Effectiveness of Delivering Dialectical Behavioral Therapy Techniques by Email in Patients With Borderline Personality Disorder: Nonrandomized Controlled Trial

Acceptance, Safety, and Effect Sizes in Online Dialectical Behavior Therapy for Borderline Personality Disorder: Interventional Pilot Study

BACKGROUND

The potential of telehealth psychotherapy (ie, the online delivery of treatment via a video web-based platform) is gaining increased attention. However, there is skepticism about its acceptance, safety, and efficacy for patients with high emotional and behavioral dysregulation.

OBJECTIVE

This study aims to provide initial effect size estimates of symptom change from pre- to post treatment, and the acceptance and safety of telehealth dialectical behavior therapy (DBT) for individuals diagnosed with borderline personality disorder (BPD).

METHODS

A total of 39 individuals meeting the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]) criteria for BPD received 1 year of outpatient telehealth DBT at 3 sites in Germany and Canada. Effect size estimates were assessed using pre-post measures of BPD symptoms, dissociation, and quality of life. Safety was evaluated by analyzing suicide attempts and self-harm. Additionally, acceptance and feasibility, satisfaction with treatment, useability of the telehealth format, and the quality of the therapeutic alliance were assessed from both therapists' and patients' perspectives. All analyses were conducted on both the intention-to-treat (ITT) and according-to-protocol (ATP) samples.

RESULTS

Analyses showed significant and large pre-post effect sizes for BPD symptoms (d=1.13 in the ITT sample and d=1.44 in the ATP sample; P<.001) and for quality of life (d=0.65 in the ITT sample and d=1.24 in the ATP sample). Dissociative symptoms showed small to nonsignificant reductions. Self-harm behaviors decreased significantly from 80% to 28% of all patients showing at least 1 self-harm behavior in the last 10 weeks (risk ratio 0.35). A high dropout rate of 38% was observed. One low-lethality suicide attempt was reported. Acceptance, feasibility, and satisfaction measures were high, although therapists reported only moderate useability of the telehealth format.

CONCLUSIONS

Telehealth DBT for BPD showed large pre-post effect sizes for BPD symptoms and quality of life. While the telehealth format appeared feasible and well-accepted, the dropout rate was relatively high. Future research should compare the efficacy of telehealth DBT with in-person formats in randomized controlled trials. Overall, telehealth DBT might offer a potentially effective alternative treatment option, enhancing treatment accessibility. However, strategies for decreasing drop-out should be considered.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00027824; https://drks.de/search/en/trial/DRKS00027824.

Online dialectical behavior therapy for binge eating disorder: an open trial

The purpose of the present study was to examine the efficacy of online Dialectical Behavior Therapy for Binge Eating Disorder (DBT-BED) in reducing eating psychopathology and investigate the factors that influence the severity and frequency of binge eating. Seventy-three individuals seeking treatment for BED participated in 20 two-hour group sessions. Participants completed the Emotional Eating Scale (EES), Binge Eating Scale (BES), and Eating Disorder Examination Questionnaire (EDE-Q) before and after the treatment and at three- and six-month follow-ups. Results from 58 participants were analyzed. The study results indicated a significant decrease in objective binge eating (OBE) days, as well as in all EES, BES, and EDE-Q subscales (except the Restraint subscale), and global EDE-Q score at the end of treatment and follow-ups. Moreover, the Body Mass Index (BMI) reduced at the end of treatment and during the follow-up period. Except for the Restraint subscale, more OBE days were linked with higher EES, BES, and EDE-Q scores. Overall, the study suggests that online DBT-BED is an effective approach to treating Binge Eating Disorder (BED) for individuals who cannot receive in-person therapy. Further research is necessary to compare the efficacy of online DBT-BED with other interventions.

Feasibility and acceptability of an online group dialectical behavioural therapy skills training in a Transdiagnostic group with Anxiety and Depression

Transdiagnostic approaches offers a paradigm shift in managing psychiatric disorders. Emotion regulation difficulties are a transdiagnostic prevalent across various mood and personality disorders. Dialectical Behavioural Therapy Skills Training (DBT-ST), initially designed as part of treatment for borderline personality disorder, targets emotion regulation and has shown promise in diverse psychiatric conditions. In lower middle-income countries with resource-constrained settings, online delivery of evidence-based interventions holds potential to bridge treatment gaps. This study assesses the feasibility and acceptability of online group DBT skills training for individuals with depression or anxiety disorders in India. Mental health professionals practising in India referred twenty-four eligible participants currently not engaged in psychotherapy. Of these, 18 initiated the 8-week virtual group DBT-ST program, with 12 completing it (66 % female, 18-35 years of age, 5 on concurrent medication). They provided feedback on therapy content's usefulness. Baseline, post-intervention, and one-month follow-up assessments measured changes in emotion regulation difficulties, depression, and anxiety symptoms. Treatment retained 66.7 % of participants, all participants found the intervention beneficial. Repeated measures ANOVA indicates significant reductions in self-reported difficulties in emotion regulation, depression, and anxiety symptoms post-intervention. These findings highlight the promise of transdiagnostic interventions like DBT-ST that merit further evaluations using RCTs with larger sample sizes.

A Qualitative Analysis of the Effects of COVID-19 on Home Visiting Service Provision

Home visiting programs have been found to improve parenting practices and to reduce negative child outcomes. The 2019 coronavirus disease (COVID-19) resulted in an abrupt transition to telehealth services for many home visiting services. Limited research has examined the impacts of delivering home visiting services via telehealth, and the effects of this abrupt transition during COVID-19 is understudied as well. This study examined the impact of the abrupt transition to telehealth as a result of COVID-19 on home visiting service provision in one mid-sized midwestern community from the perspective of clients and providers. We conducted semi-structured interviews with both home visiting clients and providers (N = 26) in prevention-focused home visiting services. Although some benefits to telehealth were reported, providers discussed challenges with regard to engaging clients in services and difficulties in completing important home visiting tasks (i.e., assessment of child development, teaching parent-child interaction). Providers and clients also noted that they missed face-to-face interactions. Effective use of telehealth in home visiting requires provision of devices that allow for video-chatting as well as development of effective methods to engage in observation and teaching tasks.

Feasibility, Acceptability, and Potential Efficacy of a Self-Guided Internet-Delivered Dialectical Behavior Therapy Intervention for Substance Use Disorders: Randomized Controlled Trial

BACKGROUND

People with alcohol and substance use disorders (SUDs) often have underlying difficulties in regulating emotions. Although dialectical behavioral therapy is effective for SUDs, it is often difficult to access. Self-guided, internet-delivered dialectical behavioral therapy (iDBT) allows for expanded availability, but few studies have rigorously evaluated it in individuals with SUDs.

OBJECTIVE

This study examines the feasibility, acceptability, and potential efficacy of an iDBT intervention in treatment-seeking adults with SUDs. We hypothesized that iDBT would be feasible, credible, acceptable, and engaging to people with SUDs. We also hypothesized that the immediate versus delayed iDBT group would show comparatively greater improvements and that both groups would show significant improvements over time.

METHODS

A 12-week, single-blinded, parallel-arm, randomized controlled trial was implemented, with assessments at baseline and at 4 (acute), 8, and 12 weeks (follow-up). A total of 72 community adults aged 18 to 64 years were randomized. The immediate group (n=38) received access to iDBT at baseline, and the delayed group (n=34) received access after 4 weeks. The intervention (Pocket Skills 2.0) was a self-guided iDBT via a website, with immediate access to all content, additional text and email reminders, and additional support meetings as requested. Our primary outcome was substance dependence, with secondary outcomes pertaining to feasibility, clinical outcomes, functional disability, and emotion dysregulation, among other measures. All outcomes were assessed using self-report questionnaires.

RESULTS

iDBT was perceived as a credible and acceptable treatment. In terms of feasibility, 94% (68/72) of the participants started iDBT, 13% (9/68) were early dropouts, 35% (24/68) used it for the recommended 8 days in the first month, and 50% (34/68) were still active 4 weeks later. On average, the participants used iDBT for 2 hours and 24 minutes across 10 separate days. In the acute period, no greater benefit was found for the immediate group on substance dependence, although we did find lower depression (b=-2.46; P=.02) and anxiety (b=-2.22; P=.02). At follow-up, there were greater benefits in terms of reduced alcohol (b=-2.00; P=.02) and nonalcoholic substance (b=-3.74; P=.01) consumption in the immediate access group. Both groups demonstrated improvements in substance dependence in the acute (b=-1.73; P<.001) and follow-up period (b=-2.09; P<.001). At follow-up, both groups reported reduced depression, anxiety, suicidal behaviors, emotional dysregulation, and functional disability.

CONCLUSIONS

iDBT is a feasible and acceptable intervention for patients with SUDs, although methods for improving engagement are warranted. Although results did not support efficacy for the primary outcome at 4 weeks, findings support reductions in substance dependence and other mental health concerns at 12 weeks. Notwithstanding the limitations of this study, the results suggest the potential value of iDBT in the treatment of SUDs and other mental health conditions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05094440; https://clinicaltrials.gov/show/NCT05094440.

Efficacy of an Electronic Cognitive Behavioral Therapy Program Delivered via the Online Psychotherapy Tool for Depression and Anxiety Related to the COVID-19 Pandemic: Pre-Post Pilot Study

BACKGROUND

Lockdowns and social distancing resulting from the COVID-19 pandemic have worsened the population's mental health and made it more difficult for individuals to receive care. Electronic cognitive behavioral therapy (e-CBT) is a cost-effective and evidence-based treatment for anxiety and depression and can be accessed remotely.

OBJECTIVE

The objective of the study was to investigate the efficacy of online psychotherapy tailored to depression and anxiety symptoms during the pandemic.

METHODS

The pilot study used a pre-post design to evaluate the efficacy of a 9-week e-CBT program designed for individuals with depression and anxiety affected by the pandemic. Participants were adults (N=59) diagnosed with major depressive disorder and generalized anxiety disorder, whose mental health symptoms initiated or worsened during the COVID-19 pandemic. The online psychotherapy program focused on teaching coping, mindfulness, and problem-solving skills. Symptoms of anxiety and depression, resilience, and quality of life were assessed.

RESULTS

Participants demonstrated significant improvements in symptoms of anxiety (P=.02) and depression (P=.03) after the intervention. Similar trends were observed in the intention-to-treat analysis. No significant differences were observed in resilience and quality-of-life measures. The sample comprised mostly females, making it challenging to discern the benefits of the intervention in males. Although a pre-post design is less rigorous than a controlled trial, this design was selected to observe changes in scores during a critical period.

CONCLUSIONS

e-CBT for COVID-19 is an effective and accessible treatment option. Improvements in clinical symptoms of anxiety and depression can be observed in individuals whose mental health is affected by the COVID-19 pandemic.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04476667; https://clinicaltrials.gov/study/NCT04476667.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/24913.

A systematic review and meta-analysis of digital interventions targeted at individuals with borderline personality disorder (BPD), emotionally unstable personality disorder (EUPD), and related symptoms

OBJECTIVES

The present review investigates the impact of digital interventions for individuals with features of borderline personality disorder (BPD)/emotional unstable personality disorder (EUPD) as digital interventions show promise as therapeutic tools in underserved groups. BPD/EUPD features are identified as clinically relevant, yet previous reviews on the use of digital interventions fail to include subthreshold symptomatology.

METHODS

Five online databases were searched for terminology in three categories: BPD/EUPD and related symptoms, mental-health interventions, and digital technology. Additionally, four relevant journals and two trial registers were searched for additional papers meeting the inclusion criteria.

RESULTS

Twelve articles met all inclusion criteria. Meta-analyses revealed statistically significant differences in symptom measures between intervention and control groups at postintervention and decreases in BPD/EUPD symptomatology and well-being from pre- to postintervention. Service users' engagement, satisfaction, and acceptability of interventions were high. Results support the previous literature on the value of using digital interventions in populations with BPD/EUPD.

CONCLUSION

Overall, it was identified that digital interventions show promise for successful implementation with this population.

Evaluating the efficacy of Web-Based Cognitive Behavioural Therapy for the treatment of patients with Bipolar II Disorder and residual depressive symptoms: Protocol for a randomized controlled trial

BACKGROUND

Bipolar disorder (BD) is a highly prevalent psychiatric condition that can significantly impact every aspect of a person's life if left untreated. A subtype of BD, Bipolar disorder II (BD-II) is characterized by long depressive episodes and residual depression symptoms, with short-lived hypomanic episodes. Medication and psychotherapy, such as cognitive behavioral therapy (CBT), are the main treatment options for BD-II. CBT specific for BD-II involves the recognition of warning signs, potentially triggering stimuli, and the development of coping skills to increase euthymic periods and improve global functioning. However, access to in-person CBT may be limited by several barriers including low availability, high costs and geographical limitations. Thus, online adaptations of CBT (e-CBT) have become a promising solution to address these treatment barriers Nevertheless, e-CBT for the treatment of BD-II remains understudied.

OBJECTIVE

The proposed study aims to establish the first e-CBT program specific for the treatment of BD-II with residual depressive symptoms. The primary objective of this study will be to determine the effect of e-CBT in managing BD symptomatology. The secondary objective will be to assess the effects of this e-CBT program on quality of life, and resilience. The tertiary objective will involve gathering user feedback using a post-treatment survey to support the continuous improvement and optimization of the proposed program.

METHODS

Adult participants (n = 170) with a confirmed diagnosis of BD-II experiencing residual depressive symptoms will be randomly assigned to either the e-CBT plus TAU (n = 85) group or the TAU (n = 85) control group. Participants in the control group will be able to participate in the online program after the first 13 weeks. The e-CBT program will consist of 13 weekly online modules designed following a validated CBT framework. Participants will complete module-related homework and receive asynchronous personalized feedback from a therapist. TAU will consist of standard treatment services conducted outside of the current research study. Depression and manic symptoms quality of life and resiliency will be assessed using clinically validated symptomatology questionnaires at baseline, week 6, and week 13.

RESULTS

The study received ethics approval in March 2020 and participant recruitment is expected to begin in February 2023 through targeted advertisements and physician referrals. Data collection and analysis are expected to conclude by December 2024. Linear and binomial regression (continuous and categorical outcomes respectively) will be conducted along with qualitative interpretive methods.

CONCLUSIONS

The findings will be the first on the effectiveness of delivering e-CBT for patients with BD-II with residual depressive symptoms. This approach can provide an innovative method to address barriers to in-person psychotherapy by increasing accessibility and decreasing costs.

CLINICALTRIAL

clinicaltrials.gov (NCT04664257); clinicaltrials.gov/ct2/show/NCT04664257.

Comparison of online and in-person cognitive behavioral therapy in individuals diagnosed with major depressive disorder: a non-randomized controlled trial

Objective

The increased prevalence of major depressive disorder (MDD) amid the COVID-19 pandemic has resulted in substantial growth in online mental health care delivery. Compared to its in-person counterpart, online cognitive behavioral therapy (e-CBT) is a time-flexible and cost-effective method of improving MDD symptoms. However, how its efficacy compares to in-person CBT is yet to be explored. Therefore, the current study compared the efficacy of a therapist-supported, electronically delivered e-CBT program to in-person therapy in individuals diagnosed with MDD.

Methods

Participants (n = 108) diagnosed with MDD selected either a 12 week in-person CBT or an asynchronous therapist-supported e-CBT program. E-CBT participants (n = 55) completed weekly interactive online modules delivered through a secure cloud-based online platform (Online Psychotherapy Tool; OPTT). These modules were followed by homework in which participants received personalized feedback from a trained therapist. Participants in the in-person CBT group (n = 53) discussed sessions and homework with their therapists during one-hour weekly meetings. Program efficacy was evaluated using clinically validated symptomatology and quality of life questionnaires.

Results

Both treatments yielded significant improvements in depressive symptoms and quality of life from baseline to post-treatment. Participants who opted for in-person therapy presented significantly higher baseline symptomatology scores than the e-CBT group. However, both treatments demonstrated comparable significant improvements in depressive symptoms and quality of life from baseline to post-treatment. e-CBT seems to afford higher participant compliance as dropouts in the e-CBT group completed more sessions on average than those in the in-person CBT group.

Conclusion

The findings support e-CBT with therapist guidance as a suitable option to treat MDD. Future studies should investigate how treatment accessibility is related to program completion rates in the e-CBT vs. in-person group.

Clinical Trial Registration

ClinicalTrials.Gov Protocol Registration and Results System (NCT04478058); clinicaltrials.gov/ct2/show/NCT04478058.

Mental health support for and telehealth use by Australians living with borderline personality disorder during the onset of the COVID-19 pandemic: A national study

Objective

To investigate mental health service use and telehealth experience of people living with BPD in Australia during the first year of the COVID-19 pandemic.

Methods

An online survey was used to collect data from people who self-identified with a diagnosis of BPD.

Results

One hundred and sixty-nine survey responses were included in the analysis. More than half of participants acknowledged receiving information from their health service about resources that they could use if they become distressed. More than 70% of participants used telehealth for receiving mental health services; the majority used telehealth to consult a psychologist or to obtain prescriptions. Telehealth sessions were conducted over the phone, via videoconferencing, or using a mix of the two. While using telehealth, some participants found it more difficult to control their impulses to self-harm, to express thoughts about self-harm and suicide, to control feelings of anger, and to establish and maintain agreed treatment boundaries. Thematic analysis of participants' experiences of telehealth identified five main themes: Communication challenges, Technology challenges, Privacy concerns, Benefits of telehealth, and Personal preferences.

Conclusion

The study findings revealed a variety of positive and negative consumer experiences. While the majority of participants found telehealth somewhat benefitted their mental health, challenges were also reported which raise concerns about the broader utility and effectiveness of telehealth.

Brief internet-delivered skills training based on DBT for adults with borderline personality disorder - a feasibility study

OBJECTIVE

Borderline personality disorder (BPD) is characterized by instability in emotions, relationships, and behaviors, such as self-injury and suicidal behavior. Dialectical Behavioral Therapy (DBT) is an established intervention for BPD, but there are long waiting times for treatment. This study aimed to explore if a brief internet-delivered DBT skills training program with minimal therapist support is acceptable, that it can be administered, useful, and does not do harm for patients with BPD.

METHODS

Acceptability was measured through data on recruitment and attrition, utilization of the intervention, reported impulses to drop out, and through ratings on self-injury and suicidality. Participants were interviewed about their experiences of the intervention; analyzed with content analysis.

RESULTS

Twenty patients on the waiting list for treatment at a DBT-clinic were invited and nine female patients (age 19-37 years) volunteered. The participants completed a large part of the intervention, which did not appear harmful since ratings of suicidal and self-harming behavior were similar before and after the intervention. In the interviews, participants stated that they had gained new knowledge and skills to manage situations, e.g. to stop and think before acting. Some even reported decreased levels of self-injury. The time spent on patient contact was short, and some patients reported difficulties to practice on their own and requested more support.

CONCLUSIONS

The intervention seems to be acceptable. Future studies should investigate in what ways some BPD patients are more susceptible to internet-delivered skills training than others, and if this intervention could be delivered within a stepped-care model.

Feasibility, Acceptability and Preliminary Efficacy of Dialectical Behavior Therapy for Autistic Adults without Intellectual Disability: A Mixed Methods Study

Self-harm and suicidal behaviors are prevalent among autistic adults without intellectual disability (ID). Emotion dysregulation (ED), the difficulty in modulating emotions, has been identified as an important risk factor. Dialectical behavior therapy (DBT) has been proved effective to treat ED in disorders other than autism spectrum disorder. Our study aimed at assessing the feasibility, acceptability and preliminary efficacy of DBT in seven autistic adults without ID exhibiting self-harm and/or suicidal behaviors linked to severe ED. Our results suggest that DBT is feasible and highly acceptable to autistic adults without ID. Additionally, mean scores on the Difficulties in Emotion Regulation Scale decreased significantly post-treatment and at 4-month follow-up, suggesting that DBT might be efficacious in reducing ED in this population.

Towards online delivery of Dialectical Behaviour Therapy: A scoping review

Dialectical Behaviour Therapy (DBT) programmes are often the only available treatment for people diagnosed with borderline personality disorder and were rapidly converted to online delivery during the COVID-19 pandemic. Limited research exists surrounding how the major elements of DBT are delivered in an online environment. This scoping review considered the operationalization of online delivery of DBT and its effectiveness. EBSCO host databases were searched using free text. Of 127 papers, 11 studies from 2010 to 2021 investigating online DBT for any clinical population were included in the review. A narrative synthesis of papers selected was undertaken. Seven articles reported results from five clinical trials (n = 437). Most adaptations mirrored face-to-face programmes although there was considerable variation in how therapy was facilitated. Attendance was reported to be greater online with comparable clinical improvements to face-to-face for those who remained in therapy. Additional challenges included managing risk, therapist preparedness and technology difficulties. Online delivery of DBT programmes is feasible and may be more accessible, acceptable and as safe and effective as face-to-face delivery. However, mirroring face to face delivery in an online environment may not be the most effective and efficient way to adapt DBT to online provision. Research is needed to identify areas which require further adaptation.

E-Mental Health for People with Personality Disorders: A Systematic Review

PURPOSE OF REVIEW

Provision of mental health services through digital technologies (e-mental health) can potentially expand access to treatments for personality disorders (PDs). We evaluated studies on e-mental health for PDs published over the last 3 years (2019-2022).

RECENT FINDINGS

Studies published in English that used e-mental health to treat people with PDs or PD-related symptoms were identified. We identified 19 studies, including four randomized controlled trials and one meta-analysis. Most interventions were based on Dialectical Behavior Therapy and delivered through smartphone applications for adults with Borderline Personality Disorder [BPD] or related symptoms. User experiences of the interventions were generally positive. Evidence for efficacy was limited. The current literature on e-mental health for PDs is limited in scope. Research in understudied populations and randomized controlled trials designed to establish efficacy are warranted. It is not yet clear whether e-mental health may be helpful for the treatment of PDs.