basis of individual circumstances Individual recommendations are explained and elaborated upon in Sections II-IV, under the following headings: Formulation and Implementation of a Treatment Plan Special Features Influencing Treatment Risk Management Issues Where a particular issue is not the subject of a specific recommendation in Section I, this review refers to the advice contained in Sections II-IV. In addition to the evidence-based recommendations, the APA guideline includes some consensus-based recommendations that were based on an informal assessment of the qualitative literature and expert opinion. As was the case for the NICE guideline, consensus-based and evidence-based pieces of guidance are not clearly differentiated from each other. The WFSBP guidelines present information according to pharmaceutical drug-class, with the goal of providing healthcare providers with information that allows them to select the drug best-suited to the psychopathology of an individual patient. Most of the recommendations included in the WFSBP document are evidence-based; however the guidelines also subsume the opinions of a range of experts in BPD.

22 14 In the current report, the recommendations presented in each of the CPGs are compared and discussed under the following subject headings: Experience of care Psychological treatments Pharmacological treatments Management of crises Configuration of services Inpatient admission Young people with BPD For each guideline, a list of all extracted recommendations is presented in Appendix C. The numbering system for NICE recommendations is identical to that used in the published guideline. Recommendations in the APA and WFSBP guidelines were not numbered in the original reports, so a numbering system has been applied post hoc. The numbering system used in Appendix C is applied in the referencing of recommendations throughout this report. Experience of care Experience of care includes recommendations about how patients should be managed in order to maximise their satisfaction with the health-care process. The NICE and APA guidelines both provide advice on experience of care, while the WFSBP guideline does not include this topic within its scope. Recommendations categorised under this heading are presented in Table 8.

23 15 Table 8: NICE Access to services Recommendations about experience of care in BPD People with BPD should not be excluded from any health or social care service because of their diagnosis or because they have self-harmed. Developing an optimistic and trusting relationship When working with people with BPD: explore treatment options in an atmosphere of hope and optimism, explaining that recovery is possible and attainable build a trusting relationship, work in an open, engaging and non-judgemental manner, and be consistent and reliable bear in mind when providing services that many people will have experienced rejection, abuse and trauma, and encountered stigma often associated with self-harm and BPD Involving families or carers Ask directly whether the person with BPD wants their family or carers to be involved in their care, and, subject to the person's consent and rights to confidentiality: encourage family or carers to be involved ensure that the involvement of families or carers does not lead to withdrawal of, or lack of access to, services inform families or carers about local support groups for families or carers, if these exist APA Not specifically addressed in recommendations. Not specifically addressed in recommendations; however in Section IIB (Principles of Psychiatric Management), the guideline notes the importance of establishing a therapeutic framework and alliance. [Page 11, C.4a, R6] While data on family therapy are also limited, they suggest that a psychoeducational approach may be beneficial [II]. [Page 11, C.4a, R7] Published clinical reports differ in their recommendations about the appropriateness of family therapy and family involvement in the treatment; family therapy is not recommended as the only form of treatment for patients with BPD [II]. In Section IID (Specific Treatment Strategies for the Clinical Features of BPD) it is further noted that "family work is most apt to be helpful and can be of critical importance when patients with BPD have significant involvement" with, or are financially dependent on, the family. Principles for healthcare professionals undertaking assessment When assessing a person with BPD: explain clearly the process of assessment use non-technical language whenever possible explain the diagnosis and the use and meaning of the term BPD offer post-assessment support, particularly if sensitive issues, such as childhood trauma, have been discussed Not specifically addressed in recommendations; however in Section IIB (Principles of Psychiatric Management) and Section IIC (Principles of Treatment Selection) the guideline presents some information about providing education about the disorder principles surrounding patient interactions.

24 16 Table 8: Recommendations about experience of care in BPD (continued) Managing endings and supporting transitions Anticipate that withdrawal and ending of treatments or services, and transition from one service to another, may evoke strong emotions and reactions in people with BPD. Ensure that: such changes are discussed carefully beforehand with the person (and their family or carers if appropriate) and are structured and phased the care plan supports effective collaboration with other care providers during endings and transitions, and includes the opportunity to access services in times of crisis when referring a person for assessment in other services (including for psychological treatment), they are supported during the referral period and arrangements for support are agreed beforehand with them [Page 12, C.6, R1] Attention to risk management issues is important [I]. Risk management considerations include the need for collaboration and communication with any other treating clinicians as well as the need for careful and adequate documentation. Any problems with transference and counter-transference should be attended to, and consultation with a colleague should be considered for unusually high-risk patients. Standard guidelines for terminating treatment should be followed in all cases. Psycho-education about the disorder is often appropriate and helpful. Other clinical features requiring particular consideration of risk management issues are the risk of suicide, the potential for boundary violations, and the potential for angry, impulsive, or violent behaviour. Abbreviations: APA, American Psychiatric Association; BPD, Borderline Personality Disorder; NICE, National Institute of Clinical Excellence The NICE guideline strongly emphasises that no patient with BPD should be excluded from access to health or social care services, and that treatment should be undertaken in an optimistic environment [ and ]. These issues are not explicitly addressed in the APA recommendations; however in Section IIB (Principles of Psychiatric Management), the guideline notes the importance of establishing a therapeutic framework and alliance. The NICE guideline suggests that while involvement of families and carers should be subject to patient preference, their inclusion in the patient s care should be encouraged [ ]. The APA guideline addresses the issue of family involvement in the context of formal therapy rather than general patient care (as per the NICE guideline). The guideline suggests that while family therapy can be helpful, it is not recommended as the only form of treatment for patients with BPD [Page 11, C.4a, R6-R7]. According to the NICE guideline, general principles for healthcare professionals when assessing a person with BPD include using nontechnical language to clearly explain the process of assessment. While they are not the subject of specific recommendations in the APA guideline, some of these issues are very broadly discussed in Section IIB (Principles of Psychiatric Management). The NICE recommendations provide detailed advice about how best to manage endings or transitions from one service or treatment to another. The APA recommendation on this topic is less explicit, stating that standard guidelines for terminating treatment should be followed in all cases. Psychological Treatment Studies on effectiveness of psychotherapeutic interventions meet some special methodological restrictions inherent to psychotherapy research because trials are never performed in a double-blind and placebo-controlled manner. Taking these factors into consideration, both the NICE and APA guidelines suggest that psychotherapy should be the primary approach to treatment of BPD. In the case of the NICE guidelines psychological treatments are the only recommended approach. The WFSBP guideline does not include issues associated with psychological treatment within its scope, but notes that psychotherapeutic regimes have an important place in the treatment of personality disorders. For a full list of recommendations categorised under psychological treatment, refer to Table 9.

25 17 Table 9: NICE Recommendations about psychological treatment in BPD General principles in psychological treatment When considering a psychological treatment for a person with BPD, take into account: the choice and preference of the service user the degree of impairment and severity of the disorder the person s willingness to engage with therapy and their motivation to change the person s ability to remain within the boundaries of a therapeutic relationship the availability of personal and professional support Before offering a psychological treatment for a person with BPD or for a comorbid condition, provide the person with written material about the psychological treatment being considered. For people who have reading difficulties, alternative means of presenting the information should be considered, such as video or DVD. So that the person can make an informed choice, there should be an opportunity for them to discuss not only this information but also the evidence for the effectiveness of different types of psychological treatment for BPD and any comorbid conditions When providing psychological treatment for people with BPD, especially those with multiple comorbidities and/or severe impairment, the following service characteristics should be in place: an explicit and integrated theoretical approach used by both the treatment team and the therapist, which is shared with the service user structured care in accordance with this guideline provision for therapist supervision When providing psychological treatment to people with BPD, monitor the effect of treatment on a broad range of outcomes, including personal functioning, drug and alcohol use, self-harm, depression and the symptoms of BPD APA [Page 10, C.3a, R1] Certain types of psychotherapy (as well as other psychosocial modalities) and certain psychotropic medications are effective in the treatment of BPD [I]. [Page 10, C.3a, R2] Although it has not been empirically established that one approach is more effective than another, clinical experience suggests that most patients with BPD will need extended psychotherapy to attain and maintain lasting improvement in their personality, interpersonal problems, and overall functioning [II]. [Page 10, C.3a, R4] No studies have compared a combination of psychotherapy and pharmacotherapy to either treatment alone, but clinical experience indicates that many patients will benefit most from a combination of these treatments [II]. [Page 11, C.4a, R2] Clinical experience suggests that there are a number of common features that help guide the psychotherapist, regardless of the specific type of therapy used [I]. These features include building a strong therapeutic alliance and monitoring selfdestructive and suicidal behaviours. Some therapists create a hierarchy of priorities to consider in the treatment (e.g., first focusing on suicidal behaviour). Other valuable interventions include validating the patient s suffering and experiences as well as helping the patient take responsibility for his or her actions. Because patients with BPD may exhibit a broad array of strengths and weaknesses, flexibility is a crucial aspect of effective therapy. Other components of effective therapy for patients with BPD include managing feelings (in both patient and therapist), promoting reflection rather than impulsive action, diminishing the patient s tendency to engage in splitting, and setting limits on any self-destructive behaviour.

26 18 Table 9: Recommendations about psychological treatment in BPD (continued) Choice of psychological treatment For women with BPD for whom reducing recurrent self-harm is a priority, consider a comprehensive dialectical behaviour therapy programme. [Page 10, C.4a, R1] Two psychotherapeutic approaches have been shown in randomized controlled trials to have efficacy: psychoanalytic/psychodynamic therapy and dialectical behaviour therapy [I]. The treatment provided in these trials has 3 key features: weekly meetings with an individual therapist, one or more weekly group sessions, and meetings of therapists for consultation/supervision. No results are available from direct comparisons of these two approaches to suggest which patients may respond better to which type of treatment. Although brief therapy for BPD has not been systematically examined, studies of more extended treatment suggest that substantial improvement may not occur until after approximately 1 year of psychotherapeutic intervention has been provided; many patients require even longer treatment. [Page 11, C.4a, R3] Individual psychodynamic psychotherapy without concomitant group therapy or other partial hospital modalities has some empirical support [II]. [Page 11, C.4a, R4] The literature on group therapy or group skills training for patients with BPD is limited but indicates that this treatment may be helpful [II]. Group approaches are usually used in combination with individual therapy and other types of treatment. [Page 11, C.4a, R5] The published literature on couples therapy is limited but suggests that it may be a useful and, at times, essential adjunctive treatment modality. However, it is not recommended as the only form of treatment for patients with BPD [II]. [Page 11, C.4a, R6] While data on family therapy are also limited, they suggest that a psycho-educational approach may be beneficial [II]. Duration and frequency of psychological treatment Do not use brief psychological interventions (of less than 3 months duration) specifically for BPD or for the individual symptoms of the disorder, outside a service that has the characteristics outlined in Although the frequency of psychotherapy sessions should be adapted to the person s needs and context of living, twice-weekly sessions may be considered. [Page 11, C.4a, R7] Published clinical reports differ in their recommendations about the appropriateness of family therapy and family involvement in the treatment; family therapy is not recommended as the only form of treatment for patients with BPD [II]. Not specifically addressed

27 19 Table 9: Organisational issues Recommendations about psychological treatment in BPD (continued) When providing psychological treatment to people with BPD as a specific intervention in their overall treatment and care, use the CPA to clarify the roles of different services, professionals providing psychological treatment and other healthcare professionals. Not specifically addressed Abbreviations: APA, American Psychiatric Association; BPD, Borderline Personality Disorder; NICE, National Institute of Clinical Excellence The NICE recommendations regarding psychological treatment were based on an extremely comprehensive review of psychological and psychosocial treatments, covering arts therapies, brief psychological interventions, complementary therapies, individual psychological therapies, combination therapy, psychological therapy programmes and therapeutic communities. The guideline concluded that the overall evidence base for psychological therapies in the treatment of BPD is relatively poor: there are few studies; low numbers of patients and therefore low power; multiple outcomes with few in common between studies; and a heterogeneous diagnostic system. There is some evidence that psychological therapy programmes, specifically dialectical behavioural therapy (DBT) and mentalisation based therapy (MBT) with partial hospitalisation, are effective in reducing suicide attempts and self-harm, anger, aggression and depression. Nonetheless, the evidence supporting the use of psychological therapies is at best weak and does not suggest that any individual therapy is superior to another. As a result, only a few specific recommendations are made regarding the most appropriate choice of therapy. These include the suggestions that brief psychological interventions (< 3 months) should be avoided [ ], and women with BPD in whom reducing self-harm is a priority should be treated with DBT [ ]. Other recommendations include general principles regarding the delivery of psychological programmes, treatment planning, frequency of sessions, and monitoring of outcomes. The APA guidance is more specific about the relative merits of individual treatments, and seems to favour psychoanalytic therapies over cognitive behavioural therapies. The guidelines recommend with substantial clinical confidence that both psychoanalytic/psychodynamic therapy and dialectical behaviour therapy have demonstrated efficacy in BPD [Page 10, C.4a, R1]. The APA guidelines also discuss the merits of brief psychological interventions, coming to the conclusion that substantial improvement may not occur until after approximately one year of treatment [Page 10, C.4a, R1]. Individual psychodynamic psychotherapy without concomitant group therapy and other partial hospital modalities are recommended with a moderate level of clinical confidence [Page 11, C.4a, R3], as are group therapy and group skills training [Page 11, C.4a, R4]. Couples therapy and/or family therapy (using a psycho-educational approach) may be recommended based on a limited amount of evidence; however neither of these interventions is recommended as the only form of treatment for patients with BPD [Page 11, C.4a, R5-R7].