Use of dialectical behavior therapy in inpatient treatment of borderline personality disorder: a systematic review

Socio-demographic Predictors of Hospitalization Duration Among Patients with Borderline Personality Disorder

Borderline personality disorder (BPD) is a complex psychopathology associated with high service utilization rates. In turn, the hospitalization of BPD patients is a controversial challenge for mental health professionals. Prior literature has identified certain socio-demographic factors as linked to an increased risk of BPD. In this study, we examined the possible connection between these socio-demographic factors and hospitalization duration. We analyzed 1077 hospitalization records of 200 BPD-diagnosed patients. Patients' gender, age, education level, employment and marital statuses, and living arrangement were statistically significantly linked with hospitalization duration. Specifically, female gender, age twenty or below, no high-school diploma (or, to a lesser extent, a diploma with no academic education), unemployment status and/or patients who live with parents are strongly associated with longer hospitalizations compared to male gender, older patients, more educated, married/divorced status and/or those who do not live with their parents. Additionally, the results point to a weak, albeit statistically significant, temporal pattern with more advanced hospitalizations generally aligning with the duration of their preceding ones, while being slightly shorter. In order to prevent potentially unnecessary prolonged and regressive hospitalizations, an estimation of the expected hospitalization duration should be explicitly considered when setting hospitalization goals and plans.

Comparison of 8-vs-12 weeks, adapted dialectical behavioral therapy (DBT) for borderline personality disorder in routine psychiatric inpatient treatment-A naturalistic study

Dialectical behavior therapy (DBT) is widely acknowledged as an effective treatment for individuals with borderline personality disorder (BPD). However, the optimal treatment duration within DBT remains a topic of investigation. This retrospective, naturalistic non-randomized study aimed to compare the efficacy of 8 week and 12 week DBT interventions with equivalent content, focusing on the change of BPD-specific symptomatology as the primary outcome and depressive symptoms as the secondary outcome. Overall, 175 patients who participated in DBT and received either 8 week or 12 week intervention were included in the analysis. Routine inpatient treatment was adapted from standard DBT with the modules: skill training, interpersonal skills, dealing with feelings, and mindfulness. Measurements were taken at baseline, mid-point, and endpoint. The borderline symptom list-23 (BSL-23) was used for the assessment of borderline-specific symptoms, while the Beck depression inventory-II (BDI-II) was used for the assessment of depressive symptoms. Statistical analysis was conducted using linear mixed models. Effect sizes were calculated for both measures. The results of the analysis indicated an improvement in both groups over time. Effect sizes were d = 1.29 for BSL-23 and d = 1.79 for BDI-II in the 8 week group, and d = 1.16 for BSL-23 and d = 1.58 for BDI-II in the 12 week group. However, there were no differences in the change of BPD-specific symptoms or the severity of depressive symptoms between the 8 week and 12 week treatment duration groups. Based on these findings, shorter treatment durations, like 8 weeks, could be a viable alternative, offering comparable therapeutic benefits, potential cost reduction, and improved accessibility. However, further research is needed to explore factors influencing treatment outcomes and evaluate the long-term effects of different treatment durations in DBT for BPD.Trial registration: drks.de (DRKS00030939) registered 19/12/2022.

Effect of Dialectical Behavior Therapy on Negative Affect, and Symptoms of Depression and Anxiety in Individuals with Borderline Personality Disorder during COVID-19 Pandemic

Background: This study investigated the effectiveness of dialectical behavior therapy (DBT) in patients with borderline personality disorder (BPD) during the COVID-19 pandemic, assessing negative affect, depression, and anxiety levels as indicators of health. Methods: A total of 287 participants were recruited, including BPD patients at different stages of treatment and the general population without a diagnosis of BPD. Questionnaires were used to assess the fear of COVID-19 and the referenced health indicators. Results: No differences were observed between groups in levels of fear of COVID-19, but there were differences in the health indicators studied. BPD patients in long-term treatment showed levels of negative affect similar to those of the general population, while those in early treatment stages exhibited significantly higher levels. However, no significant improvements were observed in levels of depression and anxiety in the long-term treatment group compared to those who underwent the initial treatment phase. Conclusions: These findings underscore the importance of effectively intervening in BPD, especially in stress-inducing situations such as the pandemic, and suggest the need to explore complementary approaches to addressing depression and anxiety in this clinical context.

Profiles of Emergency Department Users with Psychiatric Disorders Related to Barriers to Outpatient Care

Emergency department (ED) overcrowding is a growing problem worldwide. High ED users have been historically targeted to reduce ED overcrowding and associated high costs. Patients with psychiatric disorders, including substance-related disorders (SRDs), are among the largest contributors to high ED use. Since EDs are meant for urgent cases, they are not an appropriate setting for treating recurrent patients or replacing outpatient care. Identifying ED user profiles in terms of perceived barriers to care, service use, and sociodemographic and clinical characteristics is crucial to reduce ED use and unmet needs. Data were extracted from medical records and a survey was conducted among 299 ED patients from 2021 to 2022 in large Quebec networks. Cluster algorithms and comparison tests identified three profiles. Profile 1 had the most patients without barriers to care, with case managers, and received the best primary care. Profile 2 reported moderate barriers to care and low primary care use, best quality of life, and more serious psychiatric disorders. Profile 3 had the most barriers to care, high ED users, and lower service satisfaction and perceived mental/health conditions. Our findings and recommendations inform decision-makers on evidence-based strategies to address the unmet needs of these vulnerable populations.

The cultural change narrative as a core component of therapeutic change

Introduction

Research indicates a similar effect of Mentalization-based treatment (MBT) and Dialectical behavior therapy (DBT) for borderline personality disorder (BPD). However, there is a paucity in studies investigating the change narrative received from and developed in these treatments. The aim of the present study is to investigate similarities and differences in the change narratives provided by MBT and DBT, and how these narratives reflect the rationale, explanations, and procedures of the provided treatment.

Methods

The study is a qualitative analysis of seven interviews conducted by the authors. Three of the participants had received MBT, and four of the participants had received DBT. This study presents an Interpretative Phenomenological Analysis (IPA) of the change narratives received in two specialized treatments for BPD.

Results

The main findings from the IPA were that the change narratives described by the participants reflected the treatment they received. The DBT participants highlighted explicit learning of tools and techniques, with predictable and safe therapists. In contrast, the MBT participants emphasized a long-lasting process of exploring to create procedural learning with therapists who followed their lead.

Discussion

The participants' stories of change shed light on how a change narrative was developed, and therefore how the rationale, explanations and procedures were conveyed differently by MBT and DBT.

Predictors of dropout from treatment among patients using specialized addiction treatment centers

OBJECTIVES

This study investigated the use of outpatient care, and sociodemographic and clinical characteristics of patients with substance-related disorders (SRD) to predict treatment dropout from specialized addiction treatment centers. The study also explored risks of adverse outcomes, frequent emergency department (ED) use (3+ visits/year), and death, associated with treatment dropout within the subsequent 12 months.

METHODS

The study examined a cohort of 16,179 patients who completed their last treatment episode for SRD between 2012 and 13 and 2014-15 (financial years: April 1 to March 31) in 14 specialized addiction treatment centers using Quebec (Canada) health administrative databases. We used multivariable logistic regressions to measure risk of treatment dropout (1996-96 to 2014-15), while we used survival analysis controlling for sex and age to assess the odds of frequent ED use and death in 2015-16.

RESULTS

Of the 55 % of patients reporting dropout from SRD treatment over the 3-year period, 17 % were frequent ED users, and 1 % died in the subsequent 12 months. Patients residing in the most socially deprived areas, having polysubstance-related disorders or personality disorders, and having previously dropped out from specialized addiction treatment centers had increased odds of current treatment dropout. Older patients, those with a history of homelessness, past SRD treatment, or more concurrent outpatient care outside specialized addiction treatment centers had decreased odds of treatment dropout. Patients who dropped out were subsequently at higher risk of frequent ED use and death.

CONCLUSIONS

This study highlighted that patients with more severe problems and previous dropout may need more sustained and adequate help to prevent subsequent treatment dropout. Specialized addiction treatment centers may consider enhancing their follow-up care of patients over a longer duration and better integrating their treatment with other outpatient care resources to meet the multiple needs of the more vulnerable patients using their services.

Dialectical behaviour therapy (DBT) for high-risk transgender and gender diverse (TGD) youth: A qualitative study of youth and mental health providers' perspectives on intervention relevance

OBJECTIVES

Despite the significant mental health challenges and unique treatment needs of transgender and gender diverse (TGD) youth, research on the acceptability of evidence-based treatments for these youth is limited. To address this gap, the current study explored the perceived relevance of dialectical behaviour therapy (DBT) for high-risk TGD youth.

METHODS

Qualitative data were collected from six focus group discussions with a purposive sample of 21 TGD youth aged 18-25 years old who endorsed a history of depression, suicidality or self-harm and individual interviews with 10 mental health treatment providers with prior DBT and TGD client experience. The data were analysed inductively using thematic content analysis.

RESULTS

The results highlighted the perceived relevance of DBT in targeting chronic and acute stressors, some of which are unique to TGD youth such as issues related to gender dysphoria, hormone-related treatment and gender identity. Possible areas for treatment modifications including the adaptation of body awareness exercises and physiological-related coping techniques for youth experiencing gender dysphoria, and the reinforcement of self-care skills, were identified. While interpersonal effectiveness skills were acknowledged as important, treatment providers highlighted a need to prioritize safety over the practice of these skills. This is because TGD youth often experience more hostile and prejudiced interpersonal experiences than their cisgender peers.

CONCLUSION

The study's findings shed light on previously unexplored perspectives of TGD youth and treatment providers on the perceived relevance of DBT and provide treatment providers and implementation researchers with some critical issues to consider when working with high-risk TGD youth.

Brief App-Based Cognitive Behavioral Therapy for Anxiety Symptoms in Psychiatric Inpatients: Feasibility Randomized Controlled Trial

Background

Psychiatric inpatients often have limited access to psychotherapeutic education or skills for managing anxiety, a common transdiagnostic concern in severe and acute mental illness. COVID-19–related restrictions further limited access to therapy groups on inpatient psychiatric units. App-based interventions may improve access, but evidence supporting the feasibility of their use, acceptability, and effectiveness in psychiatric inpatient settings is limited. MindShift CBT is a free app based on cognitive behavioral therapy principles with evidence for alleviating anxiety symptoms in the outpatient setting.

Objective

We aimed to recruit 24 participants from an acute general psychiatric inpatient ward to a 1-month randomized control study assessing the feasibility and acceptability of providing patients with severe and acute mental illness access to the MindShift CBT app for help with managing anxiety symptoms.

Methods

Recruitment, data collection, analysis, and interpretation were completed collaboratively by clinician and peer researchers. Inpatients were randomized to two conditions: treatment as usual (TAU) versus TAU plus use of the MindShift CBT app over 6 days. We collected demographic and quantitative data on acceptability and usability of the intervention. Symptoms of depression, anxiety, and psychological distress were measured in pre- and poststudy surveys for preliminary signals of efficacy. We conducted individual semistructured interviews with participants in the MindShift CBT app group at the end of their trial period, which were interpreted using a standardized protocol for thematic analysis.

Results

Over 4 weeks, 33 inpatients were referred to the study, 24 consented to participate, 20 were randomized, and 11 completed the study. Of the 9 randomized participants who did not complete the study, 7 were withdrawn because they were discharged or transferred prior to study completion, with a similar distribution among both conditions. Among the enrolled patients, 65% (13/20) were admitted for a psychotic disorder and no patient was admitted primarily for an anxiety disorder. The average length of stay was 20 days (SD 4.4; range 3-21) and 35% (7/20) of patients were involuntarily admitted to hospital. Small sample sizes limited accurate interpretation of the efficacy data. Themes emerging from qualitative interviews included acceptability and usability of the app, and patient agency associated with voluntary participation in research while admitted to hospital.

Conclusions

Our study benefitted from collaboration between peer and clinician researchers. Due to rapid patient turnover in the acute inpatient setting, additional flexibility in recruitment and enrollment is needed to determine the efficacy of using app-based psychotherapy on an acute psychiatric ward. Despite the limited sample size, our study suggests that similar interventions may be feasible and acceptable for acutely unwell inpatients. Further study is needed to compare the efficacy of psychotherapeutic apps with existing standards of care in this setting.

Trial Registration

ClinicalTrials.gov NCT04841603; https://clinicaltrials.gov/ct2/show/NCT04841603

Just try it: Preliminary results of a six-month therapy for borderline personality disorder

Borderline Personality Disorder (BPD) is labeled as a personality disorder with impulsivity issues regarding relationships, risky behavior, and emotional dysregulation. This personality disorder is still considered to be hard-to-treat condition even though responses to treatment have improved significantly. In this field, Dialectical Behavioral Therapy is recognized as one of the most efficient therapeutical approaches, and some versions adapted from this gold-standard treatment proved their effectiveness in clinical settings. We tested the 6-month cognitive behavioral therapy (CBT) protocol ECCCLORE, composed of three modules, respectively, working on emotional regulation, distress tolerance, and relationships-in a French context to compare its effectiveness to Treatment As Usual. We recruited 56 patients with a BPD diagnosis in a day-care unit, 34 receiving ECCCLORE and 22 receiving TAU. We assessed BPD traits, impulsivity, aggressiveness, suicidal risk, and hopelessness. Our results revealed the effectiveness of the 6-month ECCCLORE protocol to decrease BPD symptoms and associated clinical dimensions. We also noted the persistence of its effect after a 1-year follow-up. Shortened CBT treatment protocols tend to prove their efficiency for symptom reduction in BPD. Further research is needed to replicate these results.

Suicidal behaviors are associated with loneliness and decrease during inpatient CBASP treatment for persistent depressive disorder

Suicidal ideation and behavior (SIB) are common in persistent depressive disorder (PDD) and may be related to interpersonal dysfunction. While SIB has been extensively analyzed in other high-risk disorders (e.g., borderline personality disorder, BPD), data on interpersonal risk factors and effects of specific psychotherapy on SIB in PDD are limited. This study aimed at investigating loneliness versus social network size as interpersonal risk factors for SIB in PDD and assess effects of cognitive behavioral analysis system of psychotherapy (CBASP) on this domain. In a prospective naturalistic study, 64 PDD patients were assessed, who underwent a 10-weeks inpatient CBASP program. Our clinical comparison group consisted of 34 BPD patients, who underwent a 10-weeks inpatient dialectical behavioral therapy (DBT) program. SIB was measured with the Columbia-Suicide Severity Rating Scale (C-SSRS), loneliness and social network size with the UCLA Loneliness Scale (UCLA) and the Social Network Index (SNI). Twenty-six PDD patients (40.6% of the PDD sample) showed current SIB at baseline in comparison with 26 BPD patients (76.5% of the BPD sample). While in suicidal PDD patients, SIB was associated with perceived social isolation (UCLA), but not with reduced social network size (SNI), this association was not observed in suicidal BPD patients. In PDD, SIB significantly decreased during CBASP. In conclusion, SIB appears to be associated with interpersonal factors related to loneliness in PDD, but not in BPD. CBASP showed first positive evidence in reducing SIB in PDD, but our pilot data need replication studies.

Mental Health Workers' Attitudes Towards Individuals With a Diagnosis of Borderline Personality Disorder: A Systematic Literature Review

The attitudes of mental health workers toward individuals with mental health conditions can impact the quality of care they provide. Negative attitudes among mental health workers seem particularly common in response to people diagnosed with borderline personality disorder (BPD). The current review aimed to identify and review the literature regarding mental health workers' attitudes toward individuals diagnosed with BPD, specifically focusing on studies comparing workers' attitudes toward BPD with attitudes toward other mental health diagnoses. The findings suggest that mental health workers have more negative attitudes toward individuals labeled as having BPD than toward individuals with other diagnoses, such as depression. This is likely due to factors associated with the label itself, in addition to workers' perceptions of BPD symptoms and previous experiences of delivering treatment. The implications of these findings are considered, with a particular focus on how mental health services can effectively address negative attitudes toward BPD.

Effects of dialectical behaviour therapy on reducing self-harming behaviours and negative emotions in patients with borderline personality disorder: A meta-analysis

INTRODUCTION

Dialectical behaviour therapy(DBT) has been widely used for borderline personality disorder(BPD). Existing studies are limited to behaviours such as self-harm, and the results for reducing self-harm were controversial. Few have systematically evaluated the effect of DBT on self-harming behaviours and negative emotions.

AIM

This study aims to evaluate the effects of DBT on self-harming behaviours and negative emotions in patients with BPD.

METHODS

RCTs on DBT for BPD were searched from PubMed, Embase, etc., and the results were performed by RevMan 5.3.

RESULTS

The meta-analysis demonstrated that DBT reduced self-harming behaviours, and alleviated depression, but had a negligible effect on suicidal ideation and anger. One subgroup revealed that standard DBT improved depression significantly, but DBT skills training improved poorly. Another subgroup revealed that there was a significant reduction in depression among patients receiving DBT for 4 months to 14 months, but not at 4 months.

DISCUSSION AND IMPLICATIONS FOR PRACTICE

Findings indicate that DBT can reduce self-harming behaviours and improve depression, but effects on suicidal ideation and anger are insignificant. Subgroup analysis suggests that standard DBT and DBT-ST lasting beyond 4 months benefits on BPD. Given the quality and quantity restrictions of RCTs, more high-quality RCTs need to verify these effects.

Effectiveness of Psychological Treatments for Borderline Personality Disorder and Predictors of Treatment Outcomes: A Multivariate Multilevel Meta-Analysis of Data from All Design Types

We examined the effectiveness of psychotherapies for adult Borderline Personality Disorder (BPD) in a multilevel meta-analysis, including all trial types (PROSPERO ID: CRD42020111351). We tested several predictors, including trial- and outcome type (continuous or dichotomous), setting, BPD symptom domain and mean age. We included 87 studies (N = 5881) from searches between 2013 and 2019 in four databases. We controlled for differing treatment lengths and a logarithmic relationship between treatment duration and effectiveness. Sensitivity analyses were conducted by excluding outliers and by prioritizing total scale scores when both subscale and total scores were reported. Schema Therapy, Mentalization-Based Treatment and reduced Dialectical Behavior Therapy were associated with higher effect sizes than average, and treatment-as-usual with lower effect sizes. General severity and affective instability showed the strongest improvement, dissociation, anger, impulsivity and suicidality/self-injury the least. Treatment effectiveness decreased as the age of participants increased. Dichotomous outcomes were associated to larger effects, and analyses based on last observation carried forward to smaller effects. Compared to the average, the highest reductions were found for certain specialized psychotherapies. All BPD domains improved, though not equally. These findings have a high generalizability. However, causal conclusions cannot be drawn, although the design type did not influence the results.

Intensive Dialectical Behavior Treatment for Individuals With Borderline Personality Disorder With and Without Substance Use Disorders

Treatment of borderline personality disorder (BPD) with comorbid substance use disorder can be challenging due to symptom overlap and limited assessment methods. Preliminary evidence has shown promising effectiveness of dialectical behavioral therapy (DBT) for BPD with comorbid substance use disorders. The current study compared the benefits of a 28-day transitional DBT treatment program for individuals with BPD with and without substance use disorders through evaluating the changes in coping skills, generalized anxiety, and depression symptom scales at admission and discharge. A total of 76 patients were split into two groups: Group 1 consisted of individuals with BPD without substance use disorders (n = 41), and Group 2 involved individuals with BPD and a substance use disorder (SUD) (n = 35). A univariate general linear model showed significant differences between the two groups in improvement of coping skills and depressive symptoms. After a 28-day transitional DBT treatment program there were significant decreases from severe to moderate depression scores in both groups. Our findings support the effectiveness of DBT treatment in patients with comorbid BPD and SUD.

Efficacy and sustainability of dialectical behaviour therapy for inpatient adolescents: a follow-up study

Background

Dialectical behaviour therapy (DBT) is an evidence-based treatment for adolescents targeting suicidal and non-suicidal self-injurious behaviours. Research supports DBT's efficacy in inpatient settings, but implementation and sustainability are understudied.

Aims

This study is a follow-up of a previous study by Tebbett-Mock et al and examines the efficacy and sustainability of an adolescent DBT inpatient unit within a psychiatric hospital in the Northeast. We hypothesised that adolescents who received DBT in our follow-up group (DBT Group 2) would not have statistical difference (ie, greater or fewer) of the following compared with the first group of patients who received DBT on the unit the year prior (DBT Group 1) and would have significantly fewer of the following compared with the treatment as usual (TAU) group: (1) constant observation hours for suicidal ideation, self-injury and aggression; (2) incidents of suicide attempts, self-injury and aggression; (3) restraints; (4) seclusions; (5) days hospitalised; (6) times readmitted to the unit within 30 days of discharge.

Methods

We conducted a retrospective chart review for adolescents receiving inpatient DBT (DBT Group 1, n=425; DBT Group 2, n=393) and a historical control group (TAU, n=376). The χ² tests and one-way analysis of variance were conducted as preliminary analyses to examine group differences on diagnosis, gender and age. Kruskal-Wallis H tests were conducted to examine group differences on outcomes. Mann-Whitney U tests were used as post hoc analyses.

Results

Patients in DBT Group 2 were comparable to DBT Group 1 for the number of constant observation hours for self-injury (U=83 432.50, p=0.901), restraints (U=82 109, p=0.171) and days hospitalised (U=83 438.5, p=0.956). Patients in DBT Group 2 had a significantly greater number of incidents of suicide attempts compared with DBT Group 1 (U=82 662.5, p=0.037) and of self-injury compared with patients in DBT Group 1 (U=71724.5, p<0.001) and TAU (U=65649.0, p<0.001).

Conclusions

Results provide support for adolescent inpatient DBT compared with TAU and highlight staff turnover and lack of training as potential barriers to sustainability and efficacy.

Outcomes of brief versions of Dialectical Behaviour Therapy for diagnostically heterogeneous groups in a routine care setting

INTRODUCTION

Brief versions of Dialectical Behaviour Therapy (DBT) may enhance patient outcomes in diverse service settings. This study examined the effectiveness of two DBT-informed treatments for diagnostically heterogeneous groups in routine practice: 5-day group training in DBT skills (DBT-5) and a 12-week DBT program (DBT-12).

METHODS

: Depression, anxiety, stress, borderline symptoms, self-esteem, and general mental wellbeing were measured at pre-and post-treatment in a sample of inpatients and outpatients (N=395). Rates of clinically significant change on these measures were calculated and effect sizes benchmarked against prior DBT outcome studies. Readmission rates were used to measure treatment response maintenance.

RESULTS

: Scores on all measures improved significantly from pre- to post-treatment. DBT-5 and DBT-12 yielded similar effect sizes compared to prior DBT outcome studies. At least 43.5% of patients were classified as recovered or improved regarding borderline symptoms at the end of both DBT-5 and DBT-12. Readmission rates were also low (5%-6.8%).

CONCLUSIONS

Brief DBT-informed treatments may offer a fast reduction in symptoms and quicker return to functioning.

Mental health clinicians views of summary and systematic review utility in evidence-based practice

BACKGROUND

Evidence-based practice (EBP) requires integration of research evidence with clinical expertise and patient preferences. It is endorsed by many regulatory bodies, using the approach is challenging for many busy clinicians.

OBJECTIVES

To explore mental health practitioners' perceptions of the factors which help, and which hinder, EBP and their views of two formats for presenting research findings - a systematic review and a one-page summary of that review. (written by a clinical librarian) METHODS: Qualitative semi-structured interviews with a multi-professional sample of mental health clinicians. (n=7) RESULTS: Participants worked under varying time constraints, with some participants perceiving a conflict between research activities such as reading the evidence and their clinical duties one-page research summary would help some participienrs to identify potentially valuable evidence quickly. However, participants agreed that they would need to read full systematic review to assess whether and how their practice could or should change.

DISCUSSION

A one-page research summary can perform useful functions for clinicians; however, they require more detailed research reports such as systematic reviews to judge research's external validity.

CONCLUSION

This exploratory study indicates that writing evidence summaries is a useful role for clinical librarians, as part of training and support for EBP.

Using a Tablet-Based App to Deliver Evidence-Based Practices for Suicidal Patients in the Emergency Department: Pilot Randomized Controlled Trial

BACKGROUND

Emergency departments (EDs) have the potential to provide evidence-based practices for suicide prevention to patients who are acutely suicidal. However, few EDs have adequate time and personnel resources to deliver recommended evidence-based assessment and interventions. To raise the clinical standard of care for patients who are suicidal and seeking psychiatric crisis services in the ED, we developed Jaspr Health, a tablet-based app for direct use by such patients, which enables the delivery of 4 evidence-based practices.

OBJECTIVE

This study aims to evaluate the feasibility, acceptability, and effectiveness of Jaspr Health among suicidal adults in EDs.

METHODS

Patients who were acutely suicidal and seeking psychiatric crisis services participated in an unblinded pilot randomized controlled trial while in the ED. Participants were randomly assigned to Jaspr Health (n=14) or care as usual (control; n=17) groups. Participants were assessed at baseline, and a 2-hour posttest using self-report measures and a semistructured interview were conducted.

RESULTS

Conditions differed significantly at baseline with regard to age but not other demographic variables or baseline measures. On average, participants had been in the ED for 17 hours before enrolling in the study. Over their lifetime, 84% (26/31) of the sample had made a suicide attempt (mean 3.4, SD 6.4) and 61% (19/31) had engaged in nonsuicidal self-injurious behaviors, with an average rate of 8.8 times in the past 3 months. All established feasibility and acceptability criteria were met: no adverse events occurred, participants' app use was high, Jaspr Health app user satisfaction ratings were high, and all participants using Jaspr Health recommended its use for other suicidal ED patients. Comparisons between study conditions provide preliminary support for the effectiveness of the app: participants using Jaspr Health reported a statistically significant increase in receiving 4 evidence-based suicide prevention interventions and overall satisfaction ratings with their ED experience. In addition, significant decreases in distress and agitation, along with significant increases in learning to cope more effectively with current and future suicidal thoughts, were observed among participants using Jaspr Health compared with those receiving care as usual.

CONCLUSIONS

Even with limited statistical power, the results showed that Jaspr Health is feasible, acceptable, and clinically effective for use by ED patients who are acutely suicidal and seeking ED-based psychiatric crisis services.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03584386; https://clinicaltrials.gov/ct2/show/NCT03584386.

Highly Structured Treatment Programs for Addicted Offenders: Comparing the Effects of the Reasoning & Rehabilitation Program and DBT-F

BACKGROUND

When treating addicted offenders in a forensic psychiatric setting, a primary concern is to decrease antisocial cognitions and behaviors. The cognitive style of offenders is often characterized by impulsiveness, egocentricity, irrational thinking, and rigidity. We examined the relative efficacy of Reasoning and Rehabilitation Program (R&R) and Dialectical Behavioral Therapy- Forensic (DBT-F) on the domains of underlying psychological constructs (e.g., mental flexibility, planning, and problem-solving).

MATERIALS AND METHODS

The R&R and DBT-F were introduced in a forensic-psychiatric hospital for offenders with substance addictions in Germany. We compared pre- and post-tests to measure the cognitive skills of addicted offenders having undergone R&R (N = 47), DBT-F (N = 34), or Treatment as Usual (TAU; N = 28). Participants' skills (cognitive flexibility, ability to inhibit cognitive interference, cognitive performance/mental speed, divergent and convergent reasoning/problem solving) were assessed using neuropsychological instruments. Analyses of variance were conducted to investigate whether there were significant improvements within groups and whether these differences were significant between groups. To examine the predictive power of treatment-program on outcomes, and diagnosis of personality disorder, a hierarchical regression model was used.

RESULTS

Both programs were associated with improvements in nearly all of the measured constructs. The only construct on which the R&R and DBT-F groups differed significantly was word fluency, with those receiving R&R improving more than those receiving DBT-F. A regression model showed no predictive power for age, IQ, or diagnosis of personality disorder. Treatment group explained 13.8% of variance in cognitive flexibility but did not predict variance in other outcomes.

CONCLUSION

Surprisingly, we did not find superiority for one intervention over TAU or differential effects between the two programs. Future research should use larger samples and additional outcomes, including recidivism, to identify possible effects of treatment programs. Additionally, qualitative methods might inform us about these programs are implemented as well as which outcomes may be relevant.

Communicating suicide risk to families of chronically suicidal borderline personality disorder patients to mitigate malpractice risk

OBJECTIVE

The distinction between acute and chronic suicidality is important, because interventions designed to address acute suicidality can worsen chronic suicidality, resulting in an escalating cycle of suicide threats, suicide attempts, and futile hospitalizations. Though most chronically suicidal borderline personality disorder patients improve and do not complete suicide, the potential for suicide contributes to these hospitalizations and a paucity of outpatient services due to treaters' concern over malpractice lawsuits in case of suicide. Communicating with patients' families about the suicide risk has been suggested as a means to mitigate this malpractice risk, but the approach to such communication has not been described.

METHOD

Once chronic suicidality is identified, a stepwise approach to communicating with the patient's family is described.

RESULTS

The potential benefits of this risk communication are described, for patients, families, treaters, healthcare systems, and health and malpractice insurers.

CONCLUSION

It helps to develop an alliance with families and patients around a shared understanding of outcomes in chronic suicidality - most eventually do better, but the risk of completed suicide is real. This enables patients and families to make a more fully informed choice about treatment, which in turn can reduce litigation risk in the minority of cases where the patient completes suicide.

The weirdness of having a bunch of other minds like yours in the room: The lived experiences of mentalization-based therapy for borderline personality disorder

OBJECTIVES

Studies of lived experiences are important for improving treatment effectiveness, but most studies of mentalization-based therapy (MBT) are quantitative. This qualitative study aimed to better understand service users' lived experiences of MBT, including their experiences of change.

DESIGN

This is a qualitative study that used one-to-one semi-structured interviews.

METHOD

Semi-structured interviews were conducted with eight MBT service users recruited via four NHS trusts. Interviews were analysed using interpretative phenomenological analysis (IPA).

FINDINGS

Three superordinate themes were identified: being borderline, being in the group, and being on a journey. 'Experiences of diagnosis' and 'the group' are salient topics in the lived experiences of service users' during the MBT journey, as is the nature/type of 'change' that can create symptom reduction albeit alongside a negative felt experience.

CONCLUSION

Our research aligns with current thought regarding the complexity and challenges of treating BPD via psychotherapy and adds a further dimension, that of experiencing MBT and changes during therapy. The participants' experiences of BPD and of experiencing MBT are discussed.

PRACTITIONER POINTS

Therapists are observant of how each client gives meaning to their experience of diagnosis, the group, and change, particularly since the experience of recovery is not all positive. Service users' emerging and ongoing construction of their experience of diagnosis is closely monitored and additional appropriate strategies implemented where necessary. The impact of joining MBT, especially the group, becomes a process for formal regular review. Therapists undertake an in-depth exploration of service users' felt experiences to capture less quantifiable dimensions of change.

Nonsuicidal Self-Injury: Management on the Inpatient Psychiatric Unit[Formula: see text]

BACKGROUND. Between 4% to 70% of inpatients engage in self-harming behaviors and effective interventions are needed to address this population. AIM. This article reviews literature from 2007 to 2017 to address treatment and management strategies specific for the treatment of nonsuicidal self-injury in the inpatient psychiatric setting. METHODS. Cochrane, PsycINFO, PubMed, and CINAHL were searched for relevant articles with 34 studies reviewed for applicability to the question, and 9 parsed into a summary of Findings table. RESULTS. Therapeutic approaches that show promise include cognitive behavioral therapy, dialectical behavior therapy, and mentalization as well as medications that act on the serotonergic, dopaminergic, and opioid systems. Effective models of care aim toward enhancing therapeutic relationships with staff, providers, and most important, encouraging the internal shift toward recovery within the patient. CONCLUSIONS. More research with controlled designs in the inpatient setting is needed, however, regardless of which approach is used, the impact of the individual caregiver on the patient's recovery is key.

Is mentalization-based therapy effective in treating the symptoms of borderline personality disorder? A systematic review

OBJECTIVE

This review sought to systematically review evidence on the efficacy of mentalization-based therapy (MBT) for the treatment of borderline personality disorder (BPD), in particular, in decreasing psychiatric symptoms associated with BPD and its comorbid disorders.

METHOD

Fourteen papers were included in the review which examined the effectiveness of MBT in the context of BPD; these included 11 original studies and three follow-up papers.

RESULTS

Mentalization-based therapy was found to achieve either superior or equal reductions in psychiatric symptoms when compared with other treatments (supportive group therapy, treatment as usual/standard psychiatric care, structured clinical management, and specialized clinical management).

DISCUSSION

Mentalization-based therapy can achieve significant reductions in BPD symptom severity and the severity of comorbid disorders as well as increase quality of life. However, caution is required, as the need for better quality research such as randomized controlled trials is pressing. Research is also needed on the proposed mediators of MBT.

PRACTITIONER POINTS

Mentalization-based therapy (MBT) is increasingly being considered as a treatment for people with borderline personality disorder (BPD), and a systematic review was required to investigate its effectiveness. MBT was found to be equally as effective or superior to well-established comparison treatments of BPD, however, the majority of studies was of unsatisfying quality. Little is known about the mechanisms of MBT. Further, better quality trials are needed to investigate its efficacy in treating BPD.

Effectiveness of a 5-Week Inpatient Dialectical Behavior Therapy for Borderline Personality Disorder

OBJECTIVE

The goal of this study was to evaluate whether symptoms are reduced and emotion regulation improves when patients with borderline personality disorder (BPD) receive a 5-week course of inpatient dialectical behavioral therapy (DBT) and if changes in emotion regulation are associated with changes in symptoms.

METHODS

Forty-four patients with BPD receiving a 5-week course of DBT in a German psychiatry clinic participated. The short version of the "Borderline Symptom List" (BSL-23) was the patient-reported outcome. To measure emotion regulation, the "Self-Report Measure for the Assessment of Emotion Regulation Skills" (SEK-27) was administered. Wilcoxon tests were performed to evaluate whether pre-post changes in the BSL-23 and SEK-27 reached statistical significance. Effect sizes (d) were calculated and correlations between the pre-post differences for both measures were computed to test associations between changes in emotion regulation and changes in symptoms. Completer (n=33) and intention-to-treat (n=43) analyses were performed.

RESULTS

Symptoms (BSL-23) were reduced and emotion regulation (SEK-27) improved during the 5-week inpatient DBT treatment (completer and intention-to-treat analysis: P<0.001). Effect sizes reached d=0.47 for the BSL-23 and d=0.84 for the SEK-27 in the completer analysis, and d=0.38 for the BSL-23 and d=0.68 for the SEK-27 in the intention-to-treat analysis. Improvements in emotion regulation (SEK-27) were correlated with reductions in symptoms (BSL-23) in both the completer (r=0.54; P=0.001) and the intention-to-treat (r=0.59; P<0.001) analyses.

CONCLUSIONS

These findings indicate that a 5-week course of inpatient DBT can effectively reduce symptoms in patients with BPD and that the more patients' emotion regulation improves, the more the patients benefit from the therapy.

Dialectical Behaviour Therapy for Emotion Regulation Difficulties: A Systematic Review

While dialectical behaviour therapy (DBT) appears efficacious in reducing suicidal and self-harming behaviour, it is unclear whether DBT reduces emotion regulation (ER) difficulties, a purported mechanism of change of treatment. This review aims to investigate and evaluate the current evidence to understand the effectiveness of DBT in improving ER difficulties. A qualitative synthesis of studies investigating the effectiveness of DBT on self-reported ER difficulties as measured by the Difficulties in Emotion Regulation Scale (DERS) was performed, identifying eligible studies using PsycINFO, PubMed, MEDLINE and EMBASE databases. Fourteen studies were identified. Current evidence indicates that DBT does not show consistent benefits relative to existing psychological treatments in improving ER difficulties. The literature is compromised by significant methodological limitations increasing risk of bias across study outcomes. Furthermore, high variability across DBT programs and a lack of investigation regarding adherence and participant engagement within interventions was observed. Further research is needed in order to conclude regarding the effectiveness of DBT in improving ER difficulties. Consistent use of active treatment conditions, greater standardisation of DBT-based interventions, in addition to further examination of participant engagement level in DBT-based interventions in the long term may assist understanding as to whether DBT improves ER difficulties.

Specialized psychotherapies for adults with borderline personality disorder: A systematic review and meta-analysis

OBJECTIVE

Borderline personality disorder affects up to 2% of the population and is associated with poor functioning, low quality of life and increased mortality. Psychotherapy is the treatment of choice, but it is unclear whether specialized psychotherapies (dialectical behavior therapy, mentalization-based treatment, transference-focused therapy and schema therapy) are more effective than non-specialized approaches (e.g. protocolized psychological treatment, general psychiatric management). The aim of this systematic review is to investigate the effectiveness of these psychotherapies.

METHODS

PubMed, PsycINFO, CINAHL, EMBASE and CENTRAL were searched from inception to November 2017. Included randomized controlled trials were assessed on risk of bias and outcomes were meta-analyzed. Confidence in the results was assessed using the Grading of Recommendations Assessment, Development and Evaluation method. The review has been reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

A total of 20 studies with 1375 participants were included. Specialized psychotherapies, when compared to treatment as usual or community treatment by experts, were associated with a medium effect based on moderate quality evidence on overall borderline personality disorder severity (standardized mean difference = -0.59 [95% confidence interval: -0.90, -0.28]), and dialectical behavior therapy, when compared to treatment as usual, with a small to medium effect on self-injury (standardized mean difference = -0.40 [95% confidence interval: -0.66, -0.13]). Other effect estimates were often inconclusive, mostly due to imprecision.

CONCLUSION

There is moderate quality evidence that specialized psychotherapies are effective in reducing overall borderline personality disorder severity. However, further research should identify which patient groups profit most of the specialized therapies.

Personality, Schizophrenia, and Violence: A Longitudinal Study

The aims of this study were (a) to investigate the presence of clinically significant personality traits and personality disorders (PD) in patients living in residential facilities, with or without a history of violence (69 and 46, respectively); and (b) to investigate any associations between clinically significant personality traits and PDs, aggression, impulsivity, hostility, and violent behavior during a 1-year follow-up. The most frequent primary diagnoses were schizophrenia (58.3%) and PD (20.9%). Those with a history of violence demonstrated more antisocial and alcohol dependence features and lower depressive PD symptoms than the control group. Hostility levels, antisocial symptoms, and drug dependence, as well as a Structured Clinical Interview for DSM-IV Axis II diagnosis of PD, predicted aggressive and violent behavior during follow-up. The study confirms the relevance of assessing PDs both to evaluate the risk of violent behavior and to plan appropriate preventive and treatment intervention.

Developing an emotional coping skills workbook for inpatient psychiatric settings: a focus group investigation

BACKGROUND

Evidence suggests an unmet need for provision of psychological interventions in inpatient psychiatric settings. However, inpatient wards can present a challenging environment in which to implement interventions. The authors developed the Emotional Coping Skills workbook, a psychosocial intervention designed to overcome these challenges and provide inpatients with an opportunity for psychologically-informed therapeutic engagement. The workbook includes information and exercises to empower inpatients to understand their emotions and learn to cope with their distress.

METHODS

A qualitative study using thematic analysis was undertaken in two UK inpatient psychiatric hospitals to explore staff's views about whether and how the workbook could be implemented, and on barriers to its use. Thirty-five nursing and occupational therapy staff members participated in four focus groups, and a further two psychologists in semi-structured interviews.

RESULTS

Staff identified key barriers to successful implementation of the workbook. These were firstly, the difficulty in finding time and space for therapeutic work in the stressful ward environment. Secondly, staff identified a culture of emotional neglect whereby neither staff nor inpatients felt able to talk about emotions, and patients' physical needs and medication were prioritised. Thirdly, staff discussed how psychotic symptoms and emotional distress could limit patients' ability to engage with the workbook material. Staff suggested ways in which the feasibility of using the workbook could be enhanced. Firstly, they discussed the importance of encouraging staff to value psychological approaches and to view the workbook as a resource to help them manage their existing tasks. Secondly, they emphasised the value of staff drawing on their expertise to deliver the workbook flexibly in different formats and settings, depending on each patient's particular presentation. Thirdly, they advocated empowering staff to decide the timing of intervention delivery in the context of each inpatient's fluctuations in distress and progress towards recovery.

CONCLUSIONS

The study has highlighted key principles for flexible and well-integrated intervention delivery; these principles will be helpful for enhancing the feasibility of any nurse-delivered psychological intervention in inpatient settings.

Exclusion-Proneness in Borderline Personality Disorder Inpatients Impairs Alliance in Mentalization-Based Group Therapy

Interpersonal sensitivity, particularly threat of potential exclusion, is a critical condition in borderline personality disorder (BPD) which impairs patients’ social adjustment. Current evidence-based treatments include group components, such as mentalization-based group therapy (MBT-G), in order to improve interpersonal functioning. These treatments additionally focus on the therapeutic alliance since it was discovered to be a robust predictor of treatment outcome. However, alliance is a multidimensional factor of group therapy, which includes the fellow patients, and may thus be negatively affected by the exclusion-proneness of BPD patients. The aim of this pilot study was to examine the predictive value of threat of social exclusion for the therapeutic alliance in MBT-G. In the first part of the study, social exclusion was experimentally induced in 23 BPD inpatients and 28 healthy subjects using the Cyberball paradigm, a virtual ball tossing game. The evoked level of threat was measured with the Need-Threat Scale (NTS) which captures four dimensions of fundamental human needs, i.e., the need for belongingness, for self-esteem, for control, and for a meaningful existence. In the second part of the study, therapeutic alliance was measured on three dimensions, the therapists, the fellow patients and the group as a whole, using the Group-Questionnaire (GQ-D). BPD patients scored higher in their level of threat according to the NTS in both, the inclusion and the exclusion condition. The level of threat after exclusion predicted impairments of the therapeutic alliance in MBT-G. It was associated with more negative relationships, lower positive bonding and a lower positive working alliance with the fellow patients and lower positive bonding to the group as a whole whilst no negative prediction of the alliance to the therapists was found. Consequently, our translational study design has shown that Cyberball is an appropriate tool to use as an approach for clinical questions. We further conclude that exclusion-proneness in BPD is a critical feature with respect to alliance in group treatments. In order to neutralize BPD patients’ exclusion bias, therapists may be advised to provide an “inclusive stance,” especially in initial sessions. It is also recommendable to strengthen patient to patient relations.

Suicidal Ideation and Skill Use During In-patient Dialectical Behavior Therapy for Borderline Personality Disorder. A Diary Card Study

Associations between suicidal ideation and skill use were investigated during in-patient dialectical behavior therapy (DBT) for borderline personality disorder (BPD). Participants were N = 44 patients with BPD undergoing a 5-week in-patient DBT program in a psychiatric clinic. They filled in a diary card each treatment day resulting in 1,334 skill use ratings and 1,364 suicidal ideation ratings. Treatment days were categorized as days with successful skill use (using skills and perceiving them as effective), days with no skill use, days with unsuccessful skill use (using skills but perceiving them as ineffective). Multilevel models were performed to account for the nested data structure. The results showed that suicidal ideation improved more for patients who applied skills successfully more often during treatment (p < 0.05). Moreover, suicidal ideation was lower on treatment days with successful skill use compared to treatment days with no skill use and compared to treatment days with unsuccessful skill use (p < 0.05). When treatment days with no skill use were compared to treatment days with unsuccessful skill use, suicidal ideation was higher on treatment days with unsuccessful skill use (p < 0.05). To conclude, using skills successfully on as many treatment days as possible is associated with lower suicidal ideation.

Effectiveness of step-down versus outpatient dialectical behaviour therapy for patients with severe levels of borderline personality disorder: a pragmatic randomized controlled trial

BACKGROUND

Step-down dialectical behaviour therapy (DBT) is a treatment consisting of 3 months of residential DBT plus 6 months of outpatient DBT. The program was specifically developed for people suffering from severe borderline personality disorder (BPD). The present study examines the effectiveness and cost-effectiveness of step-down DBT compared to 12 months of regular, outpatient DBT.

METHODS

Eighty-four participants reporting high levels of BPD-symptoms (mean age 26 years, 95% female) were randomly assigned to step-down versus standard DBT. Measurements were conducted at baseline and after 3, 6, 9 and 12 months. The Lifetime Parasuicide Count and BPD Severity Index (BPDSI) were used to assess suicidal behaviour, non-suicidal self-injury (NSSI) and borderline severity. Costs per Quality Adjusted Life Year (QALY) were calculated using data from the EQ-5D-3L and the Treatment Inventory Cost in Psychiatric Patients (TIC-P).

RESULTS

In step-down DBT, 95% of patients started the program, compared to 45% of patients in outpatient DBT. The probability of suicidal behaviour did not change significantly over 12 months. The probability of NSSI decreased significantly in step-down DBT, but not in outpatient DBT. BPDSI decreased significantly in both groups, with the improvement leveling off at the end of treatment. While step-down DBT was more effective in increasing quality of life, it also cost significantly more. The extra costs per gained QALY exceeded the €80,000 threshold that is considered acceptable for severely ill patients in the Netherlands.

CONCLUSIONS

A pragmatic randomized controlled trial in the Netherlands showed that 9 months of step-down DBT is an effective treatment for people suffering from severe levels of BPD. However, step-down DBT is not more effective than 12 months of outpatient DBT, nor is it more cost-effective. These findings should be considered tentative because of high noncompliance with the treatment assignment in outpatient DBT. Furthermore, the long-term effectiveness of step-down DBT, and moderators of treatment response, remain to be evaluated.

TRIAL REGISTRATION

www.clinicaltrials.govNCT01904227. Registered 22 July 2013 (retrospectively registered).

Mechanisms of change in dialectical behaviour therapy and cognitive behaviour therapy for borderline personality disorder: a critical review of the literature

Background: Little is known about the "active ingredients" of psychological therapy for Borderline Personality Disorder (BPD) despite a growing evidence base documenting its clinical effectiveness. This information can be used by clinicians to inform service planning and care pathways.Aims: The aim of this study was to review published empirical research investigating the potential mechanisms underlying therapeutic change in Dialectical Behaviour Therapy (DBT) and Cognitive Behaviour Therapy (CBT) for BPD.Method: A thorough search of the PsychInfo, CINAHL Plus, PubMed, MEDLINE and EMBASE databases revealed research into potential mechanisms of change.Results: A total of 52 abstracts were reviewed. After a full text screen of the most relevant studies, 14 met inclusion criteria. Twelve examined DBT and two CBT. Mechanisms of change identified broadly fell into three categories: emotion regulation/self-control, skills use and therapeutic alliance/investment in treatment. Outcomes measured included general mental health diagnoses (e.g. anxiety, depression) and BPD-specific symptoms (e.g. self-harm/suicidality, impulsivity, substance misuse, anger).Conclusion: Further empirically robust research is required to test hypotheses about the influence of the proposed mechanisms on therapeutic change in psychological therapies for BPD.

Possible role of a dysregulation of the endogenous opioid system in antisocial personality disorder

Around half the inmates in prison institutions have antisocial personality disorder (ASPD). A recent theory has proposed that a dysfunction of the endogenous opioid system (EOS) underlies the neurobiology of borderline personality disorder (BPD). In the present theoretical paper, based on a comprehensive database and hand search of the relevant literature, this hypothesis is extended to ASPD, which may be the predominant expression of EOS dysfunction in men, while the same pathology underlies BPD in women. According to evidence from human and animal studies, the problematic behaviours of persons with antisocial, callous, or psychopathic traits may be seen as desperate, unconscious attempts to stimulate their deficient EOS, which plays a key role in brain reward circuits. If the needs of this system are not being met, the affected persons experience dysphoric mood, discomfort, or irritability, and strive to increase binding of endogenous opioids to receptors by using the rewarding effects of aggression by exertion of physical or manipulative power on others, by abusing alcohol or substances that have the reward system as target, by creating an "endorphin rush" by self-harm, by increasing the frequency of their sexual contacts, or by impulsive actions and sensation seeking. Symptoms associated with ASPD can be treated with opioid antagonists like naltrexone, naloxone, or nalmefene.

Assessment and determinants of aggression in a forensic psychiatric institution in Hong Kong, China

Institutional aggression in forensic psychiatric setting is an under-researched subject, despite the magnitude of the problem. No studies have been conducted on the assessment of risk and the examination of predictors of aggression among the Chinese forensic psychiatric population. Our study aimed to examine the determinants of aggression in the only forensic psychiatric institution in Hong Kong, and to test the psychometric properties of a risk-assessment instrument, the Dynamic Appraisal of Situational Aggression (DASA). We recruited a representative sample of 530 consecutively admitted detainees. Qualified nurses completed two risk-assessment instruments, the DASA and the Brøset Violence Checklist (BVC), once daily during the participants׳ first 14 days of admission. Aggressive incidents were recorded using the revised Staff Observation Aggression Scale (SOAS-R), and participants׳ data were collected for multivariate analyses. We showed that female gender, diagnoses of personality disorder and substance-related disorder, and admission at other correctional institutions were associated with institutional aggression. Aggression was perpetrated by 17.7% of the participants, and the DASA was demonstrated to have good psychometric properties in assessing and predicting aggressive incidents. Our findings preliminarily support the use of daily in-patient risk-assessment and affirm the role of dynamic factors in institutional aggression.

Dialectical behaviour therapy (DBT) in the treatment of borderline personality disorder

Borderline personality disorder (BPD) is a complex disorder that is difficult to treat. However, dialectical behaviour therapy (DBT), developed by Dr. Marsha Linehan in the early 1990s, has emerged as a promising treatment option for those diagnosed with BPD. DBT is a multi-pronged treatment approach delivered normally in outpatient settings over 12 months and requires highly skilled and trained therapists. Many trials have provided evidence to support the use of DBT in the treatment of BPD. However, outcome measures vary and are mostly limited to measurable behavioural outcomes such as incidences of deliberate self-harm or suicidal thoughts. Two recent Cochrane reviews conclude that DBT does benefit those with BPD, but more robust evidence is needed. DBT training for health care professionals also has the potential to shift health care professionals' attitudes from one of therapeutic pessimism to one of optimism.

Efficacy and cost-effectiveness of an experimental short-term inpatient Dialectical Behavior Therapy (DBT) program: study protocol for a randomized controlled trial

BACKGROUND

Borderline Personality Disorder (BPD) is a serious psychiatric condition associated with substantial mortality, burden and public health costs. DBT is the treatment model with the largest number of published research articles showing effectiveness. However, some patients are not sufficiently engaged in outpatient treatment while presenting severe parasuicidal behavior, making hospitalization necessary. The Center for Personality Disorders Jelgersma developed an intensive 12-week inpatient DBT program that (i) rapidly reduces core borderline symptoms like suicidal behavior, (ii) minimizes the negative effects of an inpatient setting, and (iii) enhances compliance with outpatient treatment. We evaluate the (cost-) effectiveness of this experimental program.

METHODS/DESIGN

Seventy patients, aged 18 to 45 years with a primary diagnosis of BPD, showing a chronic pattern of parasuicidal gestures and/or reporting high degrees of severity of other borderline symptoms, are randomly allocated to the control and intervention groups. Subjects in the control group receive standard outpatient DBT, provided in one of three regular mental health settings in GGZ Rivierduinen. Subjects in the intervention group receive 12 weeks of intensified inpatient DBT plus six months of standard DBT, provided in the Center for Personality Disorders Jelgersma. The primary outcome is the number of suicide attempts/self-harming acts. Secondary outcomes are severity of other borderline complaints, quality of life, general psychopathological symptoms and health care utilization and productivity costs. Data are gathered using a prospective, two (group: intervention and control) by five (time of measurement) repeated measures factorial design.Participants will complete three-monthly outcome assessments in the course of therapy: at baseline, and 12, 24, 36 and 52 weeks after the start of the treatment. The period of recruitment started in March 2012 and the study will end in December 2014.

DISCUSSION

Highly suicidal outpatient patients can pose a dilemma for mental health care professionals. Although hospitalization seems inevitable under some circumstances, it has proven to be harmful in its own right. This paper outlines the background and methods of a randomized trial evaluating the possible surplus value of a short-term inpatient DBT program.

Feasibility and utility of positive psychology exercises for suicidal inpatients

OBJECTIVE

The objective was to assess the feasibility and acceptability of nine positive psychology exercises delivered to patients hospitalized for suicidal thoughts or behaviors, and to secondarily explore the relative impact of the exercises.

METHOD

Participants admitted to a psychiatric unit for suicidal ideation or behavior completed daily positive psychology exercises while hospitalized. Likert-scale ratings of efficacy (optimism, hopelessness, perceived utility) and ease of completion were consolidated and compared across exercises using mixed models accounting for age, missing data and exercise order. Overall effects of exercise on efficacy and ease were also examined using mixed models.

RESULTS

Fifty-two (85.3%) of 61 participants completed at least one exercise, and 189/213 (88.7%) assigned exercises were completed. There were overall effects of exercise on efficacy (χ(2)=19.39; P=.013) but not ease of completion (χ(2)=11.64; P=.17), accounting for age, order and skipped exercises. Effect (Cohen's d) of exercise on both optimism and hopelessness was moderate for the majority of exercises. Exercises related to gratitude and personal strengths ranked highest. Both gratitude exercises had efficacy scores that were significantly (P=.001) greater than the lowest-ranked exercise (forgiveness).

CONCLUSION

In this exploratory project, positive psychology exercises delivered to suicidal inpatients were feasible and associated with short-term gains in clinically relevant outcomes.

Continuing education to go: capacity building in psychotherapies for front-line mental health workers in underserviced communities

OBJECTIVE

To address the gaps between need and access, and between treatment guidelines and their implementation for mental illness, through capacity building of front-line health workers.

METHODS

Following a learning needs assessment, work-based continuing education courses in evidence-supported psychotherapies were developed for front-line workers in underserviced community settings. The 5-hour courses on the fundamentals of cognitive-behavioural therapy, interpersonal psychotherapy, motivational interviewing, and dialectical behaviour therapy each included videotaped captioned simulations, interactive lesson plans, and clinical practice behaviour reminders. Two courses, sequentially offered in 7 underserviced settings, were subjected to a mixed methods evaluation. Ninety-three nonmedical front-line workers enrolled in the program. Repeated measures analysis of variance was used to assess pre- and postintervention changes in knowledge and self-efficacy. Qualitative data from 5 semistructured focus groups with 25 participants were also analyzed.

RESULTS

Significant pre- and postintervention changes in knowledge (P < 0.001) were found in course completers. Counselling self-efficacy improved in participants who took the first course offered (P = 0.001). Dropouts were much less frequent in peer-led, small-group learning than in a self-directed format. Qualitative analysis revealed improved confidence, morale, self-reported practice behaviour changes, and increased comfort in working with difficult clients.

CONCLUSION

This work-based, multimodal, interactive, interprofessional curriculum for knowledge translation of psychotherapeutic techniques is feasible and helpful. A peer-led group format is preferred over self-directed learning. Its application can build capacity of front-line health workers in helping patients who suffer from common mental disorders.