Short-Term versus Long-Term Mentalization-Based Therapy for Borderline Personality Disorder: A Randomized Clinical Trial (MBT-RCT).

INTRODUCTION: Borderline personality disorder (BPD) is a severe and prevalent psychiatric disorder. Mentalization-based therapy (MBT) is an evidence-based intervention for BPD, and several countries offer treatment programs for BPD lasting for years, which is resource demanding. No previous trial has compared short-term with long-term MBT. OBJECTIVE: The aim of the study was to assess the efficacy and safety of short-term versus long-term MBT for outpatients with BPD. METHODS: Adult outpatients (≥18 years) with subthreshold or diagnosed BPD were randomly assigned (1:1) to short-term MBT (5 months) or long-term MBT (14 months). The primary outcome was BPD symptoms assessed with the Zanarini Rating Scale for Borderline Personality Disorder. Secondary outcomes were functional impairment, quality of life, global functioning, and severe self-harm. All outcomes were primarily assessed at 16 months after randomization. This trial was prospectively registered at ClinicalTrials.gov, NCT03677037. RESULTS: Between October 4, 2018, and December 3, 2020, we randomly assigned 166 participants to short-term MBT (n = 84) or long-term MBT (n = 82). Regression analyses showed no evidence of a difference when assessing BPD symptoms (MD 0.99; 95% CI: -1.06 to 3.03; p = 0.341), level of functioning (MD 1.44; 95% CI: -1.43 to 4.32; p = 0.321), quality of life (MD -0.91; 95% CI: -4.62 to 2.79; p = 0.626), global functioning (MD -2.25; 95% CI: -6.70 to 2.20; p = 0.318), or severe self-harm (RR 1.37; 95% CI: 0.70-2.84; p = 0.335). More participants in the long-term MBT group had a serious adverse event compared with short-term MBT (RR 1.63; 95% CI: 0.94-3.07; p = 0.088), primarily driven by a difference in psychiatric hospitalizations (RR 2.03; 95% CI: 0.99-5.09; p = 0.056). CONCLUSION: Long-term MBT did not lead to lower levels of BPD symptoms, nor did it influence any of the secondary outcomes compared with short-term MBT.

Adverse events in cognitive behavioral therapy and relaxation training for children and adolescents with obsessive-compulsive disorder: A mixed methods study and analysis plan for the TECTO trial.

Background: Knowledge on adverse events in psychotherapy for youth with OCD is sparse. No official guidelines exist for defining or monitoring adverse events in psychotherapy. Recent recommendations call for more qualitative and quantitative assessment of adverse events in psychotherapy trials. This mixed methods study aims to expand knowledge on adverse events in psychotherapy for youth with OCD. Methods: This is an analysis plan for a convergent mixed methods study within a randomized clinical trial (the TECTO trial). We include at least 128 youth aged 8-17 years with obsessive-compulsive disorder (OCD). Participants are randomized to either family-based cognitive behavioral therapy (FCBT) or family-based psychoeducation and relaxation training (FPRT). Adverse events are monitored quantitatively with the Negative Effects Questionnaire. Furthermore, we assess psychiatric symptoms, global functioning, quality of life, and family factors to investigate predictors for adverse events. We conduct semi-structured qualitative interviews with all youths and their parents on their experience of adverse events in FCBT or FPRT. For the mixed methods analysis, we will merge 1) a qualitative content analysis with descriptive statistics comparing the types, frequencies, and severity of adverse events; 2) a qualitative content analysis of the perceived causes for adverse events with prediction models for adverse events; and 3) a thematic analysis of the participants' treatment evaluation with a correlational analysis of adverse events and OCD severity. Discussion: The in-depth mixed methods analysis can inform 1) safer and more effective psychotherapy for OCD; 2) instruments and guidelines for monitoring adverse events; and 3) patient information on potential adverse events. The main limitation is risk of missing data. Trial registration: ClinicalTrials.gov identifier: NCT03595098. Registered on July 23, 2018.

Mentalizing the therapist - Therapist experiences with short-term mentalization-based therapy for borderline personality disorder: A qualitative study.

Background: Mentalization-Based Therapy (MBT) was originally developed as a structured psychotherapy approach developed to treat borderline personality disorder (BPD) lasting up to 18 months in outpatient settings. However, a short-term (5 months) MBT program has recently been developed. No studies have investigated how MBT therapists experience the shift towards conducting short-term MBT for BPD. Objective: The objective of this study was to explore therapist experiences with conducting short-term MBT for outpatients with BPD in the Danish mental health services. Methods: Semi-structured qualitative interviews were conducted with seven therapists about their experiences with short-term MBT after a one-year pilot phase. The interviews were verbatim transcribed and analyzed using thematic analysis. Results: The following four major themes from the therapists' experiences with short-term MBT were found in the qualitative analysis: (1) The longer the better, (2) Change processes can be intellectual or experiential, (3) Short-term therapy is hard work, and (4) Termination is more challenging in short-term MBT. Conclusion: Most therapists were overall reluctant towards changing from long-term to short-term MBT. These therapist experiences could inform implementation of short-term MBT in mental health settings in the future.

Dropout from mentalization-based group treatment for adolescents with borderline personality features: A qualitative study.

Objective: Premature termination, or dropout, is a major concern in psychotherapy in general and an issue of particular importance in treatments for borderline personality disorder (BPD). Yet few studies investigating dropout from therapy in adolescent BPD populations exist. This study investigates reasons for dropping out from group-based mentalization-based treatment (MBT-G) for BPD or borderline features in an adolescent population.Method: Ten semi-structured interviews were performed with female adolescents who had dropped out from group-based MBT for BPD. The data were analyzed qualitatively using Systematic Text Condensation.Results: The results point to the existence of a subgroup of adolescent BPD patients who do not perceive the treatment sufficiently helpful or worthwhile, who experienced treatment as emotionally demanding, time-consuming and connected with unpleasant experiences. Positive reasons for early termination were reported in the form of experienced improvement in condition. Dropping out became understood as a process of weighing perceived benefits against perceived costs of staying in treatment. This understanding of dropout as a process implies the existence of a window of time where intervention to prevent dropout is possible, presupposing the detection of at-risk patients.

Mentalization-based treatment in groups for adolescents with Borderline Personality Disorder: 3- and 12-month follow-up of a randomized controlled trial.

Mentalization-based treatment in groups (MBT-G) has never been tested in adolescents with Borderline Personality Disorder (BPD) in a randomized controlled trial. The current study aimed to test the long-term effectiveness of MBT-G in an adolescent sample with BPD or BPD features (≥ 4 DSM-5 BPD criteria). Hundred and eleven patients with BPD (n = 106) or BPD features (n = 5) were randomized to either (1) a 1-year modified MBT-G program comprising three MBT introductory sessions, five individual case formulation sessions, 37 weekly MBT group sessions, and six MBT-Parent sessions, or (2) treatment as usual (TAU), defined as at least 12 individual monthly treatment sessions with follow-up assessments at 3 and 12 months post treatment. The primary outcome was the score on the Borderline Personality Features Scale for Children (BPFS-C), and secondary outcomes included clinician-rated BPD symptoms and global level of functioning as well as self-reported self-harm, depression, externalizing and internalizing symptoms, and caregiver reports. There were no statistically significant differences between MBT-G and TAU on the primary outcome measure or any of the secondary outcomes. Both groups showed improvement on the majority of clinical and social outcomes at both follow-up points, although remission rates were modest with just 35% in MBT-G and 39% in TAU 2 years after inclusion into the study. MBT-G was not superior to TAU in improving borderline features in adolescents. Although improvement was observed equally in both interventions over time, the patients continued to exhibit prominent BPD features, general psychopathology and decreased functioning in the follow-up period, which points to a need for more research and better understanding of effective components in early intervention programs. The ClinicalTrials.gov identifier is NCT02068326.

Burden and Treatment Satisfaction among Caregivers of Adolescents with Borderline Personality Disorder.

Despite the fact that family involvement is encouraged in early interventions for borderline personality disorder (BPD), there is a limited knowledge on the experience of caring for adolescents with BPD. This is an exploratory retrospective study nested within a randomized controlled trial that compared mentalization-based treatment (MBT) in groups to treatment as usual for adolescents with BPD. Caregivers received six MBT-Parents sessions or standard care over one year. Three months after end of treatment (EOT), 75 caregivers (35 in MBT, 40 in TAU) filled out the Burden Assessment Scale, and 71 (34 in MBT, 37 in TAU) the Family Satisfaction Survey. The adolescents filled out the Borderline Personality Features Scale for Children at baseline and after twelve months at EOT. We tested whether caregiver demographics, adolescents' severity of BPD, treatment and adolescents' dropout from treatment predicted levels of caregiver burden and satisfaction with treatment. The caregivers reported high levels of burden on the BAS (M = 40.3, SD = 12.2). Our study suggests that higher BPD severity at EOT among the adolescents predicted caregiver burden (p = .03), whereas higher baseline BPD severity predicted satisfaction with treatment (p = .04) and that biological mothers could be more burdened than other types of caregivers but also might be more satisfied with treatment. Treatment and adolescents' dropout from treatment were not related to caregiver burden or satisfaction with treatment. To help inform future research and to devise appropriate interventions for caregivers and adolescents with BPD, it is important to identify possible predictors of caregiver burden. The results of this initial exploratory study indicate that caregivers (and particularly biological mothers) of adolescents with more severe levels of BPD could be particularly vulnerable toward feelings of burden and therefore are in need of support.

A pesar del hecho de que se recomienda la participación familiar en las primeras intervenciones para el trastorno límite de la personalidad (TLP), se sabe muy poco sobre la experiencia de cuidar a adolescentes con TLP. El presente es un estudio retrospectivo exploratorio enmarcado en un ensayo controlado aleatorizado que compara el tratamiento basado en la mentalización (TBM) en grupos con el tratamiento habitual (TH) para adolescentes con TLP. Los cuidadores recibieron seis sesiones de TBM para padres o la atención normal durante un año. Tres meses después del final del tratamiento, 75 cuidadores (35 en TBM, 40 en TH) completaron la Escala de Evaluación del Agobio (Burden Assessment Scale), y 71 (34 en TBM, 37 en TH) la Encuesta de Satisfacción Familiar (Family Satisfaction Survey). Los adolescentes completaron la Escala de Características de la Personalidad Límite para Niños (Borderline Personality Features Scale for Children) en el momento basal y después de doce meses al final del tratamiento. Evaluamos si las características demográficas de los cuidadores, la intensidad del TLP de los adolescentes, el tratamiento y la deserción del tratamiento por parte de los adolescentes predijeron niveles de agobio en los cuidadores y de satisfacción con el tratamiento. Los cuidadores informaron niveles altos de agobio en la Escala de Evaluación del Agobio (M = 40.3, DT= 12.2). Nuestro estudio indica que una mayor intensidad del TLP al final del tratamiento entre los adolescentes predijo el agobio del cuidador (p = .03), mientras que una mayor intensidad del TLP en el momento basal predijo la satisfacción con el tratamiento (p = .04), y que las madres biológicas podrían estar más agobiadas que otros tipos de cuidadores, pero también podrían estar más satisfechas con el tratamiento. El tratamiento y la deserción del tratamiento por parte de los adolescentes no estuvieron relacionados con el agobio del cuidador ni con la satisfacción con el tratamiento. Con el fin de contribuir a ampliar futuras investigaciones y de idear intervenciones adecuadas para cuidadores y adolescentes con TLP, es importante reconocer posibles predictores del agobio del cuidador. Los resultados de este estudio exploratorio inicial indican que los cuidadores (y particularmente las madres biológicas) de los adolescentes con niveles más intensos de TLP podrían ser particularmente vulnerables hacia sentimientos de agobio y, por lo tanto, necesitan apoyo.

Mentalization-based treatment in groups for adolescents with borderline personality disorder: a randomized controlled trial.

BACKGROUND: Borderline personality disorder (BPD) typically onsets in adolescence and predicts later functional disability in adulthood. Highly structured evidence-based psychotherapeutic programs, including mentalization-based treatment (MBT), are first choice treatment. The efficacy of MBT for BPD has mainly been tested with adults, and no RCT has examined the effectiveness of MBT in groups (MBT-G) for adolescent BPD. METHOD: A total of 112 adolescents (111 females) with BPD (106) or BPD symptoms ≥4 DSM-5 criteria (5) referred to child and adolescent psychiatric outpatient clinics were randomized to a 1-year MBT-G, consisting of three introductory, psychoeducative sessions, 37 weekly group sessions, five individual case formulation sessions, and six group sessions for caregivers, or treatment as usual (TAU) with at least 12 monthly individual sessions. The primary outcome was the score on the borderline personality features scale for children (BPFS-C); secondary outcomes included self-harm, depression, externalizing and internalizing symptoms (all self-report), caregiver reports, social functioning, and borderline symptoms rated by blinded clinicians. Outcome assessments were made at baseline, after 10, 20, and 30 weeks, and at end of treatment (EOT). The ClinicalTrials.gov identifier is NCT02068326. RESULTS: At EOT, the primary outcome was 71.3 (SD = 15.0) in the MBT-G group and 71.3 (SD = 15.2) in the TAU group (adjusted mean difference 0.4 BPFS-C units in favor of MBT-G, 95% confidence interval -6.3 to 7.1, p = .91). No significant group differences were found in the secondary outcomes. 29% in both groups remitted. 29% of the MBT group completed less than half of the sessions compared with 7% of the control group. CONCLUSIONS: There is no indication for superiority of either therapy method. The low remission rate points to the importance of continued research into early intervention. Specifically, retention problems need to be addressed.

Short-term versus long-term mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder: a protocol for a randomized clinical trial.

BACKGROUND: Psychotherapy for borderline personality disorder is often lengthy and resource-intensive. However, the current length of outpatient treatments is arbitrary and based on trials that never tested if the treatment intensity could be reduced. As a result, there is insufficient evidence to inform the decision between short-term and long-term psychotherapy for borderline personality disorder. Mentalization-based therapy is one treatment option for borderline personality disorder and consists traditionally of an 18-month treatment program. METHODS/DESIGN: This trial is an investigator-initiated single-center randomized clinical superiority trial of short-term (20 weeks) compared to long-term (14 months) mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder. Participants will be recruited from the Outpatient Clinic for Personality Disorders at Stolpegaard Psychotherapy Centre, Mental Health Services, Capital Region of Denmark. Participants will be included if they meet a minimum of four DSM-V criteria for borderline personality disorder. Participants will be assessed before randomization, and at 8, 16, and 24 months after randomization. The primary outcome is severity of borderline symptomatology assessed with the Zanarini Rating Scale for borderline personality disorder. Secondary outcomes include self-harm incidents, functional impairment (Work and Social Adjustment Scale, Global Assessment of Functioning) and quality of life (Short-Form Health Survey 36). Severity of psychiatric symptoms (Symptom Checklist 90-R) will be included as an exploratory outcome. Measures of personality functioning, attachment, borderline symptoms, group alliance, and mentalization skills will be included to explore potential predictors and mechanisms of change. DISCUSSION: This trial will provide evidence of the beneficial and harmful effects of short-term compared to long-term mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03677037 . Registered on September 19, 2018.

Mentalization-based treatment in groups for adolescents with borderline personality disorder (BPD) or subthreshold BPD versus treatment as usual (M-GAB): study protocol for a randomized controlled trial.

BACKGROUND: Evidence-based outpatient psychotherapeutic programs are first-line treatment of borderline personality disorder (BPD). Early and effective treatment of BPD is crucial to the prevention of its individual, psychosocial, and economic consequences. However, in spite of recent advantages in diagnosing adolescent BPD, there is a lack of cost-effective evidence-based treatment programs for adolescents. Mentalization-based treatment is an evidence-based program for BPD, originally developed for adults. AIMS/HYPOTHESES: We will investigate whether a specifically designed mentalization-based treatment in groups is an efficacious treatment for adolescents with BPD or subthreshold BPD compared to treatment as usual. The trial is a four-center, two-armed, parallel-group, assessor-blinded randomized clinical superiority trial. One hundred twelve patients aged 14 to 17 referred to Child and Adolescent Psychiatric Clinics in Region Zealand are randomized to 1 year of either mentalization-based treatment in groups or treatment as usual. Patients will be included if they meet at least four DSM-5 criteria for BPD. The primary outcome is self-reported borderline features at discharge. Secondary outcomes will include self-harm, depression, BPD criteria, externalizing and internalizing symptoms, and social functioning, together with parental reports on borderline features, externalizing and internalizing symptoms. Measures of attachment and mentalization will be included as mediational variables. Follow-up assessment will take place at 3 and 12 months after end of treatment. DISCUSSION: This is the first randomized controlled trial to test the efficacy of a group-based mentalization-based treatment for adolescents with BPD or subthreshold BPD. If the results confirm our hypothesis, this trial will add to the treatment options of cost-effective treatment of adolescent BPD. TRIAL REGISTRATION: Clinicaltrials.gov NCT02068326 , February 19, 2014.