Feasibility of Dialectical Behavior Therapy for Suicidal

Adolescent Inpatients
LAURENCE Y. KATZ, M.D., BRIAN J. COX, PH.D., SHINY GUNASEKARA, M.D., AND ALEC L. MILLER, PSY.D.

ABSTRACT
Objective: To evaluate the feasibility of dialectical behavior therapy (DBT) implementation in a general child and
adolescent psychiatric inpatient unit and to provide preliminary effectiveness data on DBT versus treatment as usual
(TAU). Method: Sixty-two adolescents with suicide attempts or suicidal ideation were admitted to one of two psychiatric
inpatient units. One unit used a DBT protocol and the other unit relied on TAU. Assessments of depressive symptoms,
suicidal ideation, hopelessness, parasuicidal behavior, hospitalizations, emergency room visits, and adherence to fol-
low-up recommendations were conducted before and after treatment and at 1-year follow-up for both groups. In addition,
behavioral incidents on the units were evaluated. Results: DBT significantly reduced behavioral incidents during ad-
mission when compared with TAU. Both groups demonstrated highly significant reductions in parasuicidal behavior,
depressive symptoms, and suicidal ideation at 1 year. Conclusions: DBT can be effectively implemented in acute-care
child and adolescent psychiatric inpatient units. The promising results from this pilot study suggest that further evaluation
of DBT for adolescent inpatients appears warranted. J. Am. Acad. Child Adolesc. Psychiatry, 2004;43(3):276–282. Key
Words: dialectical behavior therapy, suicide, adolescents, inpatients.

Suicide accounts for 23.8% of all deaths among 15- to
24-year-olds in Canada (Health Canada, 2002). It is
the third leading cause of death among adolescents in
the United States (National Center for Health Statis-
tics, 1996). Suicidal adolescents are known to make up
44% of adolescent psychiatric admissions (Goldston et
al., 1996), and up to 31% of suicidal adolescent inpa-
tients attempt suicide during the first year following
discharge from the hospital (Goldston et al., 1999;
Granboulan et al., 1995). Despite this serious mental
health concern, there is a paucity of data on the ef-
fectiveness of psychiatric hospitalization for suicidal
Accepted October 15, 2003.
Drs. Katz and Cox are with the Department of Psychiatry, University of
Manitoba, Winnipeg. Dr. Gunasekara is now with the Department of Psychia-
try, McMaster University, Hamilton, Ontario. Dr. Miller is with the Depart-
ment of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine,
Bronx, NY.
This research was supported by a grant from the Department of Research at
the Health Sciences Centre in Winnipeg awarded to the first author. The
authors thank Lorraine Cheyne for her efforts in gathering the 1-year follow-up
data.
Reprint requests to Dr. Katz, PZ-162, PsycHealth Centre, 771 Bannatyne
Avenue, Winnipeg, Manitoba, Canada R3E 3N4; e-mail: LKatz@exchange.
hsc.mb.ca.
0890-8567/04/4303–0276©2004 by the American Academy of Child
and Adolescent Psychiatry.
DOI: 10.1097/01.chi.0000106854.88132.4f
adolescents. Henggeler et al. (1999) conducted a ran-
domized study comparing the effectiveness of hospital-
ization to home-based multisystemic therapy for
adolescents recommended for admission to hospital;
however, this study included adolescents with varied
indications for hospitalization and did not provide data
on outcomes related to suicidality. Studies of symptom
change before and after treatment for suicidal adoles-
cent populations have not been conducted. Moreover,
studies evaluating specific treatment interventions dur-
ing psychiatric hospitalization for this population are
nonexistent. Suicidal behavior cuts across numerous
diagnostic categories and may benefit from treatment
that specifically targets suicidal behavior in addition to
treatment that is directed toward specific diagnoses.
Dialectical behavior therapy (DBT) is an empirically
supported treatment originally developed for chroni-
cally parasuicidal female outpatients diagnosed with
borderline personality disorder (BPD) (Linehan et al.,
1991). Parasuicide is defined as any acute, intentional
self-injurious behavior resulting in physical harm, with
or without intent to die. In Linehan’s (1993a) model,
patients with BPD have a biologically predisposed dif-
ficulty in regulating their emotions. These patients also
experience pervasive invalidation of their emotional,
cognitive, and behavioral experiences in their environ-

276 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:3, MARCH 2004


ments and develop maladaptive coping strategies (e.g.,
parasuicide) to regulate their emotions (Bezirganian et
al., 1993; Dubo et al., 1997; Linehan, 1993a). DBT is
a principle-based psychotherapy that attempts to
change these behaviors by balancing skills-enhancing
change strategies with validation (Linehan, 1993a,b).
In the first randomized controlled trial involving
outpatient parasuicidal adult women with BPD, DBT
significantly reduced inpatient psychiatric days, para-
suicide attempts, medical severity of parasuicide and
treatment dropouts compared to treatment as usual
(TAU) (Linehan et al., 1991). In a second randomized
controlled trial of female adult outpatient veterans with
BPD, Koons et al. (2001) found that DBT reduced
suicidal ideation, hopelessness, depression, and anger.
Initial empirical studies that attempted to modify DBT
for use on adult inpatient units (these modifications
included features not consistent with DBT principles)
produced equivocal results and raised questions about
the effectiveness of this treatment approach for inpa-
tients (Barley et al., 1993; Springer et al., 1996). Some
of these concerns include (1) potential negative rein-
forcement of parasuicidal behavior by removing the
patient from his or her environment (this removes the
patient from an aversive experience and potentially re-
inforces the parasuicidal behavior as the means to es-
cape the aversive experience), (2) the generalizability of
inpatient behavioral gains to the patient’s natural en-
vironment, (3) potential fostering of a contagion effect
of parasuicidal behavior on inpatient units, and (4) the
feasibility of condensing the standard 1-year DBT pro-
gram for a brief hospital stay. More recently, Bohus et
al. (2000) corrected some of the difficulties in previous
modifications of inpatient DBT in a pilot study of
parasuicidal adults with BPD and found that DBT led
to a reduction in parasuicidal behaviors, depression,
dissociation, anxiety, and global stress. In a quasiex-
perimental design, Rathus and Miller (2002) found
that DBT reduced psychiatric hospitalizations and im-
proved retention rates in outpatient therapy among
parasuicidal adolescent outpatients compared with
TAU. At the time of writing, we are unaware of any
studies evaluating DBT for suicidal adolescent inpa-
tients.
The aim of this study was to evaluate whether DBT
could be effectively implemented in a “real world” gen-
eral child and adolescent psychiatric inpatient unit by
examining a variety of clinical outcomes of suicidal
adolescent inpatients at a tertiary-care psychiatric hos-
pital. Pretreatment and posttreatment outcomes of sui-
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:3, MARCH 2004
DBT FOR SUICIDAL ADOLESCENTS
cidal adolescents from two separate inpatient units
using different treatment models were evaluated. Both
units are general child and adolescent psychiatric inpa-
tient units, from which only adolescents meeting study
criteria were recruited. One unit used a 2-week inpa-
tient adolescent DBT program modified from the 12-
week adolescent outpatient program (Miller et al.,
1997; Rathus and Miller, 2002). The other unit, called
TAU for research purposes, used a traditional, psycho-
dynamically oriented crisis assessment and treatment
model. Based on the results of studies of both inpatient
(e.g., Bohus et al., 2000) and outpatient adults (e.g.,
Linehan et al., 1991) and study of outpatient adoles-
cents (e.g., Rathus and Miller, 2002), we hypothesized
that DBT could be effectively implemented on a child
and adolescent inpatient unit for the treatment of sui-
cidal adolescents and would produce significantly su-
perior symptom change from the patient’s baseline
state compared to TAU. This study presents pretreat-
ment and posttreatment outcome data of these two
treatment models, as well as data on the 1-year follow-
up outcomes of these patients.
METHOD
Participants
This study was approved by the human ethical review committee
in the Faculty of Medicine at the University of Manitoba. Written
informed consent was obtained from the patients and their legal
guardians. The sample comprised 62 inpatients (10 boys, 52 girls)
aged 14 to 17 years (mean = 15.4) who were admitted to a psychi-
atric inpatient unit. Of the patients, 72.6% were white, 1.6% La-
tino, 0% African American, 4.8% Asian/Pacific Islander, 19.4%
First Nations Populations, and 1.6% other backgrounds. No de-
mographic differences were found between groups (age,
race/ethnicity, urban versus rural) at baseline. Selection of which of
the two units (DBT or TAU) the patient was admitted to was based
predominantly upon bed availability at the time of admission. In-
clusion criteria for the study consisted of the patient having been
admitted after having made a suicide attempt or having had suicidal
ideation severe enough to warrant admission as determined by a
child and adolescent psychiatrist. In addition, the adolescents
agreed to stay in the hospital for brief treatment. Patients were not
eligible for the study if they had mental retardation, psychosis,
bipolar affective disorder, or severe learning disabilities.
Sample size for each group (DBT and TAU) was calculated based
on a power analysis. Given the finding of large effect sizes in the
Bohus et al., (2000) study, with a p value of <.05 each group would
need to have 26 members for 80% power. Thus, given estimated
attrition rates over 1 year, at least 30 members were recruited per
group to allow for an adequate final sample to evaluate treatment
effectiveness within the groups across time. One-year follow-up
data were available on 26 DBT patients (83% of those initially
enrolled) and 27 TAU patients (90% of those initially enrolled).
Thus there were nine patients who did not complete the 1-year
follow-up (six DBT patients, three TAU patients). Eight patients
277
KATZ ET AL.
could not be located and one patient developed bipolar disorder
during the year and was not included in the study. There were no
differences on any measure between those who did not complete
the study and the final sample.
Assessments
Pretreatment and posttreatment assessment involved a battery of
self-report measures targeting suicide risk factors. In addition, the
number of incident reports filed by nursing staff during the admis-
sion was evaluated. Incident reports are mandated reports com-
pleted by hospital staff of clinically significant events on the units
(e.g., these would commonly involve violence toward self or others).
The self-report measures consisted of the 13-item Beck Depression
Inventory (BDI) (Beck and Beck, 1972; Beck et al., 1961), the
Kazdin Hopelessness Scale for Children (KHS) (Kazdin et al.,
1986), and the Reynolds’ Suicidal Ideation Questionnaire-Jr. (SIQ)
(Reynolds, 1988). Subjects completed these measures at admission
and at discharge. Following completion of the study, the number of
incident reports filed by the nursing staff was calculated for both the
DBT and the TAU groups.
After 1 year, hospital charts were reviewed for every participant.
Participants were then followed up through direct telephone con-
tact with the participant. In addition, at the 1-year telephone fol-
low-up, parent(s) provided information on emergency room visits,
hospitalizations, and known parasuicidal behavior in an attempt to
corroborate the patient and hospital chart reports (this also ensured
that we captured any service utilization outside the province). The
1-year assessment used the following outcome measures: (1) BDI
and SIQ scores at the end of 1 year; (2) number of parasuicidal
behaviors in the year following discharge from hospital as measured
by the Lifetime Parasuicide Count (LPC) (Linehan et al., unpub-
lished instrument, 1997); (3) emergency room visits secondary to
parasuicidal behavior or ideation; (4) number of psychiatric read-
missions to hospital; and (5) adherence to the recommended treat-
ment (medication and/or psychotherapy) in the year following
discharge. In preparation for the 1-year follow-up component of
the study, patients were administered the LPC at admission. A
1-year version of the LPC was used to record parasuicidal behaviors
in the year prior to admission and was then administered again at
the 1-year follow-up. The LPC is an interview-based measure for
recording self-reported parasuicidal behaviors and their medical se-
verity. In addition to information provided by the patients regard-
ing parasuicide, to increase the validity of the assessment we
included objective measures such as emergency room visits and
hospitalizations. Patients in the province of Manitoba, Canada,
younger than 18 who require psychiatric admission must be ad-
mitted to one of these two units, and this process ensured that the
chart review accurately captured readmission rates. In addition, as
described above, the telephone contact asked about emergency visits
to other facilities.
Clinical Procedures
The adolescent inpatient DBT program evaluated in this study
was adapted from the adolescent DBT model developed by Miller
et al. (1997). Several important modifications have been made to
the program, and these have been described in detail in a program
description (Katz et al., 2002) and in a clinical case report (Katz and
Cox, 2002). In this study, the DBT program ran for 2 weeks and
comprised 10 daily, manualized DBT skills training sessions (Line-
han, 1993b; Miller et al., 1997; skills training handouts are avail-
able from the first author). Patients in the DBT program also were
seen twice per week for individual DBT psychotherapy to review
diary cards and conduct behavioral and solution analyses. Finally,
278
the patients participated in a DBT milieu (with DBT-trained nurs-
ing staff) to facilitate skills generalization. The psychiatrist provid-
ing the DBT treatment was a Canadian board-certified psychiatrist
with 2 years of prior adolescent DBT training and supervision by an
intensively trained DBT therapist. The primary DBT treatment
team consisting of the staff psychiatrist and the full-time nursing
staff met regularly for DBT consultation meetings (a critical mo-
dality of DBT designed to increase adherence to the treatment
model and to increase staff motivation to treat this difficult popu-
lation). In addition, a DBT consultant was brought in during the
study to evaluate the treatment program.
TAU consisted of a daily psychodynamic psychotherapy group,
individual psychodynamic psychotherapy at least once per week,
and a psychodynamically oriented milieu. Although some aspects of
contingency management are inherent to most inpatient unit mi-
lieus, no formal behavior therapy was used. The psychiatrist pro-
viding the TAU was a Canadian board-certified psychiatrist with 2
years of training in adolescent psychodynamic psychiatry and 9
years of experience attending to the inpatient ward. The TAU team
met regularly for meetings to discuss ward management issues.
Ancillary treatment (e.g., pharmacotherapy) was provided to
both groups on an as-needed basis. Staff on the two wards did not
differ in terms of years of experience or level of training. Family
assessments were conducted on both wards by staff social workers,
and brief crisis intervention and psychoeducation for families was
used (this did not differ between the two wards). Patients dis-
charged from either of the two units were discharged to commu-
nity-based, outpatient mental health systems. This provided
naturalistic 1-year follow-up.
Data Analyses
Pretreatment to posttreatment effects were evaluated using 2 × 2
analyses of variance (ANOVAs) on the BDI, KHS, and SIQ. A
Student t test (two-tailed) was performed comparing the total num-
ber of incident reports per group. Due to concerns that there could
be nonspecific factors outside of the treatments on each of the
wards that influenced the number of incident reports, a post-hoc χ2
(two-sided) was conducted comparing the number of incident re-
ports during a 6-month period before DBT implementation and a
6-month period after DBT implementation on the DBT ward.
Because eight individuals were not available at the 1-year follow-
up analysis, additional 2 × 3 ANOVAs were conducted on the BDI
and SIQ (admission, discharge, and 1-year reports). Medication
and outpatient treatment adherence and rehospitalizations and
emergency room visits were evaluated using χ2 analyses (two-sided).
Pearson correlations (two-tailed) were calculated for adherence to
medication or outpatient treatment and change in BDI or SIQ
to control for effects of follow-up treatment on 1-year outcome.
Parasuicidal behaviors (LPC scores) were evaluated using 2 × 2
ANOVAs (year before treatment to year after treatment).
Effect size (Cohen’s d) provides a standardized measure of the
extent of an effect of a treatment. This allows for more direct
comparison among different studies. Cohen (1992) has suggested
that d values of 0.20, 0.50, and 0.80 represent small, medium, and
large effect sizes, respectively. Effect sizes (Cohen’s d; Cohen, 1988)
were calculated for the measures with continuous scores (BDI, SIQ,
KHS, and LPC).
RESULTS
In-Hospital Outcomes
The mean length of stay in hospital was 18 days (this
was the same in both groups). Table 1 presents mean
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:3, MARCH 2004
 DBT FOR SUICIDAL ADOLESCENTS

TABLE 1
Mean Scores (and Standard Deviations) at Admission, Discharge, and One-Year Follow-up
Admission Discharge One-Year Effect Size
BDI-13
DBT 20.61 (7.67) 12.97 (8.70) 8.23 (7.16) 1.67
TAU 16.97 (9.18) 12.69 (7.29) 8.07 (7.74) 1.05
SIQ
DBT 52.71 (19.38) 40.90 (24.73) 18.15 (12.52) 2.12
TAU 47.67 (23.51) 37.97 (24.56) 19.35 (17.89) 1.36
KHSa
DBT 9.13 (4.50) 5.87 (4.41) 0.73
TAU 8.27 (5.01) 6.55 (5.34) 0.33
LPC (after log transformation)
DBT 2.26 (1.48) 1.11 (1.22) 0.63
TAU 1.99 (1.40) 0.87 (1.05) 0.73
Note: DBT = dialectical behavior therapy; TAU = treatment as usual; BDI-13 = 13-item Beck Depression Inventory;
SIQ = Suicidal Ideation Questionnaire; KHS = Kazdin Hopelessness Scale for Children; LPC = Lifetime Parasuicide Count.
a
KHS was conducted only at admission and at discharge.

scores on the main outcome measures before and af- of these measures. In addition, Pearson correlations
ter treatment. Results of 2 × 2 repeated-measures were calculated for any possible effect of outpatient
ANOVAs indicated a significant main effect for time pharmacotherapy or outpatient psychosocial treat-
on the BDI (F1,58 = 43.51, p < .001), KHS (F1,58 = ments on the 1-year outcomes on the BDI or SIQ. The
18.37, p < .001), and SIQ (F1,58 = 19.41, p < .001). correlation for pharmacotherapy was not significant on
Both groups showed substantial symptomatic improve- the BDI (r = 0.06, NS) or the SIQ (r = −0.06, NS). In
ment at discharge. There were neither group × time addition, the correlation for psychosocial treatment was
interaction effects nor any between-group differences not significant on the BDI (r = −0.09, NS) or the SIQ
on these measures, indicating that there was no differ- (r = 0.12, NS).
ence between the groups at discharge on any of the Due to a low base rate of rehospitalizations and
measures. emergency room visits, statistical analyses did not de-
With regard to the number of incident reports, DBT tect differences between the groups. However, the ab-
patients had significantly fewer incidents on the ward solute numbers are presented in Table 2. Finally, with
than the TAU group (t1,59 = 1.98, p = .052; Table 2). regard to adherence to follow-up treatment in the year
A significant difference was found in the χ2 that com- following discharge, χ2 analyses were performed re-
pared the 6-month period before DBT implementation
to the 6- month period after DBT implementation on
the DBT ward (χ2 = 43.11, p < .001). DBT had a TABLE 2
100% retention rate for treatment. Objective Outcomes of DBT and TAU Groups
DBT TAU Significance
One-Year Follow-up
Total hospitalizations per group
There were no completed suicides in either group. Year before admission 6 2 NS
Results of 2 × 3 repeated-measures ANOVAs showed a Year after discharge 6 6 NS
continued main effect for time on the BDI (F2,50 = Total ER visits per group
40.26, p < .001) and SIQ (F2,49 = 50.63, p < .001). Year before admission 6 3 NS
The results of the LPC demonstrated a skewed profile Year after discharge 8 14 NS
Total incidents per group in
requiring a log transformation to be performed before hospital 2 10 p = .052
further analysis. Results of a 2 × 2 repeated-measures
ANOVA after the log transformation showed a con- Note: Sample size (n = 53) for total hospitalizations and ER visits
per group consists of patients with 1-year follow-up data available.
tinued main effect for time on the LPC (F1,49 = 30.50,
Sample size (n) for the total incidents per group is equal to the
p < .001). Means and effect sizes for both groups from initial sample (n = 62) minus one patient dropped from the study
admission to 1-year follow-up are presented in Table 1. due to onset of bipolar disorder. NS = not significant; DBT =
There were no group × time interaction effects on any dialectical behavior therapy; TAU = treatment as usual.

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:3, MARCH 2004 279

KATZ ET AL.
garding adherence to medications and psychosocial
treatments (Table 3). There were no statistically sig-
nificant differences between the groups in their adher-
ence to follow-up.
DISCUSSION
The present study is the first to evaluate implemen-
tation and 1-year outcome of suicidal adolescent inpa-
tients treated with DBT compared to TAU. A number
of interesting findings were observed.
Behavior on the ward appeared to vary depending on
which treatment was provided. DBT led to a signifi-
cant reduction in behavioral problems on the ward
compared to TAU. The reduction in incidents was
further supported by the finding of a significant reduc-
tion in the number of incidents on the DBT ward since
the implementation of DBT. Thus there appears to be
something about DBT that led to this change and not
something related to non-DBT ward phenomena.
What aspect of DBT led to this change cannot be
determined from this study, but it may be nonspecific
factors directly targeted by DBT such as increased staff
motivation and compassion for these patients, or per-
haps a specific factor such as staff trained in specific
behavior therapy and validation principles for parasui-
cidal patients. The reduction in behavioral incidents is
consistent with other studies of DBT in which DBT
has been shown to improve outcomes on targeted be-
haviors such as parasuicide, binge eating, and substance
abuse (e.g., Koons et al., 2001; Linehan et al., 1991,
2002; Telch et al., 2001). The reduction in incidents
may also lead to reduced costs for the consequences of
behavioral incidents (e.g., injury time for staff, repair
costs to property) and possibly greater staff satisfaction,
both of which are important to managing inpatient
facilities.
Psychiatric inpatient hospitalization of suicidal ado-
lescents using intensive, focused, short-term treatment
led to significant symptom reduction over a 1-year pe-
riod after hospitalization regardless of type of treat-
TABLE 3
DBT and TAU Outcomes on Adherence to Pharmacotherapy and Psychosocial Treatment Recommendations
DBT (n = 26)
Prescribed Adhered
Medications 20 12
Psychosocial treatment 25 16
Note: DBT = dialectical behavior therapy; TAU = treatment as usual; NS = not significant.
280
ment. The symptom reduction began in the hospital
and continued after discharge. Interestingly, this was
not affected by adherence to either outpatient pharma-
cotherapy or outpatient mental health referrals. Large
effect sizes were seen in both groups on measures of
depression and suicidal ideation. This suggests that
brief inpatient treatment may be a more powerful treat-
ment intervention than previously recognized. In the
current study with the sample sizes described above,
there was not a statistically significant difference be-
tween DBT and TAU on the BDI, SIQ, or KHS.
However, there was an absolute difference in the effect
sizes between the DBT and TAU groups on the BDI
(1.67 − 1.05 = 0.62), SIQ (2.12 − 1.36 = 0.76), and
KHS (0.73 − 0.33 = 0.4) (Table 1). This finding sug-
gests that a larger study of inpatient DBT is warranted,
as with a larger sample size a statistically significant
difference between these two active, effective treat-
ments may be detected. The effect sizes seen are con-
sistent with a study of inpatient DBT for adults with
BPD (Bohus et al., 2000), where the effect size for
depressive symptoms was similar to the current study.
Furthermore, reductions in depression and suicidal ide-
ation were found among suicidal adolescents receiving
outpatient DBT (Rathus and Miller, 2002), suggesting
that DBT consistently reduces depression and suicidal
ideation. In addition, given the current emphasis on
reduction of inpatient services for all psychiatric popu-
lations, further study is warranted of the possible ben-
efits to suicidal adolescents of inpatient, intensive,
short-term treatment. There are no other studies of
inpatient treatment of this kind for adolescents with
which to compare these results.
Both groups demonstrated a significant reduction in
the absolute number of parasuicidal behaviors in the
year after discharge. This study found a medium effect
size for inpatient treatment on future parasuicidal be-
havior. Previous studies published in the literature have
focused on suicide attempts after discharge and not on
the broader concept of parasuicide, making it difficult
to draw comparisons. The literature on outcomes in
TAU (n = 27)
Prescribed Adhered χ2 Significance
15 8 0.36 NS
27 11 2.81 .09
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:3, MARCH 2004

suicidal adolescents after hospitalization suggests that
many adolescents go on to attempt suicide after dis-
charge (Brent et al., 1993; Goldston et al., 1999). As
much as is possible given the different outcome mea-
sure, our findings are consistent with this literature, as
many of our patients did engage in parasuicidal behav-
ior. However, there is also an important difference.
Previous studies have evaluated whether patients en-
gage in further attempts but often have not delineated
the extent of change among the group compared to the
year before hospitalization. It is also difficult to com-
pare our results with previous studies, as they do not
delineate the nature of treatment that occurred while in
the hospital. Thus, our finding of significant improve-
ment in parasuicidal behaviors after hospitalization
stands in contrast to the more ominous findings of
previous studies.
Finally, DBT appears to engage patients in treat-
ment and retain them. This has been shown in outpa-
tient studies of adults and adolescents (Linehan et al.,
1991, 1999; Rathus and Miller, 2002) and is also
found here, as indicated by the finding that all patients
who entered DBT completed the inpatient treatment
(i.e., there were no treatment dropouts in the experi-
mental treatment). To add to this finding, at the time
of writing, the unit has had approximately 115 patients
enter the DBT program, and only 3 patients have not
completed the program. Furthermore, at the time of
writing, no patient has prematurely left a skills training
group session.
Thus this study addresses the four concerns identi-
fied in the introduction regarding the implementation
of DBT on inpatient wards. First, DBT does not ap-
pear to negatively reinforce parasuicidal behavior by
removing the patient from his or her environment, as
we found a reduction in parasuicide in the year follow-
ing hospitalization (this improvement occurred in both
groups, suggesting that brief hospitalization does not
negatively reinforce parasuicide in adolescents). Sec-
ond, given the continued improvement in patient func-
tioning after discharge in both groups, inpatient gains
appear to generalize to the natural environment (how-
ever, this could represent a regression to the mean and
not generalization of the treatment and thus will re-
quire further study). Third, DBT does not foster a
contagion effect on inpatient wards; in fact, we found
a reduction in behavioral incidents on the ward (this
finding was specific to DBT). Finally, it is feasible to
conduct an abbreviated DBT program on an adolescent
inpatient unit and to engage patients in this program.
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:3, MARCH 2004
DBT FOR SUICIDAL ADOLESCENTS
Limitations
The conclusions of this pilot study should be inter-
preted in the context of several methodological limita-
tions. The relatively small sample size in this study
requires that the therapeutic gains made in this study
be viewed as preliminary and requires replication.
The assessments in this study were not blinded. Due
to the suicidal acuity of this population, a decision was
made to have follow-up assessments done by an expe-
rienced nurse with access to the clinical resources to
manage a crisis if it occurred. The nurse who was able
to meet these criteria could not be blind to the study
due to her clinical position in the facility.
The patients were not randomized to the treatment
groups. This was because the wards on which the study
took place serve the emergency room and, as such, bed
availability had to determine location of admission of
patients, and true randomization was not possible.
However, the patients were admitted predominantly
based on bed availability and not the type of treatment
that could be provided.
Adherence ratings to DBT were not used. This pilot
study set out to test the feasibility of implementing
DBT on an acute care adolescent inpatient ward. It was
not clear how to test adherence to DBT in such a
modification of the treatment. It is now clear that it can
be implemented in a modified form, and future studies
would benefit from using adherence ratings to ensure
that DBT is being appropriately implemented both in
individual therapy and in skills training.
The generalizability of this study to many areas of
the United States is limited by the absence of African
American and Latino populations (for information on
the use of DBT with these populations in an outpatient
context, see Rathus and Miller, 2002). In addition, the
use of psychodynamically informed treatments and an
average length of stay of 18 days in an acute-care fa-
cility in the United States would be unusual.
Although use of pharmacotherapy was monitored
during the 1-year follow-up, it was not monitored
during the hospitalization. Both units used pharmaco-
therapy on an as-needed basis during the hospitaliza-
tion. Neither unit had any theoretical prohibition to
the use of prn medications; however, both units’ nurs-
ing staff are trained in deescalation procedures to avoid
the use of either chemical or physical restraints.
Finally, this study applied DBT to a more hetero-
geneous population than has been previously studied.
BPD was not a criterion for inclusion in the study. This
may have reduced the likelihood of finding differences
281
KATZ ET AL.
between DBT and TAU. However, this study provides
support for a broader application of DBT in suicidal
adolescent inpatients. In addition, many of the out-
come variables examined are phenomena with a low
base rate and will require larger sample sizes to ulti-
mately detect differences among treatments.
Recommendations for replication thus include larger
sample size, randomization, blinded assessments, and
adherence ratings of DBT therapists.
Clinical Implications
This was a study on the feasibility of implementing
and evaluating DBT for suicidal adolescent inpatients.
Thus implications are more oriented toward future re-
search efforts than large-scale implementation. Despite
the current climate regarding inpatient psychiatric hos-
pitalization, short-term hospitalization of acutely sui-
cidal adolescents for focused treatment appears to be
beneficial. One such treatment is DBT, a principle-
based, short-term treatment that can be taught and
implemented on inpatient units. Implementation on this
ward required a psychiatrist trained in DBT to import
this treatment onto the unit and to train the rest of the
team, who were completely unfamiliar with this treat-
ment model. The staff received training by the first and
fourth authors and the unit began implementation of
this treatment with ongoing supervision and consulta-
tion by the staff psychiatrist. Training in DBT is avail-
able. The potential benefits of engaging an inpatient
team in such an endeavor are delineated in this study.
There are also broader service delivery implications
from this study. The reduction in behavioral incidents
on the DBT ward suggests implications for staff safety,
staff morale, and ward expenditures for the conse-
quences of patient behaviors. In summary, the prom-
ising but preliminary results from this investigation
suggest that further efforts to evaluate DBT modified
for suicidal adolescent inpatients appear warranted.
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