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What combination of treatment components is sufficient for early intervention for young people with borderline personality disorder (BPD)?
In this randomized clinical trial with 139 youth with BPD, a dedicated BPD service model and a specialized BPD psychotherapy were associated with superior retention in care but not a superior rate of change in psychosocial functioning by 12 months, compared with general youth mental health care and a psychotherapy control condition.
Effective early intervention for BPD is not reliant on availability of BPD psychotherapy.
Clinical trials have neither focused on early intervention for psychosocial impairment nor on the contribution of components of borderline personality disorder (BPD) treatment beyond individual psychotherapy.
To evaluate the effectiveness of 3 early interventions for BPD of differing complexity.
Design, Settings, and Participants
This single-blinded randomized clinical trial recruited young people between March 17, 2011, and September 30, 2015, into parallel groups. The study took place at 2 government-funded mental health services for young people in Melbourne, Australia. Inclusion criteria were age 15 to 25 years (inclusive), recent DSM-IV-TR BPD diagnosis, and never receiving evidence-based BPD treatment. A total of 139 participants were randomized (pool of 876; 70 declined, 667 excluded), balanced for sex, age, and depressive symptomatology. Data analysis completed May 2020.
(1) The Helping Young People Early (HYPE) dedicated BPD service model for young people, combined with weekly cognitive analytic therapy (CAT); (2) HYPE combined with a weekly befriending psychotherapy control condition; and (3) a general youth mental health service (YMHS) model, combined with befriending. Therefore, the 3 treatment arms were HYPE + CAT, HYPE + befriending, and YMHS + befriending. Participants were randomly assigned both to 1 treatment arm (in a 1:1:1 ratio) and to a clinician.
Main Outcomes and Measures
Psychosocial functioning, measured with the Inventory of Interpersonal Problems Circumplex Version and the Social Adjustment Scale Self-report.
One hundred twenty-eight participants (104 [81.3%] were female; mean [SD] age, 19.1 [2.8] years; HYPE + CAT: 40 [31.3%]; HYPE + befriending: 45 [35.2%]; YMHS + befriending: 43 [33.6%]) who provided postbaseline data were included in the intent-to-treat analysis. Regardless of group, from baseline to 12 months, there was a mean of 19.3% to 23.8% improvement in the primary outcomes and 40.7% to 52.7% for all secondary outcomes, except severity of substance use and client satisfaction. The latter remained high across all time points. Planned comparisons (YMHS + befriending vs HYPE; HYPE + CAT vs befriending) showed that neither the service model nor the psychotherapy intervention was associated with a superior rate of change in psychosocial functioning by the 12-month primary end point. The HYPE service model was superior to YMHS + befriending for treatment attendance (median [IQR], 22  vs 3  contacts; median duration, 200 [139.5] vs 94  days) and treatment completion (44 of 92 [47.8%] vs 9 of 47 [19.2%]). HYPE + CAT was superior to befriending for treatment attendance (median [IQR], 12 [16.5] vs 3 [9.8] sessions) and treatment completion (24 of 46 [52.2%] vs 29 of 93 [31.2%]).
Conclusions and Relevance
In this randomized clinical trial of 3 interventions for young people with BPD, effective early intervention was not reliant on availability of specialist psychotherapy but did require youth-oriented clinical case management and psychiatric care. A dedicated early intervention BPD service model (HYPE), with or without individual psychotherapy, achieved greater treatment attendance and completion, making it more likely to meet service user, family, and community expectations of care.
anzctr.org.au Identifier: ACTRN12610000100099
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Andrew M. Chanen, MBBS(Hons), PhD, 35 Poplar Rd, Locked Bag 10, Parkville, VIC 3052, Australia (email@example.com).
Accepted for Publication: October 22, 2021.
Published Online: December 15, 2021. doi:10.1001/jamapsychiatry.2021.3637
Author Contributions: Profs Chanen and Cotton had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Chanen, Jackson, Cotton, Gleeson, Davey, McCutcheon.
Acquisition, analysis, or interpretation of data: Chanen, Betts, Cotton, Davey, Thompson, Perera, Rayner, Andrewes.
Drafting of the manuscript: Chanen, Betts, Jackson, Cotton, Gleeson, Davey, Andrewes.
Critical revision of the manuscript for important intellectual content: Jackson, Cotton, Gleeson, Davey, Thompson, Perera, Rayner, McCutcheon.
Statistical analysis: Betts, Cotton, Andrewes.
Obtained funding: Chanen, Jackson, Cotton, Gleeson, Davey, McCutcheon.
Administrative, technical, or material support: Chanen, Betts, Cotton, Gleeson, Davey, Perera, Rayner, McCutcheon.
Supervision: Chanen, Betts, Jackson, Gleeson, Davey, McCutcheon.
Conflict of Interest Disclosures: Prof Chanen reported grants from the Australian government’s National Health and Medical Research Council (NHMRC) during the conduct of the study and other support from the Helping Young People Early (HYPE) translational program outside the submitted work. Profs Chanen and McCutcheon cofounded and lead the HYPE clinical program, a government-funded program with continuous funding, and the HYPE translational program, which is a not-for-profit training program. No other disclosures were reported.
Funding/Support: This trial was funded by the National Health and Medical Research Council (NHMRC) (grant GNT0628739). NHMRC Career Development Fellowship supported Prof Cotton (APP1061998) and Prof Davey (APP1061757).
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Data Sharing Statement: See Supplement 3.
Additional Contributions: The authors wish to thank the clients, families, and staff of the Helping Young People Early program at Orygen and Headspace Sunshine, and also Sarah Bendall, PhD, PGDipClinPsych, MA, Orygen and the Centre for Youth Mental Health, University of Melbourne, for training and supervising clinicians performing the befriending intervention and Patrick McGorry, MD, PhD, Orygen and the Centre for Youth Mental Health, University of Melbourne, for feedback on an earlier version of this manuscript. Drs Bendall and McGorry did not receive compensation for their contribution. This study is dedicated to the 3 young participants who died during the course of this study and to their families and friends.
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