Outcomes for 18 to 25-year-olds with borderline personality disorder in a dedicated young adult only DBT programme compared to a general adult DBT programme for all ages 18

Benchmarks for dialectical behavioural therapy intervention in adults and adolescents with borderline personality symptoms

Background

Dialectical Behaviour Therapy (DBT) is a multi-component cognitive behavioural intervention with proven efficacy in treating people with borderline personality disorder symptoms. Establishing benchmarks for DBT intervention with both adults and adolescents is essential for bridging the gap between research and clinical practice, improving teams' performance and procedures.

Aim

This study aimed to establish benchmarks for DBT using the EQ-5D, Borderline Symptoms List (BSL) and Difficulties in Emotion Regulation Scale (DERS) for adults and adolescents.

Methods

After searching four databases for randomised controlled trials and effectiveness studies that applied standard DBT to people with borderline symptoms, a total of 589 studies were included (after duplicates' removal), of which 16 met our inclusion criteria. A meta-analysis and respective effect-size pooling calculations (Hedges-g) were undertaken, and heterogeneity between studies was assessed with I2 and Q tests. Benchmarks were calculated using pre-post treatment means of the studies through aggregation of adjusted effect sizes and critical values.

Results

DBT aggregated effect sizes per subsample derived from RCTs and effectiveness studies are presented, along with critical values, categorised by age group (adults vs adolescents), mode of DBT treatment (full-programme vs skills-training) and per outcome measure (EQ-5D, BSL and DERS).

Conclusions

Practitioners from routine clinical practice delivering DBT and researchers can now use these benchmarks to evaluate their teams' performance according to their clients' outcomes, using the EQ-5D, BSL and DERS. Through benchmarking, teams can reflect on their teams' efficiency and determine if their delivery needs adjustment or if it is up to the standards of current empirical studies.

Inflammation and emotion regulation: a narrative review of evidence and mechanisms in emotion dysregulation disorders

Emotion dysregulation (ED) describes a difficulty with the modulation of which emotions are felt, as well as when and how these emotions are experienced or expressed. It is a focal overarching symptom in many severe and prevalent neuropsychiatric diseases, including bipolar disorders (BD), attention deficit/hyperactivity disorder (ADHD), and borderline personality disorder (BPD). In all these disorders, ED can manifest through symptoms of depression, anxiety, or affective lability. Considering the many symptomatic similarities between BD, ADHD, and BPD, a transdiagnostic approach is a promising lens of investigation. Mounting evidence supports the role of peripheral inflammatory markers and stress in the multifactorial aetiology and physiopathology of BD, ADHD, and BPD. Of note, neural circuits that regulate emotions appear particularly vulnerable to inflammatory insults and peripheral inflammation, which can impact the neuroimmune milieu of the central nervous system. Thus far, few studies have examined the link between ED and inflammation in BD, ADHD, and BPD. To our knowledge, no specific work has provided a critical comparison of the results from these disorders. To fill this gap in the literature, we review the known associations and mechanisms linking ED and inflammation in general, and clinically, in BD, ADHD, and BD. Our narrative review begins with an examination of the routes linking ED and inflammation, followed by a discussion of disorder-specific results accounting for methodological limitations and relevant confounding factors. Finally, we critically discuss both correspondences and discrepancies in the results and comment on potential vulnerability markers and promising therapeutic interventions.

Current state of the evidence on community treatments for people with complex emotional needs: a scoping review

BACKGROUND

Improving the quality of care in community settings for people with 'Complex Emotional Needs' (CEN-our preferred working term for services for people with a "personality disorder" diagnosis or comparable needs) is recognised internationally as a priority. Plans to improve care should be rooted as far as possible in evidence. We aimed to take stock of the current state of such evidence, and identify significant gaps through a scoping review of published investigations of outcomes of community-based psychosocial interventions designed for CEN.

METHODS

We conducted a scoping review with systematic searches. We searched six bibliographic databases, including forward and backward citation searching, and reference searching of relevant systematic reviews. We included studies using quantitative methods to test for effects on any clinical, social, and functioning outcomes from community-based interventions for people with CEN. The final search was conducted in November 2020.

RESULTS

We included 226 papers in all (210 studies). Little relevant literature was published before 2000. Since then, publications per year and sample sizes have gradually increased, but most studies are relatively small, including many pilot or uncontrolled studies. Most studies focus on symptom and self-harm outcomes of various forms of specialist psychotherapy: most result in outcomes better than from inactive controls and similar to other specialist psychotherapies. We found large evidence gaps. Adaptation and testing of therapies for significant groups (e.g. people with comorbid psychosis, bipolar disorder, post-traumatic stress disorder, or substance misuse; older and younger groups; parents) have for the most part only reached a feasibility testing stage. We found little evidence regarding interventions to improve social aspects of people's lives, peer support, or ways of designing effective services.

CONCLUSIONS

Compared with other longer term mental health problems that significantly impair functioning, the evidence base on how to provide high quality care for people with CEN is very limited. There is good evidence that people with CEN can be helped when specialist therapies are available and when they are able to engage with them. However, a much more methodologically robust and substantial literature addressing a much wider range of research questions is urgently needed to optimise treatment and support across this group.

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.

Effectiveness of the family-based model of dialectical behavior therapy for both suicidal adolescents and young adults in an academic medical center

BACKGROUND

Dialectical behavior therapy (DBT) is an effective approach to decreasing suicidal behaviors; the adapted, family-based model for adolescents (through 18 years old; DBT-A) also demonstrates efficacy. Data on higher dropout rates based on age, initial research on DBT with young adults in the community, and the theory that underlies DBT suggest that adaptations may also be appropriate for young adults. This study examines the effectiveness of DBT-A, presents preliminary data on delivering DBT-A to young adults (ages 18-26), and compares clinical characteristics, service utilization, and outcomes to adolescent clients (ages 13-17) to guide clinical considerations and future research on implementing DBT-A.

METHODS

Data were collected from a DBT-A clinic and included results from semi-structured diagnostic interviews, chart review, and scores on self-report measures. The Suicide Ideation Questionnaire and Beck Depression Inventory (BDI), given at program entry, after completion of one rotation through the skills modules, and at graduation, were used to evaluate outcomes. Outcomes were benchmarked against prior DBT-A trials. Adolescents' and young adults' clinical characteristics, service utilization, and outcomes were compared.

RESULTS

The effect size observed was smaller than in efficacy trials. Few differences were observed between teens (n = 87) and young adults (n = 45). Young adults were more likely to have participated in intensive services before DBT-A. They participated in fewer family sessions and graduated in fewer months compared to teens.

CONCLUSION

This study supports the use of the family-based model of DBT for suicidal teens and young adults although future research is needed to improve the effectiveness of this model when implemented in real-world settings.

The young adult service: An evaluation of a youth mental health service in the independent sector in Ireland

AIMS

Increasing concerns about the specific needs and rates of mental illness among young adults have spurred the development of youth mental health services. Yet few outcome studies exist. This study aims to evaluate a young adult service in an independent mental health sector in Ireland.

METHODS

This is a service evaluation using a retrospective, descriptive and naturalistic study design. Routine demographic, diagnostic and service usage data were collected at entry into the service. Outcomes were recorded at discharge from the service using the Clinical Global Impression (CGI) improvement scores. Factors associated with better or worse outcomes were analyzed.

RESULTS

Five hundred and sixty-seven young adults were assessed and managed during a 3-year period by the Young Adult Service. Their characteristics fell midway between adolescent and adult mental health service populations. They had high levels of Axis I & II co-morbidities reflecting the complex and fluid nature of emerging conditions in this age group. The majority (62.8%) had clinically improved by the end of follow-up. Outcomes were significantly better in those who were hospitalized, prescribed psychotropic medication, received 1:1 psychology sessions and attended a group-based psychology program or group program for specific disorders. One hundred and sixty-six patients (29.3%) dropped out of follow-up. Drop out was associated with longer time spent in the service, being treated solely in the community, without medication, not having a developmental disorder and not transferring from CAMHS.

CONCLUSIONS

This study demonstrates that it is possible to establish an effective youth mental health service with favourable outcomes within a broader mental health system. It provides a benchmark for similar services, bridging the gap between adolescent and adult mental health services.

Motivational Enhancement as a Pretreatment to a Transdiagnostic Intervention for Emerging Adults with Emotion Dysregulation: A Pilot Randomized Controlled Trial

OBJECTIVE

New approaches are needed to help the large number of emerging adults (EA) presenting with early-stage mental health problems. The goal of this pilot study was to carry out a randomized controlled trial to investigate whether motivational enhancement therapy (MET) improved the treatment effects of a 12-week psychological intervention, Dialectical Behaviour Therapy Skills Training (DBT-ST), for EA presenting in the early stages of mental health difficulties. Participants were recruited from the Youth Wellness Centre at St. Joseph's Healthcare Hamilton and McMaster University's Student Wellness Centre in Hamilton, Canada.

METHODS

Seventy-five participants were randomized to receive MET followed by DBT-ST or to DBT-ST alone. We assessed psychological distress, emotion dysregulation, and depression and anxiety symptoms as outcomes.

RESULTS

We found that both treatment groups had significant reductions in emotional dysregulation, psychological distress, depression, and anxiety at post-treatment and at the three-month follow-up. Participants assigned to MET pre-treatment experienced greater improvement in psychological distress at the end of treatment.

CONCLUSION

This pilot study provides preliminary evidence of the potential augmentation of DBT-ST using MET in a real-world setting. Future studies should examine whether MET uniquely augments DBT-ST through the use of a comparable pre-treatment control group.