Presentation on theme: "Joan Rosenbaum Asarnow, Ph.D. University of California, Los Angeles"— Presentation transcript:
1Joan Rosenbaum Asarnow, Ph.D. University of California, Los Angeles Assessment of Depression & Suicide Risk: Strategies for Matching Youths to Optimal InterventionsJoan Rosenbaum Asarnow, Ph.D.University of California, Los AngelesMelissa InstituteSome slides adapted from M Kovacs and J. McCracken
2Disclosures: Joan Rosenbaum Asarnow, Ph.D. SourceConsult/HonorariumResearch GrantCalifornia Institute of Mental HealthDepression Treatment Quality Improvement (DTQI)Casa PacificaCBT TrainingLos Angeles County DMH and sitesCBT Training, DTQIPhillip MorrisUnrestrictedAmerican Foundation for Suicide PreventionXNIMHSAMHSASanofil-AventisSpouse
4Presentation Goals Why assess depression? Review current evidence on rates of depression and course of depression in youthsDo we have effective treatments for depression in youths?Review evidence supporting CBT as evidence-based practiceHow can we improve care for depression?Why CBT within the context of an overall Depression Treatment Quality Improvement Program
5Depression Facts Over 18 million Americans are depressed As many as 2 million of these are adolescents
7Mary Presents with frequent school absences Stomach aches Difficulty sleeping due to stomach painMissing school frequentlySad nearly all the timeRecent onset of the following symptomsCan’t sleep at nightNot eating wellCan’t concentrate at school, drop in gradesTiredFeels worthlessThoughts of death and suicide
8Clinical Depression: Major Depression Duration≥ 2 weeksCritical SymptomsDepressed, irritable , or anhedonic mood nearly all the time# Symptoms- 5 of 9 symptoms must include depressed/irritable mood or anhedoniaDepressed/Irritable MoodAnhedoniaInsomnia or hypersomniaAppetitie disturbanceConcentration problems/indecisionLow energy or fatigueWorthlessness or guilt for no reasonAgitation or moves more slowly than usualThoughts of death or suicideSeverityDistress or functional impairmentEXCLUSIONNot due to drugs/medication/medical disorder. Not bereavement, not a mixed episode
9Danny Getting into trouble at school Irritable and crabby at home, been generally unhappy for past yearComplains of being bored all of the timeFeels like not as good as other kidsCan’t concentrate in school, drop in gradesSays his life is awful, no reason to think it will get any better, feels like giving up
10Clinical Depression: Dysthymic Disorder Duration≥1 year for childrenCritical SymptomsDepressed/ irritable mood most of the time more days than not# Symptoms- 2 of 6 symptoms, must include depressed/irritable moodEither overeating or lack of appetite.Sleeping too much or having difficulty sleeping.Fatigue, lack of energy.Poor self-esteem.Difficulty with concentration or decision making.Feeling hopeless.SeverityDistress or functional impairmentEXCLUSIONNo MDD in Year 1.Never manic/hypomanic/mixed/ cyclothymicNot due to psychosis, drugs/medication/medical disorder. Not bereavement
11AnaPresents to ER with suicide attempt, serious overdose Boyfriend broke up with her Hasn’t been able to stop crying since break-up 5 days ago Feels worthless Can’t sleep Doesn’t feel like eating Worried that she is pregnant, feels nauseous
12Children do suffer from depressive disorders: Pediatric depression is a prevalent condition Rates increase with age; pattern differs by gender<13 yrs: 2.8% (+ .5)13-18 yrs 5.6% (+ .3)1:1 sex ratio (or more boys) prior to adolescenceIncreased frequency in girls during adolescence13-18 yrs girls 5.9%13-18 yrs boys 4.6%Rates approach adult prevalence by end of adolescence
13THE EPIDEMIOLOGY OF YOUTH DEPRESSION: THE FINDINGS PREVELENCE/INCIDENCE NOT YET RELIABLY ESTABLISHEDAge 9-163-mo prev.any dep d/o2.2%aBy age 16cumulative/ predicted9.5%aAge (T1)lifetimemajor dep d/o20.4%bAge (T2 )24.0%bBy age 19prorated28.0%bAge 189.4%cAge 15-16Age 17-1814.6%d13.5%daCostello et al., 2003; bLewinson et al., 1998; cReinherz et al., 1993; dKessler & Walters, 1998
14Pediatric Depression Not Benign Condition Depression recurrent (in up to ~60-75% of cases),One year recurrence greater than adults (40% vs. 24%)20% have persistence >2yrs40-60% relapse after successful treatment70% have adult depressionEpisodes are lengthy: MDD (7-9 mos) in clinical cases; DD (~3yrs)Associated with significant impairment in school, with family, and peersSuicide risk in adults with history of adolescent MDD is 5x adults with late onsetAsarnow et al., 1994; Kovacs et al., 1984a, 1994,1997; Lewinson et al., 1994; McCauley et al., 1993; Puig-Antich et al., 1989; Rao et al., 1995; Weissman et al., 1999 a,b
15Pediatric Depression: Associated With High Risk of Suicidality 9 year follow up of prepubertalchildrenKovacs et al. J Am Acad Child Adolesc Psychiatry 199338% of depressed youths had made attempt by age 17
16Elevated rates of Suicide & Suicide Attempts in Adolescent-Onset MDD by Early Adulthood From Weissman et al. (1999). Depressed Adolescents Grown Up. JAMAMean age at follow-up 26 yrs, follow-up period ≈10 years
17Burden of Pediatric Depression: Additional Consequences Eventual substance use/abuse disorders: 15% to 45%aPersistence of functional impairment: social dysfunction, work difficulties, low employment ratebDepressive episode recurrence of ~60%-69% into young adulthoodca)Geller et al., 2001; Harrington et al., 1990; Rao et al., 1995; Weissman et al., 1999b) Fergusson & Woodward, 2002; Fombonne et al., 2001; Garber et al., 1988; Geller et al., 2001;Harrington et al., 1991; Rao et al., 1995; Weissman et al., 1999 a,b; c)Harrington et al., 1990; Weissman et al., 1999 b; Rao et al., 1995
18Comorbidity/Co-Occurring Disorders: High Across Range of Disorders Most youths present with another diagnosis, ~80-90%40-50% have an anxiety disorder, anxiety disorders often precede the onset of depressive disordersDouble depression common, ~ 20% DD/MDDADHD comorbid in ~ 20%Conduct disorder in ~ 50% of school age depressivesIncreased risk for bipolar disorder (8%-49%)Common overlap with PTSD, OCDBaji et al., in press; Biederman et al., 1995; Carlson & Kashani, 1988; Ferro et al., 1994; Fombonne et al., 2001; Geller et al., 2001;Goodyer et al., 1997; Kovacs et al., 1988/89, 1994, 1997 and Unpub; McCauley et al., 1993; Mitchell et al., 1988; Rao et al., 1995;Ryan et al., 1987; Shain et al., 1991; Strober & Carlson, 1982; Strober et al., 1993; Weiss & Garber, 2003; Weissman et al., 1999a,b
19INTERIM CONCLUSION Depression in children is a serious condition Course is often protractedPresentation is complicated, often with other co-occurring mental health problemsWhile most youth recover (80%), risk of recurrence is high (around 50% or higher)Associated with long-term disorder + functional impairment, often persisting into adulthoodRecent results suggest that earlier onset MDD (child and adolescent-onsets) tends to be more severe, recurrent, and impairing than later adult-onset MDD*Most adult depressions begin during childhood-adolescent years*Zisook et al., 2007;
21Treatment for Depression in Children and Adolescents PsychotherapyPharmacotherapyCombination psychotherapy and pharmacotherapy
22Fluoxetine Treatment of Major Depression Response (CGI 2) 605040302010Fluoxetine (N=48)Placebo (N=48)p=0.02; Emslie GJ, Rush AJ, Weinberg WA, et al. Arch Gen Psychiatry. 1997;54(11):
23Fluoxetine in Juvenile Depression 219 outpatients with MDD, Ages 8-178 week trial 20 mgCGI ≤ 2*N=109N=110Emslie G et al. J Am Acad Child Adolesc Psychiatry 2002
24Fluoxetine Treatment for Depression in Children and Adolescents Remission RatesFluoxetine 41%Placebo %p<0.01; Emslie GJ, Heiligenstein JH, Hoog S, et al. J Am Acad Child Adolesc Psychiatry. 2000
25Drug Treatments for Child and Adolescent Depression: Levels of Evidence Short-TermEfficacyFluoxetineSertralineFluvoxamineParoxetineCitalopram/EscitalopramTCAsVenlafaxineDuloxetineABCA **A = >2 randomized, controlled studies; B = 1 randomized, controlled study; C = Clinical experience (open studies, case reports, etc)*-- fluoxetine FDA approved for depression ≥ 8 yrs; Escitalopram >Adapted from Jobson KO, Potter WZ. Psychopharmacol Bull. 1995;31:457–459.Adapted from McCracken, 2009
26FDA Public Health Advisory March 2004 Suicidality in Children and Adolescents Treated With Antidepressant MedicationsToday the Food and Drug Administration (FDA) directed manufacturers of all antidepressant drugs to revise the labeling for their products to include a boxed warning and expanded warning statements that alert health care providers to an increased risk of suicidality (suicidal thinking and behavior) in children and adolescents being treated with these agents, and to include additional information about the results of pediatric studies.
27Treatments Not So Robust? “The evidence for effectiveness of SSRIs compared with placebo in the treatment of depressive disorders in children and adolescents is far from compelling.”Cochrane 2007 Review of SSRIs and Child and Adolescent DepressionHerrick SE, Cochrane Database of Sys Rev. July 18McCracken, 2009
29Cognitive Behavior Therapy (CBT) Established psychosocial treatment for adolescent depression with evidence based supporting efficacyAcute treatment studies demonstrate greater efficacy for CBT (12-16 sessions) as compared to alternative psychosocial interventions and waitlist conditionsResponse rates for CBT appear to be between 60-66% (vs % in comparison conditions)
30THE STRESS SPIRAL Stressors School/Work Problems Problems with Friends Family ProblemsMedical IllnessLossesTHE STRESS SPIRALActions/BehaviorsWithdrawalDecreased activityIrritable with othersThoughtsNegative thoughtsLow self-esteemPessimisticHopelessFeelingsSadCrabbyDon’t enjoy anythingBored
31Psychotherapy Trial: MDD Remission (No MDD + BDI <9 for 3 Weeks) 605040302010CBT (N=35)Family (N=31)Supportive (N=33)Overall p=0.05; CBT vs. family p=0.03; CBT vs. supportive p=0.04Brent DA, Holder D, Kolko D, et al. Arch Gen Psychiatry. 1997(Sep);54(9):Courtesy, McCracken, 2009
32Interpersonal Psychotherapy (IPT) Psychosocial treatment for adolescent depression with evidence based supporting efficacy, but newer with fewer efficacy studies as compared to CBTResponse rates for IPT appear to be similar to those for CBTData support improvements in social functioning
33IPT for Depressed Adolescents (IPT-A) Focuses on interpersonal relationships and roles and the ways in which a person’s current relationships and social context cause or maintain symptomsInitial 3 sessions focus on (in adolescents- client's authority in relationship to parents; the development of new interpersonal relationships; first experiences of the death of a relative or friend; peer pressure; and single-parent families) to be addressed in the remainder of therapy.Mufson L, Weissman MM, Moreau D, Garfinkel R. Arch Gen Psychiatry. 1999(Jun);56(6):
34IPT for Depressed Adolescents 48 adolescent outpatients, ages years, with major depressionRandomly assigned to 12-week IPT or clinical monitoring (telephone contact)Results with IPTGreater decrease in depressive symptomsImprovement in social functioningImproved problem-solvingMufson L, Weissman MM, Moreau D, Garfinkel R. Arch Gen Psychiatry. 1999(Jun);56(6):
35IPT: MDD Response (HDRS 6 and/or BDI 9) 80706050Percent40302010IPT (N=24)Control (N=24)Mufson L, Weissman MM, Moreau D, Garfinkel R. Arch Gen Psychiatry. 1999(Jun);56(6):
36Adolescent Depression Combined CBT + Medication Treatment of Choice for Moderate to Severe Major DepressionN=439, Treatment of Adolescent Depression Study (TADS); Week 12 Acute Treatment Response
37TADS Recovery Incomplete: Low Remission Rates & 50% of Remitted Youths Had Residual Symptoms *CDRS-R total score ≤28 as the criterion for remission. COMB> FLX,CBT, PBO, P=.0009; FLX=CBT=PBOKennard et al. Remission and residual symptoms after short-term treatment in the Treatment of Adolescents with Depression Study (TADS). J Am Acad Child Adolesc Psychiatry Dec;45(12):
386-Site NIMH Study MH61835 Pittsburgh, Brent MH61864 UCLA, Asarnow MH61856 Galveston, Wagner MH61869 Portland, ClarkeMH61958 Dallas, EmslieMH62014 Brown, Keller334 outpatient adolescents, ages years, with diagnosis of major depressionDepression persists despite at least 6 weeks of SSRI treatmentAcute phase 12-week trialJAMA Feb 27, 2008Asarnow J.R., APA, 2009, Toronto
39TORDIA: Evaluate Step-2 Treatment Strategies After Step-1 SSRI Treatment SSRI response rate around 50-60%, often with incomplete remissionNo empirical studies to guide clinicians on the management of the roughly 50% of patients who fail to respond to initial SSRI treatmentAsarnow JR, APA 2009,Toronto
40TORDIA Supports Value of CBT-Clinical Response by Treatment Group %JAMA Feb 27, 2008CBT vs none, 54.8% vs 40.5%, p<0.009
41Effectiveness Trials: Strategies for Improving Community Treatment & ServicesAsarnow J.R., APA, 2009, Toronto
42A Randomized Controlled Trial Effectiveness of a Quality Improvement Intervention for Adolescent Depression in Primary Care Clinics:A Randomized Controlled TrialAsarnow, Jaycox, Duan, LaBorde, Rea, Anderson, Murray, Tang, WellsJournal of the American Medical Association2005 Jan 19; 293 (3):Sponsored by the Agency for Healthcare Research and Quality (AHRQ; Joan Asarnow, PI). Additional support from UCLA- RAND Health Services Research Center (NIMH, Ken Wells, PI)
67Am J Psychiatry. 2009 Sep;166(9):1002-10 Long-term benefits of short-term quality improvement interventions for depressed youths in primary careAsarnow JR, Jaycox LH, Tang L, Duan N, LaBorde AP, Zeledon LR, Anderson M, Murray PJ, Landon C, Rea MM, Wells KBAm J Psychiatry Sep;166(9):
68QI Intervention Associated With Shorter Time To First Recovery Wilcoxon X2 = 3.60, p=.058; 6-months, z=2.03, p=.042; . Mean times to first recovery were: QI months (SE, 0.35); UC 9.65 months (SE, 0.37); diff ≈27 days. Asarnow et al, American Journal of Psychiatry, 2009
69Strongest Intervention Effect Seen At 6-Months *We fit a mixed-effects logistic regression model using follow-up data at 6, 12, 18 months with regression adjustment for age, gender, ethnicity, the baseline measure for the same outcome, and study sites. \Asarnow et al, American Journal of Psychiatry, 2009
70Asarnow J.R., APA, 2009, TorontoN=418 Early Intervention Effects Shifted Youths Towards Healthier Pathways Through 18-Month Follow-UpQI-InterventionDepression12-monthBaseline18-month6-month(MHI-5)10.64(0.13)-0.01(0.08)-0.03(0.01)-0.39(0.15)-0.18(0.19)-0.01(0.01)0.46(0.12)Early effective treatment improves longer term outcomes.Important to intervene early with a treatment that works.Asarnow et al, American Journal of Psychiatry, 2009N=418Asarnow J.R., APA, 2009, TorontoN=41870
74Can we improve our ability to match patients to optimal treatments? Challenge: Personalized Treatment Our current treatments leave a substantial proportion of patients with residual or full-blown depressionsCan we improve our ability to match patients to optimal treatments?Can we improve patient outcomes by matching patients to the treatment strategies that are most likely to be beneficial?74
75Predictors of Poor Outcome Across Treatment Groups – Acute Treatment (TADS, TORDIA) More Chronic Depression (a) (b+)Severe Suicidal Ideation (a) (b)Comorbidity (a)Functional Impairment (a) (b)Hopelessness (a) (b)Lower Expectancies For Treatment Benefits (a)Curry J, Rohde P, Simons A et al. (2006) Predictors and Moderators of acute outcome in the Treatment for Adolescents with Depression Study (TADS). Journal of the American Academy of Child and Adolescent Psychiatry, 2006; 45:(b) Asarnow, JR, Emslie, G., Clarke, G. Wagner, K, Spirito, A., Vitiello, B, Iyengar, S, Shamseddeen, W, Ritz, L, Birmaher, B, Ryan, N, Kennard, B, Mayes, T, DeBar, L, McCracken, J, Strober, M, Suddath, R, Leonard, H, Porta, G, Keller, M, Brent, D.(2009) Treatment of SSRI-Resistant Depression in Adolescents: Predictors and Moderators of Treatment Response. Journal of the American Academy of Child and Adolescent Psychiatry, 2009; 48 (3):
76Additional Predictors of Poor Outcome- Step 2 Treatment (TORDIA) More Severe Depression (b)History Of NSSI (b)More Severe Family Conflict (b)Drug Use (b+, youths excluded for abuse/dep)Abuse History (b+)(b) Asarnow, JR, Emslie, G., Clarke, G. Wagner, K, Spirito, A., Vitiello, B, Iyengar, S, Shamseddeen, W, Ritz, L, Birmaher, B, Ryan, N, Kennard, B, Mayes, T, DeBar, L, McCracken, J, Strober, M, Suddath, R, Leonard, H, Porta, G, Keller, M, Brent, D.(2009) Treatment of SSRI-Resistant Depression in Adolescents: Predictors and Moderators of Treatment Response. Journal of the American Academy of Child and Adolescent Psychiatry, 2009; 48 (3):
77Who Benefits the Most From Medication Treatment? Lower Depression SeverityFamily DiscordComorbitySimilar to Overall PredictorsEmslie GJ. Fluoxetine in child and adolescent depression: acute and maintenance treatment. Depression Anxiety. 1998;7:32-39.77
78Who Benefits the Most From CBT/Psychosocial Treatment? Suicidal ideation: CBT > Supportive (b)Comorbid Anxiety: CBT > Supportive (a)Abuse History: No diff (c)Maternal Depression: No diff (c)(a) Brent et al. Predictors of treatment efficacy in a clinical trial of three psychosocial treaatments for adolescent depression. J Am Acad Child Adolesc Psychiatry, 1998:;7;(b) Barbe RP, Bridge J, Birmaher B et al. Suicidality and its relationship to treatment outcome in depressed adolescents. Suicide Life Threat Behav. 2004:34:44-45(c ) Barbe RP, Bridge J, Birmaher B et al. Lifetime history of sexual abuse, clinical presentation, and outcome in a clinical trial for adolescent depression. J Clin Psychiatry. 2004: 65:77-83.
79Who Benefits the Most From CBT/Combined Treatment? Mild to moderate depression severity vs. severeMild-Mod Severity: Combined > fluoxetine aloneSevere Dep: Combined=fluoxetine aloneMore cognitive distortionMore distortion: Combined > fluoxetine aloneIncome level associated with better response to CBT vs placebo79
80Moderators of CBT/Combined Treatment at Step 2 Treatment: Who Benefits the Most From Combined CBT + Medication Switch Vs. Medication Switch Alone?Significant Treatment X Baseline Variable InteractionBackward binary logistic regression, including baseline variable, medication type, CBT/combined treatment, and interaction terms.From Asarnow J.R.,JAACAP, 200880
84Depression: Conclusions Treatments with evidence for efficacy existEvidence-based treatments can be transported to community settings and yield improved outcomesChoice of treatment guided by youth and family preference, availability of treatments, and characteristics of youths and families
85Leading causes of death for selected age groups – United States, 2004 Rank10-14 years15-19 years20-29 years30-39 years40-49 years50-59 years1UnintentionalInjuriesMalignantNeoplasms2HomicideHeartDisease3Suicide4DiabetesMellitus5CongenitalMalformationsHIVCerebro-vascular6Liver7ChronicLower Respiratory Ds8Influenza & pneumoniaSource: CDC vital statistics
86Healthy People 2010 & 2020Reducing suicide and suicide attempts in adolescents.National Health Promotion Objectives 18.1 & 18.2
87Why Suicide & Suicide Attempt Prevention? Suicide is the third leading cause of death among young people ages 10-24, accounting for 4,599 deaths (MMWR, Sept. 2007, 2004 Statistics)Among 15- to 24-year olds, suicide accounts for 12.9% of all deaths annually (CDC 2005).Almost 700,000 receive medical treatment for suicide attempts
88Evidence-Based Treatment: What works Evidence-Based Treatment: What works? Emergency Interventions for Suicide & Suicide Attempt Prevention
89ED Visit: A Window of Opportunity to Deliver an Effective Intervention Most suicidal adolescents have substantial need for mental health servicesThe ED visit is a major contact point for the large group of youth who receive little to no follow-up care<50% receive referrals for follow-up care (Piacentini et al., 1995; Spirito et al., 2000)A large proportion never attend any follow-up sessions (77%) and many fail to complete a full course of treatment (Rotheram-Borus et al., 1996)
90Means Restriction Education: Parents Listed in Registry of Evidence-Based Suicide Prevention Programs- 1 of 4 “effective practices.”Parents informed that youth at risk for suicide and whyParents informed that risk can be reduced by restricting access to lethal meansEducation and problem-solving regarding how to restrict access to lethal meansKruesi, M. J. P., Grossman, J., Pennington, J. M., Woodward, P. J., Duda, D., and Hirsch, J. G. (1999). Suicide and violence prevention: Parent education in emergency department. Journal of the American Academy of Child and Adolescent Psychiatry, 38(3),Kruesi, M. J. P., Grossman, J., and Hirsch, J. G. (1995). Five Minutes of Your Time May Mean a Lifetime to a Suicidal Adolescent. Chicago, IL: Ronald McDonald House Charities, University of Illinois—Chicago.
91Specialized ED Intervention for Suicidal Adolescent Females Listed in Registry of Evidence-Based Suicide Prevention Programs (SPRC, 2/23/2005, Access at: ) One of 7 promising practices in evidence-based registry.
92Intervention Components: Specialized ED Intervention SEDIED Staff Training: enhance positive staff/patient interactions, reinforce importance of outpatient treatment, recognize seriousness of suicide attemptsMotivational video: 20 min, facilitate linkage to outpatient treatment (highlight importance and facilitate realistic expectations)ED Crisis session: discuss video, screen for suicide risk, conduct therapy session, contract for outpatient treatment
94When Combined With Access To Structured Follow-up Treatment, SEDI Associated With Improved Outcomes (Rotheram-Borus et al., 2000)Improved adherence to recommendation for follow-up treatmentYouth reported less suicidal ideation and depression at post-discharge assessmentAttended more follow-up treatment sessionsAt 18 months, youth less depressed, mothers reported higher family cohesion
95Evidence-Based Treatment: What works Evidence-Based Treatment: What works? Outpatient Treatments for Suicide & Suicide Attempt Prevention
96Multisystemic Therapy (MST): Adaptation for youth in psychiatric crisis (intensive family and community based treatment, Huey et al., 2004, Henggeler et al., 2003)Intensive community based treatment aimed at mobilizing protective factors and reducing risk factors in the youth’s ecological contextBased on “fit analysis” identifying risk and protective factors for individual youthFocuses on multiple systems- youth’s ecological niche (family, peers, school, community)Assisting responsible adults in the natural environment to monitor and provide structure in a manner that is likely to reduce risk for suicideMore effective than emergency hospitalization and usual services at reducing rates of suicide attempts, mental health symptoms, and out of home placements and improving school attendance and family functioning
97Brief home based family intervention (Harrington et al., 1998) ComponentsIn homeFamily problem-solvingIntervention (plus UC) associated with reductions in suicidal ideation at 2 and 6 month follow-up, relative to UC aloneIntervention effect not evident among youth with MDD
98Cognitive Therapy (Beck, Brown et al) Suicidal behavior is the primary target of treatmentMaladaptive cognitions seen as the primary pathway to suicidal behaviorTreatment includes a set of cognitive-behavioral interventions including:Crisis planCognitive conceptualization of the suicide attemptCoping cardsHope boxRelapse prevention task Developed by Aaron T. Beck and colleagues at the University of Pennsylvania
99Cognitive Therapy: Results A randomized controlled trial showed that participants in the CT group had an approximately 50% lower reattempt rate at 18-month follow-up than those in Usual Care.The CT group had lower rates of self-reported depression and hopelessness across the 18-month follow-up period (Brown et al., JAMA, 2005).
100Dialectical Behavior Therapy (DBT) A cognitive behavioral treatment program developed to treat suicidal clients meeting criteria for Borderline Personality DisorderDirectly targets (1) suicidal behavior, (2) behaviors that interfere with treatment delivery, and (3) other dangerous, severe, or destabilizing behaviors.
101Biosocial Theory of BPD Biological Dysfunction in theEmotion Regulation SystemInvalidating EnvironmentPervasive Emotion DysregulationBPD criterion behaviors function to regulate emotions or are a natural consequence of emotion dysregulation
102DBT: Conceptualization BPD symptoms develop due to limited behavioral skills for regulating negative emotions.BPD patients are biologically predisposed to experience intense emotions which were invalidated by caregivers., resulting in individuals with BPD not learning skills for down-regulating and managing emotions.BPD symptoms are attempts to regulate emotions.DBT emphasizes behavioral interventions, such as skills training and changing reinforcers as treatment
103DBT Addresses 5 functions Increasing behavioral capabilities/skillsImproving motivation for skillful behavior (through contingency management and reduction of interfering emotions and cognitions)Promoting generalization of gains to the natural environmentStructuring the treatment environment so that it reinforces functional rather than dysfunctional behaviorsEnhancing therapist capabilities and motivation to treat patients effectively
1044 Modes of Service Delivery Weekly individual psychotherapy (1 hr/wk)Group skills training (2 hrs/wk)Telephone consultation (as needed within the therapist's limits to ensure generalization)Weekly therapist consultation team meetings (to enhance therapist motivation and skills and to provide therapy for the therapists).
105Survival analysis for time to first suicide attempt: DBT Group had half the rate of suicide attempts (23%) vs CTBE group (46%), NNT= 4.24Linehan, M. M. et al. Arch Gen Psychiatry 2006;63:Hazard Ratio, 2.66, P = .005. CTBE indicates community treatment by expertsCopyright restrictions may apply.
106DBT for Suicidal Adolescents Rathus and Miller (2002) Subjects: Suicidal adolescents with BPD features, ages years.Quasi-experimental design: DBT = 29, TAU = 82, pre/post treatment assessments. More severe patients assigned to DBT.DBT subjects received 12 weeks of individual and group sessions.Modifications made for adolescents: including parents in therapy and skills groups, focus on adolescent “dialectical dilemmas” (e.g., leniency v. control, autonomy v. dependence)Findings: DBT group showed fewer hospitalizations and greater treatment completion than TAU. Significant pre/post decrease within DBT group in suicidal ideation, psychiatric symptoms, and BPD symptoms. Fewer suicide attempts in DBT group, but non-significant.
107Conclusions: Suicide Prevention Assessing and treating suicidal behavior/suicide risk is a major problemPromising data exist on effective treatments for suicide prevention in adultsIn youths, most effective treatments appear to be those that:Mobilize family and community supportsTeach skills for regulating emotions