Dialectical behavior therapy for adolescents with bipolar disorder: results from a pilot randomized trial

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 and Social Rhythm Therapy for Comorbid Bipolar Disorder and Borderline Personality Disorder

Bipolar disorder and borderline personality disorder commonly co-occur. Each disorder is associated with substantial morbidity and mortality, which are worsened by co-occurrence of the disorders. Emotional dysregulation, suicidality, and disrupted circadian rhythm are key aspects of psychopathology associated with both conditions. A novel psychotherapy combining elements of two evidence-based treatments (i.e., dialectical behavior therapy [DBT] for borderline personality disorder and social rhythm therapy [SRT] for bipolar disorder) is described. Unlike either treatment alone, the new therapy, called dialectical behavior and social rhythm therapy (DBSRT), targets all three disease-relevant processes and therefore may represent a promising new approach to treatment for individuals with these two conditions. DBSRT may also have utility for individuals with overlapping characteristics of bipolar disorder and borderline personality disorder or for those whose illness manifestation includes a mix of bipolar and borderline personality disorder traits. Strategies associated with DBSRT are described, and a brief case vignette illustrates its application.

Dialectical Behavior Therapy for Adolescents With Bipolar Disorder: A Randomized Clinical Trial

Importance

Early-onset bipolar disorder conveys substantial risk for suicide. No psychosocial intervention for this population expressly targets suicidal behavior.

Objective

To determine whether dialectical behavior therapy (DBT) for adolescents with bipolar spectrum disorder is more effective than standard of care (SOC) psychotherapy in decreasing suicide attempts over 1 year.

Design, Settings, and Participants

Adolescents aged 12 to 18 years diagnosed with bipolar spectrum disorder were recruited from a specialty outpatient psychiatric clinic between November 2014 and September 2019. Independent evaluators conducted quarterly assessments over 1 year with participants and parents. Data were analyzed from March 2021 to November 2022.

Interventions

Participants were randomly assigned to 1 year of DBT (36 sessions; n = 47) or SOC psychotherapy (schedule clinically determined; n = 53). All youth received medication management via a flexible algorithm.

Main Outcomes and Measures

Primary outcomes included suicide attempts over 1 year and mood symptoms and states (depression and hypomania/mania). Secondary analyses included moderation of DBT effects by history of suicide attempt and mediation through emotion dysregulation.

Results

Of 100 included participants, 85 (85%) were female, and the mean (SD) age was 16.1 (1.6) years. Participants were followed up over a mean (SD) of 47 (14) weeks. Both treatment groups demonstrated significant and similar improvement in mood symptoms and episodes over 1 year (standardized depression rating scale slope, -0.17; 95% CI, -0.31 to -0.03; standardized mania rating scale slope, -0.24; 95% CI, -0.34 to -0.14). DBT and SOC participants reported similar suicide attempt rates at intake as measured on the Adolescent Longitudinal Follow-Up Evaluation (ALIFE; mean [SD] attempts, 2.0 [4.5] vs 1.8 [3.9], respectively; P = .80). DBT participants reported slightly more suicide attempts at intake as measured on the Columbia-Suicide Severity Rating Scale Pediatric Version (C-SSRS; mean [SD] attempts, 1.4 [3.6] vs 0.6 [0.9]; P = .02). DBT participants reported significantly fewer suicide attempts over follow-up compared with SOC participants via the ALIFE (mean [SD] attempts per follow-up period, 0.2 [0.4] vs 1.1 [4.3], controlling for baseline attempts: P = .03) and the C-SSRS (mean [SD] attempts per follow-up period, 0.04 [0.2] vs 0.10 [0.3], controlling for baseline attempts; P = .03). DBT was significantly more effective than SOC psychotherapy at decreasing suicide attempts over 1 year (ALIFE: incidence rate ratio [IRR], 0.32; 95% CI, 0.11-0.96; C-SSRS: IRR, 0.13; 95% CI, 0.02-0.78). Decreased rate of suicide attempts in DBT was moderated by presence of lifetime history of suicide attempt and time (IRR, 0.23; 95% CI, 0.13-0.44) and mediated by improvement in emotion dysregulation (IRR, 0.61; 95% CI, 0.42-0.89), particularly for those with high baseline emotion dysregulation (standardized β, -0.59; 95% CI, -0.92 to -0.26).

Conclusions and Relevance

In this randomized clinical trial, DBT demonstrated efficacy in decreasing suicide attempts among the high-risk population of adolescents with bipolar spectrum disorder.

Trial Registration

ClinicalTrials.gov Identifier: NCT02003690.

Transdiagnostic skills training group of dialectical behavior therapy: a long-term naturalistic study

INTRODUCTION

Dialectical Behavior Therapy (DBT) has assembled a large body of evidence for the treatment of emotional dysregulation in borderline personality disorder (BPD), but also in other disorders characterized by emotional dysregulation (e.g., bipolar disorder (BD) and ADHD). Standalone skills learning groups address the problem of limited resources in several clinical settings. Furthermore, transdiagnostic skills groups facilitate the recruitment and decrease the scattering of resources in psychiatric settings. However, few studies have focused on the pertinence of transdiagnostic standalone skills groups in naturalistic settings as well as their long-term outcomes. The goal of this study is to assess the impact of participation in a transdiagnostic DBT skills group one year after its completion.

METHOD

Transdiagnostic DBT skills training groups were provided for BPD, BD and ADHD patients in a University Psychiatric Department (Strasbourg, France), between 2019 and 2020. They consisted of 16 group sessions of 2.5 h and 3 individual sessions. At 1-year follow-up, ad-hoc questionnaires were proposed to all participants to assess the perceived impacts, the changes in symptomatology, and the maintenance of skills learned.

RESULT

22 of the 31 participants were interviewed at the one-year post-group session (64% BPD, 41% ADHD and 27% BD). 73% participants estimated that group impact was important or very important, 64% stated using the skills learned often or very often, mainly emotion regulation skills. An improvement in emotional instability, substance use, impulsivity and suicidal thoughts was reported by respectively 100%, 91%, 86% and 85% of participants. Quality of life improved according to 90% participants. All patients reported an improvement in suicidality during the post-group year, especially in suicide attempts. Psychotropic medication decreased in 59% of participants.

DISCUSSION

Our one-year naturalistic study suggests that transdiagnostic DBT skills training groups are promising for the treatment of emotional dysregulation in people with BPD, BD and/or ADHD. The observational design and the lack of control group are the main limitations. Randomized controlled studies are required to confirm the long-term efficacy of transdiagnostic skills learning groups in naturalistic settings.

Suicide Assessment and Prevention in Bipolar Disorder: How Current Evidence Can Inform Clinical Practice

Bipolar disorder is associated with a considerable risk of suicide, and this fact must be incorporated into management of all patients with the condition. This article highlights the importance of a more nuanced understanding of the factors associated with the increased risk of suicidal behavior in people diagnosed as having bipolar disorder and interventions that could mitigate it. Several sociodemographic, clinical, environmental, and other variables have been associated with suicide attempts or deaths in bipolar disorder. Youths with bipolar disorder are a particularly vulnerable group, and their trajectory of illness could be modified by early interventions. Several medications have been studied regarding their relationship to suicide risk in bipolar disorder, and interventional psychiatry is a newer area of research focus. Finally, community-based approaches can be incorporated into a comprehensive approach to suicide prevention. This article summarizes the current understanding of key variables that can help inform a clinical risk assessment of individuals and interventions that can be employed in suicide prevention in bipolar disorder.

Review: Adverse event monitoring and reporting in studies of pediatric psychosocial interventions: a systematic review

BACKGROUND

Adverse event monitoring in studies of psychotherapy is crucial to clinical decision-making, particularly for weighing of benefits and harms of treatment approaches. In this systematic review, we identified how adverse events are defined, measured, and reported in studies of psychosocial interventions for children with mental disorders.

METHOD

Medline, PsycINFO, Embase, ProQuest Dissertations and Theses Global, and the Cochrane Library were searched from January 2011-January 2023, and Google Scholar from January 2011-February 2023. English language experimental and quasi-experimental studies that evaluated the efficacy or effectiveness of psychosocial interventions for childhood mental disorders were included. Information on the definition, assessment, and report of adverse events was extracted using a checklist based on Good Clinical Practice guidelines.

RESULTS

In this review, 117 studies were included. Studies most commonly involved treating anxiety disorders or obsessive-compulsive disorder (32/117; 27%); 44% of the experimental interventions tested (52/117) were cognitive behavioral therapies. Adverse events were monitored in 36 studies (36/117; 31%) with a protocol used in 19 of these studies to guide monitoring (19/36; 53%). Twenty-seven different events were monitored across the studies with hospitalization the most frequently monitored (3/36; 8%). Event severity was fully assessed in 6 studies (17%) and partially assessed in 12 studies (33%). Only 4/36 studies (11%) included assessing events for cause.

CONCLUSIONS

To date, adverse events have been inconsistently defined, measured and reported in psychosocial intervention studies of childhood mental health disorders. Information on adverse events is an essential knowledge component for understanding the potential impacts and risks of therapeutic interventions.

Treatment outcomes of Veteran men in a comprehensive dialectical behavior therapy program: Characterizing sex differences in symptom trajectories

Dialectical Behavior Therapy (DBT) is one of the primary psychosocial treatments for reducing suicidal behaviors and improving psychosocial outcomes among patients with borderline personality disorder (BPD) and has been shown to reduce BPD symptoms when delivered in a Veteran Affairs medical center setting. Despite evidence of similar rates of BPD in both men and women, the vast majority of treatment outcome research in BPD has focused on women. We sought to characterize sex differences in symptom trajectories among Veterans participating in a comprehensive DBT program. We found that Veteran men and women who entered the DBT program were diagnostically and demographically similar. Participants exhibited reductions in BPD symptoms and improvements in emotion regulation over the course of treatment. Moreover, Veteran men reported BPD symptom reductions that were not statistically inferior to those of Veteran women and exhibited a sharper reduction in these symptoms. This research provides support for the use of DBT as a psychosocial treatment for Veteran men with BPD symptoms.

Neural correlates of impulsivity in bipolar disorder: A systematic review and clinical implications

Impulsivity is a common feature of bipolar disorder (BD) with ramifications for functional impairment and premature mortality. This PRISMA-guided systematic review aims to integrate findings on the neurocircuitry associated with impulsivity in BD. We searched for functional neuroimaging studies that examined rapid-response impulsivity and choice impulsivity using the Go/No-Go Task, Stop-Signal Task, and Delay Discounting Task. Findings from 33 studies were synthesized with an emphasis on the effect of mood state of the sample and affective salience of the task. Results suggest trait-like brain activation abnormalities in regions implicated in impulsivity that persist across mood states. During rapid-response inhibition, BD exhibit under-activation of key frontal, insular, parietal, cingulate, and thalamic regions, but over-activation of these regions when the task involves emotional stimuli. Delay discounting tasks with functional neuroimaging in BD are lacking, but hyperactivity of orbitofrontal and striatal regions associated with reward hypersensitivity may be related to difficulty delaying gratification. We propose a working model of neurocircuitry dysfunction underlying behavioral impulsivity in BD. Clinical implications and future directions are discussed.

A systematic review on the effectiveness of dialectical behavior therapy for improving mood symptoms in bipolar disorders

BACKGROUND

Evidence-based psychotherapies available to treat patients with bipolar disorders (BD) are limited. Dialectical behavior therapy (DBT) may target several common symptoms of BD. We conducted a systematic review on the efficacy of DBT for mood symptoms in patients with BD. The systematic search used key words related to DBT and BD in Medline, Embase, PsycInfo, CINAHL, and Cochrane Library databases from 1980 to April 1st, 2022. We included studies that enrolled patients with a BD I or II diagnosis (DSM or ICD), age 12 and older who received a DBT-based intervention. Studies reviewed were clinical trials including observational studies that reported at least one outcome related to BD mood symptoms or severity. We did not exclude based upon psychiatric or physical co-morbidity.

RESULTS

We screened 848 abstracts and reviewed 28 full texts; 10 publications with 11 studies met our pre-determined eligibility criteria. All but one were feasibility pilot studies and most included participants in all mood states except for mania. The studies provided preliminary evidence suggesting these interventions may be effective for improving several core symptoms of BD. Overall, all the studies consistently supported that DBT-based interventions are feasible and acceptable for patients with BD.

CONCLUSION

DBT may be an effective treatment for BD; however, the confidence in this conclusion is limited by the small sample sizes, heterogeneity, and high risk of bias in all published trials. Larger well-designed RCTs are now required to establish the effectiveness of DBT in BD.

Clinical correlates of suicidality and self-injurious behaviour among Canadian adolescents with bipolar disorder

There is high risk of suicidality in bipolar disorder (BD), particularly in early onset cases. The literature regarding correlates and putative predictors of suicide attempts (SA), non-suicidal self-injury (NSSI) and suicidal ideation (SI) among youth with BD remains sparse. Participants included 197 adolescents with BD, divided into 4 groups: SA (with or without NSSI), NSSI (with or without SI), SI only, and comparison group (CG; no SA/NSSI/SI). Diagnoses, treatment, and suicidality measures were determined via semi-structured interviews, conducted between 2009 and 2017. Univariate analyses were followed by multinomial regression. Overall, 73.6% of participants had history of SA, NSSI, and/or SI. In comparison to CG, SA and NSSI were each associated with BD-II/-NOS (odds ratio [OR] = 15.99, p = 0.002; OR = 16.76, p = 0.003), female sex (OR = 6.89, p = 0.006; OR = 3.76, p = 0.02), and emotion dysregulation (OR = 1.10, p < 0.001; OR = 1.07, p = 0.004). NSSI and SI were each associated with most severe lifetime depression (OR = 1.10, p = 0.01; OR = 1.10, p = 0.01). SA and SI were associated with psychiatric hospitalization (OR = 19.45, p = 0.001; OR = 6.09, p = 0.03). SA was associated with poorer global functioning at most severe episode (OR = 0.88, p = 0.008). NSSI was associated with not living with both natural parents (OR = 0.22, p = 0.009). Study limitations include cross-sectional and retrospective design, stringent cut-offs for SA and NSSI, and recruitment from a tertiary clinical setting. Three quarters of adolescents with BD have had suicidality and/or self-injury. SA and NSSI were most similar to one another, and most different from CG, supporting the broader construct of self-harm. Future research should address the gap in knowledge regarding how sex differences and neurobiology are associated with the observed clinical differences.

Early Family Intervention for Youth at Risk for Bipolar Disorder: Psychosocial and Neural Mediators of Outcome

BACKGROUND

The impairing neurodevelopmental course of bipolar disorder (BD) suggests the importance of early intervention for youth in the beginning phases of the illness.

OBJECTIVE

We report the results of a 3-site randomized trial of family-focused therapy for youth at high-risk (FFT-HR) for BD, and explore psychosocial and neuroimaging variables as mediators of treatment effects.

METHODS

High-risk youth (<18 years) with major depressive disorder or other specified BD, active mood symptoms, and a family history of BD were randomly assigned to 4 months of FFT-HR (psychoeducation, communication and problem-solving skills training) or 4 months of enhanced care psychoeducation. Adjunctive pharmacotherapy was provided by study psychiatrists. Neuroimaging scans were conducted before and after psychosocial treatments in eligible participants. Independent evaluators interviewed participants every 4-6 months over 1-4 years regarding symptomatic outcomes.

RESULTS

Among 127 youth (mean 13.2 ± 2.6 years) over a median of 98 weeks, FFT-HR was associated with longer intervals prior to new mood episodes and lower levels of suicidal ideation than enhanced care. Reductions in perceived family conflict mediated the effects of psychosocial interventions on the course of mood symptoms. Among 34 participants with pre-/post-treatment fMRI scans, youth in FFT-HR had (a) stronger resting state connectivity between ventrolateral PFC and anterior default mode network, and (b) increased activity of dorsolateral and medial PFC in emotion processing and problem-solving tasks, compared to youth in enhanced care.

CONCLUSION

FFT-HR may delay new mood episodes in symptomatic youth with familial liability to BD. Putative treatment mechanisms include neural adaptations suggestive of improved emotion regulation.

Editorial: Mood Instability: What It Is, Why It Matters, and What to Do About It

Mood instability, defined as frequent, sudden, and unpredictable alterations in irritability, elation/activation, and anxiety/depression, is associated with psychopathology in youth and adults. While transdiagnostic, mood instability has unique associations with bipolar disorder (BD) and can occur inter-episodically.¹ Mood instability is a risk for BD type 1 or type 2 in high-risk individuals.

One-Year Treatment Utilization Among Adolescents With Bipolar Spectrum Disorder

OBJECTIVE

Early-onset bipolar disorder is among the costliest psychiatric disorders; yet inpatient and outpatient service use patterns in this group are largely unknown. One-year behavioral and medical health service use was examined among adolescents diagnosed as having bipolar disorder, and rates were compared between adolescents with threshold versus subthreshold bipolar disorder.

METHODS

Participants included 100 adolescents (ages 12–18 years, 85% had been assigned female sex at birth) diagnosed as having bipolar disorder (type I, N=14; type II, N=28; not otherwise specified [NOS], N=58) via semistructured interviews and who consented to electronic health record (EHR) data review for enrollment in a psychosocial treatment study. Service use data were extracted in the year preceding study entry from a data repository containing all clinical and financial records (including outpatient and inpatient behavioral and medical visits) from a large western Pennsylvania health system.

RESULTS

EHRs indicated that 99% of adolescents used some behavioral health service, most commonly outpatient psychotherapy (60%) and medication management (43%). Use of intensive behavioral health services was common (49%), and 48% had at least one psychotropic medication noted in their EHR. General medical health services were used by 78%, most commonly outpatient (67%) and emergency department (39%) visits. No differences in service use were observed for adolescents with bipolar disorder type I or II compared with NOS for any services or medications examined.

CONCLUSIONS

High use of behavioral and medical health services among adolescents with bipolar spectrum disorders has important implications for health care systems, insurers, providers, and consumers. Greater coordination of health care for this high-risk, high-use population may improve outcomes.

Application of Dialectical Behaviour Therapy in treating common psychiatric disorders: study protocol for a scoping review

INTRODUCTION

Dialectical behaviour therapy (DBT) is a well-known intervention for treating borderline personality disorder, and has been increasingly adapted for other disorders. Standard DBT consists of four treatment modes, delivered over a year. Adaptations to DBT include changes to modes of delivery, treatment length, and skills modules taught to clients, or incorporating interventions from other evidence-based therapies. There is a need to synthesise existing evidence on DBT so that stakeholders-clinicians, researchers and policymakers-can understand how it has been provided for various psychiatric conditions, and whether it has been effective.

METHODS AND ANALYSIS

This study proposes a scoping review conducted according to Arksey and O'Malley's (2005) procedures, to map and summarise the literature on DBT interventions for treating a range of psychiatric concerns. Electronic databases (ie, the Cochrane Central Register of Controlled Trials, PubMed, PsycINFO, SCOPUS, EBSCOhost and ProQuest Dissertations and Theses), conference proceedings and the US National Institutes of Health Ongoing Trial Register will be searched for intervention studies that involve a control or comparison group, and that report quantitative data on pre/post-measures for psychiatric symptom severity. The initial search was conducted on 18 September 2020, and data charting has not commenced. An update will be performed in September 2022, pending this protocol's publication. Data charting will collect individual studies' characteristics, methodology and reported findings. Outcomes will be reported by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for Scoping Reviews.

ETHICS AND DISSEMINATION

No ethical approval is required for this study. The goal of dissemination is to keep DBT stakeholders abreast on latest updates in clinical applications of DBT. Findings from this research are intended to inform a more specific topic of study (eg, a meta-analysis), to further aid in the development of DBT interventions for psychiatric populations.

REGISTRATION DETAILS

The study protocol was pre-registered with the Open Science Framework on 24 August 2021 (https://osf.io/vx6gw).

A clinical follow-up study of dialectical behavior therapy skills groups among female adolescents diagnosed with depressive disorder

Our aim was to evaluate longitudinal data for adolescents who were treated with Dialectical Behavior therapy (DBT) skills groups having been previously diagnosed with depressive disorder. Intervention with an observational cross-sectional design was implemented to evaluate the treatment outcome of a 10-week DBT skills groups with female adolescents with depression. After the patients were identified for enrollment, parents and adolescents were evaluated with psychometric measurements pre-, post-intervention, and at one-year follow-up. Repeated measures analysis was undertaken with the Child Depression Inventory (CDI), Pediatric Quality of Life Inventory (PedsQL) and Strengths and Difficulties Questionnaire (SDQ) for participants. Statistical significance was detected for self-report CDI scores and both self-report and parent SDQ and PedsQL scores. This study is the first DBT intervention in Turkish children, shows that a group DBT skills groups training can be adapted and put into practice successfully with depressed Turkish adolescents.

Psychosocial Treatments for Bipolar Disorder in Children and Adolescents

Evidence suggests that adjunctive psychosocial intervention for the treatment of pediatric bipolar spectrum disorders (BPSDs) is effective, feasible, and highly accepted as both an acute and maintenance treatment for youth with BPSD diagnoses as well as a preventive treatment for high-risk youth who are either asymptomatic or exhibit subsyndromal mood symptoms. Here, we provide a comprehensive review of all known evidence-based interventions, including detailed descriptions of treatment targets and core components, results of clinical trials, and updated research on mediators and moderators of treatment efficacy. Treatments are presented systematically according to level of empirical support (i.e., well established, probably efficacious, possibly efficacious, experimental, or questionable); upcoming and ongoing trials are included when possible. In line with a staging approach, preventive interventions are presented separately. Recommendations for best practices based on age, stage, and additional evidence-based child and family factors shown to affect treatment outcomes are provided. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

A Narrative Review on Dialectical Behavior Therapy for Patients with Depressive Difficulties

Background:

Dialectical behavior therapy (DBT) is a type of cognitive behavioral therapy (CBT) that was earlier intended to treat only patients with borderline personality disorder (BPD), but researchers have found DBT to treat several psychological disorders, including depression.

Aim:

The article aims to review the clinical shreds of evidence regarding the use of DBT to treat depression.

Methods:

PubMed literature search was done by applying the year filter range, 2010 to 2021. Another filter applied was "Randomized controlled trial", so that the strength of evidence could be enhanced. The keywords used were "Dialectical Behavior Therapy" AND "Depression

Results:

33 articles were found, out of which only 20 relevant articles were reviewed. DBT was found to alleviate depressive symptoms associated with different psychological disorders like bipolar disorder and BPD but the number of studies that validated the afore-mentioned were less than those studies which showed that DBT had no significant effect on the patients with depressive difficulties. The long-term effect of DBT for treating depression is under a suspect, as studies showed DBT got ineffective during the follow-ups

Conclusion:

DBT shows benefits in depression but further studies are still required to validate this concretely as DBT did not show a significant effect when compared to its control counterparts. There is much need for future studies which can evaluate the long-term efficacy of DBT in depression is another challenging area because follow-up data did not favor DBT.

Emotional Regulation in Teens and Improvement of Constructive Skills (EmoTIConS): study protocol for a randomized controlled trial

BACKGROUND

Emotional dysregulation (ED) constitutes a relevant factor involved in the onset and maintenance of many mental disorders. Targeting ED during adolescence could be a determinant both to identify high-risk individuals and to promote preventive interventions. This study will aim to evaluate the impact of a brief Dialectical Behavioral Therapy (DBT)-based intervention for adolescent students by measuring changes in emotional regulation skills and impulsive behaviors. Moreover, alterations in biological features related to stress response and inflammation will be assessed as potential biological variables associated with ED.

METHODS

This is a randomized trial. A total of 20 classes of adolescent students will be recruited among high schools in Brescia, a city in northern Italy. They will be randomized to the psychoeducational intervention (experimental group) or to a control condition (control group). The intervention will be based on DBT Skills Training for Emotional Problem Solving for Adolescents, and will consist of four monthly, 2-h sessions (for a total of 8 h) scheduled during regular school time. Participants will be assessed at baseline, post-intervention, and at 3 and 6 months of follow-up. The primary outcome measures will be represented by changes in the use of emotional regulation skills and by changes in the frequency of impulsive behaviors. Salivary samples will be collected at baseline and post-intervention to explore possible biological features underlying ED.

DISCUSSION

Data from the present project will offer the opportunity to better understand the complex phenomenon of ED. Repeated assessment will cover several domains (emotional, behavioral, social, biological) as potential factors associated with ED. Moreover, it will be possible to establish the effect of the proposed intervention, thus helping to improve knowledge on the impact of school-based universal preventive programs. Finally, the current trial will propose an integrated screening and intervention-based model. Ultimately, this could reduce barriers to youths' mental health care by fostering collaboration between schools and mental health services.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04349709 . Registered on April 16, 2020.

Telehealth Social Rhythm Therapy to Reduce Mood Symptoms and Suicide Risk Among Adolescents and Young Adults With Bipolar Disorder

OBJECTIVE

Social rhythm irregularities are associated with increased bipolar disorder symptoms and suicide risk. This study was the first to examine the feasibility and acceptability of a 12-week social rhythm therapy (SRT) delivered predominantly via telehealth (three in-person sessions, nine via video teleconferencing) to adolescents and young adults with bipolar disorder. The primary aim was to determine the feasibility and acceptability of SRT delivered predominantly via telehealth. Secondary aims were to explore the intervention's impacts on social rhythm regularity, mood symptoms, and suicide propensity.

METHODS

Thirteen adolescents and young adults with bipolar disorder received a modified SRT called Brain Emotion circuitry-targeted Self-Monitoring And Regulation Therapy for Daily Rhythms (BE-SMART-DR) administered mostly remotely, adjunctive to treatment as usual. Retention rates, client satisfaction, therapeutic alliance, and pre- to postintervention changes in social rhythm regularity, mood symptoms, and suicide propensity were assessed.

RESULTS

BE-SMART-DR was associated with high retention rates (77%), high mean±SD scores on the Client Satisfaction Questionnaire (29.4±2.7), and high participant global scores on the Working Alliance Inventory (231.3±8.1), indicative of strong therapeutic alliance. Secondary outcome measures on social rhythm irregularities, mood symptoms, and suicide propensity decreased from pre- to posttherapy. Increased social rhythm regularity was associated with reduced suicide propensity after analyses were controlled for reductions in mood symptoms.

CONCLUSIONS

These preliminary results indicate that SRT delivered largely by telemedicine is feasible and acceptable. The intervention appeared to reduce mood symptoms, and suicide propensity independent of mood symptoms, among adolescents and young adults with bipolar disorder.

Personal recovery in bipolar disorder: Systematic review and "best fit" framework synthesis of qualitative evidence - a POETIC adaptation of CHIME

BACKGROUND

Personal recovery, living a satisfying, hopeful life alongside symptoms, has become an increasingly valued aim across mental health care agendas internationally. However, there is little understanding of how people experience personal recovery alongside the mood challenges characteristic of a bipolar disorder diagnosis. Personal recovery frameworks have been developed for populations with mixed psychiatric diagnoses, predominantly psychotic disorders.

METHODS

This systematic review of qualitative data used the widely adopted personal recovery processes Connectedness, Hope and optimism, Identity, Meaning and purpose, Empowerment (CHIME) in a "best fit" framework synthesis to understand personal recovery experiences in bipolar disorder. Included studies were coded with deductive framework analysis based on the CHIME processes and inductive thematic analysis for aspects beyond the a priori framework.

RESULTS

A comprehensive search of six literature databases led to inclusion of twelve articles published 2010-2020. Deductive coding supported the fit with the CHIME framework but revealed difficulties, losses, and tensions within and across recovery processes. The proposed framework for personal recovery in bipolar disorder, Purpose and meaning, Optimism and hope, Empowerment, Tensions, Identity, Connectedness (POETIC), organises all CHIME processes around these tensions.

LIMITATIONS

Diversity among study participants was limited with majority middle-aged, female, Western participants.

CONCLUSIONS

The compact POETIC personal recovery framework tailored for bipolar disorder is directly applicable to clinical practice with personal recovery objectives. It highlights the need for professionals to introduce personal recovery in a realistic and balanced way to address recent criticism by service user organisations of personal recovery as overly optimistic.

Psychological therapy for mood instability within bipolar spectrum disorder: a randomised, controlled feasibility trial of a dialectical behaviour therapy-informed approach (the ThrIVe-B programme)

Background

A subgroup of those with bipolar spectrum disorders experience ongoing mood fluctuations outside of full episodes. We conducted a randomised, controlled feasibility study of a Dialectical Behavioural Therapy-informed approach for bipolar mood fluctuations (Therapy for Inter-episode mood Variability in Bipolar [ThrIVe-B]). Our study aimed to examine the feasibility and acceptability of a future definitive trial evaluating the clinical and cost effectiveness of the ThrIVe-B programme. Participants were required to meet diagnostic criteria for a bipolar spectrum disorder and report frequent mood swings outside of acute episodes. They were randomised to treatment as usual (control arm) or the ThrIVe-B intervention plus treatment as usual (intervention arm). Follow-up points were at 3, 6, 9 and 15 months after baseline, with 9 months as the primary end point. To evaluate feasibility and acceptability we examined recruitment and retention rates, completion rates for study measures, adverse events and feedback from participants on their experience of study participation and therapy.

Results

Of the target 48 participants, 43 were recruited (22 in the intervention arm; 21 in the control arm), with a recruitment rate of 3.9 participants per month. At 9 months 74% of participants engaged in research follow-up assessment, exceeding the pre-specified criterion of 60%. There were no serious concerns about the safety of the research procedures or the intervention. On one of the four candidate primary outcome measures, the 95% CI for the between-group mean difference score excluded the null effect and included the minimal clinically important difference, favouring the intervention arm, whilst on no measure was there evidence of deterioration in the intervention arm relative to the control arm. Attendance of the intervention (50% attending at least half of the mandatory sessions) was below the pre-specified continuation criterion of 60%, and qualitative feedback from participants indicated areas that may have hampered or facilitated engagement.

Conclusions

It is broadly feasible to conduct a trial of this design within the population of people with frequent bipolar mood swings. Changes should be made to the therapy to increase uptake, such as simplifying content and considering individual rather than group delivery.

Trial registration ISRCTN: ISRCTN54234300. Registered 14th July 2017, http://www.isrctn.com/ISRCTN54234300

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-021-00226-4.

Changes in suicide and non-suicidal self-injury ideation and the moderating role of specific emotions over the course of dialectical behavior therapy

OBJECTIVE

Dialectical behavior therapy (DBT) targets suicidal behavior and non-suicidal self-injury (NSSI) as well as urges/ideation to engage in these behaviors. However, it remains unclear which specific suicidal ideation (SI) and NSSI ideation domains (i.e., frequency, worst intensity, average intensity, perceived likelihood of future ideation, and duration of ideation), if any, are impacted, and whether specific emotions moderate these effects.

METHOD

73 individuals with borderline personality disorder (BPD), enrolled in six months of DBT, completed interviews of suicide and NSSI ideation and self-report measures of specific emotions at baseline, mid-treatment, and post-treatment.

RESULTS

Generalized estimation equations revealed that all domains of suicidal ideation decreased over the course of DBT, but for NSSI domains, only ideation intensity decreased. Higher levels of shame/guilt predicted less, and higher fear predicted more, reduction in SI and NSSI ideation frequency. Higher shame/guilt also predicted more reduction in worst SI intensity. Higher sadness predicted greater reductions in SI intensity and duration, but less reductions in the perceived likelihood of future NSSI ideation.

CONCLUSIONS

These findings suggest that DBT effectively reduces several facets of SI, but more work is required to target NSSI ideation. Results also suggest that targeting shame/guilt may be important to reducing SI and NSSI ideation.

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.

A Qualitative Analysis of College Counseling Center Staff Experiences of the Utility of Dialectical Behavior Therapy Programs on Campus

Dialectical behavior therapy (DBT) is an evidence-based practice for suicidal and self-injuring behavior with growing popularity in college counseling centers (CCCs). With the exception of a single, quantitative study, no research to date investigates how DBT is used in CCCs or what factors influence program implementation. We conducted qualitative interviews with 15 CCC staff that were delivering DBT programs in order to inform a more richly detailed understanding of the process of developing and implementing a DBT program housed in a CCC.

Emotional awareness, affective dysregulation, and bipolar spectrum psychopathology: A path analysis

Affective dysregulation is present in those with subsyndromal symptoms of hypomania and mania and prospectively predicts the development of bipolar spectrum disorders. A crucial, understudied area related to the experience and regulation of emotion in this population is emotional awareness - emotional clarity (Clarity) and attention to emotion (Attention). We examined whether scores on the Hypomanic Personality Scale (HPS) were associated with deficits in emotional awareness and whether these deficits were associated with heightened intensity and instability of negative (NA) and positive affect (PA). Young adults (n=233), oversampled for high HPS scores completed self-reports and 14 days of experience sampling assessing high and low arousal NA and PA. HPS scores were associated with low Clarity and unassociated with Attention. High HPS scores were associated with greater high and low arousal NA intensity and instability only for those at low and mean levels of Attention. In contrast, there was a significant indirect association between HPS scores and intensity of high and low arousal NA and PA, as well as instability of high arousal NA, through low Clarity. Results highlighted that individual differences exist in the extent to which facets of emotional awareness differentially link scores on the HPS to emotional outcomes.

The Impact of Childhood Trauma on Developing Bipolar Disorder: Current Understanding and Ensuring Continued Progress

Childhood trauma (CT) has been repeatedly linked to earlier onset and greater severity of bipolar disorder (BD) in adulthood. However, such knowledge is mostly based on retrospective and cross-sectional studies in adults with BD. The first objective of this selective review is to characterize the short-term effects of CT in the development of BD by focusing on studies in young people. The second objective is to describe the longer-term consequences of CT by considering studies with adult participants. This review first outlines the most prominent hypotheses linking CT exposure and the onset of BD. Then, it summarizes the psychological and biological risk factors implicated in the development of BD, followed by a discussion of original studies that investigated the role of CT in young people with early-onset BD, youths at increased risk of developing BD, or young people with BD with a focus on subclinical and clinical outcome measures. The review considers additional biological and psychological factors associated with a negative impact of CT on the long-term course of BD in later adulthood. Finally, we discuss how the integration of information of CT can improve ongoing early identification of BD and mitigate severe clinical expression in later adulthood.

Relationship of comorbid personality disorders to prospective outcome in bipolar disorder

Introduction There is a high incidence of Axis II personality disorders (PDs) in patients with bipolar illness, but their influence on the prospectively measured course of bipolar disorder has been less well explicated. Methods 392 outpatients with bipolar disorder gave informed consent, completed the PDQ4 99 item personality disorder rating, and where clinically rated during at least one year of prospective naturalistic treatment. They were classified as Well on admission (N = 64) or Responders (N = 146) or Non-responders (N = 182) to treatment for at least six months. Results Patients who were positive for PDs were very infrequently represented in the category of Well on admission. In addition, patients with borderline, depressive, and schizoid PDs were significantly more likely to be Non-responders compared to Responders upon prospective naturalistic treatment in the network. Conclusions Patients with bipolar disorder and comorbid PDs were in general less likely to be Well from treatment in the community at network entry or to be a Responder to prospective treatment in the network. Therapeutic approaches to patients with PDs deserve specific study in an attempt to achieve a better long-term course of bipolar disorder.

Effects of family-focused therapy on suicidal ideation and behavior in youth at high risk for bipolar disorder

BACKGROUND

Youth who are at clinical and familial risk for bipolar disorder (BD) often have significant suicidal ideation (SI). In a randomized trial, we examined whether family-focused therapy (FFT) is associated with reductions in SI and suicidal behaviors in high-risk youth.

METHODS

Participants (ages 9-17 years) met diagnostic criteria for unspecified BD or major depressive disorder with active mood symptoms and had at least one relative with BD type I or II. Participants were randomly allocated to 12 sessions in 4 months of FFT or 6 sessions in 4 months of psychoeducation (enhanced care, EC), with pharmacotherapy as needed. Clinician- and child-rated assessments of mood, suicidal thoughts and behaviors, and family conflict were obtained at baseline and 4-6 month intervals over 1-4 years.

RESULTS

Participants (N=127; mean 13.2±2.6 yrs., 82 female) were followed over an average of 105.9±64.0 weeks. Youth with high baseline levels of SI who received FFT had lower levels of (and fewer weeks with) SI at follow-up compared to youth with high baseline SI who received EC. Participants in FFT had longer intervals without suicidal behaviors than participants in EC. Youths' ratings of family conflict significantly mediated the effects of treatment on SI at follow-up.

LIMITATIONS

Family conflict was based on questionnaires rather than observer ratings of family interactions.

CONCLUSIONS

Family psychoeducation with skill training can be an effective deterrent to suicidal thoughts and behaviors in youth at high risk for BD. Reducing parent/offspring conflict should be a central objective of psychosocial interventions for high-risk youth with SI.

Enhancing Dialectical Behavior Therapy for the Treatment of Bipolar Disorder

Dialectical behavior therapy (DBT) is a third wave, behavioral therapy that is designed to target emotion dysregulation. The current study investigated whether DBT could be an effective treatment intervention for bipolar disorder and how it could be adapted for this population. Although empirical study of DBT and bipolar disorder is limited, there is evidence to suggest that DBT is a promising treatment for bipolar disorder. In this study, adapted DBT products were created for bipolar disorder, and feedback on the products was elicited from five experts in the field through semi-structured interviews. Interviews were transcribed and coded for analyses. The findings from the interviews were integrated into revised products with the intention to be used in the clinical community. Several experts reported currently using DBT for bipolar disorder treatment. We conclude that a form of DBT using adapted materials could be a promising intervention for the treatment of bipolar disorder, although more research is needed to demonstrate efficacy. Future directions include conducting randomized controlled trials on DBT and bipolar disorder, as well as testing the created product in clinical practice.

Dialectical Behavior Therapy Decreases Depressive Symptoms Among Adolescents in an Acute-Care Inpatient Unit

Objective: Research has shown that dialectical behavior therapy (DBT) is an effective treatment modality to decrease suicidal ideation, incidents of nonsuicidal self-injurious behavior, and suicide attempts in an adolescent outpatient population. However, research on the impact of DBT on depressive and manic symptoms for adolescents and within an inpatient setting is limited. The purpose of this study is to examine whether DBT significantly decreases depressive and manic symptoms compared with treatment as usual (TAU) for inpatient adolescents. Method: We conducted a retrospective chart review for adolescents receiving inpatient DBT and for a historical control group on the same unit before DBT (i.e., TAU). Group differences for continuous outcomes were analyzed using analysis of covariance (ANCOVA), where discharge scores for Hamilton Depression Rating Scale (HAMD), Young Mania Rating Scale (YMRS), Clinical Global Impressions-Severity for Symptoms (CGI-S), and Dynamic Appraisal of Situational Aggression (DASA) were predicted by treatment condition (i.e., DBT and TAU) while co-varying for admission scores and using a t test for CGI-Improvement (CGI-I) in functioning, which was administered upon discharge. Results: Patients who received DBT had significantly lower HAMD scores, F(1, 409) = 5.272, p = 0.022, η_p² = 0.013, and lower CGI-I scores, t(596) = 2.50, p = 0.00 upon discharge when controlling for admission scores, compared with patients who received TAU. ANCOVAs showed no significant differences on the YMRS, CGI-S, or DASA between the DBT and TAU groups. Conclusion: DBT on an acute-care inpatient unit for adolescents seems to significantly decrease depressive symptoms during a relatively short period of time compared with TAU. DBT may be an effective treatment modality to decrease depressive symptoms for acute-care inpatient units for adolescents.

Similarities and Differences Across Bipolar Disorder Subtypes Among Adolescents

Objectives: To compare demographic, clinical, and familial characteristics across bipolar disorder (BD) subtypes in adolescents. Methods: A total of 168 participants, 13 to 19 years of age, with BD-I (n = 41), BD-II (n = 68), or operationalized BD-not otherwise specified (NOS) (n = 59) were recruited from a tertiary subspecialty clinic at an academic health sciences center. Diagnoses were determined using the semistructured K-SADS-PL (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version) interview. Omnibus analyses were followed up with post hoc pairwise comparisons. Results: After controlling for age, race, and living with both natural parents, BD-I was associated with greater functional impairment, increased rates of psychiatric hospitalization, psychosis, and lifetime exposure to second-generation antipsychotics and lithium, less self-injurious behavior, less anxiety disorders, and less severe worst lifetime depression and lower levels of emotional dysregulation and lability compared with both BD-II and BD-NOS. Lifetime most severe manic symptoms were highest in BD-I, lowest in BD-NOS, with BD-II intermediate. Lifetime exposure to psychosocial treatment followed the opposite pattern: lowest in BD-I, highest in BD-NOS, with BD-II intermediate. Variables for which there were no significant between-group differences included suicidal ideation, suicide attempts, comorbidities other than anxiety, or family history of BD. Conclusion: Among observed differences, most distinguish BD-I from other subtypes, whereas few variables differed between BD-II and BD-NOS. Different BD subtypes share important similarities in multiple clinical and familial characteristics, including family history of BD. Present findings support and extend knowledge regarding the course and outcome of bipolar youth study operationalized definition of BD-NOS. Further research is warranted to evaluate intermediate phenotypes and treatment strategies that address these subtype-related differences.

Psychological therapy for mood instability within bipolar spectrum disorder: a single-arm feasibility study of a dialectical behaviour therapy-informed approach

Background

We sought to evaluate the acceptability of a psychological therapy programme (Therapy for Inter-episode Mood Variability in Bipolar Disorder (ThrIVe-B)) for individuals with ongoing bipolar mood instability and the feasibility and acceptability of potential trial procedures. We also evaluated the performance of clinical and process outcome measures and the extent to which the programme potentially represents a safe and effective intervention.

Method

We conducted an open (uncontrolled) trial in which 12 individuals with a bipolar spectrum diagnosis commenced the ThrIVe-B programme after completing baseline assessments. The programme comprised 16 group skills training sessions plus individual sessions and a supporting smartphone application. Follow-up assessments were at therapy end-point and 6 months post-treatment.

Results

Nine participants completed treatment. Ten provided end-of-treatment data; of these, nine were satisfied with treatment. Interviews with participants and clinicians indicated that the treatment was broadly feasible and acceptable, with suggestions for improvements to content, delivery and study procedures. Exploration of change in symptoms was consistent with the potential for the intervention to represent a safe and effective intervention.

Conclusions

Conducting further evaluation of this approach in similar settings is likely to be feasible, whilst patient reports and the pattern of clinical change observed suggest this approach holds promise for this patient group. Future research should include more than one study site and a comparison arm to address additional uncertainties prior to a definitive trial.

Trial registration

Trial Registration: ClinicalTrials.gov NCT02637401; registered 22.12.15 (retrospectively registered).

Individual experiences of psychological-based interventions for bipolar disorder: A systematic review and thematic synthesis

PURPOSE

To conduct a thematic synthesis to evaluate qualitative studies exploring individuals' experiences of psychological-based interventions for bipolar disorder (BD).

METHOD

A systematic search of relevant databases (Web of Science, PsycINFO, MEDLINE, CINAHL) was conducted using predefined search terms related to 'Bipolar' 'Qualitative method', 'Psychological-based interventions' and 'Adults'. Studies meeting the inclusion criteria were selected and were then evaluated using established quality appraisal criteria. A thematic synthesis was used to synthesize the findings.

RESULTS

From the thematic synthesis, nine analytical themes were derived from the 10 identified research studies. These were helpful and unhelpful aspects of the intervention, increased knowledge of BD, mood recognition, control of moods, change of perspective, mood stability, empowerment, improved relationships and lifestyle changes.

CONCLUSIONS

Findings from the review suggest there were characteristics of psychological-based interventions that individuals with BD valued and which helped facilitate areas of positive change, such as feeling empowered and in control of their moods and other aspects of their lives. However, there were also elements that individuals did not find as helpful and therefore reflects the challenge of a one-size-fits-all model or plan of interventions, compared to a wider recognition of the individuals as being the agent of their recovery. Future qualitative research is needed to explore individual experiences across a range of psychological interventions, in order to further understand the therapeutic processes, which may facilitate recovery.

PRACTITIONER POINTS

Psychological-based interventions for BD need to consider facilitating and measuring empowerment in individuals, rather than focusing just on mood stability. Clinicians with expertise and knowledge in BD should provide timely information to individuals and their families to help increase their understanding of the diagnosis.

Effectiveness of Dialectical Behavioral Therapy on Executive Function, Emotional Control and Severity of Symptoms in Patients with Bipolar I Disorder

Background:

Bipolar disorder is a disabling illness characterized by recurrent episodes of mania, hypomania, and depression. The dialectical behaviour therapy (DBT) is basically designed to help regulate excitement, tolerance of discomfort, mindfulness and interpersonal relationships. This study aimed to determine the effectiveness of DBT on executive function, emotional control and symptom relief in patients with type 1 bipolar disorder.

Materials and Methods:

This clinical trial was conducted on 50 patients with type 1 bipolar disorder. These patients were divided into two 25 populated groups of controls and intervention. The control group did not receive any other alternative therapy apart from routine medications, but in the intervention group, in addition to routine medications, DBT treatment was also done as complementary therapy in 12 sessions based on Dick's protocol. Then, Mania severity, emotional control and their executive functions were evaluated before and after the intervention and compared in two groups.

Results:

After the intervention, the scores of mania and depression mood with the mean of 2.12 ± 3.09 and 31.08 ± 8.98 respectively in intervention group were significantly lower than control group with the mean of 4.24 ± 4.11 and 39.92 ± 9.05 respectively (P < 0.05). Depression and executive function of the patients had no significant difference between the two groups in the post-intervention period and had a modest and non-significant change.

Conclusion:

DBT has been effective in decreasing the intensity of mania, but, it cannot be used to reduce the emotional instability and impulsivity of these patients along with drug therapy although it has improved the executive functions and depression of the patients.

One Size Does Not Fit All: A Comprehensive Clinical Approach to Reducing Suicidal Ideation, Attempts, and Deaths

While the existence of mental illness has been documented for centuries, the understanding and treatment of such illnesses has evolved considerably over time. Ritual exorcisms and locking mentally ill patients in asylums have been fundamentally replaced by the use of psychotropic medications and evidence-based psychological practices. Yet the historic roots of mental health management and care has left a certain legacy. With regard to suicidal risk, the authors argue that suicidal patients are by definition seen as mentally ill and out of control, which demands hospitalization and the treatment of the mental disorder (often using a medication-only approach). Notably, however, the evidence for inpatient care and a medication-only approach for suicidal risk is either limited or totally lacking. Thus, the "one-size-fits-all" approach to treating suicidal risk needs to be re-considered in lieu of the evolving evidence base. To this end, the authors highlight a series of evidence-based considerations for suicide-focused clinical care, culminating in a stepped care public health model for optimal clinical of suicidal risk that is cost-effective, least-restrictive, and evidence-based.

Suicide Risk in Bipolar Disorder: A Brief Review

Bipolar disorders (BDs) are prevalent mental health illnesses that affect about 1-5% of the total population, have a chronic course and are associated with a markedly elevated premature mortality. One of the contributors for the decreased life expectancy in BD is suicide. Accordingly, the rate of suicide among BD patients is approximately 10-30 times higher than the corresponding rate in the general population. Extant research found that up to 20% of (mostly untreated) BD subjects end their life by suicide, and 20-60% of them attempt suicide at least one in their lifetime. In our paper we briefly recapitulate the current knowledge on the epidemiological aspects of suicide in BD as well as factors associated with suicidal risk in BD. Furthermore, we also discuss concisely the possible means of suicide prevention in BD.

Challenges in diagnosis and treatment of comorbid eating disorders and mood disorders

PURPOSE

This paper explores complex challenges in diagnosis and treatment of patients with comorbid eating disorders and mood disorders. An integrative review of the literature examines overlapping symptoms, phenotypes, neural circuits, and genetic factors for these disorders. A case study illustrates how the integration of knowledge from research and practice can inform a diagnostic formulation and multifaceted treatment plan.

CONCLUSIONS

Patients with complex clinical presentations inspire a search for research and clinical literature that helps build the neuroscience foundations of advanced practice.

PRACTICE IMPLICATIONS

Sharing clinical challenges and processes of discovery is a form of scholarship that promotes the evolution of advanced psychiatric nursing practice.

Dialectical Behavior Therapy Is Effective for the Treatment of Suicidal Behavior: A Meta-Analysis

Dialectical Behavior Therapy (DBT) prioritizes suicidal behavior and other self-directed violence as the primary treatment targets, and has been demonstrated to reduce self-directed violence in clinical trials. This paper synthesizes findings from controlled trials that assessed self-directed violence and suicidality, including suicide attempts, non-suicidal self-injury (NSSI), suicidal ideation, and accessing psychiatric crisis services. Eighteen controlled trials of DBT were identified. Random effects meta-analyses demonstrated that DBT reduced self-directed violence (d = -.324, 95% CI = -.471 to -.176), and reduced frequency of psychiatric crisis services (d = -.379, 95% CI = -.581 to -.176). There was not a significant pooled effect of DBT with regard to suicidal ideation (d = -.229, 95% CI = -.473 to .016). Our findings may reflect the prioritization of behavior over thoughts within DBT, and offer implications for clinical practice and future research concerning the implementation of DBT for acute suicidality.

A Life Span Perspective on Borderline Personality Disorder

PURPOSE OF REVIEW

To provide an update of a life span perspective on borderline personality disorder (BPD). We address the life span course of BPD, and discuss possible implications for assessment, treatment, and research.

RECENT FINDINGS

BPD first manifests itself in adolescence and can be distinguished reliably from normal adolescent development. The course of BPD from adolescence to late life is characterized by a symptomatic switch from affective dysregulation, impulsivity, and suicidality to maladaptive interpersonal functioning and enduring functional impairments, with subsequent remission and relapse. Dimensional models of BPD appear more age neutral and more useful across the entire life span. There is a need for age-specific interventions across the life span. BPD symptoms and impairments tend to wax and wane from adolescence up to old age, and presentation depends on contextual factors. Our understanding of the onset and early course of BPD is growing, but knowledge of BPD in late life is limited. Although the categorical criteria of DSM allow for reliable diagnosis of BPD in adolescence, dimensional models appear both more age neutral, and useful up to late life. To account for the fluctuating expression of BPD, and to guide development and selection of treatment across the life span, a clinical staging model for BPD holds promise.

Child- and Family-Focused Cognitive Behavioral Therapy for Pediatric Bipolar Disorder: Applications for Suicide Prevention

Despite high rates of suicide ideation (SI) and behavior in youth with pediatric bipolar disorder (PBD), little work has examined how psychosocial interventions impact suicidality among this high-risk group. The current study examined SI outcomes in a randomized clinical trial comparing Child- and Family-Focused Cognitive Behavioral Therapy (CFF-CBT) for PBD versus psychotherapy treatment-as-usual (TAU). Although not designed for suicide prevention, CFF-CBT addresses child and family factors related to suicide risk and thus was hypothesized to generalize to the treatment of suicidality. Participants included 71 youth aged 7-13 years (M = 9.17, SD = 1.60) with DSM-IV-TR bipolar I, II, or not otherwise specified randomly assigned, with parent(s), to receive CFF-CBT or TAU. Both treatments consisted of 12 weekly and 6 monthly booster sessions. Suicide ideation was assessed via clinician interview at baseline, posttreatment, and 6-month follow-up. Results indicated that SI was prevalent pretreatment: 39% of youth reported current suicidal thoughts. All youth significantly improved in the likelihood and intensity of ideation across treatment, but group differences were not significant. Thus, findings suggest that early intervention for these high-risk youth may reduce SI, and at this stage of suicidality, youth may be responsive to even nonspecialized treatment.

The clinical and cost effectiveness of adapted dialectical behaviour therapy (DBT) for bipolar mood instability in primary care (ThrIVe-B programme): a feasibility study

Background

In bipolar spectrum disorder, some individuals experience ongoing, frequent fluctuations in mood outside of affective episodes. There are currently no evidence-based psychological interventions designed to address this. This feasibility study is a phase II evaluation of a dialectical behavioural therapy-informed approach (Therapy for Inter-episode mood Variability in Bipolar [ThrIVe-B]). It seeks to examine the feasibility and acceptability of a future definitive trial evaluating the clinical and cost effectiveness of the ThrIVe-B programme.

Methods/design

Patients will be randomised 1:1 to either treatment as usual only (control arm) or the ThrIVe-B intervention plus treatment as usual (intervention arm). Follow-up points will be at 3, 6, 9 and 15 months after baseline, with 9 months as the primary end point for the candidate primary outcome measures. We aim to recruit 48 individuals meeting diagnostic criteria for a bipolar spectrum disorder and reporting frequent mood swings outside of acute episodes, through primary and secondary care services and self-referral. To evaluate feasibility and acceptability, we will examine recruitment and retention rates, completion rates for study measures and feedback from participants on their experience of study participation and therapy.

Discussion

Proceeding to a definitive trial will be indicated if the following criteria are met: (1) trial participation does not lead to serious negative consequences for our participants; (2) any serious concerns about the acceptability and feasibility of the trial procedures can be rectified prior to a definitive trial; (3) follow-up data at 9 months are available for at least 60% of participants; (4) at least 60% of patients in the ThrIVe-B arm complete treatment.

Trial registration

ISRCTN, ISRCTN54234300. Registered on 20 July 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2926-7) contains supplementary material, which is available to authorized users.

Dimensional and Categorical Correlates of Substance Use Disorders among Canadian Adolescents with Bipolar Disorder

OBJECTIVES

Despite increasing evidence of excessive substance use disorder (SUD) prevalence among adolescents with bipolar disorder (BP), little is known about this topic among Canadian adolescents with BP. We therefore sought to examine the clinical characteristics and dimensional measures of psychopathology associated with comorbid SUD among Canadian BP adolescents.

METHOD

Participants were 100 adolescents, ages 13-19 years, with BP I, II, or not otherwise specified (NOS). Diagnoses (current and lifetime) were determined via the Schedule for Affective Disorders and Schizophrenia for School-Aged Children, Present and Lifetime version (KSADS-PL). Participants were considered to have lifetime SUD if they met DSM-IV criteria for abuse of or dependence on alcohol or any drug other than nicotine. Chi-square analyses and independent samples t-tests were followed by logistic regression analyses.

RESULTS

The lifetime prevalence of SUD was 33% (primarily alcohol and cannabis use disorders). In univariate analyses, SUD was associated with greater lifetime prevalence of conduct disorder, oppositional defiant disorder, panic disorder, assault of others, and a greater number of stressful life events. SUD was significantly associated with greater self-reported impulsivity and parent-report of anger/depression in the adolescent. In multivariable analyses, SUD was associated with panic disorder and oppositional defiant disorder.

CONCLUSION

SUD is highly prevalent among Canadian adolescents with BP and is associated with anxiety disorders, behavioural disorders, and trait impulsivity. Targeting these clinical characteristics may help guide preventative and treatment strategies for this population.

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.