Context and Policy Issues
Dialectical Behavioral Therapy (DBT) is a multicomponent psychosocial intervention based on a model which views dysfunctional behavior as either a consequence of dysregulated emotions or a maladaptive approach to emotion regulation.1–3 DBT groups a collection of skills translated from behavioral research and other evidence-based treatments into four modules: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance.1. Mindfulness skills emphasize observing, describing, and participating in the present moment efficiently and without judgment. Interpersonal effectiveness skills range from acting assertively to maintaining self-respect. Emotion regulation skills include strategies for changing emotions and the tendency to respond with appropriate emotions. Distress tolerance skills are strategies to control impulsive actions and to radically accept difficult life events.1,3
Dialectical behavior therapy was initially developed for patients with borderline personality disorders (BPD), and it has demonstrated effectiveness in treating BPD and chronic suicidal behavior.1,3–5 The characteristics of these two conditions include emotion dysregulation, impulsivity, interpersonal difficulties, treatment non-adherence, substance abuse disorders and eating disorders. Given that these traits are common to other mental illnesses; it is not surprising that in recent years, DBT and DBT-based interventions have been used to treat diverse populations of mentally ill individuals.1,5 Emerging evidence suggests that DBT skills training reduces problems with emotions and is feasible to implement with a variety of mental disorders3
This review aims to summarize evidence regarding the clinical effectiveness and guidelines for the use of DBT in the treatment of adult patients with mental illness.
Research Question
What is the clinical effectiveness of Dialectical Behavioral Therapy in adults with mental illness?
What are the evidence-based guidelines associated with the use of Dialectical Behavioral Therapy in adults with mental illness?
Key Findings
The findings from one RCT2 suggest no statistically significant differences between DBT and treatment as usual (TAU) for reducing attempted suicide, suicidal ideation, and hospitalization among veterans. The findings from four RCTs1,3–5 suggest no statistically significant differences between DBT or DBT-based interventions and various comparators at improving symptoms of emotional dysregulation,3 bipolar disorders,5 mindfulness and awareness,1 attention deficit hyperactivity disorders (ADHD),4 executive functioning,4 and quality of life4 in adults with mental illness. Overall, DBT or DBT-based interventions were not statistically significantly greater than comparators at reducing depressive and anxiety symptoms. However, in one RCT,1 clinician-reported Hamilton depression rating scale (HDRS) scores indicated a significantly greater improvement in depressive symptoms with DBT than psychoeducation (PE_ (p= 0 .048) although patient-reported Beck depression inventory (BDI-II) scores showed no significant difference between the two groups. Results from one RCT5 indicated a significantly greater reduction in the severity of anxiety compared to a wait-list control. The results of one RCT6, which also included a post-hoc secondary data analysis7 based on a subgroup of its population, indicated that in women with CSA-related PTSD, residential treatment with DBT-post-traumatic stress disorder (PTSD) significantly reduced PTSD symptoms and trauma-related emotions, and also increased acceptance of trauma-related facts and on psychosocial aspects.
Given the limitations associated with the RCTs1–5 included in this review, more robust studies are needed to confirm their reported efficacy of DBT or DBT-based interventions in the adult patients with mental illness.
The literature search did not identify any evidence-based guidelines with recommendations specific for the use of DBT in the treatment patients with mental illness.
Methods
Literature Search Methods
A limited literature search was conducted in key resources including PubMed, The Cochrane Library, the University of York Centre for Reviews and Dissemination (CRD) databases, Medline and PsycInfo, Canadian and major international health technology agencies, as well as a focused Internet search. Methodological filters were applied to limit retrieval to health technology assessments, systematic reviews, meta-analyses, randomized controlled trials and guidelines. Where possible, retrieval was limited to the human population. The search was limited to English language documents published between January 1,2012, and September 21, 2017.
Rapid Response reports are organized so that the evidence for each research question is presented separately.
Selection Criteria and Methods
One reviewer screened citations and selected studies. In the first level of screening, titles and abstracts were reviewed, and potentially relevant articles were retrieved and assessed for inclusion. The final selection of full-text articles was based on the inclusion criteria presented in .
Exclusion Criteria
Articles were excluded if they did not meet the selection criteria outlined in , they were duplicate publications, or were published before 2012. Studies which had patients with BPD or binge eating as the primary population of interest were excluded.
Critical Appraisal of Individual Studies
The included randomized controlled trials (RCTs) were critically appraised using the Downs and Black checklist.8 Summary scores were not calculated for the included studies; instead, a review of the strengths and limitations of each included study was narratively described.
Summary of Evidence
Quantity of Research Available
A total of 236 citations were identified in the literature search. Following the screening of titles and abstracts, 217 citations were excluded, and 19 potentially relevant reports from the electronic search were retrieved for full-text review. The grey literature search did not identify any potentially relevant publications. Of the 19 potentially relevant articles, 12 papers were excluded for various reasons, while seven publications representing six RCTs met the inclusion criteria and were included in this report. Appendix 1 describes the PRISMA flowchart of the study selection.
Additional references of potential interest are provided in Appendix 5.
Summary of Study Characteristics
Six RCTs1–6 with evidence of clinical effectiveness were included in this review. A seventh publication,7 was included. However, because it perfoemed a secondary data analysis of 23 women in an already included RCT,6 the two articles were considered as representing one study.6
Study Design
Three of the RCTs3–5 were pilot studies whereas three RCTs1,2,6 were not.
Elices et al.1 and Van Dijk et al.5 conducted their RCTs at general hospital settings, while Neacsiu et al.3 and Fleming et al.4 conducted their RCTs at university settings. In the RCT by Bohus et al.,6 patients underwent residential treatment in a specialized institution.
Veterans population
One RCT (Goodman et al.2) was conducted at a USA Veterans Affairs (VA) medical center.
Country of Origin
The RCTs by Neacsiue et al.,3 and Fleming et al.4 conducted in the USA, whereas Elices et al.1 Bohus et al.,6 and Van Dijk et al.5 conducted their RCTs in Spain, Germany, and Canada, respectively.
Veterans population
The RCT by Goodman et al.,2 was conducted in the United States of America (USA).
Patient Population
All but one RCT6 included patients 18 years or older. The RCT by Bohus et al.,6 included patients aged 17 to 65 years.
Elices et al.1 enrolled 75 patients previously diagnosed with major depressive disorder (MDD) involving at least two previous depressive episodes. The patients had to be in complete or partial remission and without a major depressive episode within the two months before the study initiation.1 Fleming et al.4 had thirty-three undergraduate students diagnosed with ADHD, Neacsiu et al.3 had 44 patients with high emotion dysregulation, and Van Dijk et al5 included 26 patients diagnosed with depression, or hypomanic bipolar-I or bipolar-II. Common exclusion criteria to all the RCTs1–5 were psychotic disorders, schizophrenia, or on-going violent or aggressive behaviours. Elices et al.1 and Neacsiu et al.3 excluded patients with BPD. Bohous et al. enrolled 74 women with childhood sexual assault (CSA)-related PTSD referred by their local psychiatrists for residential treatment due to treatment-resistant PTSD. About half (44.59%) of the patients in the RCT by Bohus et al.6 had co-occurring BPD, distributed evenly across study arms. Fleming et al4 and Van Dijk et al.5 did not report any information about the BPD status of the patients in their RCTs.
Veterans population
Goodman et al.2 included 91 veterans at a high risk for suicide regardless of their personality diagnosis.
Further details about inclusion and exclusion criteria of the included RCTs1–5 are available in Appendix 2.
Interventions and Comparators
The intervention of interest in all the included RCTs1–6was DBT either in its standard form or adapted to suit the targeted patient group. The comparators differed across studies and involved psychoeducation (PE), treatment as usual (TAU), self-guided skills handouts (SH), an activity-based support group (ASG), and a wait-list control.
In the RCT by Elices et al.,1 patients were randomly assigned to treatment with the emotion regulation and mindfulness skills (ER+M) components of DBT, administered in a 120-minute session each week. In the comparator group, patients received a 90-minute PE treatment every two weeks. Both interventions were applied in a group format of eight to 12 patients per group. The treatment phase was ten weeks, followed by a 52-weeks follow-up period.
In the RCT by Fleming et al.,4 patients received either DBT skills training or self-guided SH. Patients in the DBT group received training from the standard DBT to acquire skills to manage their ADHD. The intervention included 15 minutes of individual pre-group meeting focused on motivation enhancement, eight weekly 90-minute group sessions focused on skills acquisition and strengthening, and seven weekly individual coaching phone calls of between 10 and 15 minutes focused on skills generalization. The patients also received a 90-minute booster group session during the first week of follow-up. In the SH group, patients received a 34-page handout drawn from a manual for the treatment of adults with ADHD and designed to reflect publicly available self-help materials for ADHD. The treatment phase was eight weeks followed by a three-month follow-up period.
In the RCT by Neacsiu et al.,3 each patient assigned to DBT skills training met once with their group therapists for a 30-minute private orientation session to establish a crisis plan. The patients in this group attended a two-hour group therapy session every week. The comparator was ASG aimed to foster a sense of belongingness, maintain unconditional positive regard, and provide empathy, psychoeducation, and a treatment structure. The treatment phase was 16 weeks, and there was a six-month follow-up period.
Bohus et al.6 randomized patients to a newly developed a modular treatment programme called DBT-PTSD or treatment as usual wait list (TAU-WL). Patients assigned to the DBT-PTSD arm were admitted to residential care for therapy that combined the principles of DBT and trauma focused interventions specifically tailored to the needs of patients with CSA-related PTSD plus severe emotion regulation difficulties such as BPD. The programme had three treatment phases. In first phase (week one to week four), patients learned to identify their typical cognitive, emotional and behavioural escape strategies and received psychoeducation. The second phase (week five to week ten) dealt with trauma-focused cognitive and exposure-based interventions, whereas the third phase (weeks 11 and 12) focused on radical acceptance of trauma-related facts and on psychosocial aspects. The patients also received twice-weekly 45-minute sessions of individual treatment and weekly group treatments sessions focusing on skills training (90 minutes), self-esteem (60 minutes), mindfulness (25-minutes) and PTSD-specific psychoeducation (60 minutes). They also attended three 90-minute non-specific weekly group interventions. The treatment phase of the study was 12 weeks after which the patients were discharged from the residence. There was a 12-week follow-up period. Patients assigned to the TAU-WL arm received any treatment of their choice (except DBT-PTSD) through the entire 24 week period. They were allowed to contact study management for supportive counselling.
In the RCT by Van Dijk et al.,5 patients in the DBT group received a 90-minute session of DBT-based psychoeducation every week. Two sessions were devoted to education about the bipolar disorder. One session focused on medications used to treat bipolar disease, and another meeting focused on the importance of self-care. In the remaining treatment period, the patients were taught stress tolerance skills to help them cope with crises, regulate their emotions, and to reduce and tolerate emotional pain. They also received training for interpersonal effectiveness skills to help develop healthier relationships. The comparator group was described as a wait-list control. Although patients in this group had access to the group facilitator, they did not receive any specific service besides information about what to do if they were in crisis. All patients in the study were instructed to continue working with their healthcare professionals, including family physicians, psychiatrists and case managers. The treatment phase was 12 weeks. A follow-up period was not reported.
Veterans population
In the RCT by Goodman et al.,2 patients assigned to DBT attended a 90-minute group training session every week, received weekly individual DBT treatment of between 50 and 60 minutes, and a telephone coaching as needed. The comparator was TAU based on the recommendations of the patients’ mental health care team. The treatment phase was six months, with a follow-up period of an additional six months. All patients in the study were allowed to use medications as indicated by their outpatient psychiatrist. Also, all patients had access to case management services, suicide prevention care, and suicide prevention coordinators available at the VA hospitals.
Outcomes
Outcome measures of interest in the RCT by Elices et al.1 were time to relapse or recurrence of major depression, and changes in depression, general psychiatric symptoms, and dispositional mindfulness.
The RCT by Fleming et al.,4 assessed changes in ADHD symptoms and executive functioning. Neacsiu et al.3 measured changes in emotion dysregulation, skillful behaviours, depression, and anxiety. Bohus et al.6 evaluated reduction of PTSD symptoms and self-reported measures of psychopathology and social functioning, whereas Van Dijk et al.5 reported changes in severity of depression, symptoms of mania or hypomania, as well as effects of mindfulness training and belief in one’s ability to control emotions as outcomes.
Tools used to measure the various study outcomes varied across studies and included the Hamilton depression rating scale (HDRS),1 Beck depression inventory-II (BDI-II)1 and the Patient Health Questionnaire-9 (PHQ-9) for depression.1–3,5 The Columbia-suicide severity rating Scale (CSSRS) was used to measure the risk of suicide attempt;2 the mindful attention awareness scale (MAAS) for dispositional mindfulness,1 and the mindfulness-based self-efficacy scale (MSES) for the effects of mindfulness training.5 Others include the Barkley adult ADHD rating scale-IV (BAARS-IV) for ADHD symptoms, and the Brown ADD rating scales (BADDS) for executive functioning.4 Further details about outcome measures of the individual RCTs have been provided in Appendix 2
Veterans population
Goodman et al.2 reported risk of suicide attempt, time to the next suicide attempt, and suicide ideation, depression, hopelessness, and anxiety as outcomes.
Summary of Critical Appraisal
Further review of the critical appraisal of the included studies is available in Appendix 3
All the included RCTs1–6 stated the study objectives as well as the inclusion and exclusion criteria. In each study, patients who met the inclusion criteria were randomly assigned to the index intervention and the comparator groups in a blinded manner. Overall, the baseline demographic or clinical characteristics were similar between the study groups of each RCT. The RCT by Bohus et al.6 enrolled only women, and it is unknown whether findings are generalizable in men. The paper by Gorg et al.,7 is a secondary data analysis based on a subgroup of women from the RCT by Bohus et al.,6 Thus it is unlikely that the post-hoc analysis was designed for the purpose of the original study; and it is unclear whether the subsample of patients was large enough to allow a definitive conclusions of its findings. Details of the interventions and comparators were provided in all the RCTs alone with a clear description of the outcomes of interest and the measures used to assess them.1–5 Elices et al.1 and Neacsui et al.3 performed sample size calculations to ensure their studies were adequately powered to detect between-group differences in outcomes. The three other RCTs2,4,5 did not perform power analyses; thus it is unknown ” whether samples were large enough to detect meaningful differences. All the RCTs1–5 performed analysis based on the intention-to-treat (ITT) population, which is robust and preserves the initial randomization effect. Elices et al.1 Goodman et. Al.2, Neacsui et al.3, and Fleming et al.4 accounted for missing data in their analysis, whereas Van Dijk et al.5 did not report of missing data. The dropout rate varied across the studies from no dropouts in the RCT by Van Dijk et al.5 to 32% and 59% dropouts in the DBT and ASG groups, respectively, in the RCT by Neacsui et al.3. In the four RCTs1–4 with dropouts, the rates were high and had the potential to offset the initial randomization effect. Some study settings2,4,6 had the potential to limit generalizability.
Summary of Findings
1. What is the clinical effectiveness of Dialectical Behavioral Therapy in adults with mental illness?
One RCT2 reported DBT findings among veterans while five RCTs1,3–6 reported findings not directly related to veterans or military personnel.
Depressive and Anxiety symptoms
Four RCTs1,3–5 reported changes in depressive symptoms following therapy. In the RCT by Elices et al.1 patients treated with ER+M showed greater improvement in depression than those who received PE on the clinician-assessed HDRS scale following treatment (p= 0 .048). However, on the self-reported BDI-II scale, there was no statistically significant difference in depressive symptoms between patients in the E+M and PE groups. The analysis by Elices et al.1 showed no significant differences in the time to relapse or recurrence of depressive mode between the ER+M and PE groups. Fleming et al.4 and Neacsiu et al.3 reported no significant difference in improvement in depressive and anxiety symptoms between patients treated with DBT and those in the ASG and SH, groups respectively. However, Neacsui et al.3 found that patients in the DBT group experienced reductions in their anxiety severity significantly faster (d = 1.37). Van Dijk5 reported that after 12 weeks of therapy, 92% of patients who underwent DBT-based psychoeducation had minimal or mild depression compared to 42% of those in the wait-list control group, in which 58% of patients still had moderate to severe depression. This difference was significant (p = 0.0009).
Mindfulness and awareness
In the RCTs by Elices et al.1 and Van Dijk et al.,5 improvements in mindfulness and awareness among patients in the DBT groups were not statistically significantly different from patients who received PE or those in the wait-list control group, respectively. However, Fleming et al.4 reported that patients in the DBT group achieved a significantly higher improvement in overall mindfulness compared with those who received SH.
Change in emotion dysregulation and Affective Control
In the RCT by Neacsiu et al.,3 analyses showed that patients in both the DBT and ASG reported significantly less emotion dysregulation during the treatment phase without a significant difference between the groups. However, patients in the DBT group improved significantly faster (d = 1.86). At follow-up, there was no significant difference in emotion dysregulation between the two groups. Van Dijk5 found no significant difference in affective control gains following DBT compared with wait-list control.
ADHD Inattentive Symptoms
Fleming et al.4 reported that among ADHD college students, 11 (65%) showed a response to DBT treatment for inattention compared with 6 (38%) of those in the SH group. Among those who responded to treatment, 10 (59%) in the DBT group showed recovery, compared with 5 (31%) in the SH group. The difference was not statistically significant either comparison (p ≥ 0.11). However, at the three-month follow-up assessment, a significantly greater proportion of patients in the DBT group showed a positive response compared with the SH group (65% versus 25%; p = 0.02). Of these, 9 (53%) patient in the DBT showed recovery compared with 4 (25%) in the SH group. The difference was not statistically significant (p = 0.10).
Executive functioning
Fleming et al.4 found that a significantly higher proportion of ADHD patients who underwent DBT showed a positive response than those who received SH (65% versus 19%; p = .008). Among those who responded to treatment, a significantly higher proportion showed recovery with DBT than with SH (53% versus 6%; p = 0.004). At the follow-up evaluation, a significantly higher proportion of patients in the DBT group showed a positive response (59% versus 25%; p = .049) and recovery (47% versus 13%; (p = 0.03) than those in the SH group.
Quality of life
Fleming et al.4 reported that at the end of treatment, ADHD patients who underwent DBT reported a significantly better quality of life than those who received SH (p = 0.015). There was no difference in the quality of life between the groups at the follow-up assessment.
Acceptability
In the RCT by Fleming et al.,4 patients in the DBT group attended 88% of scheduled sessions, and the dropout rate was 6%. The total acceptability scores were significantly higher for DBT than for SH (p < 0.001). In the RCT by Neacsui et al.,3 the average, attendance of the therapy sessions was higher with the DBT group than with ASG (66% versus 50%), but the dropout rate was higher with ASG (59%) than with DBT-ST (32%).
The difference was not statistically significant. Neacsui et al.,3 reported that significantly more patients attributed the improvement in depression or anxiety to DBT than to ASG (p < 0.01). Patients who received DBT skills training showed a significantly higher confidence in recommending their therapy to a friend than patients treated with ASG (p <0 .01). In the RCT by Van Dijk et al.,5 75% of patients who received DBT rated their overall impression of the group as “excellent” and 24% rated their experience as “good”; one person rated the group as “fair”.
Reduction of PTSD symptoms
Bohus et al.6 found that among women with CSA-related PTSD, treatment with DBT-PTSD achieved significantly greater reduction (p < 0.001) in PTSD symptoms than TAU-WL on both the CAPS and the PDS. Between-group effect sizes were statistically significant.
Psychopathology and social functioning
The RCT br Bohus et al.6 reported mixed findings concerning measures of psychopathology and social functioning. While the BDI and the GAF scores showed that patients in the DBT-PTSD group had a significantly greater improvement than did those in the TAU-WL group, the SCL-90-R, the DES, and the BSL measures did not show statistically greater improvements.
Trauma-related emotions and radical acceptance
In a secondary data analysis of a subgroup of women from the RCT by Bohus et al.6 who received DBT-PTSD, Gorg et al.7 found that trauma-related emotions, such shame, guilt, disgust, distress, and fear decreased significantly from the start to the end of the therapy whereas radical acceptance increased.
Veterans population
Depressive and Anxiety symptoms
Goodman et al.,2 did not find a statistically significant difference in changes in depressive symptoms between veterans in DBT and TAU groups. However, Goodman et al.2 reported that DBT veterans demonstrated significantly greater improvement in anxiety symptoms than those who revived TAU during the follow-up period (p = 0.04) but not during the treatment phase. It is unclear whether the improvement in anxiety symptoms during the follow-up phase was due to DBT since the active intervention phase had come to an end.
Suicide Attempts and Suicidal Ideation
Goodman et al.2 reported that three patients (6.5%) in the DBT group compared with five patients (11.11%) in the TAU group attempted suicide during the 6-month treatment phase and 6-month follow-up, resulting in 35% hospitalization rate in both groups over the period. A survival analysis of suicide attempts and hospitalizations did not show a significant between-group difference. Patients in both the DBT and TAU groups showed improvements in suicidal ideation without a statistically significant difference between the two groups.
2. What are the evidence-based guidelines associated with the use of Dialectical Behavioral Therapy in adults with mental illness?
The literature search did not identify any evidence-based guidelines with recommendations for the use of DBT in the treatment patients with mental illness.
Limitations
Of the five included RCTs,1–5 three were small (n ≤ 44 patients) pilot studies, designed for initial evaluation of efficacy and feasibility of DBT-based therapy. Of the two RCTs1,2 that were not pilot studies, only one (Elices et al.1) was adequately powered at baseline, to detect differences between treatment groups. In the RCT by Elices et al.,1 the ER+M (DBT) sessions were scheduled weekly versus to the comparator group which received PE sessions every two weeks. Therefore, patients in the interventions group received twice the number of therapy sessions as those in the comparator group. Thus it is unknown whether the advantage of more treatment exposure to patients treated with ER+M over those who received PE may explain the trend towards more favorable findings with the intervention than the comparator group. Four RCTs1–4 reported high dropout rates with the potential to disrupt the baseline randomization effect resulting in a bias of the reported results. In all the RCTs,1–5 there were no modalities to control or standardize concurrent therapy. Thus, access to different parallel medications and psychotherapy regimens suggests that the reported treatment efficacy from the RCTs may not be due precisely to the interventions under study. Taken together, more robust studies are needed to confirm the effectiveness of the DBT or DBT-based interventions in the mentally ill patient populations targeted by the RCTs1–5. Whereas Elices et al.1 and Van Dijk et al.5 conducted their RCTs in hospital settings, the RCT by Goodman et al.2 was conducted at a VA medical center in the USA, while Neacsiu et al.3 and Fleming et al.4 conducted their RCTs in university settings. Given that TAU in a VA hospital in the USA may be different form TAU in the Canadian context, and that staff and logistics at university facilities may differ significantly from that of general practice, the generalizability of the study findings from these settings is unknown. Similarly, the intervention in the RCT by Bohus et al.6 was developed and tailored specifically for CSA-related PTSD patients, and provided as residential care in a specialized institution. Therefore, the generalizability of the study findings in other mentally ill populations and in non-residential settings is unknown. Also, there was no control group in the secondary data analysis by Gorg et al.7; therefore, it is unclear whether the DBT-PTSD treatment induced the changes in trauma-related emotions and radical acceptance the reported.
Conclusions and Implications for Decision or Policy Making
This review included five RCTs1–5 which provided evidence of clinical effectiveness of DBT in adults with mental illness including high-risk suicidal veterans,2 as well as patients with the major depressive disorder,1 ADHD,4 transdiagnostic emotional dysregulations,3 and bipolar disorders.5
The findings from one RCT2 suggest no statistically significant difference between DBT and TAU with regards to reducing suicide attempts, suicidal Ideation, and hospitalization, as well as improving depressive and anxiety symptoms among veterans. Although there was no statistically significant difference in severity of anxiety between the DBT and TAU in the treatment phase, a significant improvement in anxiety symptoms was observed during the follow-up period among veterans treated with DBT than those who received TAU (p = 0.04), It is unclear whether the improvement was due to DBT.
The findings from three the RCTs3–5 suggest that improvement in depressive and anxiety symptoms with DBT or DBT-based interventions was not significantly different than with comparator interventions. However, depressive symptom findings from one RCT1 were inconclusive as DBT (ER+M) showed statistically significantly greater improvement than PE on a clinician-administered HDRS scale but not on the self-reported BDI-II scale. Findings from one RCT5 suggest that DBT-based psychoeducation significantly reduced the severity of anxiety compared to a wait-list control. The results of two RCTs1,4,5 indicate that improvements in mindfulness and awareness were not statistically significantly different between patients treated with DBT or DBT-based interventions and those in the control groups. However, findings from one RCT4 indicated a significantly higher improvement in overall mindfulness with DBT than with SH. The results from one RCTs3 suggest no significant difference in emotion dysregulation outcomes between DBT and ASG. The findings of one RCT5 indicate no significant difference in affective control gains between DBT and a wait-list control. The findings from one RCT4 suggest no statistically
insignificant difference in ADHD symptoms, executive functioning, and quality of life in adult ADHD patients between DBT and SH The findings of three RCTs3–5 indicated that DBT had a greater acceptability than with the comparators.
The results of one RCT6 and a secondary data analysis7 based on a subgroup of its population indicate that in women with CSA-related PTSD, residential treatment with DBT-PTSD significantly reduce PTSD symptoms and trauma-related emotions, and increased acceptance of trauma-related facts and on psychosocial aspects.
Given the previously discussed methodological shortfalls and the limitations of the included RCTs, further studies are needed to confirm the effectiveness of the DBT or DBT-based interventions in the mentally ill patient populations targeted by the RCTs1–5.
The literature search did not identify any evidence-based guidelines with recommendations specific for the use of DBT in the treatment patients with mental illness.
References
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Appendix 1. Selection of Included Studies
Appendix 2. Characteristics of Included Publications
Table 1Characteristics of Included Publications
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| Author, Publication Date, Country | Study Design | Population | Intervention | Comparator(s) | Outcomes |
|---|
Elices, 20171
Spain | RCT | A total of 75 patients aged 18 to 75 years with a previous diagnosis of MDD involving at least two previous episodes of depression with the major episode occurring between 18 and two months before the study began.The patients had to be in complete or partial remission before the study initiation. Patients were excluded if they had current MDD or any other affective disorder; alcohol or drug dependence, psychotic disorders or schizophrenia; personality disorders; severe physical conditions; or receiving ongoing psychotherapy. | The ER+M components of DBT, administered as a 120-minute session weekly | PE treatments administered as a 90-minute session every two week | Primary
Time to relapse or recurrence of major depression.
Secondary
Changes in depression, general psychiatric symptoms, and dispositional mindfulness during the ten weeks intervention phase assessed by HDRS, BDI-II, SCL-90- GSI, and MAAS. |
| Both interventions were applied in a group format of eight to 12 patients per group for a 10-week treatment phase followed by a follow-up period of 52 weeks. |
Goodman, 20162
USA | RCT | A total of 91 non-psychotic veterans aged between 18 and 55 years who were at a high risk for suicide, irrespective of their personality diagnosis. Exclusion criteria were schizophrenia or schizophrenia-related disorders as defined by DSM-IV, and current evidence or history of clinically significant organic brain impairment. | DBT | TAU
(recommended by the patients’ mental health care team comprising a psychiatrist and case manager) | Primary
Risk of suicide attempt (measured with the CSSRS) and length of time to the next suicide attempt.
Secondary
Suicide ideation, depression, hopelessness, and anxiety using the BSS, BDI-II, BHS, and BAI, respectively |
| Six months treatment phase followed by six months follow-up period. Patients in both the DBT and TAU groups received SPC and case management services, and medications as indicated by their outpatient psychiatrist. |
Fleming, 20154
USA | RCT (pilot study) | Thirty-three undergraduates aged between 18 and 24 years, diagnosed with ADHD according to DSM-V, 2013 criteria for ADHD in adulthood. Exclusion criteria included current substance abuse or dependence, active suicidality, major depressive episode, and history of psychotic disorder, bipolar disorder, or PDD. | DBT group skills training | Self-guided skills handouts (SH) | Changes in ADHD symptoms, EF, and related outcomes post-treatment and 3-month follow-up |
| Duration—Eight weeks intervention phase and three months follow-up |
Neacsiu, 20143
USA | RCT (pilot study) | Forty-four non-BPD adults (>18 years) with high emotion dysregulation, clinical anxiety or depressive disorder. Participants had to agree to remain on the same dosage (if any) of psychotropic medication and to refrain from participating in ancillary psychotherapy. Exclusion criteria were BPD, high risk for suicide, ongoing psychological treatment, homeless, inability to attend group, more than five previous DBT bipolar or psychotic disorder, or a life-threatening disorder. | DBT-ST | ASG aimed to foster a sense of belongingness, maintain unconditional positive regard, and provide empathy, psychoeducation, and a treatment structure. |
|
| Duration of therapy was 16 weeks Each patient had access to a weekly two-hour group therapy session for 16 weeks and met individually with their group therapists once for a 30-minute private orientation session in which a crisis plan was established. |
Bohus, 20136
Germany | RCT | 74 female patients aged between 17 and 65 years with CSA-related PTSD. About half of the participants met the criteria for cooccurring BPD. They were referred by their local psychiatrists for residential treatment in a specialized institution, due to treatment-resistant PTSD. Patients were excluded if they had ongoing self-harm, a life-threatening behaviour, schizophrenia, substance dependence, a body mass index <16.5, and intellectual disability. | DBT-PTSD* for 12 weeks residential treatment | TAU wait-list | Primary
Reduction of PTSD symptoms using CAPS and the self-reported PDS scores.
Secondary
self-reported measures of psychopathology and social functioning using the BSL, DES (German version FDS-20, BDI-II, GAF and SCL-90R |
Gorg 20177
Germany | A secondary data analysis of a subgroup of 23 women from the RCT by Bohus, 20136 | Twenty-three women mean (SD) age 36.3 (10.5) years old, who were treated with DBT-PTSD, including patients from the TAU-WL group (n=8) who received DBT-PTSD after the original study period. In addition to CSA-related PTSD the patients had at least one of the following—BPD, current eating disorder, current MDD, or current substance abuse. | DBT-PTSD for between 12 and 14 weeks residential treatment | None | Change in ratings in trauma-related and radical acceptance from the start to the end of DBT-PTSD using questionnaire and a rating scale ranging from 0 (not at all) to 100 (maximum). |
Van Dijk, 20135
Canada | RCT (pilot study) | A total of 26 euthymic, depressed, or hypomanic bipolar-I or bipolar-II adult (≥ 18 years) patients. Patients were excluded if they were currently in a manic state, had a concurrent diagnosis of a developmental delay, had on-going violent or aggressive behaviours which might pose a threat to other group members, or were unable to read and comprehend the English language. | DBT-based psychoeducation for 12 weeks | Wait-list-control | Severity of depression (with BDI-II) Effects of mindfulness training (with MSES) Belief in ability to control emotions (with ACS) Severity of symptoms of mania or hypomania (with YMRS) |
ACS = affective control scale; ASG = activities-based support group; BAI = Beck anxiety inventory BDI-II = Beck Depression Inventory -II; BPD = borderline personality disorder; BHS = Beck hopelessness scale; BSL = borderline symptom list, BSS = Beck scale for suicide ideation; CAPS = clinician-administered PTSD scale; CEIS = credibility and expectancy of improvement scale; CSA = childhood sexual abuse; C-SSRS = Columbia-suicide severity rating scale; DBT = dialectical behavioral therapy; DBT-ST = dialectical behav ioral therapy skills training; WCCL = ways of coping checklist; DERS = difficulties in emotion regulation scale; DES = dissociative experiences scale; ER+M = emotion regulation and mindfulness skills; GAF = global assessment of functioning; HDRS = Hamilton depression rating scale; MAAS = mindful attention awareness scale; MMD = major depressive disorder; MSES = mindfulness based self-efficacy scale; OASIS = overall anxiety severity and impairment scale; PDD = pervasive developmental disorder; PDS = posttraumatic stress diagnostic scale; PE = Psychoeducation; PHQ-9 = patient health questionnaire-9; SCL-90-GSI = symptom checklist 90-global severity index; SCL-90R = symptom checklist-90 – revised; SH = self-guided skills handouts; YMRS = young mania rating scale.
- *
The authors stated that they developed DBT-PTSD, for PTSD after CSA, and it is specifically tailored to the needs of patients with CSA-related PTSD plus severe emotion regulation difficulties such as BPD.
Appendix 3. Critical Appraisal of Included Publications
Table 2Strengths and Limitations of Randomized Controlled Trials using the Downs and Black checklist.8
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| Strengths | Limitations |
|---|
| Elices, 20171 |
|---|
The objectives of the study were stated clearly Analyses of outcomes were based on both the ITT and PP populations to assess the robustness of the findings. Missing data were accounted for using the LOCF approach. The sample size determined using calculations to ensure the study was adequately powered to detect significant differences in outcome between study groups The specified inclusion and exclusion criteria were appropriate for the targeted condition Patients who met the inclusion criteria were randomized to receive one of two interventions by an independent statistician, and the interviewers were blinded to the patients ’ conditions throughout the s tudy. At baseline, demographic or clinical characteristics were similar between the ER+M and the PE groups. The pharmacological treatments as well as the proportion of patients in total or partial remission, and the mean number of previous depressive episodes were similar in both groups. The interventions and outcome measures were described, and major study findings were well-reported. The authors declared they had no competing interests concerning the publication.
|
During the intervention phase, three patients (8%) dropped out of the ER+M group while ten patients (26%) dropped out of the PE group. It is unknown how this affected the initial randomization effect and power of the study. Because the ER+M sessions were scheduled weekly as against every two weeks for PE, patients in the ER+M group received twice as many sessions of therapy as those in the PE group. It is uncertain whether this difference in treatment exposure affected the reported outcomes Results during the follow-up period were patientreported based on recall and estimates. Such outcomes were subjective and may have been affected by recall bias.
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| Goodman, 20162 |
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The objectives of the study and the inclusion and exclusion criteria were stated clearly Patients who met the inclusion criteria were randomly assigned to DBT or TAU using a computerized randomization sequence. The interventions for each group were described in details and outcomes were assessed with specific validated tools. Analyses were based on the ITT populations, and the findings were reported clearly. The demographic or clinical characteristics were similar at baseline and dropouts did not significantly differ between the treatment groups. The authors declared they had no competing interests concerning the publication.
|
Calculations were not done to determine the sample size provide adequate power for the study. The setting of the study was a VA hospital in the USA, and the comparator intervention was TAU. TAU is a very subjective term which can differ in particulars from one setting to another. TAU in a VA hospital in the USA may be different form TAU in the Canadian context. Therefore, the generalizability of the s tudy findings is unknown. The dropout rate was high (32%), and the missing data were not imputed. Instead, the investigators estimated parameters and tested hypotheses about the missing data using the GLMM to assess the covariance structure and choose the most appropriate model. It is unknown how this approach impacted the reported outcomes. Patients were allowed to have concurrent medications therapy from their psychiatrists without any standardization. Thus, there is the likelihood that the differences in medication therapy impacted the reported outcomes of the study.
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| Fleming, 20154 |
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The objectives of the study, as well as the inclusion and exclusion criteria, were stated clearly Patients who met the inclusion criteria were randomized to well-described interventions (DBT or SH) by an interviewer who was blinded to the patients ’ conditions. There were no significant differences in the demographic or clinical characteristics between the treatment groups at baseline. The various outcomes of interest were adequately described and measured with specific validated tools. The results were analyzed based on the ITT populations. Missing data were imputed using the LOCF method and findings were well-reported The author(s) declared no potential conflicts of interest concerning the research, authorship, or publication of the study.
|
The RCT was designed as a stage I pilot trial to provide an initial evaluation of the efficacy, acceptability, and feasibility of DBT and SH in ADHD among college student. Thus a more extensive and more rigorous study may be required to confirm its findings and the extent of their generalizability. No calculations were done to determine appropriate sample size for the study. However, the author stated that the sample size was small and did not provide the statistical power needed to detect small-to-moderate effect sizes or to assess mediators and moderators of treatment response.
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| Neacsiu, 20143 |
|---|
The objectives of the study and the inclusion and exclusion criteria were stated in detail. The sample size was determined based on analyses to ensure power to detect intergroup differences, and patients who met the inclusion criteria were randomly
assigned to receive DBT-ST or activity-based support as interventions. At baseline, demographic characteristics were similar between the DBT-ST and the ASG groups. The interventions and outcome measures were described, and the major study findings were wellreported. Four assessors who were blind to the treatment assignment evaluated the patients, resolving discrepancy through discussions. Analyses were based on the ITT population and scenarios which tested confounds such as the use of psychotropic medications, ancillary psychotherapy, illegal drug use expectancy of improvement and age were analyzed. Missing data were accounted for using a restricted estimated maximum likelihood model.
|
Conditions such as high risk for suicide and homelessness which are common to PTSD patients were part of the exclusion criteria. Thus, it is uncertain whether the study sample was sufficiently representative of the population of interest to this review. The study had a high dropout rate, with 32% in the DBT-ST and 59% in the ASG group dropping out before completion. Considering that patients received up to $100 in compensation for completing all the study assessments, it is reasonable to expect that the dropout rate could be higher in the absence of such incentive. Although the study protocol required patients to keep constant any ancillary treatments they were receiving at the beginning of the study, 45% of all the patients did not comply, including 32% who obtained additional psychotherapy. According to the authors, their analysis showed that neither noncompliance nor dropout impacted their results. Even so, these observations raise questions about the feasibility of using DBT-ST as a stand-alone intervention for patients with anxiety or depressive disorders and high emotional dysregulation. Although the proportion of patients with primary depressive or primary anxiety disorders was similar across the study groups, differences were observed within the subclasses of these conditions. For instance, although each group had 68.2% of primary depressive patients, the ASG had 45.5% dysthymic patients compared with 4.5% in the DBT-ST group.
|
| Bohus, 20136 |
|---|
Assessments were carried out by blinded raters at admission, at end of treatment, and at 6 and 12 weeks post-treatment. Participants and all persons involved in the study were blinded to treatment assignment until written informed consent had been obtained, and the clinicians who conducted the post-treatment assessments remained blinded to treatment assignment throughout the study An analysis was performed to determine the appropriate sample size to ensure the study was adequately powered Efficacy analysis was bassed on the ITT population and accounted for missing data. The dropout rate was low (6%) and similar across study arms . Investigators’ analysis showed that dropouts did not affect the reported outcomes.
|
DBT-PTSD was developed for PTSD after CSA, and it is specifically tailored to the needs of patients with CSA-related PTSD plus severe emotion regulation difficulties such as BPD. It is unknown whether the intervention will be effective in other populations of mentally ill patients. Being a modular treatment of many parts, including DBT and trauma-specific therapies, it is unclear which of the components of DBT-PTSD intervention are necessary for its success. It is unknown whether nonspecific variables such as group cohesion, residential care, and the removal of patients from their regular life interactions had a strong effect. The patients underwent residential treatment at a specialized institution with highly experienced and well trained staff in Germany. It is unknown if the treatment settings, expertise, and available logistics are generalizable in non-residential settings and in the general Canadian context. The study enrolled only women, it is unknown if findings are generalizable in men there was no established psychotropic medication procedure for PTSD psychiatrists in both treatment arms were free to follow their clinical experience
|
| Gorg 20177 |
|---|
|
| The following are in addition to the limitations of the original RCT by Bohus, 20136.
This was a post-hoc analysis of a subsample with outcome measure likely not designed for the purpose of the original study. Data for the analysis were patient-reported through recall and rating and is very subjective There was no control group; therefore, it is unclear whether treatment induced these changes. It is unclear if the sample size was enough for any definitive conclusions to be made from the findings
|
| Van Dijk, 20135 |
|---|
The objectives of the study were stated, and the inclusion and exclusion criteria were specified. Patients who met the inclusion criteria were randomized to receive DBT or to be on a Wait-list control, and the interviewers were unaware of the patients’ as s ignment throughout the s tudy. At baseline, demographic or clinical characteristics were similar between the groups. The interventions and outcome measures were described, and major study findings were well-reported. The authors declared they had no competing interests concerning the publication
|
The RCT was a pilot study with a small sample size (n= 26 patients) without a determination of whether it had sufficient power to detect between-group differences. There was no follow-up. Therefore, it is unknown whether or not the reported improvements were maintained after the 12 weeks treatment period. Patients were allowed to use medications and other therapy concurrently. Therefore, it is likely that the findings were not precisely due to the intervention under study.
|
ADHD = attention deficit hyperactivity disorder; ASG = Activities-based support group; DBT = dialectical behavioral therapy; DBT-ST = dialectical behavioral therapy skills training; ER+M = Emotion regulation and mindfulness skills; GLMM = general linear mixed models; ITT = intention-to-treat; LOCF = last observation was carried forward; PE = Psychoeducation; PP = per-protocol; PTSD = post-traumatic stress disorder; RCT = randomized controlled trial; SH = self-guided skills handouts; TAU = treatment as usual; USA = United States of America; VA = veterans affairs
Appendix 4. Main Study Findings and Author’s Conclusions
Table 3Summary of Findings of Included Studies
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| Main Study Findings | Author’s Conclusion |
|---|
| Elices, 20171 |
|---|
Survival curves analysis showed no significant differences in the time to relapse or recurrence of depressive mode between the ER+M and PE groups
(Long Rank Test, X2 = 2.83, p = .09). Patients treated with ER+M showed greater improvement in depression and general psychiatric symptoms than those in the PE group as indicated by the following group differences in symptom scores—
HDRS (-2.32; 95% CI: -4.51 to -.16; p= 0 .048), BDI-II (-2.22; 95% CI:-5.23 to 1.61; p = 0.36); and SCL-90-GSI (- 0.37; 95% CI: -.53 to -.013; p = 0.040
Thus, ER + M demonstrated significantly higher improvements in depressive than PE using the HDRS measure, whereas the difference the two groups did not reach the level of significance on the BDI-II scale. The group difference in the SCL-90-GSI scores indicates a significantly greater impact of ER+M than PE on the general psychiatric symptoms. Patients treated with ER+M showed a greater gain in mindfulness and awareness than those treated with PE. However the difference was not statistically significant (group difference in MAAS = 0.25 95% CI:-.26 to .42; p = 0.31)
|
“More s tudies are needed to confirm the efficacy of ER+M to decrease depressive symptoms and overall ps ychopathology.” 1 Page 1 “Future res earch s hould be conducted to continue exploring the efficacy of specific DBT skills such as emotion regulation and/or mindfulness to prevent depression relapses. In this line of research, dismantling studies of DBT skills are mandatory to better determine which combination of skills is most efficacious in preventing MDD relapse.” 1 Page 8
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| Goodman, 20162 |
|---|
Suicide Attempts
Suicidal Ideation, Depression, and Anxiety
Patients in both DBT and TAU groups showed improvements in suicidal ideation, depression, and anxiety during the six months therapy phase. There were no statistically significant differences between the two groups, with respect to any of these outcome measures. However, during the follow-up period, DBT patients demonstrated significantly greater improvement than TAU patients in anxiety symptoms as assessed by BAI scores (p = 0.04).
| “Increased mental health treatment delivery, which included enhanced monitoring, outreach, and availability of a designated SPC, did not yield statistically significant difference in outcome for veterans at risk of suicide in TAUS as compared to the DBT treatment arm. However, both treatments had difficulty with initial engagement post-hospitalization. Future studies examining sex differences and strategies to boost retention in difficult-to-engage, homeless, and substance-abusing populations are indicated.”2 Page 1591 |
| Fleming, 20154 |
|---|
ADHD Inattentive Symptoms using BAARS-IV
On BAARS-IV inattentive scores, more DBT patients showed positive response SH patients (11 [65%] DBT versus 6 [38%]; p = 0 .12). Among those responding to treatment, 10 (59%) showed recovery with DBT compared with 5 (31%) with SH (p = 0.11). the difference was not statistically significant in either comparison. At the follow-up assessment, patients with DBT showed significantly greater positive response than those with SH (65% versus 2%; p = 0.02). Of the responders, 53% with DBT showed recovery compared with 4 with SH. The difference was not statistically significant (p = 0.10).
Executive functioning using BADDS
On BADDS total scores, significantly more DBT patients showed positive response with executive functioning than SH patients (65% versus 19%6; p = 0 .008). Among the responders, a significantly higher proportion of patients with DBT showed recovery than with SH (53% versus 6%: p = 0.004). At the follow-up assessment, 10 (59%) a significantly higher proportion of DBT patients showed positive response than SH patients (59% versus 25.0%; p = 0.049). The recovery rates followed a similar trend DBT versus SH (47% versus 13% p = 0.03).
Quality of life using AAQoL
Anxiety and depressive symptoms using BAI and BDI-II
Mindfulness using FFMQ
Acceptability
|
“DBT group skills training may be efficacious, acceptable, and feasible for treating ADHD among college students. A larger randomized trial is needed for further evaluation.” 4 Page 260 “Overall, results suggest that DBT group skills training may be a useful intervention for college students with ADHD, improving participants’ ADHD symptoms, EF, and quality of life to a greater degree than skills training via self-guided handouts. Mean change effect sizes ranged from moderate to large immediately after treatment (d = 0.47-0.94) and 3 months after treatment (d = 0.71-0.84). The intervention may also improve mindfulness and sustained attention. Participant acceptability of the treatment is high, and the group-based approach requires fewer resources and thus may offer greater feasibility than interventions delivered individually.” 4 Page 269
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| Neacsiu, 20143 |
|---|
Change in emotion dysregulation as a function of skills use
During the therapy phase, patients with both DBT-ST and ASG reported significantly less emotion dysregulation over time but that those in DBT-ST improved significantly more and faster (d = 1.86) At follow-up participants in DBT-ST trended toward losing some of their gains, while participants in ASG trended toward continuing to improve. However, there was no significant difference between the two groups.
Skills use
Anxiety severity
During the therapy phase, patients in both DBT-ST and ASG reported a significant decrease in their anxiety severity, but DBT-ST participants improved significantly faster (d = 1.37). The trend was similar during the follow-up period.
Depression severity
Acceptability
The average attendance was higher (66%) with DBT-ST than with ASG (50%), but the dropout rate was higher with ASG (59%) than with DBT-ST (32%). The difference between the groups in these respects was not statistically significant in either comparison. At the end of treatment, patients treated with DBT-ST attributed the significantly greater improvement in depression or anxiety to their treatment than patients in ASG (p < 0.01). Patients treated with DBT-ST reported a significantly higher confidence in recommending their therapy to a friend than patients treated with ASG (p <0 .01)
| “In summary, DBT-ST is a promising treatment for emotion dysregulation for depressed and anxious transdiagnostic adults, although more assessment of feasibility is needed.”3 Page 40 |
| Bohus, 20136 |
|---|
Overall, a significantly higher percentage of patients in the DBT-PTSD arm than the TAU-WL arm showed a response to treatment (38.9% vs. 2.6%; p < 0.001). Within the subgroups of patients with co-occurring BPD, the respective response rates were 29.4% (n = 5) for DBT-PTSD versus 0.0% for TAU-WL. The difference was statistically significant (p = 0.039).
Clinician-assessed PTSD symptoms
At the time of discharge (week 12) the mean (SD) CAPS score in the DBT-PTSD group had reduced from 87.92 (14.20) at baseline to 60.31 (26.79) compared with no significant change in the TAU-WL group. The difference was statistically significant (p < 0.001). The mean (SD) CAPS scores at the week-18 (57.47 [25.66]) and week-24 (58.50 [24.20]) follow-up evaluation show that the patients in the DBT-PTSD group retained their gains from the treatment phase.
Patient-assessed PTSD symptoms
The mean (SD) PDS score declined from 2.22 (0.44) at baseline to 1.61 (0.64) at week-12 for patients in the DBT-PTSD group. At the follow-up evaluations, the respective PDS scores were 1.53 (0.55) at week-18 and 1.53 (0.65) and at week-24. Patients in the TAU-WL group did not have a significant change from baseline over the course of the study. None of the patients in the DBT-PTSD group showed worsening of PTSD symptoms during the study period compared with six patients in the TAU-WL group whose symptoms worsened.
Psychopathology and social functioning
Concerning measures of psychopathology and social functioning, the BDI and the GAF scores showed that patients in the DBT-PTSD group had significantly more improvement than did those in the TAU-WL group. However, the SCL-90-R, the DES, and the BSL did not show statistically better improvements.
|
“DBT-PTSD is an efficacious treatment of CSA-related PTSD, even in the presence of severe co-occurring psychopathology such as BPD.” 6 page 221} “Considering these limitations, we state that this newly developed modular treatment approach is the first to be shown to be both effective and safe for patients with CSA-related PTSD and co-occurring BPD including current self-harming behaviour. Utilisation of the treatment under outpatient conditions will be the next step.” 6 page 231
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| Gorg 20177 |
|---|
In a multilevel model, shame, guilt, disgust, distress, and fear decreased significantly from the start to the end of the therapy whereas radical acceptance increased. Therapy response measured with the CAPS was associated with change in trauma-related emotions. The therapy response was related to decreases in all other trauma-related emotions and increases in acceptance, but this relationship did not reach statistical significance in most of the measures due to the small sample size and high standard errors.
|
“Trauma-related emotions and radical acceptance showed significant changes from the start to the end of DBT-PTSD. Future studies with larger sample sizes and control group designs are needed to test whether these changes are due to the treatment.” 7 page 1
|
| Van Dijk, 20135 |
|---|
Depressive symptoms
Mindfulness and emotional control
The average MSES scores improved over time for both study groups indicating a significant enhancement in the perception of self-efficacy (p < 0.0001). Although mean scores of MSES total were not different in the two study groups, the scores improved for all patients in the DBT group whereas the pattern of scores was inconsistent for the control group. The average ACS scores improve over time for both the DBT group and the Wait-list control, but the changes were not statistically significant. However, DBT showed a trend of higher improvements in ACS depressed mood and anxiety subscale scores than the control.
Acceptability
| “There is preliminary evidence that DBT skills reduce depressive symptoms, improve affective control, and improve mindfulness self-efficacy in BD. Its application warrants further evaluation in larger studies.”5 Page 386
“While psychopharmacological treatment remains the cornerstone of managing BD, the lives of many patients with this illness could be improved further through adjunctive psychotherapy. Further trials evaluating the efficacy of using DBT skills to treat BD are needed, especially given the small sample in this study. Studies comparing the use of DBT skills to other treatments already proven effective in the treatment of BD (e.g., CBT, IPSRT) would be beneficial, as would trial with a follow-up to see if the gains made in the BDG are maintained over time. Finally, further identification of factors that would effect treatment response would be useful, so that patients can be matched with the treatment they are likely to benefit from most (for example, examining whether people with BD and comorbid Axis-II would be more likely to benefit from DBT-informed treatments).”5 Page 392 |
AAQoL = Adult ADHD Quality of Life Questionnaire; ADD = attention deficit disorder; ADHD = attention deficit hy peractivity disorder; BADDS = Brown ADD Rating Scales; BAARS = Barkley Adult ADHD Rating Scale; BDI-II = Beck Depression Inventory -II; EF = executive functioning; BD = bipolar depression; ER+M = Emotion regulation and mindfulness skills; FFMQ = Facet Mindfulness Questionnaire; HDRS Hamilton Depression Rating Scale; MAAS = Mindful Attention Awareness Scale; MMD = major depressive disorder; PE = Psychoeducation; SCL-90-GSI = Sy mptom Checklist 90-Global Severity Index; SH = self-guided skills handouts; SPC = suicide prevention coordinator
About the Series
CADTH Rapid Response Report: Summary with Critical Appraisal
Suggested citation:
Dialectical Behav ioral Therapy f or Adults with Mental Illness: A Rev iew of Clinical Ef f ectiveness and Guidelines . Ottawa: CADTH; 2017 Oct. (CADTH rapid response report: summary with critical appraisal).
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