Recommendations for research

The guideline development group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and care of service users in the future.

1 Development of an agreed set of outcomes measures

What are the best outcome measures to assess interventions for people with borderline personality disorder? This question should be addressed in a three-stage process using formal consensus methods involving people from a range of backgrounds, including service users, families or carers, clinicians and academics. The outcomes chosen should be valid and reliable for this patient group, and should include measures of quality of life, function and symptoms for both service users and carers.

The three-stage process should include: (1) identifying aspects of quality of life, functioning and symptoms that are important for service users and families/carers; (2) matching these to existing outcome measures and highlighting where measures are lacking; (3) generating a shortlist of relevant outcome measures to avoid multiple outcome measures being used in future. Where measures are lacking, further work should be done to develop appropriate outcomes.

Why this is important

Existing research examining the effects of psychological and pharmacological interventions for people with borderline personality disorder has used a wide range of outcomes measures. This makes it difficult to synthesise data from different studies and to compare interventions. Also, outcomes do not always adequately reflect patient experience. Agreeing outcome measures for future studies of interventions for people with borderline personality disorder will make it easier to develop evidence-based treatment guidelines in the future.

2 Psychological therapy programmes for people with borderline personality disorder

What is the relative efficacy of psychological therapy programmes (for example, mentalisation-based therapy, dialectical behaviour therapy or similar approach) delivered within well structured, high quality community-based services (for example, a day hospital setting, or a community mental health team) compared with high-quality community care delivered by general mental health services without the psychological intervention for people with borderline personality disorder?

This question should be answered using a randomised controlled design which reports medium-term outcomes (including cost effectiveness outcomes) of at least 18 months' duration. They should pay particular attention to the training and supervision of those providing interventions in order to ensure that systems for delivering them are both robust and generalisable.

Why this is important

Research suggests that psychological therapy programmes, such as dialectical behaviour therapy and mentalisation-based therapy as delivered in the studies reviewed for this guideline, may benefit people with borderline personality disorder. However, trials are relatively small, and research is generally at an early stage of development with studies tending to examine interventions delivered in centres of excellence. In addition, few trials have included large numbers of men. Pragmatic trials comparing psychological therapy programmes with high-quality outpatient follow-up by community mental health services would help to establish the effectiveness, costs and cost effectiveness of these interventions delivered in generalisable settings. The effect of these interventions among men and young people should also be examined.

3 Outpatient psychosocial interventions

What is the efficacy of outpatient psychosocial interventions (such as cognitive analytic therapy, cognitive behavioural therapy, schema-focused therapy, and transference focused therapy) for people with less severe (fewer comorbidities, higher level of social functioning, more able to depend on self-management methods) borderline personality disorder? This question should be answered using randomised controlled trials which report medium-term outcomes (for example, quality of life, psychosocial functioning, employment outcomes and borderline personality disorder symptomatology) of at least 18 months. They should pay particular attention to training and supervision of those delivering interventions.

Why this is important

The evidence base for the effectiveness of psychosocial interventions for people with personality disorder is at an early stage of development. Data collected from cohort studies and case series suggest that a variety of such interventions may help people with borderline personality disorder. Trials of these interventions would help to develop a better understanding of their efficacy. They should examine the process of treatment delivery in an experimental study, and explore logistical and other factors that could have an impact on the likelihood of larger scale experimental evaluations of these interventions succeeding.

4 Mood stabilisers

What is the effectiveness and cost-effectiveness of mood stabilisers on the symptoms of borderline personality disorder? This should be answered by a randomised placebo-controlled trial which should include the medium to long-term impact of such treatment. The study should be sufficiently powered to investigate both the effects and side effects of this treatment.

Why this is important

There is little evidence of the effectiveness of pharmacological treatments for people with personality disorder. However, there have been encouraging findings from small-scale studies of mood stabilisers such as topiramate and lamotrigine, which indicates the need for further research. Emotional instability is a key feature of borderline personality disorder and the effect of these treatments on mood and other key features of this disorder should be studied. The findings of such a study would support the development of future recommendations on the role of pharmacological interventions in the treatment of borderline personality disorder.

5 Developing a care pathway

What is the best care pathway for people with borderline personality disorder?
A mixed-methods cohort study examining the care pathway of a representative sample of people with borderline personality disorder should be undertaken. Such a study should include consideration of factors that should guide referral from primary to secondary care services, and examine the role of inpatient treatment. The study should examine the effect that people with borderline personality disorder and service-level factors have on the transfer between different components of care and include collection and analysis of both qualitative and quantitative data.

Why this is important

The development of a care pathway for people with borderline personality disorder would help to ensure that available resources are used effectively and that services are suited to their needs. Service provision for people with borderline personality disorder varies greatly in different parts of the country, and factors that should be considered when deciding the type and intensity of care that people receive are poorly understood. A cohort study in which qualitative and quantitative data from service users and providers are collected at the point of transfer to and from different parts of the care pathway would help to inform the decisions that people with borderline personality disorder and healthcare professionals have to make about the type of services that people receive.