181

Journal of Personality Disorders, 28(2), pp. 181197, 2014

2014 The Guilford Press
IMPACT OF TREATMENT INTENSITY
ON SUICIDAL BEHAVIOR AND DEPRESSION
IN BORDERLINE PERSONALITY DISORDER:
A CRITICAL REVIEW
Kate M. Davidson, PhD, and Cathy F. Tran, BSc
The effectiveness of less versus more intensive psychological therapies
in reducing suicidal behavior and depression in suicidal patients with
borderline personality disorder (BPD) was examined. Electronic data-
bases were searched. Trials were separated into less versus more inten-
sive therapies. Suicidal acts and depression outcome data were as-
sessed. Six trials met search criteria (cognitive-behavioral therapy for
personality disorder, mentalization-based therapy, dialectical behavior
therapy). Seven measures of suicidal acts and two measures of depres-
sion were used in studies. Both less and more intensive therapies re-
port signicant decreases in suicidal behaviors. Apart from one small
trial, both less and more intensive therapies report decreases in de-
pression with no differences between therapies and control conditions.
Two follow-up studies showed that reductions in suicidal behavior and
depression are maintained over time. The authors conclude that both
less and more intensive therapies are effective in treating depression
and suicidal behaviors in patients with BPD. Clinicians should deliver
the least intensive interventions that will provide these signicant health
gains.
Borderline personality disorder (BPD) is a disabling condition character-
ized by emotional instability, interpersonal problems, and impulsive and
self-harm behaviors. BPD patients are noted as having a high rate of com-
pleted suicide (Paris & Zweig-Frank, 2001). Treatment that is aimed at
reducing suicidal risk and other types of self-harm is therefore of clinical
importance. Affective dysregulation is also a key feature of BPD, but there
is no specic measure of this feature. Depression, a common and dis-
abling affective symptom in BPD, can, however, be measured reliably, and
psychological treatment is likely to affect depressive symptoms.
At least 19 randomized controlled trials investigating the effectiveness of
This article was accepted under the editorship of Robert F. Krueger and John Livesley.
From Mental Health and Well-Being, University of Glasgow (K. M. D., C F. T.).
Address correspondence to Professor Kate Davidson, Mental Health and Well-Being, Admin-
istrative Building, Gartnavel Royal Hospital, 1055 Great Western Rd., G12 0XH, Glasgow,
UK. E-mail: kate.davidson@glasgow.ac.uk
182 DAVIDSON AND TRAN
psychological therapies in treating suicidal behavior in BPD patients have
been conducted since 1995. There is considerable variation in the length
and intensity of therapies used to treat BPD. There is also variation in the
type and severity of problems and symptoms in the patients included in
treatment trials. This makes comparisons of trials of therapies and sum-
marizing the literature problematic.
We investigated if more intensive therapies had different outcomes from
less intensive therapies for suicidal behavior and depression in BPD pa-
tients who had a engaged in a recent suicidal act at entry into a random-
ized controlled trial.
METHODS
Criteria for considering studies for this review were type of study, partici-
pants, interventions, and outcome measures.
INITIAL SELECTION CRITERIA
The following electronic databases were systematically searched to iden-
tify studies providing information on psychological therapies that are
shown to be effective for patients with personality disorder: PsycInfo, Med-
line, Embase, and the Cochrane Central Register of Controlled Trials. We
searched for Randomized Controlled Trials or Controlled Clinical Trials
from January 1995 to February 2012, including articles on personality
disordered patients (BPD, antisocial personality disorder, dependent per-
sonality disorder, or avoidant personality disorder), examining a psycho-
therapeutic intervention with a clear account of the therapy offered.
Searches were limited to articles published in English. Papers were re-
trieved from this search and relevant articles were selected.
FINAL SELECTION CRITERIA
Type of Studies. We identied all relevant randomized controlled trials,
with or without blinding, examining psychological interventions for sui-
cidal BPD patients.
Participants. To be included, participants had to be 18 years or over,
diagnosed with borderline personality disorder according to DSM-IV (Amer-
ican Psychiatric Association [APA], 1994) or equivalent, and had to have
engaged in a suicidal act prior to the study. These criteria had to be ex-
plicitly stated within the study inclusion criteria.
Types of Interventions. All lengths and intensities of psychological treat-
ments versus a comparison treatment were included. The treatments had
to demonstrate a clear rationale, structure, and intervention. The main
psychological therapies included cognitive analytic therapy (CAT), cogni-
tive-behavioral therapy for personality disorder (CBTpd), dialectical be-
havioral therapy (DBT), interpersonal psychotherapy (IPT), mentalization-
based therapy (MBT), schema-focused therapy (SFT), transference-focused
THERAPY INTENSITY, SUICIDAL ACTS, AND DEPRESSION IN BPD 183
therapy (TFP), and Systems Training for Emotional Predictability and
Problem Solving (STEPPS). Therapies varied in length and intensity, with
some incorporating individual therapy, some group therapy, and some
both. We included only outpatient treatment.
Exclusion. A number of papers were not reviewed due to the stringent
selection criteria. The following trials were excluded:
Trials focusing on BPD patients with a comorbid Axis I disorder within
the inclusion criteria.
Trials where suicidal acts were not used as a criterion for inclusion.
Trials without a clear description of the therapy.
Trials that were not randomized or controlled.
Pilot studies or nonoriginal data trials.
Trials using pharmacotherapy within the main treatment conditions.
Trials using inpatients.
Some studies were excluded on the basis of one or more than one crite-
rion. For example, 13 trials were excluded because they did not include
suicidal acts as a criterion for being accepted into the study as a partici-
pant; 4 papers were excluded because they included pharmacotherapy as
a comparison treatment or combined a medication with a psychological
therapy; 1 paper was excluded because it was looking specically at neu-
ral correlates as an outcome measure; 12 were excluded because patients
had to have (as specied in the inclusion criteria) a comorbid Axis I disor-
der, such as substance misuse; and 1 paper was excluded because the
authors did not use outpatients and their treatment was partially hospi-
talized. Others were excluded at an earlier stage on the basis of the trial
not being randomized or controlled, or not all patients having BPD (see
Figure 1).
DATA COLLECTION AND ANALYSIS
Study Selection. Figure 1 shows a ow diagram describing the result
of the search process. Titles and abstracts of 2,383 records were
screened and 182 were reviewed. Of these, 19 were found relevant at the
initial stage. All were randomized controlled trials conducted between
the years 1999 and 2010, examining various kinds of psychological in-
terventions within the borderline population. Selection of studies was
discussed between authors, and full articles were read if any doubt ex-
isted over inclusion or exclusion criteria. Overall, six papers, not includ-
ing follow-up studies, were identied as relevant and included in the -
nal review.
Data Management. We independently extracted data from the selected
papers. All aspects of data handling and reporting were assessed. We se-
lected the intention-to-treat analysis of data because this is based on the
initial treatment intent and to avoid various unknown and misleading in-
uences that can arise in treatment research.
184 DAVIDSON AND TRAN
OUTCOMES
Outcomes were suicidal acts as assessed by a variety of measures (see
below) and self-rated or clinician-rated depression scores within an in-
trial or posttrial follow-up period of 2 years. We also noted if there were
further, longer-term follow-up of the trial patients.
Suicidal Acts. There were seven measures of suicidal acts used across
the six papers included in this review. Only two studies, both examining
DBT (Linehan et al., 2006b; McMain et al., 2009) used the same measure.
We report on the studies and reliability of the measures reported within
the papers here.
FIGURE 1. Flow diagram of study selection.
THERAPY INTENSITY, SUICIDAL ACTS, AND DEPRESSION IN BPD 185
McMain et al. (2009): Suicide Attempt Self-Injury Interview (Linehan
et al., 1993). Semistructured interview. Interrater reliability ratings
ranging from 0.85 to 0.98 (Linehan, Comtois, Brown, Heard, & Wag-
ner, 2006a).
Linehan et al. (2006b): The Suicide Attempt Self-Injury Interview: In-
terrater reliabilities were 0.88 for medical risk and 0.94 for suicide
intent.
Davidson et al. (2006a): Acts of Deliberate Self-Harm Inventory (Da-
vidson, 2008a). Semistructured interview. Interrater reliability was es-
tablished [Kappa coefcients were calculated for occurrence of any
suicidal act ( = 1.0), number of suicidal acts ( = 1.0), and occurrence
of self-mutilation ( = 1.0) indicating perfect agreement].
Carter, Willcox, Lewin, Conrad, and Bendit (2010): Lifetime Parasui-
cide Count-2 (Linehan & Comtois, 1996), Parasuicide History Inter-
view (Linehan, Wagner, & Cox, 1989). Reliability not specied.
Bateman and Fonagy (2009): Suicide and Self-Harm Inventory (un-
published). Reliability not specied.
Turner (2000): Independent assessor ratings: Rated patients on Tar-
get Behaviour Ratings for the frequency of parasuicide. Also measured
self-reported number of suicide/self-harm attempts (daily logs). The
Pearson correlations between the independent assessor and the inves-
tigator were .84 for ratings of self harm.
Denitions Used. There were differences in the denition of suicidal
acts. Both Davidson et al. (2006a) and Bateman and Fonagy (2009) dif-
ferentiated between suicidal acts and acts of self-mutilation. They had al-
most identical denitions for suicidal acts in that they had to be deliberate
and life-threatening and to result in the need for medical attention (or in-
tervention would have been warranted). Bateman and Fonagy (2009) add-
ed one more criterion to this denition, which was that there had to be
medical assessment consistent with a suicide attempt. The denition for
acts of self-harm differed slightly between the studies. The criteria in Da-
vidson et al. (2006a) were as follows: not a suicidal act as dened previ-
ously, deliberate, and resulted in potential or actual tissue damage. Bate-
man and Fonagy (2009) required self-mutilation to be deliberate, result in
visible tissue damage, and also required nursing or medical intervention.
This last criterion in Bateman and Fonagy (2009) arguably blurs the dis-
tinction between their denition of a suicidal act and an act of self-mutila-
tion. Carter et al. (2010) looked mainly at admissions for deliberate self-
harm (DSH). Their denition for general hospital admission for DSH was
in accordance with Platt, Hawton, Kreitman, Fagg, and Fosters (1988)
defnition for attempted suicide and included any intentional self-injury
or the deliberate ingestion of more than the prescribed amount of thera-
peutic substances, or deliberate ingestion of substances never intended
for human consumption (p. 408). Although the term DSH is a popular
one in literature on suicide and self-harm, it does not always necessarily
186 DAVIDSON AND TRAN
refer to a suicidal act. In this case however, it would appear that DSH, as
dened by Carter et al. (2010), refers to suicidal acts. Linehan et al.
(2006b) describe suicidal behavior nonspecically as a broad term that
includes death by suicide and intentional, nonfatal, self-injurious acts
committed with or without intent to die. Neither McMain et al. (2009) nor
Turner (2000) gave a denition or description of suicidal acts or behavior
in their respective publications.
Table 1 describes the studies and reports on suicidal outcomes. As il-
lustrated, the unit of suicidal acts or DSH used varies across studies.
Davidson et al. (2006a) reported the number of people who had committed
a suicidal act and included the percentage in each treatment condition
and median or mean of suicidal acts at baseline and posttreatment for
each treatment condition. They also reported these measures at 6-year
follow-up (Davidson, Tyrer, Norrie, Palmer, & Tyrer, 2010). Carter et al.
(2010) reported the proportion of participants who had at least one admis-
sion for DSH and the mean number of admissions and nonadmissions to
a general hospital for DSH. They did not report these data at baseline.
Bateman and Fonagy (2009) reported the number, percentage, mean, and
standard deviation for life-threatening suicide attempts at baseline and
between baseline and 6 months, 6 and 12 months, and 12 to 18 months.
In order to make a comparison across studies, where cumulative informa-
tion on suicidal acts is not available across the total follow-up period, we
included only the rst 6 months of data because someone could have en-
gaged in a suicidal act during the rst 6 months and in another act during
any of the following 6-month periods, but this would not be reported as a
repetition. For example, the data reported by Bateman and Fonagy (2009)
treat each 6-month period as discrete. Suicidal acts, especially when there
is a risk of repetition, might be better understood when counted cumula-
tively. A therapy would also aim to reduce the rate at which further new
suicidal acts occur, and therefore repetition is an important indicator of
effectiveness. Counting only episodes within a discrete time period does
not give this information. McMain et al. (2009) grouped suicidal and self-
injurious episodes together for analysis, reporting the mean and standard
deviation at baseline, 12 months after treatment, and 2 years after treat-
ment follow-up. Linehan et al. (2006b) reported the median and interquar-
tile range at baseline and at 12-month posttreatment follow-up for suicide
attempts. Finally, Turner (2000) reported the mean and standard devia-
tion for number of suicide/self-harm attempts at baseline and posttreat-
ment. For the studies that failed to dene suicidal acts or distinguish
them from self-harm, it was difcult to know how to interpret the results
in a meaningful way.
Depression. Five out of the six studies measured depression and two dif-
ferent measures were used overall. These were the self-rated Beck Depres-
sion Inventory (BDI-I and BDI-II) and the clinician-rated Hamilton Rating
Scale for Depression (HRSD). All were measured at baseline and posttreat-
ment, with varying baseline levels of severity (see Table 2 and Figure 2).
THERAPY INTENSITY, SUICIDAL ACTS, AND DEPRESSION IN BPD 187
Davidson et al. (2006a), Bateman and Fonagy (2009), and McMain et al.
(2009) used the BDI alone. Turner (2000) used both measures and Linehan
et al. (2006b) used the HRSD-17 alone. All papers reported the mean and
standard deviation at baseline and posttreatment, with Davidson et al.
(2010), McMain et al. (2009), and Linehan et al. (2006b) also reporting the
measures at follow-up. Carter et al. (2010) did not assess level of depression.
Of note, the populations sampled differed in the severity of depression.
For example, McMain et al. (2009) and Davidson et al. (2006a) included
patients whose average ratings on the BDI at baseline indicated severe
levels of depression (score of 30+ on BDI; Beck, Steer, & Carbin, 1988),
whereas the other studies included less severely depressed patients (see
Figure 2).
LENGTH AND INTENSITY OF MAIN THERAPIES
PRIMARY TREATMENTS
Therapies varied in terms of the number of sessions and overall length of
treatment. Therapies for Axis I disorders are usually fewer than 20 ses-
sions and are carried out within 6 months. We designed a metric to reect
intensity and length of treatment by multiplying the overall number of
sessions by hours per session. As can be seen in Table 1, therapies varied
between 30 (CBTpd) and 182 hours (DBT). We further divided therapies
into those with fewer than 100 hours in 12 months (CBTpd, DBT 6 months
treatment reported only) (Carter et al., 2010; Davidson et al., 2006a) and
those with more than 100 hours (MBT, DBT) (Bateman & Fonagy, 2009;
Linehan et al., 2006b; McMain et al., 2009).
Cognitive-Bbehavioral Therapy for Personality Disorder (CBTpd). This
therapy, developed by Davidson (2008b), focuses on the patients core be-
liefs and overdeveloped behavioral patterns that impair adaptive function-
ing. Davidson et al. (2006a) aimed to deliver up to 30 sessions of individu-
al CBT over 1 year, with each session lasting an hour.
Dialectical Behavior Therapy (DBT). This is a cognitive-behavioral treat-
ment program developed to treat suicidal clients with BPD. DBT directly
targets suicidal behavior; behaviors that interfere with treatment delivery;
and dangerous, severe, or destabilizing behaviors. Service delivery in-
cludes (a) weekly individual psychotherapy (1h/wk); (b) group skills train-
ing (2.5 h/wk); (c) telephone consultation; and (d) weekly therapist con-
sultation team meeting. Turner (2000) used a modied version of the DBT
intervention by Linehan (1993).
Mentalization-Based Treatment (MBT). This is a manualized therapy that
consisted of 18 months of weekly combined individual and group psycho-
therapy provided by two different therapists. It included crisis contact and
crisis plans, pharmacotherapy, general psychiatric review, and written in-
formation about treatment. MBT therapists focused on helping patients
reinstate mentalizing during a crisis via telephone contact.
188 DAVIDSON AND TRAN
TABLE 1. Suicidal Acts
Article n
Treatment
Outcome-
Suicidal Acts
Hours of Treatment
(sessions hours) Suicidal Acts Baseline
Suicidal Acts: Outcomes at End of Treatment
and in Trial Follow-up Follow-up
Davidson
et al.
(2006a)
106 CBTpd+TAU
>TAU p = .02
30 1 = 30 hours
(over 1 year)
No. of people with at least one
suicidal act 12 months prior to
BL (N), %
CBT = 38, 70.4%
TAU = 37, 71.2%
Median no. of suicide attempts
(groups combined) = 2 (range
112)
(Davidson et al., 2006b)
At 24 months after 12-month treatment phase
No. of people with at least one suicidal act 024 months, %
CBT = 23, 43%
TAU = 26, 54% (ns)
No. of suicidal acts per person M(SD)
CBT = 0.9 (1.5)
TAU = 1.7(3.1)
Mean diff (95% CI)
-0.91(95% CI -1.67 to -0.15, p = .020)
Davidson et al. (2010)
6 years
Gains maintained
(ns)
Carter
et al.
(2010)
76 DBT = TAU+WL 24 3.5 = 84 hours
(ongoing)
No data reported prior to entry
into study
After 6 months ongoing DBT treatment vs. 6 months TAU+WL
Proportion of participants with at least one general hospital admis-
sion for DSH:
DBT = 21.1%
TAU+WL = 25.7% (ns)
Hospital admissions: no. of admissions to general hospital for
DSH: M(SD)
DBT = 0.5(1.5)
TAU+WL = 1.4(4.5) (ns)
General hospital presentations without admission for DSH: M(SD)
DBT = 0.2(0.7)
TAU+WL = 0.1(0.2) (ns)

Turner
(2000)
24 DBT>CCT
p = .001
84 hours 6 months prior to BL
Mean no. of suicide/self-harm at-
tempts per person: M(SD)
DBT = 14.1(3.7)
CCT = 13.6(3.3)
At end of treatment 12 months:
Mean no. of suicide/self-harm attempts per person: M(SD)
DBT = 0.8(1.2)
CCT = 5.6(5.3)

Bateman
&
Fonagy
(2009)
134 MBT>SCM
p < .0004 for
period be-
tween 12 and
18 months
of treatment
only
70 weeks at 2 ses-
sions/wk 2.5
hours approx.
70 2.5 = 175 hours
No. of suicide attempts 6 months
prior to BL (N), %
MBT = 53, 74.6%
SCM = 42, 66.7%
No. of suicide attempts per
person 6 months prior to BL:
M(SD)
MBT = 1.3(1.2)
SCM = 1.0 (0.9)
No. of suicide attempts after 6 months (N), %
MBT = 37, 52.1%
SCM = 33, 52.4% (ns)
No. of suicide attempts from 6 to 12months (N), %
MBT = 23, 32.4%
SCM = 30, 47.6% (ns)
No. of suicide attempts from 12 to 18months (N), %
MBT = 2, 2.8%
SCM = 16, 25.4% (p < .0004)
No. of suicide attempts per person at 6 months: M(SD)
MBT = 0.6(0.7)
SCM = 0.7(0.8) (ns)

McMain
et al.
(2009)
180 DBT = GPM 52 3.5 = 182 hours Suicidal and self-injurious epi-
sodes per person at 4 months
prior to BL: M(SD)
DBT = 20.9(33.3)
GPM = 32.2(81.9)
Suicidal and self-injurious episodes per person after 4 months:
M(SD)
DBT = 10.6 (21.0)
GPM = 14.0 (43.9)
24 month PTFU: gains
maintained for both
groups. (ns) McMain
et al. (2012)
Linehan
et al.
(2006b)
111 DBT>CTBE
p = .01
52 3.5 = 182 hours Suicide attempts per person:
Median (iq)
DBT = 1.0 (0.03.0)
CTBE = 2.0 (1.04.0)
At 24 months following 12 months of treatment
Suicidal act per group %
DBT = 23.1%
CTBE = 46% (p = .01)
Suicide attempts per person:
Median (iq)
DBT = 0 (0.00.0)
CTBE = 0 (0.01.0) (ns)

Note. BL = Baseline; CI = Confidence Interval; FU = Follow-up; iq = Interquartile Range;

M(SD) = Mean (standard deviation); ns = nonsignificant; PTFU = Posttreatment Follow-Up;
TAU+WL = Treatment-as-usual plus Waiting List.
THERAPY INTENSITY, SUICIDAL ACTS, AND DEPRESSION IN BPD 189
TABLE 1. Suicidal Acts
Article n
Treatment
Outcome-
Suicidal Acts
Hours of Treatment
(sessions hours) Suicidal Acts Baseline
Suicidal Acts: Outcomes at End of Treatment
and in Trial Follow-up Follow-up
Davidson
et al.
(2006a)
106 CBTpd+TAU
>TAU p = .02
30 1 = 30 hours
(over 1 year)
No. of people with at least one
suicidal act 12 months prior to
BL (N), %
CBT = 38, 70.4%
TAU = 37, 71.2%
Median no. of suicide attempts
(groups combined) = 2 (range
112)
(Davidson et al., 2006b)
At 24 months after 12-month treatment phase
No. of people with at least one suicidal act 024 months, %
CBT = 23, 43%
TAU = 26, 54% (ns)
No. of suicidal acts per person M(SD)
CBT = 0.9 (1.5)
TAU = 1.7(3.1)
Mean diff (95% CI)
-0.91(95% CI -1.67 to -0.15, p = .020)
Davidson et al. (2010)
6 years
Gains maintained
(ns)
Carter
et al.
(2010)
76 DBT = TAU+WL 24 3.5 = 84 hours
(ongoing)
No data reported prior to entry
into study
After 6 months ongoing DBT treatment vs. 6 months TAU+WL
Proportion of participants with at least one general hospital admis-
sion for DSH:
DBT = 21.1%
TAU+WL = 25.7% (ns)
Hospital admissions: no. of admissions to general hospital for
DSH: M(SD)
DBT = 0.5(1.5)
TAU+WL = 1.4(4.5) (ns)
General hospital presentations without admission for DSH: M(SD)
DBT = 0.2(0.7)
TAU+WL = 0.1(0.2) (ns)

Turner
(2000)
24 DBT>CCT
p = .001
84 hours 6 months prior to BL
Mean no. of suicide/self-harm at-
tempts per person: M(SD)
DBT = 14.1(3.7)
CCT = 13.6(3.3)
At end of treatment 12 months:
Mean no. of suicide/self-harm attempts per person: M(SD)
DBT = 0.8(1.2)
CCT = 5.6(5.3)

Bateman
&
Fonagy
(2009)
134 MBT>SCM
p < .0004 for
period be-
tween 12 and
18 months
of treatment
only
70 weeks at 2 ses-
sions/wk 2.5
hours approx.
70 2.5 = 175 hours
No. of suicide attempts 6 months
prior to BL (N), %
MBT = 53, 74.6%
SCM = 42, 66.7%
No. of suicide attempts per
person 6 months prior to BL:
M(SD)
MBT = 1.3(1.2)
SCM = 1.0 (0.9)
No. of suicide attempts after 6 months (N), %
MBT = 37, 52.1%
SCM = 33, 52.4% (ns)
No. of suicide attempts from 6 to 12months (N), %
MBT = 23, 32.4%
SCM = 30, 47.6% (ns)
No. of suicide attempts from 12 to 18months (N), %
MBT = 2, 2.8%
SCM = 16, 25.4% (p < .0004)
No. of suicide attempts per person at 6 months: M(SD)
MBT = 0.6(0.7)
SCM = 0.7(0.8) (ns)

McMain
et al.
(2009)
180 DBT = GPM 52 3.5 = 182 hours Suicidal and self-injurious epi-
sodes per person at 4 months
prior to BL: M(SD)
DBT = 20.9(33.3)
GPM = 32.2(81.9)
Suicidal and self-injurious episodes per person after 4 months:
M(SD)
DBT = 10.6 (21.0)
GPM = 14.0 (43.9)
24 month PTFU: gains
maintained for both
groups. (ns) McMain
et al. (2012)
Linehan
et al.
(2006b)
111 DBT>CTBE
p = .01
52 3.5 = 182 hours Suicide attempts per person:
Median (iq)
DBT = 1.0 (0.03.0)
CTBE = 2.0 (1.04.0)
At 24 months following 12 months of treatment
Suicidal act per group %
DBT = 23.1%
CTBE = 46% (p = .01)
Suicide attempts per person:
Median (iq)
DBT = 0 (0.00.0)
CTBE = 0 (0.01.0) (ns)

Note. BL = Baseline; CI = Confidence Interval; FU = Follow-up; iq = Interquartile Range;

M(SD) = Mean (standard deviation); ns = nonsignificant; PTFU = Posttreatment Follow-Up;
TAU+WL = Treatment-as-usual plus Waiting List.
190 DAVIDSON AND TRAN
TABLE 2. Depression
Article n
Treatment
Outcome-
Depression
Hours of Treatment
(sessions hours) Depression Score BL (n) Depression Scores Posttreatment Follow-up
Davidson
et al.
(2006a)
106 CBTpd+TAU =
TAU
30 1 = 30 hours BDI-II total score at BL: M(SD)
CBT+TAU = 42.6(10.1)
TAU = 42.5(12.3)
BDI-II total score at 24 months after 12-month
treatment phase M(SD):
12 months
CBT+TAU = 29.6(14.8)
TAU = 31.3(16.6) (ns)
24 months
CBT+TAU = 26.5(15.3)
TAU = 28.8(15.7) (ns)
Davidson et al. (2010) 6 years post-
treatment, gains maintained:
CBT+TAU = 26.5(16.5)
TAU = 26.2 (17.5)
Carter
et al.
(2010)
76 24 3.5 = 84 hours
Turner
(2000)
24 DBT>CCT 84 hours BDI-I at BL: M(SD)
DBT = 27.6(5.3)
CCT = 27.8(6.1)
HRSD: M(SD)
DBT = 20.8(4.3)
CCT = 17.4(4.5)
BDI-I at 12 months: M(SD)
DBT = 14.9(8.3)
CCT = 24.1(5.6)
[95% CI (1.3, 9.3)]
HRSD: M(SD)
DBT = 7.5(6.0)
CCT = 12.6(3.9)
[95% CI (0.9, 5.5)]

Bateman
&
Fonagy
(2009)
134 MBT = SCM 70 weeks at 2 ses-
sions/wk 2.5
hours approx.
70 2.5 = 175 hours
BDI-I total score 6 months prior
to BL: M(SD)
MBT = 29.8(10.1)
SCM = 29.1(8.8)
BDI-I total score after 6 months: M(SD)
MBT = 26.2(9.6)
SCM = 26.3(8.1) (ns)
After 12 months:
MBT = 20.6(9.5)
SCM = 22.4(8.6) (ns)
After 18 months:
MBT = 14.8(8.6)
SCM = 18.7(8.8) (ns)

McMain
et al.
(2009)
180 DBT = GPM 52 3.5 = 182 hours BDI-II total score at BL: M(SD)
DBT = 37.2(12.5)
GPM = 35.4(10.6)
BDI-II total score after 4 months: M(SD)
DBT = 29.1(15.0)
GPM = 28.3(14.0) (ns)
After 8 months:
DBT = 24.2(15.3)
GPM = 27.6(15.5) (ns)
After 12 months:
DBT = 22.2(16.1)
GPM = 24.8(14.8) (ns)
2 year FU: further improvements on
BDI-II scores (ns) (McMain et al.
2012)
Linehan
et al.
(2006b)
111 DBT = CTBE 52 3.5 = 182 hours HRSD-17 at BL M(SD):
DBT = 20.2(5.9)
CTBE = 21.7(7.3)
HRSD-17 at 12 months M(SD):
DBT = 14.0(7.3)
CTBE = 17.0(8.2) (ns)
At 24 months:
DBT = 12.6(6.8)
CTBE = 14.4(9.1) (ns)
Note. BL = Baseline; CI = Confidence Interval; FU = Follow-up; iq = Interquartile Range;
M(SD) = Mean (standard deviation); ns = nonsignificant; PTFU = Posttreatment Follow-Up;
TAU+WL = Treatment-as-usual plus Waiting List.
THERAPY INTENSITY, SUICIDAL ACTS, AND DEPRESSION IN BPD 191
TABLE 2. Depression
Article n
Treatment
Outcome-
Depression
Hours of Treatment
(sessions hours) Depression Score BL (n) Depression Scores Posttreatment Follow-up
Davidson
et al.
(2006a)
106 CBTpd+TAU =
TAU
30 1 = 30 hours BDI-II total score at BL: M(SD)
CBT+TAU = 42.6(10.1)
TAU = 42.5(12.3)
BDI-II total score at 24 months after 12-month
treatment phase M(SD):
12 months
CBT+TAU = 29.6(14.8)
TAU = 31.3(16.6) (ns)
24 months
CBT+TAU = 26.5(15.3)
TAU = 28.8(15.7) (ns)
Davidson et al. (2010) 6 years post-
treatment, gains maintained:
CBT+TAU = 26.5(16.5)
TAU = 26.2 (17.5)
Carter
et al.
(2010)
76 24 3.5 = 84 hours
Turner
(2000)
24 DBT>CCT 84 hours BDI-I at BL: M(SD)
DBT = 27.6(5.3)
CCT = 27.8(6.1)
HRSD: M(SD)
DBT = 20.8(4.3)
CCT = 17.4(4.5)
BDI-I at 12 months: M(SD)
DBT = 14.9(8.3)
CCT = 24.1(5.6)
[95% CI (1.3, 9.3)]
HRSD: M(SD)
DBT = 7.5(6.0)
CCT = 12.6(3.9)
[95% CI (0.9, 5.5)]

Bateman
&
Fonagy
(2009)
134 MBT = SCM 70 weeks at 2 ses-
sions/wk 2.5
hours approx.
70 2.5 = 175 hours
BDI-I total score 6 months prior
to BL: M(SD)
MBT = 29.8(10.1)
SCM = 29.1(8.8)
BDI-I total score after 6 months: M(SD)
MBT = 26.2(9.6)
SCM = 26.3(8.1) (ns)
After 12 months:
MBT = 20.6(9.5)
SCM = 22.4(8.6) (ns)
After 18 months:
MBT = 14.8(8.6)
SCM = 18.7(8.8) (ns)

McMain
et al.
(2009)
180 DBT = GPM 52 3.5 = 182 hours BDI-II total score at BL: M(SD)
DBT = 37.2(12.5)
GPM = 35.4(10.6)
BDI-II total score after 4 months: M(SD)
DBT = 29.1(15.0)
GPM = 28.3(14.0) (ns)
After 8 months:
DBT = 24.2(15.3)
GPM = 27.6(15.5) (ns)
After 12 months:
DBT = 22.2(16.1)
GPM = 24.8(14.8) (ns)
2 year FU: further improvements on
BDI-II scores (ns) (McMain et al.
2012)
Linehan
et al.
(2006b)
111 DBT = CTBE 52 3.5 = 182 hours HRSD-17 at BL M(SD):
DBT = 20.2(5.9)
CTBE = 21.7(7.3)
HRSD-17 at 12 months M(SD):
DBT = 14.0(7.3)
CTBE = 17.0(8.2) (ns)
At 24 months:
DBT = 12.6(6.8)
CTBE = 14.4(9.1) (ns)
Note. BL = Baseline; CI = Confidence Interval; FU = Follow-up; iq = Interquartile Range;
M(SD) = Mean (standard deviation); ns = nonsignificant; PTFU = Posttreatment Follow-Up;
TAU+WL = Treatment-as-usual plus Waiting List.
192 DAVIDSON AND TRAN
COMPARISON TREATMENTS
Client-Centered Therapy (CCT). This treatment emphasizes empathic
understanding of the patients sense of aloneness and provides a support-
ive atmosphere for individuation.
Community Treatment by Experts (CTBE). Characteristics of CTBE ther-
apists were controlled by the study via selection of therapists and supervi-
sory arrangements. Therapists provided type and dose of therapy that
they believed was most suited to the patient with a minimum of one sched-
uled individual session per week.
General Psychiatric Management (GPM). This is based on the APA Prac-
tice Guideline for the treatment of patients with BPD and was manualized
for the trial. It consists of case management, dynamically informed psy-
chotherapy, and symptom-targeted medication management.
Structured Clinical Management (SCM). This intervention focuses on
support and problem-solving. It includes crisis contact and crisis plans,
pharmacotherapy, general psychiatric review, and written information
about treatment. Regular individual and group sessions were offered with
appointments every 3 months for psychiatric review.
Treatment-as-usual (TAU). This is the standard treatment that patients
would have received had the trial not been in place and is likely to include
involvement with general psychiatric and community mental health teams
at a minimum. This information is carefully monitored and reported be-
cause it has a bearing on cost-effectiveness analyses (Carter et al., 2010,
Palmer et al., 2006).
FIGURE 2. Severity of depression and response to therapy across trials.
THERAPY INTENSITY, SUICIDAL ACTS, AND DEPRESSION IN BPD 193
MAIN RESULTS
SUICIDAL ACTS
Less Intensive Therapies (100 hours or less over 12 months maximum).
Three trials examined the effect of less intensive psychological treatment
for BPD patients who have had a suicidal episode. Two were randomized
controlled trials of DBT. Carter et al. (2010) delivered up to 84 hours of
therapy over 6 months and Turner (2000) also up to 84 hours but over 12
months. The third trial was of CBTpd (Davidson et al., 2006a) with 30
hours of therapy delivered over 12 months. Davidson et al. (2006a) com-
pared CBTpd plus TAU with TAU alone. Carter et al. (2010) compared DBT
with TAU+ Waiting list (WL), and Turner (2000) compared DBT with CCT.
There was a signicant decrease in the mean number of suicidal acts over
the total 24 months for those who had received CBTpd (Davidson et al.,
2006a). Likewise, Turner (2000) reported a signicant decrease in the
mean number of suicidal and self-harm episodes with DBT over the
12-month treatment period. Davidson et al. (2006a) reported no difference
between groups in the total number of people who engaged in any suicidal
act over the 24-month period. Carter et al. (2010) reported no difference
between groups in suicidal behavior.
More Intensive Therapies (over 100 hours in 12 or more months). Three
trials examined longer-term psychological treatments in borderline pa-
tients who have had a suicidal episode. Two examined DBT (Linehan et
al., 2006b; McMain et al., 2009) and one examined MBT (Bateman & Fon-
agy, 2009). Only in one of the more intensive DBT studies was there a
signicant difference in favor of DBT in terms of a reduction in the per-
centage of people with suicidal acts (Linehan et al., 2006b). MBT was su-
perior to SCM in terms of the number of people with suicidal attempts
only between months 12 to 18 of therapy. No signicant differences were
found between the groups in the previous two time periods (0 to 6 months
and 6 to 12 months), indicating that differences only become apparent
toward the end of therapy.
With all treatments, including treatment-as-usual, structured clinical
management, and general psychiatric management, patients showed a de-
crease in suicidal behavior over time.
DEPRESSION
Less Intensive Therapies (100 hours or fewer over 12 months maximum).
Turner (2000) reported a signicant decrease in depression on both the
HRSD and the BDI-I with DBT in this small sample. Davidson et al.
(2006a) noted no signicant difference between groups on the BDI-II at
the end of treatment or at 24-month follow-up. Both of these studies also
show a decrease in depression across both groups over time. Carter et al.
(2010) did not report depression directly.
More Intensive Therapies (over 100 hours in 12 or more months). None of
the more intensive therapy studies, involving MBT and DBT, found a sig-
nicant difference in groups in depression, either on the BDI (Bateman &
194 DAVIDSON AND TRAN
Fonagy, 2009 and McMain et al., 2009) or on the HRSD (Linehan et al.,
2006b). All therapies showed a decrease in depression over time.
FOLLOW-UP
Only two of the studies reported follow-up data beyond the in-trial period.
At 6-year follow-up, two patients had died by suicide: One had been ran-
domized to CBTpd and the other to usual treatment (Davidson et al.,
2010). At the 2-year follow-up, McMain et al. (2012) reported no complet-
ed suicides. For those patients followed up, following treatment with less
intensive and more intensive therapy (CBTpd and DBT), there was no in-
crease in suicidal acts or in depression at a further 2 and 6 years, respec-
tively, and no signicant differences were found between groups. In gen-
eral, patients maintained or improved over follow-up.
DISCUSSION
An important clinical implication from this review is that more intensive
therapies are not necessarily superior to less intensive therapies in reducing
both suicidal acts and depression. Indeed, up to 30 sessions of CBTpd is ef-
fective at reducing both depression and suicidal acts in severely depressed
patients with borderline personality disorder (Davidson et al., 2006a). All
therapies, including treatment-as-usual and high-quality general psychiat-
ric care, reduce depressive symptoms, with only one study (Turner, 2000)
declaring a signicant difference in favor of DBT. This study, however, had a
small sample, and other larger DBT studies showed no differences between
groups. The review also highlighted the differences in levels of severity of
depression at entry into the study. Both Davidson et al. (2006b) and McMain
et al. (2009) recruited suicidal patients who had more severe levels of de-
pression than those recruited in other studies. Bateman and Fonagy (2009)
and Turner (2000), for example, recruited patients who were much less de-
pressed at entry into the study. Comparisons between studies are therefore
not straightforward and need to be interpreted carefully.
Of the two studies that did not show a signicant difference between
treatment groups, the measurement of suicidal acts may have been differ-
ent compared to the other studies. For example, McMain et al. (2009)
measured suicidal acts and other self-injurious episodes together, and
Carter et al. (2010) did not measure suicidal acts directly but assessed
general hospital admissions for self-harm. It also would appear that high-
quality general psychiatric care (SCM and GPM) for BPD may also be help-
ful in reducing suicidal behaviors in comparison to treatment-as-usual.
The characteristics of studies varied: sample sizes, participant severity
of depression, length and intensity of therapy offered, measures and re-
porting of results. Even though participants had engaged in a suicidal or
self-harm act at some point before entry into the studies, it was not pos-
sible to compare these behaviors across studies because of the different
THERAPY INTENSITY, SUICIDAL ACTS, AND DEPRESSION IN BPD 195
metrics used. The lack of a common metric for suicidal acts brought to
light the importance of using similar measures across studies to be able to
meaningfully assess and compare across studies. Some authors reported
on change in symptoms within specic time periods of therapy, whereas
others reported at end of therapy and in-trial follow-up. Some patients will
have multiple acts and others none following entry into a study. With sui-
cidal acts being relatively rare but potentially life-threatening, it would
appear to be important to look at the impact of therapy across the whole
of the time period of therapy or in-trial follow-up. It is clear from the stud-
ies reported here that this behavior does decrease across time for most
BPD patients, but the rapidity with which therapy can reduce suicidal
behavior would be better judged through time-to-event (in this case, a sui-
cidal act) type of analyses. We would also recommend that the number or
proportion of people with at least one suicidal act be reported at end of
treatment and at follow-up.
Distinguishing between suicidal acts and nonsuicidal self-harm may be
important because the latter may be an attempt to regulate mood whereas
the former may be a deliberate and life-threatening event. It is obvious
that these two types of behaviors can blur into one another, but there is a
consistency in the data reported here to suggest that these are separate
and distinct behaviors. We should be clear regarding denitions of sui-
cidal acts and self-harm and have a common metric to count these impor-
tant data. Depression, on the other hand, was easier to compare because
most studies used the same well-validated and reliable measure.
Inevitably, we had to exclude studies that did not meet our stringent
entry criteria. It may be that the results of this review would have differed
had we had more general entry criteria. In addition, we selected only the
intention-to-treat analysis data, but this will only have biased the conclu-
sions in the direction of being more cautious.
Given that individuals with personality disorders use health services ex-
tensively, the nding that less and more intensive therapies do not differ in
these two important clinical outcomes is important in terms of both health
costs (Bender et al., 2001) and the effort and time involvement of clinical
staff and patients. Regardless of intensity, all of the therapies are tailored,
highly specialized interventions, delivered by experienced clinicians. The
rationale for delivering more intensive therapies is not persuasive if one
considers that there is little difference in important clinical outcomes for
this costly patient group. Clinicians should be encouraged to deliver the
least intensive interventions that will provide these signicant health gains.
REFERENCES
American Psychiatric Association. (1994). Di-
agnostic and statistical manual of
mental disorders (4th ed.). Washing-
ton, DC: Author.
Bateman, A., & Fonagy, P. (2009). Random-
ized controlled trial of outpatient
mentalization-based treatment versus
structured clinical management for
196 DAVIDSON AND TRAN
borderline personality disorder. Ameri-
can Journal of Psychiatry, 166(12),
13551364.
Beck, A. T., Steer, R. A., & Carbin, M. G.
(1988). Psychometric properties of the
Beck Depression Inventory: Twenty-
ve years of evaluation. Clinical Psy-
chology Review, 8(1), 77100.
Bender, D. S., Dolan, R. T., Skodol, A. E.,
Sanislow, C. A., Dyck, I. R., Mc-
Glashan, T. H., et al. (2001). Treat-
ment utilization by patients with per-
sonality disorders. American Journal
of Psychiatry, 158(2), 295302.
Carter, G. L., Willcox, C. H., Lewin, T. J.,
Conrad, A. M., & Bendit, N. (2010).
Hunter DBT project: Randomized con-
trolled trial of dialectical behaviour
therapy in women with borderline per-
sonality disorder. Australian & New
Zealand Journal of Psychiatry, 44(2),
162173.
Davidson, K. M. (2008a). Acts of deliberate
self-harm inventory. In Cognitive ther-
apy for personality disorders: A guide
for clinicians (2nd ed., pp. 177182).
Hove, UK: Routledge.
Davidson, K. M. (2008b) Cognitive therapy
for personality disorders: A guide for
clinicians (2nd ed.). Hove, UK: Rout-
ledge.
Davidson, K., Norrie, J., Tyrer, P., Gumley,
A., Tata, P., Murray, H., et al. (2006a).
The effectiveness of cognitive behavior
therapy for borderline personality dis-
order: Results from the Borderline
Personality Disorder Study of Cogni-
tive Therapy (BOSCOT) trial. Journal
of Personality Disorders, 20(5), 450
465.
Davidson, K. M., Tyrer, P., Gumley, A., Tata,
P., Norrie, J., Palmer, S., et al. (2006b).
A randomized controlled trial of cogni-
tive behavior therapy for borderline
personality disorder: Rationale for tri-
al, method, and description of Sample.
Journal of Personality Disorders, 20(5),
431449.
Davidson, K. M., Tyrer, P., Norrie, J., Palmer,
S. J., & Tyrer, H. (2010). Cognitive
therapy v. usual treatment for border-
line personality disorder: Prospective
6-year follow-up. British Journal of
Psychiatry, 197, 456462.
Linehan, M. M. (1993). Cognitive-behavioral
treatment of borderline personality dis-
order. New York: Guilford Press.
Linehan, M. M., & Comtois, K. A. (1996).
Lifetime parasuicidal count-2. Seattle:
University of Washington, Behavioral
and Therapy Clinics.
Linehan, M. M., Comtois, K. A., Brown,
M. Z., Heard, H. L., & Wagner, A. M.
(2006a). Suicide Attempt Self-Injury
Interview (SASII): Development, reli-
ability, and validity of a scale to assess
suicide attempts and intentional self-
injury. Psychological Assessment, 18(3),
303312.
Linehan, M. M., Comtois, K. A., Murray,
A. M., Brown, M. Z., Gallop, R. J.,
Heard, H. L., et al. (2006b). Two-year
randomized controlled trial and fol-
low-up of dialectical behavior therapy
vs. therapy by experts for suicidal be-
haviors and borderline personality
disorder. Archives of General Psychia-
try, 63, 757766.
Linehan, M. M., et al. (1983). The Suicide At-
tempt Self-Injury Interview. Unpub-
lished manuscript.
Linehan, M. M., Wagner, A. W., & Cox, G.
(1989). Parasuicide History Interview:
Comprehensive assessment of parasui-
cidal behaviour. Seattle: University of
Washington.
McMain, S. F., Guimond, T., Streiner, D. L.,
Cardish, R. J., & Links, P. S. (2012).
Dialectical behavior therapy compared
with general psychiatric management
for borderline personality disorder:
Clinical outcomes and functioning
over a 2-year follow-up. American
Journal of Psychiatry, 169, 650661.
McMain, S. F., Links, P. S., Gnam, W. H.,
Guimond, T., Cardish, R. J., Korman,
L., et al. (2009). A randomized trial of
dialectical behavior therapy versus
general psychiatric management for
borderline personality disorder. Ameri-
can Journal of Psychiatry, 166(12),
13651374.
Palmer, S., Davidson, K., Tyrer, P., Gumley,
A., Tata, P., Norrie, J., et al. (2006).
The cost-effectiveness of cognitive
therapy for borderline personality dis-
order: Results from the BOSCOT trial.
Journal of Personality Disorders, 20,
466481.
Paris, J., & Zweig-Frank, H. (2001). A 27-
year follow-up of patients with border-
line personality disorder. Comprehen-
sive Psychiatry, 42(6), 482487.
Platt, S., Hawton, K., Kreitman, N., Fagg, J.,
THERAPY INTENSITY, SUICIDAL ACTS, AND DEPRESSION IN BPD 197
& Foster, J. (1988). Recent clinical and
epidemiological trends in parasuicide
in Edinburgh and Oxford: A tale of two
cities. Psychological Medicine, 18,
405418.
Turner, R. M. (2000). Naturalistic evaluation
of dialectical behavior therapy-orient-
ed treatment for borderline personali-
ty disorder. Cognitive and Behavioral
Practice, 7, 413419.