Suicide is the fourth leading cause of death, with rates rising during adolescence. In the United States, suicide deaths rose among 15-24-year-olds and more than doubled among 10-14-year-olds from 2008 to 2018, with one in six reporting suicidal ideation (SI) annually. Weight stigma (WS), both experienced and internalized, is a significant suicide risk factor. WS fosters shame, self-doubt, and reduced body trust, or feeling unsafe in one's body-all of which are linked to SI. This study tested whether body trust mediated the relation between WS and SI among Iranian adolescents. Participants (N = 1243) completed online measures at three timepoints (baseline, 1-month, 3 months). Cross-lagged panel models were tested in MPlus to examine relations between constructs. Higher internalized WS predicted lower body trust at 1-month follow-up, but body trust at 1-month follow-up did not significantly predict SI at 3-month follow-up. Experienced WS and SI demonstrated reciprocal relations such that experienced WS and SI at baseline predicted one another at 1-month follow-up. Higher body trust at baseline predicted lower experienced WS, Internalized WS, and SI at 3-month follow-up, as well as lower internalized WS at 1-month follow-up. WS was not indirectly associated with SI through low body trust. These findings show independent links between WS, body trust, and SI, underscoring the need for targeted interventions. Clinicians should assess and address these factors in adolescents at risk. Approaches that challenge weight-biased beliefs and build body trust, such as mindfulness or acceptance-based strategies, may reduce distress.
OBJECTIVE:Social connection predicts health, but remains largely underexplored as an outcome of psychotherapy. A friendly relationship to oneself is linked to positive relationships to others, but it is not clear how they influence each other across time during and after treatment. This study evaluates change in a measure of social connection and support, the Quantity and Quality of Social Relations (QQSR), and investigates its longitudinal associations with the Structural Analysis of Social Behavior Introject self-affiliation. METHODS:370 adult outpatients in Norway with various presenting problems were assessed before and after open-ended psychotherapy, with up to 2.5 years follow-up. We fitted latent growth curves and structured residual models. RESULTS:There was significant growth in QQSR across long-term follow-up, particularly in support and non-family relationships. There was no change from pre- to posttreatment, and significant between-patient variation in both intercepts and growth rates. Improved QQSR after treatment predicted improved self-affiliation in the next follow-up, which in turn predicted improved QQSR. These effects were robust to detrending and controlling for pretreatment personality disorder. Pretreatment QQSR correlated with self-affiliation growth. CONCLUSION:On average over a long timespan, patients' social connection shows gradual positive growth, and reciprocal lagged associations with self-affiliation. The QQSR might measure relatively stable characteristics and between-patient differences relevant to self-affiliation change. Clinicians might screen for social and self-relationships throughout therapy, both as outcomes and resources.
OBJECTIVE:Eating disorders are associated with marked distress and impairment, including elevated risk for anxiety, depression, and suicidality. Bullying victimization is associated with eating disorder symptoms in late adolescence and young adulthood, when peer relationships and social evaluation are developmentally salient. Cognitive-affective processes, including self-esteem and repetitive negative thinking, may help explain this association; however, less is known about whether these constructs show unique indirect associations when examined simultaneously. METHODS:Self-esteem and repetitive negative thinking were examined as parallel statistical mediators of the association between bullying victimization and eating disorder symptoms in a large community sample of emerging and young adults aged 17-23 years (N = 2132). Participants completed validated self-report measures of bullying victimization, eating disorder symptoms, self-esteem, and repetitive negative thinking. RESULTS:Greater bullying victimization was associated with higher eating disorder symptoms, lower self-esteem, and greater repetitive negative thinking. In the parallel mediation model, both self-esteem and repetitive negative thinking showed significant indirect effects. The direct effect of bullying victimization remained significant, indicating partial mediation. The indirect effect through self-esteem was significantly larger than the indirect effect through repetitive negative thinking. CONCLUSION:These findings suggest that self-esteem and repetitive negative thinking are distinct cognitive-affective correlates of the association between bullying victimization and eating disorder symptoms in emerging and young adults. Although the indirect effect through self-esteem was larger, both processes may be clinically relevant. Findings highlight the potential value of assessing bullying-related distress, self-evaluative concerns, and repetitive negative thinking among individuals with elevated eating disorder symptoms.
BACKGROUND:The parental acceptance questionnaire (6-PAQ) is a user-friendly and contextually sensitive scale of psychological flexibility. OBJECTIVE:This research aimed to translate the original English version of the 6-PAQ into Chinese and to test its psychometric properties among Chinese parents of children with or without hearing loss (HL). METHODS:Two phases were conducted: (1) translation from English to Chinese (6-PAQ-C), followed by a semantic equivalence evaluation between two versions, a pre-test and face validity with 40 parents of children with or without HL, and content validity with 15 experts; (2) A cross-sectional study was conducted for providing empirical support among two samples: parents of children with (n = 204) or without (n = 336) HL. All participants were assessed for test-retest reliability over an 8-week interval. RESULTS:The 6-PAQ-C showed satisfactory semantic equivalence with the original version, excellent internal consistency, and good 8-week test-retest stability. Exploratory factor analysis and parallel analysis confirmed a six-factor structure consisting of 18 items. Confirmatory factor analysis supported both the original six-factor structure and a bifactor model (one general factor plus six specific factors), both demonstrating excellent fit. Bifactor indices indicated a strong general factor (omega = 0.95; omega hierarchical = 0.80; proportion of uncontaminated correlations = 0.88) and more modest independent specific-factor reliability (omega hierarchical subscale = 0.41-0.49; specific explained common variance = 0.08-0.10), supporting use of the total score as the primary metric and subscale scores as supplementary indicators. The scale also exhibited significant mean score differences between parents with high and low parenting stress in both samples and correlated with measures of psychological flexibility, symptomatology, and mental well-being. CONCLUSIONS:These findings suggest that the 6-PAQ-C is a reliable and valid instrument for measuring psychological flexibility among parents of children with or without HL. In practice, the total score should be treated as the primary scoring metric, whereas the six subscale scores may be used cautiously to describe ACT process profiles rather than as fully independent dimensions. Future research should test the 6-PAQ-C with diverse samples across cultures/contexts to improve its generalizability.
INTRODUCTION:Using the concept of games against nature from decision theory, this study explored whether the perceived utility of living and the perceived utility of dying were related to an individual's desire to live, desire to die, and suicidal ideation. METHODS:One hundred thirty-eight participants listed their perceived costs and benefits associated with living and dying and rated their importance. They also answered questions about their desire to live, desire to die, and suicidal ideation. We tested whether perceived utility (ratio of benefits to costs) of living and dying were associated with participants' desire to live, desire to die, and suicidal ideation at baseline and 1 week later. RESULTS:Cross-sectionally, benefits of living, costs of living, and benefits of dying were each associated with desire to live, desire to die, and suicidal ideation, and the perceived utility of living and dying interacted in relation to all three outcomes. At 1-week follow-up, the utility ratios and most of the associations found in the cross-sectional analyses were no longer significant after adjusting for baseline levels of each outcome; the exception was perceived costs of living, which predicted lower desire to live over and above baseline desire to live. CONCLUSION:Findings provide preliminary, primarily cross-sectional support for using the perceived utility framework as a lens for understanding suicidal ideation and point to perceived costs of living as a candidate target for future prospective and intervention research.
OBJECTIVES:Mindfulness is increasingly being implemented in child and adolescent therapy. However, little is known about its effectiveness in individual settings within a clinical outpatient context. We investigated the effects of session-introducing mindfulness interventions (IG-M) compared to session-introducing relaxation interventions (CG-R) and no standardized session-introduction (CG) on symptomatic outcome and therapeutic alliance in cognitive-behavioral therapy using a randomized controlled design. METHOD:One thousand four hundred and seventy-eight of 90 outpatient adolescents (11-19 years) diagnosed with depression, an anxiety disorder, or a hyperkinetic disorder were assessed. Symptomatic outcome was assessed by the German version of the Youth Self-Report 11-18R at five measurement time points (pre, 3rd, 10th, 17th therapy session, post), therapeutic alliance was assessed by the German version of the Therapeutic Alliance Scales for Children after every therapy session (1st-24th therapy session). Statistical analyses were conducted using multilevel modeling. The RCT was registered at ClinicalTrials.gov (NCT04034576). RESULTS:Multilevel modeling revealed a significant decrease of symptomatic outcome in IG-M compared to CG, but not compared to CG-R, over time. A significant increase in therapeutic alliance over time was observed from the therapists' perspective with no group differences. Therapeutic alliance from patients' perspective significantly increased in IG-M and significantly decreased in CG. There was no statistically meaningful change in therapeutic alliance from the patients' perspective in CG-R. CONCLUSION:IG-M had positive effects on symptomatic outcome and therapeutic alliance compared to CG, but did not outperform CG-R. Future studies that control confounding variables are highly relevant to understand the role of mindfulness in individual youth psychotherapy.
The longitudinal progression of depression and suicidal thoughts and behaviors among graduate students has emerged as a critical public health concern. This three-wave longitudinal study (N = 827) employed cross-lagged panel models as the primary analytic framework to examine the temporal ordering and prospective associations among depression, suicidal thoughts and behaviors, and multidimensional social support. Complementarily, latent growth curve models were utilized to delineate developmental trajectories and concurrent associations. The latent growth curve models revealed significant longitudinal increases in depression and suicidal thoughts and behaviors, alongside declining perceived social support. Primary cross-lagged panel models identified a reciprocal, self-reinforcing dynamic between depression and suicidal thoughts and behaviors over time. Furthermore, multidimensional social support exhibited robust lagged inverse associations with subsequent depression and suicidal thoughts and behaviors, as well as significant concurrent negative associations. These findings clarify the developmental context and temporal precedence of these constructs, suggesting that proactively reinforcing social support networks is a valuable strategy for addressing graduate student mental health.
OBJECTIVES:While some research suggests that increases in anxiety symptoms drive changes in insomnia and depression symptoms, other studies support that these relations may be bidirectional. The present study therefore aimed to further examine how anxiety, insomnia and depression symptoms predict changes in these symptoms over time. METHODS:Participants were recruited via an online participant database, social media advertisements, and other online sites, resulting in a large sample (N = 2,666) of adults from across the United States. Well validated instruments were used to measure symptoms of depression (CES-D), anxiety (STAI), and insomnia (ISI). Data were collected via a series of Qualtrics surveys administered online at two time points: March-June 2020 (baseline) and January-March 2021 (follow-up). RESULTS:Insomnia symptoms (β = 0.142, p < 0.001) but not anxiety symptoms (β = 0.019, p = 0.445) significantly predicted depression symptoms. Depression symptoms (β = 0.077, p = 0.001) but not anxiety symptoms (β = 0.039, p = 0.075) significantly predicted insomnia symptoms. Both insomnia (β = 0.060, p = 0.001) and depression symptoms (β = 0.281, p < 0.001) significantly predicted anxiety symptoms. Although multiple cross-lagged paths were statistically significant, effect sizes were generally small, and no single pathway was meaningfully stronger than others. Additionally, secondary exploratory mediation models revealed significant indirect effects between anxiety and depression through insomnia (model 1 indirect β = 0.027, p = 0.007; model 2 indirect β = 0.008, p = 0.036). CONCLUSIONS:Findings suggest that insomnia symptoms were prospectively associated with subsequent depressive and anxiety symptoms. Depression symptoms also predicted later anxiety symptoms, highlighting the complex longitudinal associations among these symptom domains. However, results did not support a temporal pathway in which anxiety precedes the development of comorbid insomnia. Future studies should assess temporal order more closely, using high density longitudinal sampling strategies (i.e., more than two data collection points) to further clarify the temporal ordering of these symptom domains.
OBJECTIVE:Psychological flexibility (PF; the ability to be fully present and open to experience and engage in values-based activities) and inflexibility (PI; the absence of this ability) may affect patients' emotional well-being after cancer treatment. However, understanding the impact of psychological (in)flexibility in the daily lives of cancer survivors remains limited. This study distinguished within- and between-person associations between PF and PI subprocesses and daily affect in hematopoietic cell transplantation (HCT) survivors. METHODS:Participants (N = 155; mean age 45.74 ± 12.38 years; 55.5% male; 100% Polish/White) completed daily assessments of PF subprocesses (present moment awareness, self as context, acceptance, defusion, values, committed actions), their PI counterparts, and affect (positive and negative) for 14 consecutive days after hospital discharge. Multilevel structural equation modeling was used to distinguish within- and between-person associations. RESULTS:For PF subprocesses, committed action and acceptance were associated with better affect at the within- and between-person levels, respectively. Contact with values was associated with better affect at both levels. Present-moment awareness coincided with worse emotional well-being, though this between-person association lacked robustness. The PI subprocesses of fusion, inaction, and lack of contact with the present moment demonstrated within-person associations with worse affect, though the latter two relationships were not robust. At the between-person level, fusion and lack of contact with values were associated with higher negative and lower positive affect, respectively. CONCLUSION:PF and PI subprocesses had diverse, level-specific correlates of emotional well-being in HCT survivors. These findings may help identify processes that merit further investigation as potential intervention targets.
INTRODUCTION:Previous studies based on the Monitoring and Acceptance Theory (MAT) failed to find differential effects of monitoring plus acceptance (MA) and monitoring only (MO) training on negative affect. This study aimed to investigate the differences between MA and MO from the perspective of mindfulness and emotional outcomes. METHODS:A total of 392 participants were randomly assigned to three groups (MA, MO, or Waiting-List [WL]). MA or MO participants received a 14-day online mindfulness training focused on monitoring and acceptance skills, or only monitoring skills, respectively. We used the Five Facet Mindfulness Questionnaire, the Positive and Negative Affect Scale, and the Emotional Reactivity Scale (ERS) assess the outcomes before the intervention (T1), after the intervention (T2), and at the 2-week follow up (T3). Linear mixed model (LMM) was conducted to explore the data based on intent-to-treat (ITT) and per-protocol (PP) analyses. RESULTS:Both the MA and MO groups demonstrated significant improvements in the total mindfulness score and positive affect compared to the WL group (p < 0.05). A significant Group × Time interaction was observed for ERS; however, post hoc tests revealed no significant between-group differences. Negative affect did not differ significantly across groups (p > 0.05). No significant differences between MA and MO were observed for any outcome (p > 0.05). DISCUSSION:This study demonstrated that MA and MO had equivalent effects on mindfulness and emotional outcomes following a 2-week online training program.
A single-case study is presented, which describes the application of EMDR for a justice involved health care worker, presenting with active suicidality and self-harm, within the context of high levels of offense-related shame. "Alex" was a 42-year-old female, serving a prison sentence for Theft. Prior to her offense, Alex was a nurse with an unblemished career. Her offending occurred as a result of her addiction to pain medication. Alex attended 20 treatment sessions, which followed the eight phases of EMDR therapy: (i) history taking; (ii) preparation; (iii) assessment; (iv) desensitization; (v) installation; (vi) body scan; (vii) closure; and (viii) evaluation. Eye Movement Desensitization and Reprocessing (EMDR) has a growing body of evidence for its effectiveness with offense-related trauma; shame-based disorders; and with those presenting with self-harm and suicidality. Given the postulated link between shame and recidivism, it is perplexing that to-date there has been no published research pertaining to the psychological treatment of offense-related shame, specifically. The importance of EMDR case formulation in regard to treatment planning is described. Therapeutic processes and clinical outcome will be discussed. Overall this case-study builds on the existing research base and highlights the utility of EMDR for the treatment of offense-related shame, self-harm and active suicidality.
OBJECTIVE:The reliable change index (RCI) is a valuable idiographic tool used by clinicians and researchers to evaluate whether individual clients experienced statistically detectable change on a given measure. However, numerous RCI methods exist, and the popular Jacobson and Truax (1991) method is underspecified, raising the potential for inconsistent operationalization across studies. The present study evaluated how the RCI is operationalized in psychology clinical trials and explored how RCI operationalization can influence numerical thresholds. METHODS:We conducted a methodological scoping review of four clinical psychology journals published from 2020 to 2023 and coded the operationalization of reliable change in psychology clinical trials. We then used descriptive data from a convenience sample of published psychometric studies to illustrate the impact of operationalization on reliable change thresholds. RESULTS:Among 226 clinical trials, 29 (13%) formally assessed reliable change. We identified at least seven distinct operationalizations of the RCI, including five distinct operationalizations of the same formula from Jacobson and Truax (1991). In illustrative examples, differences in the specific operationalization of this formula produced absolute RCI threshold discrepancies as large as 79%, or 1.02 standard deviation units. CONCLUSION:Operationalization of reliable change is highly inconsistent in clinical trials, which can harm comparability of results across studies. We recommend improved reporting and that clinical trials compute two RCIs. First, the Jacobson & Truax method-using the baseline standard deviation and internal consistency-supports clinician use and improves between-study comparability, though other sources of non-comparability remain. Second, one of several modern methods provides improved within-study RCI evaluation.
BACKGROUND/OBJECTIVE:This study maps existing empirical evidence on the impact of Adverse Childhood Experiences (ACEs; including, in addition to experiences of violence or acts of omission and neglect directed at the child, dysfunctionality in the family environment), on suicidal acts in adolescents. METHODS:The PRISMA methodology was followed, and three databases were accessed: Medline/PubMed, Embase, and PsycInfo. The data selection process took place in stages. In the first stage, titles and abstracts of the articles resulting from the search were reviewed and, in the second stage, potentially eligible articles were analyzed in full, using the following set of eligibility criteria: scientific papers with peer review; research written in English; studies that empirically and specifically examined suicidal acts (excluding suicidal ideation and non-suicidal self- injurious behaviors); papers that specifically tested the association between ACEs and suicidal acts; research that specifically reported on adolescent populations. RESULTS:The final pool of analyzed articles numbered 26. Based on this review, included studies provided consistent evidence of an association between ACEs and suicide attempts. Only one study tested the association between ACEs and completed suicide. Further, sexual abuse, physical abuse, parental separation or divorce, and peer bullying were among the types of ACEs most consistently associated with suicide attempts across the reviewed studies. Several studies suggested that non-suicidal self-injurious behavior and exposure to suicidal behavior in friends or family may play a role in explaining the association between ACEs and suicide attempts. Studies examining potential buffering factors also suggested that parental support, family communication, social support, and school connectedness may attenuate this association. CONCLUSIONS:The available evidence indicates a consistent association between ACEs and suicidal acts, particularly suicide attempts. Evidence for specific ACE subtypes, specific populations, mediators, and moderators should be interpreted more cautiously, given it is based on a fewer number of studies.
OBJECTIVE:The menopause transition is accompanied by various psychological and physical symptoms including hot flashes. There is emerging evidence on the link between stress and hot flashes, yet findings have been limited and mixed. Most studies have relied primarily on between-person relationships and have overlooked important nuances of whether stress on any given day is associated with more severe hot flashes on that same day. Our study bridges this gap by examining both the between- and within-person relationships between daily psychological stress (number of stressors, stressor severity sum, and stressor severity average) and hot flash severity among women who reported experiencing at least one hot flash. We also tested the potential moderating role of neuroticism. METHODS:We conducted a secondary analysis of data from Midlife Development in the United States (MIDUS), and analyzed data from an 8-day self-report diary phase. Participants were 130 women aged 42 to 60 who reported experiencing at least 1 day of hot flashes in the 8-day period. RESULTS:Results showed that on days when hot flash was reported, daily stress was significantly associated with hot flash severity on both the between- and within-person levels. However, the relationship between daily stress and hot flash occurrence was not significant. Neuroticism did not significantly moderate any of the relationships. CONCLUSIONS:These findings indicate that among women who experienced hot flashes, on days when hot flash was reported, higher perceived stress is associated with higher hot flash severity; more importantly, hot flash severity is higher on days when stress is higher. If the within-person association is replicated in future studies, these findings may have implications for therapeutically targeting stress as a potential avenue for alleviating hot flashes.
OBJECTIVES:Inspired by an affective processing model of negative reinforcement, this study aimed to examine the effects of mindfulness induction on self-reported methamphetamine craving and investigate the mechanism underlying this relationship. METHODS:Participants were female methamphetamine users, with 120 in Experiment 1 (intervention: n = 59, control: n = 61) and 107 in Experiment 2 (intervention: n = 54, control: n = 53). Participants in the intervention condition listened to an 18.45-min mindful audiotape to attain a state of mindfulness. Participants in Experiment 1 listened to the audiotape after viewing images of methamphetamine to induce craving, whereas those in Experiment 2 listened to the mindful audiotape after viewing a film clip to induce craving. Experiment 1 used a rating task to measure craving and negative affect. Experiment 2 adopted a pretest-posttest design in which negative affect and craving were assessed using the PANAS scale and craving scale, respectively. Self-reported craving was the primary outcome of both experiments. ANOVAs and PROCESS macro Model 6 were used to test the direct and indirect effects of mindfulness induction on craving. RESULTS:Mindfulness induction had not only a direct effect on self-reported craving but also an indirect effect by decreasing negative affect and then improving emotion regulation in Experiments 1 and 2. CONCLUSION:The findings affirm and enrich theoretical and empirical evidence of the immediate positive effects of mindfulness induction on substance craving, suggesting its promise as a method to decrease substance craving.
An understanding of the relations between psychological flexibility processes and quality of life among autistic adults could help inform treatment development to improve the acceptability of mental healthcare among autistic adults. This pre-registered (https://osf.io/t3pws) secondary analysis of a mixed-methods pilot open trial provides a preliminary test of which subprocesses of psychological flexibility are associated with improvements in quality of life among a sample of 56 autistic adults who received a 6-week digital self-help acceptance and commitment therapy (ACT) intervention. Online self-report assessments were collected at pre-treatment, 6 weeks (post-treatment), and 10 weeks (1-month follow-up). Pre- to post-treatment improvements in values progress and valued action, but not openness to experience, behavioral awareness, or values obstruction, were associated with pre- to follow-up improvements in quality of life. Qualitative themes suggested that psychological flexibility with thoughts, emotions, and behaviors may be experienced as impacting quality of life. An exploratory analysis found that greater adherence to the digital ACT program was associated with greater pre- to post-treatment improvements in awareness and values obstruction, but not other psychological flexibility subprocesses. Although these are preliminary associative findings limited by a single-arm design, they suggest psychological flexibility, especially values, is a promising candidate for future research on mechanisms for improving quality of life among autistic adults.
Obsessive-compulsive disorder (OCD) is characterized by its symptomatology heterogeneity, which poses challenges for its assessment and treatment. Ecological momentary assessment (EMA) has been proposed as a promising method for gathering information and may offer advantages over retrospective methods. The present study aims to conduct a systematic review of the use of EMA in OCD, examining the main variables assessed, methodological considerations, and the advantages of EMA compared with retrospective measures to assess OCD. The systematic search was conducted using databases including Scopus, Pubmed, Web of Science, PsycNET, and Cochrane Library. Of the identified studies, 28 met the inclusion criteria. These studies focused on the assessment of obsessions, compulsions, experiential avoidance, and sleep, with compulsions being the most studied variable. The studies reveal diverse EMA methods, with traditional paper recordings and smartphones differing in frequency and duration of the records. Some studies reported that EMA may serve as a valid and sensitive tool for detecting changes in OCD and overcome some limitations of retrospective assessments. Despite the potential of EMA, their validity is still questionable, and their application during intervention processes is limited, particularly given the heterogeneity of the available evidence and the limited application of EMA during intervention processes. Further research is essential to enhance their integration in clinical settings.
Research has suggested that independently and in combination, positive affect, emotional closeness, and perceived positive communication behaviors, are important to relationship satisfaction for adults in romantic relationships. The current study leveraged daily diary data from 158 individuals in cohabitating romantic couples to better understand the isolated and interactive effects of an individual's daily positive affect, emotional closeness, and perceived positive communication behaviors (verbal and nonverbal) on their daily relationship satisfaction. We expected that higher scores on each daily predictor would be associated with higher daily relationship satisfaction. Informed by positivity resonance theory, we also expected that the effect of these predictors would enhance each other in pairs, regardless of inclusion of the third component. We found that each of these predictors was individually associated with higher daily relationship satisfaction. We also found significant interactions between daily emotional closeness and both daily perceived positive communication behaviors and daily positive affect, in association with daily relationship satisfaction. There was not a significant interaction between positive affect and perceived positive communication behaviors. Across analyses, we found a buffering effect such that when one construct was low, the other tended to protect against the negative association with relationship satisfaction. Daily emotional closeness consistently emerged as beneficial to daily relationship satisfaction. Findings suggest that, from an individual perspective, endorsement of these positive experiences over the course of the day is relevant to relationship satisfaction on the same day.
Dialectical behavior therapy (DBT) has shown efficacy in reducing suicidality, though less is known about its effectiveness when delivered in usual care (UC) settings, where the resource-intensive nature of the program often results in modifications during implementation. This systematic meta-analysis examined the effectiveness of DBT in reducing suicidality-related outcomes when delivered in usual care settings. A systematic search was conducted and studies were identified for inclusion if they evaluated a DBT-based intervention with original, quantitative data reflecting pre- and post-treatment measurement of at least one of the three suicidality-related outcomes: (i) self-directed violence (SDV), (ii) crisis service use (CSU), and (iii) suicidal ideation (SI). Random effects models were used to estimate pooled effects. Meta-regression analyses were used to compare pooled effects across usual care and non-usual care settings and to examine the differential effects of theoretical predictors often involved in treatment modification. The final sample included 83 studies. In uncontrolled studies, DBT was associated with a large reduction in SDV and medium reductions in CSU and SI. In controlled studies, DBT demonstrated a significant effect for SDV but not for CSU or SI. Adjustment for publication bias attenuated the CSU findings. No differences were observed between usual care and non-usual care settings. Substantial heterogeneity was observed across models. In uncontrolled studies, positive associations emerged between therapist training and SDV reduction, adherence reporting and CSU reduction, and outpatient setting and SI reduction. Results provide the strongest support for the effectiveness of DBT in reducing SDV, with more limited and variable evidence for CSU and SI. Results should be interpreted with caution given heterogeneity and evidence of publication bias.
