Anita Johanna Tørmoen

Dialectical Behavior Therapy Compared With Enhanced Usual Care for Adolescents With Repeated Suicidal and Self-Harming Behavior: Outcomes Over a One-Year Follow-Up.

OBJECTIVE We conducted a 1-year prospective follow-up study of posttreatment clinical outcomes in adolescents with recent and repetitive self-harm who had been randomly allocated to receive 19 weeks of either dialectical behavior therapy adapted for adolescents (DBT-A) or enhanced usual care (EUC) at community child and adolescent psychiatric outpatient clinics. METHOD Assessments of self-harm, suicidal ideation, depression, hopelessness, borderline symptoms, and global level of functioning were made at the end of the 19-week treatment period and at follow-up 1 year later. Altogether 75 of the 77 (97%) adolescents participated at both time points. Frequencies of hospitalizations, emergency department visits and other use of mental health care during the 1-year follow-up period were recorded. Change analyses were performed using mixed effects linear spline regression and mixed effect Poisson regression with robust variance. RESULTS Over the 52-week follow-up period, DBT-A remained superior to EUC in reducing the frequency of self-harm. For other outcomes such as suicidal ideation, hopelessness, and depressive or borderline symptoms and for the global level of functioning, inter-group differences apparent at the 19-week assessment were no longer observed, mainly due to participants in the EUC group having significantly improved on these dimensions over the follow-up year, whereas DBT-A participants remained unchanged. CONCLUSION A stronger long-term reduction in self-harm and a more rapid recovery in suicidal ideation, depression, and borderline symptoms suggest that DBT-A may be a favorable treatment alternative for adolescents with repetitive self-harming behavior. CLINICAL TRIAL REGISTRATION INFORMATION Treatment for Adolescents With Deliberate Self Harm; http://clinicaltrials.gov/; NCT00675129.

Use of health services following self-harm in urban versus suburban and rural areas: a national cross-sectional study

Objectives This study examines whether there is a difference between urban versus suburban and rural adolescents in their use of health services following two types of self-harm distinguished as self-harm with or without suicide intent. Setting A nationwide cross-sectional school survey of 11 406 Norwegian adolescents aged 13–19 years in 73 Norwegian junior and senior high schools. Participants Adolescents who reported self-harm and provided valid responses to a follow-up question about having received subsequent help or treatment (n=959) were included in the study. Adolescents were divided into urban versus suburban and rural depending on: (1) the location of municipalities where they attended school and (2) the place of residence. Associations between urban versus suburban and rural areas and the use of health services following self-harm were assessed in those who self-harmed with and without suicide intent. Primary outcome measure Use of health services following self-harm. Results 1 in 4 adolescents reported using health services following self-harm. Adolescents reporting self-harm with suicide intent were more likely to use health services than those who self-harmed without suicide intent. Following self-harm without suicide intent, adolescents in urban areas were four times more likely to use health services than adolescents in suburban and rural areas. There was no statistically significant area difference in the use of health services following self-harm with suicide intent. Conclusions This study found a geographical variation in the use of health services following self-harm without suicide intent, but not following self-harm with suicide intent. Differences in perception of self-harm and help-seeking behaviour between areas and different accessibility to services are suggested as possible explanations. There is a need to better understand how the interplay between individual characteristics and accessibility to services influences adolescents’ use of health services following self-harm. We suggest that multilevel models are a valuable approach to achieve this goal.

Feasibility of Dialectical Behavior Therapy with Suicidal and Self-Harming Adolescents with Multi-Problems: Training, Adherence, and Retention

We evaluated the feasibility of DBT training, adherence, and retention preparing for a randomized controlled trial of Dialectical Behavior Therapy (DBT) adapted for Norwegian adolescents engaging in self-harming behavior and diagnosed with features of borderline personality disorder. Therapists were intensively trained and evaluated for adherence. Adherence scores, treatment retention, and present and previous self-harm were assessed. Twenty-seven patients were included (mean age 15.7 years), all of them with recent self-harming behaviors and at least 3 features of Borderline Personality Disorder. Therapists were adherent and 21 (78%) patients completed the whole treatment. Three subjects reported self-harm at the end of treatment, and urges to self-harm decreased. At follow up, 7 of 10 subjects reported no self-harm. DBT was found to be well accepted and feasible. Randomized controlled trials are required to test the effectiveness of DBT for adolescents.

Dialektisk atferdsterapi for ungdommer med gjentatt suicidal og selvskadende adferd – en randomisert kontrollert undersøkelse

Vi undersokte hvorvidt en forkortet versjon av dialektisk atferdsterapi tilpasset for tenaringer (DBT-A) er mer effektiv enn vanlig behandling (VB) i a redusere villet egenskade. I undersokelsen deltok 77 ungdommer med nylig og repetert villet egenskade, tilfeldig fordelt til a motta enten DBT-A eller VB i 19 uker. Vi malte antall episoder med villet egenskade, niva av selvmordstanker, depresjon, haploshet og symptomer pa ustabil personlighetsforstyrrelse ved behandlingsstart og etter 9, 15 og 19 uker. Vi fant at de fleste ungdommene i begge grupper fullforte behandlingen og at bruken av krisetjenester var beskjeden. De ungdommene som fikk DBT-A, rapporterte imidlertid signifikant faerre episoder med villet egenskade og lavere niva av selvmordstanker og depresjonsymptomer enn ungdommene som fikk VB. Var konklusjon er at DBT-A er mer effektivt i a behandle ungdommer med villet egenskade enn vanlig behandling. We examined whether a shortened form of dialectical behavior therapy (DBT-A) is more effective than enhanced usual care (EUC) to reduce self-harm in adolescents. This was a randomized study of 77 adolescents with recent and repetitive self-harm treated at community child and adolescent psychiatric outpatient clinics randomly allocated to either DBT-A or EUC. Assessments of self-harm, suicidal ideation, depression, hopelessness and symptoms of borderline personality disorder were made at baseline and after 9, 15 and 19 weeks (end of trial period) and frequency of hospitalizations and emergencydepartment visits over the trial period were recorded. Treatment retention was generally good in both treatment conditions and the use of emergency services was low. DBT-A was superior to EUC in reducing self-harm, suicidal ideation and depressive symptoms. Effect sizes were large for treatment outcomes in patients who received DBT-A, whereas effect sizes were small for outcomes in patients receiving EUC. We conclude that DBT-A may be an effective intervention to reduce self-harm, suicidal ideation and depression and adolescents with repetitive self-harming behavior.

Økonomisk evaluering av behandling for ungdom med villet egenskade – hvorfor og hvordan?

I studier av kostnadseffektivitet evaluerer man om behandlingskostnader star i et rimelig forhold til effekten. Gitt begrensede ressurser er slike studier viktige som beslutningsgrunnlag vedrorende implementering av nye behandlingsformer. I forbindelse med en intervensjonsstudie for ungdommer med repetert villet egenskade, der dialektisk atferdsterapi for ungdom (DBT-A) sammenlignes med standard behandling, planlegges det a gjore en okonomisk evaluering. Formalet med denne artikkelen er a gjore rede for metoden for evaluering av kostnadseffektivitet, samt belyse rasjonalet for en slik evaluering. Eksisterende forskning peker i retning av at ungdommer med repetert selvskading har et stort forbruk av helsetjenester, men at det er lite kunnskap om hvorvidt behandlingen som tilbys er kostnadseffektiv. Nylig publiserte resultater fra den nevnte intervensjonsstudien viste at DBTA var mer effektiv enn standard behandling etter en behandlingsperiode pa 19 uker (Mehlum et al., 2014), samtidig som DBT-A medforte mer omfattende bruk av ressurser. I lys av dette synes det saerlig relevant for beslutningstagere at DBT-A evalueres med henblikk pa kostnadseffektivitet. Den endelige okonomiske evalueringen vil gjores over en periode pa til sammen 71 uker (behandlings- og oppfolgingsperiode) og vil basere seg pa gjennomsnittlig totalkostnad per pasient (DBT-A vs. standard behandling) og effektanalyser. The aim of cost-effectiveness studies is to evaluate whether the costs of a new treatment are reasonable in relation to treatment effects. Given limited resources such studies are important for decision-makers when making priorities with respect to implementation of new treatments. Following an intervention study for adolescents with repeated deliberate self-harm, comparing dialectical behavior therapy for adolescents (DBT-A) with standard treatment, the costeffectiveness of DBT-A will be evaluated. The objective of this paper is to outline the method for evaluation of cost-effectiveness, as well as discussing the rationale for conducting a costeffectiveness study of DBT-A. Research indicates that adolescents with selfharm is a patient group with extensive use of health services, however, that the knowledge of cost-effectiveness of treatment is sparse. The intervention study showed that DBT-A was more effective than standard treatment after a treatment period of 19 weeks (Mehlum et al., 2014), but that DBT-A also lead to more use of outpatient resources. Thus, it appears highly relevant to evaluate the cost-effectiveness of DBT-A. The evaluation will be conducted over a period of 71 weeks (treatment and follow-up), and will be based on average total costs per patient (DBT-A vs standard treatment) and analyses of treatment effects.

Dialektisk atferdsterapi – en relevant behandling for pasienter med rusmisbruk og emosjonelt ustabil personlighetsforstyrrelse?

Emosjonelt ustabil personlighetsforstyrrelse og ruslidelser er vanlig i kliniske populasjoner og diagnostisk komorbiditet mellom disse lidelsene forekommer ofte. En slik komorbiditet gir ofte en negativ additiv effekt, for debut av lidelsen, forlop, prognose og behandling. Det er holdepunkter for a hevde at de deler en felles etiologi i form av emosjonell dysregulering og impulskontrollsvikt. Dialektisk adferdsterapi (DBT) kombinerer en kognitiv atferdsterapeutisk tilnaerming med akseptorienterte strategier og en dialektisk filosofisk holdning. DBT er empirisk validert som effektiv behandling for personer med ustabil personlighetsforstyrrelse. I denne artikkelen undersokte vi om litteraturen tilsier at DBT ogsa er et hensiktsmessig behandlingstilbud til pasienter med bade ustabil personlighetsforstyrrelse og ruslidelse. Et litteratursok identifiserte tre studier som undersoker dette. Resultatene er ikke entydige, men samlet sett gir de et optimistisk grunnlag til stotte for at DBT kan vaere et hensiktsmessig tilbud ogsa for ruspasienter, bade knyttet til reduksjon av rusmiddelmisbruk, lavere drop-out rate fra behandling og at behandlingseffekten kan vare over tid. Borderline personality disorder and substance use disorders are prevalent in clinical samples, and they often co-occur. The co-occurrence of these disorders often increases the risk for problems, and has negative impact on the trajectory, prognosis and treatment. The assumption that both disorders share the same underlying problems of emotional dysregulation is supported by a large body of evidence. Dialectical behaviour therapy, a treatment developed for patients with borderline personality disorder addresses directly the core problems of regulating emotions. The aim of this literature review was to examine whether this specific treatment had evidence regarding effectiveness also for patients with co-morbid borderline personality disorder and substance use disorder. The article is based on non-systematic literature review, and found three studies who directly examined the effect of dialectical behaviour therapy for this group. The results from these studies are promising, indicating less use of substances, lower dropout rate, and the observed effect lasts over time.