Internet-Delivered Dialectical Behavioral Therapy Skills Training for Suicidal and Heavy Episodic Drinkers: Protocol and Preliminary Results of a Randomized Controlled Trial

Effectiveness of internet-delivered dialectical behavior therapy skills training on executive functions among college students with borderline personality traits: a non-randomized controlled trial

Given the enormous influence of emotions on cognitive processes, individuals with borderline personality disorder (BPD) suffer from marked deficits in higher-order thinking abilities. Considering the prevalence of BPD among college students, this study aimed to investigate the changes in perceived executive functioning among college students with traits/presence of BPD undergoing internet-delivered dialectical behavior therapy skills training (DBT-ST) that included the mindfulness and emotion regulation modules. An internet-delivered version of DBT-ST was opted for, as technological advancements in the present era promote the use of online platforms for psychotherapy. This non-randomized controlled trial consisted of 36 college students with traits/presence of BPD. The intervention group attended 13 sessions of DBT-ST, and the control group attended 13 sessions of behavioral activation. Perceived executive functioning was assessed using the Behavior Rating Inventory of Executive Functions for Adults. A 2-way repeated measures analysis of variance was used to evaluate the treatment impact on the outcome variable. Results showed that the DBT-ST group had larger improvements in their abilities to initiate, plan, and organize current and future-oriented task demands and to organize their everyday environment, compared to the control group. Both, the DBT-ST group and the control group demonstrated improvements in emotional control, working memory, and their abilities to shift and task monitor. Findings suggest that the internet-delivered version of DBT-ST, consisting of the mindfulness and emotion regulation modules, can foster notable improvements in executive functions among college students with traits/presence of BPD. Improved executive functioning is one of the several multifaceted outcomes of dialectical behavior therapy.

Borderline personality disorder traits and rates of NSSI during the COVID-19 pandemic: An initial investigation

Objective: The current study evaluated frequency of nonsuicidal self-injury (NSSI) and associated maladaptive traits between three time periods: pre-pandemic, early pandemic, and later pandemic. Participants: Two college student samples (n = 362; n = 337) were collected via two online studies. Method: Participants completed measures assessing maladaptive borderline personality traits, engagement in NSSI over the past month, and reasons for and types of NSSI engaged in across the lifetime. Results: Results demonstrated a stable and potentially a slight increase in general rates of NSSI over the course of the pandemic. Further, specific maladaptive traits that underly borderline personality disorder (i.e., despondence, fragility, self-disturbance, and anxious-uncertainty) were related to engagement in NSSI 1-month post COVID. Conclusion: The study highlights the need for added interventions that might reach at risk populations during these heightened periods of stress.

Towards online delivery of Dialectical Behaviour Therapy: A scoping review

Dialectical Behaviour Therapy (DBT) programmes are often the only available treatment for people diagnosed with borderline personality disorder and were rapidly converted to online delivery during the COVID-19 pandemic. Limited research exists surrounding how the major elements of DBT are delivered in an online environment. This scoping review considered the operationalization of online delivery of DBT and its effectiveness. EBSCO host databases were searched using free text. Of 127 papers, 11 studies from 2010 to 2021 investigating online DBT for any clinical population were included in the review. A narrative synthesis of papers selected was undertaken. Seven articles reported results from five clinical trials (n = 437). Most adaptations mirrored face-to-face programmes although there was considerable variation in how therapy was facilitated. Attendance was reported to be greater online with comparable clinical improvements to face-to-face for those who remained in therapy. Additional challenges included managing risk, therapist preparedness and technology difficulties. Online delivery of DBT programmes is feasible and may be more accessible, acceptable and as safe and effective as face-to-face delivery. However, mirroring face to face delivery in an online environment may not be the most effective and efficient way to adapt DBT to online provision. Research is needed to identify areas which require further adaptation.

Reviewing the availability, efficacy and clinical utility of Telepsychology in dialectical behavior therapy (Tele-DBT)

BACKGROUND

Telepsychology is increasingly being implemented in mental health care. We conducted a scoping review on the best available research evidence regarding availability, efficacy and clinical utility of telepsychology in DBT. The review was performed using PRISMA-ScR guidelines. Our aim was to help DBT-therapists make empirically supported decisions about the use of telepsychology during and after the current pandemic and to anticipate the changing digital needs of patients and clinicians.

METHODS

A search was conducted in PubMed, Embase, PsycARTICLES and Web of Science. Search terms for telepsychology were included and combined with search terms that relate to DBT.

RESULTS

Our search and selection procedures resulted in 41 articles containing information on phone consultation, smartphone applications, internet delivered skills training, videoconferencing, virtual reality and computer- or video-assisted interventions in DBT.

CONCLUSIONS

The majority of research about telepsychology in DBT has focused on the treatment mode of between-session contact. However, more trials using sophisticated empirical methodologies are needed. Quantitative data on the efficacy and utility of online and blended alternatives to standard (i.e. face-to-face) individual therapy, skills training and therapist consultation team were scarce. The studies that we found were designed to evaluate feasibility and usability. A permanent shift to videoconferencing or online training is therefore not warranted as long as face-to-face is an option. In all, there is an urgent need to compare standard DBT to online or blended DBT. Smartphone apps and virtual reality (VR) are experienced as an acceptable facilitator in access and implantation of DBT skills. In addition, we have to move forward on telepsychology applications by consulting our patients, younger peers and experts in adjacent fields if we want DBT to remain effective and relevant in the digital age.

The No Worries Trial: Efficacy of Online Dialectical Behaviour Therapy Skills Training for Chronic Pain (iDBT-Pain) Using A Single Case Experimental Design

Emotion dysregulation frequently co-occurs with chronic pain, which in turn leads to heightened emotional and physical suffering. This cycle of association has prompted a recommendation for psychological treatment of chronic pain to target mechanisms for emotion regulation. The current trial addressed this need by investigating a new internet-delivered treatment incorporating emotional skills training from dialectical behavioural therapy (DBT). Using a single-case experimental design that is suited to heterogeneous populations and can demonstrate efficacy with a small sample, three participants with chronic pain were recruited. Participants received four weeks of online DBT skills training (iDBT-Pain intervention) which incorporated one-on-one sessions over Zoom and a web app. Results revealed compelling evidence for the intervention on the primary outcome of emotion dysregulation and were promising for the secondary outcome of pain intensity. Improvement was also identified on pre-and post-measures of depression, coping behaviours, sleep problems, wellbeing, and harm avoidance, indicating that the intervention may positively influence other factors related to chronic pain. Overall, the trial provides preliminary efficacy for the intervention to improve chronic pain. However, we recommend further investigation of the iDBT-Pain intervention, either in single case trials, which when conducted with scientific rigour may be aggregated to derive nomothetic conclusions, or in a group-comparison trial to compare with usual modes of treatment. Perspective: This trial advances understanding of emotion-focused treatment for chronic pain and provides evidence for a viable new technological treatment. Importantly, as an internet-delivered approach, the iDBT-Pain intervention is accessible to those with restricted mobility and remote communities where there are often limited psychological services for people with chronic pain. Trial registration: The trial was registered on the Australian and New Zealand Clinical Trials Registry (ACTRN12620000604909).

Effect of alcohol interventions on suicidal ideation and behaviour: A systematic review and meta-analysis

BACKGROUND

Alcohol consumption is related to both suicidal ideation and behaviour, but evidence regarding the effect of psychological interventions to reduce alcohol use on self-harm, suicidal behaviour and ideation is limited. Therefore, the aim of the current study was to conduct a systematic literature review and meta-analysis of the effect of alcohol-related psychological interventions on these outcomes at the individual level.

METHODS

We searched the Cochrane CENTRAL, Cochrane DARE, EMBASE, Medline, ProQuest, PsycINFO, PubMed, SCOPUS, and Web of Science electronic databases to 5 January 2021. We included all English-language papers worldwide utilising psychological interventions with a focus on harmful alcohol use and suicidal ideation, self-harm, and/or suicidal behaviour.

RESULTS

We identified 11 studies, nine provided sufficient numerical data for meta-analysis. Although the methods and effect sizes varied substantially in the studies, reducing alcohol may led to a reduction in self-harm and suicide attempt by the final follow-up assessment (Odds ratio [OR] 0.57, 95% confidence interval [CI] 0.33 to 0.97, 6 studies, 491 participants, I² = 0%). However, there was no apparent effect for these interventions on suicidal ideation or suicide deaths. There was no significant difference in effect by therapeutic approach. Neither intervention dose (in hours) nor duration (in months) significantly explained differences in treatment effectiveness.

CONCLUSIONS

Interventions targeting harmful alcohol consumption may contribute towards a reduction in self-harm at the individual level. However, there was no apparent effect of these interventions on suicidal ideation (measured either continuously or dichotomously) or suicide deaths.

Implementing Dialectical Behavior Therapy Skills Training for Emotional Problem Solving for Adolescents (DBT STEPS-A) in a Low-Income School

Adolescents living in low-income areas often have high need for mental health supports due to experiences of poverty and trauma, coupled with limited access and availability of such supports. This study investigated the implementation of a socio-emotional learning curriculum titled, “Dialectical Behavior Therapy Skills Training for Emotional Problem Solving for Adolescents (DBT STEPS-A),” which was integrated into health classes in a low-income high school. While preliminary evidence suggests that DBT STEPS-A can be effective in reducing mental health symptoms in high school students, this study is the first to explore the program’s acceptability, appropriateness, and feasibility when implemented in a low-income school. The implementation presented here also diverged from recommended training protocols due to time and cost limitations. Quantitative and qualitative data were collected from 29 school stakeholders prior to implementation and from 23 school stakeholders post-implementation. Our results indicate that DBT STEPS-A is acceptable and feasible for teachers involved in offering the program and that more work is needed to address appropriateness of the content for racially and socio-economically diverse students, ease of implementing lessons, and support for teachers using DBT STEPS-A skills outside of class. We conclude with a discussion of key implementation challenges and solutions generated.

Wellness and resilience for college and beyond: protocol for a quasi-experimental pilot study investigating a dialectical behaviour therapy skill-infused college course

INTRODUCTION

College students' mental health problems and suicidal behaviour are serious, persistent and prevalent public health issues. With the need for mental health support greatly exceeding the availability of on-campus treatment, a recent trend on college campuses is to offer courses designed to teach students strategies for developing mental health or resilience. While these courses are exceptionally popular among students, a paucity of research investigates the health outcomes associated with participation. The purpose of this study is to investigate the acceptability, appropriateness, feasibility and preliminary effectiveness of a college course grounded in skills from dialectical behaviour therapy (DBT) titled, 'Wellness and Resilience for College and Beyond'.

METHODS AND ANALYSIS

During the spring and fall 2020 semesters, the course will be offered on five campuses in Southwestern Pennsylvania and West Virginia. The course consists of 15 weekly 2.5-hour lessons, weekly homework assignments and a final examination with content drawn from DBT, acceptance and commitment therapy and positive psychology. Undergraduate students aged 18-24 will self-select into the course and control subjects receiving 'university as usual' will be recruited to serve as a comparison group. Students who receive the course will complete measures of course acceptability, appropriateness and feasibility. All study participants will complete measures of adaptive coping skills use, emotion dysregulation and suicidality.

ETHICS AND DISSEMINATION

All of the study procedures were approved as an exempt protocol for evaluation of educational curricula by the University of Pittsburgh Human Research Protections Office (HRPO); the study was approved as a research study by the institutional review board (IRB) of the fifth study site. The University of Pittsburgh HRPO served as the IRB of record for all except one study site, which required standard IRB review. Data from this study will be disseminated via conference presentations, peer-reviewed publications and via our online stakeholder learning collaborative.

TRIAL REGISTRATION NUMBER

NCT04338256.

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.

Internet-Based Cognitive Behavioral Therapy to Reduce Suicidal Ideation: A Systematic Review and Meta-analysis

IMPORTANCE

Suicidal ideation is a widespread phenomenon. However, many individuals at risk for suicide do not seek treatment, which might be addressed by providing low-threshold, internet-based self-help interventions.

OBJECTIVE

To investigate whether internet-based self-help interventions directly targeting suicidal ideation or behavior are associated with reductions in suicidal ideation.

DATA SOURCES

A systematic search of PsycINFO, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and the Centre for Research Excellence of Suicide Prevention (CRESP) databases for trials from inception to April 6, 2019, was performed, supplemented by reference searches. Search strings consisted of various search terms related to the concepts of internet, suicide, and randomized clinical trials.

STUDY SELECTION

Two independent researchers reviewed titles, abstracts, and full texts. Randomized clinical trials evaluating the effectiveness of internet-based self-help interventions to reduce suicidal ideation were included. Interventions were eligible if they were based on psychotherapeutic elements. Trials had to report a quantitative measure of a suicide-specific outcome. Mobile-based and gatekeeper interventions were excluded; no further restrictions were placed on participant characteristics or date of publication.

DATA EXTRACTION AND SYNTHESIS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Risk of bias was evaluated using the Cochrane Risk of Bias Tool. Standardized mean differences were calculated using a random-effects model.

MAIN OUTCOMES AND MEASURES

Suicidal ideation was the a priori primary outcome.

RESULTS

Six unique eligible trials (1567 unique participants; 1046 [66.8%] female; pooled mean [SD] age, 36.2 [12.5] years) were included in the systematic review and meta-analysis. All identified interventions were internet-based cognitive behavioral therapy (iCBT). Participants assigned to the iCBT condition experienced a significantly reduced suicidal ideation compared with controls following intervention in all 6 trials (standardized mean difference, -0.29; 95% CI, -0.40 to -0.19; P < .001). Heterogeneity was low (I2 = 0%). The effect appeared to be maintained at follow-up in 4 trials (standardized mean difference, -0.18; 95% CI, -0.34 to -0.02; P = .03; I2 = 36%). Studies did not report sufficient data on completed suicides and suicide attempts to assess potential associations.

CONCLUSIONS AND RELEVANCE

These results show that iCBT interventions are associated with significant reductions in suicidal ideation compared with control conditions. Considering their high scalability, iCBT interventions have the potential to reduce suicide mortality. Future research should assess the effect of these digital health interventions on suicidal behavior and identify moderators and mediators to advance understanding of the mechanisms of effectiveness of these interventions.

Prevention of suicide and reduction of self-harm among people with substance use disorder: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

People with substance use disorder (SUD) are at significantly greater risk of suicide compared with the general population. In recent years the number of suicides resulting from drug poisoning in England and Wales has increased. We sought to identify and evaluate the effect of interventions to prevent suicide or reduce self-harm among people with SUD.

METHODS

We conducted a systematic review of randomised controlled trials (RCTs) of interventions for people with SUD that included suicide or self-harm-related primary outcomes. We searched Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, PubMed, Embase and Web of Science from inception until 13th January 2019. Studies were assessed for bias using the Cochrane Risk of Bias 2 tool. A random effects meta-analysis of standardised mean differences (SMD) was conducted.

RESULTS

We identified six RCTs from four countries (Australia, Iran, the United States of America and the United Kingdom) comprising 468 participants in total. All but one study investigated psychosocial interventions. On average across studies there was weak evidence of a small positive effect of interventions on suicide or self-harm outcomes (d=-0.20, 95% CI=-0.39-0.00).

LIMITATIONS

Studies were heterogeneous in terms of population, intervention, controls and outcome. There were some concerns regarding bias for all trials. All trials were liable to type II error.

CONCLUSIONS

Evidence is currently lacking regarding the effectiveness of interventions to prevent suicide and reduce self-harm amongst people with SUD.

Protocol for the REVISIT-BPD Trial, a Randomized Controlled Trial Testing the Effectiveness of an Internet-Based Self-Management Intervention in the Treatment of Borderline Personality Disorder (BPD)

Introduction: Borderline Personality Disorder (BPD) is a prevalent condition that is often under-treated. This is partly because very few psychotherapists offer treatment for this disabling disorder. Internet-based self-management interventions could contribute to reducing the treatment gap but-mainly due to safety concerns-these have never been tested for BPD in controlled trials. Methods: Patients with BPD will be recruited primarily via the internet and randomized to two groups: care as usual (CAU) alone) or the self-management intervention priovi® in addition to CAU. At the end of the diagnostic interview, all participants will discuss an emergency plan. The main outcome measure is the clinician-rated symptom severity using the BPD Severity Index (BPDSI). Secondary outcome measures include a range of self-reported scales, an SCID-diagnosis of BPD and several safety parameters including serious adverse events (e.g., a life-threatening event, hospitalization or suicide attempt). Discussion: This trial will evaluate the effectiveness of the self-management intervention, priovi, in reducing symptoms of BPD. It will also assess the safety of its use in this target population. If successful, this intervention would be the first comprehensive internet intervention for the treatment of BPD and complement the wide range of internet interventions effective in treating other mental disorders, particularly depression and anxiety disorders. Trial Registration: NCT03418142 (clinicaltrials.gov) on January 23rd 2018. Trial status: recruiting, currently N = 108 (July 2018).

A randomized controlled trial of an Internet delivered dialectical behavior therapy skills training for suicidal and heavy episodic drinkers

BACKGROUND

Given that alcohol misuse elevates risk of suicide death among ideators, the paucity of treatment outcome research for individuals presenting with both suicide ideation and problem drinking is particularly troubling. Dialectical behavior therapy (DBT) skills training, which effectively targets behaviors associated with emotion dysregulation including addictive and suicidal behaviors, provides a fitting model amenable to computerization. As stigma and scarcity stand as potential barriers to treatment, online dissemination platforms provide means for efficient treatment delivery that can augment the utility of suitable interventions. This pilot RCT sought to evaluate the feasibility, acceptability, and preliminary efficacy of an Internet-delivered DBT skills training intervention (iDBT-ST) for suicidal individuals who engage in heavy episodic drinking METHODS: Participants (N = 59) were randomized to receive iDBT-ST immediately or after an 8-week waiting period. Clinical outcomes were suicide ideation, alcohol use, and emotion dysregulation.

RESULTS

Participants on average saw a significant reduction in all outcomes over the four-month study period. Compared to waitlist controls, individuals who received iDBT-ST immediately showed faster reductions in alcohol consumption.

CONCLUSIONS

Preliminary results suggest that iDBT-ST may be a viable resource for the high-risk and underserved group represented in this study, and pathways for future development are suggested.

LIMITATIONS

There was difficulty retaining and engaging participants due to technological barriers.