An open pilot feasibility study of a brief dialectical behavior therapy skills-based intervention for suicidal individuals

Effectiveness of single-session therapy for adult common mental disorders: a systematic review

BACKGROUND

Common mental disorders (CMDs) impose significant socioeconomic impacts on the global community. Nevertheless, over 50% of individuals with CMDs do not receive proper treatment, indicating that the current treatment modalities do not adequately tackle this issue. Since single-session therapy (SST) is a potential method for reducing the treatment gap, it is crucial to evaluate its effectiveness. Therefore, this systematic review aimed to evaluate the effectiveness of SST on CMD symptoms in adults.

METHODS

This systematic review included randomised and non-randomised studies assessing the clinical effectiveness of SST on CMD symptoms in adults. English-written, peer-reviewed studies or dissertations were included, while grey literature was excluded. MEDLINE, Embase, PsycINFO, and Cochrane's CENTRAL were searched on December 13, 2022, from their inception dates. The risk of bias in the included studies was evaluated using RoB 2 and ROBINS-I. A narrative synthesis was performed. This systematic review was registered in the PROSPERO database on July 6, 2022 (CRD42022343925).

RESULTS

Six randomised and three non-randomised studies were included after screening 2,130 records. Three non-randomised studies with a "critical" or "serious" risk of bias were excluded from the synthesis. Therefore, six randomised trials involving 298 participants were included in the synthesis. Four out of six studies had a "high" risk of bias. The participants had non-severe symptoms at baseline, and three intervention types (behavioural activation, DBT, and solution-focused psychotherapy) were evaluated. Five of six studies showed positive results for depression, with only one reporting a positive result for anxiety.

CONCLUSIONS

SST may be effective in improving CMD symptoms in adults, particularly depression. However, there is a limit to deriving definite conclusions due to a high risk of bias in included studies, insufficient sample size and research volume. Further research exploring the characteristics of clients who can benefit from SST is required to facilitate its widespread use.

Adapting dialectical behavior therapy in Mandarin-speaking Chinese patients with borderline personality disorder: An open pilot trial in Taiwan

INTRODUCTION

Dialectical behavior therapy (DBT) is the most commonly used treatment for patients suffering from borderline personality disorder (BPD). However, data on its applications in Asian countries remain lacking. This pilot study aims to evaluate the feasibility and effectiveness of applying Mandarin-translated DBT among suicidal Chinese patients with BPD in Taiwan.

METHODS

An open-label trial design was implemented for the 1-year standard DBT model. Patients from a psychiatric outpatient department in a general hospital in Taiwan with a history of ≥2 episodes of suicidal behavior within the previous year and who scored >40 on the Borderline Symptom List were invited to participate in this trial. Outcomes of suicidal behaviors, severity of BPD and depression symptoms, suicidal ideation, hopelessness, and quality of life were assessed at the beginning of the treatment and every 3 months until 12 months.

RESULTS

Eighteen patients participated, three of whom (16.7%) dropped out. Significant improvements were found in the frequency and severity of suicidal behaviors and ideations, depressive symptoms, and BPD symptoms beginning as early as the third month after initiating DBT.

DISCUSSION

This pilot study found that DBT may be an effective and feasible intervention for Mandarin-speaking individuals with a recent history of suicidal behaviors with BPD. Future randomized controlled trials with comparison groups are needed to further determine the efficacy of DBT on this population.

Creating a Flexible Outpatient Mental Health Transitions Program

Limited resources to support persons with mental illness create a crisis in our health care system. There is a shortage of inpatient beds, and emergency departments are overwhelmed by the number of persons experiencing a mental illness crisis. This article describes the design of a program to address the gaps in treatment. The goal of the program was to decrease the length of stay for inpatient mental health care and to divert emergency department patients. We describe the multidisciplinary brainstorming session that envisioned this program, how it differs from previous programs, the staffing model, curriculum, outcomes, and future plans.

Dialectical behavioral therapy skills group as an adjunct to family-based therapy in adolescents with restrictive eating disorders

Dialectical behavior therapy (DBT) is commonly used in the treatment of eating disorders (ED), yet few studies have examined the utility of DBT skills groups as an adjunct to evidence-based therapy for ED. Thus, we sought to examine the preliminary efficacy of a DBT skills group as an adjunct to Family-Based Treatment (FBT) for adolescent restrictive ED. Our preliminary pilot study included 18 adolescent girls ages 13-18 (M= 15.3, SD = 1.64) with restrictive ED, including Anorexia Nervosa (AN; N = 10), Atypical Anorexia Nervosa (AAN, N = 5), and Other Specific Feeding or Eating Disorder (OSFED; N = 3). All participants were enrolled in a 6-month, weekly DBT skills group and were concurrently receiving family-based treatment (FBT). Participants who completed the intervention experienced large effect sizes for increases in adaptive skills (Cohen's d = .71) and decreases in general dysfunctional coping strategies (Cohen's d = .85); and small to medium effect sizes for decreases in binge eating (Cohen's d = .40) and increases in percent expected body weight (% EBW; Cohen's d = .32). Finally, small effect sizes were evidenced in decreases in Global EDE-Q scores (Cohen's d = .26), EDE-Q restraint (Cohen's d = .29) and CDI scores (Cohen's d = .28). Our study presents promising preliminary data suggesting that adolescents with restrictive EDs receiving FBT could benefit from an adjunctive DBT skills group. Feasibility of and considerations for tailoring a DBT skills group to an outpatient ED treatment program are discussed.

Development and Evaluation of a Web-Based Resource for Suicidal Thoughts: NowMattersNow.org

Background

Nearly half of people who die by suicide see a health care provider in the month before their death. With the release of new care guidelines, detection of suicidal patients will likely increase. Providers need access to suicide-specific resources that can be used as part of immediate, brief interventions with a suicidal patient. Web-based suicide prevention resources have the potential to address this need.

Objective

This study aimed to describe the development of the NowMattersNow.org website as a resource for individuals with suicidal thoughts and to evaluate the utility of the site via user experience surveys.

Methods

NowMattersNow.org is an online video-based free public resource that provides evidence-based teachings, examples, and resources for managing suicidal thoughts and intense emotions focused largely around skills from dialectical behavior therapy. Developed with assistance from mental health consumers, it is intended to address gaps in access to services for suicidal patients in health care systems. Visitors stay an average of a minute and a half on the website. From March 2015 to December 2017, a user experience survey measured self-reported changes on a 1 (not at all) to 5 (completely overwhelming) scale regarding intensity of suicidal thoughts and negative emotions while on the website. Longitudinal regression analyses using generalized estimating equations evaluated the magnitude and statistical significance of user-reported changes in suicidal ideation and negative emotion. In secondary analyses, user-reported changes specific to subgroups, including men aged 36 to 64 years, mental health care providers, and other health care providers were evaluated.

Results

During the period of analysis, there were 138,386 unique website visitors. We analyzed surveys (N=3670) collected during that time. Subsamples included men aged 36 to 64 years (n=512), mental health providers (n=460), and other health care providers (n=308). A total of 28% (1028/3670) of survey completers rated their suicidal thoughts as a 5 or “completely overwhelming” when they entered the website. We observed significant reductions in self-reported intensity of suicidal thoughts (–0.21, P<.001) and negative emotions (–0.32, P<.001), including decreases for users with the most severe suicidal thoughts (–6.4%, P<.001), most severe negative emotions (–10.9%, P<.001), and for middle-aged men (–0.13, P<001). Results remained significant after controlling for length of visit to website (before the survey) and technology type (mobile, desktop, and tablet).

Conclusions

Survey respondents reported measurable reductions in intensity of suicidal thoughts and emotions, including those rating their suicidal thoughts as completely or almost completely overwhelming and among middle-aged men. Although results from this user-experience survey administered at one point in time to a convenience sample of users must be interpreted with caution, results provide preliminary support for the potential effectiveness of the NowMattersNow.org website as a tool for short-term management of suicidal thoughts and negative emotions.

Effectiveness of Psychotherapy on Suicidal Risk: A Systematic Review of Observational Studies

Background: Suicidal behavior is a major public health concern worldwide, and the interest in the development of novel and more efficient treatment strategies and therapies to reduce suicidal risk is increasing. Some recent studies have summarized the results of randomized clinical trials (RCTs) assessing the efficacy of psychotherapeutic tools designed to treat patients at suicidal risk. However, observational studies, which reflect real-world effectiveness and may use original approaches, have not been reviewed. Method: The aim of this study is to systematically review the available scientific evidence issued from observational studies on the clinical effectiveness of psychotherapeutic tools designed to treat patients at suicide risk. We have thus performed a systematic search of PubMed and Web of Science databases. Results: Out of 1578 papers, 40 original observational studies fulfilled our selection criteria. The most used psychotherapeutic treatments were dialectical behavioral therapy (DBT, 27.5%) and cognitive behavioral therapy (CBT, 15.0%) in patients with a diagnosis of borderline personality disorder (32.5%) and depression (15.0%). Despite the between-study heterogeneity, interventions lead to a reduction in suicidal outcomes, i.e., suicidal ideation (55.0%) and suicide attempts (37.5%). The content and reporting quality varied considerably between the studies. Conclusion: DBT and CBT are the most widely used psychotherapeutic interventions and show promising results in existing observational studies. Some of the included studies provide innovative approaches. Group therapies and internet-based therapies, which are cost-effective methods, are promising treatments and would need further study.

Development and pilot evaluation of an online psychoeducational program for suicide prevention among university students: A randomised controlled trial

INTRODUCTION

Suicide is the second leading cause of death for the university aged population globally. A significant proportion of students with suicidal ideation or behaviours do not seek professional help. Few primary suicide prevention programs have specifically targeted help seeking for suicidal ideation or behaviours among university students.

METHODS

This study reported the development and pilot test of a brief, two-module online psychoeducational program (ProHelp) that aimed to encourage help seeking for suicidal ideation and behaviours among university students. The program consists of two five-minute modules that address the risk factors and warning signs of suicide, stigmatising attitudes, and perceived barriers to help seeking. 156 Chinese university students and 101 Australian university students were recruited to evaluate the effectiveness of this program at post-test and one-month follow-up. Participants were randomly assigned to the psychoeducational program or an attention control program.

RESULTS

Of the Chinese and Australian students who were randomised into the study, around 50% completed the two-day post-test survey, and 30% completed the one-month follow-up survey. Although no significant difference was found between the control and experimental group on professional help-seeking beliefs and intentions, both groups' help-seeking attitudes increased during the study (p = 0.003 for the post-test survey, and p = 0.008 for the follow-up survey). The experimental group in both countries demonstrated a significant improvement in suicide literacy at the post-test survey (p = 0.015) compared to control. Qualitative feedback indicated that the ProHelp program was user-friendly, clear, and helpful.

CONCLUSIONS

This study provides initial evidence that a brief online psychoeducational program could enhance university students' suicide literacy in both China and Australia. It also suggests that increasing suicide literacy might not be sufficient to improve students' help seeking, although effect sizes indicated that this low-intensity online approach shows promise in encouraging more positive beliefs towards help seeking and preparedness to help individuals with suicidal ideation among young people.

Comparing brief interventions for suicidal individuals not engaged in treatment: A randomized clinical trial

BACKGROUND

Non-treatment-engaged individuals experiencing suicidal thoughts have been largely overlooked in the intervention literature, despite reviews suggesting most individuals who die by suicide were not in treatment immediately prior to their death. Most intervention studies recruit individuals from treatment providers, potentially neglecting those individuals who are not already engaged in services. These individuals clearly represent a group in need of additional empirical attention.

METHODS

A randomized clinical trial was conducted to compare a single-session dialectical behavior therapy skills-based intervention to a relaxation training control condition. Ninety-three non-treatment-engaged subjects participated in a single in-person assessment, received one of the intervention protocols, and completed follow-up phone interviews for three months including measures of suicidal ideation, emotion dysregulation, and coping skills, as well as other relevant assessments.

RESULTS

Both conditions reported significantly reduced levels of suicidal ideation, depression, and anxiety; however, analyses revealed no significant differences between conditions on the main outcome measures of suicidal ideation, emotion dysregulation, skills use, depression, or anxiety.

LIMITATIONS

The two interventions may have been too similar to permit detection of differential effects with this sample size. Specifically, the control condition may have been too active and there may have been stylistic overlap by providers who delivered both interventions.

CONCLUSIONS

Encouragingly, half of subjects contacted other mental health services during the follow-up period. Although the two interventions under investigation did not yield differential results, the significant changes in important domains across interventions suggest that brief interventions may hold promise for this difficult-to-reach population.

Suicide prevention strategies revisited: 10-year systematic review

BACKGROUND

Many countries are developing suicide prevention strategies for which up-to-date, high-quality evidence is required. We present updated evidence for the effectiveness of suicide prevention interventions since 2005.

METHODS

We searched PubMed and the Cochrane Library using multiple terms related to suicide prevention for studies published between Jan 1, 2005, and Dec 31, 2014. We assessed seven interventions: public and physician education, media strategies, screening, restricting access to suicide means, treatments, and internet or hotline support. Data were extracted on primary outcomes of interest, namely suicidal behaviour (suicide, attempt, or ideation), and intermediate or secondary outcomes (treatment-seeking, identification of at-risk individuals, antidepressant prescription or use rates, or referrals). 18 suicide prevention experts from 13 European countries reviewed all articles and rated the strength of evidence using the Oxford criteria. Because the heterogeneity of populations and methodology did not permit formal meta-analysis, we present a narrative analysis.

FINDINGS

We identified 1797 studies, including 23 systematic reviews, 12 meta-analyses, 40 randomised controlled trials (RCTs), 67 cohort trials, and 22 ecological or population-based investigations. Evidence for restricting access to lethal means in prevention of suicide has strengthened since 2005, especially with regard to control of analgesics (overall decrease of 43% since 2005) and hot-spots for suicide by jumping (reduction of 86% since 2005, 79% to 91%). School-based awareness programmes have been shown to reduce suicide attempts (odds ratio [OR] 0·45, 95% CI 0·24-0·85; p=0·014) and suicidal ideation (0·5, 0·27-0·92; p=0·025). The anti-suicidal effects of clozapine and lithium have been substantiated, but might be less specific than previously thought. Effective pharmacological and psychological treatments of depression are important in prevention. Insufficient evidence exists to assess the possible benefits for suicide prevention of screening in primary care, in general public education and media guidelines. Other approaches that need further investigation include gatekeeper training, education of physicians, and internet and helpline support. The paucity of RCTs is a major limitation in the evaluation of preventive interventions.

INTERPRETATION

In the quest for effective suicide prevention initiatives, no single strategy clearly stands above the others. Combinations of evidence-based strategies at the individual level and the population level should be assessed with robust research designs.

FUNDING

The Expert Platform on Mental Health, Focus on Depression, and the European College of Neuropsychopharmacology.

Single-session dialectical behavior therapy skills training versus relaxation training for non-treatment-engaged suicidal adults: a randomized controlled trial

BACKGROUND

Individuals who are not engaged in treatment are commonly overlooked in the design of intervention trials targeting suicidal populations as a result of recruitment methodology that requires individuals to be referred from their current provider. In fact, research suggests that the majority of individuals who die by suicide have not been in contact with mental health services in the year before their death.

METHODS/DESIGN

A randomized controlled trial of two brief, one-session interventions for adults who are not engaged in mental health treatment. Inclusion criteria include 1) 18 years or older, 2) experiencing suicidal ideation in the past week, 3) have not received mental health treatment in the month prior to screening, 4) living within commuting distance to the research office, and 5) willing to consent to recording and assessment. Exclusion criteria are 1) non-English speaking and 2) significant cognitive impairment. Recruitment takes place in the community via flyers, radio, and online advertisements. Interested individuals are screened via telephone and those who are eligible attend a one-time in-person assessment and intervention appointment. During this appointment, they are randomized to a single-session intervention in which they are presented with either dialectical behavior therapy skills or supportive discussion and instruction in relaxation. Following the in-person appointment, participants complete three follow-up interviews via telephone at one-week, four-weeks, and twelve-weeks post-intervention. The primary outcomes are suicidal ideation, emotion dysregulation, and skills use. Secondary outcomes include depression, anxiety, self-efficacy, and treatment utilization. Exploratory outcomes are suicidal and intentionally self-injurious behaviors. Intent-to-treat analyses will be conducted on primary and secondary outcomes.

DISCUSSION

Suicidal individuals who are not engaged in mental health treatment are an understudied and significantly at-risk group for death by suicide. A better understanding of this population, targeted efforts to recruit and engage these individuals, and developing effective interventions for this group are critical areas for investigation in the field that this trial seeks to address.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02236325 ; Date of registration: 05-Sept-2014.