Dialectical Behavior Therapy vs Enhanced Usual Care for Suicidal and Self-harming Adolescents. 10 Year Follow-up
Condition: Self-Harm, Deliberate; Borderline Personality Disorder
MeSH terms: Personality Disorders; Borderline Personality Disorder; Self-Injurious Behavior
Study type: Interventional

Summary: 
      The purpose of the study is to evaluate the long-term efficacy of dialectical behavior
      therapy (DBT) in treatment of adolescents with deliberate self harm compared to enhanced
      usual care (EUC). This study follows-up 77 patients in the ages of 12-18 yrs who have been
      included in an RCT of DBT-A vs EUC. The main inclusion criterion for this study was
      repetitive self-harm behaviour. The patients were randomly allocated to receive 16 weeks of
      outpatient DBT or EUC in child and adolescent psychiatric clinics in Oslo. Participants have
      been assessed so far on six different time-points: baseline (before starting treatment), 9
      weeks, 15 weeks, 19 weeks, 71 weeks and 3 years after start of the treatment. In the current
      project patients will be assessed a 7th time 10 years after treatment completion.

      It is hypothesized that compared with participants who had received EUC in the original trial
      during their adolescence participants who had received DBT-A will:

      A) report a significantly lower frequency of episodes of self-harm, both last year and over
      the extended 10-year follow-up interval.

      B) be significantly less impaired with respect to social, family and occupational functioning
      and report a higher quality of life.

      C) have retained significantly fewer diagnostic criteria of BPD and have less severe
      borderline features according to dimensional measures and have significantly fewer signs of
      emotion dysregulation.
    

Detailed description: 
      Suicide attempts and non-suicidal self-harm, highly prevalent in adolescents, are behaviours
      strongly associated with severe emotion dysregulation, mental health problems and increased
      suicide risk. The original study, on which the present study is building, used a randomized
      controlled design, with a stratified block randomization procedure, and blinded
      pre-treatment, post-treatment and follow-up evaluations comparing 19weeks of DBT-A with EUC
      of equal length.

      Of special interest to this follow-up study is to gain more knowledge on their capacity to
      regulate emotions, since failures in emotion regulation is an underlying mechanism of
      repetitive self-harm behaviours and several other difficulties, and since a main aim of DBT-A
      is to enhance adolescents capacity to use healthy emotion regulation strategies. The study is
      designed to carefully include user and family perspectives on the definition of specific
      outcomes and how to measure them, we will collect detailed data on important outcomes
      employing a combination of quantitative and qualitative methods, innovative approaches such
      as ecological momentary assessment and register data. Adding new data to the existing rich
      data will give us a basis to study the dynamic interplay between symptoms, emotions, and
      functional and dysfunctional behaviours and make new discoveries of mechanisms of therapeutic
      change, knowledge to further increase treatment response rates and individualize treatments
      and to inform further development of this treatment and its implementation in Norway and
      other countries.

      The proposed study will investigate:

        1. the 10-year post-randomization treatment outcomes of DBT-A compared with EUC with
           respect to: a) frequency of subsequent episodes of self-harm, b) severity of suicidal
           ideation, c) level of depressive symptoms and d) frequency of subsequent emergency room
           visits, hospitalizations and use of additional treatments due to risk of self-harm
           behaviour.

        2. the 10-year post-randomization clinical course and stability of a diagnosis of BPD, its
           diagnostic criteria and borderline symptoms.

        3. participants' adult mental health, social, family and occupational functioning and
           quality of life.

        4. participants' adult strategies for and capacity to cope with stressful life-events and
           situations in their daily lives and effectively regulate emotions.

        5. the association between participants' adult life use of skills and functional coping
           strategies and self-harm behaviour and other problem behaviours, and whether any
           substitution from onedysfunctional coping behaviour to another has occurred.

        6. participants' evaluation of what components of the treatment was most helpful and led to
           the strongest and most persistent change in important functions and aspects of life.

        7. the economic cost of treatments consumed and functional impairment and occupational
           disability over the 10-year post-randomization period and the long-term
           cost-effectiveness of DBT-A.
    

Intervention name(s): Dialectical Behaviour Therapy for Adolescents (DBT-A); Enhanced usual care
Intervention type(s): Behavioral; Behavioral
Intervention description(s): 16 weeks of Dialectical behavior therapy with one weekly session of individual therapy, one weekly session of multifamily skills training group, telephone coaching and ancillary family therapy and/or pharmacological treatment as needed.
The treatment has been developed by Marsha Linehan (Linehan, 1993a; 1993b)and adapted for adolescents by Alec Miller (Miller, Rathus & Linehan, 2007). Individual DBT therapists have been trained by drs Alec L Miller and Sarah K Reynolds and have a minimum of one year clinical practise as DBT therapists. The therapists are organised in two consultation teams supervised on a bimonthly basis throughout the entire study by drs Miller and Reynolds respectively.; 16 weeks of outpatient treatment in child and adolescent psychiatric clinics in Oslo, on average one weekly session of individual therapy and ancillary supportive family and/or pharmacological treatment as needed.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: self harm; dialectical behaviour therapy; borderline personality disorder; emotional dysregulation