A systematic review of interventions for co-occurring substance use and borderline personality disorders

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1 bs_bs_banner R E V I E W Drug and Alcohol Review (November 2015), 34, DOI: /dar REVIEW A systematic review of interventions for co-occurring substance use and borderline personality disorders NICOLE K. LEE 1,2,3, JACQUI CAMERON 1,2,4 & LINDA JENNER 1 1 LeeJenn Health Consultants, Melbourne, Australia, 2 National Centre for Education and Training on Addiction, Flinders University, Adelaide, Australia, 3 National Drug Research Institute, Curtin University, Perth, Australia, and 4 Department of General Practice, University of Melbourne, Melbourne, Australia. Abstract Issues. The aim of this study was to undertake a systematic review on effective treatment options for co-occurring substance use and borderline personality disorders to examine effective treatments for this group. Approach. A systematic review using a narrative analysis approach was undertaken as there were too few studies within each intervention type to undertake a meta-analysis.the inclusion criteria comprised of English language studies (between 1999 and 2014) and a sample of >70% borderline personality disorder, with measurable outcomes for substance use and borderline personality disorder. All abstracts were screened (n = 376) resulting in 49 studies assessed for eligibility, with 10 studies, examining three different treatment types, included in the final review. Key Findings. There were four studies that examined dialectical behaviour therapy (DBT), three studies that examined dynamic deconstructive psychotherapy (DDP) and three studies that examined dual-focused schema therapy (DFST). Both DBT and DDP demonstrated reductions in substance use, suicidal/self-harm behaviours and improved treatment retention. DBT also improved global and social functioning. DFST reduced substance use and both DFST and DPP improved treatment utilisation, but no other significant positive changes were noted. Implications. Overall, there were a small number of studies with small sample sizes, so further research is required. However, in the absence of a strong evidence base, there is a critical need to respond to this group with co-occurring borderline personality disorder and substance use. Conclusion. Both DBT and DPP showed some benefit in reducing symptoms, with DBT the preferred option given its superior evidence base with women in particular. [Lee NK, Cameron J, Jenner L. A systematic review of interventions for co-occurring substance use and borderline personality disorders. Drug Alcohol Rev 2015;34:663 72] Key words: review, substance use disorder, borderline personality disorder, therapy, intervention. Introduction Borderline personality disorder (BPD) is characterised by a complex cluster of persistent symptoms that impact on general and interpersonal functioning and commonly co-occur along with other psychiatric disorders and symptoms [1,2]. Substance use disorders (SUD) appear to be particularly common [3 5]. Although an estimated 1% of the general population meet the criteria for a BPD diagnosis [6], the rate among individuals with SUD is substantially higher up to an estimated 65% of those in treatment [7]. Co-occurring SUD increase the level of complexity, severity and impairment of BPD and are associated with increased rates of self-harm and suicidal behaviour among people with BPD [8,9]. Women experience higher rates of BPD than men and will present more frequently for hospital admissions [9]. Both BPD and SUD are associated with emotional dysregulation [10,11], impaired decision making [12] and high rates of relapse [13,14]. Although there is an extensive literature on the psychological treatment of both BPD and SUD independently [15], and BPD has been the most studied in Nicole K. Lee PhD, Director, Jacqui Cameron MPhil, Senior Consultant, Linda Jenner MSc, Director. All work was completed at LeeJenn Health Consultants. Correspondence to Professor Nicole Lee, LeeJenn Health Consultants, PO Box 359 Elwood 3184,Victoria, Australia. Tel: ; nicolelee@leejenn.com.au Received 7 April 2014; accepted for publication 8 February 2015.

2 664 N. K. Lee et al. terms of treatment of psychological therapies [16], less is known about treatment of co-occurring BPD and SUD. Practitioners often find it difficult to treat BPD and substance use, becoming pessimistic about treatment outcomes [11,17]. Identifying evidence-based interventions for this group is crucial in both preventing relapse and achieving effective outcomes. In a previous review of BPD and SUD treatments, Pennay et al. [18] concluded that at that time there was insufficient evidence to recommend one treatment over another. The study examined the literature up to early Since then, additional research has been published. The aim of this study was to build upon previous works by undertaking a systematic review on effective treatment options for co-occurring SUD and BPD to examine effective treatments for this group. Method This study was undertaken as part of the development of the Australian Clinical Practice Guideline for the Management of Borderline Personality Disorder [19]. A systematic review utilises a structured procedure to search for, identify and assess studies. Two options for analysing the results of a systematic search are a metaanalysis [20] or a narrative analysis [21,22]. This paper used a narrative analysis because there were too few studies of each treatment type to make a meta-analysis feasible. An illustration of the systematic review is provided in Figure 1. Search strategy Initial search terms were based on the National Institute for Heath Care Excellence Guideline on Borderline Personality Disorder:Treatment and Management [23]. A search protocol was developed and approved by the committee before the review was undertaken. In addition, a combination of MeSH headings, keyword terms and words in the text and titles were used to develop the search terms, an example of this string search is provided in Table 1. Four electronic databases were searched, including Medline, PsycINFO, Embase and the Cochrane Database of Systematic Reviews, and the results were summarised in Table 2. First screen The citations from all sources were collated for screening with a total of n = 668 studies included prior to duplicates and incorrect citations being removed. During the first screen, we included all eligible studies Included Eligibility Screening Iden fica on Records iden fied through database searching (n = 668) Records a er duplicates removed (n = 376) Records screened (n = 292) Full-text ar cles assessed for eligibility (n = 49) Full-text ar cles included in final review (n = 10) Figure 1. Systematic review flow diagram. Databases Cochrane=208 Medline=118 PsycINFO=125 EMBASE=217 Records excluded a er screening (n = 243) Records excluded a er screening (n = 39) (n = 292 excluding duplicates); the citations were then reviewed against the inclusion criteria (a further n = 243 were excluded). For inclusion in the review, studies needed to meet the following criteria: Included any outcome data from treatment or intervention for both BPD and SUD. >70% sample size of BPD. English language. Study years Randomised controlled trial. Second screen During the second screen, two reviewers independently assessed the remaining studies (n = 49) for eligibility using quality checklists adapted for the purpose of this review from the National Institute for Health and Clinical Excellence [23] as well as from Petticrew and Roberts [24]. During this stage, a further n = 39 references were excluded because they did not meet the inclusion criteria. For each of the remaining studies (n = 10), the data were extracted into a specifically developed extraction sheet. If inclusion status was not

3 Review of treatment for substance use and BPD 665 Table 1. Example of string search 1 borderline personality disorder.mp. or Borderline Personality Disorder/ 2 Borderline Personality Disorder/ or borderline personality symptom$.mp. 3 Personality disorder$.sh. or PD$1.ti. or personaltit$.sh. or Personality.sh. or personality disorder$.sh. or personality disorders.sh. 4 personality dysfunction.mp. 5 Personality Disorders/ or cluster c personality disorder$.mp. 6 (Borderline or borderline person$ or borderline state or borderline$).sh. 7 borderline patient$.mp. 8 or/1 7 9 or randomized control trials 10 randomised control trials 11 random allocation or random assignment or random sample or random sampling 12 random or randomization 13 randomized controlled trial or randomized control trials 14 randomised controlled trial or randomised control trials 15 double blind method or double blind procedure or double blind study or double blind studies or doubleblind or double 16 single blind procedure or single blind method or single blind study or single blind studies or single or single blind or single blind method 17 crossover or crossover design or crossover procedure or cross over studies 18 clinical or clinical trial or clinical trials 19 controlled clinical trial or controlled clinical trials 20 or/ axis II disorder*.mp. 22 axis II disorder*.m_titl. 23 Depression/ or depression.mp. 24 anxiety.mp. or Anxiety/ or Anxiety Disorders/ 25 Bipolar Disorder/ or bipolar.mp. 26 Substance-Related Disorders/ or Substance-Related Disorder*.mp. 27 comorbidity.mp. or Comorbidity/ 28 or/ treatment*.mp. 30 treatment*.m_titl. 31 or/ and 28 and and limit 33 to (human and english language and yr = ) clear, this was resolved by team consensus.table 3 provides an overall assessment of the quality of evidence. Extraction As with the previous phases, two reviewers completed the data extraction. The data extraction sheet we adapted fromtorgerson [25] documented key information from each study including citation details, reference type, study setting, study objective, outcome measures, Database Table 2. Number of citations per database Accessed via: Search period Number of citations found (pre-duplicates removed) Cochrane Wiley Database of Systematic Reviews Medline Ovid PsycINFO Ovid Embase Embase design, participants details, intervention and results as well as a summary of study and the completed quality check. In the case of inconsistencies or ambiguity during the extraction process, studies were re-examined and discussed by both the original and additional reviewers for consensus. The data were then transferred to an evidence table, which we adapted for our review and based on the minimum data recommended by Higgins and Green [26]. We included the following data summaries: Participant details: number, age, gender and diagnosis. Intervention: details of intervention and comparison. Outcomes: primary outcome related to BPD and substance use. Other relevant fields: follow up and summary of study. As there were too few studies for each intervention type to undertake a meta-analytic review, a narrative analysis was undertaken. Results Ten studies, examining three different treatment interventions, met the inclusion criteria. There were four studies of dialectical behaviour therapy (DBT), three studies of dynamic deconstructive therapy (DDP) and three of dual-focused schema therapy (DFST). A summary of outcomes on symptoms measured for each intervention type is detailed in Table 4. A descriptive summary of each study including the participants, intervention, comparison intervention, primary outcome, length of follow up and summary of the results is provided in Table 5. DBT DBT is a cognitive behavioural therapy that was developed in the late 1980s to specifically target women with

4 666 N. K. Lee et al. Table 3. Quality of evidence assessment Evidence checklist Dialectical behaviour therapy + replacement medication (two studies) Dialectical behaviour therapy (two studies) Dual-focus schema therapy (three studies) Dynamic deconstructive psychotherapy (three studies) Level Level II Level II Level II Level II Quality Good Good Good Good Relevance Low Low High High Table 4. Improvements in symptoms Intervention/Symptom Substance use Suicidal behaviour/ self-harm Global and social functioning Retention in treatment Treatment utilisation Dialectical behaviour therapy (four studies) x Dual-focus schema therapy (three studies) x x Dynamic deconstructive psychotherapy (three studies), potential benefit; x, no clear benefit. a history of chronic suicide attempts [2]. DBT is a skills-based form of cognitive behavioural therapy and promotes acceptance and change; it can be used in both inpatient and outpatient settings and targets suicidal behaviours, self-harm and therapy-interfering behaviours, such as non-attendance, inappropriate interpersonal interaction and boundary issues [2]. There is typically a combination of group and individual treatment sessions and high levels of practitioner clinical supervision [32]. One study of Axis I disorders [36] among those with BPD showed an improvement in substance use abstinence with DBT [29]. Participants were 101 women (age 18 45) who met criteria for BPD and reported at least two suicide attempts and/or non-suicidal selfinjury acts in the past 5 years, with at least one act in the 8-week pre-study period. DBT was more likely to result in full and partial remission of symptoms and more drug and alcohol-abstinent days than community treatment by experts. Two studies [1,27] used adapted DBT with medication. In the first study [1], DBT involved individual weekly psychotherapy plus weekly group skills support and additional phone support as needed and was compared with treatment as usual (TAU). This was a small sample study with a high drop-out rate and no randomisation. The mean age of all female participants was 30.4 years. There were no differences between groups on history of suicide and self-harm behaviours or on the State-Trait Anger Inventory. However, the DBT group showed a decrease in SUD and the DBT group attended almost twice the number of therapy hours as the TAU group, although the medication made it difficult to isolate the contribution of the DBT alone. In the second study, Linehan et al. [27] used an adapted version of DBT for weeks; both treatment groups also received opiate agonist medication l-alpha-acetylmethadol (LAAM). The treatment consisted of comprehensive validation therapy with 12 steps (CVT) versus a manual-based treatment that included strategies similar to DBT in combination with the standard 12 steps. There was no difference between groups on suicide and self-harm behaviours or global and social functioning and no difference in opiate use as measured by urinalysis until 12 months when DBT showed less opiate use than CVT (P < 0.02). At 16 months, there was no difference between groups. van den Bosch et al. [28] analysed secondary data on SUD and personality disorders, not specific to BPD. The study investigated whether standard DBT could be successfully implemented in a mixed population of BPD patients with or without co-occurring SUD. Participants were 58 women with BPD. The DBT group showed greater (non-significant) reduction in self-harm behaviours. There were no differences in reduction of SUD. The DBT group had greater treatment retention and greater reductions in self-harm.

5 Review of treatment for substance use and BPD 667 Table 5. Summary of included studies Reference Participants (N, age, gender, diagnosis) Intervention Comparison Measures (Symptom) Primary outcomes Follow up Summary Linehan et al. [1] N = 28 N = 12 (DBT + medications) N = 16 (TAU) Mean age = 30.4 Female 100% BPD (Personality Disorders Exam and SCID-II) SUD (SCID-I) Adapted DBT with replacement medication for 4 months plus 4 months of tapering TAU was defined as meeting with case managers as required Structured clinical interview Urinalysis Timeline follow back Parasuicide history interview (suicide/ self-harm) State-Trait Anger Expression Inventory (anger) Social history interview (global and social functioning) Treatment history interview (treatment utilisation) DBT group showed greater reduction in SUD than TAU (P < 0.05). No between group differences on parasuicide, anger (12 months), but slightly better global and social functioning (16 months). There was no difference in treatment utilisation between groups. 12 months Small sample study with high drop-out rate and no randomisation. Those in the DBT groups received almost twice the amount of therapy hours as compared to TAU. The medication made it difficult to isolate the contribution of DBT. Linehan et al. [27] N = 23 N = 11 (DBT) N = 12 (CVT+12S) Mean age = 36.1 Female 100% BPD (SCID-II and personality disorder examination SUD (SCID-I) Adapted DBT for weeks plus opiate agonist medication (LAAM) CVT with 12-step manual-based treatment that included strategies similar to DBT in combination with the standard 12 steps plus opiate agonist medication (LAAM) Urinalyses Timeline follow back Social history interview (global and social functioning) Parasuicide history Interview (suicide/ self-harm Results of urinalyses indicated that both groups were effective in reducing opiate use relative to baseline. The DBT group had a significantly lower percentage of opiate-positive urinalyses than the comparison (t = 2.32, P < 0.02). At 16 months (4 months post-treatment), all participants had a low proportion of opiate-positive urinalyses (27% in DBT; 33% in comparison). No between group difference in parasuicide or global and social functioning. CVT had higher retention rates than DBT. 16 months Strong research design. Higher retention rates in comparison group (100% for study duration). With regard to between group differences, DBT maintained reductions in mean opiate use through 12 months of active treatment while the comparison significantly increased opiate use during the last 4 months of treatment. van den Bosch et al. [28] N = 58 N = 27 (DBT) N = 31 (TAU) Mean age = 37.5 Female 100% BPD (DSM-IV diagnosis of BPD) SUD (European version of the Addiction Severity Index) DBT TAU was not defined. European version of the Addiction Severity Index Instruments used were not reported but also measured suicide/self-harm and treatment retention. No between group differences in reduction of SUD. DBT group showed greater reduction in self-harm behaviours but not significant. The DBT group had higher retention rates (37% DBT vs. 77% TAU attrition). 12 months Participants reported high rates of suicide attempts, self-harm and substance use at baseline, the DBT group had better treatment retention and greater reductions in self-harm. No change in SUD. Harned et al. [29] N = 101 N = 52 (DBT) N = 49 (CTBE) Mean age = 29 Female 100% BPD BPD (Structured Clinical Interview for DSM-III-R Personality Disorders) SUD (DSM-III) DBT CTBE was developed to control for expertise, treatment allegiance, availability of a clinical supervision group, prestige, general factors and assistance in finding a therapist, availability of affordable and sufficient treatment hours and therapist gender, training and clinical experience. Diagnostic and Statistical Manual of Mental Disorders Treatment history interview (psychotropic medication) Timeline follow back (psychological status) DBT participants had a significantly greater proportion of drug- and alcohol-abstinent days across time than did CTBE patients with SUD. For specific Axis I disorders, DBT patients were significantly more likely to achieve full remission from SUD than were CTBE patients. DBT patients spent significantly more time in partial remission and less time in no remission from SUD than did CTBE patients. 12 months The study concluded that DBT is superior to CTBE in treating co-occurring SUD among suicidal BPD patients. DBT and CTBE patients did not significantly differ in the proportion of Axis I disorders that reached full remission or that subsequently relapsed.

6 668 N. K. Lee et al. Table 5. (Continued) Reference Participants (N, age, gender, diagnosis) Intervention Comparison Measures (Symptom) Primary outcomes Follow up Summary Ball et al. [30] N = 52 Mean age = 38.3 Female 6% PD (PDQ) SUD (Substance use in past 30 days) DFST is a 24-week manual-guided individual therapy that consists of set core topics and relapse prevention, coping skills, craving and schema-focused techniques. SAC included a drop-in centre for clients and also typically included three counselling or education sessions a week. Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition substance use disorders Addiction Severity Index Brief Symptom Inventory (global and social functioning) Inventory of Interpersonal Problems Circumplex (global and social functioning) Early Maladaptive Schema Questionnaire (global and social functioning) Therapy retention (total weeks in treatment) Treatment utilisation (number of weeks in which sessions were attended) No change in SUD assessed due to high drop-out rate. No change in PD symptoms assessed because of high drop-out rate. Study attrition prevented evaluation of outcomes other than retention and utilisation. Treatment utilisation of DFST compared to SAC was statistically significant. 24 weeks This study had a significant problem, which was that study attrition prevented analysis of outcomes other than retention and utilisation. 60% dropped out after 1 month and 77% after 3 months. Overall, there was greater utilisation of individual DFST than the SAC group (but less so for more severe personality disorder symptoms demonstrated better utilization of SAC than DFST). Ball [31] N = 30 N = 15 (DFST) N = 15 (12FT) Mean age = 37 Female 50% PD (SCID-II) SUD (Substance Use Timeline Calendar) DFST 12FT is a manually guided 12-step group therapy focusing on the disease model of addiction. Substance Use Timeline Calendar Addiction Severity Index Brief Symptom Inventory (global and social functioning) Multiple-Affect Adjective Checklist (anger) Working Alliance Inventory (therapeutic alliance) Reduction in SUD in the DFST group as measured by a timeline calendar. Change in symptoms not reported. 24 weeks DFST was associated with a stronger therapeutic alliance. Contrary to predictions, 12FT demonstrated better reduction of dysphoric affect than did DFST. Ball et al. [15] N = 105 N = 54 (DFST) N = 51 (IDC) Mean age = 26.5 Female 19% BPD (PDQ-4R) SUD (DSM-IV) Manual-guided, weekly DFST delivered during the first 6 months in a residential therapeutic community. Manual-guided weekly individual drug counselling known as IDC was delivered during the first 6 months in a residential therapeutic community (IDC). Brief Symptom Inventory Multiple-Affect Adjective Checklist Revised Inventory of Interpersonal Problems Circumplex Adherence/Competence Rating Scale Treatment retention The substance-free status of most participants on admission and the controlled residential environment made substance use an irrelevant outcome variable. Participants diagnosed with BPD showed significant symptom reductions during the first 3 months, however, IDC demonstrated continued reductions during the remaining 3 months, whereas DFST showed no further improvement. 6 months Investigators concluded that the value of adding dual-focus therapies for a range of co-occurring PDs and substance dependence in residential rehabilitation settings was not supported by this trial. Gregory et al. [32] N = 30 N = 15 (DDP) N = 15 (TAU) Mean age = 28.7 Female (80%) BPD (DSM-IV Axis II PDs) SUD (DSM-IV-TR Axis 1 Disorders) DDP TAU was defined as usual treatment in the community but included mostly individual psychotherapy and medication management. Lifetime Parasuicide Count (suicide/self-harm) Addiction Severity Index Treatment history interview (treatment utilisation) Beck Depression Inventory Dissociative Experience Scale Social Provisions Scale (social support) BEST (BPD severity) DDP was associated with statistically significant improvement in alcohol misuse. DDP was associated with statistically significant improvement in parasuicide/self-harm. Treatment retention and was better in the DDP (73%) compared with TAU (63%). Treatment utilisation was statistically significant in the DPP group months A well-conducted study however the small sample size limits it power to detect treatment effects so results should be interpreted cautiously. DDP was associated with statistically significant improvement in secondary outcome measures, including core symptoms of BPD, depression and dissociation. Perceived social support also improved but was not statistically significant.

7 Review of treatment for substance use and BPD 669 Table 5. (Continued) Reference Participants (N, age, gender, diagnosis) Intervention Comparison Measures (Symptom) Primary outcomes Follow up Summary Gregory et al. [33] N = 30 N = 15 (DDP) N = 15 (TAU) Mean age = 28.7 Female (80%) BPD (DSM-IV) SUD (Alcohol use) DDP TAU was defined as usual treatment in the community. Actual measures not reported but outcomes included measures of parasuicide (suicide/self-harm), alcohol misuse and institutional care (treatment utilisation) and treatment retention. Relative risk for an episode of intoxication decreased by 31% for both treatment groups over 6 months. Mean number of drinking days decreased by half in both groups (53% for the DDP group, 48% for TAU). Mean number of days using illicit substances decreased 54% for DDP and 25% for TAU. DDP parasuicidal behaviour decreased by 38%, compared to TAU which had a 35% increase in relative risk. Of participants that continued to report parasuicidal behaviour, there was a 64% reduction in incidents, suggesting a harm reduction benefit. DPP was associated with a significant decrease in institutional care and had higher rates of retention than TAU. 3 6 months Improvements in both BPD and alcohol use disorder symptoms for DDP group are greater than TAU. The results suggest a clinically meaningful effect between groups but not reaching statistical significance (P = 0.071). Gregory et al. [34] N = 30 N = 15 (DPP) N = 15 (OCC) Mean age = 28.3 Female (80%) BPD (SCID II) and SUD (SCID) DDP OCC referred to the best treatment available in the community within the restrictions of their own financial resources, availability of treatment and their willingness to engage. Addiction Severity Index BEST (BPD severity) Beck Depression Inventory Dissociative Experiences Scale Treatment history interview (treatment utilisation) Lifetime Parasuicide Count (suicide/self-harm) Social Provisions Scale (social support) OCC participants (N = 5) were using recreational drugs at 30 months and heavier drinking at 12 months than DPP. DDP participants displayed significant improvement in heavy drinking. DPP recreational drug use at 30 months ceased. DDP had statistically significant reductions over time in. Both groups improved in parasuicide behaviour over time (30 months); however, the DPP group improved faster in suicide/ self-harm. There was no between group difference on treatment utilisation at 30 months. 30 months Sample size is small, making it difficult to draw firm conclusions and there was substantial loss to follow up. 12FT, 12-step facilitation therapy; BEST, borderline evaluation of severity over time; BPD, borderline personality disorder; CTBE, community treatment by experts; CVT, comprehensive validation therapy; DBT, dialectical behaviour therapy; DFST, dual-focus schema therapy; DSM, Diagnostic and Statistical Manual of Mental Disorders; IDC, individual drug counselling; LAAM, l-alpha-acetylmethadol; OCC, optimised community care; PD, personality disorder; PDQ, Personality Diagnostic Questionnaire;, randomised controlled trial; SAC, substance abuse counselling; SCID, Structured Clinical Interview for DSM; SUD, substance use disorder; TAU, treatment as usual. DDP DDP was developed for particularly challenging cases of BPD, such as those with co-occurring SUD. It is a modified form of psychodynamic psychotherapy [32]. The treatment involves individual weekly sessions over months using a manual-based protocol [32]. Three studies were published by the same research group reporting on the same DPP study [32,33,23], which showed that DDP was significantly more effective than TAU in addressing both BPD and alcohol use disorder symptoms. The first paper reported on the [32] feasibility, tolerability and efficacy of manual-based version of DDP for co-occurring BPD and alcohol use disorder. The

8 670 N. K. Lee et al. participants were 30 adults with diagnosis of BPD and alcohol use disorder (abuse or dependence). There were assessments every 3 months for a year. DDP participants showed statistically significant improvement in suicide and self-harm behaviour, alcohol use disorder, institutional care (treatment utilisation), depression, dissociation, and treatment retention. TAU participants received higher average treatment intensity but showed only limited change during the same period. The proportion of DDP participants reporting suicide and self-harm behaviours decreased from 73% (n = 11) pretreatment to 30% (n = 3) at 12 months. The proportion of DDP participants reporting incidents of alcohol misuse (>=5 drinks on a single occasion) decreased from 67% (n = 10) pre-treatment to 30% (n = 3) at 12 months. The proportion of DDP participants remaining abstinent more than doubled over the 12 months of treatment. The proportion of DDP participants needing institutional care decreased from 67% (n = 10) pre-treatment to 10% (n = 1) at 12 months. In the second paper [33], 3 and 6 month data were reported. Improvements in both BPD and alcohol use disorder symptoms were reported for the DDP group. During the first 6 months, both treatment groups received approximately the same number of individual treatment contact hours/month, but the TAU participants received more hours of group therapy. Study retention rates were equivalent for both groups at 6 months. However, therapist retention rates differed markedly between the treatment groups (73% DDP vs. 18% TAU). Risk for suicide and self-harm behaviour in the DDP group decreased by 38%, against an increase in relative risk of 35% for TAU. Even for participants who continued to report suicide and self-harm behaviour, the number of incidents decreased by 64%. The risk for an episode of intoxication decreased by 31% for both groups. Mean number of drinking days decreased by approximately half in both groups (53% for the DDP group, 48% for TAU). The mean number of days using illicit substances decreased by 54% for DDP and 25% for TAU. The relative risk of institutional care (treatment utilisation) decreased by 55% for DDP and 32% for TAU. In addition, the mean number of inpatient days decreased by 94% for DDP and 64% for TAU. The mean number of visits to emergency room decreased by 93% for DDP and 86% for TAU. In the final study [34], 16 of the 19 original participants were followed up at 30 months. Results showed that at 30 months subjects who received DDP had more improvement overall than those receiving community TAU on measures of core, depression, parasuicide and recreational drug use, while there was a trend that favoured DDP in reduced alcohol consumption (but not treatment utilisation). Using a modified intent-to-treat (ITT) analysis across time points from baseline, 6, 12 and 30 months, almost all DDP participants displayed clinically meaningful improvement in (average of 25% reduction) by 12 months compared with only 38% of participants receiving TAU. This difference was sustained during the naturalistic follow-up period. DFST DFST combines relapse prevention for substance dependence with targeted work on early maladaptive schemas (enduring negative beliefs about oneself, others and events) and coping styles [37]. There were three studies by Ball et al. examining DFST for co-occurring BPD and SUD. In one study [15], DFST failed to show any benefit over individual drug counselling (IDC) and IDC appeared to show more sustained reductions in symptoms. The study intervention was a weekly DFST individual therapy delivered during the first 6 months in a residential therapeutic community. Participants diagnosed with BPD showed significant symptom reductions during the first 3 months in both therapy conditions; however, IDC showed continued reductions during the remaining 3 months, whereas DFST showed no further improvement. The three-way interaction of personality disorder by time by therapy condition was significant. IDC resulted in more sustained reductions than did DFST in psychiatric and affective symptoms BPD, but not for participants without a personality disorder. Investigators concluded that the value of adding dual-focused therapies for a range of co-occurring personality disorders and substance dependence in residential rehabilitation settings was not supported by this trial. The research group s other studies [31,30] were not specific to BPD; however, the first study [28] evaluated the personality disorder symptoms of SUD clients of a homeless drop-in facility. There was a high drop-out rate in both groups, with a slightly better result for DFST group for number of weeks attended. In the second study [31], there was a reduction in SUD in the DFST group, but not in treatment utilisation or retention. In the third study [30], participants showed significant BPD symptom reductions during the first 3 months; however, IDC demonstrated continued reductions during the remaining 3 months, whereas DFST showed no further improvement. The substance-free status of most participants on admission and the

9 Review of treatment for substance use and BPD 671 controlled residential environment made substance use an irrelevant outcome variable. Discussion This systematic review examined the efficacy of three interventions for co-occurring BPD and SUD. The review was based on randomised controlled trials and used a narrative analysis because of the small number of studies in each treatment type and the widely varying outcome measures. Ten studies met criteria for inclusion examining three different treatment options: DBT (four studies), DFST (three studies) and DDP (three studies). Most of the studies had small sample sizes and variable outcomes. DFST showed minimal beneficial outcomes and does not appear to be an efficacious option. DDP showed generally good outcomes across the range of symptoms, including reductions in substance use and suicidal behaviour. The results are limited by a small number of studies with small sample sizes, but there were significant benefits across main outcome measures. DBT showed generally good outcomes compared withtau and other non-validated manualised comparison treatments. The studies were of generally good quality. Some studies were confounded by the introduction of pharmacotherapy, which is known to be an effective intervention.the results, although limited by a small number of studies with small sample sizes, suggest that DBT has a good enough evidence base to be utilised with clients with co-occurring BPD and SUD. As DBT is one of the only evidence-based treatments for women with BPD [19], it should at least be considered for women with co-occurring BPD and SUD. In studies of DDP for BPD without co-occurring SUD, DDP performed poorly, showing fewer significant outcomes than DBT [23]. Given this, DBT seems to be most likely the first choice in the treatment of BPD and SUD. Most of the studies primarily recruited women, so the efficacy of these interventions for men with co-occurring BPD and substance use is still unclear and, while the rate of personality disorder is high in substance use treatment, there is no indication from this review that these interventions are particularly helpful for substance use clients with other personality disorders. Moreover, Dimeff and Linehan [38] note that while Dialectical Behaviour Therapy is likely to be effective for people with substance dependence, it is may be too intensive for those who do not have co-occurring BPD; they recommend consistent with a stepped care framework that for people in substance use treatment, efficacious treatments for that group be tried first [38]. Conclusion Overall, there were a limited number of studies and the sample sizes were small, so further well-conducted randomised trials are required, making it difficult to draw firm conclusions. It is often difficult for studies of very low prevalence disorders to recruit participants, but further studies, even with small sample sizes would lend themselves to meta-analysis, improving understanding of the outcomes of these treatments. However, in the absence of a strong evidence base, and the critical need to respond to this group, for women with co-occurring BPD and SUD, DBT and DDP are both likely to have some benefit in reducing symptoms, with DBT the preferred option given its better evidence base with women with BPD without SUD. DFST had limited benefit. Acknowledgements The review on which this paper draws was commissioned by the National Health and Medical Research Council (NHMRC) and funded by the Commonwealth Department of Health and Ageing. We would like to acknowledge the NHMRC and members of the BPD Guideline Development Committee for their input into defining search parameters for the review and for advice on the implications of studies. 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