Feasibility of comparing DBT with treatment as usual for suicidal & self-injuring adolescents
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Feasibility of researching Dialectical Behaviour Therapy for
suicidal and self-injuring adolescents
Emily Cooney, Kirsten Davis, Pania Thompson, Julie Wharewera-Mika & Joanna Stewart
Why do this study?
• Self-harm remains a significant problem for adolescents in our country. Despite several trials focussing on treatment for self-harm, we don’t really know what works for suicidal young people.
• Dialectical Behaviour Therapy (DBT) seems effective for adults with chronic suicidality and severe emotional instability (Linehan et al, 1991, 1993, 2006, McMain et al., 2009, Verheul et al., 2003)
• Field trials evaluating adaptations of DBT for use with adolescents suggest that DBT shows promise for young people (Goldstein et al., 2007, Katz et al., 2004, Rathus & Miller, 2002).
But before we can do a big study….
…..we have some big questions
? Is comprehensive DBT acceptable to adolescents, families and clinicians in New Zealand?
? Is random assignment acceptable to suicidal adolescents, their families and treatment services in New Zealand?
? Are our assessments and screens feasible and acceptable? ? Will emotionally vulnerable adolescents tolerate the
screening and assessment measures? ? What participant retention rate can we expect?
Feasibility questions
Participants
Young people (and their families) seen at two government-funded community mental health outpatient services who
– were aged between 13 and 18 years*– had self-injured or attempted suicide in the
previous 3 months– didn’t meet criteria for a psychotic disorder or
life-threatening Anorexia Nervosa– didn’t have an intellectual disability– could speak and read English
• Self-harm• Suicidal ideation and reasons for living• Substance use• Emotion Regulation • Therapist burnout
We measured
DBT• Multifamily skills groups• Individual therapy• 24/7 phone consultation• Consultation team for therapists• Family sessions and parent sessions as
needed
TAU• Depended on what the team, therapist and
family thought would be helpful• Range of therapy approaches, with
cognitive-behavioural therapy being the most common treatment
• Provided by clinical psychologists, social workers, occupational therapists, and alcohol & drug counsellors
• Medication
• Respite care
• Hospital
If needed, participants in both conditions could access:
2 not eligible2 not eligible
15 (30%) declined15 (30%) declined
2929
50 young people and families had an orientation meeting
50 young people and families had an orientation meeting
Screening assessmentScreening assessment
DBT = 14DBT = 14TAU = 15TAU = 15
4 discontinued during the
assessments
4 discontinued during the
assessments29 completed the pre-treatment
assessment29 completed the pre-treatment
assessment
Ethnicities of participants
UK10%
South African7%
NZ European77%
Other European
3%NZ Māori
3%
Pre-treatment characteristics of DBT and TAU participants
Treatment condition
Dialectical Behaviour Therapy (N=14)
Treatment as Usual (N=15)
Gender - female - n (%) 10 (71%) 12 (80%)Age - mean (SD) 16.2 (.98) 15.7 (1.1)# self-harm acts in past 3 months – median (SD) 7.5 (17.6) 4 (10.1)
At school - n (%) 9 (64%) 10 (67%)
At work - n (%) 1 (7%) 3 (20%)
Structured activity - n (%) 10 (71%) 11 (73%)
Site - North - n (%) 11 (79%) 14 (93%)
Kia tupato! While nosing through these results, we can’t draw many conclusions about how the treatments compare
• Variable assessment times• Small n• Differences between groups
before they began treatment
Treatment engagement
• 1/14 DBT participants dropped out (4/15 TAU participants ‘dropped out’)
• The mean percent of sessions missed was 9% of individual sessions, and 12% of group sessions for adolescents in DBT (the mean percent of individual sessions missed was 29% for TAU participants).
DBT TAU
Treatment condition Mean SD Mean SD
Individual sessions attended 22.6 6.4 6.5 4.1
Individual sessions not attended 1.9 1.8 3 3.8
Group sessions attended 20.3 5.3 0 0
Group sessions not attended 2.6 3.1 0 0
Family sessions attended 8 3.1 3.1 3.3
Med reviews attended 2.4 2.2 1.6 2.9
Parent sessions attended 3.9 4.1 0.5 0.7
Means and standard deviations of sessions attended and not attended across the 6 months following pre-treatment assessment
Assessment period321
Per
cen
t at
tem
pti
ng
su
icid
e
60%
40%
20%
0%
Treatment as UsualDialectical Behaviour Therapy
Treatment condition
3/14 0/15 2/14 1/159/14 9/15
Results of focus group with DBT participants
• Found DBT valuable and worthwhile
• Parents wanted their own support
• Treatment ending seemed arbitrary and was too abrupt
DBT therapists
• Adherence ratings comparable to “gold-standard” DBT outcome trials
• Therapist burnout scores were within the ‘average’ range before and after treatment
• Team support and adherence feedback were critical
Lessons learned so far• Randomisation is acceptable to families
and clinicians. Dual roles of research staff complicate this
• Consider risk factors for self-harm when deciding how to randomise
• Treatment ending has to be managed very carefully
• Contagion is potentially a greater concern than with adults
• Consider recruiting outside of services
Acknowledgements
• staff from Auckland DHB• Dr. Sue Crengle • Dr. Sarah Fortune • the families who took
part in this research • Dr. Melanie Harned • Dr. Simon Hatcher • Dr. Kathryn Korslund • Dr. Marsha Linehan
• Dr. Sally Merry• Dr. Alec Miller • Dr. Jill Rathus • the research therapists
(Mike Batcheler, Helen Clack and Ben Te Maro)
• Sharon Rickard • Amy Rosso • Dr. Paul Vroegrop• staff from Waitemata
DHB
• This study was funded by the New Zealand Ministry of Health• We are very grateful to the following people for their help and
support:
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