JMIR Publications

ABSTRACT

Background:

Borderline personality disorder (BPD) is a mental health condition with insufficient care availability worldwide. Digital mental health interventions could reduce this treatment gap. Persuasive system design (PSD) is a conceptual framework outlining elements of digital interventions that support behaviour change.

Objective:

This systematic review aims to characterize digital interventions targeting BPD symptoms, assess their treatment efficacy, and identify associations between treatment effect and intervention features including PSD elements.

Methods:

Systematic review of automated digital interventions targeting symptoms of BPD was conducted. Studies were eligible if they recruited participants ≥ 18 years of age, based on a diagnosis of BPD, one of its common comorbidities, or as healthy volunteers. OVID Embase, Medline, and PsycINFO, and the Cochrane Central Register for Controlled Trials were searched on 19 July 2022 and 28 February 2023. Intervention characteristics were tabulated. Meta-analytic review of randomised controlled trials (RCTs) determined treatment effects separately for each core symptom of BPD using Hedges’ g. Associations between treatment effect and intervention features, including PSD elements, were assessed by subgroup analysis (Cochran’s Q). Risk of bias was assessed with Cochrane’s ROB2 tool for RCTs and the National Institute for Health’s Quality Assessment for Pre-Post Studies.

Results:

Forty publications out of 8,520 met review inclusion criteria, representing a total of 6,611 participants. Studies comprised examinations of 38 unique interventions, of which 32 were RCTs. Synthesis found that included interventions had the following transdiagnostic treatment targets: severity of BPD symptoms (n = 4), suicidal ideation (n = 17), paranoia (n = 5), non-suicidal self-injury (n = 5), emotion regulation (n = 4), and anger (n= 3). Common therapeutic approaches were based on dialectical behavioural therapy (n = 8), cognitive behavioural therapy (n = 6) or both (n = 5). Meta-analysis found significant effects of digital intervention for both symptoms of paranoia, Hedges’ g = -0.52 with 95% CI: [-0.86; -0.18], P = 0.01, and suicidal ideation, Hedges’ g = -0.13, 95% CI: [-0.25; -0.01], P = 0.03, but not overall BPD symptom severity: Hedges’ g = -0.17, 95% CI: [-0.42; 0.10], P = 0.72. Subgroup analysis of suicidal ideation interventions found that evidence-based treatments such as CBT and DBT were significantly more effective than alternative modalities. Degree of human support was not significantly associated with treatment effect. Interventions targeting suicidal ideation which used reminders, offered self-monitoring, and encouraged users to rehearse behaviours were associated with greater reduction in ideation severity.

Conclusions:

Evidence suggests digital interventions may reduce symptoms of suicidal ideation and paranoia, and that the design of digital interventions may impact efficacy for treatments targeting suicidal ideation. The most effective suicidal ideation interventions employed evidence-based treatment methods. These results support the use of transdiagnostic digital interventions for paranoia and suicidal ideation. Clinical Trial: Prospero ID: CRD42022358270.