Self-harm in Teens: Rapid Response With Novel Behavior Therapy

Liam Davenport

February 09, 2016

A behavioral therapy that teaches coping skills, used in conjunction with psychotherapy, not only significantly reduces self-harm among adolescents but also more rapidly leads to recovery from suicidal ideation and depression than enhanced usual care (EUC), a Norwegian study suggests.

Following 19 weeks of dialectical behavior therapy adapted for adolescents (DBT-A), self-harming adolescents were significantly less likely to self-harm than those who underwent EUC, a difference that persisted up to 1 year.

In addition, patients who underwent DBT-A experienced improvements in suicidal ideation, hopelessness, and depression, as well as global functioning, earlier than did EUC patients, with the latter catching up by the final follow-up.

The team says: "This study suggests that DBT-A is associated with greater long-term reduction in self-harm and more rapid clinical improvements in suicidal ideation, depression, and borderline symptoms than usual care. These findings indicate that DBT-A may be a favorable treatment alternative for adolescents with repetitive self-harming behavior."

The article was published online January 27 in the Journal of the American Academy of Child and Adolescent Psychiatry.

Public Health Problem

Lead author Lars Mehlum, MD, PhD, the National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Norway, explained that self-harm constitutes a public health problem in most of the developed world.

Speaking to Medscape Medical News, he said that in the general population, 8% to 10% of adolescents aged 14 to 17 years report that they have self-harmed. This figure rises to approximately 25% among individuals seen in child and adolescent psychiatric outpatient units, regardless of their diagnoses.

"Not all of those who report this...are equally disturbed or are having a lot of problems, but other studies have shown that it's possible to find a gradient of risk factors associated with self-harm out in the general population," said Dr Mehlum.

"The more it is repetitive and the more it is combined with suicide attempts, the more we are talking about a very disturbed and an at-risk population of youngsters who are in need of treatment," he added.

For the study, researchers randomly assigned 77 adolescents from Oslo (mean age, 15.6 years) who reported at least two prior episodes of self-harm to receive 19 weeks of either DBT-A or EUC.

EUC consisted of standard care plus no less than one weekly therapist-led treatment session per patient throughout the course of the trial. This was intended only for the 19-week treatment period but could last longer, depending on the therapists' assessment of patients' needs.

The DBT-A used in the study was an adaptation of standard DBT and comprised four modules, the first of which consisted of 1 hour of weekly psychotherapy with an individual therapist.

The second was a skills training seminar, led by two therapists, in which adolescents and their parents or care providers were invited to participate. From three to six family groups took part. In the seminiar, the families learned new skills and participated in brief rehearsals that demonstrated the relevance of the new skills and how they could be used. Homework was also assigned.

The third module consisted of telephone-based coaching. Individual therapists were available 24 hours a day, 7 days a week for the adolescents to call to discuss feelings that would ordinarily lead to self-harm. Follow-up calls were made 20 minutes after completion of the sessions.

The fourth module, which was termed "consultation team," consisted of a once-weekly session for the therapists to meet together. The purpose was to keep the therapists motivated and on track for treating patients without becoming burned out, demotivated, or hopeless.

Motivation Part of Treatment

At the end of the 19-week treatment period and at 1-year follow-up, the adolescents underwent assessments of self-harm, suicidal ideation, depression, feelings of hopelessness, borderline symptoms, and global level of functioning. Data on hospitalizations, emergency department visits, and other mental health care interventions were recorded.

All 77 adolescents completed the treatment period; 75 returned for the 1-year follow-up.

No suicides occurred in either group. EUC patients reported a 44.9% reduction in self-harm episodes between the 19 weeks of treatment and the 1-year follow-up, from 22.5 to 14.8 episodes. This compared with a 55.9% reduction with DBT-A, from 9.0 to 5.5 episodes, respectively. The between-group difference was significant at both time points (P < .05).

Levels of suicidal ideation, hopelessness, and depressive or borderline symptoms and global level of functioning were all lower in the DBT-A group at the 19-week assessment. However, these differences disappeared by the 1-year follow-up, largely as a result of significant improvements in the EUC group. The participants were unchanged.

Two patients from each group were hospitalized during follow-up. Outpatient treatment was received by 38.9% of EUC patients vs 10.8% of DBT-A patients. However, 12.1% and 22.1% of EUC and DBT-A patients, respectively, visited emergency departments during follow-up. The difference was not significant.

Dr Mehlum said the findings show "that it is possible within a rather limited time period to reduce self-harm but also to increase the quality of life and reduce the number of mental ill-health factors that are associated with this self-harm practice."

He believes that it would be possible to roll out this treatment into standard clinical practice. Because it lasts for only 4 months, it is "feasible to offer it to larger groups of patients than previous treatments that range from 12 months to up to 3 years, which is forever for a teenager but also very resource-demanding."

The team is also examining ways to apply components of DBT-A to child protection services and general medical practices.

"At the moment, we are working with adaptations like that, because we know that some patients will never come to child and adolescent psychiatric services," he said.

"They won't do it and/or that service won't be available, or there might be one million other factors [related to] the patients, their families, but also in the system and in society."

One issue that the authors raise in their article is that compliance with treatment services among adolescents who self-harm has typically been low. Dr Mehlum explained that, previously, a patient's motivation for treatment and therapy was considered a prerequisite for starting therapy.

"I would say that we need to define making our patients more motivated and compliant as a very important part of the treatment in itself," he said. He explained that DBT-A defines motivation as part of the treatment process.

"You need to be challenged, but also validated for all of the hard work you are doing, and sometimes the pain you are feeling when you are going in treatment," said Dr Mehlum.

Rapid Response Important

Commenting on the findings for Medscape Medical News, David A. Brent, MD, Endowed Chair in Suicide Studies and professor of psychiatry, pediatrics, epidemiology, and clinical and translational science, University of Pittsburgh, Pennsylvania, said that the study was "well-constructed."

The rapid response seen with DBT-A in comparison with EUC is "really important."

"The longer someone has high levels of depression or suicidal ideation, the longer that person is at risk to attempt or complete suicide. The differences are meaningful, and will be especially so if the authors choose to do cost-benefit analyses, which may show better improvement per unit cost of treatment in DBT-A," he said.

Dr Brent added that once the findings have been replicated in further studies, he would like to see DBT-A become more widely available. However, there is a need to compare DBT-A with other available treatments, especially insofar as the time-intensive nature of the therapy means that "many people eschew participating."

The study was funded by grants from the Norwegian Directorate of Health, the South Eastern Regional Health Authority, the ExtraFoundation for Health and Rehabilitation, and the University of Oslo. The authors have disclosed no relevant financial relationships.

J Am Acad Child Adolesc Psychiatry. Published online January 27, 2016. Abstract

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