Among young people under age 18 who are diagnosed with disorders on the bipolar spectrum (BD), as many as one in two attempts suicide. Of all psychiatric diagnoses in this age group, BD is associated with the highest risk of suicide death, psychological autopsy-based research has indicated.

Bipolar disorder beginning before 18 is considered “early-onset” by psychiatrists who specialize in treating it—most often with a combination of drug therapy (e.g., mood stabilizers) and talk therapy. “Several psychosocial interventions have demonstrated efficacy” for stabilizing mood and lowering the rate of recurrence,” note a team of researchers at the University of Pittsburgh School of Medicine. “Yet to our knowledge, no treatment expressly targets suicidal behavior in this patient population.”

To make the situation even more frustrating for those trying to address this problem in young BD patients, clinical trials that have been effective in lowering suicidal ideation and behavior in adolescents across psychiatric diagnoses have, for a variety of reasons, often specifically excluded youth with BD from participating.

These were among the chief motivations for the Pittsburgh team, who recently reported results of a clinical trial testing a specific form of psychotherapy, dialectical behavior therapy (DBT), in young people diagnosed with bipolar spectrum disorders. DBT is an evidence-based psychosocial treatment that was developed for adults with borderline personality disorder (BPD). DBT has been shown to reduce suicidal behavior in BPD patients, but also, more broadly, in reducing suicidal ideation, self-harm, and suicide attempts in suicidal youths who don’t have BPD—although not, to date, including those with bipolar diagnoses, who have been largely excluded from prior trials.

The new Pittsburgh trial, led by Tina R. Goldstein Ph.D., was reported in JAMA Psychiatry. The team’s senior member was Boris Birmaher, M.D., winner of BBRF’s Ruane Prize for outstanding child and adolescent psychiatric research in 2022 and the BBRF Colvin Prize for outstanding mood disorders research in 2013. Three other BBRF grantees were members of the team.

One hundred young people took part in the randomized clinical trial. All had BD diagnoses—14 with Bipolar type I, 28 with Bipolar type II and 58 with unspecified Bipolar Disorder. Bipolar disorder type I involves more pronounced manic episode(s), while in bipolar disorder type II, elevated periods are called hypomania. Forty-seven participants were randomly assigned to receive 1 year of DBT sessions (DBT therapy included a number of “family skills training” sessions involving at least one family member of the participants as well as individual DBT therapy sessions); in the comparison group, 53 received “standard-of-care” psychotherapy delivered by clinicians experienced in treating youth with BD. Participants in both groups continued to receive drug therapies.

The average patient was White, female, and about 16 years old. Over 40% of participants had a history of psychiatric hospitalization; over 60% had a history of suicide attempt; the average age of BD onset was about 13; about three-fourths had a co-occurring anxiety disorder and over one-fourth had been diagnosed with comorbid ADHD. Both groups reported similar suicide attempt rates at the time they were recruited for the trial.

Analysis revealed that youths who received DBT had fewer suicide attempts over 1 year. Further, suicide attempts declined to a greater extent over time among those who received DBT compared with those receiving standard of care psychotherapy. This was particularly true among participants who had a recent or lifetime history of suicide attempt.

The study results also indicate that the decreased rate of suicide attempt in the DBT-treated group was a result of the degree to which the therapy helped reduce emotional dysregulation—particularly among those for whom emotional dysregulation was especially acute at the start of the trial.

DBT and standard psychotherapy were associated with similar amounts of improvement in depression and hypomania/mania over the 1-year period of the trial. Both therapies delivered in this trial were “more rigorous and intensive” than that received typically by young people when treated in the community, the team said.

Importantly, though, standard of care psychotherapy was found to have “minimal impact on suicide risk,” the team noted. “To our knowledge, this is the only study to date to demonstrate a treatment effect on suicide attempts among adolescents with BD.”

“Data provide particularly strong support for DBT among adolescents with BD with a history of suicide attempt. Yet for up to 60% of individuals, their first suicide attempt is lethal, and for those who survive, risk of death increases with each successive attempt.” For this reason, the team stressed, it remains very important for future research to enhance the ability to predict first attempts among youths with BD.

The team suggested that their findings offered additional empirical support for the theory that DBT exerts its beneficial effects in reducing suicidality by helping patients manage emotional dysregulation.

 

The researchers noted that DBT needs to be tested in a much more diverse patient population, and in settings that reflect more accurately conditions actually encountered in clinics across the nation by most patients.

The team also included: Peter Franzen, Ph.D., 2016 BBRF Independent Investigator; Dara Sakolsky, M.D., Ph.D., 2008 BBRF Young Investigator; and Danella M. Hafeman, M.D., Ph.D., 2019 BBRF Young Investigator.