Reference: Cochrane Database Syst Rev. 2022 Nov 14;11(11):CD012956
Practice Point: Pharmacotherapy probably doesn’t help borderline personality disorder itself, but may help symptom management.
EBM Pearl: Cochrane Reviews can be a beacon in a fog of information.
In 2023 the Cochrane Institute, originator of Cochrane Reviews (CRs), will be 30 years old. If you are not academically inclined, you may have only a vague idea of what a CR is. The institute and reviews bearing the name “Cochrane” were started 6 years after the 1987 death of their namesake Archie Cochrane, an early and ardent champion of both randomized controlled trials and the systematic aggregation and analysis of data from multiple trials.
A recent CR examining the effectiveness of medication use in treating borderline personality disorder illustrates both the power and limitations of the Cochrane methodology. Researchers searched 20 databases to come up with over 25 thousand initial reports. They narrowed this down to 45 randomized controlled studies which were closely examined for bias, specificity of the question asked, transparency/relevance of methodology, and a variety of other predefined criteria. This checklist of criteria funneling many studies into only the most germane is both a strength and critique of the Cochrane approach. On the one hand, it standardizes how to approach a clinical problem, such that whether the review is performed in Seoul or Buenos Aires, a reader knows what to expect, almost like a franchise. However, the strict inclusion and exclusion criteria used may result in potentially relevant, more qualitative studies being left out.
After examining all of the trials that made it through their critical funnel for bias, heterogeneity, and other parameters, the authors of this paper conclude that there is no high-quality evidence supporting the use of any pharmacotherapy for borderline personality disorder itself, although some medications may help with some specific symptoms such as anger or dissociation. The ability to confidently state that there currently isn’t enough information to give a definitive answer to a question is another advantage of the Cochrane methodology.
For most of us, CRs are considered remarkably trustworthy, even when the results aren’t as directive as we might hope. That isn’t to say the system itself isn’t flawed. Borderline personality disorder is a complicated problem, but even so, the 379 page report of this review is daunting to consider at the point of care, particularly considering there is another separate report on psychological therapies from 2020 (522 pages). Digesting the meticulously detailed Cochrane reviews is so onerous there is an entire group of “umbrella” or “review summaries” designed to take the drudgery out of locating and digesting high quality evidence. Aside from the length of the papers, there is reported variability both in the criteria used for study inclusion and how the results are presented. Additionally, Cochrane reviews aren’t as helpful for summarizing observational data and although they try to reduce publication bias, it’s a persistent weakness to their method. The group is aware of its own limitations, and is actively trying to improve.
The trick is finding an umbrella reviewer of CRs that is equally transparent and trustworthy. DynaMed editors work tirelessly to be one such resource. Hopefully, by the time of our company’s 30th anniversary, we will have as good a reputation as Cochrane. Happy Anniversary to everyone at the Cochrane Collaboration!
For more information, see the topic Borderline Personality Disorder in DynaMed.
DynaMed EBM Focus Editorial Team
This EBM Focus was written by Dan Randall, MD, Deputy Editor at DynaMed. Edited by Alan Ehrlich, MD, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School; Katharine DeGeorge, MD, MS, Deputy Editor at DynaMed and Associate Professor of Family Medicine at the University of Virginia; Nicole Jensen, MD, Family Physician at WholeHealth Medical; Vincent Lemaitre, PhD, Senior Medical Writer at DynaMed; and Sarah Hill, MSc, Associate Editor at DynaMed.