BI-REAL: A 12-session DBT skills group intervention adapted for bipolar disorder - A feasibility randomised pilot trial

International guidelines endorse psychological treatment for Bipolar Disorder (BD); however, the absence of a recognised gold-standard intervention requires further research. A Dialectical Behaviour Therapy (DBT) skills group intervention with 12 sessions was developed. This pilot randomised controlled trial (RCT) aims to evaluate the feasibility, acceptability, and outcomes variance of Bi-REAL - Respond Effectively, Assertively, and Live mindfully, tailored for individuals with BD, in preparation for a future RCT.

METHODS

52 participants (female = 62.7 %; mean age = 43.2 ± 11.1) with BD were randomised by blocks to either the experimental group (EG; n = 26; Bi-REAL + Treatment as Usual, TAU) receiving 12 weekly 90-minutes sessions, or the control group (CG; n = 26, TAU). Feasibility and acceptability were assessed with a multimethod approach (qualitative interviews, semi-structured clinical interviews and a battery of self-report questionnaires - candidate main outcomes Bipolar Recovery Questionnaire (BRQ) and brief Quality of Life for Bipolar Disorder (QoL.BD)). All participants were evaluated at baseline (T0), post-intervention (T1) and 3-month follow-up (T2).

RESULTS

Acceptability was supported by participants' positive feedback and ratings of the sessions and programme overall, as well as the treatment attendance (86.25 % of sessions attended). The trial overall retention rate was 74.5 %, with CG having a higher dropout rate across the 3-timepoints (42.31 %). A significant Time × Group interaction effect was found for BRQ and QoL.BD favouring the intervention group (p < .05).

LIMITATIONS

The assessors were not blind at T1 (only at T2). Recruitment plan was impacted due to COVID-19 restrictions and replication is questionable. High attrition rates in the CG.

CONCLUSIONS

The acceptability of Bi-REAL was sustained, and subsequent feasibility testing will be necessary to establish whether the retention rates of the overall trial improve and if feasibility is confirmed, before progressing to a definitive trial.

Dialectical Behavior Therapy as an intervention for Treatment Resistant Depression in adults: A protocol for systematic review and meta-analysis

BACKGROUND

Major Depressive Disorder is a long-term, recurring, and very common illness that is associated with a significant decline in functional ability. The gold-standard method of treating depression is pharmacotherapy, which involves the use of antidepressant medications either alone or in various combinations. However, approximately 30% of Major Depressive Disorder patients suffer from Treatment Resistant Depression, a more severe condition that has a profound impact on patients' lives. Our study aims to conduct the first comprehensive review and meta-analysis to assess the effectiveness and safety of adding Dialectical Behavior Therapy to antidepressant medications compared to groups using pharmacotherapy alone as an intervention for adults with Treatment Resistant Depression.

MATERIALS AND METHODS

We will search for publications in the following databases: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Lilacs, Web of Science, and PsycINFO. We will manually review the reference lists of the included studies to identify potentially relevant studies. There will be no restrictions on the language or publication date. Quality assessment of the included studies will be performed independently according to the Cochrane Risk of Bias instrument. To assess the certainty of the findings' body of evidence, we will use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. This study aims to determine the effectiveness and safety of Dialectical Behavior Therapy as an intervention for Treatment Resistant Depression in adults.

ETHICS AND DISSEMINATION

Ethical approval was not required as individual patient data was not obtained. Our intention is to publish the systematic review in a medical journal that offers open access upon completion of the process.

TRIAL REGISTRATION

PROSPERO registration number CRD42023406301. Registered on March 24, 2023.

Barriers and Facilitators to Dialectical Behavior Therapy Skills Groups in the Veterans Health Administration

INTRODUCTION

Dialectical behavior therapy (DBT) is a multimodal evidence-based suicide prevention psychotherapy with barriers to full implementation. This study qualitatively examined barriers and facilitators to the DBT skills group treatment mode, which can be implemented as a stand-alone intervention. Using data from a national mixed-methods program evaluation of DBT in the Veterans Health Administration (VHA), this is the first article to examine barriers and facilitators to DBT skills groups implemented with a DBT consultation team or as a stand-alone intervention.

MATERIALS AND METHODS

A subset of data from semi-structured telephone interviews of six clinicians and three administrators (n = 9 respondents) was analyzed to provide complementarity and expansion on prior quantitative findings. The data were coded using an iterative process based on content analysis and a codebook based on the Promoting Action on Research Implementation in Health Services framework. The study was approved by the institutional review board for the Palo Alto VA Health Care System.

RESULTS

Barriers and facilitators were organized by Promoting Action on Research Implementation in Health Services domains of evidence, context, and facilitation. Results showed how reduced leadership support and low receptivity to providing DBT skills groups functioned as barriers and also identified a barrier not described earlier in the literature: the perception that this group could conflict with expanding access to care for more veterans. The results showed how leadership supported implementation, including by mapping clinic grids and supporting training, and also revealed how a supportive culture among providers facilitated division of labor between skills group providers, and how offering a treatment that filled a gap in services supported the group. At some sites, a provider with prior DBT experience was instrumental in starting DBT skills groups or developing ongoing training.

CONCLUSIONS

Qualitatively analyzed barriers and facilitators to a group-delivered suicide prevention intervention, DBT skills groups, expanded on quantitative findings on the importance of leadership support, culture, and training as facilitators. Future work implementing DBT skills group as a stand-alone treatment will need to address the barrier of receptivity and perceived barriers about access to care.

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.

Emotional Regulation as a Transdiagnostic Process of Emotional Disorders in Therapy: A Systematic Review and Meta-Analysis

CONTEXT

Several studies have shown that emotional regulation (ER) is a transdiagnostic construct of emotional disorders. Therefore, if therapy improves ER, it would improve psychological distress.

OBJECTIVE

This review assesses and compares the changes in ER due to psychological treatment in different therapies.

METHODS

A systematic review and meta-analysis of RCTs published in the databases PubMed, PsycINFO and Web of Science was performed. It was registered in PROSPERO under the number CRD42023387317. Two independent experts in the field reviewed the articles.

RESULTS

A total of 18 articles met the criteria for inclusion in the review. Analysis of these studies suggests that in unified protocol (UP), cognitive behaviour therapy, dialectical behaviour therapy (DBT) and mindfulness, there is evidence to support that a moderate effect occurs during treatment. Furthermore, in mindfulness and DBT, the effect was moderate in the follow-up period, while in UP, it was high.

LIMITATIONS

Given the heterogeneity of the applied interventions and the methodological limitations found in the reviewed trials, the results should be interpreted with caution.

CONCLUSIONS

UP, cognitive behaviour therapy, DBT and mindfulness can improve ER after therapy, while UP, DBT and mindfulness in the follow-up period. Other therapies, such as SKY or Flotation REST, require more research.

Effects of borderline personality disorder symptoms on dialectical behavior therapy outcomes for eating disorders

Existing literature on the effects of borderline personality disorder (BPD) and eating disorder (ED) comorbidity in terms of clinical presentation and treatment outcome has been limited and inconclusive. The present study examined whether clients with EDs and varying levels of BPD symptoms presented with more severe ED symptoms at admission, and whether they responded to dialectical behavior therapy (DBT)-based treatment. Participants (N = 176) were adults in a DBT-based partial hospitalization program for EDs at an academic medical center. Participants completed self-report measures at admission, 1-month postadmission, discharge, and 6-month follow-up. Results suggested that patients with elevated BPD symptoms at admission had greater ED symptoms during treatment, evidenced by small to moderate effect sizes. However, patients with high BPD symptoms demonstrated steeper declines in binge eating, fasting, and parasuicidal behavior early during treatment compared to patients with low BPD symptoms. Individuals with high BPD symptoms at admission (i.e., probable BPD diagnosis) were as likely to meet remission criteria and relapse as individuals with low BPD symptoms, though this null finding may be influenced by small cell sizes. Our findings also suggest that DBT skills use does not predict changes in symptoms. In sum, our findings suggest that while clients with higher BPD symptoms may improve during DBT-based partial hospitalization, their ED symptoms may remain more severe. Future studies are needed to determine whether adjunctive treatments improve outcomes for clients with EDs and comorbid BPD symptoms in DBT programs and whether skills use quality is a better predictor of ED symptom changes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Feasibility and Efficacy of Intensive Dialectical Behavior Therapy Skills Training in An Outpatient Setting for A Group of Patients with Extensive Care Needs - A Transdiagnostic Approach

PURPOSE

Dialectical behavior therapy (DBT) is a treatment originally developed för chronically suicidal adults. It is common to adapt it by using one specific component, the DBT skills training (DBT-ST) and apply it in a group therapy setting for a variety of mental disorders. The primary aim of the study was to explore whether patients with extended care needs would report improved mental health after participating in an intensive form of DBT-ST. The secondary aim was to explore whether the use of psychiatric inpatient care for the group would decrease.

METHODS

Thirty-seven participants completed the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM), and visual analogue scale (VAS) at three time points: pre-intervention, post-intervention and at 6-month follow-up after intensive DBT-ST.

RESULTS

One-way ANOVA showed a significant effect for time on the CORE-OM: F (2,35) = 7.93, p = .001, η2 = 0.312 (large effect size). Post hoc tests indicated a significant difference between pre-intervention and post-intervention (p = .001) and between pre-intervention and follow-up (p = .01). A Friedman test indicated a statistically significant difference in the VAS scale scores across the three time points, with p-values between 0.00 and 0.05. There was no difference in psychiatric healthcare consumption.

CONCLUSION

These study results confirm to some extent the feasibility and effectiveness of the intensive DBT-ST in a transdiagnostic clinical setting. The participants had a positive outcome from the skills training program, but psychiatric healthcare consumption did not decrease.

Drug use and suicidal ideation in the daily lives of individuals in a dialectical behavior therapy program

OBJECTIVES

Substance use disorders and borderline personality disorders (BPD) often co-occur and may be concurrently treated by Dialectical Behavior Therapy (DBT). However, there is limited information on how drug use and suicidal ideation may interact in the daily lives of individuals receiving DBT treatment.

METHODS

This study examined the DBT diary cards of 47 individuals in a community mental health center's partial hospital and intensive outpatient program. Multilevel modeling techniques were used to examine the moderating effects of BPD symptom severity on the relationship between same day, 1-, 2-, and 3-day lagged drug use and suicidal ideation.

RESULTS

Results indicated a significant relationship between same-day, 1-day lagged, 2-day lagged drug use and suicidal ideation. BPD was a moderator for the relationship between 1-day lagged drug use and suicidal ideation.

CONCLUSION

Limitations of the study include the measure for BPD symptom severity was only collected pretreatment and the results are likely limited to the effects of cannabis use on suicidal ideation. Clinicians may need to consider the prolonged effects of drug use on suicidal ideation when conducting chain analyses on suicidal behaviors.

Dialectical Behavior Therapy in Juvenile Correctional and Detention Facilities: A Scoping Review

Dialectical behavior therapy (DBT) has shown preliminary success in the treatment of youth in forensic settings. However, the implementation of DBT varies considerably from facility to facility. A scoping review was conducted to detail DBT intervention protocols in juvenile correctional and detention facilities. We described eight works' treatment setting, study design, youth characteristics, staff training, DBT approach, DBT skills modules, and main findings. All works involved DBT skills sessions, but few incorporated other DBT components such as individual therapy or skills coaching. Outcomes included reducing problematic behaviors such as aggression, improving mental health, and largely positive feedback regarding the DBT intervention from youth and staff. Our results consolidate the existing literature regarding DBT intervention in forensic settings for youth and inform future implementation and research of DBT in such facilities.

Effectiveness of adolescent identity treatment (AIT) versus DBT-a for the treatment of adolescent borderline personality disorder

Borderline personality disorder (BPD) is among the most severe mental health problems with long-lasting deterioration of functioning. According to a Cochrane review, evidence for methods focused on treatment for adolescent BPD patients is very limited. Aims of the study were to demonstrate the noninferiority of adolescent identity treatment (AIT) compared with dialectical behavior therapy for adolescents (DBT-A), and that intensive early treatment of BPD leads to significant improvement of psychosocial and personality functioning in adolescent patients. In a nonrandomized controlled trial using a noninferiority approach, we compared 37 patients treated with DBT-A with 23 patients treated with AIT. Both treatments included 25 weekly individual psychotherapy sessions and five to eight family sessions. Patients were assessed at four timepoints: baseline, posttreatment, 1- and 2-year follow-up. Primary outcome was psychosocial functioning at 1-year follow-up. We performed both intention-to-treat analyses and per-protocol analyses (completers). Baseline characteristics of both groups were not significantly different except for age and self-injurious behavior. In all, six AIT patients (26%) and 10 DBT-A patients (27%) dropped out of treatment. Both DBT-A and AIT significantly improved adolescents' psychosocial functioning (AIT: d = 1.82; DBT-A: d = 1.73) and personality functioning. BPD criteria and depression were significantly reduced by both treatments. Overall, AIT was found to be not inferior to DBT-A and even more efficient in reducing BPD criteria. Both treatments are highly effective in improving psychosocial functioning and personality functioning in adolescent BPD patients. AIT is a promising approach and not inferior to DBT-A in respect to treatment efficiency. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Psychotherapeutic interventions for the prevention of suicide re-attempts: a systematic review

A history of suicide attempt (SA) is a strong predictor of future suicide re-attempts or suicide. The aim of this systematic review is to evaluate the efficacy of psychotherapeutic interventions specifically designed for the prevention of suicide re-attempts. A systematic search from 1980 to June 2020 was performed via the databases PubMed and Google Scholar. Only randomized controlled trials were included which clearly differentiated suicidal self-harm from non-suicidal self-injury in terms of intent to die. Moreover, psychotherapeutic interventions had to be focused on suicidal behaviour and the numbers of suicide re-attempts had to be used as outcome variables. By this procedure, 18 studies were identified. Statistical comparison of all studies revealed that psychotherapeutic interventions in general were significantly more efficacious than control conditions in reducing the risk of future suicidal behaviour nearly by a third. Separate analyses revealed that cognitive-behavioural therapy as well as two different psychodynamic approaches were significantly more efficacious than control conditions. Dialectical behaviour therapy and elementary problem-solving therapy were not superior to control conditions in reducing the number of SAs. However, methodological reasons may explain to some extent these negative results. Considering the great significance of suicidal behaviour, there is unquestionably an urgent need for further development of psychotherapeutic techniques for the prevention of suicide re-attempts. Based on the encouraging results of this systematic review, it can be assumed that laying the focus on suicidal episodes might be the key intervention for preventing suicide re-attempts and suicides.

Efficacy of dialectical behavior therapy for adolescent self-harm and suicidal ideation: a systematic review and meta-analysis

BACKGROUND

Given the widespread nature and clinical consequences of self-harm and suicidal ideation among adolescents, establishing the efficacy of developmentally appropriate treatments that reduce both self-harm and suicidal ideation in the context of broader adolescent psychopathology is critical.

METHODS

We conducted a systematic review and meta-analysis of the Dialectical Behaviour Therapy for Adolescents (DBT-A) literature on treating self-injury in adolescents (12-19 years). We searched for eligible trials and treatment evaluations published prior to July 2020 in MEDLINE/PubMed, Scopus, Google Scholar, EMBASE, and the Cochrane Library databases for clinical trials. Twenty-one studies were identified [five randomized-controlled trials (RCTs), three controlled clinical trials (CCTs), and 13 pre-post evaluations]. We extracted data for predefined primary (self-harm, suicidal ideation) and secondary outcomes (borderline personality symptoms; BPD) and calculated treatment effects for RCTs/CCTs and pre-post evaluations. This meta-analysis was pre-registered with OSF: osf.io/v83e7.

RESULTS

Overall, the studies comprised 1673 adolescents. Compared to control groups, DBT-A showed small to moderate effects for reducing self-harm (g = -0.44; 95% CI -0.81 to -0.07) and suicidal ideation (g = -0.31, 95% CI -0.52 to -0.09). Pre-post evaluations suggested large effects for all outcomes (self-harm: g = -0.98, 95% CI -1.15 to -0.81; suicidal ideation: g = -1.16, 95% CI -1.51 to -0.80; BPD symptoms: g = -0.97, 95% CI -1.31 to -0.63).

CONCLUSIONS

DBT-A appears to be a valuable treatment in reducing both adolescent self-harm and suicidal ideation. However, evidence that DBT-A reduces BPD symptoms was only found in pre-post evaluations.

Interventions for self-harm in children and adolescents

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most countries, often repeated, and associated with suicide. Evidence assessing the effectiveness of interventions in the treatment of SH in children and adolescents is lacking, especially when compared with the evidence for psychosocial interventions in adults. This review therefore updates a previous Cochrane Review (last published in 2015) on the role of interventions for SH in children and adolescents.

OBJECTIVES

To assess the effects of psychosocial interventions or pharmacological agents or natural products for SH compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator, placebo, alternative pharmacological treatment, or a combination of these) for children and adolescents (up to 18 years of age) who engage in SH.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Specialized Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic Reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing specific psychosocial interventions or pharmacological agents or natural products with treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, placebo, alternative pharmacological treatment, or a combination of these, in children and adolescents with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide.

DATA COLLECTION AND ANALYSIS

We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence internals (CIs). For continuous outcomes, we calculated the mean difference (MD) or standardised mean difference (SMD) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach.

MAIN RESULTS

We included data from 17 trials with a total of 2280 participants. Participants in these trials were predominately female (87.6%) with a mean age of 14.7 years (standard deviation (SD) 1.5 years). The trials included in this review investigated the effectiveness of various forms of psychosocial interventions. None of the included trials evaluated the effectiveness of pharmacological agents in this clinical population. There was a lower rate of SH repetition for DBT-A (30%) as compared to TAU, EUC, or alternative psychotherapy (43%) on repetition of SH at post-intervention in four trials (OR 0.46, 95% CI 0.26 to 0.82; N = 270; k = 4; high-certainty evidence). There may be no evidence of a difference for individual cognitive behavioural therapy (CBT)-based psychotherapy and TAU for repetition of SH at post-intervention (OR 0.93, 95% CI 0.12 to 7.24; N = 51; k = 2; low-certainty evidence). We are uncertain whether mentalisation based therapy for adolescents (MBT-A) reduces repetition of SH at post-intervention as compared to TAU (OR 0.70, 95% CI 0.06 to 8.46; N = 85; k = 2; very low-certainty evidence). Heterogeneity for this outcome was substantial ( I² = 68%). There is probably no evidence of a difference between family therapy and either TAU or EUC on repetition of SH at post-intervention (OR 1.00, 95% CI 0.49 to 2.07; N = 191; k = 2; moderate-certainty evidence). However, there was no evidence of a difference for compliance enhancement approaches on repetition of SH by the six-month follow-up assessment, for group-based psychotherapy at the six- or 12-month follow-up assessments, for a remote contact intervention (emergency cards) at the 12-month assessment, or for therapeutic assessment at the 12- or 24-month follow-up assessments.

AUTHORS' CONCLUSIONS

Given the moderate or very low quality of the available evidence, and the small number of trials identified, there is only uncertain evidence regarding a number of psychosocial interventions in children and adolescents who engage in SH. Further evaluation of DBT-A is warranted. Given the evidence for its benefit in adults who engage in SH, individual CBT-based psychotherapy should also be further developed and evaluated in children and adolescents.

A preliminary evaluation of the effectiveness of dialectical behaviour therapy in a forensic psychiatric setting

Dialectical behaviour therapy (DBT) is a therapy model incorporating elements of Eastern philosophies and cognitive behavioural principles. Originally designed for people struggling with chronic suicidality and borderline personality disorder (BPD), it has been adapted to treat complex, multi-diagnostic presentations, such as those in forensic mental health settings. To date, there has been little evaluation when the primary diagnosis is of psychosis. To explore the effectiveness of DBT, with patients, with multiple comorbidities, including psychosis, in a forensic psychiatric inpatient setting. A descriptive outcome study with a cohort of offender-patients in one specialist forensic mental health unit. Before and after treatment change scores were compared on anger, aggression, hopefulness, coping abilities, emotional intelligence, insight and subjective symptom severity scales, as well as staff-rated risk, and length of stay. Nine men and five women residents in one Canadian secure hospital completed a standard DBT programme, and self-ratings, over about 1 year. Scale scores indicated significantly increased insight and acknowledgment of problems. Apparently increased anger and vengeance scores were clinically associated. Independent staff ratings indicated reductions in risk and most patients achieved early release. This study provides support for extension of the use of DBT to offender-patients with psychosis among the complex mix in their presentation. It suggests that a randomised controlled trial with cost-benefit analysis is warranted, as well as further work, to promote understanding of mechanisms of effectiveness.

Dialectical behaviour therapy v. mentalisation-based therapy for borderline personality disorder

BACKGROUND

Dialectical behaviour therapy (DBT) and mentalisation-based therapy (MBT) are both widely used evidence-based treatments for borderline personality disorder (BPD), yet a head-to-head comparison of outcomes has never been conducted. The present study therefore aimed to compare the clinical outcomes of DBT v. MBT in patients with BPD.

METHODS

A non-randomised comparison of clinical outcomes in N = 90 patients with BPD receiving either DBT or MBT over a 12-month period.

RESULTS

After adjusting for potentially confounding differences between participants, participants receiving DBT reported a significantly steeper decline over time in incidents of self-harm (adjusted IRR = 0.93, 95% CI 0.87-0.99, p = 0.02) and in emotional dysregulation (adjusted β = -1.94, 95% CI -3.37 to -0.51, p < 0.01) than participants receiving MBT. Differences in treatment dropout and use of crisis services were no longer significant after adjusting for confounding, and there were no significant differences in BPD symptoms or interpersonal problems.

CONCLUSIONS

Within this sample of people using specialist personality disorder treatment services, reductions in self-harm and improvements in emotional regulation at 12 months were greater amongst those receiving DBT than amongst those receiving MBT. Experimental studies assessing outcomes beyond 12 months are needed to examine whether these findings represent differences in the clinical effectiveness of these therapies.

Self-injury: Treatment, Assessment, Recovery (STAR): online intervention for adolescent non-suicidal self-injury - study protocol for a randomized controlled trial

BACKGROUND

Non-suicidal self-injury (NSSI) is a clinically significant behavior affecting approximately 18% of adolescents and young adults worldwide. The importance of NSSI is supported by its association with a broad spectrum of mental disorders. Despite its high relevance, evidence-based, specific, time-, and cost-effective treatment approaches are scarce. Cognitive behavioral therapy (CBT) seems effective in reducing the frequency of NSSI in adolescents and young adults. However, young people are often reluctant to seek professional help and effective interventions adressing NSSI are not sufficiently available across all regions of Germany. Research indicates that the majority of youth with risk behavior (including NSSI) prefer technology-based interventions. To date, effective interventions for adolescents and young adults with NSSI that are deliverd online are not available.

METHODS

The present project aims to develop and evaluate an online intervention for adolescents and young adults with NSSI based on the content of a recently evaluated face-to-face short-term program that includes elements of CBT and dialectical behavior therapy (DBT): "The Cutting Down Programme" (CDP). The efficacy of the new online CDP intervention will be tested in a randomized controlled trial (RCT) in which n = 700 youths engaging in repetitive NSSI will participate in either an online psychoeducation (n = 350) or online CDP (n = 350). Within a postline assessment four months after baseline (end of treatment; T1), and follow-up evaluations 12 and 18 months after baseline (follow-ups; T2 and T3), NSSI and comorbid symptoms as well as quality of life will be assessed. It is hypothesized that participants receiving online CDP report a greater reduction in the frequency of NSSI within the last three months at T2 (primary endpoint) compared to those receiving online psychoeducation. Exploratory analyses will focus on predictors of treatment outcome.

DISCUSSION

We report on the development and evaluation of an online intervention for adolescents and young adults engaging in NSSI based on the CDP. If supported by empirical evidence, an online-based intervention for NSSI might help to overcome the limited availability of adequate interventions for youth.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00014623 . Registered on 22 May 2018.

Evaluation of a structured skills training group for adolescents with attention deficit/hyperactivity disorder (ADHD) - study protocol of a randomised controlled trial

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) has a negative impact on several domains of life. However, there is a shortage of evidence-based non-pharmacological treatments for adolescents with ADHD. A structured skills training group (SSTG) based on dialectical behaviour therapy (DBT) has been used in adult patients with ADHD with some promising results, although the treatment has not yet been adapted or evaluated for adolescents with ADHD. This study protocol describes how this treatment was adapted for an adolescent population and how the efficacy of the SSTG will be evaluated using a randomised controlled trial (RCT) design.

METHODS

A sample of 184 adolescents (15-18 years of age) with a diagnosis of ADHD has been recruited from seven child and adolescent psychiatric outpatient units and randomised to either the SSTG or an active control group based on psychoeducation. Measures are conducted weekly during the treatment, as well as 2 weeks before treatment and 2 weeks and 6 months after treatment. The primary outcome measures are ADHD symptoms, functional impairment, quality of life and mindfulness. Secondary outcome measures are symptoms of comorbid psychopathology, perceived stress and sleep problems. This article describes the design, methods and analysis plan for evaluating the efficacy of the SSTG.

DISCUSSION

The study will be the first RCT to examine the acceptability and efficacy of a SSTG based on DBT adapted for adolescents with ADHD. We believe that the study will extend the current knowledge base about psychological treatment for adolescents with ADHD.

TRIAL REGISTRATION

ISRCTN registry ( ISRCTN17366720 ). Retrospectively registered May 112,016.

Dialectical behaviour therapy (DBT) for forensic psychiatric patients: An Italian pilot study

BACKGROUND

Several previous randomised controlled trials of dialectical behaviour therapy (DBT) since Linehan's original have shown that it has an advantage over standard care or other psychological treatments, but focus is usually on suicide-related behaviours, and little is known about its effect with offender-patients.

AIMS

To evaluate DBT with a group of offender-patients in the Italian high intensity therapeutic facilities-the Residenze per l'Esecuzione delle Misure di Sicurezza (REMS), established under the Italian Law 81/2014.

METHODS

Twenty-one male forensic psychiatric in-patients with borderline personality disorder were enrolled and randomly assigned to 12 months of standard DBT together with all the usual REMS treatments (n = 10) or usual REMS treatments alone (n = 11). All participants completed the same pretreatment and posttreatment assessments, including the Barratt Impulsiveness Scale (BIS-11), Difficulties in Emotion Regulation Scale (DERS), and Toronto Alexithymia Scale 20 (TAS-20).

RESULTS

Men receiving DBT showed a significantly greater reduction in motor impulsiveness, as measured by the BIS-11, and emotional regulation, as reflected by the DERS total score, than the controls. There were no significant differences between groups in alexithymia scores.

CONCLUSIONS

Italy has innovative forensic psychiatric facilities with a new recovery-rehabilitation approach, but the ambitious goals behind these cannot be achieved by pharmacology alone. For the first time in clinical forensic settings in Italy, there has been limited access to DBT. This small pilot study suggests this is likely to help ameliorate traits associated with violent and antisocial behaviours, so a full-scale randomised controlled trial should follow.

On the potential for iatrogenic effects of psychiatric crisis services: The example of dialectical behavior therapy for adult women with borderline personality disorder

OBJECTIVE

Although previous research has suggested that people with a history of using psychiatric crisis services are at higher risk for suicide, it is unclear whether this link is attributable to individual risk factors or iatrogenic effects of service utilization. We examined this question by analyzing data from a randomized controlled trial of dialectical behavior therapy (DBT), a treatment for highly suicidal individuals in which patients took advantage of crisis services less than those in the comparison condition. We hypothesized that crisis-service utilization during a treatment year, rather than pretreatment indicators of suicide risk, would be associated with higher suicide risk after treatment, and that DBT's treatment effects would be partially attributable to this association.

METHOD

Participants were 101 women (Mage = 29.3, 87% Caucasian) with recent suicidal and self-injurious behaviors meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994) criteria for borderline personality disorder. We examined relationships between suicidal ideation (using the Suicide Behaviors Questionnaire; Linehan, 1981), number of suicide attempts (using the Suicide Attempt Self-Injury Interview; Linehan, Comtois, Brown, Heard, & Wagner, 2006), and number of psychiatric inpatient admissions and psychiatric emergency-room (ER) visits (using the Treatment History Interview; Linehan & Heard, 1987) from the years prior to, during, and following treatment.

RESULTS

Treatment-year psychiatric ER visits were the sole predictor of the number of follow-up year suicide attempts. Treatment condition and pretreatment inpatient admissions predicted treatment-year psychiatric ER visits. Finally, there was evidence that DBT resulted in fewer suicide attempts at follow-up, in part because getting DBT led to fewer psychiatric ER visits.

CONCLUSION

In this population and context, data suggest that crisis-service utilization conveys risk for suicide. DBT may reduce suicide risk in part by reducing use of these services. (PsycINFO Database Record

Beginning to envision a life worth living: An introduction to pretreatment sessions in dialectical behavior therapy

The pretreatment phase in dialectical behavior therapy (DBT) sets the critical foundation for working with multiproblem, often highly suicidal clients. Despite the importance of this stage of treatment, very little has been written to aid DBT clinicians in navigating these early sessions most effectively. This article describes the functions and goals of pretreatment in DBT and research relevant to strategies employed in pretreatment. Additionally, a case example of a pretreatment session in DBT is provided, and challenges commonly encountered in pretreatment are discussed, along with recommendations for overcoming those challenges. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Evaluation of a Dialectical Behavior Therapy Psychiatry Residency Training Program

OBJECTIVE

Dialectical behavior therapy (DBT) is a widely disseminated evidence-based treatment for patients with borderline personality disorder (BPD). This evaluation of a community psychiatry residency rotation compared a DBT training program to a standard care training program to determine the levels of confidence in treating patients with BPD, willingness to treat patients with BPD, and attitudes towards this patient population.

METHODS

Participants were 57 psychiatry residents who completed a 3-month community psychiatry rotation in a DBT clinic (N = 33), or standard care clinic (N = 24) based in a partial hospitalization program in a community mental health center. A mixed method design was used to collect qualitative and quantitative data on participants' experiences working with BPD and patients at high-risk for suicide. Participants were asked several open-ended questions to determine what aspect of their community psychiatry rotation influenced their level of confidence in treating, and willingness to treat BPD, non-suicidal self-injurious behaviors, and suicidal behaviors.

RESULTS

Compared to training in the standard care condition, the DBT condition demonstrated significantly higher rates of willingness to treat, and confidence in treating patients with BPD, and confidence in treating non-suicidal self-injury. There were no significant differences between the two conditions in the level of confidence in treating suicidal patients. Four themes emerged from a qualitative content analysis examining the benefits of the training program, including (1) exposure to high-risk patients, (2) team-based treatment structure, (3) formal didactic training, and (4) individual or group supervision.

CONCLUSION

Participants receiving DBT training had more willingness to treat and confidence in treating patients with BPD compared to participants receiving training in the standard care clinic. Team-based structure of DBT and exposure to high-risk patients were two themes from the training that impacted these variables across both study arms, according to participant self-report. Internal validity of the study was limited by the lack of randomization and pre-post design. External validity of the study was strengthened due to the setting of a community mental health clinic and resident training program.

Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk for Suicide: A Randomized Clinical Trial

Importance

Suicide is a leading cause of death among 10- to 24-year-old individuals in the United States; evidence on effective treatment for adolescents who engage in suicidal and self-harm behaviors is limited.

Objective

To evaluate the efficacy of dialectical behavior therapy (DBT) compared with individual and group supportive therapy (IGST) for reducing suicide attempts, nonsuicidal self-injury, and overall self-harm among high-risk youths.

Design, Setting, and Participants

This randomized clinical trial was conducted from January 1, 2012, through August 31, 2014, at 4 academic medical centers. A total of 173 participants (pool of 195; 22 withdrew or were excluded) 12 to 18 years of age with a prior lifetime suicide attempt (≥3 prior self-harm episodes, suicidal ideation, or emotional dysregulation) were studied. Adaptive randomization balanced participants across conditions within sites based on age, number of prior suicide attempts, and psychotropic medication use. Participants were followed up for 1 year.

Interventions

Study participants were randomly assigned to DBT or IGST. Treatment duration was 6 months. Both groups had weekly individual and group psychotherapy, therapist consultation meetings, and parent contact as needed.

Main Outcomes and Measures

A priori planned outcomes were suicide attempts, nonsuicidal self-injury, and total self-harm assessed using the Suicide Attempt Self-Injury Interview.

Results

A total of 173 adolescents (163 [94.8%] female and 97 [56.4%] white; mean [SD] age, 14.89 [1.47] years) were studied. Significant advantages were found for DBT on all primary outcomes after treatment: suicide attempts (65 [90.3%] of 72 receiving DBT vs 51 [78.9%] of 65 receiving IGST with no suicide attempts; odds ratio [OR], 0.30; 95% CI, 0.10-0.91), nonsuicidal self-injury (41 [56.9%] of 72 receiving DBT vs 26 [40.0%] of 65 receiving IGST with no self-injury; OR, 0.32; 95% CI, 0.13-0.70), and self-harm (39 [54.2%] of 72 receiving DBT vs 24 [36.9%] of 65 receiving IGST with no self-harm; OR, 0.33; 95% CI, 0.14-0.78). Rates of self-harm decreased through 1-year follow-up. The advantage of DBT decreased, with no statistically significant between-group differences from 6 to 12 months (OR, 0.65; 95% CI, 0.12-3.36; P = .61). Treatment completion rates were higher for DBT (75.6%) than for IGST (55.2%), but pattern-mixture models indicated that this difference did not informatively affect outcomes.

Conclusions and Relevance

The results of this trial support the efficacy of DBT for reducing self-harm and suicide attempts in highly suicidal self-harming adolescents. On the basis of the criteria of 2 independent trials supporting efficacy, results support DBT as the first well-established, empirically supported treatment for decreasing repeated suicide attempts and self-harm in youths.

Trial Registration

ClinicalTrials.gov Identifier: NCT01528020.

The effectiveness of 6 versus 12-months of dialectical behaviour therapy for borderline personality disorder: the feasibility of a shorter treatment and evaluating responses (FASTER) trial protocol

BACKGROUND

Although Dialectical Behaviour Therapy (DBT) is an evidence-based psychosocial treatment for borderline personality disorder (BPD), the demand for it exceeds available resources. The commonly researched 12-month version of DBT is lengthy; this can pose a barrier to its adoption in many health care settings. Further, there are no data on the optimal length of psychotherapy for BPD. The aim of this study is to examine the clinical and cost-effectiveness of 6 versus 12 months of DBT for chronically suicidal individuals with BPD. A second aim of this study is to determine which patients are as likely to benefit from shorter treatment as from longer treatment.

METHODS/DESIGN

Powered for non-inferiority testing, this two-site single-blind trial involves the random assignment of 240 patients diagnosed with BPD to 6 or 12 months of standard DBT. The primary outcome is the frequency of suicidal or non-suicidal self-injurious episodes. Secondary outcomes include healthcare utilization, psychiatric and emotional symptoms, general and social functioning, and health status. Cost-effectiveness outcomes will include the cost of providing each treatment as well as health care and societal costs (e.g., missed work days and lost productivity). Assessments are scheduled at pretreatment and at 3-month intervals until 24 months.

DISCUSSION

This is the first study to directly examine the dose-effect of psychotherapy for chronically suicidal individuals diagnosed with BPD. Examining both clinical and cost effectiveness in 6 versus 12 months of DBT will produce answers to the question of how much treatment is good enough. Information from this study will help to guide decisions about the allocation of scarce treatment resources and recommendations about the benefits of briefer treatment.

TRIAL REGISTRATION

NCT02387736 . Registered February 20, 2015.

Identifying novel applications of dialectical behavior therapy: considering emotion regulation and parenting

Dialectical behavior therapy (DBT) is an effective treatment for an increasing number of mental disorders. Its increased application to a range of disorders has been prompted by the recognition that DBT targets emotion dysregulation, which is a transdiagnostic feature underlying several forms of psychopathology. More recently, DBT has been used to target additional clinically relevant domains that are outside diagnostically bound categories, such as improving parenting quality as a means of preventing psychopathology in children of parents with psychopathology. As the ability to regulate emotions is critical to parenting, this paper uses the connection between DBT, emotion regulation, and parenting as an illustration of how focusing on mechanistic features by which DBT is effective aids in strategically identifying areas by which DBT may be a highly useful treatment option.