Transcript PowerPoint file

Feasibility of researching
Dialectical Behaviour Therapy for
suicidal and self-injuring
adolescents
Emily Cooney, Kirsten Davis, Pania Thompson, Julie
Wharewera-Mika & Joanna Stewart
Why do this study?
• Self-harm remains a significant problem for adolescents
in our country. Despite several trials focussing on
treatment for self-harm, we don’t really know what works
for suicidal young people.
• Dialectical Behaviour Therapy (DBT) seems effective for
adults with chronic suicidality and severe emotional
instability (Linehan et al, 1991, 1993, 2006, McMain et al.,
2009, Verheul et al., 2003)
• Field trials evaluating adaptations of DBT for use with
adolescents suggest that DBT shows promise for young
people (Goldstein et al., 2007, Katz et al., 2004, Rathus &
Miller, 2002).
But before we can do a big
study….
…..we have some big
questions
Feasibility questions
? Is comprehensive DBT acceptable to adolescents,
families and clinicians in New Zealand?
? Is random assignment acceptable to suicidal
adolescents, their families and treatment services
in New Zealand?
? Are our assessments and screens feasible and
acceptable?
? Will emotionally vulnerable adolescents tolerate the
screening and assessment measures?
? What participant retention rate can we expect?
Participants
Young people (and their families) seen at two
government-funded community mental health
outpatient services who
– were aged between 13 and 18 years*
– had self-injured or attempted suicide in the
previous 3 months
– didn’t meet criteria for a psychotic disorder or
life-threatening Anorexia Nervosa
– didn’t have an intellectual disability
– could speak and read English
We measured
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Self-harm
Suicidal ideation and reasons for living
Substance use
Emotion Regulation
Therapist burnout
DBT
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Multifamily skills groups
Individual therapy
24/7 phone consultation
Consultation team for therapists
Family sessions and parent sessions as
needed
TAU
• Depended on what the team, therapist and
family thought would be helpful
• Range of therapy approaches, with
cognitive-behavioural therapy being the
most common treatment
• Provided by clinical psychologists, social
workers, occupational therapists, and
alcohol & drug counsellors
If needed, participants in both
conditions could access:
• Medication
• Respite care
• Hospital
15 (30%)
declined
50 young people and families had
an orientation meeting
Screening assessment
4 discontinued
during the
assessments
2 not eligible
29 completed the pre-treatment
assessment
TAU = 15
DBT = 14
29
Ethnicities of participants
Other
European
3%
NZ Māori
3%
South African
7%
NZ European
77%
UK
10%
Pre-treatment characteristics of DBT and TAU participants
Treatment
condition
Gender - female - n (%)
Age - mean (SD)
# self-harm acts in past 3
months – median (SD)
Dialectical Behaviour
Therapy (N=14)
10 (71%)
16.2 (.98)
Treatment as Usual
(N=15)
12 (80%)
15.7 (1.1)
7.5 (17.6)
4 (10.1)
At school - n (%)
9 (64%)
10 (67%)
At work - n (%)
1 (7%)
3 (20%)
Structured activity - n
(%)
10 (71%)
11 (73%)
Site - North - n (%)
11 (79%)
14 (93%)
Kia tupato! While nosing through
these results, we can’t draw many
conclusions about how the
treatments compare
• Variable assessment times
• Small n
• Differences between groups
before they began treatment
Treatment engagement
• 1/14 DBT participants dropped out (4/15
TAU participants ‘dropped out’)
• The mean percent of sessions missed was
9% of individual sessions, and 12% of
group sessions for adolescents in DBT
(the mean percent of individual sessions
missed was 29% for TAU participants).
Means and standard deviations of sessions attended and not attended
across the 6 months following pre-treatment assessment
DBT
Treatment condition
Individual sessions attended
TAU
Mean
SD
Mean
SD
22.6
6.4
6.5
4.1
1.9
1.8
3
3.8
20.3
5.3
0
0
2.6
3.1
0
0
8
3.1
3.1
3.3
Med reviews attended
2.4
2.2
1.6
2.9
Parent sessions attended
3.9
4.1
0.5
0.7
Individual sessions not
attended
Group sessions attended
Group sessions not attended
Family sessions attended
Percent attempting suicide
Treatment condition
Dialectical Behaviour Therapy
Treatment as Usual
60%
40%
20%
9/14
9/15
3/14
0/15
0%
1
2
Assessment period
2/14
1/15
3
Results of focus group with
DBT participants
• Found DBT valuable and
worthwhile
• Parents wanted their own
support
• Treatment ending seemed
arbitrary and was too abrupt
DBT therapists
• Adherence ratings
comparable to “goldstandard” DBT outcome
trials
• Therapist burnout
scores were within the
‘average’ range before
and after treatment
• Team support and
adherence feedback
were critical
Lessons learned so far
• Randomisation is acceptable to
families and clinicians. Dual roles
of research staff complicate this
• Consider risk factors for self-harm
when deciding how to randomise
• Treatment ending has to be
managed very carefully
• Contagion is potentially a greater
concern than with adults
• Consider recruiting outside of
services
Acknowledgements
• This study was funded by the New Zealand Ministry of
Health
• We are very grateful to the following people for their
help and support:
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staff from Auckland DHB
Dr. Sue Crengle
Dr. Sarah Fortune
the families who took
part in this research
Dr. Melanie Harned
Dr. Simon Hatcher
Dr. Kathryn Korslund
Dr. Marsha Linehan
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Dr. Sally Merry
Dr. Alec Miller
Dr. Jill Rathus
the research therapists
(Mike Batcheler, Helen
Clack and Ben Te Maro)
Sharon Rickard
Amy Rosso
Dr. Paul Vroegrop
staff from Waitemata
DHB