Borderline personality disorder: STEPPS

ED FROM Blum N, John DS, Pfohl B, et al. Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up. Am J Psychiatry 2008;165:468–78. Correspondence to: Dr Black, Psychiatry Research/2-126b MEB, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA; [email protected] Source of funding: Sources of funding: Shire and Forest Laboratories, speaker’s bureau honoraria from Pfizer, honoraria for other consulting from Forest Laboratories and Jazz Pharmaceuticals, AstraZeneca and Wyeth, and Dr Black received grant MH63746 from NIMH. C O M M EN TA R Y B orderline personality disorder (BPD) is a common psychiatric disorder associated with high heath costs. There is widespread pessimism about treatment for borderline personality disorder, but over the past 15 years promising evidence of effectiveness has begun to change attitudes. Compared with other personality disorders, by far the majority of therapeutic trials have been in borderline personality disorder. Psychological therapies, such as CBT, schema focused therapy, dialectical therapy and psychodynamicallybased therapies have all been shown to improve outcome in BPD. More recent trials have used larger samples and been more methodologically rigorous and therefore more robust scientifically. This study by Blum and colleagues is an example of this second wave of trials. Originating in The Netherlands, STEPPS is a cognitive behavioural therapy psychoeducational group programme that includes a session for family members or significant others and a mental health professional involved in the patient’s care. This latter systems element is innovative and makes a great deal of sense given the interpersonal problems and misunderstandings that arise about the condition in those who are trying to help. With three phases: psychoeducation, emotion management skills training and behavioural management skills training, STEPPS is designed to augment usual treatment. The weaknesses are that there was a relatively large attrition rate and blinding of assessors was problematic. The study strengths are that this is a randomised controlled trial in a sample size of over 100 and the participants were followed up over one year post-intervention. As such, the results of this study are more generalisable than earlier trials of therapies for borderline personality disorder. The STEPPS programme seems straightforward, relevant and could be delivered as an adjunctive group treatment in mental health settings. It adds to our therapeutic armamentarium. Although the systems element is innovative, and intuitively it would appear to be useful clinically, the study does not answer whether this is an essential element in leading to improvement. Kate M Davidson, PhD, FBPsS Professor of Clinical Psychology, Faculty of Medicine, University of Glasgow, Glasgow, UK Competing interests: None. 1. Zanarini M, Frankenburg F, Hebben J, et al. Mental health service utilization by borderline personality disorder patients and Axis II comparison subjects prospectively followed up for 6 years. J Clin Psychiatry 2004;65:28–36. Therapeutics 120 EBMH November 2008 Vol 11 No 4 on 4 July 2009 ebmh.bmj.com Downloaded from