Dialectical behavior therapy for suicide and self-harm

Dialectical behavioral therapy (DBT) is a form of cognitive behavioral therapy that was developed for suicidal and self-harming people with borderline personality disorder. Later, the intervention has also been adapted for other types of problems such as addiction, eating disorders, depression and post-traumatic stress.

Table 1. Systematic reviews that included patients with borderline.
BPD = Borderline personality disorder; DBT = Dialectical behaviour therapy; MBT = Mentalization based therapy; RCT = Randomized controlled trial; SMD = Standardized mean difference; TAU = Treatment as usual
Included studies Population/Intervention Outcome
Storebø et al. 2020. [1]
Study design: Included only randomised controlled trials.
Included studies: The review included 75 studies, where of 24 investigated the effect of DBT.
Population: Persons of all ages with a diagnosis of BPD. At least 70% of sample had to have a formal diagnosis.

Control: Outcomes listed are versus a treatment as usual control group. Full review also includes other analysis with active psychotherapeutic controls.

Intervention: Any psychological intervention designed for BPD treatment (including DBT).
Self-harm
SMD: –0.28 (–0.48 to –0.07).
n = 376, 7 RCT.
GRADE: Low Symbol which means limited scientific evidence

Suicide-related outcomes:
SMD: –0.23 (–0.68 to 0.23).
n = 231, 5 RCTs.

Other included outcomes: 
BPD symptom severity, Psychosocial functioning, Anger, Affective instability, Chronic feelings of emptiness, Impulsivity, Interpersonal problems, Dissociation and psychotic-like symptoms, Depression, Attrition, Adverse effects
Authors conclusion: We found no unequivocal, high-quality evidence to support one BPD-specific therapy over another in the treatment of BPD; our subgroup analyses showed no differences in effect estimates between the different types of therapies. However, compared to TAU, we observed significant effects in favour of DBT for the primary outcomes of BPD severity, self-harm, and psychosocial functioning, and in favour of MBT for self-harm, suicidality, and depression. We rated the quality of the evidence for these outcomes as low, meaning that the true magnitude of these effects is uncertain

 

Table 2. Systematic reviews that only included adolescents.
BPD = Borderline personality disorder; DBT = Dialectical behaviour therapy; DBT-A = Dialectical behaviour therapy – adolescent; MD = Mean difference; OR = Odds ratio; RCT = Randomized controlled trial; SMD = Standardized mean difference; TAU = Treatment as usual
Included studies Population/Intervention Outcome
Witt et al. 2021. [2]
Study design: Only included randomised controlled trials.
Included studies: The review included 17 studies, whereof 4 investigated the effect of DBT
Population: Children and adolescent (<18 years) with a recent (< 6 months) presentation to hospital or clinical services for self-harm (SH). 49.1% of the included participants were diagnosed with borderline personality disorder.
Comparator:
All relevant studies included had a requirement of a history of multiple episodes of SH.
Intervention:
1. Individual CBT-based psychotherapy;
2. Dialectical behavioural therapy;
3. Mentalisation therapy;
4. Group-based psychotherapy;
5. Enhanced assessment approaches;
6. Compliance enhancement approaches;
7. Family interventions;
8. Remote contact interventions.
Repetition of self-harm
OR:
0.46 (0.26 to 0.82)
n = 270, 4 RCTs.
GRADE: High Symbol which means strong scientific evidence
Comparator TAU:
OR 2.55 (0.20 to 31.86)
Comparator EUC:
OR 0.29 (0.10 to 0.85)
Comparator AT:
OR 0.50 (0.25 to 0.98)
Frequency of self-harm: MD: –0.71 (–1.55 to 0.14)
n = 271, 4 RCTs.

Secondary outcomes:
Number of individual, group, telephone or family therapy sessions attended.
Depressions scores
Hopelessness scores
General functioning
Suicidal ideation
Author’s conclusion: “On the basis of data from four trials, DBT for adolescents (DBT-A) reduces repetition of SH at post-intervention compared with TAU, EUC, and alternative psychotherapy.”
“...We also found some positive effects of DBT-A, but methodological factors limit confidence in the generalizability of the results. We recommend further evaluation of these approaches to assess the impact of these interventions in different samples and settings”

 

Table 3. Systematic reviews that included studies on persons with substance abuse.
BPD = Borderline personality disorder; CTBE = Community treatment by experts; CVT = comprehensive validation therapy; DBT = Dialectical behaviour therapy; RCT = Randomized controlled trial; SMD = Standardized mean difference; TAU = Treatment as usual
Included studies Population/Intervention Outcome
Lee et al. 2015. [3]
Study design: Only randomised controlled trails.
Included studies: The review included 10 studies, whereof 4 investigated the effect of DBT.
Population: Patients with BPD (<70% of sample) and a co-occurring substance abuse.
Control: All control groups where included. The included studies used: TAU, CVT and CTBE
Intervention: Multiple psychological treatments, including DBT.
Suicide or self-harm: No studies indicated that DBT reduced suicide or self-harm

Substance use: Three of four studies indicated that DBT reduced substance use.
Authors conclusion: “DBT showed generally good outcomes compared with TAU and other non-validated manualised comparison treatments. The studies were of generally good quality. Some studies were confounded by the introduction of pharmacotherapy, which is known to be an effective intervention. The results, although limited by a small number of studies with small sample sizes, suggest that DBT has a good enough evidence base to be utilised with clients with co-occurring BPD and SUD.”

 

Table 4. Health economic studies with at least medium quality regarding economic aspects and transferability of economic results.
QALY = Quality adjusted life years; BPD = Borderline personality disorder; CCT = Client centred therapy; DBT = Dialectical behavioural therapy; TAU = Treatment as usual; CEAC = Cost effectiveness acceptability curve; WTP = Willingness to pay; RCT = Randomised controlled trial
Included studies Population/Intervention Outcome
Brazier et al. 2006. (4)
Systematic review: The literature search resulted in only one relevant cost-effectiveness study.
Analysis:
 The authors performed own analysis to try to estimate cost-effectiveness from data taken from four clinical studies.
Method:
 When possible a cost-utility analysis with QALY as outcome was used. If not a cost-effectiveness analysis with avoided parasuicidal events were performed
Perspective:
 A government perspective excluding voluntary services, unstaffed community accommodation and productivity cost.
Time horizon:
 12 months
Costs:
 United Kingdom, 2003
Population: Patients with BPD. According to the authors most of the participants where female with co-occurring substance abuse.
Control: Control was either treatment as usual (TAU) or client centred therapy (CCT).
Intervention: The review included multiple psychological therapies, including DBT.
Turner et al (DBT vs CCT)
Incremental cost: – GBP 5242
Incremental QALY: 0.12
Parasuicidal events avoided: 9.4
CEAC (WTP: GBP 20.000): 90%
Linehan (DBT vs TAU)
Incremental cost: – GBP 1207
Parasuicidal events avoided: 26.7
Van den Bosch (DBT vs TAU)
Incremental cost: GBP 724
Parasuicidal events avoided: 18.1
Koons (DBT vs TAU)
Incremental cost: GBP 8625
Incremental QALY: 0.03
Parasuicidal events avoided: 0.2
CEAC (WTP: GBP 20.000): 5%
Authors' conclusion: “In terms of cost-effectiveness, this review attempted to examine the cost-effectiveness of the intervention in six RCTs. The mix of results between the four trials of DBT, along with the high levels of uncertainty and the limitations of the analyses, do not support the cost-effectiveness of DBT, although they suggest that it has the potential to be cost-effective.”
Duarte et al. 2019. [5]
Study design: Full economic evaluations and partial economic evaluations.
Included studies: 11 studies where included, whereof 4 investigated DBT. (2 full and 2 partial economic evaluations)
Population: Participants with mental health disorders as described in the DSM-5.
Intervention: A acceptance and mindfulness‐based therapy. (MBCT, MBSR; DBT, ACT, MBRP or other)
Priebe (cost-effectiveness analysis).
incremental cost of GBP 36 to achieve a one percentage point reduction in the incidence of self‐harm.
(Pound Sterling, 2012)
Pasieczny and Connor (cost-consequence analysis). Mean saving of AUD 5927 per patient over a 6‐month period and mean reduction in suicide attempts of 1.34 per patient
(Australian dollars, 2011)
Amner (CC before-after):
Mean cost saving per participant:GBP 1741.
(Pound Sterling, 2010)
Wagner (CC before-after)
Total mean annua societal cost‐of‐illness was EUR 28026 during pre‐treatment, EUR 18758 during the DBT treatment year and EUR 14750 during the follow‐up year.
(Euros, 2010)
Authors' conclusion: “The review identified four studies that evaluated the health economic impact of DBT on patients with EUPD. None of these studies provided convincing evidence to support a hypothesis that A/MBIs are a cost‐effective treatment, due in part to economic evaluation design and uncertainty around results.”

References

  1. Storebø OJ, Stoffers-Winterling JM, Völlm BA, Kongerslev MT, Mattivi JT, Jørgensen MS, et al. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2020:Issue 5. Art. No.: CD012955.
  2. Witt KG, Hetrick SE, Rajaram G, Hazell P, Taylor Salisbury TL, Townsend E, et al. Interventions for self‐harm in children and adolescents. Cochrane Database Syst Rev. 2021(3).
  3. Lee NK, Cameron J, Jenner L. A systematic review of interventions for co-occurring substance use and borderline personality disorders. Drug and alcohol review. 2015;34(6):663-72.
  4. Brazier J, Tumur I, Holmes M, Ferriter M, Parry G, Dent-Brown K, et al. Psychological therapies including dialectical behaviour therapy for borderline personality disorder: A systematic review and preliminary economic evaluation. Health Technol Assess. 2006;10(35):1-61.
  5. Duarte R, Lloyd A, Kotas E, Andronis L, White R. Are acceptance and mindfulness-based interventions 'value for money'? Evidence from a systematic literature review. Br J Clin Psychol. 2019;58(2):187-210.

SBU Enquiry Service Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

Published: 4/22/2021
Report no: ut202106
Registration no: SBU 2021/118