Evidence base for DBTSupport for DBT

Randomized Clinical Trials = 7 with BPD (see Lynch, Trost, Salsman, Linehan, 2007 and NICE Guidelines for BPD, 2009). Reducing:

Suicide attempts and self-injury Medical risk Premature drop-out Inpatient /ER admissions and days Drug abuse Depression, hopelessness, anger

Increasing: Global adjustment Social adjustment

DBT has recently been conceptualized as a treatment with utility for intervening with difficult-to-treat & multiply-disordered clients not just BPD

(Linehan, Bohus, & Lynch, 2007; Lynch et al., 2006).

Randomized Clinical Trials = Three for Treatment Resistant Depression and Emotionally Constricted Personality Disorders (Lynch et al., 2003; 2006; Harley et al., 2008) DBT Superior to Controls:

Reducing: Interpersonal Sensitivity (2006) Interpersonal Aggression (2006) Depressive symptoms (2008) Quicker reductions in depression (2006)

Increasing: Depression remission (2003)

Verheul et al. (2004): Lower attrition rates than other treatments, Better at reducing self-harm in fairly severe self-harm group, Can effectively treat people with substance misuse problems, No better at reducing suicide than TAU, No better at reducing depression than TAU

Stanley et al. (1998). DBT better than treatment as usual (TAU): self-mutilation, suicidal ideation, suicidal urges, urges to self-mutilate

Miller & Rathmus (1991). DBT better than TAU: treatment drop-out, inpatient psych days, (outpatient adolescents).DBT = TAU suicide attempts However, DBT subject group had much higher initial rates of suicide attempts

McCann & Ball (1996). DBT pre-treatment scores better than post-treatment scores: depressed and hostile mood, paranoia, psychotic behaviours, maladaptive interpersonal coping styles, staff burn-out (trend) (forensic inpatients).

Bohus et al. (2001). DBT vs. waiting list: the people who had the greatest response as measured by the difference in individual pre and post measures were all in the DBT group. (German inpatients)

Linehan et al. (1999). DBT better than TAU: dropouts, dirty urine post treatment (drug use), global adjustment, social adjustment

Manchester, New Hampshire study. People receiving DBT showed 77% decrease in hospital days, 76% decrease in partial hospital days, 56% decrease in crisis beds, 80% decrease in face-to-face contact with emergency services, and significant increase in outpatient services.

Linehan et al. (1991, 1992, 1993, 1994). DBT better than TAU: % of subjects with parasuicidal behaviour, number of parasuicides, medical risk of parasuicide, treatment drop-outs, psychiatric inpatient days, anger, social adjustment, global adjustment. DBT is about 50% of TAU: inpatient days, self-harm, A&E, MAU, therapy drop out.

Koons, et al. (2001). DBT better than TAU: number of parasuicides (at start DBT group had higher incidence of parasuicide), SI, depression, hopelessness, anger out.

Katz et al (2004). DBT better than TAU: decreased behavioural incidents (number of incident reports). (inpatient adolescents) study compared outcome of patients before and after DBT was implemented on the ward.

Barley et al. (1993). Psychodynamic unit incorporates DBT skills training. Rates of parasuicide post DBT significantly lower than pre DBT.

Trupin et al.(in press) DBT vs TAU: behavioural problems (Parasuicide, aggression, class disruption) in DBT cottage significantly higher pre-DBT, but decreased significantly compared to other cottage. Staff in juvenile offenders in mental health cottages used significantly fewer restrictive, punitive responses than those in other cottage.

Verheul et al. (2004) DBT>TAU: retention rates, reductions in self-harm especially in those with history of frequent self-harm.

Data which do not support DBT above other treatments

Linehan (2002). Opiate dependent women, DBT no better than validation and 12 steps. Worse drop-out rate.

Linehan (1993). General psychotherapy with or without DBT skills group – DBT group no better than other.

Leichsenring & Leibing (2003). meta-analysis. Empirical data needs improving, but both CBT (including DBT) and Psychodynamic therapy seem to work.

Stanley et al (1998) DBT = TAU depression, hopelessness and global adjustment scores

Linehan et al (1999) DBT vs TAU for sample of substance abusers: no significant difference parasuicide episodes and anger.

Linehan et al. (1991,1992,1993,1994). DBT vs TAU: no significant difference pre-treatment >12 month, depression, hopelessness, suicide ideation.

Katz et al. (2004) DBT= TAU for sample of adolescent inpatients: parasuicidal behaviour, depressive symptoms, and SI at 1 year.

Verheul et al. (2004) DBT=TAU, DBT pre=DBT post: Suicidal behaviours, self-harm in patients who infrequently self-harm.

DBT studies are small, few randomized controlled trials, amount of DBT given varied, adherence to the manual varies.

References

Bohus, M., Haaf, B. & Stiglmayr, C. (2000). Evaluation of inpatient dialectical-behavioural therapy for borderline personality disorder – a prospective study. Behavior Research and Therapy, 38, 875-887.

Barley, W. D., Buie, S.E., Peterson, E.W., Hollingsworth, A.S., Griva, M., Hickerson, S.C., Lawson, J.E., &Bailey, B.J. (1993). The development of an inpatient cognitive-behavioural treatment program for borderline personality disorder. Journal of Personality Disorders, 7, 232-240.

Katz, L.Y., Gunasekara, S., Miller, A.L., (2002). Dialectical behavior therapy for inpatient and outpatient suicidal adolescents. In Flaherty, L. (Ed.). Adolescent Psychiatry: The annuals of the American Society for Adolescent Psychiatry. The Analytic Press: Hillsdale, NJ.

Koons, C. R., Robins,C.J., Tweed, J.L. Lynch, T.R., Gonzalez, A.M., Morse, J.Q., Bishop, G.K., Butterfield, M.I. & Bastian, L.A. (2001). Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy, 32, 371-390.

Leichsenring, F. & Leibing, E. et al. (2003).The effectiveness of psychodynamic therapy and cognitive behaviour therapy in the treatment of personality disorders: A meta-analysis. American Journal of Psychiatry, 160, 1223-1232.

Linehan, M.M., Armstrong, H.E., Suarez, A., Allmon, D. & Heard, H.L. (1991). Cognitive-behavioural treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064.

Linehan, M.M., Heard, H.L. & Armstrong, H.E. (1993). Naturalistic follow up of a behavioural treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry, 50, 971.

Linehan, M.M., Schmidt, H., Dimeff, L.A., Craft, J.C., Kanter, J. & Comtois, K.A. (1999). Dialectical behaviour therapy for people with borderline personality disorder and drug-dependence. American Journal on Addiction, 8, 279-292.

Linehan, M.M., Dimeff, L.A., Reynolds, S.K., Comtois, K.A., Shaw Welch, S., Heagerty, P., Kivlahan, D.R. (2002). Dialectical behavior therapy versus 12-step for the treatment of opiod dependant women meeting criteria for borderline personality disorder.

McCann, R. & Ball, E.M. (1996, November). Using dialectical behavior therapy with an inpatient forensic population. Workshop presented at the 1st annual meeting of the International Society for the Improvement and Teaching of Dialectical Behavior Therapy (ISITDBT), New York, NY.

Miller, A.L., Rathus, J.H., Leigh, E., and Landsman, M. (1996, November). A pilot study: Dialectical behavior therapy adapted for suicidal adolescents. Poster presented at the 1st annual meeting of the International Society for the Improvement and Teaching of Dialectical Behavior Therapy (ISITDBT), New York, NY. Stanley, B., Ivanoff, A., Brodsky, B., Oppenheim, S., & Mann, J. (1998). Comparison of DBT and ‘treatment as usual’ in suicidal and self-mutilating behavior. Proceedings from the 32nd Association for the Advancement of Behavior Therapy Convention, Washington D.C.

Trupin, E.W., Stewart, D.G., Beach, B. & Boesky, L. (in press). Effectiveness of a dialectical behavior therapy program for incarcerated female juvenile offenders. Child Psychology and Psychiatric Review.

Verheul, R., Van Den Bosch, L. M., Koeter, M. W., De Ridder, M. A., Stijnen, T., & Van Den Brink, W. (2003). Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in The Netherlands. British Journal of Psychiatry, 182, 135 -140.