Treating co-occurring Axis I disorders in recurrently suicidal women with borderline personality disorder: A 2-year randomized trial of dialectical behavior therapy versus community treatment by experts.

This study evaluated whether dialectical behavior therapy (DBT) was more efficacious than treatment by nonbehavioral psychotherapy experts in reducing co-occurring Axis I disorders among suicidal individuals with borderline personality disorder (BPD). Women with BPD and recent and repeated suicidal and/or self-injurious behavior (n = 101) were randomly assigned to 1 year of DBT or community treatment by experts (CTBE), plus 1 year of follow-up assessment. For substance dependence disorders (SDD), DBT patients were more likely to achieve full remission, spent more time in partial remission, spent less time meeting full criteria, and reported more drug- and alcohol-abstinent days than did CTBE patients. These findings suggest that improvements in co-occurring SDD among suicidal BPD patients are specific to DBT and cannot be attributed to general factors associated with nonbehavioral expert psychotherapy. Further, group differences in SDD remission were not explained by either psychotropic medication usage or changes in BPD criterion behaviors. DBT and CTBE did not significantly differ in the reduction of anxiety disorders, eating disorders, or major depressive disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Extending research on the utility of an adjunctive emotion regulation group therapy for deliberate self-harm among women with borderline personality pathology.

Deliberate self-harm (DSH) is a clinically important behavior commonly associated with borderline personality disorder (BPD). Despite the clinical relevance and associated negative consequences of this behavior, however, there are few empirically supported treatments for DSH among individuals with BPD, and those that exist are difficult to implement in many clinical settings (due to their duration and intensity). To address this limitation, Gratz and Gunderson (2006) examined the efficacy of a 14-week, adjunctive emotion regulation group therapy (ERGT) for DSH among women with BPD. Although the results of this initial trial were promising (indicating positive effects of this treatment on DSH, emotion dysregulation, experiential avoidance, and psychiatric symptoms), they require replication and extension. Thus, the purpose of this study was to further develop this ERGT by examining its utility across other settings, a more diverse group of patients, a wider range of outcomes, and group leaders other than the principal investigator. Twenty-three women received this ERGT in addition to their ongoing treatment in the community. Self-report and interview-based measures of DSH and other self-destructive behaviors, psychiatric symptoms, adaptive functioning (including social and vocational impairment and quality of life), and the proposed mechanisms of change (emotion dysregulation and experiential avoidance) were administered pre- and posttreatment. Results indicate significant changes over time (accompanied by large effect sizes) on all outcome measures except quality of life and self-destructive behaviors (although the latter was a large-sized effect). Further, 55% of participants reported abstinence from DSH during the last two months of the group. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Revealing the form and function of self-injurious thoughts and behaviors: A real-time ecological assessment study among adolescents and young adults.

Self-injurious behaviors are among the leading causes of death worldwide. However, the basic nature of self-injurious thoughts and behaviors (SITBs) is not well understood because prior studies have relied on long-term, retrospective, aggregate, self-report assessment methods. The authors used ecological momentary assessment methods to measure suicidal and nonsuicidal SITBs as they naturally occur in real time. Participants were 30 adolescents and young adults with a recent history of self-injury who completed signal- and event-contingent assessments on handheld computers over a 14-day period, resulting in the collection of data on 1,262 thought and behavior episodes. Participants reported an average of 5.0 thoughts of nonsuicidal self-injury (NSSI) per week, most often of moderate intensity and short duration (1–30 min), and 1.6 episodes of NSSI per week. Suicidal thoughts occurred less frequently (1.1 per week), were of longer duration, and led to self-injurious behavior (i.e., suicide attempts) less often. Details are reported about the contexts in which SITBs most often occur (e.g., what participants were doing, who they were with, and what they were feeling before and after each episode). This study provides a first glimpse of how SITBs are experienced in everyday life and has significant implications for scientific and clinical work on self-injurious behaviors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Does pretreatment severity moderate the efficacy of psychological treatment of adult outpatient depression? A meta-analysis.

Objective: It is widely believed that psychological treatment has little effect on more severely depressed patients. This study assessed whether pretreatment severity moderates psychological treatment outcome relative to controls by means of meta-analyses. Method: We included 132 studies (10,134 participants) from a database of studies (www.evidencebasedpsychotherapies.org) in which the effects of psychological treatment on adult outpatients with a depressive disorder or an elevated level of depressive symptoms were compared with a control condition in a randomized controlled trial. Two raters independently extracted outcome data and rated study characteristics. We conducted metaregression analyses assessing whether mean pretreatment depression scores predicted psychological treatment versus control condition posttreatment effect size and subgroup analyses summarizing the results of studies reporting within-study analyses of depression severity and psychological treatment outcome. Results: Psychological treatment was found to be consistently superior to control conditions (d = 0.40–0.88). We found no indication that pretreatment mean depression scores predicted psychological treatment versus control condition posttreatment effect size, even after adjusting for relevant study characteristics. However, among the smaller subset of studies that reported within-study severity analyses, posttreatment effect sizes were higher for high-severity patients (d = 0.63) than for low-severity patients (d = 0.22) when psychological treatment was efficacious relative to a more stringent control. Conclusion: Contrary to conventional wisdom, our findings suggest that when compared with control conditions, psychological treatment might be more efficacious for high-severity than for low-severity patients. Because the number of studies reporting within-study severity analyses is small, we recommend that future studies routinely report tests for Severity × Treatment interactions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Introduction to the special section on suicide and nonsuicidal self-injury: A review of unique challenges and important directions for self-injury science.

Self-injurious behaviors, including nonsuicidal self-injury (NSSI) and suicidal behaviors, are remarkably prevalent and woefully understudied. This area of research involves numerous methodological, ethical, and practical challenges that have limited progress in understanding some of the most basic characteristics and correlates of self-injurious behavior. To date, relatively little data are available to develop empirically based preventions or interventions, and no empirically supported treatments currently are available to reduce NSSI or suicidality in most populations. The articles in this special section offer examples of methodologically innovative, theoretically based work that address these research needs. Articles in this special section include studies of functional models of NSSI, studies that examine more distal risk factors for NSSI, and studies of suicidality. A brief review of current research in these areas is offered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Suicidal, abused African American women's response to a culturally informed intervention.

Objective: This study examined (a) the efficacy of a manualized, culturally informed, empowerment-focused psychoeducational group intervention (Nia) designed in accord with the theory of triadic influence or treatment as usual (TAU) for reducing psychological symptomatology (suicidal ideation, depressive symptoms, posttraumatic stress symptoms, general psychological distress), and (b) the effect of Nia versus TAU on the relation between exposure to intimate partner violence (IPV) and psychological symptomatology in these women. Method: Two hundred eight low-socioeconomic-status African American women with a recent history of IPV and a suicide attempt were randomized to Nia or TAU and assessed at baseline, postintervention, and 6- and 12-month follow-up. They were assessed on their levels of IPV (Index of Spouse Abuse), suicidal ideation (Beck Scale for Suicidal Ideation), depressive symptoms (Beck Depression Inventory–II), posttraumatic stress symptoms, and general psychological distress (Brief Symptom Inventory). Results:Hierarchical linear modeling found that women receiving the culturally informed Nia intervention showed more rapid reductions in depressive symptoms and general distress initially, and the between-group difference in depressive symptoms persisted at follow-up. Following intervention, compared with women randomized to TAU, women in Nia exhibited less severe suicidal ideation when exposed to physical and nonphysical IPV. Conclusions:Findings highlight the value of incorporating Nia as an adjunctive intervention for abused, suicidal, low-income women. They underscore the ways the intervention needs to be bolstered to address more directly more mediating and moderating constructs, as well as the need to target more effectively the key outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An exploratory study of child-centered play therapy with aggressive children.

Children exhibiting aggressive problem behaviors typically reach a peak of aggressive acts at an early age, providing evidence that early intervention for aggression is needed. Child-centered play therapy (CCPT) is 1 intervention that offers the child an environment in which aggression can be expressed and empathically responded to by a play therapist. Forty-one elementary school age children were assigned to a CCPT condition or a wait-list control group condition. Children who participated in 14 sessions of CCPT showed a moderate decrease in aggressive behaviors over children in the control group, according to effect sizes as reported by parents (N = 32). Teachers reported that both groups significantly improved over time (N = 41). Post hoc analysis revealed that children assigned to CCPT decreased aggressive behaviors statistically significantly and children assigned to control group demonstrated no statistically significant difference. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment-related changes in objectively measured parenting behaviors in the multimodal treatment study of children with attention-deficit/hyperactivity disorder.

The present study examined treatment outcomes for objectively measured parenting behavior in the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (ADHD). Five hundred seventy-nine ethnically and socioeconomically diverse children with ADHD-combined type (ages 7.0-9.9 years) and their parent(s) were recruited at 6 sites in the United States and Canada and randomly assigned to 1 of 4 treatment groups for 14 months of active intervention: medication management (MedMgt), intensive behavior therapy, combination of the 2 (Comb), or a community-treated comparison (CC). Baseline and posttreatment laboratory observations of parent-child interactions were coded by observers blind to treatment condition. Comb produced significantly greater improvements in constructive parenting than did MedMgt or CC, with effect sizes approaching medium for these contrasts. Treatment effects on child behaviors were not significant. The authors discuss the importance of changes in parenting behavior for families of children with ADHD and the need for reliable and objective measures in evaluating treatment outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review.

Objective: Although mindfulness-based therapy has become a popular treatment, little is known about its efficacy. Therefore, our objective was to conduct an effect size analysis of this popular intervention for anxiety and mood symptoms in clinical samples. Method: We conducted a literature search using PubMed, PsycINFO, the Cochrane Library, and manual searches. Our meta-analysis was based on 39 studies totaling 1,140 participants receiving mindfulness-based therapy for a range of conditions, including cancer, generalized anxiety disorder, depression, and other psychiatric or medical conditions. Results: Effect size estimates suggest that mindfulness-based therapy was moderately effective for improving anxiety (Hedges’s g = 0.63) and mood symptoms (Hedges’s g = 0.59) from pre- to posttreatment in the overall sample. In patients with anxiety and mood disorders, this intervention was associated with effect sizes (Hedges’s g) of 0.97 and 0.95 for improving anxiety and mood symptoms, respectively. These effect sizes were robust, were unrelated to publication year or number of treatment sessions, and were maintained over follow-up. Conclusions: These results suggest that mindfulness-based therapy is a promising intervention for treating anxiety and mood problems in clinical populations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Suicidality as a function of impulsivity, callous–unemotional traits, and depressive symptoms in youth.

Suicidality represents one of the most important areas of risk for adolescents, with both internalizing (e.g., depression, anxiety) and externalizing–antisocial (e.g., substance use, conduct) disorders conferring risk for suicidal ideation and attempts (e.g., Bridge, Goldstein, & Brent, 2006). However, no study has attended to gender differences in relationships between suicidality and different facets of psychopathic tendencies in youth. Further, very little research has focused on disentangling the multiple manifestations of suicide risk in the same study, including behaviors (suicide attempts with intent to die, self-injurious behavior) and general suicide risk marked by suicidal ideation and plans. To better understand these relationships, we recruited 184 adolescents from the community and in treatment. As predicted, psychopathic traits and depressive symptoms in youth showed differential associations with components of suicidality. Specifically, impulsive traits uniquely contributed to suicide attempts and self-injurious behaviors, above the influence of depression. Indeed, once psychopathic tendencies were entered in the model, depressive symptoms only explained general suicide risk marked by ideation or plans but not behaviors. Further, callous–unemotional traits conferred protection from suicide attempts selectively in girls. These findings have important implications for developing integrative models that incorporate differential relationships between (a) depressed mood and (b) personality risk factors (i.e., impulsivity and callous–unemotional traits) for suicidality in youth. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: A meta-analytic review.

Objective: This study was designed to quantitatively evaluate the effectiveness of motivational interviewing (MI) interventions for adolescent substance use behavior change. Method: Literature searches of electronic databases were undertaken in addition to manual reference searches of identified review articles. Databases searched include PsycINFO, PUBMED/MEDLINE, and Educational Resources Information Center. Twenty-one independent studies, representing 5,471 participants, were located and analyzed. Results: An omnibus weighted mean effect size for all identified MI interventions revealed a small, but significant, posttreatment effect size (mean d = .173, 95% CI [.094, .252], n = 21). Small, but significant, effect sizes were observed at follow-up suggesting that MI interventions for adolescent substance use retain their effect over time. MI interventions were effective across a variety of substance use behaviors, varying session lengths, and different settings, and for interventions that used clinicians with different levels of education. Conclusions: The effectiveness of MI interventions for adolescent substance use behavior change is supported by this meta-analytic review. In consideration of these results, as well as the larger literature, MI should be considered as a treatment for adolescent substance use. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Marital status and satisfaction five years following a randomized clinical trial comparing traditional versus integrative behavioral couple therapy.

Objective: To follow distressed married couples for 5 years after their participation in a randomized clinical trial. Method: A total of 134 chronically and seriously distressed married couples were randomly assigned to approximately 8 months of either traditional behavioral couple therapy (TBCT; Jacobson & Margolin, 1979) or integrative behavioral couple therapy (IBCT; Jacobson & Christensen, 1998). Marital status and satisfaction were assessed approximately every 3 months during treatment and every 6 months for 5 years after treatment. Results: Pre- to posttreatment effect sizes on marital satisfaction were d = 0.90 for IBCT and d = 0.71 for TBCT, which were not significantly different. However, data through 2-year follow-ups revealed statistically significant superiority of IBCT over TBCT in relationship satisfaction, but subsequent data showed increasing similarity and nonsignificant differences in outcome. At 5-year follow-up for marital satisfaction relative to pretreatment, effect sizes were d = 1.03 for IBCT and d = 0.92 for TBCT; 50.0% of IBCT couples and 45.9% of TBCT couples showed clinically significant improvement. Relationship status, obtained on all 134 couples, revealed that 25.7% of IBCT couples and 27.9% of TBCT couples were separated or divorced. These follow-up data compared favorably to other, long-term results of couple therapy. Conclusion: TBCT and IBCT both produced substantial effect sizes in even seriously and chronically distressed couples. IBCT produced significantly but not dramatically superior outcomes through the first 2 years after treatment termination but without further intervention; outcomes for the 2 treatments converged over longer follow-up periods. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Longitudinal trajectories and predictors of adolescent suicidal ideation and attempts following inpatient hospitalization.

Remarkably little is known regarding the temporal course of adolescent suicidal ideation and behavior, the prediction of suicidal attempts from changes in suicidal ideation, or the prediction of suicidal attempts after accounting for suicidal ideation as a predictor. A sample of 143 adolescents 12-15 years old was assessed during psychiatric inpatient hospitalization and again at 3, 6, 9, 15, and 18 months postdischarge through a series of structured interviews and parent- and adolescent-reported instruments. Symptoms of depression, posttraumatic stress disorder, externalizing psychopathology, hopelessness, and engagement in several forms of self-injurious/suicidal behaviors (i.e., suicide threats/gestures, plans, nonsuicidal self-injury [NSSI]) were assessed. Latent growth curve analyses revealed a period of suicidal ideation remission between baseline and 6 months following discharge, as well as a subtle period of suicidal ideation reemergence between 9 and 18 months postdischarge. Changes in suicidal ideation predicted suicide attempts. After accounting for the effects of suicidal ideation, baseline suicide threats/gestures also predicted future suicide attempts. Higher adolescent-reported depressive symptoms, lower parent-reported externalizing symptoms, and higher frequencies of NSSI predicted weaker suicidal ideation remission slopes. Findings underscore the need for more longitudinal research on the course of adolescent suicidality. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Does comorbid substance use disorder exacerbate borderline personality features? A comparison of borderline personality disorder individuals with vs. without current substance dependence.

There is compelling evidence that comorbid borderline personality disorder (BPD) negatively impact the clinical courses and outcomes of substance use disorders (SUD). Conversely, there is little evidence that concurrent SUD exacerbates the clinical characteristics of BPD. Thus, this study sought to examine whether the presence of current substance dependence among BPD patients would be associated with stronger BPD-relevant personality traits and behavioral characteristics. Female BPD patients without (BOR; n = 37) or with current substance dependence (BSUD; n = 19), and female non-BPD/SUD controls (CON; n = 48) were compared with respect to impulsivity, affective lability, affective intensity, externalizing behaviors, and self-harming/suicidal tendencies, taking into consideration their comorbid mood disorders, anxiety disorders, and antisocial personality disorder. Results indicated that both BOR and BSUD groups scored higher than CON in most of the measures, but BOR and BSUD failed to reveal significant group differences especially when the influence of comorbid psychopathology was removed. The overall pattern of findings remained identical even when comparing BPD patients with versus without the diagnosis of lifetime substance dependence. Our results do not support the notion that BPD individuals with SUD display more severe BPD features than individuals with BPD alone. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Dialectical behavior therapy for binge eating disorder.

This study evaluated the use of dialectical behavior therapy (DBT) adapted for binge eating disorder (BED). Women with BED (N=44) were randomly assigned to group DBT or to a wait-list control condition and were administered the Eating Disorder Examination in addition to measures of weight, mood, and affect regulation at baseline and posttreatment. Treated women evidenced significant improvement on measures of binge eating and eating pathology compared with controls, and 89% of the women receiving DBT had stopped binge eating by the end of treatment. Abstinence rates were reduced to 56% at the 6-month follow-up. Overall, the findings on the measures of weight, mood, and affect regulation were not significant. These results support further research into DBT as a treatment for BED. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment Utility of Functional Versus Empiric Assessment Within Consultation for Reading Problems.

In this study, 18 teachers and 32 of their students who had reading difficulties were randomly assigned to 1 of 2 assessment conditions. In the functional assessment condition, consultants identified functional relationships among environmental events and targeted reading behaviors to develop an intervention plan. In the empiric condition, consultants selected an intervention plan based on interventions matched to various reading problems (omitting individualized problem analysis). Consultants facilitated interventions consistent with the 2 conditions through a problem-solving consultation model and collected multiple outcome measures. Both functional assessment and empiric conditions led to improved outcomes in targeted reading behaviors, with most improvements falling in the moderate to large range of single-participant effect sizes. No significant differences were found between functional assessment and empiric conditions on the outcome variables of intervention effects, curriculum-based assessment, consumer satisfaction, or material costs, although empiric assessment took less time than functional. Implications regarding the generalizability of these results and directions for further study regarding the treatment utility of assessment for consultation are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Youth-Nominated Support Team for suicidal adolescents (Version 1): A randomized controlled trial.

In this study, the authors investigated the efficacy of the Youth-Nominated Support Team-Version 1 (YST-1), a psychoeducational social network intervention, with 289 suicidal, psychiatrically hospitalized adolescents (197 girls, 92 boys). Adolescents were randomly assigned to treatment-as-usual plus YST-1 or treatment-as-usual only. Assessments were completed pre- and postintervention (6 months). There were no main effects for YST-1 on suicide ideation or attempts, internalizing symptoms, or related functional impairment. Relative to other girls, however, those who received YST-1 reported greater decreases in self-reported suicidal ideation (actually treated analytic strategy) and significantly greater decreases in mood-related functional impairment reported by their parents (intent to treat and actually treated analytic strategies). This is the first randomized controlled clinical trial to investigate the efficacy of a social network intervention with suicidal youths. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims.

Ninety-six female assault victims with chronic posttraumatic stress disorder (PTSD) were randomly assigned to 4 treatment conditions: prolonged exposure (PE), stress inoculation training (SIT), combined treatment (PE-SIT), or wait-list control (WL). Treatment consisted of 9 twice-weekly, individual sessions. Independent evaluations were conducted at pretreatment; posttreatment; and 3-, 6-, and 12-month follow-ups. All 3 active treatments reduced severity of PTSD and depression compared with WL but did not differ significantly from each other, and these gains were maintained throughout the follow-up period. However, in the intent-to-treat sample, PE was superior to SIT and PE-SIT on posttreatment anxiety and global social adjustment at follow-up and had larger effect sizes on PTSD severity, depression, and anxiety. SIT and PE-SIT did not differ significantly from each other on any outcome measure. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Internet-Based Treatment for Insomnia: A Controlled Evaluation.

This study investigated the effects of an Internet-based intervention for insomnia. Participants who met criteria for insomnia (N = 109) were randomly assigned to either a cognitive-behavioral self-help treatment or a waiting list control condition. The 5-week intervention mainly consisted of sleep restriction, stimulus control, and cognitive restructuring. Sleep diary data were collected for 2 weeks at baseline and at posttreatment. The dropout rate was 24% (n = 28). Results showed statistically significant improvements in the treatment group on many outcome measures, including total sleep time, total wake time in bed, and sleep efficiency. However, improvements were also found in the control group. Overall, between-groups effect sizes were low, with the exception of the Beliefs and Attitudes About Sleep Scale (Cohen's d = .81). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A study of self-injurious and suicidal behavior in a veteran population.

This patient safety improvement study was conducted (1) to establish a database of intentional patient self-injuries and suicidal behavior among veterans in a large urban VA health care system, and (2) to investigate whether there were demographic and/or clinical characteristics of veterans who self-injure that might predict seriousness of suicidal intent and aid in future efforts at prevention. A total of 175 clinician-administered, post self-injury interviews were completed between 2006 and 2008 in a VA health care system in the Northeast. Findings suggest that self-injuries with high suicidal intent were characterized by male gender, older age, planning of self-injury, no wish to be saved, and a negative feeling about having survived. Additional results indicated that staff ratings of patient intent to die were significantly lower than patient self-rated intent to die, a finding that gives rise to questions of whether staff may tend to underestimate patient suicidal intent. Also, although more than 80% of the veterans in this sample considered their self-injurious actions impulsive, planning of self-injury was significantly associated with higher intent to die. Veterans who completed suicide during the study time period were significantly more likely than those who had nonfatal self-injuries to have experienced combat. The implications of these findings are discussed, including whether combat exposure may lead to an acquired capacity for lethal behaviors such as suicide (Joiner, 2005). (PsycINFO Database Record (c) 2011 APA, all rights reserved)