Professional Documents
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8189
doi:10.1111/camh.12112
Dialectical behavior therapy for nonsuicidal selfinjury and depression among adolescents:
preliminary meta-analytic evidence
Nathan E. Cook1,2 & Maggie Gorraiz3
1
Massachusetts General Hospital Department of Psychiatry, Learning and Emotional Assessment Program, 151 Merrimac
Street 5th Floor, Boston, Massachusetts 02114, USA. E-mail: necook@mgh.harvard.edu
2
Department of Psychiatry, Harvard Medical School, Boston, MA, USA
3
Center for Cognitive and Dialectical Behavior Therapy, Lake Success, NY, USA
Background: Dialectical behavior therapy (DBT) has proven effective in reducing symptoms and behaviors
related to Borderline Personality Disorder. More recently, it has been modified and applied to adolescents
struggling with regulating their emotions and who may engage in impulsive, self-destructive behaviors,
including nonsuicidal self-injury (NSSI). However, there is limited research evidence regarding the effectiveness
of DBT for reducing NSSI behavior and depression among adolescents. Given the high suicide risk associated
with NSSI and its association with depression, this is clearly an important focus of clinical and research attention. Method: This meta-analysis sought to offer preliminary evidence regarding the effectiveness of DBT to
treat NSSI and depression in adolescents. Twelve published studies were included; all 12 reported pre- and
post-treatment measures of depression and six of these studies reported pre- and post-treatment measures of
NSSI. Results: The weighted mean effect size for NSSI was large (g = 0.81, 95% CI = 0.591.03); the weighted
mean effect size for depression was small (g = 0.36, 95% CI = 0.300.42). Conclusions: Intervention effects for
both outcomes were positive, suggesting decreased NSSI and improvement in depressive symptoms for adolescents following a course of DBT. However, given considerable limitations in the research base available for
meta-analysis, these findings are preliminary and tentative. Limitations in the current knowledge base and
suggestions for future research are discussed.
Research in adult populations suggests that DBT is effective in reducing emotional and behavioral difficulties, consistent with borderline personality disorder. However, limited research evidence exists regarding
the utility of DBT interventions in helping adolescents who have trouble modulating their emotions and
controlling their behaviors.
Meta-analytic results from 12 studies examining DBT interventions among adolescents suggest decreased
NSSI and improvement in depressive symptoms.
Practitioners can consider DBT interventions as a possible therapeutic option in the treatment of adolescents who engage in self-harm and suffer with depression; however, practitioners must also continue to
monitor the research evidence base as investigators seek to address and improve upon methodological
shortcomings in the extant literature.
Introduction
Dialectical behavior therapy (DBT; Linehan, 1993a,
2014) is a comprehensive, cognitive-behavioral treatment
(CBT), comprised of principles from behavioral science,
dialectical philosophy, and Zen practice (Lynch, Trost,
Salsman, & Linehan, 2007). It was originally developed
for chronically suicidal females who met the criteria for
Borderline Personality Disorder (BPD) (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991). Diagnostic features of BPD include a chronic, pattern of emotion
dysregulation, which may impact areas of interpersonal
functioning, self-identity and contribute to impulsive,
self-destructive behaviors (American Psychiatric Associa-
82
(2008)
Ost,
2008; Tarrier, Taylor, & Gooding, 2008). Ost
conducted a thorough meta-analysis on a large range of
third wave empirically supported behavioral therapies
examining the methodology, efcacy, and criteria for
empirically supported treatments. For DBT, 13 RCTs,
totaling 539 participants, were used. Nine RCTs examined the treatment of BPD, two examined disordered eating, and the other two examined the treatment of
depression in elderly adults. The overall meta-analysis
resulted in a moderate mean effect size of 0.58.
Similarly, Tarrier et al. (2008) conducted a systematic review and meta-analysis of 28 studies that used
a form of cognitive-behavioral therapy to reduce suicidal behavior in adolescent and adult populations.
The results indicated that cognitive therapy had an
overall positive effect on the outcome variables related
to suicidality (combined Hedges g = 0.59), while
doi:10.1111/camh.12112
As with the adult literature, research studies investigating DBT interventions for adolescents have focused
on its potential to reduce nonsuicidal self-injury (NSSI).
While there is tremendous variability within the literature in the usage of standard denitions, NSSI has been
dened as direct, deliberate destruction of ones own
body tissue in the absence of intent to die (Nock, Joiner,
Gordon, Lloyd-Richardson, & Prinstein, 2006; p. 65).
NSSI occurs in alarmingly high rates (Nock, 2010). In a
systematic review of 52 empirical studies on the international prevalence of NSSI and deliberate self-harm, a
mean NSSI lifetime prevalence rate of 18.0% and 16% for
deliberate self-harm was found (Muehlenkamp, Claes,
Havertape, & Plener, 2012). It is likely that the incidence
rates of self-harm are variable, given the lack of standardized conceptualization and assessment measures
(Nock, 2010).
More recently, Ougrin, Tranah, Stahl, Moran, and
Asarnow (2015) conducted a review and meta-analysis
of a variety of therapeutic interventions in reducing both
suicidal and nonsuicidal self-harm in adolescents. In
doing so, they reviewed 19 RCTs with self-harm as the
primary outcome. There was a reduction in self-harm for
adolescents in the combined intervention groups compared to the control group, when self-harm was considered globally. Yet, when self-harm, dened only as NSSI
and suicidal attempts was analyzed, results were not
signicant. The authors did not recommend a specic
intervention for the treatment of self-harm, due to the
limited evidence; however, the authors emphasized the
importance of standard denitions and assessments of
self-harm and replication of therapeutic interventions,
specically DBT, CBT, and Mentalization-Based Therapy (MBT) as they had the largest effect sizes.
To date, there are two published RCTs targeting adolescents with BPD, one in DBT and one in MBT. Mehlum
et al. (2014) examined the efcacy of DBT in adolescents
meeting at least three of nine BPD criteria (Mehlum
et al., 2014). This was a single-blind randomized trial of
77 adolescents with recent and repetitive self-harm. The
study compared a 16-week outpatient DBT treatment
intervention to an enhanced usual care (EUC), which
consisted of psychodynamic or cognitive-behavioral
individual therapy. The results indicated that the DBT
intervention was superior to EUC in reducing frequency
of depressive symptoms, suicidal ideations, and NSSI.
Rossouw and Fonagy (2012) examined the efcacy of a
1-year mentalization-based treatment program adapted
for adolescents (MBT-A) who had self-harmed, compared
to TAU, among 80 adolescents. MBT-A utilized once a
week individual therapy and monthly family sessions.
The treatment is psychodynamic in nature and works
toward increasing the adolescent and familys ability to
understand behaviors in terms of thoughts and feelings
(see Rossouw & Fonagy, 2012 for more information on
MBT-A). The results indicated a signicant reduction in
self-harm and depressive symptoms compared to TAU.
In addition to DBT and MBT, there is a preliminary
evidence of a CBT intervention specically targeted for
adolescent self-harm that may be benecial (Taylor
et al., 2011). A pilot study examining the acceptability
and feasibility of a time-limited CBT intervention
reported reduced self-harm post-treatment and at
3 month follow-up. Moreover, participants reported a
reduction in trait anxiety, and comorbid depression.
2015 Association for Child and Adolescent Mental Health.
83
Current study
This study seeks to provide the rst meta-analysis of
the developing literature base on DBT for adolescents.
The primary goal was to quantify the effectiveness of
DBT treatment for depression and NSSI with the hope
that the ndings might clarify DBTs utility in reducing NSSI behaviors and depressive symptomatology in
adolescents.
Method
Literature search
We located published studies through computer-based
searches of the reference databases PsycINFO, PsychArticles,
Academic Search Complete, Pubmed, and Medline. Key search
criteria combined the following terms: DBT, adolescents, and
teens. In addition, bibliographies of relevant research and
review articles were manually searched. Finally, articles citing
identied studies were examined for relevance. The sampling
time frame included all studies published prior to August 2014.
Inclusion criteria were: (a) the study reported an evaluation
of a DBT-based intervention, (b) with an adolescent sample (age
1218 years old), (c) included both pre- and post-treatment
measures of NSSI and/or depression, (d) and had a sample size
of at least 10 adolescents. Case studies and studies targeting
outcomes other than NSSI and depression were excluded.
Data extraction
The authors independently reviewed each potentially relevant
article to determine if it met inclusion criteria. Next, both
authors independently extracted study data including sample
recruitment, intervention setting, length of treatment, participant demographics, DBT intervention characteristics, and
effect sizes for pre- to post-treatment change in the outcome
measures of interest. Given the limited number of study characteristics extracted, agreement between raters was high and in
the few cases of discrepancy the authors reached consensus.
Study quality was assessed using the Newcastle-Ottawa
Quality Assessment Scale (NOS; Wells et al., n.d), which was
specically designed to measure quality among nonrandomized
studies. The NOS includes nine items assessing the study features including Sample Selection, Comparability between
Research Groups, and Outcome. Sample Selection items are: (a)
adequacy of case denition, (b) representativeness of cases, (c)
selection of controls, and (d) denition of controls. The Comparability item assess whether the study controls for any important factors to assure comparability of the study groups.
Finally, Outcome items are: (a) how outcomes were assessed
(e.g. by independent evaluator, self-report, etc.), (b) adequacy of
follow-up length, and (c) adequacy of follow-up cohort. For each
of the nine items, stars are earned for stronger, higher quality
design features based on criteria presented in the coding manual.1 An examination of quality assessment measures identied
the NOS as suitable for systematic reviews (Deeks et al., 2003).
Statistical analysis
Due to the predominance of within-group, repeated measures
designs, Hedges g was calculated for each individual study to
quantify gain or change from pretreatment to post-treatment
using formulas provided in Card (2012). However, g has been
shown to overestimate the population effect size, particularly in
small samples (Hedges & Olkin, 1985). Thus, a small sample size
adjustment was used in samples with less than 20 adolescents
(Card, 2012). Effect sizes were further adjusted by weighting
each data point by sample size and a 95% condence interval
was computed around each weighted effect size estimate. An
overall weighted mean effect size was calculated and tested for
statistical signicance. Finally, heterogeneity among the individual study effect sizes was examined. Given the small number of
studies included, no moderator analyses were conducted (e.g. to
examine differences between short and longer term follow-ups).
84
Quality assessment
Results
Search results
Eligibility
Records excluded
(N = 287)
Included
Studies included in
meta-analysis
(N = 12)
Studies reporting
depression outcome
(N = 12)
Figure 1. Results of a systematic literature search conducted to identify studies of dialectical behavior therapy (DBT) interventions with
adolescents that reported either depression or nonsuicidal self-injury outcomes (NSSI)
2015 Association for Child and Adolescent Mental Health.
doi:10.1111/camh.12112
85
Study
2002
29a
93a
16.1a
12 weeks
Outpatient
Rathus and
Miller
Katz et al.
2004
62
84
15.4
2 weeks
Inpatient
Apsche et al.
2006
10
15.9
12 months
Nelson-Gray
et al.
Goldstein
et al.
2006
31
15
12.6
16 weeks
Residential
Treatment
Outpatient
2007
10
80
15.8
12 months
Outpatient
16.4
12 months
Outpatient
% Female
Avg. age
Prepost
interval
Year
Authors
Setting
James et al.
2008
16
100
Woodberry and
Popenoe
2008
46
89
16
15 weeks
Outpatient
Wasser et al.
2008
12
25
14.7
Residential
Fleischhaker
et al.
2011
12
100
NR
Average of
14 months
6 months
10
James et al.
2011
18
83
15.5
12 weeks
Outpatient
11
Perepletchikova
et al.
2011
11
55
9.8
6 weeks
Outpatient
12
Ricard et al.
2013
125
44
4 weeks
Alternative
Education
Program
NR
Outpatient
DBT characteristics
Twice weekly individual and
multifamily skills groups
10 daily, manualized skills sessions,
twice weekly individual therapy,
diary cards, DBT milieu
Weekly individual therapy and at
least one skills group per week
16 weekly 2-hr group treatment
sessions
Weekly sessions alternating between
family skills training and individual
therapy, skills coaching by
telephone, diary cards
Once weekly skills group, 1 hr per
week individual therapy,
telephone support
Weekly individual therapy, skills
training group, and therapist
consultation team meetings,
pharmacotherapy as indicated
and telephone support
Weekly skills training group sessions
for 17-weeks
Manualized 16-week protocol, once
weekly individual therapy, family
therapy as needed, multifamily
skills group
Once weekly 2-hr long skills group,
once weekly hour-long
individual therapy, telephone
support
Twice weekly session, for 6 weeks
using detailed protocol with
session plans
Twice weekly same-gender
group sessions, for 4 weeks
Selection
Comparability
Outcome
86
Sample size
SE
26
10
16
16
12
18
0.84
0.69
1.04
0.43
0.78
1.06
0.18
0.45
0.32
0.26
0.38
0.28
2
5
6
7
9
10
Total n
Lower 95% CI
0.49
0.12
0.48
0.06
0.10
0.55
Upper 95%CI
NSSI measure
1.19
1.64
1.72
0.96
1.60
1.67
Mean ES
SE
Lower 95% CI
Upper 95%CI
0.81
0.11
0.59
1.03
7.20
<.001
98
Positive effect sizes reflect a positive treatment effect, i.e. a decrease in NSSI from pre- to post-treatment assessments.
a
LPC interview to assess lifetime history of self-injurious behaviors grouped by method, intent to die, and level of medical treatment.
b
K-SADS-DRS is a subscale from the K-SADS-PL, a semistructured diagnostic interview to assess current and past episodes of psychopathology in children and adolescents.
c
Parent reported yes/no item assessing any deliberate acts of self-harm in the past 6 months.
Mean ES, mean effect size.
Overall
0.5
0.5
1
1.5
Effect size (g)
2.5
was statistically signicant, Q (11) = 34.04, p < .001, suggesting that the effect sizes are heterogeneous and not all estimates of a single population value. To characterize the
magnitude of heterogeneity we computed the I2 index, which
is interpreted as the ratio of between-study variability relative
to the total variability, expressed as a percentage ranging
from 0% to 100% (Card, 2012). Among these 12 studies the
I2 index was 67.7%. Using available interpretive guidelines
(Huedo-Medina, S
anchez-Meca, Marn-Martnez, & Botella,
2006), this represents a medium amount of heterogeneity.
Discussion
The overall large positive effect size for NSSI and small
positive effect size for depression suggest improvement
in treatment outcomes among adolescents engaged in a
modied DBT intervention. Specically, adolescents
exhibited less NSSI following a course of DBT, compared
to pretreatment assessment. Also, adolescents exhibited
Limitations
The literature base available for meta-analysis presented
several notable methodological limitations. The majority
of the studies used in this meta-analysis were based on
small samples, which limits the precision in estimating
the individual study effect sizes. Indeed, our ndings
suggested a considerably larger effect size for the NSSI
(g = 0.81) outcome compared to depression (g = 0.36).
This difference could be due to the much smaller sample
size for the NSSI outcome. However, the condence
intervals for the overall mean weighted effect sizes for
each of the two outcomes demonstrated that there was
enough power across studies to offer a preliminary, ten 2015 Association for Child and Adolescent Mental Health.
doi:10.1111/camh.12112
87
Sample Size
SE
1
2
3
4
5
6
7
8
9
10
11
12
10
26
10
31
10
16
25
12
11
18
11
125
1.09
0.92
1.26
0.47
0.07
0.76
0.77
0.65
1.37
0.81
0.95
0.30
0.52
0.19
0.56
0.14
0.40
0.29
0.18
0.37
0.53
0.26
0.45
0.03
Total n
Mean ES
SE
Lower 95% CI
Upper 95% CI
0.36
0.03
0.30
0.42
12.02
<.001
305
Lower 95% CI
Upper 95%CI
0.07
0.55
0.16
0.20
0.71
0.20
0.41
0.07
0.32
0.30
0.08
0.24
Depression measure
2.11
1.29
2.36
0.74
0.85
1.32
1.13
1.37
2.42
1.32
1.82
0.36
SCL-90
BDI-13
BDI-II
CDI
K-SADS-DRS
BDI
RADS
BPRS-C
SCL-90 R
BDI
MFQ
YOQ-30.2
Positive effect sizes reflect a positive treatment effect, i.e. a decrease in depressive symptoms from pre- to post-treatment assessments.
0.5
0.5
1
Effect size (g)
1.5
2.5
Figure 3. Forest plot of individual study and overall effect sizes (Hedges g) for depression. Error bars represent the 95% confidence interval. Thick vertical line represents the mean weighted effect size
Future directions
This is the rst meta-analysis to examine the efcacy of
DBT interventions among adolescent populations for
depression and NSSI. These preliminary ndings suggest that further development and evaluation of DBT
interventions to treat adolescent depression and NSSI is
warranted. The ability to quantify treatment effective-
88
Acknowledgements
This study did not receive any external funding. The authors
thank Joseph Rossi for providing guidance and offering his
methodological expertise in support of this project. The authors
have declared that they do not have any potential or competing
conicts of interest.
Notes
1
Interested readers are encouraged to access the NewcastleOttawa Quality Assessment Scale manual for more details
regarding scoring criteria (http://www.ohri.ca/programs/clini
cal_epidemiology/nos_manual.pdf).
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