Effectiveness of Dialectic Behavioral Therapy in Adolescents (DBT-A) in the treatment of depression and emotional dysregulation: A Colombian prospective cohort study

doi:10.21203/rs.3.rs-3617181/v1

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Effectiveness of Dialectic Behavioral Therapy in Adolescents (DBT-A) in the treatment of depression and emotional dysregulation: A Colombian prospective cohort study

https://doi.org/10.21203/rs.3.rs-3617181/v1

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Background

Dialectic behavioral therapy (DBT) is a psychotherapeutic treatment to address emotional dysregulation (EDys) through acceptance and change strategies. It has been specifically adapted for use in adolescents (DBT-A). The aim of this study was to determine the effectiveness of a DBT-A skills training program in two different group formats, compared with standard care, for the treatment of EDys and depressive symptoms in adolescents.

Methods

We carried out a prospective cohort study on adolescents who were exposed to DBT-A skills training compared with standard care. The program included 14 sessions, two hours in duration, fortnightly. We examined clinical outcomes and measures of EDys (with the Difficulties in Emotion Regulation Scale - DERS) and depression (with the Children’s Depression Inventory - CDI) in three groups: Group A corresponded to separate DBT group skills training for patients and their caregivers; Group B-Multifamily, in which adolescents and their caregivers participated in the same sessions; and Group C was the treatment as usual group, with no DBT skills training. Group assignment was non-random and was subject to training group availability at time of inclusion. Linear models were used to control the effect of potential confounders.

Results

We identified a final sample of 130 subjects. Groups were significantly different only in sex distribution, and problematic alcohol/substance use. Significant differences in DERS and CDI scores were observed when comparing training groups (A and B) with the control (ANOVA p value < 0.001). The adjusted model for the difference in DERS scores showed a significant association between either of the intervention groups vs. treatment as usual. The model for change in the CDI scores showed a significant effect of Group B assignment over treatment as usual, but not of group A. Age showed a significant effect with an average decrease in the difference between pre and post scores of -1.207 per year (95%CI -2.292;-0.122). The use of antidepressants showed a significant effect with a magnitude of 5.411 (95%CI 1.415;9.407).

Conclusions

The implementation of DBT-A skills training, in either a separate or multifamily format, was both effective and safe for EDys treatment. DBT-A skills training delivered in a multifamily format may have the added benefit of impacting symptoms of depression.

Adolescent

Depression

Emotional Dysregulation

Dialectical Behavior Therapy

Skills Training

Adolescence is a stage with physical, social and emotional changes in which continued development calls for varied adaptive strategies. For some, this complex process leads to challenging situations with highly impactful social and personal consequences. Psychopathology is thus frequent in adolescents, and it has been estimated that 15% of adolescents 10–19 years live with some kind of mental disorder, and that half of the mental disorders in adults have their onset before the age of 14 years (1). Colombia is no exception, and the latest mental health bulleting showed that 141.364 people under 20 years sought mental health services between 2009–2017 for depression. Of these, 59.3% were female and the group 15–19 was the most commonly affected (2, 3). Depression and impulsiveness in adolescents have become increasingly more frequent in the last decade, particularly after the COVID-19 pandemic, after which it was estimated that 14% of subjects with mental disorders were adolescents (1, 4).

Although impulsiveness is frequent among adolescents, a fact that is related to their developing brains, comorbid depression and an adverse psychosocial setting which generates an invalidating environment increase the risk for alterations in emotional regulation (4, 5). Emotional dysregulation (EDys) is the inability to balance emotional cues, experiences, actions, and verbal and nonverbal expressions under normal circumstances, which leads to maladaptive responses (6). The manifestations of this dysregulation include risky behaviors (alcohol and substance use disorders, risky sexual behaviors), disruptive behaviors (damaging objects or hetero-aggressive behaviors) and self-harm with or without suicidal intent. A rising number of adolescents with these characteristics are hospitalized in mental health services, with prolonged hospital stays, decreasing quality of life and higher healthcare costs (7, 8).

The early identification of risky behaviors and depressive disorders in adolescents allows for a more prompt referral to mental health professionals (psychologists, social workers, psychiatrists). The National Institute for Health and Care Excellence guidelines recommend that mild and moderate depressive disorders be treated using psychotherapy as a first line treatment. If response is suboptimal, the guidelines recommend a review of risk factors and of elements of the psychosocial environment that can be addressed (9). However, the demand for qualified mental healthcare personnel far exceeds demand, which leads to insufficient treatments and poor outcomes for patients and their families.

Dialectic behavioral therapy (DBT) offers several benefits that can help address these issues. DBT is a psychotherapeutic treatment which aims to address EDys through acceptance and change strategies. This type of third-generation therapy keeps in mind the subjects personal goals while following structured protocols with well-defined, replicable, objectives (9, 10). DBT is the most efficacious treatment for borderline personality disorder (11, 12), and it has been effective as a monotherapy in people with addictions (13), suicidal ideation (14), post-traumatic stress disorder (15), among others. It has also been specifically adapted for use in adolescents (DBT-A) (16).

The strain of the burden of psychopathology in Colombia on the healthcare system led us to implement one of the components of DBT-A, skills group training. We offered this training to adolescents with depression and EDys who could not access individual psychotherapy. The group format of this training allowed us to reach a larger number of patients and families in a shorter time period and with fewer resources. The aim of this study was to determine the effectiveness of a DBT-A skills training program delivering therapy in two different group formats, compared with standard care, for the treatment of EDys and depressive symptoms in adolescents.

Study Design

We carried out a prospective cohort study on adolescents who were exposed to DBT-A skills training compared with standard care. Prior to this, the researchers carried out a transcultural adaptation of an established DBT-A skills training program (16). This adaptation of DBT-A demands that at least one of the primary caregivers is present for all training sessions. The program included 14 sessions, two hours in duration, fortnightly. This cohort study examined clinical outcomes and measures of EDys and depression in three groups: the first group (Group A) corresponded to separate DBT group therapy for patients and their caregivers; the second group (Group B, multifamily) corresponded to DBT group therapy, in which adolescents and their caregivers participated in the same sessions; the third group (group C) was the treatment as usual group (averaging monthly or bimonthly psychiatry and psychology sessions), with no DBT skills training. All caregivers signed informed consent forms covering the participation of their children and themselves in the study. The included adolescents signed informed assent forms. The protocol for this study was approved by the Research Ethics Committee of the Fundación Universitaria Sanitas (CEIFUS 348 − 19).

Setting

Sanitas EPS is a Healthcare Management Organization (HMO) in Colombia with over 5 million patients under its care. Since November 2017, Sanitas EPS has offered treatment with dialectic behavioral therapy skills training in Bogota to families of adolescent patients with a diagnosis of depression and EDys. Group therapies are carried out with or without caregivers in joint 120-minute sessions fortnightly over 7 months for a total of 14 sessions. The sessions include groups of 8–15 families at a time.

Participants

Included subjects were undergoing child and adolescent psychiatry or psychology treatment at any of the Sanitas EPS medical centers in Bogota, had to be 12–18 years at treatment start, and were required to have a diagnosis of a mayor depressive disorder per DSM-5 criteria (mild severity in a recurrent or single episode), alongside some problematic behavior as a result of EDys (mild alcohol or substance use disorders, feeding and eating disorders, non-suicidal self-injury including cutting). Exclusion criteria included patients who were judged by their treating psychiatrist/psychologist to be uninterested in starting a psychotherapeutic process, patients with moderate or severe substance abuse disorders, patients with paraphilias, incarcerated individuals, and patients enrolled in the day-hospital program. Patients and their families were also excluded if they were absent for 7 or more sessions or if they did not complete the post-treatment assessment. Importantly, for each adolescent included in the therapy groups, both parents were invited to complete the DERS scale individually.

Subjects were offered to participate based on each treating psychiatrist’s or psychologist’s judgment, which included considerations of caregiver engagement as one caregiver had to be present in all group sessions for groups A and B. Given the patients’ clinical condition, some form of treatment was required by the HMO to be instituted as quickly as possible. However, due to personnel constraints, training groups were not available throughout the study, and patients were offered participation if a given group was recruiting at that moment. Every four sessions (approximately two months) a new training group became available in an alternating fashion. If a patient declined participation in the training group available at the time, they were assigned to group C (standard of care).

Variables

We collected data on general demographic characteristics, the presence and frequency of problematic behaviors, including suicidality, cutting, eating disorders and alcohol/drug use by means of direct questions and throughout the clinical interview before and after training. The primary outcome of emotional deregulation was established using the results for the Difficulties in Emotion Regulation Scale (DERS) and its subscales before and after training for patients and at least one of the caregivers (17, 18). The self-reported Children’s Depression Inventory (CDI) was obtained at baseline and after treatment (19–21). We also obtained data on prior psychiatric diagnoses, use of antidepressants, prior hospitalization and length of hospitalization for patients.

Study Size

Sample size was calculated based on a paired Student’s t-test for pre and post intervention DERS scores. Historical values of the DERS scale in adolescents treated with comparable treatments by similar care teams showed means for the A and B groups of 41 (SD: 26) and 24 (SD: 31), respectively. For a statistical power of 90%, and an alpha of 5%, we calculated an approximate sample size of 32 patients per group, which was adjusted to 40 patients per group taking into account losses to follow-up (a total of 120 adolescents).

Statistical Methods

Patient characteristics were determined at baseline and after training. Categorical variables are reported as absolute and relative frequencies. After determining normality using the Shapiro-Wilk test (p < 0.1), we reported the means and standard deviations of quantitative variables. One-tailed paired t-tests were used to analyze the before and after training DERS scores using a value of 5% for significance. We compared DERS results between treatment groups.

Dichotomic variables (depression, anxiety, family communication perception, cutting, problematic alcohol or substance use) before and after training were compared between groups using a one-tailed McNemar’s Chi-squared test. Differences between the pre and post intervention scores in the DERS and CDI scales were calculated and used as dependent variables. We compared the differences in these changes between groups using Student’s t test for independent groups with heterogenous variances (determined using Levene’s test). We used an ANOVA on the DBT-A skills training groups adjusting for multiple comparisons using the Bonferroni, Tamhane and Student-Neuman-Keuls (S-N-K) tests. We compared DERS and CDI results between treatment groups with a repeated measures ANOVA test. Two linear multiple regression models were used to obtain estimates for differences in means adjusted for potential confounders (age, sex, number of sessions attended, number of prior hospitalizations, cutting, family dysfunction, sexual abuse, use of antidepressants, depression and anxiety due to psychiatric interview). The first model used the pre-post DERS score difference as a dependent variable, and the second the corresponding difference for the CDI scores. The intervention groups were the independent variables in both models.

We identified 331 adolescents and their families as initially eligible for inclusion in the study. After applying exclusion criteria, 201 subjects were excluded from the study, leaving a final sample of 130 subjects as depicted in Fig. 1. Females were more frequent and represented 93.1% of the sample (n = 121). The average age was of 14.8 (standard deviation 1.6 years, median 15 years), ranging from 12–18 years. At baseline, 129 patients exhibited very severe EDys, with only one subject exhibiting moderate EDys, as determined using the DERS scale. On formal psychiatric assessment, comorbid depression was present in 88.5% (n = 115) and anxiety in 82.3% (n = 107). A diagnosis of childhood depression according to the CDI was present in 66.2% (n = 86). Baseline characteristics for each group are shown in Table 1. P values corresponding to Chi-squared tests are shown in the rightmost column. Groups were significantly different in sex distribution (more males in Group B), and problematic alcohol and substance use (more common in Group C).

Table 1

Baseline characteristics per study group.
Variable	Group A (n = 44)	Group B (n = 51)	Group C (n = 35)	p value
Variable	n (%)			p value
Sex
Male	2 (4.5)	7 (13.7)	0 (0)	0.03
Female	42 (95.5)	44 (86.3)	35 (100)	0.03
Age
< 15 years	18 (40.9)	26 (51)	10 (28.6)	0.12
>= 15 years	26 (59.1)	25 (49)	25 (71.4)	0.12
Clinical Depression
Yes	38 (86.4)	46 (90.2)	31 (88.6)
No	6 (13.6)	5 (9.8)	4 (11.4)
Clinical Anxiety
Yes	37 (84.1)	41 (80.4)	29 (82.9)	0.92
No	7 (15.9)	10 (19.6)	6 (17.1)	0.92
EDys Level (DERS)
Moderate	0 (0)	1 (2)	0 (0)	1
Very Severe	44 (100)	50 (98)	35 (100)	1
Depression (CDI)
Positive	32 (72.7)	32 (62.7)	22 (62.9)	0.55
Negative	12 (27.3)	19 (37.3)	13 (37.1)	0.55
Eating disorder
Yes	7 (15.9)	11 (21.6)	3 (8.6)	0.28
No	37 (84.1)	40 (78.4)	32 (91.4)	0.28
Eating disorder frequency
None	37 (88.1)	40 (78.4)	32 (97)	0.15
1 or 2 times in a lifetime	2 (4.8)	3 (5.9)	0 (0)
Monthly	1 (2.4)	4 (7.8)	0 (0)
Weekly	2 (4.8)	1 (2)	0 (0)
Daily	0 (0)	3 (5.9)	1 (3)
Sexual abuse
Yes	6 (13.6)	8 (15.7)	4 (11.4)	0.95
No	38 (86.4)	43 (84.3)	31 (88.6)	0.95
Familiar disfunction
Yes	30 (68.2)	41 (80.4)	22 (66.7)	0.29
No	14 (31.8)	10 (19.6)	11 (33.3)	0.29
Prior Hospitalization
Yes	23 (52.3)	17 (33.3)	15 (42.9)	0.18
No	21 (47.7)	34 (66.7)	20 (57.1)	0.18
Cutting
Yes	36 (81.8)	40 (78.4)	25 (71.4)	0.56
No	8 (18.2)	11 (21.6)	10 (28.6)	0.56
Problematic alcohol or substance use
Yes	5 (11.4)	9 (17.6)	13 (37.1)	0.02
No	39 (88.6)	42 (82.4)	22 (62.9)	0.02
Frequency of alcohol or substance use
None	39 (88.6)	42 (82.4)	22 (64.7)	0.25
1 or 2 times in a lifetime	5 (11.4)	7 (13.7)	8 (23.5)
Monthly	0 (0)	1 (2)	2 (5.9)
Weekly	0 (0)	1 (2)	1 (2.9)
Daily	0 (0)	0 (0)	1 (2.9)
Use of antidepressant
Yes	34 (77.3)	35 (68.6)	20 (57.1)	0.17
No	10 (22.7)	16 (31.4)	15 (42.9)	0.17
Type of antidepressant
SSRI	26 (81.3)	27 (77.1)	17 (89.5)	0.661
SNRI	4 (12.5)	5 (14.3)	2 (10.5)
Other	2 (6.3)	3 (8.6)	0 (0)
EDys: Emotional dysregulation; DERS: Difficulties in Emotion Regulation Scale; CDI: Children’s Depression Inventory; SSRI: Selective Serotonin Reuptake Inhibitors; SNRI: Selective Norepinephrine Reuptake Inhibitors

Table 2

Comparison of means at baseline, post-treatment and pre-post differences between treatment groups for (A) DERS and (B) CDI
(A) DERS
Groups		N	Mean (SD)	95% CI
Pre	Group A	44	130.61 (24.96)	123.02; 138.20
	Group B	51	127.45 (28.24)	119.51; 135.39
	Group C	35	116.66 (27.72)	107.13; 126.18
	Total	130	125.62 (27.41)	120.86; 130.37
Post	Group A	44	104.20 (26.55)	96.13; 112.28
	Group B	51	97.65 (29.69)	89.30; 106.00
	Group C	34	117.59 (24.87)	108.91; 126.27
	Total	129	105.14 (28.36)	100.20; 110.08
Pre - Post	Group A	44	26.41 (29.70)	17.38; 35.44
	Group B	51	29.81 (32.44)	20.68; 38.93
	Group C	34	-0.79 (18.38)	-7.21; 5.62
	Total	129	20.58 (31.01)	15.18; 25.98
(B) CDI
Pre	Group A	44	10.34 (1.56)	21.33; 27.62
	Group B	51	10.22 (1.43)	20.44; 26.19
	Group C	35	9.28 (1.57)	17.73; 24.10
	Total	130	10.04 (0.88)	21.32; 24.80
Post	Group A	44	10.53 (1.59)	15.62; 22.02
	Group B	51	8.70 (1.22)	12.65; 17.54
	Group C	34	10.32 (1.77)	18.22; 25.42
	Total	129	10.09 (0.89)	16.38; 19.90
Pre - Post	Group A	44	9.35 (1.41)	2.82; 8.50
	Group B	51	10.91 (1.53)	5.15; 11.28
	Group C	34	7.86 (1.35)	-3.74; 1.74
	Total	129	10.27 (0.91)	3.13; 6.71

Table 3

Multiple linear regressions for the difference between pre- and post-treatment in (A) DERS and (B) CDI scores, controlling for potential confounders.
(A) DERS
Variable	B (CI95%)	p value
(Constant)	43.481 (-8.884; 95.845)	0.103
Group A	22.471 (6.987; 37.955)	0.005
Group B	24.988 (8.467; 41.510)	0.003
Problematic alcohol/substance use	-1.944 (-14.999; 11.112)	0.769
Sex (mas/fem)	-8.368 (-29.011; 11.735)	0.403
Age	-3.236 (-6.523; 0.051)	0.054
No. sessions attended ( > = 10)	4.840 (-7.650; 17.330)	0.444
Prior hospitalization	2.185 (-8.843; 13.213)	0.695
Cutting	3.399 (-9.493; 16.292)	0.602
Family disfunction	-0.960 (-12.521; 10.601)	0.870
Sexual abuse	-4.964 (-19.494; 9.565)	0.500
Depression	6.796 (-9.730; 23.323)	0.417
Anxiety	-12.145 (-25.691; 1.401)	0.078
Use of antidepressants	11.285 (-0.826; 23.396)	0.067
(B) CDI
(Constant)	15.403 (-1.875; 32.682)	0.080
Group A	5.043 (-0.066; 10.152)	0.053
Group B	8.149 (2.698; 13.601)	0.004
Problematic alcohol/substance use	-3.169 (-7.477; 1.139)	0.148
Sex (mas/fem)	-5.118 (-11.840; 1.605)	0.134
Age	-1.207 (-2.292; -0.122)	0.030
No. sessions attended ( > = 10)	-0.712 (-4.834; 3.409)	0.733
Prior hospitalization	0.189 (-3.450; 3.828)	0.918
Cutting	2.816 (-1.438; 7.070)	0.192
Family disfunction	0.494 (-3.321; 4.309)	0.798
Sexual abuse	-1.479 (-6.273; 3.316)	0.542
Depression	0.494 (-4.960; 5.947)	0.858
Anxiety	-3.385 (-7.855; 1.085)	0.136
Use of antidepressants	5.411 (1.415; 9.407)	0.008

Changes in the DERS and CDI scale scores after DBT skills training

At baseline, no significant differences were found between the mean DERS scores of the three groups (ANOVA p value = 0.065), although significant differences appeared between them after treatment. Significant differences were observed when comparing intervention groups A and B with control Group C (ANOVA p value < 0.001, heterogenous variance) (Table 2A). Pairwise comparisons between group A and control were significant (p < 0.001, Bonferroni’s test), as well as those between group B and control (p < 0.001, Tamhane’s test).

Similarly, at baseline, the average scores on the CDI scales of the three groups did not differ (ANOVA p = 0.288). However, significant post-intervention differences were found between treatment groups (ANOVA p = 0.008). There were significant differences between intervention groups A and B and control group C (Table 2B). The differences between pre and post intervention CDI scores were significant on post-hoc testing when comparing group A and control group C (p = 0.009, Bonferroni’s test), and between group B and control group C (p < 0.001, Tamhane’s test). Groups A and B did not differ between them.

Linear regression models for change in DERS and CDI scores

The adjusted model for the difference in DERS scores showed a significant association between either of the intervention groups vs. treatment as usual. The magnitude of the coefficients suggests average differences of over 10% of the range of the DERS scale. None of the other variables included in the DERS model showed significance (Table 3A). The model for change in the CDI scores showed a significant effect of Group B assignment over treatment as usual, but not of group A (Table 3B). The magnitude of the coefficient corresponded to approximately 14% of the CDI range. Additionally, age showed a significant effect with an average decrease in the difference between pre and post scores of -1.207 per year (95% CI -2.292; -0.122). The use of antidepressants also showed a significant effect with a magnitude of 5.411 (95% CI 1.415; 9.407).

Longitudinal evaluation before and after treatment on, anxiety, problematic behaviors and other outcomes

In groups A and B, we found significant reductions in the frequency of cutting, hospitalization, family dysfunction, eating disorders and anxiety (Supplementary Table 1). In cohort group A, we found a significant reduction in problematic alcohol and/or substance use. It is worth noting that a large statistically and clinically significant reduction in family dysfunction was observed in group B. Regarding other outcomes, there were no deaths due to any cause and there was a single psychiatric illness-related hospitalization during the study period.

Given the limitations faced by Colombian patients in receiving treatment for psychopathology, we aimed to examine the effectiveness of DBT-A skills training delivered in group formats in Colombia. This study is the first of its kind to compare the effectiveness of two distinct DBT-A skills training modalities (separate vs. multifamily) in the reduction of EDys and symptoms of depression in a country with significant constraints in the provision of mental health services. Both models were effective in reducing EDys and problematic behaviors (cutting, eating disorders, problematic alcohol and substance use).

DBT-A skills training is provided by some teams separately for parents and adolescents (as was the case in group A) (22), and by others in a multifamily format (as in group B) (23). Our results show that the multifamily format may provide an advantage in controlling depressive symptoms, at the cost of requiring greater caregiver involvement and less flexibility in session scheduling. The format followed by group A offers increased flexibility in scheduling and may be more appropriate in other scenarios. However, further studies replicating these findings are necessary.

Regarding the results on the CDI scale, there were significant improvements for either of the DBT-A skills training groups. In contrast, the control group (Group C) showed a tendency towards worsening. However, this may be a reflection of a selection bias due to greater willingness of both caregivers and adolescents to participate in the psychotherapeutic process in the active arms. Although DBT-A skills training was designed for use in patients with EDys, these positive results on symptoms of depression show that there are opportunities for group interventions to be explored in a variety of other applications like the treatment of depression.

The effect of antidepressants found in this study was consistent with prior literature (24, 25). We did not identify an effect of antidepressants on EDys, but as expected, we did identify an effect on symptoms of depression. The coexistence of depressive symptoms and EDys has been identified as a predictor of poor response to treatment (26, 27). Hence, it is also possible that treatment with DBT-A skills training of adolescents and their caregivers alongside pharmacotherapy may have synergistic effects, particularly since the percentage of subjects receiving antidepressants was balanced across study groups. However, this was not a specific objective of this study, and it bears further consideration in future studies.

Our results show that female sex was the predominant in the three groups. This is in keeping with common observations in clinical practice and with prevalence studies worldwide (28–30). Although one of our inclusion criteria was a formal diagnosis of clinical depression by the treating practitioner, only 66.2% of subjects at baseline met the CDI threshold for depression. This may be a reflection of the self-report nature of the CDI, with a greater tendency in adolescents to minimize or normalize symptoms of depression. There was also a tendency for females to report more symptoms of depression. Salk et al. have reported similar findings, and have shown that the difference in reported symptoms of depression between sexes is greatest in adolescence and up to 20 years old (30). This has been attributed mainly to cultural influences related with the tendency to associate symptoms of depression with female stereotypes, although differences in the timing of hormonal peaks in puberty may also be at play (28, 30). The stigma towards seeking mental health services may be also disproportionately affecting males, which may lead to a greater impact in their mental health and risk taking (31, 32).

Although females seek care earlier than males, levels of EDys as measured by the DERS scale are compatible with severe dysregulation in the majority of subjects in all three groups. This shows that patients are accessing specialized health services when dysregulation is high and when problematic behaviors have increased in both their frequency and severity (33). However, it is worth noting that the frequency of symptoms of eating disorders and problematic alcohol use were below that expected for a group with such severe dysregulation. Adolescents were frequently interviewed with their parents present which may have led to an underestimation of the frequency of these behaviors. Similarly, the frequency of sexual abuse was below expectations given its known association with symptoms of depression and risky behaviors (34). It is well known that revealing early traumatic events may take time and requires a solid therapeutic alliance, which may have led to underreporting in this study.

Although we did observe an impact on EDys of DBT-A skills training, it is possible that the impact of standard DBT-A (with its 4 classic components) would have been far greater. Although DBT-A therapy would be the ideal treatment, the group format may be a reasonable alternative given the limitations of the Colombian healthcare system, which are frequent in many other countries. This therapy offers an excellent and safe alternative for EDys treatment in adolescents in these limited settings. It is worth noting that there were no deaths during the study period and that there was no increase in psychiatric illness-related hospitalizations.

The finding of an effect of age on depressive symptoms may be due to the fact that at an earlier age emotional coping strategies, interpersonal skills and personality traits are still undergoing development. The effects of therapy may be facilitated by the presence of neuronal plasticity, leading to lifelong changes (35, 36). A second finding worth reviewing is the greater effect with increasing sessions attendance. This may be a reflection of a dose-response effect, and it shows that it is important for subjects to attend to the greatest number of sessions possible so that they may leverage the strategies reviewed in prior modules. Issues with attendance are commonplace in psychotherapeutic interventions, and adherence in this study was not below that expected for this kind of therapy. It is interesting that attendance improved during the COVID-19 pandemic, which demanded that the sessions took place online. The specific challenges encountered in delivering therapy in this manner will be addressed in an upcoming publication.

This study’s primary limitation is in its design, which is not optimal in the determination of effectiveness. However, the same economic factors that led to us delivering DBT-A skills therapy in a group format made a clinical trial unfeasible. Availability of therapy groups was seldom parallel and patients had to be assigned to whichever therapy groups were available at the time of recruitment, making randomization impossible. The follow-up was also brief, and we have no information regarding the persistence of treatment effects in time, if any. It should be clear that all analyses are per protocol, and that no intention to treat analyses were carried out. This distinction is made all the more important by the high attrition rate, much higher than what was expected during study design. The effects of delivering the intervention online could not be fully ascertained since we lacked the statistical power for this secondary analysis. Future studies could compare outcomes related with online interventions vs. in-person ones.

This cohort study showed that the implementation of DBT-A skills training in groups, in either a separate or multifamily format, was both effective and safe for emotional dysregulation treatment, and that it may be a particularly attractive option in resource-limited settings. DBT-A skills training delivered in a multifamily format may have the added benefit of impacting symptoms of depression. Further studies should be carried out to verify these results in other settings and using clinical trial designs.

CDI: Children’s Depression Inventory.

DBT: Dialectic behavioral therapy.

DBT-A: Dialectic behavioral therapy adapted for use in adolescents.

DERS: Difficulties in Emotion Regulation Scale.

EDys: Emotional Dysregulation.

SSRI: Selective Serotonin Reuptake Inhibitors.

SNRI: Selective Norepinephrine Reuptake Inhibitors

Ethics approval and consent to participate.

This study followed the guidelines of the Colombian Ministry of Health resolution 8430 of 1993, as well as the World Medical Association’s Declaration of Helsinki in its 2013 version, and the Council for International Organizations of Medical Sciences’ International Ethical Guidelines for Health-related Research Involving Humans.

All caregivers signed informed consent forms covering the participation of themselves in the study. Also, informed consent has been obtained from a parent and/or legal guardian for the adolescent's participation in the study, and the included adolescents signed informed assent forms. The protocol for this study was approved by the Research Ethics Committee of the Fundación Universitaria Sanitas (CEIFUS 348-19).

Consent for publication

Not applicable

Availability of data and materials

The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author. The raw data supporting the conclusions of this article will be made available by the corresponding author only if this request is approved by the Research Ethics Committee of Fundación Universitaria Sanitas, Bogotá D.C., Colombia, according to the current regulation of patient protection in Colombia.

Competing interests

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding

Research reported in this article was supported by the National Program of Science, Technology and Innovation in Health of the Ministry of Science and Technology of the Republic of Colombia under award number 844-2019 of the Pact to Generate New Knowledge (Registration Code: 67644).

Authors' contributions

Dr. Catalina Ayala-Corredor had the original idea, conception and design of the protocol, supervised data collection and contributed to the writing of the manuscript. Dr. Diana Lorena Clavijo-Bocanegra participated in the data collection for the study and contributed to the writing of the manuscript. Dr. María Alejandra Palacios-Ariza was responsible for protocol execution, data curation, preliminary descriptive data analysis and writing of the manuscript. Psy.D. Luisa Forero-Quintana participated in the data collection for the study and contributed to the writing of the manuscript. Dr. Juliana Vanessa Rincón-López and Psy.D. Andrea Niño supervised the design and execution of the study and contributed to the writing of the manuscript. Eng. Sara Yinneth Villalba-Niño performed the final data analyses and contributed to the writing of the manuscript.

Acknowledgements

The authors would like to thank doctors Abel González and César Gómez for their contributions to study design. Additionally, we would like to thank Dr. Ivan Pradilla for his suggestions during the drafting of the final manuscript.

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No competing interests reported.

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Effectiveness of Dialectic Behavioral Therapy in Adolescents (DBT-A) in the treatment of depression and emotional dysregulation: A Colombian prospective cohort study

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Background

Methods

Study Design

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Participants

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Results

Changes in the DERS and CDI scale scores after DBT skills training

Linear regression models for change in DERS and CDI scores

Longitudinal evaluation before and after treatment on, anxiety, problematic behaviors and other outcomes

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