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Targeted Therapy Halves Suicide Attempts in Borderline Personality Disorder

Science Update

Dialectical Behavior Therapy (DBT) reduced suicide attempts by half compared with other types of psychotherapy available in the community in patients with borderline personality disorder, an NIMH-funded study has found. DBT also excelled at reducing use of emergency room and inpatient services and more than halved therapy dropout rates compared to the mostly traditional approaches, report Marsha Linehan, Ph.D., University of Washington, and colleagues in the July 2006 issue of Archives of General Psychiatry.

"All treatments are not equal for such suicidal patients," said Linehan.

Borderline personality disorder is a difficult-to-treat mental illness affecting up to two percent of adults, 5.8-8.7 million Americans, mostly young women. People with this disorder of emotion regulation experience intense bouts of anger, depression, and anxiety that may last only hours, often in response to perceived rejection. They typically have tumultuous work and family life and may engage in risky, impulsive behaviors. Cutting, burning and other forms of self-harm are common, with up to 9% ultimately killing themselves. Although they account for at least 20 percent of psychiatric inpatient admissions, and frequently seek mental health services, patients with the disorder often fail to respond to commonly available treatments.

Hence, NIMH has supported the development and testing of DBT by Linehan and her colleagues over the past two decades. This variation on cognitive behavioral therapy specifically targets suicidal behavior, behaviors that interfere with treatment, and risky social behaviors. While previous controlled trials had demonstrated DBT's usefulness, whether this was attributable to psychotherapy generally rather than to specific features of DBT remained unclear.

To help resolve this issue, the researchers created a more tightly-defined comparison condition. They treated for one year 101 female patients with borderline personality disorder, ages 18-45, in the Seattle area with either currently available "Treatment By Experts" (TBE) in the community, or therapists specifically trained in DBT.

The 52 patients randomly assigned to the DBT group received one hour of individual therapy and 2.5 hours of group skills training each week, in addition to phone consultations. DBT focused on improving patients' coping skills and motivation by helping them reduce interfering emotions and thinking and reinforce functional behaviors. Their 16 DBT therapists also met weekly to enhance their motivation and skills.

The 49 patients who received TBE were offered one weekly therapy session plus additional treatment as needed, at the therapists' discretion. Most of them received psychodynamic therapy that focused on gaining insight into unconscious motives, needs and defenses rather than directly on behavior change. Their 25 therapists, nominated by community mental health leaders for their skill in dealing with difficult patients, had the option of attending a weekly supervisory group convened at a prestigious local psychoanalytic institute.

Although DBT patients were provided with significantly more therapy within the study, the two groups ended up with about the same total therapy hours, since TBE patients were more prone to switching therapists and seeing therapists outside the study. The risk of dropping out of therapy was nearly three times higher among the TBE group — 59 percent dropped their first assigned therapist, compared to 25 percent of DBT patients. More than twice as many of the former also dropped out of the study entirely. Fewer DBT patients continued taking psychotropic medications during the study year, perhaps reflecting their therapists' behaviorally-focused treatment philosophies.

While there were no completed suicides, 46.7 percent of the TBE and 23.1 percent of the DBT patients attempted suicide during the study year. Among TBE patients, 57.8 percent visited emergency rooms for psychiatric problems, compared with 43.1 percent among DBT patients; 48.9 percent of TBE patients had at least one psychiatric hospitalization, often for suicidal thoughts, in contrast to 19.6 percent of DBT patients. No significant differences emerged between the groups in proneness to non-suicidal self-injury. And both therapies reduced patients' suicidal thinking and strengthened their appreciation of life.

Noting that DBT is the only psychosocial treatment shown in multiple randomized clinical trials to be effective for borderline personality disorder, the researchers suggested that "DBT may be uniquely effective in treating suicidal individuals."

Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, Korslund KE, Tutek DA, Reynolds SK, Lindenboim N. Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder.  Arch Gen Psychiatry. 2006 Jul;63(7):757-766.