Various DBT Interventions Reduce Suicide Risk
Abstract
Results suggest this form of behavioral therapy often used to treat borderline personality disorder is useful even if it is just partially incorporated, though the full regimen still offers the most potential benefit.
Dialectical behavior therapy (DBT) is a proven approach to help reduce the risk of suicide and self-harm in people with borderline personality disorder.
However, DBT is not a quick-fix solution; it is an intense, multi-component treatment involving weekly individual, group, and telephone-based interventions; DBT requires time, personnel, and resources—three items often in short supply in many a clinic.
“Behavioral therapy can work, but it’s a challenge because there is a shortage of trained therapists in this country who can carry out a full DBT program,” said John Oldham, M.D., the Barbara and Corbin Robertson Jr. Endowed Chair for Personality Disorders at Baylor College of Medicine and senior vice president and chief of staff at the Menninger Clinic in Houston.
Oldham, who chaired the panel that developed APA’s practice guideline for borderline personality disorder in 2001, believes that if clinics could get a better sense of how the two main components of DBT—individual psychotherapy and group-based behavioral skills training—contribute to patient well-being, they could tailor their strategies to make the best use of their resources and personnel.
As published March 25 in JAMA Psychiatry, a clinical study led by Marsha Linehan, Ph.D., a professor of psychology at the University of Washington and the developer of DBT, explored that very question by comparing the effectiveness of three slightly different DBT strategies.
Key Points
Ninety-nine women with borderline personality disorder received one of three DBT programs: (1) standard DBT, including group skills training and individual therapy; (2) DBT-S, which replaced individual therapy with case management; (3) DBT-I, which replaced group skills training with group activities.
All three strategies provided significant improvements in the frequency and severity of suicide attempts, suicidal thoughts, and the use of suicide crisis services.
DBT and DBT-S provided additional improvements in frequency of nonsuicidal self-harm and severity of depression and anxiety during the treatment period.
DBT provided further improvements in retention rate and use of crisis services during the follow-up period.
Bottom Line: A DBT strategy that incorporates either skills training or individual therapy can benefit patients at risk for suicide, though interventions that include skills training may provide more robust improvements than those without.
The first was standard DBT, which included both group skills training and individual therapy; the second was DBT-S, which emphasized skills training by replacing individual therapy with a case manager; the third, DBT-I, replaced group skills training with group activities (like drawing or social outings) to put a focus on the individual therapy.
Ninety-nine women with borderline personality disorder and high suicide risk were randomly divided to receive one of these three treatments for one year, with one year of follow-up.
“Going in, we were sure that standard treatment would be far more effective, but that is not what we found,” said Linehan. “You know you’re a researcher when you don’t find what you were looking for.”
Though some small differences were uncovered among the variations, all three DBT strategies provided strong and similar reductions in the frequency and severity of suicide attempts, suicidal thoughts, and the use of suicide-crisis services.
“This is great news, as it opens up the possibility of making this behavioral therapy more broadly available, at least in some capacity, and that will help a lot of patients,” Oldham told Psychiatric News.
Oldham added that these positive results add more evidence that DBT is a valuable therapy for this emotionally delicate patient group that is at high risk of suicide. “Because of the length of time required, it’s still difficult to get insurance to cover DBT, and we need to keep demonstrating that behavioral therapy is important and it works.”
Skills training did show some advantages in other areas, as patients receiving DBT or DBT-S had fewer incidents of nonsuicidal self-harm compared with DBT-I, as well as slightly better improvements in depression and anxiety during the treatment year (though the DBT-I group did eventually catch up during the follow-up year).
Those differences suggest that skills training can provide a better chance of getting quicker and more comprehensive relief, and it’s a component that shouldn’t be dropped from a DBT regimen, Linehan believes.
As for the DBT and DBT-S programs, while the interventions were associated with similar patient outcomes during the treatment year, Linehan noted that the standard DBT program did have a modest edge in helping patients maintain their health gains during the follow-up year. The patients receiving the standard DBT also had a slightly lower dropout rate.
“We definitely need to replicate these findings in a larger population to see if the results hold up, but at the moment, if I were talking to someone considering DBT, I would tell them to incorporate both the individualized therapy and skills training,” she said.
Linehan added that since the team believed that regular DBT would prove superior, every therapist involved in the study was given the DBT suicide assessment and management protocol as a precaution, and that might have contributed to the similar suicide-related outcomes; it’s another reason further clinical studies for DBT are needed.
This study was supported by a grant from the National Institute of Mental Health. ■
An abstract of “Dialectical Behavior Therapy for High Suicide Risk in Individuals With Borderline Personality Disorder: A Randomized Clinical Trial and Component Analysis” can be accessed here.
