Towards an informed research agenda for the field of personality disorders by experts with lived and living experience and researchers.

BACKGROUND: We describe a collection of themes for a research agenda for personality disorders that was originally formulated for the ESSPD Borderline Congress in 2022. METHODS: Experts with lived and living experience (EE), researchers and clinicians met virtually, exchanged ideas and discussed research topics for the field of personality disorders. The experts - patients, relatives, significant others - named the topics they thought most relevant for further research in the field. These topics were presented at the ESPPD conference in October 2022. RESULTS: The five top themes were: 1. Prevention, early detection and intervention, 2. Recovery beyond symptom improvement, 3. Involvement of relatives in treatment, 4. Gender dysphoria, and 5. Stigma. CONCLUSIONS: In general, the topics reflect current issues and changes in societal values. Overarching aims of research on these topics are the improvement of social participation and integration in society, better dissemination of research, and better information of the general public and political stakeholders.

BI-REAL: A 12-session DBT skills group intervention adapted for bipolar disorder - A feasibility randomised pilot trial.

International guidelines endorse psychological treatment for Bipolar Disorder (BD); however, the absence of a recognised gold-standard intervention requires further research. A Dialectical Behaviour Therapy (DBT) skills group intervention with 12 sessions was developed. This pilot randomised controlled trial (RCT) aims to evaluate the feasibility, acceptability, and outcomes variance of Bi-REAL - Respond Effectively, Assertively, and Live mindfully, tailored for individuals with BD, in preparation for a future RCT. METHODS: 52 participants (female = 62.7 %; mean age = 43.2 ± 11.1) with BD were randomised by blocks to either the experimental group (EG; n = 26; Bi-REAL + Treatment as Usual, TAU) receiving 12 weekly 90-minutes sessions, or the control group (CG; n = 26, TAU). Feasibility and acceptability were assessed with a multimethod approach (qualitative interviews, semi-structured clinical interviews and a battery of self-report questionnaires - candidate main outcomes Bipolar Recovery Questionnaire (BRQ) and brief Quality of Life for Bipolar Disorder (QoL.BD)). All participants were evaluated at baseline (T0), post-intervention (T1) and 3-month follow-up (T2). RESULTS: Acceptability was supported by participants' positive feedback and ratings of the sessions and programme overall, as well as the treatment attendance (86.25 % of sessions attended). The trial overall retention rate was 74.5 %, with CG having a higher dropout rate across the 3-timepoints (42.31 %). A significant Time × Group interaction effect was found for BRQ and QoL.BD favouring the intervention group (p < .05). LIMITATIONS: The assessors were not blind at T1 (only at T2). Recruitment plan was impacted due to COVID-19 restrictions and replication is questionable. High attrition rates in the CG. CONCLUSIONS: The acceptability of Bi-REAL was sustained, and subsequent feasibility testing will be necessary to establish whether the retention rates of the overall trial improve and if feasibility is confirmed, before progressing to a definitive trial.

Benchmarks for dialectical behavioural therapy intervention in adults and adolescents with borderline personality symptoms.

Background: Dialectical Behaviour Therapy (DBT) is a multi-component cognitive behavioural intervention with proven efficacy in treating people with borderline personality disorder symptoms. Establishing benchmarks for DBT intervention with both adults and adolescents is essential for bridging the gap between research and clinical practice, improving teams' performance and procedures. Aim: This study aimed to establish benchmarks for DBT using the EQ-5D, Borderline Symptoms List (BSL) and Difficulties in Emotion Regulation Scale (DERS) for adults and adolescents. Methods: After searching four databases for randomised controlled trials and effectiveness studies that applied standard DBT to people with borderline symptoms, a total of 589 studies were included (after duplicates' removal), of which 16 met our inclusion criteria. A meta-analysis and respective effect-size pooling calculations (Hedges-g) were undertaken, and heterogeneity between studies was assessed with I2 and Q tests. Benchmarks were calculated using pre-post treatment means of the studies through aggregation of adjusted effect sizes and critical values. Results: DBT aggregated effect sizes per subsample derived from RCTs and effectiveness studies are presented, along with critical values, categorised by age group (adults vs adolescents), mode of DBT treatment (full-programme vs skills-training) and per outcome measure (EQ-5D, BSL and DERS). Conclusions: Practitioners from routine clinical practice delivering DBT and researchers can now use these benchmarks to evaluate their teams' performance according to their clients' outcomes, using the EQ-5D, BSL and DERS. Through benchmarking, teams can reflect on their teams' efficiency and determine if their delivery needs adjustment or if it is up to the standards of current empirical studies.

Emotional and behavioural problems of children with autism spectrum disorder attending mainstream schools.

Emotional and behavioural problems occur more commonly in children with Autism Spectrum Disorder (ASD) compared to other children. Few studies have focused on these problems in children with ASD attending mainstream schools. We assessed via parent report the emotional and behavioural problems in 160 children aged 4-17 years with ASD attending mainstream schools and investigated differences between the primary and secondary aged children. Children with ASD had higher levels of problems across all domains of the Strengths and Difficulties Questionnaire (SDQ) compared to UK norms. Within the ASD sample, SDQ scores were associated with male sex, living in a household with more children, more severe autism symptoms and fewer adaptive skills, and higher levels of family socio-economic risk. No robust primary-secondary school differences were found. Implications for future research and the support of children with ASD in mainstream school settings are discussed.

A feasibility randomised controlled trial with an embedded qualitative evaluation of perinatal emotional skills groups for women with borderline personality disorder: protocol for the EASE study.

BACKGROUND: Borderline personality disorder (BPD) is a severe mental disorder characterised by emotional instability, impaired interpersonal functioning and an increased risk of suicide. There is no clear evidence about how best to help women with BPD during the perinatal period. Perinatal Emotional Skills Groups (ESGs) consist of 12 group sessions, focussing on core skills in emotion regulation, interpersonal effectiveness, distress tolerance and mindfulness and how these skills can best be utilised during the perinatal period. Prior observational research has shown that perinatal ESGs may help women with BPD. We set out to test the feasibility of conducting a randomised controlled trial to investigate the clinical effectiveness of perinatal ESGs. METHODS: A two-arm, parallel-group, feasibility randomised controlled trial of Perinatal ESGs in addition to Treatment as Usual (TAU) versus TAU for women aged over 18 years, who are likely to have a diagnosis of BPD and are either pregnant or are within 12 months of having a live birth. We will exclude women who have a co-existing organic, psychotic mental disorder or substance use dependence syndrome; those with cognitive or language difficulties that would preclude them from consenting or participating in study procedures; those judged to pose an acute risk to their baby and those requiring admission to a mother and baby unit. After consenting to participation and completing screening assessments, eligible individuals will be randomly allocated, on a 1:1 ratio, to either ESGs + TAU or to TAU. Randomisation will be stratified according to recruitment centre. Feasibility outcomes will be the proportion of participants: (1) consenting; (2) completing baseline measures and randomised; (3) completing the intervention and (4) completing follow-up assessments. All study participants will complete a battery of self-report measures at 2 and 4 months post-randomisation. A nested qualitative study will examine participants' and therapists' experiences of the trial and the intervention. DISCUSSION: Evidence is lacking about how to help women with BPD during the perinatal period. Perinatal ESGs are a promising intervention and if they prove to be an effective adjunct to usual care, a large population of vulnerable women and their children could experience substantial health gains. TRIAL REGISTRATION: ISRCTN80470632.

The ICD-11 classification of personality disorders: a European perspective on challenges and opportunities.

The 11th revision of the World Health Organization (WHO) International Classification of Diseases (ICD-11) includes a fundamentally new approach to Personality Disorders (PD). ICD-11 is expected to be implemented first in European countries before other WHO member states. The present paper provides an overview of this new ICD-11 model including PD severity classification, trait domain specifiers, and the additional borderline pattern specifier. We discuss the perceived challenges and opportunities of using the ICD-11 approach with particular focus on its continuity and discontinuity with familiar PD categories such as avoidant PD and narcissistic PD. The advent of the ICD-11 PD classification involves major changes for health care workers, researchers, administrators, and service providers as well as patients and families involved. The anticipated challenges and opportunities are put forward in terms of specific unanswered questions. It is our hope that these questions will stimulate further research and discussion among researchers and clinicians in the coming years.

Personality Disorder Diagnoses in ICD-11: Transforming Conceptualisations and Practice.

Background: Until the advent of the ICD-11, classification of personality disorders was based on categorical prototypes with a long history. These prototypes, whilst familiar, were not based in the science of personality. Prototypical classifications were also complex to administer in non-specialist settings requiring knowledge of many signs and symptoms. Method: This article introduces the new structure of ICD-11 for personality disorders, describing the different severity levels and trait domain specifiers. Case studies illustrate the main aspects of the classification. Results: The new ICD-11 system acknowledges the fundamentally dimensional nature of personality and its disturbances whilst requiring clinicians to make categorical decisions on the presence or absence of personality disorder and severity (mild, moderate or severe). The connection between normal personality functioning and personality disorder is established by identifying five trait domain specifiers to describe the pattern of a person's personality disturbance (negative affectivity, detachment, dissociality, disinhibition, and anankastia) that connect to the Big 5 personality traits established in the broader study of personality. Conclusions: Whilst new assessment measures have been and are in development, the success of the new system will rely on clinicians and researchers embracing the new system to conceptualise and describe personality disturbances and to utilise the classification in the investigation of treatment outcome.

Euthanasia and assisted suicide in patients with personality disorders: a review of current practice and challenges.

BACKGROUND: Over the last two decades an increasing number of countries have legalized euthanasia and physician-assisted suicide (EAS) leading to considerable debate over the inherent ethical dilemmas. Increasing numbers of people with personality disorders, faced with unbearable suffering, have requested and received assistance in terminating their lives. EAS in people with personality disorders has, however, received very sparse attention from clinicians and researchers. In this paper, we examine the literature on the practice and prevalence of EAS in people with personality disorders to date and discuss the associated challenges for research and practice. METHODS: Narrative review of the literature combined with the authors' collective experience and knowledge of personality disorders. RESULTS: In six of the eight countries where EAS is currently legal, mental disorders are accepted as disorders for which EAS may be granted. In four of these countries, EAS in minors with mental disorders is also accepted. Our literature search resulted in 9 papers on the subject of EAS in people with personality disorders. These studies suggest that most clinicians who grant EAS have indeed perceived their patients' suffering as chronic, unbearable and untreatable without prospect of improvement. The majority of patients with personality disorders had tried some form of psychotherapy, but very few had received any of the relevant evidence-based treatments. The decision to grant EAS based on a perception of the patient's illness as being untreatable with no prospect of improvement, could, thus, in many cases fail to meet the due care criteria listed in EAS laws. People with personality disorders more often wish for death for extended periods of time than people without these disorders. However, there is ample empirical data to show that suicidal tendencies and behaviour can be treated and that they fluctuate rapidly over time. CONCLUSIONS: In light of our findings, we believe that the current legislation and practice of EAS for people with personality disorders is based on an inadequate understanding of underlying psychopathology and a lack of awareness about the contemporary treatment literature. Moreover, we assert that this practice neglects the individual's potential for having a life worth living.

Evaluating the national multisite implementation of dialectical behaviour therapy in a community setting: a mixed methods approach.

BACKGROUND: The implementation of evidence-based interventions for borderline personality disorder in community settings is important given that individuals with this diagnosis are often extensive users of both inpatient and outpatient mental health services. Although work in this area is limited, previous studies have identified facilitators and barriers to successful DBT implementation. This study seeks to expand on previous work by evaluating a coordinated implementation of DBT in community settings at a national level. The Consolidated Framework for Implementation Research (CFIR) (Damschroder et al., Implementation Sci. 4:50, 2009) provided structural guidance for this national level coordinated implementation. METHODS: A mixed methods approach was utilised to explore the national multisite implementation of DBT from the perspective of team leaders and therapists who participated in the coordinated training and subsequent implementation of DBT. Qualitative interviews with DBT team leaders (n = 8) explored their experiences of implementing DBT in their local service and was analysed using content analysis. Quantitative surveys from DBT therapists (n = 74) examined their experience of multiple aspects of the implementation process including orienting the system, and preparations and support for implementation. Frequencies of responses were calculated. Written qualitative feedback was analysed using content analysis. RESULTS: Five themes were identified from the interview data: team formation, implementation preparation, client selection, service level challenges and team leader role. Participants identified team size and support for the team leader as key points for consideration in DBT implementation. Key challenges encountered were the lack of system support to facilitate phone coaching and a lack of allocated time to focus on DBT. Implementation facilitators included having dedicated team members and support from management. CONCLUSIONS: The barriers and facilitators identified in this study are broadly similar to those reported in previous research. Barriers and facilitators were identified across several domains of the CFIR and are consistent with a recently published DBT implementation Framework (Toms et al., Borderline Personal Disord Emot Dysregul. 6: 2, 2019). Future research should pay particular attention to the domain of characteristics of individuals involved in DBT implementation. The results highlight the importance of a mandated service plan for the coordinated implementation of an evidence-based treatment in a public health service. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03180541; Registered June 7th 2017 'retrospectively registered'.

Outcomes for 18 to 25-year-olds with borderline personality disorder in a dedicated young adult only DBT programme compared to a general adult DBT programme for all ages 18.

AIM: Targeting young adults with borderline personality disorder (BPD) for treatment may carry significant social and clinical benefits. We aimed to evaluate a community-based Dialectical Behaviour Therapy (DBT) programme delivered exclusively to young adults with BPD. METHODS: We describe a naturally occurring non-equivalent, quasi-experimental comparison of outcomes for young adults (18-25 years) with BPD following 1 year of treatment in either a young adult only DBT programme or a general adult DBT programme (18+ years). Twenty-four young adults enrolled in a community-based young adult DBT programme open only to 18- to 25-year-olds with BPD. Another 13 young adults, also 18-25 years, enrolled in a general adult DBT programme open to all ages above 18 years. Both treatment conditions offered all modes of standard DBT for 1 year. Participants completed a battery of self-report measures on mental health symptoms at baseline and again at treatment completion after 1 year. Discharge rates at 2 years post-treatment completion were also recorded. RESULTS: Better outcomes were found on borderline symptom severity and general psychopathology among completers of young adult DBT, with a large effect size for treatment condition as well as greater clinically significant change. Discharge rates from mental health services 24 months later were also higher for completers of young adult DBT. CONCLUSIONS: There may be advantages in delivering DBT to young adults in an age-specific programme, possibly due to group cohesion. Methodological limitations apply, such as small sample size and non-randomization. Further controlled research is needed.

Multisite Implementation and Evaluation of 12-Month Standard Dialectical Behavior Therapy in a Public Community Setting.

Dialectical behavior therapy (DBT) is an effective intervention for treating adults with emotional and behavioral dysregulation. The National DBT Project, Ireland was established in 2013 to coordinate the implementation of DBT across public community mental health settings at a national level. This study describes the implementation and evaluation of DBT across multiple independent sites in adult mental health services (AMHS). The Consolidated Framework for Implementation Research was used to guide this national implementation where barriers and facilitators to DBT implementation were considered. Nine AMHS teams completed DBT training and delivered the standard 12-month program. One hundred and ninety-six adults with borderline personality disorder participated in the program, and outcome measures were recorded at four time points. Significant reductions on outcome measures, including frequency of self-harm and suicidal ideation, were observed. This study highlights that DBT can be successfully implemented in community mental health settings as part of a coordinated implementation.

Refractory depression - mechanisms and efficacy of radically open dialectical behaviour therapy (RefraMED): findings of a randomised trial on benefits and harms.

BACKGROUND: Individuals with depression often do not respond to medication or psychotherapy. Radically open dialectical behaviour therapy (RO DBT) is a new treatment targeting overcontrolled personality, common in refractory depression. AIMS: To compare RO DBT plus treatment as usual (TAU) for refractory depression with TAU alone (trial registration: ISRCTN 85784627). METHOD: RO DBT comprised 29 therapy sessions and 27 skills classes over 6 months. Our completed randomised trial evaluated RO DBT for refractory depression over 18 months in three British secondary care centres. Of 250 adult participants, we randomised 162 (65%) to RO DBT. The primary outcome was the Hamilton Rating Scale for Depression (HRSD), assessed masked and analysed by treatment allocated. RESULTS: After 7 months, immediately following therapy, RO DBT had significantly reduced depressive symptoms by 5.40 points on the HRSD relative to TAU (95% CI 0.94-9.85). After 12 months (primary end-point), the difference of 2.15 points on the HRSD in favour of RO DBT was not significant (95% CI -2.28 to 6.59); nor was that of 1.69 points on the HRSD at 18 months (95% CI -2.84 to 6.22). Throughout RO DBT participants reported significantly better psychological flexibility and emotional coping than controls. However, they reported eight possible serious adverse reactions compared with none in the control group. CONCLUSIONS: The RO DBT group reported significantly lower HRSD scores than the control group after 7 months, but not thereafter. The imbalance in serious adverse reactions was probably because of the controls' limited opportunities to report these.

Standalone DBT Group Skills Training Versus Standard (i.e. All Modes) DBT for Borderline Personality Disorder: A Natural Quasi-experiment in Routine Clinical Practice.

We describe a naturally occurring, real-world comparison of outcomes following 6 months in standalone DBT skills training group for adults with Borderline Personality Disorder (BPD) without recent suicidal or severe self-harming behaviours and standard (i.e. all modes) DBT for BPD including patients with recent high-risk behaviours. 34 patients chose standalone skills over waiting for standard DBT and 54 were offered standard DBT. Dropout was higher for standalone skills than standard DBT (38.2% vs. 16.7%). No statistically or clinically significant differences were found among completers between conditions on borderline symptoms, general psychopathology, and suicide ideation. There was a moderate effect for standalone skills on hopelessness and emotion regulation difficulties which may have reflected non-equivalence of treatment groups. Significant methodological factors limit generalisability of findings which offer support for feasibility of standalone DBT skills as an effective alternative to waitlist for standard DBT for at least some patients with BPD in the community.

Refractory depression - cost-effectiveness of radically open dialectical behaviour therapy: findings of economic evaluation of RefraMED trial.

BACKGROUND: Refractory depression is a major contributor to the economic burden of depression. Radically open dialectical behaviour therapy (RO DBT) is an unevaluated new treatment targeting overcontrolled personality, common in refractory depression, but it is not yet known whether the additional expense of RO DBT is good value for money.AimsTo estimate the cost-effectiveness of RO DBT plus treatment as usual (TAU) compared with TAU alone in people with refractory depression (trial registration: ISRCTN85784627). METHOD: We undertook a cost-effectiveness analysis alongside a randomised trial evaluating RO DBT plus TAU versus TAU alone for refractory depression in three UK secondary care centres. Our economic evaluation, 12 months after randomisation, adopted the perspective of the UK National Health Service (NHS) and personal social services. It evaluated cost-effectiveness by comparing the net cost of RO DBT with the net gain in quality-adjusted life-years (QALYs), estimated using the EQ-5D-3L measure of health-related quality of life. RESULTS: The additional cost of RO DBT plus TAU compared with TAU alone was £7048 and was associated with a difference of 0.032 QALYs, yielding an incremental cost-effectiveness ratio (ICER) of £220 250 per QALY. This ICER was well above the National Institute for Health and Care Excellence (NICE) upper threshold of £30 000 per QALY. A cost-effectiveness acceptability curve indicated that RO DBT had a zero probability of being cost-effective compared with TAU at the NICE £30 000 threshold. CONCLUSIONS: In its current resource-intensive form, RO DBT is not a cost-effective use of resources in the UK NHS.Declaration of interestR.H. is co-owner and director of Radically Open Ltd, the RO DBT training and dissemination company. D.K. reports grants outside the submitted work from the National Institute for Health Research (NIHR). T.L. receives royalties from New Harbinger Publishing for sales of RO DBT treatment manuals, speaking fees from Radically Open Ltd, and a grant outside the submitted work from the Medical Research Council. He was co-director of Radically Open Ltd between November 2014 and May 2015 and is married to Erica Smith-Lynch, the principal shareholder and one of two directors of Radically Open Ltd. H.O'M. reports personal fees outside the submitted work from the Charlie Waller Institute and Improving Access to Psychological Therapy. S.R. provides RO DBT supervision through her company S C Rushbrook Ltd. I.R. reports grants outside the submitted work from NIHR and Health & Care Research Wales. M. Stanton reports personal fees outside the submitted work from British Isles DBT Training, Stanton Psychological Services Ltd and Taylor & Francis. M. Swales reports personal fees outside the submitted work from British Isles DBT Training, Guilford Press, Oxford University Press and Taylor & Francis. B.W. was co-director of Radically Open Ltd between November 2014 and February 2015.

The development and theoretical application of an implementation framework for dialectical behaviour therapy: a critical literature review.

BACKGROUND: Dialectical behaviour therapy (DBT) is a third wave behaviour therapy combining behaviour based components with elements of mindfulness. Although DBT effectiveness has been explored, relatively little attention has been given to its implementation. Frameworks are often the basis for gathering information about implementation and can also direct how the implementation of an intervention is conducted. Using existing implementation frameworks, this critical literature review scoped the DBT implementation literature to develop and refine a bespoke DBT implementation framework. METHOD AND RESULTS: The initial framework was developed by consolidating existing implementation frameworks and published guidance on DBT implementation. The critical literature review retrieved papers from Medline, CINAHL, PsycInfo, PubMed, and the reference lists of included papers. Framework elements were used as codes which were applied to the literature and guided the synthesis. Findings from the synthesis refined the framework.The critical literature review retrieved 60 papers but only 14 of these explicitly focused on implementation. The DBT implementation framework captured all the execution barriers and facilitators described in the literature. However, the evidence synthesis led to a more parsimonious framework as some elements (e.g., research and published guidance) were seldom discussed in DBT implementation. CONCLUSION: To our knowledge this is the first published review exploring DBT implementation. The literature synthesis suggests some tentative recommendations which warrant further exploration. For instance, if DBT implementation is not pre-planned, having someone in the organisation who champions DBT can be advantageous. However, as the literature is limited and has methodological limitations, further prospective studies of DBT implementation are needed.

Innovations in Practice: Dialectical behaviour therapy for adolescents: multisite implementation and evaluation of a 16-week programme in a public community mental health setting.

BACKGROUND: Dialectical behaviour therapy for adolescents (DBT-A) is an intervention with a growing evidence base for treating adolescents with emotional and behavioural dysregulation. This study describes the implementation and effectiveness of 16-week DBT-A across multiple sites in publicly funded child/adolescent mental health services (CAMHS) in Ireland. METHOD: The Consolidated Framework for Implementation Research was used to guide this national implementation. Fifty-four clinicians from seven CAMHS teams completed DBT training and delivered the 16-week DBT-A programme. Eighty-four adolescents with emotional and behavioural dysregulation participated in the intervention and outcome measures were administered at preintervention, postintervention and 16-week follow-up. RESULTS: Significant reductions on all outcome measures were observed for DBT-A participants including presence and frequency of self-harm, suicidal ideation and depression. Reductions in the number of acute inpatient admissions, bed days and emergency department visits were also reported. CONCLUSIONS: DBT-A can be successfully implemented in CAMHS settings and yield positive outcomes for adolescents with emotional and behavioural dysregulation.

The survivability of dialectical behaviour therapy programmes: a mixed methods analysis of barriers and facilitators to implementation within UK healthcare settings.

BACKGROUND: Dialectical Behaviour Therapy (DBT) is an evidence-based intervention that has been included in the National Institute of Health and Care Excellence guidelines as a recommended treatment for Borderline Personality Disorder in the UK. However, implementing and sustaining evidence-based treatments in routine practice can be difficult to achieve. This study compared the survival of early and late adopters of DBT as well as teams trained via different training modes (on-site versus off-site), and explored factors that aided or hindered implementation of DBT into routine healthcare settings. METHODS: A mixed-method approach was used. Kaplan-Meier survival analyses were conducted to quantify and compare survivability as a measure of sustainability between early and late implementers and those trained on- and off-site. An online questionnaire based on the Consolidated Framework for Implementation Research was used to explore barriers and facilitators in implementation. A quantitative content analysis of survey responses was carried out. RESULTS: Early implementers were significantly less likely to survive than late implementers, although, the effect size was small. DBT teams trained off-site were significantly more likely to survive. The effect size for this difference was large.  An unequal amount of censored data between groups in both analyses means that findings should be considered tentative. Practitioner turnover and financing were the most frequently cited barriers to implementation. Individual characteristics of practitioners and quality of the evidence base were the most commonly reported facilitators to implementation. CONCLUSIONS: A number of common barriers and facilitators to successful implementation of DBT were found among DBT programmes. Location of DBT training may mediate programme survival.

Implementing Dialectical Behaviour Therapy: programme survival in routine healthcare settings.

BACKGROUND: The National Institute of Health and Clinical Excellence recommends considering Dialectical Behaviour Therapy (DBT), an efficacious treatment for borderline personality disorder, especially when reduction in self-harm is a clinical priority [ NCCMH (2009) . Borderline Personality Disorder: Treatment and Management. Leicester: The British Psychological Society and the Royal College of Psychiatrists]. Treatment teams began using DBT in the UK in 1994. Concerns have been raised, however, about the sustainability of DBT programmes in routine clinical practice [Pitman, A., & Tyrer, P. (2008). Implementing clinical guidelines for self-harm - highlighting key issues arising from the NICE guideline for self-harm. Psychology and Psychotherapy: Theory, Research and Practice, 81, 377-397]. AIMS: This study sought to establish the sustainability of UK DBT programmes and to explore factors that impacted on effective implementation. METHOD: All teams trained in DBT in the UK between 1994 and 2007 were contacted. Each team was categorised as either active or inactive. The date of programme cessation was established. Team leaders of active, and as far as possible inactive, programmes were interviewed about aspects of implementation. RESULTS: The survival curve demonstrated that DBT programmes ran an increased risk of failure in the second and fifth years after training. Absence of organisational support and staff turnover were the most commonly reported implementation challenges. CONCLUSIONS: Sustainable implementation of DBT, as with other evidence-based interventions, requires organisational support that incorporates a strategy for further staff training and development.

The use of mindfulness-based approaches for suicidal patients.

Mindfulness-based approaches are becoming more widely used for individuals at risk of suicidal behavior: in the treatment of borderline personality disorder (in Dialectical Behavior Therapy), and as a way to reduce relapse in recurrent major depression (in Mindfulness-based Cognitive Therapy). This article describes and examines the commonalities and differences in the use of mindfulness in these two treatments. The reasons for considering the use of mindfulness-based approaches with suicidal individuals more widely are considered and potential risks outlined. The article closes with case examples to illustrate the use of mindfulness in the treatment of suicidal thoughts and behaviors.