Results of a trial published in JAMA Psychiatry support dialectical behavior therapy as the first well-established, empirically supported treatment for reducing repeated suicide attempts and self-harm in adolescents.1
To evaluate the efficacy of dialectical behavior therapy vs individual and group supportive therapy for reducing suicide attempts, nonsuicidal self-injury, and self-harm in high-risk adolescents, researchers conducted a randomized clinical trial (ClinicalTrials.gov Identifier: NCT01528020) with 173 participants aged 12 to 18 years (94.8% girls, 56.4% white) from January 1, 2012, through August 31, 2014, at 4 academic medical centers. All participants had a prior lifetime suicide attempt (≥3 prior self-harm episodes, suicidal ideation, or emotional dysregulation). Participants were balanced across conditions within sites using adaptive randomization based on age, number of prior suicide attempts, and psychotropic medication use, and were followed-up for 1 year.
Researchers randomly assigned participants to dialectical behavior therapy (n=72) or to individual and group supportive therapy (n=65), with treatment lasting for 6 months. Both groups had weekly individual and group psychotherapy, therapist consultation meetings, and parent contact as needed. The main study outcomes included suicide attempts, nonsuicidal self-injury, and total self-harm assessed with the Suicide Attempt Self-Injury Interview.
After treatment, the researchers found significant advantages from dialectical behavior therapy in all primary outcomes. In the dialectical behavior therapy group, 65 out of 72 participants had no suicide attempts, compared with 51 out of 65 participants in individual and group supportive therapy (odds ratio [OR] 0.30; 95% CI, 0.10-0.91). For nonsuicidal self-injury, 41 out of 72 in the dialectical behavior therapy group did not conduct nonsuicidal self-injury, compared with 26 out of 65 in the individual and group supportive therapy group (OR 0.32; 95% CI, 0.13-0.70). For self-harm, 39 out of 72 in the dialectical behavior therapy group did not self-harm, compared with 24 out of 65 in the individual and group supportive therapy group (OR 0.33; 95% CI, 0.14-0.78). Rates of self-harm decreased over 1-year follow-up.
However, the advantage of dialectical behavior therapy decreased, with no statistically significant between-group differences from 6 to 12 months (OR 0.65; 95% CI, 0.12-3.36; P =.61). Treatment completion rates were higher for dialectical behavior therapy (75.6%) than for individual and group supportive therapy (55.2%), but pattern-mixture models indicated that this did not informatively affect outcomes.
“The results of this trial support the efficacy of [dialectical behavior therapy] for reducing self-harm and suicide attempts in highly suicidal self-harming adolescents,” the researchers concluded. “On the basis of the criteria of 2 independent trials supporting efficacy,2,3 results support [dialectical behavior therapy] as the first well-established, empirically supported treatment for decreasing repeated suicide attempts and self-harm in youths.”
Disclosures: Drs McCauley, Berk, Adrian, Cohen, Korslund, Hughes, and Avina reported receiving grant support from the National Institute of Mental Health (NIMH), National Institutes of Health. Dr Asarnow reported receiving grant support and support from the American Psychological Association and the Society of Clinical Child and Adolescent Psychology and serving as a consultant on quality improvement interventions for depression and suicidal/self-harm behavior. Dr Harned reported receiving grant support and personal fees from the Behavioral Tech LLC outside the work represented in this article. Dr Linehan reported receiving royalties from Guilford Press for books that she has written on dialectical behavior therapy, royalties for training materials from Behavioral Tech LLC, and compensation for dialectical behavior therapy workshops, online programs, and books. No other disclosures were reported.
- McCauley E, Berk MS, Asarnow JR, et al. Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: a randomized clinical trial [published online June 20, 2018]. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2018.1109
- Mehlum L, Tørmoen AJ, Ramberg M, et al. Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. J Am Acad Child Adolesc Psychiatry. 2014;53(10):1082-1091.
- Mehlum L, Ramberg M, Tørmoen AJ, et al. Dialectical behavior therapy compared with enhanced usual care for adolescents with repeated suicidal and self-harming behavior: outcomes over a one-year follow-up. J Am Acad Child Adolesc Psychiatry. 2016;55(4):295-300.