Trajectories of Treatment Response and Nonresponse in Youth at High Risk for Suicide

Two-year course of non-suicidal self-injury in an adolescent clinical cohort: The role of childhood adversity in interaction with cortisol secretion

AIM

Non-suicidal self-injury (NSSI) is a highly prevalent phenomenon during adolescence. Nonetheless, research on predictors of the clinical course of NSSI over time is still scarce. The present study aimed at investigating the impact of adverse childhood experiences (ACE) and hypothalamus-pituitary-adrenal (HPA) axis functioning on the longitudinal course of NSSI.

METHODS

In a sample of n = 51 help-seeking adolescents engaging in NSSI, diurnal cortisol secretion (CAR, cortisol awakening response; DSL, diurnal slope), hair cortisol concentrations and ACE were assessed at baseline. Clinical outcome was defined by change in the frequency of NSSI in the past 6 months measured 12 and 24 months after the baseline assessments. Mixed-effects linear regression models were used to test for effects of ACE and HPA axis functioning on the course of NSSI.

RESULTS

ACE and HPA axis functioning did not show main but interaction effects in the prediction of NSSI frequency over time: Adolescents with a low severity of ACE and either an increased CAR or a flattened DSL showed a steep decline of NSSI frequency in the first year followed by a subsequent increase of NSSI frequency in the second year.

CONCLUSIONS

Our findings could be interpreted in the sense of high diurnal cortisol concentrations in the absence of ACE being favorable for clinical improvement on the short-term but bearing a risk of allostatic load and subsequent increase of NSSI frequency. In contrast, adolescents with severe ACE may benefit from elevated cortisol concentrations leading to slower but lasting decreases of NSSI frequency.

Remission, Recovery, Relapse, and Recurrence Rates for Suicide Attempts and Nonsuicidal Self-Injury for Suicidal Youth Treated With Dialectical Behavior Therapy or Supportive Therapy

OBJECTIVE

To evaluate rates of remission, recovery, relapse, and recurrence in suicidal youth who participated in a clinical trial comparing Dialectical Behavior Therapy (DBT) and Individual and Group Supportive Therapy (IGST).

METHOD

Participants were 173 youth, aged 12 to 18 years, with repetitive self-harm (including at least 1 prior suicide attempt [SA]) and elevated suicidal ideation (SI). Participants received 6 months of DBT or IGST and were followed for 6 months post-treatment. The sample was 95% female, 56.4% White, and 27.49% Latina. Remission was defined as absence of SA or nonsuicidal self-injury (NSSI) across one 3-month interval; recovery was defined across 2 or more consecutive intervals. Relapse and recurrence were defined as SA or NSSI following remission or recovery. Cross-tabulation with χ2 was used for between-group contrasts.

RESULTS

Over 70% of the sample reported remission of SA at each treatment and follow-up interval. There were significantly higher rates of remission and recovery and lower rates of relapse and recurrence for SA in DBT than for IGST. Across treatments and time points, SA had higher remission and recovery rates and lower relapse and recurrence rates than NSSI. There were no significant differences in NSSI remission between conditions; however, participants receiving DBT had significantly higher NSSI recovery rates than those receiving IGST for the 3- to 9-month, 3- to 12-month, and 6- to 12-month intervals.

CONCLUSION

Results showed higher percentages of SA remission and recovery for DBT as compared to IGST. NSSI was less likely to remit than SA.

PLAIN LANGUAGE SUMMARY

This study examined rates of remission, recovery, relapse, and recurrence of suicide attempts (SA) and nonsuicidal self-injury (NSSI) among the participants in the CARES Study, a randomized clinical trial of 6 months of Dialectical Behavior Therapy or Individual and Group Supportive Therapy. 173 youth aged 12 to 18 years participated in the study and were followed for 6 months post treatment. Over 70% of the sample reported remission of SA at each treatment and follow-up interval. There were significantly higher rates of remission and recovery and lower rates of relapse and recurrence for SA among participants who received Dialectical Behavioral Therapy. Across both treatments, remission and recovery rates were lower and relapse and recurrence rates were higher for NSSI than for SA. These results underscore the value of Dialectical Behavioral Therapy as a first line treatment for youth at high risk for suicide.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants.

CLINICAL TRIAL REGISTRATION INFORMATION

Collaborative Adolescent Research on Emotions and Suicide (CARES); https://www.

CLINICALTRIALS

gov/; NCT01528020.

The role of emotion dysregulation and interpersonal dysfunction in nonsuicidal self-injury during dialectical behavior therapy for borderline personality disorder

Dialectical Behaviour Therapy (DBT) is an evidence-based treatment for borderline personality disorder (BPD), with findings demonstrating improvements in various BPD features and related behaviours, such as nonsuicidal self-injury (NSSI). Theory and research suggest that reductions in emotion dysregulation and interpersonal dysfunction could account for at least some of the reduction in NSSI observed during the course of DBT. The current research investigated: 1) the trajectory of changes in emotion dysregulation, interpersonal dysfunction, and NSSI over the course of DBT, and 2) whether changes in emotion dysregulation mediate the relationship between changes in interpersonal dysfunction and changes in NSSI over treatment. One hundred and twenty individuals with BPD enrolled in a multi-site randomized-clinical trial were assessed at five timepoints over 12 months of standard DBT. Results indicated that interpersonal dysfunction and NSSI decreased over the course of DBT. Emotion dysregulation decreased in a quadratic manner such that most of the gains in emotion dysregulation occurred in earlier phases of DBT. Although changes in interpersonal dysfunction predicted changes in emotion dysregulation, changes in emotion dysregulation did not mediate the relationship between changes in interpersonal dysfunction and changes in NSSI.

Trajectories and Predictors of Change in Emotion Dysregulation and Deliberate Self-Harm Amongst Adolescents with Borderline Features

BACKGROUND

Deliberate self-harm (DSH) and emotion dysregulation (ED) peaks in adolescence, and is associated with an increased risk of psychopathology, suicide and lower functioning in adulthood. DBT-A has been established as an effective treatment for reducing DSH, however less is known about changes in emotion dysregulation. This study aimed to identify baseline predictors of treatment response in outcome trajectories of DSH and emotion dysregulation.

METHODS

Response trajectories of DSH and ED were investigated using Latent Class Analysis on RCT data comparing DBT-A and EUC for 77 adolescents treated for deliberate self-harm and borderline traits. Logistic regression analysis was used to examine baseline predictors.

RESULTS

Two-class solutions were selected for both indicators, distinguishing between early and late responders in DSH, and responders and non-responders in ED. Higher levels of depression, shorter DSH histories and not receiving DBT-A predicted less favourable response in DSH, while DBT-A was the only predictor of treatment response in ED.

CONCLUSIONS

DBT-A was associated with a significantly faster reduction of deliberate self-harm in the short-term and improved emotion regulation in the long-term.

Psychotropic medication use among adolescents participating in three randomized trials of DBT

BACKGROUND

Frequently presenting with symptoms of mood or anxiety disorders, substance abuse or borderline personality disorder, suicidal and self-harming adolescents often are prescribed psychotropic medication. Though such treatment may be warranted, recurrent suicidal and self-harming behaviour is often linked to emotion dysregulation where pharmacological treatment has weak empirical support. There is a need for more clinical research into the frequency, type and rationale for pharmacological treatment in this group. In this secondary analysis of three randomized clinical trials of dialectical behaviour therapy for adolescents, we report on psychotropic medication use in the respective samples at the time of recruitment, compare use of psychotropic medication across trials and describe sample characteristics that may be associated with possible differences in psychotropic medication.

FINDINGS

Trials were conducted in Norway, the US and Spain (labelled the Oslo, US and Barcelona samples). At baseline, 86% of the Barcelona sample, 67% of the US sample and 12% of the Oslo sample were taking at least one psychotropic medication with antidepressants as the most frequent, followed by antipsychotics (72%, 22% and 1.3% respectively) and mood stabilizers (14.2%, 16.2% and 0%). In the Oslo sample there was a significant association between receiving a diagnosis of major depression and the likelihood of receiving antidepressants, but no such association was found in the Barcelona and US samples. The overall 7-8 times higher proportion of participants in the US and Barcelona samples treated with psychotropic medication could only partially be explained by differences between the samples in diagnostic profiles, symptom severity or level of dysfunction.

CONCLUSIONS

Highly prevalent in use among suicidal and self-harming adolescents with borderline features, psychotropic medication was still very unevenly prescribed across trials, differences not explained by differences in sample characteristics suggesting that current treatment practices are not fully empirically supported. We call for continued medical education and increased availability of evidence-based psychosocial interventions.

Systematic Review: Patient Outcomes in Transdiagnostic Adolescent Partial Hospitalization Programs

OBJECTIVE

Partial hospitalization programs (PHPs) are designed to help stabilize patients with acute mental health problems and are considered more cost-effective than inpatient care for patients who do not require 24-hour monitoring. Many PHPs treat transdiagnostic adolescents to reduce suicidality, self-harm, and other high-risk behaviors; however, the effectiveness of such programs is unknown. We aimed to review the existing evidence for the effects of PHPs on adolescent mental health symptoms and functioning.

METHOD

We retrieved peer-reviewed evaluations of PHPs treating adolescents with a range of disorders that reported quantitative clinical outcomes. We followed PRISMA guidelines for systematic reviews and included studies published since 2000.

RESULTS

Fifteen studies of 10 PHPs in North America, Europe, Asia, and Australia met inclusion criteria, 5 of which used comparison groups. Most participants were White and female with depressive disorders. All studies found improvements in adolescents' functioning and mental health from admission to discharge; however, only 1 study tested PHP relative to other levels of care, and only 1 study included follow-up data. Dialectical behavior therapy (DBT) may be an effective theoretical orientation for PHP settings, but evidence is limited.

CONCLUSION

Evidence for effectiveness of PHPs relative to other models is limited. Currently available research suggests that many high-risk transdiagnostic adolescents tend to improve during PHP treatment; however, controlled studies with follow-up data are needed to determine whether partial hospitalization is effective and, if so, how effective, and whether treatment gains persist after discharge.

Frequency and predictors of individual treatment outcomes (response, remission, exacerbation, and relapse) in clinical adolescents with nonsuicidal self-injury

BACKGROUND

Nonsuicidal self-injury (NSSI) is prevalent in adolescent clinical samples. There is evidence that NSSI can be treated effectively but data on individual treatment outcomes is limited. The goal of this study was to examine response, remission, exacerbation, and relapse rates over one and two years, respectively, among a clinical sample of adolescents with NSSI. Furthermore, we aimed to identify clinically relevant predictors of NSSI trajectories.

METHODS

The sample consists of n = 203 adolescents (12-17 y., 94% female) from a specialized outpatient clinic for risk-taking and self-harming behavior with NSSI on at least five days in the six months before first assessment. Assessments were completed at baseline and one (FU1) and two (FU2) years later using structured clinical interviews and self-report questionnaires.

RESULTS

At FU1, 75% reported a reduction in NSSI frequency by at least 50% (treatment response); among those, one third (25% of the entire sample) achieved a remission (0 NSSI); an exacerbation (⩾50% more NSSI) was observed in 11% of patients. Of those in remission, 41% relapsed one year later. Predictors of non-response or non-remission were inpatient treatment and depressive symptoms. Adolescents with lower NSSI frequency at baseline had a higher risk of exacerbation. Due to limited sample size at FU2 no prediction model for relapse was established.

CONCLUSIONS

While most adolescents presenting with NSSI achieved significant improvement, more attention should be paid to the rather low rates of full remission. Prediction and early detection of individuals who deteriorate during or relapse after treatment is critical.

Paved with good intentions: How our systems intersect to create health disparities for multiply marginalized youth

BACKGROUND

Youth who hold multiply marginalized identities often experience barriers in accessing care following psychiatric hospitalization METHODOLOGY: The following commentary piece shares a case amalgamation from a multidisciplinary gender clinic in a tertiary care children's hospital which illustrates the myriad of ways that our current mental healthcare systems fail to connect youth efficiently and effectively to the evidence-based, culturally relevant, and affirming care that they require, particularly youth experiencing overlapping systems of discrimination and disadvantage.

CONCLUSIONS

This piece highlights the inaccessibility of dialectical behavior therapy for multiply marginalized youth, and outlines suggestions for improving access to high-quality care for minoritized youth engaging in suicidal behavior.

Investigating predictors of treatment response in Dialectical Behavior Therapy for borderline personality disorder using LASSO regression

OBJECTIVE

Prior studies of Dialectical Behavior Therapy (DBT) for borderline personality disorder (BPD) have yielded heterogeneous findings on what factors differentiate individuals with or without sufficient treatment response, highlighting the need for further research.

METHOD

We investigated a sample of 105 individuals with BPD receiving a 6-month course of DBT. Participants were categorized as sufficient or insufficient responders using clinical and statistical change indices (based on emotion dysregulation, BPD symptom severity, utilization of DBT skills, and functional impairment). Sociodemographic, clinical severity, and treatment process factors were tested as potential predictors of treatment response using a machine learning approach (LASSO regression).

RESULTS

Two cross-validated LASSO regression models predicted treatment response (AUCs > .75). They suggested that higher homework completion rate, retention in treatment, and greater baseline severity were the most important predictors of DBT treatment response indicated by BPD symptom severity and utilization of DBT skills. Favorable effects of some aspects of therapeutic alliance during initial sessions were also found.

CONCLUSIONS

Future research may benefit from consolidating the criteria of treatment response, identifying clinically relevant variables, and testing the generalizability of findings to enhance knowledge of insufficient treatment response in DBT for BPD.

Editorial: Dialectical Behavior Therapy: More Is Not Always Better When Different Is Required

The study by Berk et al.1 highlights potential trajectories of response and nonresponse to dialectical behavior therapy (DBT) as compared to individual and group supportive therapy (IGST) for teens with repeated self-harm and suicidal ideation. The authors also posit a testable function to predict responsiveness vs nonresponsiveness and provide critical guidance about when to reassess nonresponders and alter treatment. This is the fourth major article from a large federally funded, randomized controlled trial. Previous publications have highlighted superiority of DBT over IGST,2 reported the moderating factors of treatment outcomes,3 and explored the mechanism of effectiveness for DBT in the treatment of suicidal ideation and self-harm.4 These articles provide useful information given the rising rates of suicidal ideation and suicide attempts among youth5 and recent research suggesting the powerful role of social media in supporting contagion of suicidal behavior among youth.