Treatment Effects following Residential Dialectical Behavior Therapy for Adolescents with Borderline Personality Disorder

Dialectical Behavior Therapy Programming for Adolescents: A Systematic Review and Meta-Analysis of Clinical and Implementation Outcomes

OBJECTIVE

The purpose of this systematic review and meta-analysis is to provide an updated examination of the adolescent Dialectical Behavioral Therapy (DBT) literature and synthesize study findings across treatment settings (e.g. inpatient, outpatient, school), and treatment levels (e.g. clinical intervention, targeted, universal prevention). We also provide meta-analytic findings of the impact of DBT across key problem behaviors: depression, emotion dysregulation, suicidal and self-harm behaviors, externalizing problems, and eating disorders.

METHOD

A reference database search was used to identify studies conducted on adolescent DBT interventions from 2000 through 2023 (N = 72). In addition to ensuring that the review process conformed to the PRISMA statement, we independently verified that each study met inclusion criteria before triple coding each article to examine variables of interest and extracted outcome data needed to conduct meta-analyses.

RESULTS

DBT appears to demonstrate effectiveness in improving mental health outcomes in adolescents across a range of psychiatric problems. To meet these treatment needs, DBT interventions have been appropriately adapted based on care setting, suggesting empirical support in inpatient, residential, partial hospitalization, and intensive outpatient programs, as well as in outpatient settings, juvenile correctional facilities, and schools.

CONCLUSIONS

The growing evidence base for adolescent DBT appears to reflect its promise and versatile clinical utility. Clinical implications and recommendations for future directions are discussed, including the need for more randomized controls and representation of diverse communities.

Implementation Feasibility and Hidden Costs of Statewide Scaling of Evidence-Based Therapies for Children and Adolescents

OBJECTIVE

State mental health systems are retraining their workforces to deliver services supported by research. Knowledge about evidence-based therapies (EBTs) for child and adolescent disorders is robust, but the feasibility of their statewide scaling has not been examined. The authors reviewed implementation feasibility for 12 commonly used EBTs, defining feasibility for statewide scaling as an EBT having at least one study documenting acceptability, facilitators and barriers, or fidelity; at least one study with a racially and ethnically diverse sample; an entity for training, certification, or licensing; and fiscal data reflecting the costs of implementation.

METHODS

The authors reviewed materials for 12 EBTs being scaled in New York State and conducted a literature review with search terms relevant to their implementation. Costs and certification information were supplemented by discussions with treatment developers and implementers.

RESULTS

All 12 EBTs had been examined for implementation feasibility, but only three had been examined for statewide scaling. Eleven had been studied in populations reflecting racial-ethnic diversity, but few had sufficient power for subgroup analyses to demonstrate effectiveness with these samples. All had certifying or licensing entities. The per-clinician costs of implementation ranged from $500 to $3,500, with overall ongoing costs ranging from $100 to $6,000. A fiscal analysis of three EBTs revealed hidden costs ranging from $5,000 to $24,000 per clinician, potentially limiting sustainability.

CONCLUSIONS

The evidence necessary for embedding EBTs in state systems has notable gaps that may hinder sustainability. Research-funding agencies should prioritize studies that focus on the practical aspects of scaling to assist states as they retrain their workforces.

Effects of a Standardized DBT-A Program on Identity Development in Adolescents

BACKGROUND

Identity diffusion plays a central role in the onset of borderline personality disorders. Dialectical Behavioral Therapy for Adolescents (DBT-A) is a treatment program for adolescents with emotional instability and dysregulation. The interest of this study is to examine the potential effects of a standardized and certified DBT-A therapy program on the identity development of adolescents in an inpatient setting.

METHODS

A total of 138 adolescents aged 13 to 18 years with symptoms of severe emotional instability were assessed before and after a certified and standardized 12-week in-patient DBT-A program targeting emotional regulation with the following standardized instruments: the Assessment of Identity Development in Adolescence (AIDA), Scale of the Experience of Emotions (SEE), and Symptom Checklist (SCL-90-R).

RESULTS

The results indicate a significant change in identity development, emotion regulation, and general symptoms of psychopathology after treatment with DBT-A.

CONCLUSIONS

In this large sample of adolescents, DBT-A significantly improved identity development and reduced identity diffusion, however, without a treatment-as-usual control group as a limitation. Nevertheless, our results may become clinically relevant for the prevention of chronic impairment in emotionally unstable adolescents.

Non-response to psychotherapy for borderline personality disorder: A systematic review

HIGHLIGHT

This is the first systematic review to investigate non-response to psychotherapy for borderline personality disorder.

BACKGROUND

Psychotherapy is the recommended treatment for borderline personality disorder. While systematic reviews have demonstrated the effectiveness of psychotherapy for borderline personality disorder, effect sizes remain small and influenced by bias. Furthermore, the proportion of people who do not respond to treatment is seldom reported or analysed.

OBJECTIVE

To obtain an informed estimate of the proportion of people who do not respond to psychotherapy for borderline personality disorder.

METHODS

Systematic searches of five databases, PubMed, Web of Science, Scopus, PsycINFO and the Cochrane Library, occurred in November 2020. Inclusion criteria: participants diagnosed with borderline personality disorder, treated with psychotherapy and data reporting either (a) the proportion of the sample that experienced 'reliable change' or (b) the percentage of sample that no longer met criteria for borderline personality disorder at conclusion of therapy. Exclusion criteria: studies published prior to 1980 or not in English. Of the 19,517 studies identified, 28 met inclusion criteria.

RESULTS

Twenty-eight studies were included in the review comprising a total of 2436 participants. Average treatment duration was 11 months using well-known evidence-based approaches. Approximately half did not respond to treatment; M = 48.80% (SD = 22.77).

LIMITATIONS

Data regarding within sample variability and non-response are seldom reported. Methods of reporting data on dosage and comorbidities were highly divergent which precluded the ability to conduct predictive analyses. Other limitations include lack of sensitivity analysis, and studies published in English only.

CONCLUSION

Results of this review suggest that a large proportion of people are not responding to psychotherapy for borderline personality disorder and that factors relating to non-response are both elusive and inconsistently reported. Novel, tailored or enhanced interventions are needed to improve outcomes for individuals not responding to current established treatments.

Now and then: a ten-year comparison of young people in residential substance use disorder treatment receiving group dialectical behaviour therapy

BACKGROUND

Reducing substance use in youth is a global health priority. We compared two cohorts from the same 12-week residential substance use disorder (SUD) facility over a 10 year period: Cohort A (2008-2009) and Cohort B (2018-2020). The essential components of the program remained the same with the primary treatment being dialectical behaviour therapy (DBT) plus residential milieu.

METHODS

Young people in the current Cohort B (N = 100) versus historical Cohort A (N = 102) had a similar ratio of males (74 vs. 70%) but were slightly older (mean 20.6 vs. 19.5 years). Linear mixed models were used to model outcome measures (global psychiatric symptoms, substance use severity, and quality of life) longitudinally up to 12 months later.

RESULTS

Baseline to end-of-treatment comparisons showed that the current Cohort B had overall higher levels of global psychiatric symptoms (d = 0.70), but both groups reduced psychiatric symptoms (Cohort A: d = 1.05; Cohort B: d = 0.61), and had comparable increases in confidence to resist substance use (d = 0.95). Longitudinal data from the current Cohort B showed significant decreases in substance use severity from baseline to 6-month follow-up (d = 1.83), which were sustained at 12-month follow-up (d = 0.94), and increases in quality of life from baseline to end-of-treatment (d = 0.83).

CONCLUSIONS

We demonstrate how DBT plus milieu residential care for young people continues to show positive effects in a 10-year comparison. However, youth seeking treatment today compared to 10 years ago evidenced higher acuity of psychiatric symptoms reinforcing the importance of continuous improvement of psychological treatments.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: trial ID ACTRN12618000866202 , retrospectively registered on 22/05/2018, .

Do Mindfulness Interventions Improve Obesity Rates in Children and Adolescents: A Review of the Evidence

Mindfulness interventions have shown promise in improving self-regulation, depression, anxiety, and stress levels across all ages. Obesity rates in children are rising worldwide. It has been postulated that through improvements in self-regulation with mindfulness interventions, obesity rates can be improved in children and adolescents. In this review, we attempt to explain how mindfulness interventions may impact obesity rates and obesity-related complications and give the current state of evidence for the following mindfulness interventions: Mindful Eating, Mindfulness-Based Stress Reduction, Yoga, Spirituality, and Dialectical Behavior Therapy.

Effects of a Mindfulness-Based Intervention on Self-Compassion and Psychological Health Among Young Adults With a History of Childhood Maltreatment

Background

Individuals who were maltreated during childhood are faced with increased risks for developing various psychological symptoms that are particularly resistant to traditional treatments. This pilot study investigated the effects of a mindfulness based behavioral intervention for young adults with a childhood maltreatment history.

Methods

This study looked at self-report psychological questionnaires from 20 subjects (5 males) before and after a mindfulness-based behavioral intervention, compared to 18 subjects (6 males) in the waiting list control group (age range 22–29); all subjects experienced mild-to-moderate childhood maltreatment. We analyzed changes in stress, anxiety, depression, mindfulness and self-compassion related to the intervention with linear mixed effects models; we also analyzed the relationships among questionnaire score changes with partial correlation analyses and mediation analysis.

Results

Linear mixed effects model analyses revealed significant group by time interaction on stress (p < 0.01), anxiety (p < 0.05), and self-compassion (p < 0.01), with the mindfulness group having significant reduction in stress and anxiety (p < 0.01), and significant increase in mindfulness (p < 0.05) and self-compassion (p < 0.001). Partial correlation analyses showed that among all subjects from both groups, changes in mindfulness positively correlated with changes in self-compassion (r = 0.578, p = 0.001), which negatively correlated with changes in depression (r = −0.374, p = 0.05) and anxiety (r = −0.395, p < 0.05). Changes in self-compassion mediated, in part, the relationship between changes in mindfulness and changes in anxiety (average causal mediation effect = −4.721, p < 0.05). We observed a dose-dependent effect of the treatment, i.e., the number of intervention sessions attended were negatively correlated with changes in stress (r = −0.674, p < 0.01), anxiety (r = −0.580, p < 0.01), and depression (r = −0.544, p < 0.05), after controlling for the individual differences in childhood maltreatment severity.

Conclusion

Our results suggest that, to some extent, the mindfulness-based intervention can be helpful for improving self-compassion and psychological health among young adults with a childhood maltreatment history.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier NCT02447744.