In this podcast, Professor Lars Mehlum discusses suicide and self-harm and his contribution to the JCPP’s special issue on the subject.
Lars discusses dialectical behaviour therapy for adolescents (DBT-A) as an intervention, his most recent paper in The JCPP, national strategies for suicide prevention and the latest clinical research.
Interviewer: Hello, my name is Matthew Kempen. I’m the marketing manager for The Association for Child and Adolescent Mental Health and welcome to the latest in our In Conversation podcast series. Today, I’m talking to Professor Lars Mehlum. Lars is the founding director of the National Center for Suicide Research and Prevention at The Institute of Clinical Medicine at the University of Oslo in Norway. Lars, on behalf of ACAMH, we’d like to thank you for your contribution to the JCPP special issue and for taking the time out to talk to us today. Lars, could you explain to those unfamiliar, what dialectic behavioural therapy for adolescents entails and how it compares to DBT in adults and standard outpatient treatment?
Lars Mehlum: So, a lot of people have heard about cognitive behaviuoral therapy, I think. This is a so-called third generation, further development of cognitive behavioural therapy with a slightly more emphasis on behaviour. It doesn’t mean that we are only into behaviours, but we are defining problems that people are experiencing in their lives as behaviours, so that we target them for change. People with borderline personality disorder or traits of that disorder, they have often, very many difficulties of regulating emotions and behaviours. This treatment was designed and developed by Professor Marsha Linehan in the US, directly targeting people with borderline personality disorder and self-harming behaviour. People who had essentially, huge difficulties in regulating emotions and the DBT tries to use principles that are proven and well-known, to analyse these problems of regulating emotions in situations of daily life and then, add behavioural skills for people to learn so that they can apply them in their daily life instead of problem behaviour. Such as, for example, suicidal and self-harm behaviours. This is particularly relevant for people who are experiencing this not only in very deep crisis in their life. I mean anyone can have a very hard time in their life and even become mentally ill. Then, hopefully, they will recover after having a longer or shorter trial of treatment.
But for these people, it’s not that easy. It is style of personality that it is actually enduring and pervasive. So this treatment targets this in a multitude of different situations and therefore, it’s particularly relevant for these people. After this was adapted from originally developed for adults, it was adapted for teenagers. It was abbreviated and made with a language and an adaptation that would be particularly suitable for them. It has then, been shown that it is equally effective as it is for adults. You know, DBT is probably the most evidence-based of all psychotherapies now, with more than 40 randomised trials. But it was not until we did this trial on teenagers that we could show that this could actually also be used to treat teenagers with these traits of borderline personality disorder and self-harming behaviour. I mean, only a few years ago, this was not thought to be so and people would dread trying to treat, directly, these behaviours. It was actually something that even researchers would shun because they would systematically exclude suicidal teenagers from treatment trials. And that was a bad idea but very understandable.
Interviewer: Your latest publication assessed the long-term effects of DBT-A, in terms of reducing self-harm frequency in adolescence compared to enhanced usual care. Can you give us a bit of a background to the conception of this project, and what your main aims were?
Lars Mehlum: Yeah. So, when we started to plan the study, sometimes you wonder if you knew what you were doing when you started these trials because, since it was the first ever trial with this population, we need to take every precaution. Also, we need to do a lot of piloting but the aim was nothing less than to try upstream in young adolescents, to try and change something that would make a huge different, downstream. Because, as I’m sure you know, people with borderline personality disorder in adult life, they are a treatable population but still, a very huge challenge to both their families, to their own sense of well-being and meaningfulness in life but also, to the health service. So, that was actually our aim, to see if we could actually change how the stream would go in another direction. That’s why we also designed this as not only a short-term treatment trial but also for a long-term follow-up study.
Now we have published the three years follow-up data with a very favourable result, but we are actually planning to do a ten year. Since you know, it takes on average, if you are going to have a sizeable cohort of people in a trial like this, it takes you a few years to include them. Now, the first in our group are actually up for the 10-year evaluation and we are very hopeful that they will still be with us because now, those few first kids in the cohort, they have now entered the second half of their 20s. So, now, we will have the answer did it really change the downstream life of these people? I’m really curious.
Interviewer: And for those that have not yet had the chance to read your paper in detail, could you briefly explain the main take-home messages of your study and what the findings mean going forward in terms of future lines of research, clinical practice and potentially, policy impact?
Lars Mehlum: So, what this paper here shows is that not only after the treatment trial was over, did we detect significant reductions in all of the three primary outcome measures, which were self-harm frequency and suicidal ideation and level of depression. But that was also the case, notably, for self-harm frequency after three years, post-randomization. So, this holds in the long run, which is really what we want to see. Not only a transient improvement and then, relapse but you really make a change so that they really have a different trajectory. So, that’s one main result from this paper and, of course, the other result is that there were no relapse signs in this group of people who had received the treatment. Mind you, of course, this is on a group level. There will always, in all treatment trials, be a variety of outcomes.
So, one of the things we were also after was to see, so, if you look in this group and see what will be the characteristics and variables that would actually mean a difference so that it would actually mediate, as we say in statistical terms, the association between the treatment you got and the reduction you had in the long term frequency of self-harming behaviours? So, we found, after we had also put it up as a hypothesis, we found that if our kid had a significant reduction in the level of hopelessness during the 19 weeks of treatment, that would make a huge significance for the long term frequency of self-harming behaviours. That would actually be a mediator of the long-term effect. So, I would say that, for people who are doing psychotherapy and interventions for kids with a chronic pattern of self-harming behaviour, that would be something they should be targeting, actively. That is actually what we do in DBT. Now, I feel even more convinced that we should refine these interventions in DBT, which we are using. Also, take them out of DBT and implement them in more than DBT contexts. So, I would say that I would advise my colleagues who are treating people, young people with this problem, that they look for ways of how to counteract and attack the hopelessness feeling.
Because think about it. If you might not be having a profound hopelessness, but let’s say you have given up on something. A relationship, could be a car or it could be something that you have really given up. You’re not likely to engage in anything anymore, around that small or large aspect of your life. You just let it be. You don’t want to change it. You have given it up. So, hopelessness is actually lack of a capacity to envision that you can actually make a difference in your life. So, it makes a lot of sense to me that we should, and actually, we can use psychotherapeutic strategies to attack hopelessness. So, I would say that would be a main message in this, in addition to this long-term effect.
Interviewer: There’s a great push for mental health awareness and training in schools, to be a top priority for the UK government. Could you give us some perspective as to the current situation on suicide prevention strategies in Norway, and how schools are supported to prevent and intervene on self-harm and suicidal behaviours in adolescence?
Lars Mehlum: So, I think really, it’s a great thing that you are putting a lot of emphasis on this in the UK and I’ve been fighting for this in Norway for many years and now, we seem to be making progress. Not that we haven’t had a lot of programs in the school. Actually, we’ve had more than nearly 10 programs over the years that have been, some of them, pretty well documented. Problem is that none of them have been made mandatory and they haven’t really been funded. So, it’s up to the single school and single local municipality to decide to do it or not. Now, we have reached the level of the Ministry and the Directorate of Education, which would be that the directorate not for the universities, but for the primary education and they finally made this a mandatory issue to have implemented in all schools.
Still, we are fighting to get it more explicitly targeting depression and suicide and self-harm. So far, it is at least explicit when it comes to mental health and coping. So, we are hopeful and of course, I could mention a lot of places and projects, but I’m a great believer and then, when we are using the school, I know that here in the UK most kids still are probably part of a publicly funded school, right? And that’s the same in Norway. That’s a fantastic instrument in the public health domain because it is reaching nearly everyone. So, I think we should use that opportunity and I think many countries actually, are looking for that, I think, in a special issue, there was a study, which is a great example of how we can do that.
Interviewer: Lars, you have advised on many national strategies for suicide preventions in various countries. In your experience, what are the common barriers to suicide prevention in adolescence that you’ve seen across different countries you’ve worked with, and what needs to be done from research and policy perspectives to address these common issues?
Lars Mehlum: So, I would say it is difficult to compare very different countries, of course. In some countries like even in China, but also India, Sri Lanka, the Philippines, still young people are dying in the thousands because of easy access to lethal means. So whereas, for example, here in the UK a young girl would take a painkiller, that is not something to be just wasting away. It is dangerous. But still, it’s not going to kill you instantaneously and it’s not very high fatal toxicity level. But for example, pesticides in the rural countryside of these countries I mentioned, is a very fatal thing and it’s very accessible. So, I would say in those countries, the lowest hanging fruit would be to advocate and implement safe storage of these lethal means. I’m going to share some information in the end of my talk today, not on pesticides, which has never been a problem in our country, but on firearms, which really was a huge problem in the youth suicide in our country and how we dealt with that and brought it down to very low level. So, there are commonalities but there are also differences.
In countries like the UK and Norway, I would think that the largest now remaining, low fruits or perhaps not that low hanging fruits but still, they are accessible, would be for us to work on access to affordable and acceptable treatments. Among those kids who need treatment, we are particularly bad at reaching young men, young boys. I mean, in those trials we are going to mention today, if you don’t read the papers carefully, you won’t notice that nine out of ten participants in all of those trials are girls. Where are the boys? They are simply not there and also, we cannot generalise our results to the boys who are not there because we did not include them. We don’t know what they would have done if they had been there, but we don’t even get to include them. We know that the problem of suicide is bigger among boys and when it comes to non-lethal self-harm, it is not that much less than for girls. So, we have a really big problem there and I would say that we, in a way, are neglecting this. I don’t know really, why but this is a reverse discrimination against boys and men.
Interviewer: So, is there a solution to this problem then?
Lars Mehlum: Yes, I think there is. For one thing, it is information. And again, then we come to the school because I mean, I’m a psychiatrist and I know that there’s only a limit. Even though I am a pretty big communicator back home, I do a lot of public information but still, there is a limit to how far we can reach out. So, we need to be innovative. So, for example, at the moment, we are running together with many other countries in Europe the so-called European Alliance Against Depression, which is aiming at reaching further out in the population and particularly, reaching men and young boys who would otherwise, well, it’s a little harsh to say it but I will say it, nevertheless. Some men and some boys would rather be dead than be seen in the waiting room of a doctor or God forbid, a psychologist or psychiatrist. It would simply be incompatible with their self-esteem. So, we need to do something about that and information is key but also, to beat down the threshold and be more smart. For example, deliver treatments over the internet. So, what we do in this alliance is to deliver web-based cognitive behavioural treatment that can be delivered to people, without being identified.
Interviewer: Do you think these types of digital interventions are the future, then?
Lars Mehlum: I think in suicide prevention, I’ve learned that this is a multicausal and very complex problem. So, we don’t have one solution. We need to have a toolbox and this is one tool in the toolbox, new tools. So, we hope that eventually, we will cover as much of the field as we can.
Interviewer: As well as your epidemiological research, you’re also leading clinical research on the cause and risk factors for suicide and self-harming behaviours, at the University of Oslo. Could you tell listeners a little bit more about what the other lines of clinical research are that are really exciting you at the moment?
Lars Mehlum: So, for people in the ages, in the teenage years, it seems to me, right now, that for suicidal and self-harming behaviours, there is little to gain by using medication. We hope, in the future, that we will make progress even there, but there is a limited evidence that this will have a huge impact. So, for the moment, that would be psychotherapy. So I am doing several psychotherapy developments in the trial activity. So, that’s one.
For the other age groups, of course, medication would be important. Still, what we do is we were talking about dialectical behavioural therapy. So, after having done these first trials, we have now been inspired actually, by one of your brilliant researchers, David Clark, who, with the support from the parliament, I think, was able to implement a lot of affordable and accessible short-term treatments to a large proportion of people who need them in the National Health Service. And what we are doing is that we are implementing DBT in clinics all over the country and we are also inviting them to become part of our network so that they systematically evaluate every case they have throughout the treatment, check for treatment response in every patient. Also, follow them for six months.
That creates now, a larger and larger expanding research network that will allow us, without these huge costs that we have with implementing randomised controlled trials, to get more data so that we can study unresolved questions. Such as, do we really need to have all of these modules in this treatment? Are they all indispensable and do all of our patients need them? And can we do it easier? Or who would actually also be non-responders? Who would need even more or something else? And what would be the essential mechanisms of change? We know something now and we are now building this evidence base because we strongly think that we need to know more or why? Why does psychotherapy work? We know that it changes the brain. We know that. I mean, there’s fascinating evidence from many countries now on FMRI studies, who shows at least, that those regions of the brain are activated and changing but we have limited knowledge. So, these kinds of information are the most, I think, hot today, that we, I would think in let’s say a decade from now, we will be able to have another seminar like this and tell people more about, so when you receive this treatment, this will remedy or this will mitigate or this will do something to this dysfunction that you were suffering from. Just like we can do with other illnesses because I think the society at large and patients, I mean, we all need to know what we are doing, don’t we? Because it’s serious business and also, of course, I’m very curious and interested in all of this. But I think if I was the patient and I’ve been a patient. Not because of psychiatric problems, but other things and I would certainly like to know what was going on in my body when I received the treatment. It is also strengthening the hope, I think, that you feel that this is actually working.
Interviewer: Some really exciting times ahead for us, Lars. Thanks very much for your time. You’ll be able to watch Lars’ lecture on our website, www.ACAMH.org.
Lars is the founding director of the National Centre for Suicide Research and Prevention at the Institute of Clinical Medicine, University of Oslo, Norway. Mehlum is a psychiatrist and psychotherapist. He has had many leader positions on national and international levels. He is the current president of the International Academy of Suicide Research, vice president of the ISSPD, a past president of the ESSPD and the International Association of Suicide Prevention and has acted as an advisor for national suicide preventive strategies to the European Union and in numerous countries. The founding editor of the journal ‘Suicidologi’ published since 1996 he is also a member of the editorial board of the three leading international suicidological journals Suicide & Life-Threatening Behaviour, Archives of Suicide Research and Crisis. He has published widely on these subjects and received several national and international awards. On a part time basis he maintains a private practice in psychiatry in the city of Oslo.