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Original Investigation
December 15, 2021

Effect of 3 Forms of Early Intervention for Young People With Borderline Personality Disorder: The MOBY Randomized Clinical Trial

Author Affiliations
  • 1Orygen, Melbourne, Victoria, Australia
  • 2Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
  • 3Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Victoria, Australia
  • 4Healthy Brain and Mind Research Centre and School of Behavioural and Health Sciences, Australian Catholic University, Melbourne Campus, Melbourne, Victoria, Australia
  • 5Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
JAMA Psychiatry. 2022;79(2):109-119. doi:10.1001/jamapsychiatry.2021.3637
Key Points

Question  What combination of treatment components is sufficient for early intervention for young people with borderline personality disorder (BPD)?

Findings  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.

Meaning  Effective early intervention for BPD is not reliant on availability of BPD psychotherapy.

Abstract

Importance  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.

Objective  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.

Interventions  (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.

Results  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 [19] vs 3 [16] contacts; median duration, 200 [139.5] vs 94 [125] 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.

Trial Registration  anzctr.org.au Identifier: ACTRN12610000100099

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