What is the efficacy and comparative effectiveness of pharmacological and nonpharmacological treatments for adults with borderline personality disorder What are the harms from pharmacological and nonpharmacological treatments for adults with borderline personality disorderWhat is the effectiveness of treatments to reduce the side effects of first line treatments What patient characteristics predict the effectiveness and harms of pharmacological and nonpharmacological treatments for adults with borderline personality disorder Examples of relevant patient characteristics would include demographic factors e.g. age sex raceethnicity socioeconomic status time since illness onset prior treatment history and degree of treatment resistance cooccurring disorders e.g. medical substance use and other psychiatric disorders and history of trauma or abuse. Nonpharmacological treatments would include psychotherapy psychoeducation and other psychosocial interventions including multicomponent programs. It would also include nonpharmacological somatic therapies such as electroconvulsive therapy or transcranial magnetic stimulation if applicable. Outcome measures of interest would include improvements in socialoccupational functioning improvements in health related quality of life the proportion of patients who experience a response or a full remission the magnitude of reduction in target symptoms reductions in hospitalizations reductions in selfharm including suicide and suicide attempts reductions in agitation or aggressive behaviors changes in the status of cooccurring disorders and the proportion of patients who experience key harms with a given treatment. See recent AHRQ protocols on bipolar disorder major depressive disorder and use of atypical antipsychotics for typical harms to be assessed with psychotropic medications and nonpharmacological interventions.

Borderline personality disorder has been reported to affect 12 of the population Lieb et al. Lancet. 364943245361 2004 although a subsequent community sample in the US has noted a prevalence of approximately 6 with a somewhat higher rate in women than in men Grant et al. J Clin Psychiatry. 69453345 2008. Rates in clinical samples are even higher Lieb et al. Lancet. 364943245361 2004. In one recent study of highutilizers of psychiatric services 2040 of individuals had a clinical diagnosis or met DSMIV criteria for borderline personality disorder Comtois and Carmel J Behav Health Serv Res. Published online May 30 2014.. Borderline personality disorder is also associated with a significant risk of suicide Chesney et al. World Psychiatry. 13215360 2014 Qin J Psychiatr Res. 4511144552 2011. Selfinjury is common among individuals with borderline personality disorder Lieb et al. Lancet. 364943245361 2004 and carries its own morbidity. Overall borderline personality disorder is associated with substantial mental and physical disability Zanarini et al. J Pers Disord. 23434656 2009 as well as high rates of comorbidity with other psychiatric conditions Friborg et al. J Affect Disord. 152154111 2014 Grant et al. J Clin Psychiatry. 69453345 2008. Comorbid mood anxiety and substance use disorders are particularly common. The presence of borderline personality can have a negative impact on the treatment outcomes for the comorbid disorder Grilo et al. J Clin Psychiatry. 7112162935 2010 Skodol et al. Am J Psychiatry 168325764 2011. Given the substantial morbidity mortality disability and health service utilization associated with the presence of borderline personality disorder an uptodate evidencebased review of the efficacy and comparative effectiveness of borderline personality disorder treatments would inform development of clinical practice guidelines aimed at optimizing clinical interventions and patient outcomes.

The results of the comparative effectiveness review will be used to inform development of a practice guideline on the treatment of individuals with borderline personality disorder.

The most recent practice guideline of the American Psychiatric Association was published in 2001 with an updated discussion of subsequent literature in 2005.

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