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"Dialectical behavior therapy."
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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.
Journal Article
The effectiveness and safety of dialectical behavior therapy for suicidal ideation and behavior in autistic adults: a pragmatic randomized controlled trial
Many autistic people in mental health are suicidal. This study evaluated the effectiveness of dialectical behavior therapy (DBT)
treatment as usual (TAU) in reducing suicidal ideation and suicide attempts.
At six Dutch mental health centers, 123 outpatients (18-65 years) with DSM-5 diagnosed autism spectrum disorder (ASD) and suicidal behavior were randomly assigned to the DBT intervention group (
= 63) or TAU control group (
= 60). Assessments were conducted at baseline, post-treatment at 6 months and 12-month follow-up. The primary outcomes were severity of suicidal ideation and frequency of suicide attempts. The severity of depression and social anxiety were secondary outcomes.
At end-of-treatment, DBT significantly reduced both suicidal ideation (
= -2.24;
= 0.025;
= -4.41; s.e. = 197.0) and suicide attempts (
= -3.15;
= 0.002;
= 0.046; s.e. = 0.045) compared to TAU, but lost statistical significance at the 12-month follow-up. Depression severity significantly decreased with DBT (
= -1.99;
= 0.046:
= -2.74; s.e. = 1.37) remaining so at 12 months (
= -2.46;
= 0.014;
= -3.37; s.e. = 1.37). No effects were observed on social anxiety. Severe adverse events included two suicides in the TAU condition.
DBT is an acceptable, safe, and short-term effective intervention to reduce suicidal ideation and suicide attempts in autistic adults with suicidal behavior.
Journal Article
Refractory depression – mechanisms and efficacy of radically open dialectical behaviour therapy (RefraMED): findings of a randomised trial on benefits and harms
Individuals with depression often do not respond to medication or psychotherapy. Radically open dialectical behaviour therapy (RO DBT) is a new treatment targeting overcontrolled personality, common in refractory depression.
To compare RO DBT plus treatment as usual (TAU) for refractory depression with TAU alone (trial registration: ISRCTN 85784627).
RO DBT comprised 29 therapy sessions and 27 skills classes over 6 months. Our completed randomised trial evaluated RO DBT for refractory depression over 18 months in three British secondary care centres. Of 250 adult participants, we randomised 162 (65%) to RO DBT. The primary outcome was the Hamilton Rating Scale for Depression (HRSD), assessed masked and analysed by treatment allocated.
After 7 months, immediately following therapy, RO DBT had significantly reduced depressive symptoms by 5.40 points on the HRSD relative to TAU (95% CI 0.94-9.85). After 12 months (primary end-point), the difference of 2.15 points on the HRSD in favour of RO DBT was not significant (95% CI -2.28 to 6.59); nor was that of 1.69 points on the HRSD at 18 months (95% CI -2.84 to 6.22). Throughout RO DBT participants reported significantly better psychological flexibility and emotional coping than controls. However, they reported eight possible serious adverse reactions compared with none in the control group.
The RO DBT group reported significantly lower HRSD scores than the control group after 7 months, but not thereafter. The imbalance in serious adverse reactions was probably because of the controls' limited opportunities to report these.
Journal Article
Is dissociation predicting the efficacy of psychological therapies for PTSD? Results from a randomized controlled trial comparing Dialectical Behavior Therapy for PTSD (DBT-PTSD) and Cognitive Processing Therapy (CPT)
Neuropsychological evidence suggests that dissociation might disturb emotional learning, which is a fundamental mechanism of psychotherapy. However, a recent meta-analysis on the impact of dissociation on treatment outcomes in psychotherapy trials for posttraumatic stress disorder (PTSD) reported inconsistent results and concluded that further high-quality clinical trials are needed to test whether dissociation affects the efficacy of psychotherapies. We had two main aims: First, to test whether the efficacy of two evidence-based psychotherapies for individuals with trauma-related PTSD is affected by the level of pretreatment dissociation. Second, we investigated whether a significant reduction in dissociation at an early stage of treatment is beneficial for subsequent efficacy.
The potential impact of dissociation on efficacy was studied in 193 women with PTSD related to childhood abuse who were randomized to dialectical behavior therapy for PTSD (DBT-PTSD) or cognitive processing therapy (CPT). Efficacy was operationalized as a change in the Clinician-Administered PTSD Scale (CAPS). Dissociation was assessed with the Dissociation Tension Scale (DSS). The analyses accounted for major confounders (in particular initial PTSD severity).
Two main findings emerged from this study. First, baseline dissociation was a negative predictor for treatment efficacy. Second, a significant drop in dissociation at the initial stages of treatment was beneficial for subsequent efficacy.
Dissociation likely reduces the efficacy of trauma-focused therapies. Accordingly, successful reduction of dissociation at an early stage of treatment assists the efficacy of trauma-focused psychotherapies.
Journal Article
Dialectical behaviour therapy v. mentalisation-based therapy for borderline personality disorder
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.
A non-randomised comparison of clinical outcomes in N = 90 patients with BPD receiving either DBT or MBT over a 12-month period.
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.
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.
Journal Article