Hope for the Chronically Suicidal Patient
Condition: Borderline Personality Disorder
MeSH terms: Personality Disorders; Borderline Personality Disorder
Study type: Interventional

Summary: 
      The aim of this study is to evaluate the clinical and cost effectiveness of Dialectical
      Behavior Therapy (DBT) for chronically suicidal behavior in individuals diagnosed with
      borderline personality disorder (BPD). Recent investigations of DBT have yielded positive
      results and have challenged the widely held opinion that the prognosis for this condition is
      poor. This study will consist of a two-arm randomized controlled trial that will compare DBT
      with a General Psychiatric Management (GPM) condition consisting of a structured algorithmic
      medication intervention plus psychosocial counseling. One-hundred and eighty participants
      will be randomly assigned to either DBT or to the GPM condition. Clinical outcomes will be
      assessed by changes in: (1) parasuicidal behaviour; (2) treatment retention; (3) psychiatric
      symptomatology; (4) anger expression; (5) social functioning and (6) health status. Cost
      outcomes will include an analysis of health service utilization. Clinical and cost
      evaluations will occur at 4-month intervals over the course of the one-year treatment and
      over a two-year follow-up.
    

Detailed description: 
      Suicide, a major cause of death worldwide, is a serious public health problem. Forty percent
      of individuals who commit suicide meet diagnostic criteria for a personality disorder and an
      even higher percent of those attempting suicide have a personality disorder . Borderline
      personality disorder (BPD) is highly associated with parasuicidal behaviour. Parasuicidal
      behaviour refers to suicide attempts or other self-injurious behaviour and is a risk factor
      for completed suicide. Approximately 69% - 80% of people diagnosed with BPD have committed at
      least one act of self-harm. Estimates of completed suicides in this population are about 9%,
      with this rate quadrupling for patients who meet 8 or more of the 9 DSM criteria for BPD.

      Chronically suicidal behaviour in people with BPD is estimated to be among the most expensive
      psychiatric disorders to treat. While there is an extensive anecdotal literature on the
      treatment of this population, clinical outcomes have been dismal and treatment evidence based
      on well-designed trials is sparse. Dialectical Behavior Therapy (DBT), a broad-based
      cognitive-behavioral therapy (CBT), has recently shown promise in the treatment of this
      population. DBT is being widely adopted in the treatment of this disorder despite its limited
      empirical base. To date, there are few studies on DBT and no replications of the original
      research on DBT by researchers independent of the treatment developer.

      The aim of this study is to evaluate the clinical and cost effectiveness of DBT for the
      treatment of parasuicidal individuals with BPD compared to a General Psychiatric Management
      (GPM) control condition involving a structured algorithm medication intervention plus
      psychosocial support. This study will compare the following outcome measures in participants
      who receive Dialectical Behavior Therapy versus General Psychiatric Management, Best
      Practices during a one-year treatment interval and two-year follow-up: (1) frequency and
      severity of parasuicidal behaviours ; (2) number of self-harm episodes (3) improvement in
      quality of life (4) cost effectiveness.

      Hypotheses:(1) Patients in the DBT condition will show greater reductions in the frequency
      and severity of parasuicidal behaviours compared to patients in the GPM condition during a
      one-year treatment interval and two-year follow-up; (2) Compared to GPM, DBT will result in a
      greater reduction in the number of self-harm episodes and a greater improvement in quality of
      life but will have a higher direct cost. However, because DBT will result in significant
      offsetting reductions in other health service costs, the incremental cost-effectiveness
      ratios will fall within the range of many accepted medical interventions.
    

Intervention name(s): General Psychiatric Management; Dialectical Behaviour Therapy
Intervention type(s): Behavioral; Behavioral
Intervention description(s): General Psychiatric Management (GPM) condition consisting of a structured algorithmic medication intervention plus psychosocial counseling.; Modification of behaviours achieved with reframing thoughts and impulses
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: borderline personality disorder; BPD; treatment; dialectical behavior therapy; DBT; general Psychiatric management; GPM; suicide; parasuicide; randomized control trials