Dialectical behavior therapy for adolescents with bipolar disorder: a 1-year open 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.

Feasibility and Efficacy of Intensive Dialectical Behavior Therapy Skills Training in An Outpatient Setting for A Group of Patients with Extensive Care Needs - A Transdiagnostic Approach

PURPOSE

Dialectical behavior therapy (DBT) is a treatment originally developed för chronically suicidal adults. It is common to adapt it by using one specific component, the DBT skills training (DBT-ST) and apply it in a group therapy setting for a variety of mental disorders. The primary aim of the study was to explore whether patients with extended care needs would report improved mental health after participating in an intensive form of DBT-ST. The secondary aim was to explore whether the use of psychiatric inpatient care for the group would decrease.

METHODS

Thirty-seven participants completed the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM), and visual analogue scale (VAS) at three time points: pre-intervention, post-intervention and at 6-month follow-up after intensive DBT-ST.

RESULTS

One-way ANOVA showed a significant effect for time on the CORE-OM: F (2,35) = 7.93, p = .001, η2 = 0.312 (large effect size). Post hoc tests indicated a significant difference between pre-intervention and post-intervention (p = .001) and between pre-intervention and follow-up (p = .01). A Friedman test indicated a statistically significant difference in the VAS scale scores across the three time points, with p-values between 0.00 and 0.05. There was no difference in psychiatric healthcare consumption.

CONCLUSION

These study results confirm to some extent the feasibility and effectiveness of the intensive DBT-ST in a transdiagnostic clinical setting. The participants had a positive outcome from the skills training program, but psychiatric healthcare consumption did not decrease.

Diagnosis and Treatment of Bipolar Disorder: A Review

Importance

Bipolar disorder affects approximately 8 million adults in the US and approximately 40 million individuals worldwide.

Observations

Bipolar disorder is characterized by recurrent episodes of depression and mania or hypomania. Bipolar depressive episodes are similar to major depressive episodes. Manic and hypomanic episodes are characterized by a distinct change in mood and behavior during discrete time periods. The age of onset is usually between 15 and 25 years, and depression is the most frequent initial presentation. Approximately 75% of symptomatic time consists of depressive episodes or symptoms. Early diagnosis and treatment are associated with a more favorable prognosis. Diagnosis and optimal treatment are often delayed by a mean of approximately 9 years following an initial depressive episode. Long-term treatment consists of mood stabilizers, such as lithium, valproate, and lamotrigine. Antipsychotic agents, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine, are recommended, but some are associated with weight gain. Antidepressants are not recommended as monotherapy. More than 50% of patients with bipolar disorder are not adherent to treatment. Life expectancy is reduced by approximately 12 to 14 years in people with bipolar disorder, with a 1.6-fold to 2-fold increase in cardiovascular mortality occurring a mean of 17 years earlier compared with the general population. Prevalence rates of metabolic syndrome (37%), obesity (21%), cigarette smoking (45%), and type 2 diabetes (14%) are higher among people with bipolar disorder, contributing to the risk of early mortality. The annual suicide rate is approximately 0.9% among individuals with bipolar disorder, compared with 0.014% in the general population. Approximately 15% to 20% of people with bipolar disorder die by suicide.

Conclusions and Relevance

Bipolar disorder affects approximately 8 million adults in the US. First-line therapy includes mood stabilizers, such as lithium, anticonvulsants, such as valproate and lamotrigine, and atypical antipsychotic drugs, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine.

Emotional and behavioral alterations and their relationship with executive functioning in the pediatric population with autism spectrum disorder and epilepsy: a comparative study

Introduction

The pediatric population with Autism Spectrum Disorder (ASD) and epilepsy presents behavioral and emotional alterations that hinder their correct developmental maturation as well as their integration in different contexts such as school, family or social. This population shows atypical behavioral and emotional patterns, with difficulties in emotional regulation, understanding of emotions, aggressiveness, or low frustration tolerance. They also present alterations in executive functions, which significantly influence the emotional and behavioral characteristics of this population. Research suggests that epilepsy worsens the emotional, behavioral, and executive functioning status.

Objective

To explore differences in behavioral, emotional, and executive functioning profile in individuals with a diagnosis of ASD, epilepsy, and ASD with epilepsy.

Method

In this quasi-experimental and cross-sectional study, a total of 170 participants were selected and distributed into three groups: a group of participants with ASD, a group with epilepsy, and a group of participants with ASD and epilepsy. The SENA, BASC-3, and ENFEN tests were administered to verify the behavioral, emotional, and executive functioning profile in the three groups.

Results

The results indicate that individuals diagnosed with ASD and epilepsy present greater emotional, behavioral, and executive functioning alterations compared to those who only present ASD or epilepsy.

Conclusion

Individuals with ASD and epilepsy present significant alterations in emotional, behavioral, and executive functioning processes, which hinder their adaptation to different contexts, as well as decreasing their quality of life and that of their family.

Adolescent and Family-Focused Cognitive-Behavioral Therapy for Pediatric Bipolar Disorders: An Open Trial and Individual Trajectories Study in Routine Psychiatric Care

Psychosocial treatments improve outcome in Pediatric bipolar disorder (PBD), but few are developed specifically for adolescents and none has been evaluated in Europe. This study evaluates family-focused cognitive-behavioral therapy for adolescents (ages 13-18) with PBD in routine psychiatric care in Sweden, adapted for teenagers in a European setting from the Child and Family-Focused Cognitive Behavioral Therapy for PBD (ages 8-12) developed in the US. In a repeated-measure open trial, psychosocial functioning, depression, skills and knowledge about PBD, and family climate were assessed at pre-treatment, post-treatment, and after 6 months. Assessments were made by adolescents (n = 45), parents (n = 61) and clinicians. Both group statistics and individual trajectories are reported. Psychosocial function, as rated by parents and clinicians, improved at post-treatment, and parents reported less mania and improved family climate at post-treatment. Both parents and adolescents reported improved skills and knowledge. Most results after treatment showed medium effect sizes. Significant improvements were seen in most individual trajectories, however no change and even deterioration was observed in some. The present trial shows that AFF-CBT is well accepted and associated with improved psychosocial function in adolescents and improved skills and knowledge about PBD in adolescents and their parents. Regarding mood symptoms and family climate the results showed more individual variability, indicating that adjustments in delivery of the treatment according to the unique patient could be of importance. AFF-CBT seems to be a valuable addition to pharmacological treatments in PBD.

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.

Using Mindfulness-Based Interventions to Support Self-regulation in Young Children: A Review of the Literature

The COVID-19 pandemic has caused a rise in stress, mental health concerns, and externalizing behaviors in children and their caregivers across the globe and illuminated the need to reduce stress levels and support self-regulation skills in even the youngest of children. The goal of this literature review is to describe what research has shown about the use of mindfulness-based interventions (MBIs) to support young children's self-regulation in early childhood settings. A total of 18 research studies conducted between 2010 and 2021 were identified. The main purposes of the studies reviewed were to examine the effects of MBIs on the development of emotional, behavioral, and cognitive self-regulation. Results showed that teachers generally found mindfulness practices feasible, acceptable, and effective in their classrooms. Although MBIs were found to have mixed effects on self-regulation in young children, positive effects on self-regulation were significantly greater for children in need of additional support, including those with difficulties or delays in developing self-regulation skills. The current review found a wide variety of MBIs used in early childhood settings globally. The results of this review suggest that teaching mindfulness practices to young children and their caregivers can both support the development of self-regulation of young children and foster socially and emotionally healthy environments in which this development can occur.

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.

Are personality disorders in bipolar patients more frequent in the US than Europe?

OBJECTIVE

Bipolar patients in the United States (US) compared to those from the Netherlands and Germany (here abbrev. as "Europe") have more Axis I comorbidities and more poor prognosis factors such as early onset and psychosocial adversity in childhood. We wished to examine whether these differences also extended to Axis II personality disorders (PDs).

METHODS

793 outpatients with bipolar disorder diagnosed by SCID gave informed consent for participating in a prospective longitudinal follow up study with clinician ratings at each visit. They completed detailed patient questionnaires and a 99 item personality disorder inventory (PDQ-4). US versus European differences in PDs were examined in univariate analyses and then logistic regressions, controlling for severity of depression, age, gender, and other poor prognosis factors.

RESULTS

In the univariate analysis, 7 PDs were more prevalent in the US than in Europe, including antisocial, avoidant, borderline, depressive, histrionic, obsessive compulsive, and schizoid PDs. In the multivariate analysis, the last 4 of these PDs remained independently greater in the US than Europe.

CONCLUSIONS

Although limited by use of self report and other potentially confounding factors, multiple PDs were more prevalent in the US than in Europe, but these preliminary findings need to be confirmed using other methodologies. Other poor prognosis factors are prevalent in the US, including early age of onset, more childhood adversity, anxiety and substance abuse comorbidity, and more episodes and rapid cycling. The interactions among these variables in relationship to the more adverse course of illness in the US than in Europe require further study.

Identifying Specific Emotion Regulation Deficits that Associate with Nonsuicidal Self-injury and Suicide Ideation in Adolescents

It is not known how emotion regulation deficits and strategies may differentially relate to nonsuicidal self-injury (NSSI) and suicide ideation in samples of community-based adolescents. The current study examined emotion regulation using comprehensive multi-method assessment to identify which specific deficits are uniquely related to NSSI and suicide ideation in a sample of high school students. Regarding specific deficits, it was expected that lack of emotional awareness, lack of access to emotion regulation strategies, poor cognitive reappraisal, and poorer automatic emotion processing would uniquely associate with past-year NSSI engagement. It was also predicted that lack of access to strategies, lack of impulse control, lack of awareness, and nonacceptance of emotion would uniquely associate with past-year presence of suicide ideation and suicide ideation severity. The sample included 696 adolescents (54.8% female; ages 14-17; mean age = 15.5) recruited from public high schools. Self-report measures were administered assessing suicide ideation, NSSI engagement, dimensions of emotion regulation, and automatic emotion processing (Emotion Stroop). Emotion suppression was the only unique and significant predictor of past-year NSSI engagement, and lack of access to emotion regulation strategies was the strongest predictor of both past-year presence of suicide ideation and recent suicide ideation severity when accounting for all deficits in the same model. Acquiring emotion regulation skills during the period of adolescence has great potential to buffer from occurrence of NSSI and severity of suicide ideation.

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.

Research Status in Clinical Practice Regarding Pediatric and Adolescent Bipolar Disorders

Bipolar disorders (BDs) have high morbidity. The first onset of 27.7% of BDs occurs in children under 13 years and of 37.6% occurs in adolescents between 13 and 18 years. However, not all of the pediatric and adolescent patients with BD receive therapy in time. Therefore, studies about pediatric and adolescent patients with disorders have aroused increased attention in the scientific community. Pediatric and adolescent patients with BD present with a high prevalence rate (0.9-3.9%), and the pathogenic factors are mostly due to genetics and the environment; however, the pathological mechanisms remain unclear. Pediatric and adolescent patients with BD manifest differently from adults with BDs and the use of scales can be helpful for diagnosis and treatment evaluation. Pediatric and adolescent patients with BDs have been confirmed to have a high comorbidity rate with many other kinds of disorders. Both medication and psychological therapies have been shown to be safe and efficient methods for the treatment of BD. This review summarizes the research status related to the epidemiology, pathogenic factors, clinical manifestations, comorbidities, diagnostic and treatment scales, medications, and psychological therapies associated with BDs.

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.

Effectiveness of current psychological interventions to improve emotion regulation in youth: a meta-analysis

BACKGROUND

Research investigating the role of emotion regulation (ER) in the development and treatment of psychopathology has increased in recent years. Evidence suggests that an increased focus on ER in treatment can improve existing interventions. Most ER research has neglected young people, therefore the present meta-analysis summarizes the evidence for existing psychosocial intervention and their effectiveness to improve ER in youth. A systematic review and meta-analysis was conducted according to the PRISMA guidelines. Twenty-one randomized-control-trials (RCTs) assessed changes in ER following a psychological intervention in youth exhibiting various psychopathological symptoms. We found moderate effect sizes for current interventions to decrease emotion dysregulation in youth (g = - 0.46) and small effect sizes to improve emotion regulation (g = 0.36). Significant differences between studies including intervention components, ER measures and populations studied resulted in large heterogeneity. This is the first meta-analysis that summarizes the effectiveness for existing interventions to improve ER in youth. The results suggest that interventions can enhance ER in youth, and that these improvements correlate with improvements in psychopathology. More RCTs including larger sample sizes, different age groups and psychopathologies are needed to increase our understanding of what works for who and when.

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.

Emotion regulation in pediatric bipolar disorder: A meta-analysis of published studies

BACKGROUND

Emotion regulation is a relatively recent topic in psychiatry, and has only recently begun to be tested across Pediatric Bipolar Disorder (PBD). To date, no meta-analysis has investigated the presence of emotion regulation deficits in PBD patients.

OBJECTIVES

The aim of this study is to understand where the literature stands on this topic, as well as how different researchers are measuring and grasping the concept of emotion regulation in pediatric bipolar disorders.

METHODS

A systematic search of trials using the terms ("Pediatric Bipolar Disorder") AND ("Emotion Regulation" OR "Affect Regulation" OR "Mood Lability" OR "Mood Instability" OR "Irritability") was conducted using PubMed, Google Scholar, ResearchGate, Web of Science and Psych Info databases. Of the initial 366 articles identified, 8 met eligibility criteria for the meta-analysis and were included in this study.

RESULTS

There is a statistically significant difference in Accuracy in Emotion Regulation tasks, with a tendency for lower accuracy in PBD patients; however, both groups did not differ statistically regarding Response Time.

CONCLUSION

Our data suggests that PBD patients do present emotion regulation deficits, particularly regarding facial emotion recognition and affective language interference tasks mediated by cognitive assignments. These results have important implications in developing novel psychotherapeutic interventions for this population.

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.

Moody kids years later: Long-term outcomes of youth from the Omega-3 and therapy (OATS) studies

BACKGROUND

This naturalistic follow-up study examines outcomes for youth with depression (n = 25) or subsyndromal bipolar disorder (n = 13) 2-5 years after participation in randomized clinical trials (RCTs) of omega-3 fatty acids (Ω3), individual family psychoeducational psychotherapy (IF-PEP), and their combination METHODS: Forty percent (38/95) of RCT families completed a follow-up assessment RESULTS: Relapse rates and conversion to bipolar disorder were consistent with published literature. Original treatment assignment did not impact current functioning. Overall, participants' mood severity, executive functioning, and global functioning continued to be better than at RCT baseline. Depressive symptoms increased significantly from end of RCT. Manic symptom severity, executive functioning, and global functioning remained comparable to end of RCT. The majority of parents and youth reported improved youth emotion regulation skills and family communication. They considered study participation beneficial, with increased understanding of mood disorders being the top reason. Half of youth commenced or continued Ω3 and 58% commenced or continued psychotherapy post-RCT, suggesting some degree of consumer satisfaction; these youth had lower depression severity than other participants.

LIMITATIONS

Only 40% returned to this naturalistic follow-up; they were less likely to have an African-American parent, were of higher income, and youth were more symptomatic at end of RCT than those who did not return CONCLUSIONS: Improvement from RCT baseline continued although depressive symptom severity increased from end of RCT to follow-up. Meaningful improvements in youth and family functioning persisted 2-5 years later. Interventions that prevent relapse or conversion to BPSD are still needed for these vulnerable populations.

Emotional Dysregulation in Children and Adolescents With Psychiatric Disorders. A Narrative Review

Background: Emotional dysregulation (ED) is a transdiagnostic construct defined as the inability to regulate the intensity and quality of emotions (such as, fear, anger, sadness), in order to generate an appropriate emotional response, to handle excitability, mood instability, and emotional overreactivity, and to come down to an emotional baseline. Because ED has not been defined as a clinical entity, and because ED plays a major role in child and adolescent psychopathology, we decided to summarize current knowledge on this topic based on a narrative review of the current literature. Methods: This narrative review is based on a literature search of peer-reviewed journals. We searched the databases ERIC, PsycARTICLES, PsycINFO and PSYNDEX on June 2, 2020 for peer reviewed articles published between 2000 and 2020 in English language for the preschool, school, and adolescent age (2-17 years) using the following search terms: "emotional dysregulation" OR "affect dysregulation," retrieving 943 articles. Results: The results of the literature search are presented in the following sections: the relationship between ED and psychiatric disorders (ADHD, Mood Disorders, Psychological Trauma, Posttraumatic Stress Disorder, Non-suicidal Self-Injury, Eating Disorders, Oppositional Defiant Disorder, Conduct Disorder, Disruptive Disruptive Mood Dysregulation Disorder, Personality Disorders, Substance Use Disorder, Developmental Disorders, Autism Spectrum Disorder, Psychosis and Schizophrenia, and Gaming Disorder), prevention, and treatment of ED. Conclusion: Basic conditions of ED are genetic disposition, the experience of trauma, especially sexual or physical abuse, emotional neglect in childhood or adolescence, and personal stress. ED is a complex construct and a comprehensive concept, aggravating a number of various mental disorders. Differential treatment is mandatory for individual and social functioning.

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.

Adapted Dialectical Behavior Therapy for Adolescents with a High Risk of Suicide in a Community Clinic: A Pragmatic Randomized Controlled Trial

OBJECTIVE

This study is a pragmatic randomized controlled trial, which compares the effectiveness of an adapted form of Dialectical Behavior Therapy for Adolescents (DBT-A) and treatment as usual plus group sessions (TAU + GS) to reduce suicidal risk for adolescents in a community health mental clinic.

METHOD

Thirty-five adolescents from a community outpatient clinic, with repetitive NSSI alone or with SA over the last 12 months and with current high suicide risk as assessed by the Columbia-Suicide Severity Rating Scale (C-SSRS), were enrolled. Participants were randomly assigned to undergo either DBT-A (n = 18) or TAU + GT (n = 17) treatments over a 16-week period. Primary outcomes were the difference between NSSI and SA recorded during the first 4 weeks and the final 4 weeks of treatment. Secondary outcomes included changes in Children's Global Assessment Scale (C-GAS), Suicidal Ideation Questionnaire (SIQ-JR), and Beck Depression Inventory-II (BDI-II).

RESULTS

Dialectical Behavior Therapy for Adolescents was more effective than TAU + GS at reducing NSSI, use of antipsychotics, and improving C-GAS. No SAs were reported in the two groups at the end of the treatment. Both treatments were equally effective in decreasing SIQ-JR and BDI-II scores.

CONCLUSIONS

These findings support the feasibility and effectiveness of DBT-A for adolescents at high risk of suicide in community settings.

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).

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.

Childhood factors associated with increased risk for mood episode recurrences in bipolar disorder-A systematic review

BACKGROUND

Bipolar Disorder (BD) is a recurrent illness associated with high morbidity and mortality. The frequency of mood episode recurrence in BD is highly heterogeneous and significantly impacts the person's psychosocial functioning and well-being. Understanding the factors associated with mood recurrences could inform the prognosis and treatment. The objective of this review is to summarize the literature on factors, present during childhood, that influence recurrence.

METHODOLOGY

A systematic review of PubMed (1946-2017) and PsycINFO (1884-2017) databases was conducted to identify candidate studies. Search terms included bipolar disorder, episodes, predictors, recurrences, and course. Study characteristics, risk for bias, and factors associated with recurrence were coded by two raters according to predetermined criteria.

RESULTS

Twenty child studies and 28 adult studies that retrospectively evaluated childhood variables associated with mood recurrences were included. Early age of onset, low socioeconomic status, comorbid disorders, inter-episode subsyndromal mood symptoms, BD-I/II subtypes, presence of stressors, and family history of BD were associated with higher number of recurrences.

LIMITATIONS

Risk factors and mood recurrences were assessed and defined in different ways, limiting generalizability.

CONCLUSION

Multiple factors are associated with increased risk of mood episode recurrence in BD. Interventions targeting modifiable factors could reduce the impact of BD. For example, treatment of comorbid disorders and subsyndromal mood symptoms, coupled with appropriate cognitive behavioral and family-focused therapies could ameliorate risk related to many clinical factors. When coupled with social services to address environmental factors, the number of episodes could be reduced and the course of BD significantly improved.

Sleep alterations in pediatric bipolar disorder versus attention deficit disorder

Bipolar disorder (BD) and attention deficit/hyperactivity disorder (ADHD) share numerous clinical features, which can make the differential diagnosis challenging. Studies conducted in adults suggest that patients with BD and ADHD have different sleep patterns. However, in pediatric populations, data on these potential differences are scant. The present preliminary study was conducted to identify potential differences in sleep alterations among youths diagnosed with BD or ADHD compared to healthy controls (HC). A total of 26 patients diagnosed with BD (n = 13) or ADHD (n = 13) were compared to 26 sex- and age-matched HC ([HC_BD], n = 13, and [HC_ADHD], n = 13). All participants underwent polysomnography. The mean duration of stage N2 sleep was shorter in the BD group than in controls (HC_BD). The BD group also had higher (non-significant) REM density (REMd) scores than controls while mean REMd scores were lower in the ADHD group versus controls. Compared to the ADHD group, the BD group presented a shorter N2 stage, a longer first REM sleep duration (R1), and greater REMd. According to our findings, these three variables-N2 stage, REMd, and R1-appear to differentiate patients with BD from those with ADHD and from HC.

Difficulties in emotion regulation and suicide ideation and attempt in adolescent inpatients

This study aimed to examine the concurrent relation between six dimensions of emotion dysregulation, proposed by Gratz and Roemer (2004), and suicide ideation and attempt in a large sample of psychiatric adolescent inpatients. A sample of 547 adolescent inpatients completed measures on dimensions of emotion dysregulation, psychiatric diagnoses, and suicidal ideation and attempt. Binary logistic regression analyses revealed that limited access to emotion regulation strategies, difficulties in impulse control, and mood disorder diagnosis, were significantly associated with past year suicidal ideation, covarying for other emotion dysregulation subscales, anxiety and externalizing diagnoses, sex, and age. However, difficulties in impulse control was not significantly related to suicide ideation when analyses were conducted separately by sex. Binary logistic regressions also revealed that past year suicidal ideation uniquely and significantly associated with lifetime attempt, covarying for sociodemographics, psychiatric diagnoses, and all emotion dysregulation subscales; these results held when analyses were also conducted separately by sex. Results indicating an association between perceived limited emotion regulation strategies and suicide ideation are consistent with existing research and suicide-focused theory. This finding may have some tentative benefit to informing clinical assessment and treatment of suicidal thoughts. Other findings are discussed.

Treatment-induced brain plasticity in borderline personality disorder: review of functional MRI studies

Although neural substrates of symptoms expression in borderline personality disorder (BPD) have been studied extensively, neural mechanisms mediating post treatment amelioration of symptoms remain poorly characterized. Herein present review sheds a critical light on all here-to-date functional MRI findings of brain changes in BPD patients following a treatment with psychotherapy or drugs. Preliminary evidence points to downregulation of neuronal activity within the insula and amygdala, together with differential employment of prefrontal areas, mainly orbitofrontal cortex, anterior cingulate cortex and dorsolateral prefrontal cortex, as well as enhanced functional connectivity between limbic and prefrontal regions induced by dialectical behavioral therapy. Identifying neural circuits behind treatment processes may refine strategies to target specific symptoms, thereby resolving some of the controversies over BPD 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.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third- line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment-emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second- line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence-based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first-line treatments for acute mania. First-line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.

Emotion Dysregulation Is Associated With Social Impairment Among Young Adolescents With ADHD

OBJECTIVE

The purpose of this study was to evaluate aspects of emotion dysregulation (ED) that characterize young adolescents with ADHD, examine the effects of subtype and comorbidity, and determine the extent to which ED is related to aggression and rule-breaking and social impairment.

METHOD

We examined which aspects of ED are most relevant to ADHD in 180 young adolescents (75% boys), as well as whether ED differs across ADHD subtypes or comorbid oppositional defiant disorder (ODD) status. We also examined the association between ED and aggression, rule-breaking, and social impairment.

RESULTS

Young adolescent females and males with ADHD exhibited various manifestations of ED, including behavioral dyscontrol in the presence of strong emotions and inflexibility/slow return to emotional baseline. ED did not differ as a function of ADHD subtype or comorbid ODD. Three aspects of ED, namely, low threshold for emotional excitability/impatience, behavioral dyscontrol in the face of strong emotions, and inflexibility/slow return to baseline, predicted three of six measured indices of parent- and self-reported social impairment, above and beyond comorbid ODD.

CONCLUSIONS

ED is associated with ADHD among young adolescents, does not differ based on ADHD subtype or ODD status, and is associated with social impairment.

Empirical Examinations of Modifications and Adaptations to Evidence-Based Psychotherapies: Methodologies, Impact, and Future Directions

This review describes methods used to examine the modifications and adaptations to evidence-based psychological treatments (EBPTs), assesses what is known about the impact of modifications and adaptations to EBPTs, and makes recommendations for future research and clinical care. One hundred eight primary studies and three meta-analyses were identified. All studies examined planned adaptations, and many simultaneously investigated multiple types of adaptations. With the exception of studies on adding or removing specific EBPT elements, few studies compared adapted EBPTs to the original protocols. There was little evidence that adaptations in the studies were detrimental, but there was also limited consistent evidence that adapted protocols outperformed the original protocols, with the exception of adding components to EBPTs. Implications for EBPT delivery and future research are discussed.

Dialectical Behavior Therapy Group Skills Training for Bipolar Disorder

There is growing evidence that the capacity for emotion regulation is compromised in individuals with bipolar disorder. Dialectical behavior therapy (DBT), an empirically supported treatment that specifically targets emotion dysregulation, may be an effective adjunct treatment for improving emotion regulation and residual mood symptoms in patients with bipolar disorder. In this open, proof-of-concept pilot study, 37 participants engaged in a 12-week DBT group skills training program, learning mindfulness, emotion regulation, and distress tolerance skills. Repeated measures mixed models revealed skill acquisition in the areas of mindfulness, emotion regulation and distress tolerance, as well as improved psychological well-being and decreased emotion reactivity. The results of this study support a burgeoning literature that DBT is a feasible adjunct intervention for patients with bipolar disorder.

Empirically supported psychosocial interventions for bipolar disorder: Current state of the research

OBJECTIVES

Bipolar disorder requires psychiatric medications, but even guideline-concordant treatment fails to bring many patients to remission or keep them euthymic. To address this gap, researchers have developed adjunctive psychotherapies. The purpose of this paper is to critically review the evidence for the efficacy of manualized psychosocial interventions for bipolar disorder.

METHODS

We conducted a search of the literature to examine recent (2007-present), randomized controlled studies of the following psychotherapy interventions for bipolar disorder: psychoeducation (PE), cognitive behavioral therapy (CBT), interpersonal and social rhythm therapy (IPSRT), dialectical behavior therapy (DBT), mindfulness-based cognitive therapy (MBCT), and family therapies such as family focused therapy (FFT).

RESULTS

All of the psychotherapy interventions appear to be effective in reducing depressive symptoms. Psychoeducation and CBT are associated with increased time to mood episode relapse or recurrence. MBCT has demonstrated a particular effectiveness in improving depressive and anxiety symptoms. Online psychotherapy interventions, programs combining one or more psychotherapy interventions, and targeted interventions centering on particular symptoms have been the focus of recent, randomized controlled studies in bipolar disorder.

CONCLUSIONS

Psychotherapy interventions for the treatment of bipolar disorder have substantial evidence for efficacy. The next challenge will to disseminate these psychotherapies into the community.

Mindfulness-Based Approaches for Children and Youth

Mindfulness meditation is a useful adjunct to behavioral and medical interventions to manage a range of symptoms, including psychological and physical responses to stress, anxiety, depression, and disruptive behavior. Mindfulness approaches can be taught to children, adolescents, and their parents to improve self-regulation, particularly in response to stress. Mindfulness may be particularly relevant for youth and families who have an increased risk for exposure to chronic stress and unique stressors associated with medical and/or social-contextual considerations. Moreover, mindfulness parenting techniques can augment traditional behavioral approaches to improve children׳s behavior through specific parent-child interactions. A growing body of empirical studies and clinical experience suggest that incorporating mindfulness practices will enable clinicians to more effectively treat youth and their families in coping optimally with a range of challenging symptoms.

Outcome of a web-based mindfulness intervention for families living with mental illness - A feasibility study

BACKGROUND

Families living with a person with mental illness can experience distress requiring therapeutic interventions. Web-based mindfulness interventions have shown beneficial health outcomes for both clinical and healthy populations, and may help families cope and overcome barriers that can otherwise hinder a help-seeking process.

AIMS

To develop and assess outcomes of a web-based mindfulness intervention for families living with a person with mental illness.

METHODS

A pilot study investigating an 8-week web-based mindfulness intervention with a pre-post design and follow-up after 3 months, with mindfulness as the primary outcome and perceived stress, caregiver burden and self-compassion as secondary outcomes. The study included a sample of 97 persons approached by advertisement in newspapers, newsletters, and online.

RESULTS

The study showed significant improvements in levels of mindfulness post-intervention and at follow-up as well as significant improvements in levels of perceived stress, caregiver burden, and self-compassion both post-intervention and at follow-up.

DISCUSSION

Acceptability and feasibility of the intervention were high, outcomes were relevant, and the intervention showed positive and significant results supporting the hypothesis that the intervention may help families cope with a stressful situation.

CONCLUSION

Further randomized controlled studies of the intervention are needed to investigate the intervention's effectiveness, including dose-effect studies.

Dialectical behavior therapy for nonsuicidal self-injury and depression among adolescents: preliminary meta-analytic evidence

BACKGROUND

Dialectical behavior therapy (DBT) has proven effective in reducing symptoms and behaviors related to Borderline Personality Disorder. More recently, it has been modified and applied to adolescents struggling with regulating their emotions and who may engage in impulsive, self-destructive behaviors, including nonsuicidal self-injury (NSSI). However, there is limited research evidence regarding the effectiveness of DBT for reducing NSSI behavior and depression among adolescents. Given the high suicide risk associated with NSSI and its association with depression, this is clearly an important focus of clinical and research attention.

METHOD

This meta-analysis sought to offer preliminary evidence regarding the effectiveness of DBT to treat NSSI and depression in adolescents. Twelve published studies were included; all 12 reported pre- and post-treatment measures of depression and six of these studies reported pre- and post-treatment measures of NSSI.

RESULTS

The weighted mean effect size for NSSI was large (g = 0.81, 95% CI = 0.59-1.03); the weighted mean effect size for depression was small (g = 0.36, 95% CI = 0.30-0.42).

CONCLUSIONS

Intervention effects for both outcomes were positive, suggesting decreased NSSI and improvement in depressive symptoms for adolescents following a course of DBT. However, given considerable limitations in the research base available for meta-analysis, these findings are preliminary and tentative. Limitations in the current knowledge base and suggestions for future research are discussed.

Adjunctive Behavioral Activation for the Treatment of Bipolar Depression: A Proof of Concept Trial

BACKGROUND

Grounded in a model focused on exposure to response-contingent positive reinforcement, and with evidence supporting its acute treatment effects for unipolar depression, an adjunctive behavioral activation (BA) intervention may be especially well suited to the treatment of bipolar depression. The goal of this study was to modify BA for the adjunctive treatment of bipolar depression and to pilot it in a proof of concept trial to assess its preliminary feasibility and acceptability for this population.

METHODS

Twelve adults with bipolar depression were recruited from hospital settings and enrolled in a 20-week open trial of the modified BA, delivered in 16 outpatient sessions, as an adjunct to community pharmacotherapy for bipolar disorder. Symptom severity was assessed at pretreatment and posttreatment by an independent evaluator. Patient satisfaction was also assessed posttreatment.

RESULTS

Feasibility and acceptability were high, with 10 of 12 patients completing treatment, an average of 14.8 (SD=5.2) of 16 sessions attended, and high levels of self-reported treatment satisfaction. Patients exhibited statistically significant improvement from pretreatment to posttreatment on measures of depressive symptoms, manic symptoms, and severity of suicidal ideation.

CONCLUSIONS

Although preliminary and requiring replication in a larger sample, these study data suggest that a modified BA intervention may offer promise as an adjunctive approach for the acute treatment of bipolar depression. Future studies that use more rigorous randomized controlled designs and that directly assess potential mechanisms of action are recommended.

Psychotherapeutic Treatment of Bipolar Depression

The gold standard for treating bipolar depression is based on the combination of mood stabilizers and psychotherapy. Therefore, the authors present evidence-based models and promising approaches for psychotherapy for bipolar depression. Cognitive-behavioral therapy, family focused therapy, interpersonal and social rhythm therapy, mindfulness-based cognitive therapy, and dialectical behavior therapy are discussed. Behavioral activation, the cognitive behavioral analysis system of psychotherapy, and the unified protocol as promising future directions are presented. This review informs medical providers of the most appropriate referral guidelines for psychotherapy for bipolar depression. The authors conclude with a decision tree delineating optimal referrals to each psychotherapy approach.

The Social Appearance Anxiety Scale in Italian Adolescent Populations: Construct Validation and Group Discrimination in Community and Clinical Eating Disorders Samples

Anxiety in situations where one's overall appearance (including body shape) may be negatively evaluated is hypothesized to play a central role in Eating Disorders (EDs) and in their co-occurrence with Social Anxiety Disorder (SAD). Three studies were conducted among community (N = 1995) and clinical (N = 703) ED samples of 11- to 18-year-old Italian girls and boys to (a) evaluate the psychometric qualities and measurement equivalence/invariance (ME/I) of the Social Appearance Anxiety (SAA) Scale (SAAS) and (b) determine to what extent SAA or other situational domains of social anxiety related to EDs distinguish adolescents with an ED only from those with SAD. Results upheld the one-factor structure and ME/I of the SAAS across samples, gender, age categories, and diagnostic status (i.e., ED participants with and without comorbid SAD). The SAAS demonstrated high internal consistency and 3-week test-retest reliability. The strength of the inter-relationships between SAAS and measures of body image, teasing about appearance, ED symptoms, depression, social anxiety, avoidance, and distress, as well as the ability of SAAS to discriminate community adolescents with high and low levels of ED symptoms and community participants from ED participants provided construct validity evidence. Only SAA strongly differentiated adolescents with any ED from those with comorbid SAD (23.2 %). Latent mean comparisons across all study groups were performed and discussed.

A feasibility study of a Family Focused Treatment for Adolescents with Bipolar Disorder-the FAB study

Background

The aim of this study is to examine the feasibility of a future definitive randomised controlled trial of Family Focused Treatment for Adolescents UK (FFT-A UK) in the management of early-onset bipolar disorder (EOBD) (under 18 years). The FFT-A has been evaluated in the USA to augment the pharmacological treatment of adolescents with bipolar disorder (BD). The FFT-A UK has been condensed to 16 sessions over approximately 6 months to be utilised within the UK National Health Service.

Research from the USA suggests that families experience high levels of distress, stress, burden and family disharmony when living with a young person who has BD. The FFT-A UK is a family-based approach designed to increase understanding of BD (psycho-education), improve communication and increase ability to problem-solve.

Methods/Design

The trial will examine the feasibility of a randomised, parallel group, non-blinded design and the procedures of a subsequent definitive trial. Thirty-three young people with BD and their families will be recruited. Participants will complete measures at baseline, on completion of the 6-month treatment and again after a further 6 months. The self-report measures include the Warwick Edinburgh Mental Well-being Scale, The McMaster Family Assessment Device (FAD), Conflict Behaviour Questionnaire aka ‘Interaction Behaviour Questionnaire’, EuroQuol EQ-5D-3L and EQ-5D-Y. Primary outcomes will be rates of eligibility, recruitment and retention, estimates of the variability in the self-report measures and assessment of the intervention delivery in the study population. Participants’ qualitative views on the measures and intervention will be sought to confirm the acceptability of intervention and study design. The health economics component will establish how cost-effectiveness will be assessed in a future definitive trial.

Discussion

The study will produce a full trial protocol and amendments to the FFT-A UK to inform a well-designed multi-centre randomised controlled trial (RCT) as an adjunct to pharmacotherapy in the management of EOBD.

Trial registration

Current Controlled Trials ISRCTN59769322

A systematic review of cognitive rehabilitation for bipolar disorder

Introduction: It has been shown that bipolar disorder (BD) has a direct impact on neurocognitive functioning and behavior. This finding has prompted studies to investigate cognitive enhancement programs as potential treatments for BD, primarily focusing on cognitive reinforcement and daily functioning and not restricted to psychoeducation and coping strategies, unlike traditional psychosocial treatments. Objective: This study presents a systematic review of controlled trials of cognitive rehabilitation (CR) for BD. Our main objective is to describe the results of studies of rehabilitation programs for BD and related methodological issues. Method: Electronic database searches (MEDLINE, Web of Science, and Embase) were conducted to identify articles using terms related to BD and CR. The methodological quality of each article was measured using the 5-item Jadad scale. Results: A total of 239 articles were initially identified, but after application of exclusion criteria, only four were retained for this review. An average of 17 hours of intervention sessions were conducted, distributed as 0.95 hours per week and three of the four studies reported better executive function performance after CR interventions. Conclusions: We did not find robust evidence to support cognitive rehabilitation as an effective treatment for BD, because of: 1) the variety of intervention designs; 2) the methodological limitations of the studies; and 3) the lack of studies in the field.

Practitioner Review: Borderline personality disorder in adolescence--recent conceptualization, intervention, and implications for clinical practice

BACKGROUND

The past decade has seen an unprecedented increase in research activity on personality disorders (PDs) in adolescents. The increase in research activity, in addition to major nosological systems legitimizing the diagnosis of borderline personality disorder (BPD) in adolescents, highlights the need to communicate new research on adolescent personality problems to practitioners.

SCOPE

In this review, we provide up-to-date information on the phenomenology, prevalence, associated clinical problems, etiology, and intervention for BPD in adolescents. Our aim was to provide a clinically useful practitioner review and to dispel long-held myths about the validity, diagnostic utility, and treatability of PDs in adolescents.

FINDINGS AND CONCLUSION

Alongside providing up-to-date information on the phenomenology, prevalence, and etiology, we also report on associated clinical problems and interventions for adolescent BPD. It is only through early active assessment and identification of youngsters with these problems that a lifetime of personal suffering and health system burden can be reduced or altogether avoided. A variety of evidence-based approaches are now available to treat BPD and related clinical problems in young people. Future research should focus on establishing optimal precision in the diagnostic processes in different treatment settings.