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

Journal of Substance Abuse Treatment 41 (2011) 363 – 373

Regular article

A systematic review of interventions for co-occurring substance use disorder and borderline personality disorder Amy Pennay, (B.A.(Hons)) a,b,⁎, Jacqui Cameron, (M.Phil. Soc. Sci. Research, B.S.W., B.A.) a,b , Tiffany Reichert, (Ph.D.) a,1 , Heidi Strickland, (B.App.Sci. (Health Prom), Grad. Cert.A.O.D.) a , Nicole K. Lee, (Ph.D.) a,b,2 , Kate Hall, (Ph.D.) a , Dan I. Lubman, (Ph.D.) a,b a

Turning Point Alcohol and Drug Centre, Eastern Health, Fitzroy, Victoria, Australia, 3065 b Monash University; Clayton, Victoria, Australia, 3168

Received 14 December 2010; received in revised form 17 May 2011; accepted 17 May 2011

Abstract Rates of borderline personality disorder (BPD) among individuals with substance use disorder (SUD) are estimated to be as high as 65%. Such elevated rates present considerable challenges for drug treatment services given that individuals with co-occurring SUD and BPD have higher rates of relapse, treatment noncompliance, and poorer outcomes than those with either diagnosis alone. A systematic review investigating current treatment options for co-occurring SUD and BPD was conducted using Medline and PsycINFO. Randomized controlled trials were the focus. Six studies were included that examined the use of three psychosocial therapies: dialectical behavior therapy, dual focused schema therapy and dynamic deconstructive psychotherapy. Despite all studies demonstrating some treatment gains over time, there is currently insufficient evidence to recommend one treatment over another. Further research is needed to examine effective treatment options for co-occurring SUD and BPD, especially those that are likely to be applicable in mainstream drug treatment settings. © 2011 Elsevier Inc. All rights reserved. Keywords: Substance use disorder; Borderline personality disorder; Treatment; Systematic review

1. Introduction Both epidemiological and clinical studies consistently identify high rates of co-occurring mental health disorders among substance misusing populations (Burns & Teesson, 2002; Hall, Hando, Darke, & Ross, 1996; Lubman, Allen, Rogers, Cementon, & Bonomo, 2007; McKetin, McLaren, Lubman, & Hides, 2006). Studies have shown that up to 79% of individuals with substance use disorders (SUDs) experience symptoms of depression and up to 76% exhibit ⁎ Corresponding author. Turning Point Alcohol and Drug Centre, Fitzroy, Victoria, Australia, 3065. Tel.: +61 3 8413 8460. E-mail address: [email protected] (A. Pennay). 1 Dr. Reichert is now at the Victorian University of Technology, Melbourne, Australia. 2 Dr. Lee is now at the National Centre for Education and Training on Addictions, Flinders University, Adelaide, Australia. 0740-5472/11/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2011.05.004

symptoms of anxiety (Burns & Teesson, 2002; Darke & Ross, 1997; Degenhardt, Hall, & Lynskey, 2001; Lubman et al., 2007). As a result, there has been a small but growing literature focused on developing effective treatment responses for co-occurring disorders (Baker, Hides, & Lubman, 2010; Hendrickson, 2006; McGovern, Xie, Segal, Siembab, & Drake, 2006). Relatively less attention has been paid to more enduring personality disorders, despite evidence that they also commonly co-occur among those with SUD histories (Bowden-Jones et al., 2004) and are associated with poorer outcomes (Bowden-Jones et al., 2004; Darke, Ross, Williamson, & Teeson, 2005; McMain & Ellery, 2008). One of the most commonly identified personality disorders among SUD populations is borderline personality disorder (BPD; Bowden-Jones et al., 2004; Mills, Teesson, Darke, Ross, & Lynskey, 2004; Trull, Sher, Minks-Brown, Durbin, & Burr, 2000).

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Although around 1%–2% of the general population meet criteria for a BPD diagnosis (Lenzenweger, Lane, Loranger, & Kessler, 2007; Torgersen, Kringlen, & Cramer, 2001), the rate among individuals with SUD is substantially higher, ranging from around 9% in community samples to around 65% in treatment samples (Trull et al., 2000). Such high rates present considerable challenges for drug treatment services, given the higher levels of psychosocial impairment, more severe psychopathology and substance use, and increased rates of self-harm and suicidal behavior among this population (Bowden-Jones et al., 2004; Darke et al., 2005; McMain & Ellery, 2008). Indeed, treatment studies highlight that individuals with co-occurring SUD and BPD have higher rates of relapse, treatment noncompliance, and poorer outcomes than those with either diagnosis alone (Kienast & Foerster, 2008; van den Bosch & Verheul, 2007; Zanarini, Frankenburg, Hennen, Reich, & Silk, 2005). Although there is an extensive literature on effective interventions for SUD and BPD independently, there are limited data available on treatment approaches for cooccurring SUD and BPD. Considering that co-occurring BPD may be prevalent in more than 50% of those seeking SUD treatment and there is limited clinical understanding about the most effective treatment approach for these clients, a review of the existing evidence was identified as an important first step. The aim of this article is to systematically review current evidence regarding effective treatment options for co-occurring SUD and BPD and discuss the clinical implications of these findings for the alcohol and drug field.

2. Method Three reviewers (A. P., J. C., and H. S.) performed a systematic literature review, comparing and synthesizing the purposes, methods, and results of existing high-quality studies. Randomized controlled trials (RCTs) were the focus of the review. The databases searched were Medline and PsycINFO. These databases were selected for their breadth and relevance to the subject. The search date was from database inception to March 2010. Three search terms were used: 1. SUD (substance use or substance use disorder or substance abuse or substance dependence or drug use or drug abuse or drug dependence or addiction or drug addiction or alcohol or cannabis or marijuana or amphetamine⁎ or cocaine or heroin or opioid or opiate) 2. BPD (borderline personality disorder or personality disorder or borderline or personality or borderline states or affective disorder or mood disorder or impulse control or emotion dysregulation) 3. Treatment (treatment or therapy or drug treatment or drug therapy or alcohol treatment or alcohol therapy or

intervention or clinical trial or RCT or co-morbidity or comorbidity or dual diagnosis or clinic or treatment outcome or group treatment or group therapy or psychotherapy or psychosocial treatment or counseling or cognitive behavio(u)ral therapy or psychodynamic or pharmacotherapy). A search of 1 + 2 + 3 (limiting to human studies and English language) produced 16,887 articles (Medline = 8,269; PsycINFO = 8,618). Limiting these to RCTs produced 1468 articles (Medline = 1,151; PsycINFO = 317). All abstracts were obtained, and three reviewers examined all studies for inclusion, cross-referencing with one another to maximize validity. Periodic supervisory review was provided by a fourth author (T. R.). To qualify for inclusion, studies needed to be RCTs primarily concerned with the treatment of co-occurring SUD and BPD. Most research papers were excluded on two conditions: first, if they were not primarily about cooccurring presentations, and second, if SUD was incidental among other primarily studied factors. If reading the abstracts did not allow for conclusive exclusion, then fulltext articles were retrieved. All articles were checked by at least two reviewers before inclusion or exclusion. After reviewing all publications identified via the search strategy, only six studies were included for examination. These six articles investigated psychosocial approaches to the treatment of SUD and BPD. Two of these studies included subjects with personality disorders (not identified) and so were not BPD specific, but a decision was made to include them based on their potential relevance for treating SUD and BPD. A third analyzed SUD outcomes in a secondary analysis and was also included given its potential contribution to this field. No pharmacotherapy trials for treating co-occurring SUD and BPD were identified. The results of the three rigorous RCTs of SUD and BPD are presented first, followed by the studies that did not fully meet the inclusion criteria.

3. Results 3.1. Three RCTs of treatment for co-occurring SUD and BPD Dialectical behavior therapy (DBT) was the intervention applied in two of the three studies of treatment for cooccurring SUD and BPD. DBT was originally developed for the treatment of BPD, specifically among individuals with chronic suicidal or parasuicidal behavior (Linehan, 1993). DBT operates from a biosocial framework that understands that emotional vulnerability and environmental invalidation give rise to pervasive emotional problems (Linehan, McDavid, Brown, Sayrs, & Gallop, 2008; Rosenthal, Lynch, & Linehan, 2005). DBT combines standard cognitive–behavioral techniques for emotion regulation and

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reality testing with Buddhist concepts of mindful awareness, distress tolerance, and acceptance (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991). DBT is the most widely researched of the psychological therapies for BPD, with a number of randomized controlled trials demonstrating its efficacy (Clarkin, Levy, Lenzenweger, & Kernberg, 2007; Koons et al., 2001; Linehan, Cochran, & Kehrer, 2008; Linehan et al., 2006; Simpson et al., 2004; Soler et al., 2005; Verheul et al., 2003). DBT has also been adapted specifically for the treatment of co-occurring SUD within BPD populations (Dimeff & Linehan, 2008; Linehan et al., 2002; Linehan et al., 1999). In the first trial (Linehan et al., 1999), 28 female subjects who met criteria for both SUD and BPD were randomly assigned to receive DBT with replacement medications (n = 12) or treatment as usual (TAU; n = 16) for 12 months. SUD was assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID), and BPD was assessed using the Personality Disorder Questionnaire (PDQ). DBT was delivered by a group of clinicians (two psychologists, one psychiatrist, and two master's-level clinicians) who had received extensive training on DBT. DBT involved weekly individual psychotherapy, weekly group skills training, skills coaching phone calls when needed, and weekly consultation between clinicians. Replacement medications received by those in the DBT group included methylphenidate for stimulant users and methadone for opiate users. Dosages of methylphenidate and methadone received by those in the DBT group were determined in the initial stages of treatment. Drug replacement consisted of 4 months of drug maintenance, 4 months of tapering, and 4 months of no drug replacement. Participants on drugs other than opiates or stimulants, such as cannabis, were not offered drug replacement treatment. TAU varied from continuation of current treatment or referral to community mental health or drug treatment. TAU participants were offered ongoing referral if they ceased treatment. Therapist adherence was measured in a post hoc analysis using a DBT Expert Rating Scale, which showed mixed levels of therapist adherence. More than half of the sample was dependent on cocaine (58%) and alcohol (52%), and 74% met criteria for dependence on more than one drug. There were also high rates of depression, posttraumatic stress disorder, and antisocial personality disorder. There were no differences between the two groups on the use of other psychotropic medications; however, the DBT group were dependent on more substances than the TAU group and exhibited higher rates of other Axis I disorders at baseline. Participants were followed up over 16 months. Missing data were dealt with using the last observation carried forward method or where no data were available, using the worst possible outcome. The study revealed that DBT with replacement medications more effectively reduced substance use (as measured by the SCID and urinalysis) and retained participants in treatment over the 12-month period (both reaching signifi-

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cance). There were no between-group differences in symptoms of BPD (using the Parasuicide History Review [PHR] and the State-Trait Anger Expression Inventory) and global and social functioning (using the Global Social Adjustment [GSA] and Global Adjustment Scale [GAS]) at 12 months, but at 16 months, participants in the DBT group showed improved global and social functioning compared with those in the TAU group. Methodological limitations of this study include a small sample size (n = 28) and a high dropout rate (leaving n = 18 in the treated sample, but n = 28 in the intention-to-treat sample). Randomization was not stratified, and subsequently, the DBT group showed greater levels of substance dependence and Axis I disorders at baseline. Subjects in the DBT group also received more than twice the therapy hours of those in the TAU group (around 4 hours per week compared with 1–2 hours); however, there were no significant differences found in treatment contact when case management hours were taken into consideration in the TAU group. A limitation of the analysis was that only a one-tailed test of significance was used. A post hoc analysis revealed that there were varying levels of adherence to DBT protocols among therapists. Finally, targeted pharmacotherapeutic intervention (methadone for opiate users and methylphenidate for stimulant users) in the DBT group makes it difficult to isolate the contribution of DBT. The second study (Linehan et al., 2002), conducted by the same research group, investigated the efficacy of DBT among a sample of opiate-dependent women (n = 23) with BPD using a more rigorous control condition than the first. SUD was assessed using the SCID, and BPD was assessed using the SCID Axis II (SCID-II). A minimization method of randomization was used to assign participants to treatment conditions matching on severity of drug dependence, cocaine use, antisocial personality disorder, and global functioning. The experimental group (n = 11) received adapted DBT for substance users for 48–52 weeks, whereas the control group (n = 12) received Comprehensive Validation Therapy with 12-step (CVT+12S), a manual-based treatment that provides major acceptance-based strategies (similar to DBT) in combination with standard 12-step abstinence programs (i.e., Alcoholics Anonymous/Narcotics Anonymous). CVT+ 12S was applied according to a treatment manual developed specifically for the research and was designed to control for the provision of support, validation, and general therapeutic acceptance strategies specific to DBT. In addition, CVT+12S was designed to provide a similar level of support to DBT, including telephone consultation and after-hours use of a local crisis line. DBT was delivered by two doctoral-level and one master's-level clinicians who had received extensive DBT training. CVT+12S was delivered by two master'slevel clinicians with chemical dependency certification who had also received extensive training. This project design ensured that both treatment groups received individual and group therapy and received close to the same amount of treatment contact. Both treatment groups also received opiate pharmacotherapy (levomethadyl acetate hydrochloride

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[LAAM]) throughout the entire treatment period (dosages were adjusted by clinicians as an ongoing feature of treatment). Treatment adherence was promoted through weekly meetings with a supervisor in which videotaped sessions were reviewed; however, there was no information provided about actual levels of adherence. Participants were using a range of substances including opiates, cocaine, alcohol, amphetamine, sedatives, hypnotics, and anxiolytics at baseline. More than half of the sample met criteria for cocaine dependence, and there were also high rates of antisocial personality disorder, depression, and anxiety in the sample at baseline. However, there were no differences between groups on levels of substance use or other Axis I and II disorders due to the randomization approach. Participants were followed up over 16 months. Where urinalysis tests were missing, a “percent dirty” score was calculated as the ratio of positive urine specimens. Where self-reported drug use information was unavailable, missing values were conservatively treated as positive. The results showed that both groups demonstrated significant reduction in opiate use over the first 30 weeks of treatment (as measured by urinalyses); however, those in the DBT group showed better maintenance of treatment gains, with opiate use in the CVT+12S group increasing after 30 weeks but remaining reduced in the DBT group. At 16 months however, there were no differences in opiate use between groups. There was also no difference between groups in non-opiate drug use over the treatment period. Participants in the CVT+12S showed better treatment retention, with all CVT+12S participants staying in treatment for 12 months and 36% of the DBT dropping out over the same period. However, participants in the DBT group attended a greater number of group sessions than the CVT+ 12S group. There were no differences between groups in parasuicide (using the PHR) and global and social functioning (using the GAS and GSA). This study had a strong research design and tested adapted DBT against a rigorous control intervention. The study employed a minimization stratification to enhance the validity of the findings, and a further strength is that all participants were opiate dependent and all received agonist medication in conjunction with treatment. There were differences in therapist gender and qualifications, which may have influenced the findings. In addition, there was no information included about levels of therapist adherence to the treatments. The third RCT of treatment for co-occurring SUD and BPD used dynamic deconstructive psychotherapy (DDP). The primary focus of psychodynamic therapy is to explore the unconscious content of the psyche in an effort to alleviate psychic tension. In particular, psychodynamic therapies emphasize insight generated by exploration of the impact of previous experience on current challenges. DDP was developed by Gregory and Remen (2008) specifically for clients with BPD who are treatment resistant and have a poor prognosis (including those with co-occurring SUD). The basis of this approach is to activate three deficits in neurocognitive

functioning that are impaired by BPD. These include (a) an inability to form associations between different aspects of affective experience (association), (b) an inability to provide integrated attributions to those experiences (attribution), and (c) an inability to assess the accuracy of those attributions in an objective way (alterity; Gregory & Remen, 2008). Only one RCT examining the efficacy of DDP among those with co-occurring SUD and BPD has been conducted to date (Gregory et al., 2008). This study randomized 30 adults (female n = 24) with alcohol dependence and BPD to 12 months of DDP or TAU. Alcohol dependence was assessed using the SCID, and BPD was assessed using the SCID-II. At baseline, participants had high rates of drug use and Axis I and II disorders, including antisocial personality disorder, depression, symptoms of parasuicide, and illicit drug use. However, there were no differences between groups because a minimization method of randomization was employed, which adjusted for age, gender, alcohol use versus dependence, current alcohol use, antisocial personality disorder, inpatient utilization, and number of parasuicides. Missing data were treated using the last observation carried forward method. DDP treatment involved individual weekly sessions by one psychiatrist and five psychiatry residents. All therapists were subject to competency evaluations prior to seeing their first participant. Participants were also encouraged to attend independent group therapy (i.e., 12-step programs), which four participants did during the first 6 months of treatment. Participants assigned to TAU were referred to an alcohol rehabilitation centre, as well as local psychiatric clinics, or continued with their current therapist. Psychotropic medication was prescribed according to the clinical judgment of each clinician. Alcohol pharmacotherapy (i.e., naltrexone) was not prescribed. Treatment adherence was monitored through weekly group supervision and fortnightly individual supervision of videotaped sessions with the lead author (although no data were provided on levels of adherence). Participants in the DDP group demonstrated a significant reduction in core symptoms of BPD (using the Borderline Evaluation of Severity over Time [BEST]), alcohol use (using the Addiction Severity Index [ASI]), parasuicidal behavior (using the Lifetime Parasuicide Count), depression (Beck's Depression Inventory), and dissociation (Dissociative Experiences Scale) after 12 months compared with the TAU group. Treatment retention rates were comparable between groups. This study had a strong research design, and limiting the sample to those with alcohol dependence is likely to have reduced any influences associated with other drug use; however, there were high rates of current polydrug use in the sample, but no measure of dependence on these other drugs. 3.2. One RCT of treatment for BPD with a secondary analysis of SUD outcomes There has been one RCT reporting on the efficacy of DBT for BPD (Verheul et al., 2003) that examined SUD outcomes in a secondary analysis (van den Bosch, Verheul, Schippers,

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& van den Brink, 2002). Fifty-eight female participants with BPD were randomized to receive DBT (n = 27) or TAU (n = 31) for 12 months. BPD was assessed using the PDQ and SCID-II. A minimization method was used to control for alcohol and other substance use and social problems. The DBT group received weekly psychotherapy, weekly skillsbased groups, and weekly supervision, and therapists engaged in weekly consultation. TAU consisted of standard clinical management from their current provider, including addiction treatment (n = 11) and psychiatry services (n = 20). Participants in the TAU group generally attended no more than two sessions per month with a social worker, psychologist or psychiatrist. DBT was delivered by four psychiatrists and 12 clinical psychologists. The group sessions were led jointly by social workers and clinical psychologists. Treatment adherence was monitored using videotaped sessions and weekly individual and group supervision; however, no information was provided on levels of adherence. Participants were followed up at 18 months (Verheul et al., 2003). Participants reported high levels of previous suicide attempts, self-harming behavior, and substance dependence at baseline. A general linear mixed model approach was used, which allowed for inclusion of cases with missing values by providing an informed estimate of the value. This study showed that the DBT group had better retention in treatment (which reached significance) and greater reductions in selfharming behaviors (using the Personality Disorder Severity Index) but did not report on changes in substance use, as it was not a primary outcome measure (Verheul et al., 2003). A second paper was published from this study that analyzed SUD outcomes in a secondary analysis (van den Bosch et al., 2002). SUD was analyzed using the ASI. Patients with a score of greater than 5 on the alcohol or drug section were considered substance abusers. This resulted in 53% of the sample being deemed as having an SUD. Substances used among the sample included sedatives (64%), alcohol (52%), cannabis (30%), and cocaine (17%). Fifty-six percent were polydrug users. It is unclear how many of those with an SUD were in the DBT and TAU groups, but it is likely to be comparable given that the minimization method of randomization controlled for alcohol and other drug use. The secondary analysis showed that SUD did not reduce significantly in either the DBT or TAU groups over the 18 months. Through qualitative analysis, the authors reported that patients with BPD with and without SUD could be treated together without any problems. This study is limited in that it did not intend to address SUD and BPD, and as such, there were no significant changes on SUD among the sample. In addition, treatment adherence was not reported. 3.3. Two RCTs of treatment for co-occurring SUD and personality disorder (not BPD specific) Dual-focus schema therapy (DFST; Ball, 1998) has been modified from schema-focused therapy (Young, 1994) for

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the treatment of co-occurring SUD and personality disorder. The core construct of schema-focused therapy is that personality disorder results from maladaptive schemas that develop at an early age. Schema therapy integrates elements of cognitive therapy, behavior therapy, object relations, and gestalt therapy into one unified systematic approach for the treatment of personality disorders (Young, 1994). DFST has been investigated in two RCTs. In the first trial (Ball, Cobb-Richardson, Connolly, Bujosa, & O'Neall, 2005), 52 homeless people (female n = 3) with a personality disorder who were seeking services at a drop-in program and who had used alcohol or drugs in the past 30 days were randomized to DFST or standard drug abuse counseling for 24 weeks. Personality disorder was assessed using the PDQ. It is unclear how substance use was assessed. DFST involved 24 weeks of individual therapy (one session a week) focusing on relapse prevention, coping skills, and schemafocused techniques. DFST was delivered by one master'slevel clinician who had received 10 days of training from the developer of schema therapy. Standard drug abuse counseling involved three weekly opportunities for group psychoeducation (meaning that it potentially provided three times the amount of treatment contact compared with DFST) delivered by a master's-level clinician who had developed the curriculum based on years of experience. Adherence to DFST was reviewed by the first author through the review of audiotapes; however, no data were presented on the extent to which adherence was maintained. Only 51% of the sample met criteria for BPD. Half of the sample identified alcohol, and half identified illicit drugs (23% cocaine, 14% heroin, and 14% cannabis) as their substance of choice. Participants had high levels of psychological problems (including comorbid personality disorders such as paranoid, schizotypal, avoidant, and obsessive compulsive, as well depression and anxiety), but there were no significant differences between groups on these measures at baseline. Six participants were also receiving methadone treatment on top of their current treatment, although it is not clear which group these participants were assigned to. Only descriptive statistics were used, and so missing data methods were not employed. Because of low retention rates among this homeless client group, changes in personality disorder symptoms and substance use could not be evaluated; however, those in the DFST group showed higher overall use of treatment, with the DFST group attending a mean total session of 7.31 out of a possible total of 24 sessions and the standard drug abuse counseling group attending a mean total of 6.86 sessions out of a possible 72. The study had several limitations. Firstly, entry into the trial was qualified by recent alcohol or drug use, and therefore, participants did not necessarily meet criteria for SUD. Indeed, only 27% of alcohol users and 42% of illicit drug users met criteria for current dependence. Secondly, only 51% of the sample met criteria for BPD, with other personality disorders, including paranoid, schizotypal,

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Table 1 Summary of RCTs for treatment of SUD and BPD Study

Sample

Diagnostic measure

Inclusion criteria

Study design

Additional medications

Participation rate

Substances used

Intervention

Linehan et al. (1999)

28 adults with coborbid SUD and BPD Female 100% Mean age = 30.4 23 adults with comorbid opiate dependence and BPD Female 100% Mean age = 36.1

BPD—PDQ SUD—SCID-I

Diagnosis of BPD Diagnosis of SUD

12-Month RCT comparing adapted DBT for SUD (n = 12) vs. TAU (n = 16)

Diagnosis of BPD Diagnosis of SUD (opiate dependence)

12-Month RCT comparing adapted DBT (n = 11) for SUD vs. CVT+12S (n = 12)

Polydrug (74%), cocaine (58%), alcohol (52%), opiates (21%), cannabis (14%), and methamphetamine (11%) Opiates (100%) Cocaine (52%)

Gregory et al. (2008)

30 adults with comorbid alcohol dependence and BPD Female 80% Mean age = 29

BPD—SCID-II SUD—SCID-I

Diagnosis of BPD Diagnosis of SUD (alcohol dependence)

12- to 18-month RCT comparing DDP (n = 15) vs. TAU (n = 15)

None

- Screened (unknown) - 28 eligible and randomized - 18 completed treatment - 64 screened - 24 eligible and randomized - 1 removed from sample for breaching eligibility - 23 completed treatment - 103 screened - 66 eligible - 30 entered and completed treatment

DBT adapted for SUD

BPD—SCID-II and personality disorder examination (PDE) SUD—SCID-I

Agonist medication offered to DBT group (methadone for opiate users and methylphenidate for stimulant users) Both groups received opiate agonist medication (LAAM)

DDP

van den Bosch et al. (2002)

58 adults (n = 27 with comorbid SUD and BPD; n = 31 with BPD only) Female 100% Mean age = 37.5 52 homeless adults with a PD and drug use in the past 30 days Female 6% Mean age = 38.3

BPD—PDQ and SCID-II SUD—ASI

Diagnosis of BPD Currently in outpatient psychiatric or SUD treatment

12-Month RCT comparing DBT (n = 27) vs. TAU (n = 31). Post-hoc analysis of SUD

None

- 92 screened - 64 eligible and randomized - 58 completed treatment

Personality disorder (PD)—PDQ SUD—substance use in past 30 days, tool not specified

Diagnosis of PD (note: only 51% of the sample had a diagnosis of BPD) Substance use in past 30 days

6-Month RCT comparing DFST vs. standard substance abuse counseling

None

- 318 screened - 248 eligible - 52 entered and completed treatment

- 78 screened - 41 eligible and randomized - 11 included as pilot data - 30 completed treatment and included as trial data

Alcohol (100%) Current drug use also included heroin (20%), other opiates (37%), sedative hypnotics (33%), amphetamine (40%), hallucinogens (47%), cocaine (53%), and cannabis (83%) Prescribed sedatives (64%), polydrug (56%), alcohol (50%), cannabis (30%), cocaine (17%), methadone (13%), and heroin (9%) Use in past 30 days— alcohol (50%), cocaine (23%), heroin (14%), and cannabis (14%) Current dependence— alcohol (27%) and other drug (42%) Methadone (100%) Drug use in past 30 days— heroin (50%), cocaine (43%), alcohol (37%), tranquilizers (27%), and cannabis (7%)

Linehan et al. (2002)

Ball (2007)

30 adults on methadone with a PD Female 50% Mean age = 37

PD—SCID-II SUD—substance use timeline calendar

Diagnosis of PD (note: only 57% sample met criteria for BPD) On a stable dose of methadone (50–110 mg) for at least 1 month Used an illicit drug in past 30 days

6-Month RCT comparing DFST vs. 12FT

None

Study

Treatment retention

Changes in symptoms of SUD

Changes in symptoms of BPD

Changes in other symptoms (i.e., social functioning)

Methodological limitations

Linehan et al. (1999)

36% dropped out of DBT; 73% from TAU DBT group showed

DBT group showed greater reduction in SUD (using the SCID and urinalysis) than

No between-group differences on Parasuicide History Interview or State-Trait

DBT group showed better scores on the GSA (p b .05) and GAS (p b .001) at 16 months

Small sample High dropout rate No stratification evident in randomization

DBT

DFST

DFST

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Ball et al. (2005)

DBT adapted for SUD

TAU (p b .05)

Anger Inventory

Linehan et al. (2002)

27% dropped out of DBT; no treatment dropout in CVT+12S (p b .04)

No between-group differences on Parasuicidal History Interview

No between-group differences on the Brief Symptoms Inventory, GAS, and GSA

Gregory et al. (2008)

33% dropped out of DDP group, 40% dropped out of TAU group (not significant)

As measured by urinalysis, no differences in opiate use until 12 months when DBT group showed less opiate use (p b .02) At 16 months there was no difference between groups in opiate use No difference in other drug use across the entire treatment episode At 12 months DDP group showed greater reduction in alcohol use using the ASI (p b .05)

At 12 months DDP group showed greater reduction of BPD symptoms on BEST and Parasuicide Count (p b .05)

van den Bosch et al. (2002)

81% of entire sample still in treatment at week 52 (no betweengroup data reported)

No difference between groups in reduction of SUD using the ASI

Ball et al. (2005)

60% of entire sample dropped out after 1 month and 77% dropped out after 3 months No difference in retention between groups

No change in substance use assessed due to high dropout rate

DBT group showed greater reduction in self-harming behaviors using the Personality Disorder Severity Index (non-significant) No change in PD symptoms assessed due to high dropout rate

At 12 months DDP group showed decreased episodes of institutional care using the Treatment History Review, decreased scores on Beck's Depression Inventory, and a decrease on the Dissociative Experiences Scale (p b .05) Not reported

Ball (2007)

No differences in treatment utilization or retention between groups

Reduction in SUD in the DFST group as measured by the substance use timeline calendar (p b .05)

Changes in PD not reported

No changes in other domains assessed due to high dropout rate

Small sample TAU treatment variable No data provided on levels of adherence

SUD analyzed post hoc TAU treatment variable No information about levels of therapist adherence

Not all participants were currently substance dependent No stratification evident in randomization High dropout rate Substantial differences in treatment types (individual versus group) No information about treatment adherence No analyses of PD symptoms or substance use due to high dropout rate Small sample No stratification evident in randomization No mention of betweengroup sample size Substantial differences in treatment types (individual vs.group)

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Reduction in dysphoria on the Multiple Affect Adjective ChecklistRevised in the 12FT group (p b .01) No differences on the Brief Symptoms Inventory

One tail-test of significance TAU treatment variable Levels of therapist adherence to DBT was variable Agonist medication offered to DBT group may have confounded results Small sample Some difference between therapists in qualifications and gender No outcomes reported in relation to treatment adherence

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greater retention in treatment (p b .05)

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avoidant, and obsessive compulsive, more common. In addition, there was no information provided about how many participants were randomized to each group, and there was no evidence of stratification in the randomization. The two treatments were vastly different, with DFST involving individual counseling and standard drug abuse counseling involving group therapy. Finally, retention rates were low among this client group (with 60% dropping out after 1 month and 77% dropping out after 3 months), and so, changes in personality disorder symptoms and substance use could not be evaluated. A second RCT (Ball, 2007) compared DFST with 12-step facilitation therapy (12FT) in a sample of opiate-dependent patients on opiate pharmacotherapy. Thirty participants (female n = 15) on methadone maintenance (50–110 mg daily) with coexisting personality disorders were randomly assigned to one of the two therapies for 24 weeks. DFST targets both personality dysfunction and substance abuse. 12FT is a manual-guided 12-step group therapy emphasizing the disease concept of addiction (Nowinski, Bakers, & Carroll, 1992). Both treatment types involved limited supportive individual counseling and group counseling. Six licensed doctoral-level psychologists received training on DFST and 12FT. All therapy appointments were videotaped and reviewed and independently evaluated to ensure treatment fidelity. Treatment adherence was confirmed in both DFST and 12FT groups (and was statistically significant). Only 57% of the sample met criteria for BPD. Although all participants were on methadone maintenance treatment, only 56% identified heroin as their drug of choice, with 23% reporting cocaine and 10% reporting alcohol and benzodiazepines. Axis I and II disorders were high among the sample, with high rates of antisocial and avoidant personality disorders, as well as depression and anxiety. There were no baseline differences between groups on demographics and Axis I and II disorders including SUD. Missing data were calculated by plotting the missing data on a regression line. The DFST group showed greater reductions in their substance use than the 12FT group (measured using the Substance Use Time-Line Calendar), and DFST also promoted a stronger bond between therapist and participant (using the Working Alliance Inventory). However, 12FT was associated with greater reductions in dysphoria (using the Multiple Affect Adjective Checklist-Revised). All three of these results were significant. There were no differences between groups on treatment retention or utilization, with the DFST group accessing a mean of 4.3 group sessions and 1.5 individual sessions and the 12FT group accessing a mean of 3.2 group sessions and 1 individual session. There were also no differences on measures of psychosocial impairment and psychiatric symptoms (using the Brief Symptoms Inventory). This project was more robustly designed than the first trial of DFST, with all the participants opiate dependent and receiving methadone maintenance. However, as with the first

trial of DFST (Ball et al., 2005), there was no mention of how many participants were randomized to each group and no evidence of stratification in the randomization. A further limitation of the study is that the control arm was substance treatment only, making personality disorder outcomes difficult to compare (although the 12FT group showed better outcomes in dysphoria). In addition, participants in both groups only accessed a small number of group and individual sessions over the 6-month period (Table 1).

4. Discussion Three types of psychosocial treatment have been examined under randomized controlled conditions for cooccurring SUD and BPD: dialectical behavioral therapy (adapted for substance users), DFST (modified for substance users), and DDP. No pharmacotherapy RCTs have been conducted. Importantly, all of the studies demonstrated some treatment gains over time, indicating that the complex copresentation of SUD and BPD is treatable if appropriate interventions are applied. The first trial of DBT adapted for substance users (Linehan et al., 1999) showed that DBT significantly reduced substance use, more effectively retained participants in treatment, and showed improvements in global and social functioning compared with TAU; however, it is difficult to tell from this trial whether the results of DBT alone would have been superior to TAU, as the addition of medication (methadone for opiate users and methylphenidate for stimulant users) in the DBT group makes it difficult to isolate the value of DBT. Importantly, the second trial of DBT (Linehan et al., 2002) was more rigorous than the first, demonstrating the research group's acknowledgement of the methodological limitations of the first trial. The second trial of adapted DBT for substance users (Linehan et al., 2002) aimed to reduce the likelihood of confounding variables and test DBT against a controlled treatment arm (CVT+12S), with both groups receiving the same agonist medication. This study is likely to be more representative of the efficacy of DBT but showed mixed results, with the DBT group demonstrating a higher likelihood of sustained reduction in opiate use after 12 months (but not at 16 months), no change in other drug use between groups, and lower rates of treatment retention in the DBT group. The reduction in opiate use over the first 12 months (and no change in other drug use) makes it likely that the reductions in opiate use were due to the opiate replacement therapy rather than the psychosocial interventions. Importantly, given the positive outcomes associated with the CVT +12S arm, this treatment may warrant further consideration for the treatment of SUD and BPD. The RCT reporting on the efficacy of DBT for BPD (Verheul et al., 2003), which examined SUD outcomes in a secondary analysis (van den Bosch et al., 2002), contributes little to our understanding of the usefulness

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of DBT for co-occurring SUD and BPD. The secondary analysis revealed that 53% of the BPD sample had a cooccurring SUD; however, SUD did not reduce significantly in either the DBT or TAU groups over 12 months, as it was not a focus of treatment. There have been a number of studies that have investigated the use of DBT among other “complex” populations other than SUD populations, including those with BPD and eating disorders (Chen, Matthews, Allen, Kuo, & Linehan, 2008), BPD and co-occurring posttraumatic stress disorder (Harned & Linehan, 2008), and adolescents with symptoms of BPD demonstrating persistent and deliberate self-harm (James, Taylor, Winmill, & Aldoadari, 2008). These studies show that DBT is effective when working with populations that involve a co-occurrence of BPD with other disorders. These results lend themselves to the presumption that DBT may be appropriate for treating the difficult copresentation of SUD and BPD; however, further research is required. The trial of DDP (Gregory et al., 2008) showed the most positive outcomes across a range of psychosocial domains, including parasuicidal behavior, depression, dissociation, and other symptoms of BPD, and a greater reduction in alcohol use compared with the TAU group and was a wellcontrolled trial. This trial was the most methodologically sound of the five trials; however, the sample size was small, and the TAU arm was not controlled. This study was restricted to those with alcohol dependence, and as such, further research on DDP needs to be undertaken among other populations of substance users. DFST has shown some promise treating co-occurring SUD and personality disorders in two preliminary trials; however, these trials have significant limitations. In the first (Ball et al., 2005), entry into the study was qualified by alcohol or drug use in the past 30 days, which means that participants were not necessarily substance dependent. Furthermore, retention rates were low among this client group (which is not unexpected given that participants were homeless, and as such may have impacted the results), and so, changes in personality disorder symptoms and substance use could not be evaluated. However, in the second study (Ball, 2007), which had stronger methodological rigor, there were no differences in retention between the two groups, although those in the DFST group showed greater reductions in substance use. One of the problems with DFST is that it focuses on personality disorders in general and is not BPD specific; therefore, the results cannot necessarily be generalized to BPD. Further research should focus on the use of DFST in a co-occurring SUD and BPD population. All the studies reviewed here had methodological limitations. All had small sample sizes (n = 23 to n = 58) and high attrition rates, and the mechanisms of change were unclear. All five studies experienced difficulties retaining participants in treatment. Substance users are known to have poor retention in treatment (Sindelar & Fiellin, 2001), and treatment retention is essential for achieving positive

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outcomes among both SUD and BPD populations (Zanarini, Frankenburg, Hennen, & Silk, 2003). Although two studies focused on people with opiate dependence (Ball, 2007; Linehan et al., 2002) and one study focused on alcohol dependence (Gregory et al., 2008), all six studies showed high levels of polydrug use among the samples. Cocaine was the most common drug used, along with alcohol and heroin. In addition, all studies showed high levels of co-occurring Axis I and II disorders, particularly depression, anxiety, and antisocial personality disorder. Only two studies used a minimization method of randomization to ensure that the groups were matched on these important domains (Gregory et al., 2008; Linehan et al., 2002). The high levels of co-occurring disorders and polydrug use are likely to have influenced the results. Another limitation of the studies is that they used different measures of SUD, BPD, and other psychological symptoms, which have differing levels of validity and reliability and make comparisons between the studies difficult. Furthermore, females were substantially overrepresented in the studies, which limits the applicability of the findings to males. 4.1. Implications for alcohol and other drug treatment All studies reviewed here involved treatment over a period of at least 6 months. In the case of DBT, treatment usually spans 12 months, and the treatment length of DDP is 18 months. In some literature, it is suggested that treatment of co-occurring SUD and BPD may be required as a permanent, ongoing, feature of lifestyle (Zanarini, 2008). The length of these treatments is at odds with the design of many drug treatment services, where substitution pharmacotherapy is a major focus and structured psychological treatments are generally time limited. In addition, DBT, DFST, and DDP are intensive specialist therapies requiring significant resources in relation to both training of staff and implementation, whereas the drug treatment workforce in many countries has varying levels of education and experience and high staff turnover rates (Roche, 2002). Considering that co-occurring BPD may be prevalent in more than 50% of those seeking SUD treatment, there are considerable resource implications for drug treatment agencies, particularly if they are to provide “best practice” for this client group. Perhaps one way of attempting to address the apparent contradiction between what is evidencebased practice for clients with SUD with BPD and what is actually happening in current drug treatment would be to conduct cost–benefit analyses of the more typical low-cost counseling models of care provided in standard substance treatment (taking into consideration repeated episodes of care) to the more intensive and focused treatment models outlined in this review. A further research direction would be to take into account structural issues in current drug treatment and include an examination of shorter interventions (i.e., 4–8 weeks) that may be more realistically applicable within drug treatment settings.

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