How can we help people with borderline personality disorder who are in crisis? New Cochrane review is inconclusive


Borderline personality disorder (BPD) affects our mood and our ability to interact with others. It’s one of the most common personality disorders, affecting around 2% of the population. People with BPD often have other mental health conditions such as substance misuse problems, anxiety, depression, bipolar disorder, eating disorders or other personality disorders.

Many people with BPD are treated in the community with psychotherapy and some are cared for within a therapeutic community. People in crisis may sometimes be detained in hospital under the Mental Health Act and in some cases they may be given a short course of tranquillisers to calm their mood.

Very little is known about what might help people with BPD who are experiencing an acute crisis, so it’s good to see a new systematic review from the Cochrane Collaboration that has recently been published on this topic. The review follows other research on BPD in the Cochrane Library that looks at psychotherapies and drug therapies for people with BPD.

The reviewers conducted the usual systematic literature search of a wide range of databases, looking for randomised controlled trials that compared crisis interventions with usual care or no intervention or a waiting list control for adults of any age with BPD. They found 15 trials, but none could be included in the review because they:

  • Were not randomised
  • Were designed retrospectively
  • Involved a complex psychotherapy lasting longer than 1 month, or
  • Were not yet published

The two unpublished trials (including around 688 patients) met the inclusion criteria for the review, so it is hoped that these can be included in an update:

  1. The effectiveness of joint crisis plans for people with borderline personality disorder: an exploratory randomised controlled trial
  2. Impact of a 24/24 phone permanency on suicide attempts of borderline patients

The reviewers concluded:

A comprehensive search of the literature showed that currently there is no RCT-based evidence for the management of acute crises in people with BPD and therefore we could not reach any conclusions about the effectiveness of any single crisis intervention.

Borderline Personality Disorder really is the poor cousin of other mental health conditions. Professionals have complained about the dearth of good quality research for years and yet we are still conducting reviews that find no reliable trials.  Large well-conducted randomised controlled trials are urgently needed in this area so that effective care can be provided for people who suffer from this disabling and frightening condition.


Borschmann R, Henderson C, Hogg J, Phillips R, Moran P. Crisis interventions for people with borderline personality disorder. Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD009353. DOI: 10.1002/14651858.CD009353.pub2.

Binks C, Fenton M, McCarthy L, Lee T, Adams CE, Duggan C. Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD005652. DOI: 10.1002/14651858.CD005652.

This review concluded:

Some of the problems frequently encountered by people with borderline personality disorder may be amenable to talking/behavioural treatments but all therapies remain experimental and the studies are too few and small to inspire full confidence in their results. These findings require replication in larger ‘real-world’ studies.

Stoffers J, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K. Pharmacological interventions for borderline personality disorder. Cochrane Database of Systematic Reviews 2010, Issue 6. Art. No.: CD005653. DOI: 10.1002/14651858.CD005653.pub2.

This review concluded:

The available evidence indicates some beneficial effects with second-generation antipsychotics, mood stabilisers, and dietary supplementation by omega-3 fatty acids. However, these are mostly based on single study effect estimates. Antidepressants are not widely supported for BPD treatment, but may be helpful in the presence of comorbid conditions. Total BPD severity was not significantly influenced by any drug. No promising results are available for the core BPD symptoms of chronic feelings of emptiness, identity disturbance and abandonment. Conclusions have to be drawn carefully in the light of several limitations of the RCT evidence that constrain applicability to everyday clinical settings (among others, patients’ characteristics and duration of interventions and observation periods).

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Andre Tomlin

André Tomlin is an Information Scientist with 20 years experience working in evidence-based healthcare. He's worked in the NHS, for Oxford University and since 2002 as Managing Director of Minervation Ltd, a consultancy company who do clever digital stuff for charities, universities and the public sector. Most recently André has been the driving force behind the Mental Elf and the National Elf Service; an innovative digital platform that helps professionals keep up to date with simple, clear and engaging summaries of evidence-based research. André is a Trustee at the Centre for Mental Health and an Honorary Research Fellow at University College London Division of Psychiatry. He lives in Bristol, surrounded by dogs, elflings and lots of woodland!

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