Public health officials, clinicians, and researchers often discuss scaling up psychological interventions to reach a broader group. This usually entails providing low-intensity and low-cost interventions to the affected population to prevent the worsening of symptoms and reduce hospital admissions. The assumption is that one can take a psychological intervention, provide it at a low cost to many people and reduce the risk of a negative mental health outcome in the population. One of those outcomes is suicide and self-harm among people who have received mental health care. An intervention that has been tested to reduce suicide or self-harm is dialectical behavior therapy (DBT). In this large randomized controlled trial, Simon and colleagues recruited almost 19,000 patients reporting frequent suicidal ideation from health maintenance organizations in the United States. The patients were randomly assigned to receive usual care (mental health or general medical services ordinarily available), care management (usual care plus messages from care managers to enhance motivation and to help navigate outpatient care), or online DBT skills (usual care plus an interactive online program supported by a skills coach). The online DBT program included instruction on DBT skills like mindfulness, mindfulness of current emotions, opposite action, and pacing breathing. While 39% of patients accepted the invitation to join the online DBT program, only 2% remained engaged 9 months later. Regarding primary outcomes, 3.1% of those receiving usual care had a negative outcome (suicide or self-harm), 3.27% of those receiving care management had a negative outcome, and 3.92% of those receiving DBT had a negative outcome. A planned comparison of the DBT skills training and usual care groups found a significantly higher risk of self-harm in the skills DBT training group (hazard ratio, 1.29; 97.5% CI, 1.02-1.64; P = .015).
Practice Implications
This study suggests that there could be unintended negative consequences of providing low-intensity and low-cost versions of psychological interventions like DBT. Only 2% of patients stayed with the online DBT program after 9 months, and the program resulted in worse outcomes compared to usual care. Patients who are suffering from depression and are at risk of self-harm or suicide may need the human connection found in most psychotherapy encounters. This study suggests that offering them an online program with minimal contact could further alienate a group that needs more, not less, connections with others.
Simon, G. E., Shortreed, S. M., Rossom, R. C., Beck, A., Clarke, G. N., Whiteside, U., Richards, J. E., Penfold, R. B., Boggs, J. M., & Smith, J. (2022). Effect of offering care management or online dialectical behavior therapy skills training vs usual care on self-harm among adult outpatients with suicidal ideation: A randomized clinical trial. JAMA: Journal of the American Medical Association, 327(7), 630–638. https://doi.org/10.1001/jama.2022.0423