Dialectical Behavior Therapy Treatment Research Articles

Skills-homework completion and phone coaching as predictors of therapeutic change and outcomes in completers of a DBT intensive outpatient programme.

Dialectical behaviour therapy (DBT) emphasizes generalization of skills to the patient's real-world context as a primary mechanism of change in treatment. To promote generalization, DBT includes weekly skills-focused homework assignments and as-needed phone coaching. Despite this central function of generalization in DBT, research on these treatment components is limited. The current study addresses this research gap by assessing the association of homework and phone coaching to DBT treatment outcomes. A longitudinal study design explored the extent to which (a) completion of skills homework and (b) frequency of phone coaching were associated with therapeutic changes and treatment outcomes in a DBT intensive outpatient programme (DBT-IOP). Medical records and diary cards of 56 patients who had completed a four-month treatment cycle of DBT-IOP were reviewed and coded for proportion of skills homework completed, frequency of phone coaching calls, and reported urges for and engagement in suicide, non-suicidal self-injury, illicit or non-prescribed substance use, and alcohol use behaviours. Completion of skills homework and frequency of phone coaching were significantly associated with (a) reduced urges for suicide, non-suicidal self-injury, illicit or non-prescribed substance use, and alcohol use from the beginning to end of treatment and (b) a lower likelihood of engaging in any of these behaviours during the final month of treatment. Results suggest that within a DBT programme modified for an intensive outpatient setting, skills homework and phone coaching may enhance therapeutic change and outcomes in target behaviours. These generalization methods appear to be important ingredients of DBT effectiveness. In dialectical behaviour therapy (DBT), therapeutic skills homework and phone coaching are specifically designed to promote generalization of skills from the therapeutic context to the patient's real-world contexts. In a DBT intensive outpatient programme, patient engagement with therapeutic homework and phone coaching were associated with favourable therapeutic change and outcomes in target urges and behaviours. Clinicians may consider a patient's lack of homework completion and/or phone coaching to be early warning signs of poor therapeutic progress within dialectical behaviour therapy.

Predictors of Dropout in a Cohort of People Undergoing Treatment for Borderline Personality Disorder in a Public Community Mental Health Service: A Time-to-Event Analysis

Background: Dialectical Behaviour Therapy (DBT) is an effective evidence based treatment for Borderline Personality Disorder (BPD). However, irrespective of the success of the treatment, a dropout rate of approximately 30%-40% is regarded as the norm. In this analysis we aimed to investigate whether early predictors of dropout can be identified from baseline data. Methods: Between 2014 and 2017, data was collected from 196 participants at multiple timepoints as part of a coordinated multisite study of standard DBT treatment for community based service users being treated for BPD in Ireland. Dropout was strictly defined as per the standard DBT programme four-miss rule. For this analysis data were censored at 48 weeks and risk factors for dropout were identified using a Cox proportional hazards model that adjusted for age and gender. Engagement with phone coaching in the first month was examined as a time dependant covariate. Outcomes: Of the 196 participants, 12 (6%) were censored and 9 (4%) removed leaving 187 for analysis of whom, 109 (58%) completed and 66 (32%) dropped out. Results from univariable Cox proportional hazard regressions found off-label use of anti-psychotic medication was associated with an increased risk of drop-out, while full time employment status, receipt of disability support and engagement with phone coaching in the first month were associated with a reduced risk of dropout. Entering these variables in a multivariable Cox proportional hazard regression found off-label use of anti-psychotic medication (adjusted HR 2·69, 95% CI 1·50 - 4·83; p=0·001); full time employment status (adjusted HR 0.23, 95% CI 0.07-0.77; p=0.02) and disability (adjusted HR 0.20, 95% CI 0.05-0.85; p=0.03) remained significant predictors. Interpretation: Awareness of employment status and off-label prescription of anti-psychotic medication at baseline as significant risk factors for dropout may provide clinicians with valuable insight when starting treatment and could potentially inform treatment approach. Funding Information: This work, as part of the The National DBT Project, was funded by the Irish Health Service Executive (HSE) and the National Office for Suicide Prevention (NOSP). The fund is administered via the National Suicide Research Foundation (NSRF). Declaration of Interests: We declare no competing interests. Ethics Approval Statement: All procedures were reviewed and approved by the following research ethics committees: Clinical Research Ethics Committee of the Cork University Teaching Hospitals, Galway Clinical Research Ethics Committee, HSE Mid Western Regional Hospital Research Ethics Committee, HSE North East Area Research Ethics Committee, HSE South East Area Research Ethics Committee, Linn Dara & Beechpark Ethics Committee; Naas General Hospital Ethics Committee; Saint John of God Hospitaller Ministries Research Ethics Committee and Sligo General Hospital Research Ethics Committee.

A Pilot Investigation of Positive Psychology Instruments and Dialectical Behavior Therapy Treatment Outcomes

There is efficacy evidence for dialectical behavior therapy (DBT) and positive psychology interventions. However, there is minimal research examining positive psychology constructs alongside psychopathology measures in clinical populations. Accordingly, this study examined these associations in a DBT intensive outpatient program (IOP). Participants included 39 adults enrolled in a DBT IOP who completed measures of depression, anxiety, stress, emotion regulation, hope, and self-compassion. Results indicated hope and self-compassion were higher in graduates than in dropouts and were negatively associated with psychopathology measures. The relationship between depression and graduation status reached practical significance but not statistical significance. Two self-compassion subscales, mindfulness and common humanity, were significantly related to the number of sessions attended in this brief program. These findings indicate positive psychology measures possess utility within clinical populations. To accurately assess treatment success, counselors should consider measuring both the pathological and the positive.

Mobile App Integration Into Dialectical Behavior Therapy for Persons With Borderline Personality Disorder: Qualitative and Quantitative Study.

BackgroundThe advancement of and access to technology such as smartphones has implications for psychotherapeutic health care and how interventions for a range of mental health disorders are provided.ObjectiveThe objective of this study was to describe the experiences of participants while using a mobile phone app that was designed to enhance and support dialectical behavior therapy for personality disorders.MethodsA combination of in-depth interviews and questionnaires were used to capture the experiences of participants who used the app while undergoing dialectical behavior therapy treatment. A mixed methods approach was used; qualitative data from the interviews were analyzed using thematic analysis and were combined with quantitative data from the questionnaires.ResultsParticipants (N=24) who were receiving dialectical behavior therapy used the trial app. Participants (n=20) completed an evaluation questionnaire and a subset of this group (n=8) participated in semistructured interviews. Major themes that were identified from the interviews were (1) an overall positive experience of using the app—participants perceived that the app facilitated access and implementation of dialectical behavior therapy strategies (to regulate mood and behavior in challenging situations)—and (2) that the app provided a common source of information for patient and therapist interactions—app-based interactions were perceived to facilitate therapeutic alliance. Qualitative themes from the interviews were largely congruent with the quantitative responses from the questionnaires.ConclusionsParticipants welcomed the integration of technology as a supplement to clinical treatment. The app was perceived to facilitate and support many of the therapeutic techniques associated with dialectical behavior therapy treatment. The incorporation of technology into psychotherapeutic interventions may facilitate the transfer of knowledge and strategies that are learned in therapy to use in real-world settings thereby promoting recovery from mental health problems.

The effect of dialectical behaviour therapy in autism spectrum patients with suicidality and/ or self-destructive behaviour (DIASS): study protocol for a multicentre randomised controlled trial

BackgroundMany persons with autism spectrum disorder (ASD) are treated in long-term specialised care. In this population, suicidal behaviour troubles patients, families, and specialists in the field because it is difficult to treat. At present, there is no documented effective therapy for suicidal behaviour in ASD (Autism Research 7:507-521, 2014; Crisis 35:301-309, 2014). Dialectical Behaviour Therapy (DBT) is an efficacious treatment programme for chronically suicidal and/or self-harm behaviour in patients with Borderline Personality Disorder (J Psychiatry 166:1365-1374, 2014; Linehan MM. Cognitive behavioural therapy of borderline personality disorder. 1993). This study will evaluate the efficacy of DBT in persons with ASD and suicidal/ self- destructive behaviour in a multicentre randomised controlled clinical trial.MethodOne hundred twenty-eight persons with autism and suicidal and/or self-harming behaviour will be recruited from specialised mental healthcare services and randomised into two conditions: 1) the DBT condition in which the participants have weekly individual cognitive behavioural therapy sessions and a 2.5 h skills training group session twice per week during 6 months, and 2) the treatment as usual condition which consists of weekly individual therapy sessions of 30–45 min with a psychotherapist or social worker. Assessments will take place at baseline, at post-treatment (6 months), and after a follow-up period of 12 months. The mediators will also be assessed at 3 months. The primary outcome is the level of suicidal ideation and behaviour. The secondary outcomes are anxiety and social performance, depression, core symptoms of ASD, quality of life, and cost-utility. Emotion regulation and therapeutic alliance are hypothesised to mediate the effects on the primary outcome.DiscussionThe results from this study will provide an evaluation of the efficacy of DBT treatment in persons with ASD on suicidal and self-harming behaviour. The study is conducted in routine mental health services which enhances the generalisability of the study results to clinical practice.Trial registrationISRCTN96632579. Registered 1 May 2019. Retrospectively registered.

Emotional experiences of clients with borderline personality disorder in dialectical behavior therapy: An empirical investigation of in-session affect.

Borderline personality disorder (BPD) is a diagnosis characterized by intense and labile emotion; dialectical behavior therapy, a common treatment for BPD, aims to reduce the intensity and lability of clients' emotion through multiple methods, some of which occur in the therapy session, with the expectation that changes will generalize to the rest of clients' lives. However, little research has examined how BPD clients' affect presents and varies in session or whether affect in session reflects patients' patterns of affect outside of treatment. This study had 2 aims: (a) to explore changes in clients' positive and negative affect in therapy, and (b) to assess if the severity of client psychopathology relates to affect in treatment. Positive and negative affect ratings were collected from clients (N = 73) at the start and end of every individual therapy session (total sessions = 1,474). Hierarchical linear modeling and linear regression were used to examine patterns of affect and assess the relationship between affect and severity. Results indicated that positive affect increased while negative affect decreased between the start and end of sessions, with the same pattern of change in presession affect from week to week. In addition, increased BPD severity was associated with lower presession positive affect ratings and higher negative affect ratings. Further exploration is needed to assess which dialectical behavior therapy treatment processes contribute to changes in in-session affect and how in-session affect relates to treatment outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Principles of Behavioral Assessment and Management of “Life-Threatening Behavior” in Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) in its initial iteration was developed for the treatment of suicidal and self-injuring adults. As a result, the assessment and management of suicidal and nonsuicidal self-injurious (NSSI) behavior was and is central to the conduct of standard DBT. In this paper the authors describe the DBT approach to suicide risk assessment including discussion of both comprehensive and targeted suicide risk assessment and the associated documentation. In addition, it describes when and when not to conduct such assessment. Finally, this article describes management of both imminent and distant suicide risk and the application of DBT treatment strategies that can be applied in session.

Effectiveness of a 5-Week Inpatient Dialectical Behavior Therapy for Borderline Personality Disorder.

The goal of this study was to evaluate whether symptoms are reduced and emotion regulation improves when patients with borderline personality disorder (BPD) receive a 5-week course of inpatient dialectical behavioral therapy (DBT) and if changes in emotion regulation are associated with changes in symptoms. Forty-four patients with BPD receiving a 5-week course of DBT in a German psychiatry clinic participated. The short version of the "Borderline Symptom List" (BSL-23) was the patient-reported outcome. To measure emotion regulation, the "Self-Report Measure for the Assessment of Emotion Regulation Skills" (SEK-27) was administered. Wilcoxon tests were performed to evaluate whether pre-post changes in the BSL-23 and SEK-27 reached statistical significance. Effect sizes (d) were calculated and correlations between the pre-post differences for both measures were computed to test associations between changes in emotion regulation and changes in symptoms. Completer (n=33) and intention-to-treat (n=43) analyses were performed. Symptoms (BSL-23) were reduced and emotion regulation (SEK-27) improved during the 5-week inpatient DBT treatment (completer and intention-to-treat analysis: P<0.001). Effect sizes reached d=0.47 for the BSL-23 and d=0.84 for the SEK-27 in the completer analysis, and d=0.38 for the BSL-23 and d=0.68 for the SEK-27 in the intention-to-treat analysis. Improvements in emotion regulation (SEK-27) were correlated with reductions in symptoms (BSL-23) in both the completer (r=0.54; P=0.001) and the intention-to-treat (r=0.59; P<0.001) analyses. These findings indicate that a 5-week course of inpatient DBT can effectively reduce symptoms in patients with BPD and that the more patients' emotion regulation improves, the more the patients benefit from the therapy.

Effectiveness of Dialectical Behavioral Therapy on Executive Function, Emotional Control and Severity of Symptoms in Patients with Bipolar I Disorder.

Background:Bipolar disorder is a disabling illness characterized by recurrent episodes of mania, hypomania, and depression. The dialectical behaviour therapy (DBT) is basically designed to help regulate excitement, tolerance of discomfort, mindfulness and interpersonal relationships. This study aimed to determine the effectiveness of DBT on executive function, emotional control and symptom relief in patients with type 1 bipolar disorder.Materials and Methods:This clinical trial was conducted on 50 patients with type 1 bipolar disorder. These patients were divided into two 25 populated groups of controls and intervention. The control group did not receive any other alternative therapy apart from routine medications, but in the intervention group, in addition to routine medications, DBT treatment was also done as complementary therapy in 12 sessions based on Dick's protocol. Then, Mania severity, emotional control and their executive functions were evaluated before and after the intervention and compared in two groups.Results:After the intervention, the scores of mania and depression mood with the mean of 2.12 ± 3.09 and 31.08 ± 8.98 respectively in intervention group were significantly lower than control group with the mean of 4.24 ± 4.11 and 39.92 ± 9.05 respectively (P < 0.05). Depression and executive function of the patients had no significant difference between the two groups in the post-intervention period and had a modest and non-significant change.Conclusion:DBT has been effective in decreasing the intensity of mania, but, it cannot be used to reduce the emotional instability and impulsivity of these patients along with drug therapy although it has improved the executive functions and depression of the patients.

M57 - DNA METHYLATION OF APBA3 AND MCF2 IN BORDERLINE PERSONALITY DISORDER: POTENTIAL BIOMARKERS FOR RESPONSE TO PSYCHOTHERAPY

Borderline Personality Disorder (BPD) is a severe and complex mental disease associated with high suicidal tendencies and hospitalization rates. Accumulating evidence suggests that epigenetic mechanisms are implicated in the etiology of BPD. A recent epigenome-wide study identified several novel genes, which are epigenetically dysregulated in BPD. Those genes include APBA3, MCF2 and NINJ2. Psychotherapy such as Dialectical Behavior Therapy (DBT), an established treatment for BPD, provides an excellent setting to investigate environmental influences on epigenetic mechanisms in order to identify biomarkers for disease status and therapy success. However, the effects of DBT on epigenetic regulation have only been researched in one previous study analyzing BDNF. In the present study, we aimed to investigate the role of DNA methylation of APBA3, MCF2 and NINJ2 as possible biomarkers for treatment-outcome in BPD, whilst validating the previous findings of differential DNA methylation in a cohort of 44 BPD patients and 44 well matched healthy control individuals. The sample was comprised of 44 BPD patients hospitalized for a 12-week DBT program and 44 age and gender matched healthy control individuals. Phenotypic information about patients and control individuals was obtained by self-administered questionnaires. DNA methylation was assessed by pyrosequencing. Unexpectedly, we did not detect significant DNA methylation differences between patients and control individuals. However, we found a high correlation between the methylation status of APBA3 and MCF2 and therapy outcome: before DBT treatment, both genes were significantly higher methylated in patients responding to therapy compared to patients that did not respond. Our study is the first to report results pointing to possible predictive epigenetic biomarkers of DBT outcome in BPD patients. Following replication in independent cohorts our finding could facilitate the development of more personalized therapy concepts for BPD patients by including epigenetic information.

A Schema Therapy-Based eHealth Program for Patients with Borderline Personality Disorder (priovi): Naturalistic Single-Arm Observational Study.

BackgroundElectronic health (eHealth) programs have been found to be effective in treating many psychological conditions. However, regarding borderline personality disorder (BPD), only a few eHealth programs have been tested, involving small interventions based on the dialectical behavior therapy treatment approach. We investigated priovi, a program based on the schema therapy (ST) approach. priovi is considerably more comprehensive than prior programs, offering broad psychoeducation content and many therapeutic exercises.ObjectiveWe tested the acceptability and feasibility of priovi in 14 patients with BPD as an add-on to individual face-to-face ST.MethodsPatients received weekly individual ST and used priovi over a period of 12 months. We assessed BPD symptom severity using self-reported and interview-based measures. Qualitative interviews were conducted with both patients and therapists to assess their experiences with priovi.ResultsBPD symptoms improved significantly (Cohen d=1.0). Overall, qualitative data showed that priovi was positively received by both patients and therapists. Some exercises provoked mild anxiety; however, no serious threat to safety was detected.Conclusionspriovi is a potentially helpful and safe tool that could support individual ST. It needs to be further tested in a randomized controlled study.Trial RegistrationGerman Clinical Trials Register DRKS00011538; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00011538 (Archived by WebCite at http://www.webcitation.org/74jb0AgV8)

The effect of therapist use of validation strategies on change in client emotion in individual dbt treatment sessions.

Dialectical behavior therapy (DBT) is a treatment for borderline personality disorder, a disorder for which emotion dysregulation is central. Within DBT, there are 6 explicitly defined validation strategies that range hierarchically from validation level (VL) 1 to VL 6. To date, there have been no studies on the frequency of use of VLs in actual DBT sessions. The aim of the current study was to explore DBT therapists' use of VLs and examine the relationship between VLs and change in a client emotion during therapy sessions. DBT treatment sessions (n = 121) across 35 participants in a DBT training clinic were coded for therapist use of VLs. A repeated-measures analysis of variance (ANOVA) was used to assess for change in therapist use of VLs over time and hierarchical linear modeling was used to correlate therapist use of these strategies with change in client emotion. Results indicated no significant relationship between overall frequency of VLs and change in client emotion. However, an increase in frequency of high VLs was associated with an increase in positive affect (PA) and a decrease in negative affect (NA) while an increase in frequency of low VLs was associated with a decrease in PA and no change in NA. An increase in frequency of VL 4 was associated with an increase in NA. VL 6 was associated with an increase in PA and a decrease in NA. Findings suggest that specific validation strategies may be related to session changes in affect and have implications for identifying potential mechanisms of change. (PsycINFO Database Record

Phone coaching in Dialectical Behavior Therapy: frequency and relationship to client variables

Telephone coaching is a treatment mode in Dialectical Behavior Therapy (DBT) that is designed to help clients generalize skills, prevent suicidal behaviors, and repair therapeutic ruptures. To date, phone coaching has received scant empirical investigation. The aims of this study were to (1) describe patterns in frequency of telephone calls and text messaging in DBT and (2) investigate whether demographic factors, baseline severity, suicidal behaviors, and therapeutic alliance are associated with phone and text frequency. Participants were 51 adults (35 treatment completers) with borderline personality disorder (BPD) in a six-month comprehensive DBT treatment program. Phone coaching frequency was documented by therapist weekly session notes. The average number of contacts per month was 2.55 (SD = 4.49). Four of the 35 treatment completers comprised 56% of the contacts. Having a recent history of suicidal behaviors, degree of severity at baseline, or the strength of the therapeutic alliance was not associated with phone coaching use. However, lower income was significantly associated with a higher frequency of phone coaching use. These preliminary results can help clinicians and administrators make informed decisions on how to better provide phone coaching and clarify the degree of effort involved in providing this service to clients with BPD.

On the potential for iatrogenic effects of psychiatric crisis services: The example of dialectical behavior therapy for adult women with borderline personality disorder.

Although previous research has suggested that people with a history of using psychiatric crisis services are at higher risk for suicide, it is unclear whether this link is attributable to individual risk factors or iatrogenic effects of service utilization. We examined this question by analyzing data from a randomized controlled trial of dialectical behavior therapy (DBT), a treatment for highly suicidal individuals in which patients took advantage of crisis services less than those in the comparison condition. We hypothesized that crisis-service utilization during a treatment year, rather than pretreatment indicators of suicide risk, would be associated with higher suicide risk after treatment, and that DBT's treatment effects would be partially attributable to this association. Participants were 101 women (Mage = 29.3, 87% Caucasian) with recent suicidal and self-injurious behaviors meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994) criteria for borderline personality disorder. We examined relationships between suicidal ideation (using the Suicide Behaviors Questionnaire; Linehan, 1981), number of suicide attempts (using the Suicide Attempt Self-Injury Interview; Linehan, Comtois, Brown, Heard, & Wagner, 2006), and number of psychiatric inpatient admissions and psychiatric emergency-room (ER) visits (using the Treatment History Interview; Linehan & Heard, 1987) from the years prior to, during, and following treatment. Treatment-year psychiatric ER visits were the sole predictor of the number of follow-up year suicide attempts. Treatment condition and pretreatment inpatient admissions predicted treatment-year psychiatric ER visits. Finally, there was evidence that DBT resulted in fewer suicide attempts at follow-up, in part because getting DBT led to fewer psychiatric ER visits. In this population and context, data suggest that crisis-service utilization conveys risk for suicide. DBT may reduce suicide risk in part by reducing use of these services. (PsycINFO Database Record

DNA methylation of APBA3 and MCF2 in borderline personality disorder: Potential biomarkers for response to psychotherapy

Borderline personality disorder (BPD) is a severe and complex mental disease associated with high suicidal tendencies and hospitalization rates. Accumulating evidence suggests that epigenetic mechanisms are implicated in the etiology of BPD. A recent epigenome-wide study identified several novel genes which are epigenetically dysregulated in BPD. Those genes include APBA3 and MCF2. Psychotherapy such as Dialectical Behavior Therapy (DBT), an established treatment for BPD, provides an excellent setting to investigate environmental influences on epigenetic mechanisms in order to identify biomarkers for disease status and therapy success. However, the effects of DBT on epigenetic regulation has only been researched in one previous study analyzing BDNF. In the present study, we aimed to investigate the role of DNA methylation of APBA3 and MCF2 as possible biomarkers for treatment outcome in BPD, whilst validating the previous findings of differential DNA methylation in a cohort of 44 BPD patients and 44 well-matched healthy control individuals. Unexpectedly, we did not detect significant DNA methylation differences between patients and control individuals. However, we found a high correlation between the methylation status of APBA3 and MCF2 and therapy outcome: before DBT treatment, both genes were significantly higher methylated in patients responding to therapy compared to patients that did not respond. Our study is the first to report results pointing to possible predictive epigenetic biomarkers of DBT outcome in BPD patients. Following replication in independent cohorts, our finding could facilitate the development of more personalized therapy concepts for BPD patients by including epigenetic information.

Assessment-Driven Case Formulation and Treatment Planning in Dialectical Behavior Therapy: Using Principles to Guide Effective Treatment

Dialectical Behavior Therapy (DBT) is a complex cognitive-behavioral treatment designed for a population with multiple problematic and high-risk behaviors. As with any behavioral treatment, the role of assessment in DBT is critical. Although there is a significant body of research supporting the efficacy of DBT, there is a relative dearth of practical and principle-based information that help therapists formulate cases and treatment from a DBT perspective. In this article, we provide a step-by-step guide for creating an assessment-driven DBT case formulation and treatment plan. We focus on identifying stage of treatment, determining goals, developing the target hierarchy, assessing and treating the primary target behavior, and tracking outcomes. We highlight the few rules that inform DBT assesssment and practice, note and correct several common misconceptions, and demonstrate how the use of thorough assessment can result in a more nuanced case formulation and treatment plan.

Adapting dialectical behaviour therapy for binge eating disorder: A pilot study

Historically, binge eating disorder has not been treated within the Forth Valley Eating Disorder Service; these patients are often referred directly to weight management services, which can result in poor outcomes. The use of dialectical behaviour therapy for patients with binge eating disorder has developed recently and, as part of the Eating Disorder Service in Forth Valley, an adapted dialectical behaviour therapy treatment programme has been piloted prior to patients progressing on to the weight management service, to find out if an adapted dialectical behaviour therapy group can help patients with binge eating disorder reduce bingeing behaviour and improve quality of life.

Can Trainees Effectively Deliver Dialectical Behavior Therapy for Individuals With Borderline Personality Disorder? Outcomes From a Training Clinic.

The aim of the current study was to evaluate the effectiveness of a 6-month course of comprehensive dialectical behavior therapy (DBT) provided in a training clinic with doctoral students as therapists and assessors. Clinical outcomes for 50 individuals with borderline personality disorder (80% female, Mage = 29.52 [SD = 9.64]) are reported. Reliable change indices and clinical significance were calculated for measures. Finally, our results were benchmarked against a "gold standard" randomized clinical trial (RCT; McMain etal., 2009). Analyses with both the full sample and the treatment completers indicate significant reductions in mental health symptomatology that were reliable, clinically and statistically significant, and comparable in effect size to the benchmarked RCT. This DBT training clinic produced good outcomes, comparable to that of a large RCT. Results have implications for who can provide DBT treatment, as well as improving access to DBT in community settings where training clinics may be located.

A Randomized Trial of Dialectical Behavior Therapy in High-Risk Suicidal Veterans.

Despite advances in suicide prevention implemented throughout the US Department of Veterans Affairs (VA) including the hiring of Suicide Prevention Coordinators (SPCs) at every VA hospital, enhanced monitoring, and the availability of 24-hour crisis hotline services, suicide by veterans remains a critical problem affecting 20 veterans daily. Few empirically based treatment strategies for suicide prevention for postdeployment military personnel exist. This study aimed to test whether dialectical behavior therapy (DBT), one of the few psychosocial treatments with proven efficacy in diminishing suicidal behavior in individuals with personality disorder, can be applied to veterans irrespective of personality diagnosis. From January 2010 to December 2014, 91 nonpsychotic veterans at high risk for suicide (61 men, 30 women) were randomly assigned to a 6-month treatment trial at a veterans' medical center comparing standard DBT to treatment as usual (TAU) and followed for 6 months after trial completion. Primary outcome was suicide attempts, measured with the Columbia-Suicide Severity Rating Scale, and secondary outcomes were suicide ideation, depression, hopelessness, and anxiety. There were no exclusions pertaining to substance abuse, homelessness, or medical comorbidity. Both DBT and TAU resulted in improvements in suicidal ideation, depression, and anxiety during the course of the 6-month treatment trial that did not differ between treatment arms. Survival analyses for suicide attempts and hospitalizations did not differ between treatment arms. However, DBT subjects utilized significantly more individual mental health services than TAU subjects (28.5 ± 19.6 vs 14.7 ± 10.9, F₁,₇₇ = 11.60, P = .001). This study is the first to examine 6-month DBT in a mostly male, veteran population. Increased mental health treatment service delivery, which included enhanced monitoring, outreach, and availability of a designated SPC, did not yield statistically significant differences in outcome for veterans at risk for suicide in TAU as compared to the DBT treatment arm. However, both treatments had difficulty with initial engagement post-hospitalization. Future studies examining possible sex differences and strategies to boost retention in difficult-to-engage, homeless, and substance-abusing populations are indicated. ClinicalTrials.gov identifier: NCT02462694.

The Youth-Mental Health Engagement Network: An Exploratory Pilot Study of a Smartphone and Computer-Based Personal Health Record for Youth Experiencing Depressive Symptoms

:The Youth-Mental Health Engagement Network study explored the use of mobile technology to support youth in managing their mental health. The Lawson SMART record (LSR) is a web-based application that allows individuals to create and manage an electronic personal health record (ePHR). Through this record, individuals can store their personal health information (e.g., list of medications, family history, immunization records, allergies, care provider contact information, care plans, and crisis plans) and use interactive tools to manage their health care (e.g., mood monitor, reminder prompts, alerts, and mental health assessments). The purpose of this study was to evaluate the usability and acceptability of using an ePHR in providing mental health care to youth with mental illnesses who were experiencing depressive symptoms, from the perspectives of both the patients and their care providers. This 6-month study employed an exploratory descriptive design. Mixed methods research methodology was used to determine the uptake of the LSR as part of their mental health treatment by youth experiencing depressive symptoms. Participants included 41 patients, aged 16 to 21, receiving outpatient services from one of 9 care providers employed within a hospital-based youth mental health care program. Focus groups were held with participating care providers and patients throughout the study to explore youth and care provider perceptions of using the LSR for mental health care management. In addition, both patients and care providers completed surveys to elaborate on their use of and comfort with the technology. This study found that the majority of patients used a phone (90.6%) and computer (70.7%) daily and felt extremely comfortable using cell phones (71.9%) and computers (58.5%). Of the 41 patients, 9 (22%) had their smartphone lost, stolen, broken, or given away. Qualitative analysis of focus group discussions with patients and care providers revealed 6 themes: 1) extent of LSR use was related to the severity of illness and treatment intensity; 2) symptom tracking was the most common use of the LSR; 3) patients reported increased self-awareness and autonomy with LSR use; 4) use of the LSR changed and had the potential to enhance the therapeutic relationship; 5) use of the LSR was a good fit with Cognitive Behavioural Therapy and Dialectical Behaviour Therapy treatment requirements; and 6) the LSR should be personalized and simplified. In a population of youth with mental illnesses who were experiencing depressive symptoms, the LSR was found to be useful and to fit well with standard treatment practices. However, youth would prefer a simpler tool. Future research should evaluate the clinical- and cost-effectiveness of using an ePHR in a larger sample of youth with mixed clinical presentations and over a longer period of time. This additional research would be valuable in understanding the usability and acceptability of smart technologies as an integral part of usual mental health care for youth.