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Dialectical behavior therapy (DBT) for adolescent self-harming behavior

Children's Mental Health: Other
Benefit-cost methods last updated December 2019.  Literature review updated August 2017.
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Dialectical behavior therapy (DBT) is a cognitive behavioral treatment originally developed for chronically parasuicidal adults. DBT involves both group skills training and individual psychotherapy and focuses on mindfulness, interpersonal, emotion-regulating, and self-management skills. In studies included in this meta-analysis, DBT was modified to treat adolescents by shortening the treatment length, streamlining and simplifying some lessons, and including parents in some sessions. Studies in this analysis include adolescents in both inpatient and outpatient treatment settings presenting with suicidal ideation, non-suicidal self-harm, and/or prior suicide attempts. Treatment duration ranges from 2-19 weeks, with multiple sessions per week.
For an overview of WSIPP's Benefit-Cost Model, please see this guide. The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2018). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $1,000 Benefits minus costs $1,643
Participants $33 Benefit to cost ratio $11.30
Others $217 Chance the program will produce
Indirect $552 benefits greater than the costs 51 %
Total benefits $1,802
Net program cost ($159)
Benefits minus cost $1,643

^WSIPP’s benefit-cost model does not monetize this outcome.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases. See Estimating Program Effects Using Effect Sizes for additional information.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Treatment age No. of effect sizes Treatment N Adjusted effect sizes(ES) and standard errors(SE) used in the benefit - cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
16 2 71 -0.445 0.180 16 0.000 0.310 18 -0.445 0.014
16 2 55 -0.116 0.258 16 n/a n/a n/a -0.116 0.652
16 2 55 -0.606 0.231 16 0.000 0.118 17 -0.606 0.009
16 2 71 -0.434 0.321 16 n/a n/a n/a -0.434 0.176
16 2 71 0.493 0.181 16 n/a n/a n/a 0.493 0.006
16 1 39 -0.531 0.253 16 n/a n/a n/a -0.531 0.036
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Affected outcome: Resulting benefits:1 Benefits accrue to:
Taxpayers Participants Others2 Indirect3 Total
Major depressive disorder K-12 grade repetition $29 $0 $0 $15 $44
Labor market earnings associated with major depression $0 $0 $0 $0 $0
Mortality associated with depression $8 $20 $0 $136 $164
Hospitalization (psychiatric) Health care associated with psychiatric hospitalization $962 $13 $217 $481 $1,674
Program cost Adjustment for deadweight cost of program $0 $0 $0 ($80) ($80)
Totals $1,000 $33 $217 $552 $1,802
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Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $2,792 2016 Present value of net program costs (in 2018 dollars) ($159)
Comparison costs $2,641 2016 Cost range (+ or -) 25 %
Per-participant costs are based on a weighted average for therapist time of 15.97 hours in individual sessions and 18.17 hours of group sessions, as reported in the treatment studies, multiplied by the hourly therapist cost is based on the 2016 actuarial estimates of reimbursement for individual therapy (Mercer, 2015, Behavioral Health Data Book for the State of Washington for Rates Effective January 1, 2016). Comparison costs are calculated in the same way from study reports of control group treatments.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Benefits Minus Costs
Benefits by Perspective
Taxpayer Benefits by Source of Value
Benefits Minus Costs Over Time (Cumulative Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in discounted dollars. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

Citations Used in the Meta-Analysis

Katz, L.Y., Cox, B.J., Gunasekara, S., & Miller, A.L. (2004). Feasibility of dialectical behavior therapy for suicidal adolescent inpatients. Journal of the American Academy of Child and Adolescent Psychiatry, 43(3), 276-282.

Mehlum, L., Tørmoen, A.J., Ramberg, M., Haga, E., Diep, L.M., Laberg, S., . . . Grøholt, B. (2014). Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. Journal of the American Academy of Child & Adolescent Psychiatry, 53(10), 1082-1091.

Mehlum, L., Ramberg, M., Tormoen, A.J., Haga, E., Diep, L.M., Stanley, B.H., . . . Sund, A.M. (2016). Dialectical behavior therapy compared with enhanced usual care for adolescents with repeated suicidal and self-harming behavior: Outcomes over a one-year follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 55(4), 295-300.

Rathus, J.H., & Miller, A.L. (2002). Dialectical behavior therapy adapted for suicidal adolescents. Suicide and Life Threatening Behavior, 32, 146-157.