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Original Investigation |

Dialectical Behavior Therapy for High Suicide Risk in Individuals With Borderline Personality Disorder A Randomized Clinical Trial and Component Analysis FREE

Marsha M. Linehan, PhD1; Kathryn E. Korslund, PhD1; Melanie S. Harned, PhD1; Robert J. Gallop, PhD2; Anita Lungu, PhD1; Andrada D. Neacsiu, PhD1,3; Joshua McDavid, MD1,4; Katherine Anne Comtois, PhD1; Angela M. Murray-Gregory, MSW1
[+] Author Affiliations
1Department of Psychology, Behavioral Research and Therapy Clinics, University of Washington, Seattle
2Department of Mathematics, West Chester University, West Chester, Pennsylvania
3Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina
4Department of State, Washington, DC
JAMA Psychiatry. 2015;72(5):475-482. doi:10.1001/jamapsychiatry.2014.3039.
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Published online

Importance  Dialectical behavior therapy (DBT) is an empirically supported treatment for suicidal individuals. However, DBT consists of multiple components, including individual therapy, skills training, telephone coaching, and a therapist consultation team, and little is known about which components are needed to achieve positive outcomes.

Objective  To evaluate the importance of the skills training component of DBT by comparing skills training plus case management (DBT-S), DBT individual therapy plus activities group (DBT-I), and standard DBT which includes skills training and individual therapy.

Design, Setting, and Participants  We performed a single-blind randomized clinical trial from April 24, 2004, through January 26, 2010, involving 1 year of treatment and 1 year of follow-up. Participants included 99 women (mean age, 30.3 years; 69 [71%] white) with borderline personality disorder who had at least 2 suicide attempts and/or nonsuicidal self-injury (NSSI) acts in the last 5 years, an NSSI act or suicide attempt in the 8 weeks before screening, and a suicide attempt in the past year. We used an adaptive randomization procedure to assign participants to each condition. Treatment was delivered from June 3, 2004, through September 29, 2008, in a university-affiliated clinic and community settings by therapists or case managers. Outcomes were evaluated quarterly by blinded assessors. We hypothesized that standard DBT would outperform DBT-S and DBT-I.

Interventions  The study compared standard DBT, DBT-S, and DBT-I. Treatment dose was controlled across conditions, and all treatment providers used the DBT suicide risk assessment and management protocol.

Main Outcomes and Measures  Frequency and severity of suicide attempts and NSSI episodes.

Results  All treatment conditions resulted in similar improvements in the frequency and severity of suicide attempts, suicide ideation, use of crisis services due to suicidality, and reasons for living. Compared with the DBT-I group, interventions that included skills training resulted in greater improvements in the frequency of NSSI acts (F1,85 = 59.1 [P < .001] for standard DBT and F1,85 = 56.3 [P < .001] for DBT-S) and depression (t399 = 1.8 [P = .03] for standard DBT and t399 = 2.9 [P = .004] for DBT-S) during the treatment year. In addition, anxiety significantly improved during the treatment year in standard DBT (t94 = −3.5 [P < .001]) and DBT-S (t94 = −2.6 [P = .01]), but not in DBT-I. Compared with the DBT-I group, the standard DBT group had lower dropout rates from treatment (8 patients [24%] vs 16 patients [48%] [P = .04]), and patients were less likely to use crisis services in follow-up (ED visits, 1 [3%] vs 3 [13%] [P = .02]; psychiatric hospitalizations, 1 [3%] vs 3 [13%] [P = .03]).

Conclusions and Relevance  A variety of DBT interventions with therapists trained in the DBT suicide risk assessment and management protocol are effective for reducing suicide attempts and NSSI episodes. Interventions that include DBT skills training are more effective than DBT without skills training, and standard DBT may be superior in some areas.

Trial Registration  clinicaltrials.gov Identifier: NCT00183651

Figures in this Article

Evidence continues to accumulate supporting the efficacy of standard dialectical behavior therapy (DBT)1 for the treatment of suicidal individuals with borderline personality disorder (BPD). A meta-analysis of 16 studies of DBT for BPD2 found a low overall dropout rate (27.3%) and moderate before-and-after effect sizes for global outcomes as well as suicidal and self-injurious behaviors.The most recent Cochrane review3 concluded that DBT is the only treatment with sufficient replication to be considered evidence based for BPD.

Although DBT is clearly efficacious and increasingly available in practice settings, demand for DBT far exceeds existing resources.4 The multicomponent nature of DBT (individual therapy, group skills training, between-session telephone coaching, and a therapist consultation team) lends itself to dismantling in clinical settings. Group skills training in DBT is frequently offered alone or, in community mental health settings, with standard case management instead of DBT individual therapy. Other clinicians, often those in private practice, offer DBT individual therapy without any DBT group skills training. The relative importance of DBT skills training compared with other DBT components has not been studied directly, and the overarching aim of the present study was to conduct a dismantling study of DBT to evaluate this question. We predicted that standard DBT, including DBT individual therapy and DBT group skills training, would be significantly better than DBT skills training without DBT individual therapy but with manualized case management (DBT-S) and better than DBT individual therapy without DBT skills training but with an activities group (DBT-I) in reducing suicide attempts, nonsuicidal self-injury (NSSI) episodes, inpatient and emergency department (ED) admissions, depression, anxiety, and treatment dropout. We made no predictions for differences between DBT-S and DBT-I.

Study Design

We conducted a 3-arm, single-blind randomized clinical trial from April 24, 2004, through January 26, 2010. A computerized adaptive randomization procedure5 matched participants on age, number of suicide attempts, number of NSSI episodes, psychiatric hospitalizations in the past year, and depression severity. Assessments were conducted before treatment and quarterly during 1 year of treatment and 1 year of follow-up by blinded independent assessors trained by instrument developers or approved trainers (including K.A.C. and A.M.M.-G.) and evaluated as reliable for each instrument. The participant coordinator, who was not blinded to the treatment condition, executed the randomization and collected treatment-related data. Participants were informed of their treatment assignment at the first therapy session. All study procedures were approved by the institutional review board of the University of Washington and were performed at the Behavioral Research and Therapy Clinics and community settings in Seattle. The full study protocol can be found in the trial protocol in Supplement 1. All participants provided written informed consent after the study procedures were explained. The flow of participants through the study is shown in the Figure.

Place holder to copy figure label and caption
Figure.
Participant Flowchart

The CONSORT diagram shows the randomization of participants to standard dialectical behavior therapy (DBT) consisting of individual therapy, group skills training, therapist consultation team, and as-needed between-session telephone coaching; DBT individual therapy (DBT-I) consisting of individual therapists focused on helping patients use the skills they already have; and skills training DBT (DBT-S) consisting of group skills training while removing the individual therapy component.

Graphic Jump Location
Participants

Participants were 99 women aged 18 to 60 years who met criteria for BPD on the International Personality Disorder Examination6 and the Structured Clinical Interview for DSM-IV, Axis II7 and had at least 2 suicide attempts and/or NSSI episodes in the past 5 years, at least 1 suicide attempt or NSSI act in the 8-week period before entering the study, and at least 1 suicide attempt in the past year. Owing to recruitment difficulties, inclusion criteria were relaxed late in the study, which allowed 1 participant to enter who had a suicide attempt in the 8 weeks before the study but no additional NSSI episodes and 5 participants to enter who met the recurrent NSSI criteria but did not have a suicide attempt in the past year. Individuals were excluded if they had an IQ score of less than 70 on the Peabody Picture Vocabulary Test–Revised8; met criteria for current psychotic or bipolar disorders on the Structured Clinical Interview for DSM-IV, Axis I9; had a seizure disorder requiring medication; or required primary treatment for another life-threatening condition (eg, severe anorexia nervosa). Recruitment was via outreach to health care practitioners.

Measures

The Suicide Attempt Self-injury Interview10 measured the frequency, intent, and medical severity of suicide attempts and NSSI acts. The Suicidal Behaviors Questionnaire11 assessed suicide ideation. The importance of reasons for living was assessed with the Reasons for Living Inventory.12 Use of crisis services and psychotropic medications was assessed via the Treatment History Interview (M.M.L., unpublished data, 1987), which has been shown to have high (90%) agreement with hospital records. The severity of depression and anxiety was assessed via the Hamilton Rating Scale for Depression13 and Hamilton Rating Scale for Anxiety.14

Therapists

Therapists who delivered individual DBT (n = 15), DBT group therapists (n = 3), and case managers (n = 5) did not differ by sex (17 female [74%]) or clinical experience (18 [78%] had received their degree <10 years earlier). Fifteen therapists delivering individual DBT (93%) had a doctoral degree compared with 1 therapist delivering group DBT (33%) and none of the case managers (χ22 = 15.9 [P < .001]). Therapists and case managers were trained independently and monitored by experts in their respective interventions. A licensed psychiatric nurse practitioner provided psychotropic medications under the supervision of a psychiatrist.

Treatments

A detailed description of the treatment conditions and associated protocols is provided in Table 1. The DBT Adherence Scale (M.M.L. and K.E.K, unpublished data, 2003) was used to code randomly selected DBT individual and group therapy sessions, and 10% of the coded sessions were evaluated for interrater reliability (intraclass correlation, 0.93).

Table Graphic Jump LocationTable 1.  Components of the Study Treatment Conditions
Standard DBT

Standard DBT1,15,16 is a comprehensive multicomponent intervention designed to treat individuals at high risk for suicide who meet criteria for multiple disorders. Standard DBT is divided into the following 4 weekly components: individual therapy, group skills training, therapist consultation team, and as-needed between-session telephone coaching. Strategies drawn from cognitive and behavioral interventions (eg, behavioral assessment, contingency management, exposure, cognitive restructuring, and skills training), dialectics, and the radical acceptance practices of validation and mindfulness are used across all 4 DBT components, as are an array of DBT protocol-based suicide interventions, including use of the Linehan Suicide Risk Assessment and Management Protocol (LRAMP).17

DBT Skills Training

The DBT skills training condition (DBT-S) was designed to evaluate the effect of DBT skills training by providing DBT group skills training while removing the DBT individual therapy component. To control for treatment dose and to ensure crisis and suicide management, individual therapy was replaced by a manualized case management intervention.18 Case management followed a strengths-based needs assessment model and involved finding resources, providing information, managing suicidal crises, and assisting with solving problems.

DBT Individual Therapy

The DBT individual therapy condition (DBT-I) was designed to eliminate all DBT skills training from the treatment by removing group skills training and prohibiting individual therapists from teaching DBT skills. Instead, individual therapists focused on helping patients use the skills they already had and only offered suggestions, using standard behavioral vocabulary, when patients were unable to generate their own solutions. To control for treatment dose, an activity-based support group was added and delivered by case managers that included psychoeducation and activities commonly used in recreational and activity therapy (eg, drawing, movies, or social outings).

Statistical Analysis

Primary outcome analyses implemented mixed-effects modeling, including mixed-model analysis of variance for nonlinear data,19 hierarchical linear models for linear data,20 zero-inflated negative binomial models for outcomes with a preponderance of zeroes,21 and generalized linear mixed models for binary outcomes.22 Pairwise contrasts from the mixed-effects models were used to evaluate between-group differences. Pattern-mixture models were used to assess whether estimates in the mixed-effects models were dependent on missing data patterns. For the time to events outcomes, survival curves using the Cox proportional hazards model with censoring for patients who were lost to or unavailable for follow-up or who never achieved the event of interest were used. Cross-sectional comparisons were conducted using analysis of variance, Kruskal-Wallis tests, and χ2 tests. The study was powered for 1-tailed tests to demonstrate superiority of standard DBT to each of the component treatment conditions. Therefore, all predicted differences were tested with 1-tailed tests, and exploratory analyses comparing DBT-S and DBT-I were conducted with 2-tailed tests. With a sample size of 33 per condition, we estimated 83% power to detect a 1-tailed difference on the primary outcomes of suicide attempts and NSSI acts with an effect size of 0.55.

Treatment Dropout, Implementation, and Adherence

The treatment groups did not differ significantly on pretreatment characteristics (Table 2). As shown in Table 3, more clients dropped out of treatment in DBT-I than in standard DBT. Time to treatment dropout was more than 2 times faster for DBT-I than for standard DBT (χ21 = 3.7 [P = .03]; hazard ratio, 2.3 [95% CI, 1.1-4.7]). Participants in standard DBT received significantly more individual sessions than those in DBT-S owing to weekly sessions in standard DBT and as-needed sessions in DBT-S. Participants in standard DBT and DBT-S received more group therapy sessions than those in DBT-I owing to the optional nature of group therapy in DBT-I. Participants in standard DBT attended more groups than those in DBT-S owing to trend-level differences in treatment retention. Treatment adherence did not differ between standard DBT and DBT-S for group skills training, but it did differ between standard DBT and DBT-I for individual therapy. We found no between-group differences in use of psychotropic medications.

Table Graphic Jump LocationTable 2.  Baseline Demographic and Diagnostic Characteristicsa
Table Graphic Jump LocationTable 3.  Treatment Dropout, Implementation, and Adherencea
Missing Data Patterns

We found no difference in the rate of dropout from study assessments (standard DBT, 6 participants [18%]; DBT-I, 11 [33%]; and DBT-S, 9 [27%] [P >.15]). No evidence indicated that the findings on any major outcome variable were biased by group differences in missing data.

Outcome Analyses

Results of all outcome analyses are shown in the eTable in Supplement 2. These results indicate that participants experienced significant improvements over time on all outcomes.

Suicide-Related Outcomes

One participant in the standard DBT intervention committed suicide during the study 1.5 years after the individual dropped out of the study treatment. We found no significant differences between groups in the occurrence of any suicide attempt, the mean number of suicide attempts among those who attempted suicide, the occurrence of any NSSI act, the highest medical risk for suicide attempts and NSSI acts, suicide ideation, or reasons for living. Survival analysis also indicated no difference between groups in the time to the first suicide attempt (χ22 = 1.4 [P = .50]). The only significant between-group difference was in the mean number of NSSI acts among participants who engaged in the behavior. Specifically, the frequency of NSSI acts among those engaging in the behavior was significantly higher in DBT-I than in standard DBT (F1,85 = 59.1 [P < .001]) and DBT-S (F1,85 = 56.3 [P < .001]) during the treatment year but not during the follow-up year.

Use of Crisis Services

During the treatment year, we found no differences between groups in the rates of ED visits or hospital admissions for any psychiatric reason. During the follow-up year, fewer participants in the standard DBT group than in the DBT-I group visited an ED for any psychiatric reason (1 [3%] vs 3 [13%]; t72 = 2.0 [P = .02]) or were admitted to a psychiatric hospital for any psychiatric reason (1 [3%] vs 3 [13%]; t72 = 2.0 [P = .03]). We found no differences between groups in the rate of ED visits or hospital admissions for suicidality during the treatment or the follow-up year.

Mental Health Outcomes

During the treatment year, depression improved less in DBT-I than in standard DBT (t399 = 1.8 [P = .03]) and DBT-S (t399 = 2.9 [P = .004]). During the follow-up year, depression improved more in the DBT-I than the standard DBT (t399 = 3.8 [P < .001]) and DBT-S (t399 = 3.1 [P < .01]) groups. The rate of change in anxiety did not significantly differ between groups during the treatment year, although anxiety significantly improved in the standard DBT (t94 = −3.5 [P < .001]) and DBT-S (t94 = −2.6 [P = .01]) groups but not in the DBT-I group (t94 = −0.8 [P = .42]). We found a significant difference between groups in the rate of change in anxiety during the follow-up year, with the DBT-I group improving more than the standard DBT (t94 = 2.5 [P = .01]) and DBT-S (t94 = 2.0 [P = .048]) groups. In sum, the pattern of change was similar for depression and anxiety, with the DBT-I group improving less than the other groups during the treatment year and then catching up during the follow-up year.

The focus of this randomized clinical trial was to determine whether the skills training component of DBT is necessary and/or sufficient to reduce suicidal behaviors and improve other outcomes among individuals at high risk for suicide. To that end, we compared standard DBT, which included DBT group skills training and DBT individual therapy, with a treatment that evaluated DBT group skills training with manualized case management and removed DBT individual therapy (DBT-S) and a treatment that removed DBT skills training by providing only DBT individual therapy with an activities group and prohibited individual therapists from teaching DBT skills (DBT-I). All 3 conditions resulted in significantly reduced suicide attempts, suicide ideation, medical severity of intentional self-injury, use of crisis services owing to suicidality, and improved reasons for living. Contrary to our expectations, standard DBT was not superior to either comparison condition for any suicide-related outcome, and no significant differences were detected between DBT-S and DBT-I. Thus, all 3 versions of DBT were comparably effective at reducing suicidality among individuals at high risk for suicide.

In contrast, findings suggested that DBT interventions that included DBT skills training (standard DBT and DBT-S) were more effective in reducing NSSI acts and improving other mental health problems than a DBT intervention without skills training (DBT-I). Specifically, among patients who engaged in at least 1 episode of NSSI during the treatment year, those with skills training engaged in fewer NSSI acts than those without skills training. Those without skills training were also slower to improve on measures of depression and anxiety during the treatment year. These findings are consistent with research indicating that increasing DBT skills use mediates reductions in NSSI and depression,23 and they suggest that DBT skills training is a necessary component to achieve optimal outcomes in these areas.

Overall, our findings suggest that standard DBT may have several potential benefits compared with both dismantled conditions. Compared with DBT-I, standard DBT was superior in retaining patients in treatment, reducing the frequency of NSSI, improving mental health outcomes during treatment, and reducing ED visits and hospitalizations after treatment. In addition, although not reaching the level of statistical significance, several clinically meaningful differences emerged during the follow-up year between standard DBT and DBT-S. Specifically, during the follow-up year, the rates of suicide attempts, ED visits, and hospitalizations were each 2.0 to 2.4 times lower in the standard DBT than in the DBT-S groups. Together, our findings suggest that standard DBT and DBT-S show advantages over DBT-I during the acute treatment year, and standard DBT may be particularly effective in maintaining gains in the year after treatment.

Several characteristics of our design are important to remember when interpreting these results. First, because we believed that standard DBT would be superior, we were not willing to let someone die by suicide to make a point. Therefore, every treatment provider, including the study pharmacotherapist, was trained in the DBT suicide risk assessment and management protocol (the LRAMP17). Several notable effects resulted from such a decision. First, all practitioners were required to fill out the LRAMP whenever there was an increase in suicidality, a credible suicide threat, or an actual NSSI act or suicide attempt. The impact was to enforce consistent monitoring of suicidality on all treatment providers. Although routine assessment of suicide risk is a critical component of competent care for suicidal individuals,24 it is not the norm among mental health care professionals.25 Moreover, monitoring of behavior inevitably leads to targeting of problem behaviors and, based on our clinical experience, we believe that behaviors monitored and targeted are those most likely to change.

Second, by virtue of training in the LRAMP, treatment providers across conditions had specialized training in the assessment and management of suicidal behavior. Specialized training in suicide management may be a critical factor in the management and reduction of suicidal behaviors. For example, in a study that compared rates of suicide attempts among individuals discharged from inpatient units for suicidality,26 those who continued treatment with their inpatient psychiatrist had higher rates of suicide attempts than those referred to a suicide crisis center. Similarly, in a large study finding no significant differences in suicidality between DBT and an emotion-focused psychodynamic treatment plus medications,27 both conditions were led by experts in suicide interventions.

Third, DBT has always had a strong bias toward having 1 and only 1 practitioner in charge of treatment planning, including managing risk. Therefore, across all conditions, patients believed to be at imminent risk for suicide were referred immediately to their individual treatment provider for risk management. This practice is in contrast to many settings where the treatment providers interacting with the client routinely make independent decisions for or against admission to the ED or the inpatient unit. This procedure combined with DBT’s bias toward outpatient rather than inpatient treatment for suicidality may have been instrumental in keeping ED and inpatient admissions reasonably low. Although we know of no research on this issue to date, hospitalizing suicidal individuals might be iatrogenic rather than therapeutic, as is suggested by the well-documented findings that individuals leaving psychiatric inpatient units have a very high risk of committing suicide in the week and year after discharge.28 To our knowledge, no credible evidence suggests that hospitalization is more effective than outpatient treatment in keeping suicidal individuals alive. The 2 small studies that have compared inpatient with outpatient interventions29,30 found no differences in subsequent suicide or suicide attempts. Furthermore, in several trials,3133 use of crisis services has been significantly lower in DBT than in control conditions, whereas DBT simultaneously achieved a significantly lower rate of suicide attempts and NSSI acts.

Should clinicians shift treatment from standard DBT to DBT-S? Recent data suggest that DBT skills training alone is superior to wait lists (Shelly McMain, PhD, written communication, July 4, 2014) and standard group therapy34 for individuals with BPD. The skills training component of DBT alone has also been shown to be effective across a range of clinical populations, such as individuals with major depression,35 treatment-resistant depression,36 high emotion dysregulation,37 attention-deficit/hyperactivity disorder,38 and eating disorders39,40 and in disabled adults with mental illness.41,42 Our study was not powered to assess equivalence between DBT-S and standard DBT, and equivalence should not be assumed. In addition, dropout rates were particularly high in the DBT-I and DBT-S groups, although the latter did not have a higher dropout rate than the standard DBT group. These high dropout rates together with low power limit our ability to fully interpret our results.

In future studies, examination of the significance of suicide expertise, the LRAMP in particular, and the possible iatrogenic vs therapeutic effects of hospitalization in terms of their effect on suicide-related outcomes will be important. In addition, because therapists could not teach DBT skills within the DBT-I condition, we do not know whether DBT individual therapy without this restriction would look more like standard DBT or DBT-S in terms of outcomes. Furthermore, the differences in dropout rates led to differential treatment doses across conditions, which might have affected the results. More research is needed before strong conclusions can be made as to what is the best DBT intervention for highly suicidal individuals.

Submitted for Publication: August 1, 2014; final revision received October 13, 2014; accepted November 19, 2014.

Corresponding Author: Marsha M. Linehan, PhD, Behavioral Research and Therapy Clinics, Department of Psychology, Box 355915, University of Washington, Seattle, WA 98195 (linehan@u.washington.edu).

Published Online: March 25, 2015. doi:10.1001/jamapsychiatry.2014.3039.

Author Contributions: Drs Harned and Gallop had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Linehan, Korslund, Harned, Comtois.

Acquisition, analysis, or interpretation of data: Linehan, Korslund, Harned, Gallop, Lungu, Neacsiu, McDavid, Murray-Gregory.

Drafting of the manuscript: Linehan, Korslund, Harned, Gallop, Lungu.

Critical revision of the manuscript for important intellectual content: Linehan, Korslund, Harned, Neacsiu, Comtois, McDavid, Murray-Gregory.

Statistical analysis: Linehan, Harned, Gallop, Lungu.

Obtained funding: Linehan, Korslund, Comtois.

Administrative, technical, or material support: Linehan, Korslund, Harned, Lungu, Neacsiu, Murray-Gregory.

Study supervision: Linehan, Korslund, Harned, McDavid.

Conflict of Interest Disclosures: Dr Linehan receives royalties from Guilford Press for books she has written on Dialectical Behavior Therapy (DBT) and from Behavioral Tech, LLC, for DBT training materials she has developed; she owns Behavioral Tech Research, Inc, a company that develops online learning and clinical applications that include products for DBT. Drs Linehan, Korslund, Harned, Neacsiu, and Comtois are compensated for providing DBT training and consultation. No other disclosures were reported.

Funding/Support: This study was supported by grant R01MH034486 from the National Institute of Mental Health for the design and conduct of the study and for collection, management, analysis, and interpretation of the data.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Previous Presentation: Portions of these data were presented at the 44th Annual Convention of the Association for Behavioral and Cognitive Therapies; November 19, 2010; San Francisco, California.

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Large  M, Sharma  S, Cannon  E, Ryan  C, Nielssen  O.  Risk factors for suicide within a year of discharge from psychiatric hospital: a systematic meta-analysis. Aust N Z J Psychiatry. 2011;45(8):619-628.
PubMed   |  Link to Article
van der Sande  R, van Rooijen  L, Buskens  E,  et al.  Intensive in-patient and community intervention versus routine care after attempted suicide: a randomised controlled intervention study. Br J Psychiatry. 1997;171:35-41.
PubMed   |  Link to Article
Waterhouse  J, Platt  S.  General hospital admission in the management of parasuicide: a randomised controlled trial. Br J Psychiatry. 1990;156:236-242.
PubMed   |  Link to Article
Linehan  MM, Armstrong  HE, Suarez  A, Allmon  D, Heard  HL.  Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry. 1991;48(12):1060-1064.
PubMed   |  Link to Article
Linehan  MM, Comtois  KA, Murray  AM,  et al.  Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757-766.
PubMed   |  Link to Article
Barnicot  K, Savill  M, Bhatti  N, Priebe  S.  A pragmatic randomised controlled trial of dialectical behaviour therapy: effects on hospitalisation and post-treatment follow-up. Psychother Psychosom. 2014;83(3):192-193.
PubMed   |  Link to Article
Soler  J, Pascual  JC, Tiana  T,  et al.  Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: a 3-month randomised controlled clinical trial. Behav Res Ther. 2009;47(5):353-358.
PubMed   |  Link to Article
Lynch  TR, Morse  JQ, Mendelson  T, Robins  CJ.  Dialectical behavior therapy for depressed older adults: a randomized pilot study. Am J Geriatr Psychiatry. 2003;11(1):33-45.
PubMed   |  Link to Article
Harley  R, Sprich  S, Safren  S, Jacobo  M, Fava  M.  Adaptation of dialectical behavior therapy skills training group for treatment-resistant depression. J Nerv Ment Dis. 2008;196(2):136-143.
PubMed   |  Link to Article
Neacsiu  AD, Eberle  JE, Kramer  R, Wiesmann  T, Linehan  MM.  Dialectical behavior therapy skills for transdiagnostic emotion dysregulation: a pilot randomized controlled trial. Behav Res Ther. 2014;59:40-51.
PubMed   |  Link to Article
Hirvikoski  T, Waaler  E, Alfredsson  J,  et al.  Reduced ADHD symptoms in adults with ADHD after structured skills training group: results from a randomized controlled trial. Behav Res Ther. 2011;49(3):175-185.
PubMed   |  Link to Article
Telch  CF, Agras  WS, Linehan  MM.  Dialectical behavior therapy for binge eating disorder. J Consult Clin Psychol. 2001;69(6):1061-1065.
PubMed   |  Link to Article
Safer  DL, Robinson  AH, Jo  B.  Outcome from a randomized controlled trial of group therapy for binge eating disorder: comparing dialectical behavior therapy adapted for binge eating to an active comparison group therapy [published correction appears in Behav Ther. 2010;41(3):432]. Behav Ther. 2010;41(1):106-120.
PubMed   |  Link to Article
Koons  CR, Chapman  AL, Betts  BB, O'Rourke  B, Morse  N, Robins  CJ.  Dialectical behavior therapy adapted for the vocational rehabilitation of significantly disabled mentally ill adults. Cognit Behav Pract. 2006;13(2):146-156.
Link to Article
Valentine  SE, Bankoff  SM, Poulin  RM, Reidler  EB, Pantalone  DW.  The use of dialectical behavior therapy skills training as stand-alone treatment: a systematic review of the treatment outcome literature. J Clin Psychol. 2015;71(1):1-20.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Participant Flowchart

The CONSORT diagram shows the randomization of participants to standard dialectical behavior therapy (DBT) consisting of individual therapy, group skills training, therapist consultation team, and as-needed between-session telephone coaching; DBT individual therapy (DBT-I) consisting of individual therapists focused on helping patients use the skills they already have; and skills training DBT (DBT-S) consisting of group skills training while removing the individual therapy component.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1.  Components of the Study Treatment Conditions
Table Graphic Jump LocationTable 2.  Baseline Demographic and Diagnostic Characteristicsa
Table Graphic Jump LocationTable 3.  Treatment Dropout, Implementation, and Adherencea

References

Linehan  MM. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, NY: Guilford Press; 1993.
Kliem  S, Kröger  C, Kosfelder  J.  Dialectical behavior therapy for borderline personality disorder: a meta-analysis using mixed-effects modeling. J Consult Clin Psychol. 2010;78(6):936-951.
PubMed   |  Link to Article
Stoffers  JM, Vollm  BA, Rucker  G, Timmer  A, Huband  N, Lieb  K.  Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2012;8:CD005652.
PubMed
Swenson  CR.  How can we account for DBT's widespread popularity? Clin Psychol Sci Pract. 2000;7(1):87-91.
Link to Article
White  SJ, Freedman  LS.  Allocation of patients to treatment groups in a controlled clinical study. Br J Cancer. 1978;37(5):849-857.
PubMed   |  Link to Article
Loranger  AW. International Personality Disorder Examination (IPDE) Manual. White Plains, NY: Cornell Medical Center; 1995.
First  MB, Spitzer  RL, Gibbons  M, Williams  JBW, Benjamin  L. User’s Guide for the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). New York: Biometrics Research Dept, New York State Psychiatric Institute; 1996.
Dunn  LM. Peabody Picture Vocabulary Test–Revised. Circle Pines, MN: American Guidance Service; 1981.
First  MB, Spitzer  RL, Gibbon  M, Williams  JBW. Structured Clinical Interview for Axis I DSM-IV Disorders–Patient Edition (SCID-I/P). New York: Biometrics Research Dept, New York State Psychiatric Institute; 1995.
Linehan  MM, Comtois  KA, Brown  MZ, Heard  HL, Wagner  A.  Suicide Attempt Self-injury Interview (SASII): development, reliability, and validity of a scale to assess suicide attempts and intentional self-injury. Psychol Assess. 2006;18(3):303-312.
PubMed   |  Link to Article
Addis  M, Linehan  MM. Predicting suicidal behavior: psychometric properties of the Suicidal Behaviors Questionnaire. Poster presented at: Annual Meeting of the Association for the Advancement Behavior Therapy; November 2-5, 1989; Washington, DC.
Linehan  MM, Goodstein  JL, Nielsen  SL, Chiles  JA.  Reasons for staying alive when you are thinking of killing yourself: the Reasons for Living Inventory. J Consult Clin Psychol. 1983;51(2):276-286.
PubMed   |  Link to Article
Hamilton  M.  A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56-62.
PubMed   |  Link to Article
Hamilton  M.  The assessment of anxiety states by rating. Br J Med Psychol. 1959;32(1):50-55.
PubMed   |  Link to Article
Linehan  MM. DBT Skills Training Manual.2nd ed. New York, NY: Guilford Press; 2014.
Linehan  MM. DBT Skills Training Handouts and Worksheets. New York, NY: Guilford Press; 2014.
Linehan  MM, Comtois  KA, Ward-Ciesielski  EF.  Assessing and managing risk with suicidal individuals. Cognit Behav Pract. 2012;19(2):218-232.
Link to Article
King County Mental Health, Chemical Abuse and Dependency Services. King County mental health plan policies and procedures. Revision 2004-R1. 2015 version. http://www.kingcounty.gov/healthservices/MentalHealth/Policies%20and%20Procedures.aspx. Accessed February 23, 2015.
Khuri  AI, Mathew  T, Sinha  BK. Statistical Tests for Mixed Linear Models. New York, NY: John Wiley & Sons; 1998.
Bryk  AS, Raudenbush  SW. Hierarchical Linear Models: Applications and Data Analysis Methods. Newbury Park, CA: Sage; 1992.
Lambert  D.  Zero-inflated Poisson regression, with an application to defects in manufacturing. Technometrics. 1992;34:1-14.
Link to Article
Stroup  WW. Generalized Linear Mixed Models: Modern Concepts, Methods and Applications. New York, NY: Chapman & Hall/CRC Press; 2012.
Neacsiu  AD, Rizvi  SL, Linehan  MM.  Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder. Behav Res Ther. 2010;48(9):832-839.
PubMed   |  Link to Article
Bongar  B. The Suicidal Patient: Clinical and Legal Standards of Care. Washington, DC: American Psychological Association; 1991.
Coombs  DW, Miller  HL, Alarcon  R, Herlihy  C, Lee  JM, Morrison  DP.  Presuicide attempt communications between parasuicides and consulted caregivers. Suicide Life Threat Behav. 1992;22(3):289-302.
PubMed
Torhorst  A, Möller  HJ, Bürk  F, Kurz  A, Wächtler  C, Lauter  H.  The psychiatric management of parasuicide patients: a controlled clinical study comparing different strategies of outpatient treatment. Crisis. 1987;8(1):53-61.
PubMed
McMain  SF, Links  PS, Gnam  WH,  et al.  A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. Am J Psychiatry. 2009;166(12):1365-1374.
PubMed   |  Link to Article
Large  M, Sharma  S, Cannon  E, Ryan  C, Nielssen  O.  Risk factors for suicide within a year of discharge from psychiatric hospital: a systematic meta-analysis. Aust N Z J Psychiatry. 2011;45(8):619-628.
PubMed   |  Link to Article
van der Sande  R, van Rooijen  L, Buskens  E,  et al.  Intensive in-patient and community intervention versus routine care after attempted suicide: a randomised controlled intervention study. Br J Psychiatry. 1997;171:35-41.
PubMed   |  Link to Article
Waterhouse  J, Platt  S.  General hospital admission in the management of parasuicide: a randomised controlled trial. Br J Psychiatry. 1990;156:236-242.
PubMed   |  Link to Article
Linehan  MM, Armstrong  HE, Suarez  A, Allmon  D, Heard  HL.  Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry. 1991;48(12):1060-1064.
PubMed   |  Link to Article
Linehan  MM, Comtois  KA, Murray  AM,  et al.  Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757-766.
PubMed   |  Link to Article
Barnicot  K, Savill  M, Bhatti  N, Priebe  S.  A pragmatic randomised controlled trial of dialectical behaviour therapy: effects on hospitalisation and post-treatment follow-up. Psychother Psychosom. 2014;83(3):192-193.
PubMed   |  Link to Article
Soler  J, Pascual  JC, Tiana  T,  et al.  Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: a 3-month randomised controlled clinical trial. Behav Res Ther. 2009;47(5):353-358.
PubMed   |  Link to Article
Lynch  TR, Morse  JQ, Mendelson  T, Robins  CJ.  Dialectical behavior therapy for depressed older adults: a randomized pilot study. Am J Geriatr Psychiatry. 2003;11(1):33-45.
PubMed   |  Link to Article
Harley  R, Sprich  S, Safren  S, Jacobo  M, Fava  M.  Adaptation of dialectical behavior therapy skills training group for treatment-resistant depression. J Nerv Ment Dis. 2008;196(2):136-143.
PubMed   |  Link to Article
Neacsiu  AD, Eberle  JE, Kramer  R, Wiesmann  T, Linehan  MM.  Dialectical behavior therapy skills for transdiagnostic emotion dysregulation: a pilot randomized controlled trial. Behav Res Ther. 2014;59:40-51.
PubMed   |  Link to Article
Hirvikoski  T, Waaler  E, Alfredsson  J,  et al.  Reduced ADHD symptoms in adults with ADHD after structured skills training group: results from a randomized controlled trial. Behav Res Ther. 2011;49(3):175-185.
PubMed   |  Link to Article
Telch  CF, Agras  WS, Linehan  MM.  Dialectical behavior therapy for binge eating disorder. J Consult Clin Psychol. 2001;69(6):1061-1065.
PubMed   |  Link to Article
Safer  DL, Robinson  AH, Jo  B.  Outcome from a randomized controlled trial of group therapy for binge eating disorder: comparing dialectical behavior therapy adapted for binge eating to an active comparison group therapy [published correction appears in Behav Ther. 2010;41(3):432]. Behav Ther. 2010;41(1):106-120.
PubMed   |  Link to Article
Koons  CR, Chapman  AL, Betts  BB, O'Rourke  B, Morse  N, Robins  CJ.  Dialectical behavior therapy adapted for the vocational rehabilitation of significantly disabled mentally ill adults. Cognit Behav Pract. 2006;13(2):146-156.
Link to Article
Valentine  SE, Bankoff  SM, Poulin  RM, Reidler  EB, Pantalone  DW.  The use of dialectical behavior therapy skills training as stand-alone treatment: a systematic review of the treatment outcome literature. J Clin Psychol. 2015;71(1):1-20.
PubMed   |  Link to Article

Correspondence

CME


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Is psychiatric hospitalisation suicidogenic?
Posted on April 6, 2015
Matthew M Large, Christopher J Ryan
University of NSW, Australia and University of Sydney, Australia
Conflict of Interest: None Declared

In their recent paper describing a randomized clinical trial of dialectical behavior therapy for people with a high risk of suicide and Borderline Personality Disorder, Linehan and associates observe that there is “no credible evidence” that inpatient treatment is more effective in preventing suicide than outpatient treatment. They then go further to suggest that “hospitalizing suicidal individuals might be iatrogenic rather than therapeutic”[1]. We agree that psychiatric hospitals might be suicidogenic, at least for some people, in some inpatient units. In a recent meta-analysis of rates of inpatient suicide we found very high and highly variable rates of inpatient suicide. We synthesized the data from over 6 million admissions and found a pooled suicide rate of 147 per 100,000 inpatient years. There was an enormous degree of variation between studies in the reported inpatient suicide rates (range 3.6–10489, 1st quartile 98, median 358, 3rd quartile 808) and studies published after 1999 had a higher pooled suicide rate of 646 per 100,000 inpatient years [2]. In our view such dramatic variation in suicide rates is unlikely to be fully explained by differences in patient populations between hospitals and it is likely that hospital related factors contribute significantly. It may be that some inpatient units do not optimally protect patients from suicide or, more worryingly, that the milieu in some institutions is such that some patients, who would not otherwise suicide, are driven to take their own lives. It is usually assumed that the high rate of suicide among inpatients is due to the aggregation of high-risk patients in hospital coupled with our acknowledged inability to prevent some suicides even in the inpatient environment. However, even if this combination accounts for some, or even most, inpatient suicides there is no reason to assume that there are not factors associated with inpatient psychiatric care that directly contribute to the incidence of suicide among inpatients. Suicides due to factors such as the trauma, stigma and loss of liberty and social support as a result of inpatient psychiatric treatment can be termed ‘nosocomial suicides’[3]. We were relieved to see that this uncomfortable idea aired in relation to borderline personality disorder. However, there is a need for more research into the protective and suicidogenic aspects of psychiatric hospitalization more generally and clinicians should be aware of the possibility of doing more harm than good. 

References 

1. Linehan MM, Korslund KE, Harned MS, et al. Dialectical Behavior Therapy for High Suicide Risk in Individuals With Borderline Personality Disorder: A Randomized Clinical Trial and Component Analysis. JAMA Psychiatry. 2015.

2. Walsh G, Sara G, Ryan CJ, Large M. Meta-analysis of suicide rates among psychiatric in-patients. Acta psychiatrica Scandinavica. 2015;131(3):174-184.3. Large M, Ryan C, Walsh G, Stein-Parbury J, Patfield M. Nosocomial suicide. Australasian psychiatry : bulletin of Royal Australian and New Zealand College of Psychiatrists. 2014;22(2):118-121.

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