| Key points |
Is dialectical behavior therapy (DBT) effective in treating mood symptoms, states, and suicidal behavior among adolescents with bipolar spectrum disorder? Findings In this randomized clinical trial of 100 adolescents with bipolar spectrum disorder, compared with those who received standard psychotherapy, youth who received 1 year of dialectical behavioral therapy (DBT) had fewer suicide attempts over 1 year. The groups showed similar improvement in depression, hypomania, and mania. Meaning: These findings support dialectical behavior therapy (DBT) as the first psychosocial intervention with demonstrated effects on suicidal behavior in adolescents with bipolar spectrum disorder. |
Up to 50% of youth with bipolar spectrum disorder (BPD) attempt suicide, and psychological autopsy studies indicate that, of all psychiatric diagnoses, BPD imparts the highest risk of death by suicide in youth.
Expert practice parameters for early-onset AD include a combination of pharmacotherapy and psychotherapy. Several psychosocial interventions have demonstrated effectiveness in stabilizing mood and reducing the risk of recurrence in young people with AD. However, to our knowledge, no treatment expressly targets suicidal behavior in this population, and there are few reports of suicidal outcomes.
In a secondary data analysis from a randomized clinical trial of child- and family-focused cognitive-behavioral therapy versus treatment as usual among participants ages 7 to 13 years with PA, Weinstein et al demonstrated improvement in suicidal ideation in all treatment groups. . However, suicide attempts were not examined. In contrast, trials demonstrating treatment effectiveness in decreasing adolescent suicidal ideation and behavior in transdiagnostic populations generally exclude youth with AD, resulting in a paucity of evidence to guide suicide prevention in this group. ultra-high risk.
Dialectical behavioral therapy ( DBT) is an evidence-based psychosocial treatment developed for adults with borderline personality disorder with demonstrated effectiveness in decreasing suicidal behavior. Randomized clinical trials and meta-analyses examining DBT for suicidal and self-harming adolescents support the effectiveness of DBT over comparator treatments in reducing suicidal ideation, self-harm, and suicide attempts, making DBT a well-established treatment for suicidal youth. However, youth with AD were largely excluded from these trials despite their high-risk status.
We assert that DBT is appropriate for the treatment of adolescents with AD, given their increased risk of suicide as well as other shared treatment goals, including emotional dysregulation (a core feature of early-onset AD)9 and psychosocial functioning.
Herein, we describe the results of a randomized clinical trial of DBT compared to SOC psychotherapy in a specialized clinic for adolescents with BED.
All participants received pharmacotherapy from psychiatrists affiliated with the study. We hypothesized that adolescents receiving DBT would exhibit fewer suicide attempts and greater mood stability over 1 year compared to adolescents receiving SOC psychotherapy (primary outcomes). We planned a priori to test the moderation of the effects of DBT by history of suicidality and mediation through emotional dysregulation.
| Importance |
Early-onset bipolar disorder carries a substantial risk of suicide. No psychosocial intervention for this population expressly targets suicidal behavior.
| Objective |
To determine whether dialectical behavior therapy (DBT) for adolescents with bipolar spectrum disorder is more effective than standard of care (SOC) psychotherapy in decreasing suicide attempts over 1 year.
| Design, environments and participants |
Adolescents aged 12 to 18 years diagnosed with bipolar spectrum disorder were recruited from a specialized outpatient psychiatric clinic between November 2014 and September 2019. Independent evaluators conducted quarterly evaluations for 1 year with participants and their parents. Data was analyzed from March 2021 to November 2022.
| Interventions |
Participants were randomly assigned to 1 year of dialectical behavior therapy (DBT) (36 sessions; n = 47) or SOC psychotherapy (clinically determined schedule; n = 53). All youth received medication management through a flexible algorithm.
| Main results and measures |
Primary outcomes included suicide attempts over 1 year and mood symptoms and states (depression and hypomania/mania). Secondary analyzes included moderation of the effects of dialectical behavioral therapy (DBT) by history of suicide attempt and mediation through emotion dysregulation.
| Results |
Of 100 included participants, 85 (85%) were women and the mean (SD) age was 16.1 (1.6) years. Participants were followed for a mean (SD) of 47 (14) weeks.
Both treatment groups demonstrated significant and similar improvement in symptoms and mood episodes over 1 year (standardized depression rating scale slope, −0.17; 95% CI, −0.31 to −0 .03; standardized mania rating scale slope, −0.24; 95% CI, −0.34 to −0.14).
DBT and SOC participants reported similar rates of suicide attempts at intake, as measured on the Adolescent Longitudinal Follow-up Evaluation (ALIFE; mean [SD] attempts, 2.0 [4.5] vs. 1.8 [3.9], respectively; P = .80).
Dialectical behavioral therapy (DBT) participants reported slightly more suicide attempts at intake, as measured by the pediatric version of the Columbia Suicide Severity Rating Scale (C-SSRS; mean [SD] attempts, 1.4 [3.6] vs 0.6 [0.9]; P = 0.02).
Dialectical behavioral therapy (DBT) participants reported significantly fewer suicide attempts at follow-up compared to SOC participants via ALIFE (mean [SD] attempts per follow-up period, 0.2 [0.4] vs. 1.1 [4.3], controlling for initial attempts: P = 0.03) and the C-SSRS (mean [SD] attempts per follow-up period, 0.04 [0.2] vs. 0.10 [ 0.3], controlling for initial attempts; P = 0.03).
Dialectical behavioral therapy (DBT) was significantly more effective than SOC psychotherapy in decreasing suicide attempts over 1 year (ALIFE: incidence rate ratio [IRR], 0.32; 95% CI, 0.11-0 .96; C-SSRS: IRR, 0.13; 95% CI, 0.02-0.78).
The decrease in the rate of suicide attempts with dialectical behavioral therapy (DBT) was moderated by the presence of a history of suicide attempts and length of life (IRR, 0.23; 95% CI, 0.13-0. 44) and mediated by improvement in emotion dysregulation (IRR, 0.61; 95% CI, 0.42-0.42). 0.89), particularly for those with high baseline emotion dysregulation (standardized β, −0.59; 95% CI, −0.92 to −0.26).
| Conclusions and relevance |
Adolescents with ED at high risk for suicidal behavior and those who exhibit high emotional dysregulation are those who will benefit most from the effects of dialectical behavioral therapy (DBT) to reduce the risk of suicide attempts by improving emotion regulation. .
Coupled with improvement of mood episodes and symptoms from dialectical behavioral therapy (DBT) alongside other evidence-based strategies for this population, DBT shows promise in a stepped-care treatment model for BP. early onset.
In this randomized clinical trial, dialectical behavioral therapy (DBT) demonstrated efficacy in decreasing suicide attempts among the population of high-risk adolescents with bipolar spectrum disorder.
