Journal of Affective Disorders 300 (2022) 305–313

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Review article

Dialectical behaviour therapy skills training groups for common mental

health disorders: A systematic review and meta-analysis
Chantal P. Delaquis a, Kayla M. Joyce a, Maureen Zalewski b, Laurence Y. Katz c, Julia Sulymka a,
Tayla Agostinho a, Leslie E. Roos a, d, e, *
a
Department of Psychology, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
b
Department of Psychology, University of Oregon, Oregon, United States
c
Department of Psychiatry, University of Manitoba, Winnipeg, Canada
d
Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
e
Children’s Hospital Research Institute of Manitoba, Winnipeg, Canada

A growing body of research points toward the underlying role of
emotion regulation deficits in the development and maintenance of
psychopathology (Aldao et al., 2010; Cludius et al., 2020; Sloan et al.,
2017). Many common mental health disorders are characterised by
symptoms of emotion dysregulation, including heightened sensitivity to
emotional stimuli, and a slow return to emotional baseline following
intense emotions (Linehan, 1993, 2015). Interventions targeting these
maladaptive regulatory patterns have the potential to be effective for
multiple disorders with underlying emotion regulation difficulties,
including anxiety, depression, eating disorders, and borderline person­
ality disorder (BPD; Aldao et al., 2010; Carpenter and Trull, 2012). The
identification of effective transdiagnostic interventions is particularly
valuable, given that the presence of multiple psychiatric disorders is risk
factor for greater symptom severity, longer illness duration, and symp­
tom re-occurrence (Brown et al., 2001).
In recent years, dialectical behaviour therapy (DBT) has been
increasingly regarded as a transdiagnostic intervention for emotion
dysregulation (Linehan et al., 2007). DBT offers many practical and
clinical advantages as a transdiagnostic treatment. Specifically, DBT
targets shared mechanisms between disorders (i.e., emotion regulation),
and its modular structure and flexibility allow clinicians to tailor content
and treatment duration to client needs (Linehan, 2015; Martin et al.,
2018). In contrast to other third-wave cognitive behavioural therapies,
DBT emphasizes the primary importance of treating life-threatening
behaviour through dialectically balancing acceptance and change stra­
tegies. Dialectical skills include crisis management, problem solving,
skills training, and the validation of one’s emotional experiences
(Linehan, 1993). Thus, DBT supports clients in building cognitive flex­
ibility, self-compassion, and diverse coping skills, all of which are
important for maintaining mental wellness in the face of adversity
(Linehan, 2015). Full model DBT involves two 24-week cycles of skills
training groups, individual weekly psychotherapy sessions, and tele­
phone contact with the therapist between sessions (Linehan, 1993).
However, this intensive treatment may not be clinically necessary for
clients who do not experience severe self-harm behaviours or suicidality
as seen in clients with BPD (Valentine et al., 2015). Stand-alone DBT
skills training groups ranging from 8 to 32 weeks of treatment are shown
to be effective in treating common mental health disorders (e.g.,
depression and binge eating disorder [BED]; Valentine et al., 2015).
While evidence from randomised control trials (RCT) has demon­
strated the effectiveness of DBT for clients with BPD (Cristea et al.,
2017), to date, a synthesis of literature examining DBT for common
mental health disorders without co-occurring BPD is lacking. A growing
series of studies, many with small sample sizes, suggest modest support
of DBT skills training for the treatment of eating disorders (Bankoff
et al., 2012), depression (Harley et al., 2008), and co-occurring anxiety
and depression (Neacsiu et al., 2014). Here, we highlight the potential of
DBT skills training groups as a transdiagnostic treatment for common
mental health disorders with a systematic review and meta-analysis. By
examining emotion regulation outcomes, this review aims to test the
hypothesis that DBT skills groups will improve emotion regulation
across psychiatric disorders. We expect that DBT will improve emotion
regulation, and overall primary symptom reduction in clients with
common mental health disorders in the absence of co-occurring BPD.
1. Method
This meta-analysis adheres to the Preferred Reporting for Systematic
Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009)
and is registered with PROSPERO (ID #: CRD42020157927) and on
Open Science Framework (https://osf.io/tur4p/).

* Corresponding author at: Department of Psychology, University of Manitoba, Winnipeg, MB R3T 2N2, Canada.
E-mail address: leslie.roos@umanitoba.ca (L.E. Roos).

https://doi.org/10.1016/j.jad.2021.12.062
Received 5 January 2021; Received in revised form 12 October 2021; Accepted 19 December 2021
Available online 26 December 2021
0165-0327/© 2021 Elsevier B.V. All rights reserved.
C.P. Delaquis et al.
Fig. 1. PRISMA diagram of the study inclusion process.
1.1. Identification and selection of studies
A systematic literature search was conducted within the following
electronic databases: PsychINFO, PubMed, Embase, The Cochrane Li­
brary (CENTRAL), and Google Scholar. Each database was searched
from the first available date until May 26th, 2020 (see Appendix A for
search terms). Additionally, three clinical trial registries (www.clinic
altrialsregister.eu, www.isrctn.com, and www.clinicaltrials.gov) were
searched on May 26th, 2020 to identify completed trials not yet
published.
To be included, studies must: employ RCT methodology, have DBT
skills groups lasting ≥8 weeks, include participants ≥18 years old
diagnosed with a mental health disorder without a co-occurring per­
sonality disorder1 and be available in English. Titles and abstracts of all
studies and then the full-texts of eligible articles were screened
1
Not all studies assessed the presence of personality disorders. In the anal­
ysis, we included both studies that listed the presence of a personality disorder
as an exclusion criteria, as well as studies where the target group was a disorder
other than a personality disorder (e.g. depression), and the presence of a per­
sonality disorder was not assessed.
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Journal of Affective Disorders 300 (2022) 305–313
independently by two reviewers. Disagreements were resolved through
consensus.
1.2. Data extraction
Extracted data included baseline characteristics, study design, sam­
ple size, sample demographics, psychiatric diagnosis and relevant
comorbidities, study inclusion/exclusion criteria, outcome measures,
and study results. All continuous pre- and post-measures of mental
health relevant to participants’ primary diagnosis, as well as emotion
regulation outcomes, were collected. Data were extracted by the first
author and trained student co-authors independently.
1.3. Statistical analyses
Overall pooled effect sizes were calculated using a random effects
meta-analysis. Since data from multiple studies were combined across
different clinical populations and were performed by independent re­
searchers, between-study heterogeneity was expected (Borenstein et al.,
2009). Effect sizes with and without outliers are reported. Effect sizes
and 95% confidence intervals (CI) for each study were calculated using
Hedges’ g instead of Cohen’s d, as Cohen’s d may overestimate effect size
C.P. Delaquis et al. Journal of Affective Disorders 300 (2022) 305–313

in analyses including less than 20 studies. Therefore, we used Hedges g Table 1

to control for potential bias presented by Cohen’s d. Hedges g controls Characteristics of 12 DBT randomised control trials for common mental health
for this bias by using a slightly different formula – the main difference disorders.
being that Hedges g uses pooled weighted standard deviation instead of Study Conditions Primary Diagnosis Nsess Risk of
pooled standard deviation (as is the case for Cohen’s d). Hedges g is (basis for diagnosis) Bias
interpreted as follows: small (g = 0.2), moderate (g = 0.5), and large abcde
Cancian (2017) DBT vs. Waitlist BED (BES) 10 -----
effect (g = 0.8; Hedges, 1981). Due to the heterogenous nature of the
outcomes measured between studies, dependent outcomes in each study
were aggregated using the meta-analysis with mean differences (MAd) Carter (2019) GSH-DBT vs. BED (DSM-V) 12 --+--
package in R (Del Re and Hoyt, 2014; R Core Team, 2013). Heteroge­ SE-USH
Fleming (2015) DBT vs. Waitlist ADHD (BAARS-IV) 9 -----
neity was assessed using Q tests and the I2 index to determine the extent
to which effect sizes varied across studies. I2 should be interpreted as: Harley et al. DBT vs. Waitlist MDD (SCID-I) 16 -----
0–40% heterogeneity may not be important, 30–60% may represent (2008)
moderate heterogeneity, 50–90% may represent substantial heteroge­ Hill (2011) DBT vs. Waitlist BN (modified criteria) 12 -----
neity, and 75–100% represents considerable heterogeneity (Deeks et al.,
Keuthen (2012) CBT+ DBT vs. TTM (DSM-IV) 11 /----
2020).
MAC
Pooled effect sizes were calculated for disorders where at least two
studies examined psychiatric outcomes.2 Further, the Difficulties in Lynch (2003) DBT+MED vs. MDD (DDES) 28 -/+-/
Emotion Regulation Scale (DERS; Gratz and Roemer, 2004) is amongst MED
Masson (2013) DBT vs. Waitlist BED (SCID-I) 13 -----
the most widely used measure of emotion regulation in DBT trials, with
constructs closely linked to DBT therapeutic domains; therefore, we Neasciu (2018) DBT vs. ASG Mood or Anxiety 16 ---+-
examined emotion regulation in two separate analysis by examining pre- disorder (SCID-I)
and post-assessment DERS scores and a pooled effect size of aggregated
emotion regulation outcomes. A meta-regression was performed to Rahmani (2018) DBT vs. Waitlist BED (SCID-I) 20 -/---

determine if length of DBT treatment had a significant impact on

treatment effects.
1.4. Addressing sources of bias
1.4.1. Risk of bias assessment
The risk of bias assessment tool developed by the Cochrane Collab­
oration (Higgins et al., 2020) determined the internal validity of each
included study. The risk of bias analysis assessed (a) adequate genera­
tion of allocation, (b) concealment of allocation to conditions, (c)
blinding of assessors, (d) incomplete outcome data, and (e) selective
data reporting. The risk of bias assessment was judged as low, high, or
some concern, for each criterion by two independent reviewers. Cohen’s
kappa was calculated for 5 domains across 12 studies, and is interpreted
as follows: κ = 0.00–0.20, no agreement; κ = 0.21–0.39, weak agree­
ment; κ = 0.40–0.59, minimal agreement; κ = 0.60–0.79, moderate
agreement; κ = 0.80–0.90, strong agreement; and κ > 0.90, almost
perfect agreement (McHugh, 2012).
1.4.2. Publication bias
Publication bias was assessed using Egger’s Test, visual inspection of
funnel plots, and the trim-and-fill procedure which results in an effect
size estimate after considering publication bias (Duval and Tweedie,
2000).
Safer (2001) DBT vs. Waitlist BN (modified criteria) 20 -----
Sahranavard DBT vs. Waitlist MDD (BDI-I) 8 --/+-
(2018)
Note. Nsess = number of sessions; ADHD = attention deficit hyperactive disor­
der; ASG = active skills group; BAARS-IV = Barkley Adult ADHD Rating Scale;
BDI-I = Beck Depression Inventory; BED = binge eating disorder; BES = Binge
Eating Scale; BN = bulimia; DBT = dialectical behaviour therapy; DDES =
Detection of Depression in the Elderly Scale; DSM-IV/ V = Diagnostic and Sta­
tistical Manual; GSH-DBT = Guided Self-Help Dialectical Behaviour Therapy;
HADS = Hospital Anxiety and Depression Scale; iCBT = internet CBT; MAC =
minimal attention control; MDD = major depressive disorder; MED = medica­
tion; SCID-I = Structured Clinical Interview for DSM-IV Axis I Disorders; SE-USG
= Self-Esteem, Unguided Self-Help; TAU = treatment as usual; TTM = tricho­
tillomania; Risk of Bias assessment: a = adequate generation of allocation
sequence, b = concealment of allocation to conditions, c = blinding of assessors,
d = incomplete outcome data, and e = selective data reporting; - = low risk of
bias; / = some concern or unclear; + = high risk of bias.
avoid weighing these samples twice, the two studies’ outcomes were
aggregated and treated as a single study in each case.3 As such, 12
studies were included in the meta-analysis when accounting for aggre­
gated studies (see Fig. 1 for the PRISMA flow diagram).
2.2. Study characteristics

2. Results
Amongst the 12 studies included, there were 425 participants with
215 in the treatment groups and 210 in the control groups. The primary
2.1. Study selection
diagnoses identified included: BED, major depressive disorder (MDD),
co-occurring mood and anxiety disorder, bulimia nervosa, attention
A total of 1191 articles were retrieved from database searches and
deficit hyperactive disorder (ADHD), and trichotillomania. The number
three articles from other sources. After reviewing titles and abstracts,
of treatment sessions ranged from 8 to 28 (Mdn = 12.5 sessions; see
1146 studies were discarded for not meeting inclusion criteria. The full
Table 1 for study characteristics and assessment tools and Table 2 for
texts of the remaining 45 articles were examined. During the full text
DBT skills training components).
screening stage, four authors were contacted, but did not respond to
requests for additional information to determine eligibility. A total of 14
studies met inclusion criteria. However, four studies examined the same 2.3. Sample characteristics
participant data across different outcomes in two separate studies. To
In the treatment groups, the average age was 34.32 years old. The

2
There was insufficient outcome data (n = 1) for ADHD, trichotillomania,
3
and (n = 0) for substance use disorder to conduct subgroup analyses for these Neacsiu et al. (2014, 2018) were aggregated, as well as Feldman et al.
diagnoses. (2009) and Harley et al. (2008).

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Table 2 Table 3a
Characteristics of DBT Skills Training Groups in 12 Randomized Control Trials. Meta-analysis studies comparing DBT efficacy for overall psychiatric outcomes.
Study Therapy Components Nsess Study Ni g 95% CI gpooled Q I2
Overall Effect 0.99* 32.67 66.3
Cancian, 2017 Adapted DBT i. Mindfulness 2
Trimmed Effect 0.79*** 16.4 39
ii. Emotion Regulation 5
Masson (2013) 30 0.69 0.16; 1.21
iii. Distress Tolerance 2
Carter (2019) 24 0.4 -0.18; 0.97
iv. Review 1
Hill (2011) 18 1.15 0.39; 1.91
Carter, 2019 GSH-DBT + video-chat i. Mindfulness N/A
Rahmani (2018) 30 1.44 0.87; 2.01
support
Rahmani (2018)a 10 0.84 0.13; 0.82
ii. Emotion Regulation
Harley (2008) 18 1.32 0.77; 1.87
iii. Distress Tolerance
Lynch (2003) 15 0.25 -0.33; 0.83
Fleming, 2015 DBT-ST i. Orientation and 2
Neacsiu (2018) 22 0.33 -0.36; 1.02
Mindfulness
Safer (2001) 14 0.76 0.25; 1.27
ii. Social Support 1
Fleming (2015) 17 0.71 0.00; 1.42
iii. Managing Sleep, Eating 1
Cancian (2017) 14 0.77 0.03; 1.51
and Exercise
Sahranavard (2018)a 10 4.46 2.69; 6.24
iv. Troubleshooting Skills 2
v. Emotion Regulation 1 Note: Ni = number of participants in intervention condition; 95% CI = 95%
vi. Review 2 confidence interval.
Harley (2008) DBT-ST i. Mindfulness 2 a
= excluded in trimmed analysis.
ii. Interpersonal 4 *
p < .05.
Effectiveness ***
iii. Review 2
p < .0001.
iv. Emotion Regulation 4
v. Distress Tolerance 4 majority of participants were female (85.24%) and Caucasian (63.07%)
Hill, 2011 DBT-AF i. Appetite Awareness 4
with two studies reporting uniquely Iranian samples (Rahmani et al.,
Training & Mindfulness
ii. Distress Tolerance 4 2018; Sahranavard et al., 2018), one study with a uniquely Brazilian
iii. Emotion Regulation 4 sample (Cancian et al., 2019) and one study not reporting ethnicity in­
Keuthen, 2012 CBT+DBT i. Psychoeducation & 1 formation (Keuthen et al., 2012). Education levels varied between
Chain Analysis studies. Most participants, on average, had some college education or
ii. Prevention training & 1
Stimulus Control
higher, however one study reported that 63.3% of their sample was
iii. Mindfulness 3 illiterate, and only 6.7% had a diploma (Sahranavard et al., 2018).
iv. Emotion Regulation 3 Participants had, on average, high baseline levels of emotion dys­
v. Distress Tolerance 2 regulation as measured by the DERS (M = 108.87), whereas healthy
vi. Relapse Prevention & 5
controls generally score between 63 and 76 (Becerra et al., 2013; Har­
Review
Lynch, 2003 DBT + MED + phone i. Psychoeducation and 8 rison et al., 2010). Baseline scores on the Beck Depression Inventory-II
support Mindfulness (BDI-II; Beck et al., 1996) showed moderate levels of depression (M =
ii. Distress Tolerance 4 19.56, clinical cut-off =16; Smarr and Keefer, 2011) and baseline scores
iii. Emotion Regulation 6 on the Eating Disorder Examination – Questionnaire (EDE-Q) were also
iv. Interpersonal 10
clinically significant (M = 3.19, clinical cut-off = 2.50; (Rø et al., 2015).
Effectiveness
Masson, 2013 GSH-DBT + phone i. Mindfulness N/A No study independently examined anxiety disorders, and in the sample,
support anxiety generally co-occurred with a mood disorder.
ii. Emotion Regulation Borderline personality disorder was explicitly assessed in only two of
iii. Distress Tolerance
the 12 included studies. Neacsiu and colleagues excluded participants if
Neasciu, 2018 DBT-ST i. Mindfulness 3
ii. Emotion Regulation 6
they scored above 2.5 on the Borderline Symptom List-23 or if they met
iii. Distress Tolerance 4 full criteria for BPD on the Structured Clinical Interview for DSM-IV for
iv. Interpersonal 3 personality disorders (SCID-II: Neacsiu et al., 2014). Feldman and col­
Effectiveness leagues excluded participants who met BPD criteria on the SCID-II
Rahmani, 2018 DBT-BED i. Dialectics and Treatment 2
(Feldman et al., 2009). While the rest of the included studies did not
Commitment
ii. Mindfulness 4 directly assess BPD, the majority excluded participants with active sui­
iii. Emotion Regulation 7 cidal ideation or a previous suicide attempt in the past year, which is a
iv. Distress Tolerance 5 prominent symptom of BPD (Cancian et al., 2019; Flemming et al., 2015;
v. Review and Relapse 2
Hill et al., 2011; Keuthen et al., 2012). One study also excluded those
Prevention
Safer, 2001 DBT-BED i. Goals and Treatment 2
who had a primary diagnosis other than binge eating disorder (Rahmani
Commitment et al., 2018).
ii. Mindfulness 4
iii. Emotion Regulation 7
iv. Distress Tolerance 5
2.4. Overall effects
v. Review and Relapse 2
Prevention The overall trimmed effect of DBT skills groups on primary symptom
Sahranavard, DBT-ST i. Mindfulness 2 reduction compared to waitlist and active control groups was large (g =
2018
0.79; 95% CI [0.52, 1.06], p < .0001; see Table 3a) with moderate
ii. Interpersonal 2
Effectiveness heterogeneity (I2 = 39.00; 95% CI [0.00, 70.00], p = .08). One major
iii. Emotion Regulation 2 outlier was detected, (Sahranavard and Miri, 2018) with a z-score well
iv. Distress Tolerance 2 above 1.96 (z = 2.23, ). The untrimmed effect of DBT skills training
Note. Nsess = number of sessions; CBT = cognitive behaviour therapy; groups compared to waitlist and active control groups was large (g =
DBT = dialectical behaviour therapy; DBT-AF = dialectical behaviour therapy – 0.99, 95% CI [0.38, 1.59], p = .004), with moderate heterogeneity (I2 =
appetite focused; DBT-BED = dialectical behaviour therapy for binge eating 66.30; 95% CI [38.10, 81.70], p < .001). The outlier had a large influ­
disorder; DBT-ST = dialectical behaviour therapy skills training; GSH- ence on the overall effect size and significantly contributed to
DBT = Guided Self-Help Dialectical Behaviour Therapy; MED = medication between-study heterogeneity, therefore we chose to present trimmed

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C.P. Delaquis et al.
Fig. 2. Overall trimmed effect of DBT on aggregated outcomes. Error bars represent 95% confidence intervals (CI).
effect sizes (see Fig. 2).
A sensitivity analysis was conducted to examine studies where an
intent-to-treat (ITT) analysis was performed a priori (k = 5). This anal­
ysis yielded a non-significant large effect size with a trend toward
favouring DBT skills training (g = 1.71, 95% CI [-1.83, 5.25], p = .25).
Heterogeneity was high (I2 = 97.40; 95% CI [95.70, 98.40]).
2.5. Subgroup effects
2.5.1. Emotion regulation
The trimmed effect of DBT skills training on emotion regulation
outcomes (k = 7) compared to the waitlist and active control groups
yielded a small-to-moderate effect (g = 0.48, 95% CI [0.22, 0.74], p =
.0038) with low heterogeneity (I2 = 0.00; 95% CI [0.00, 65.70]). The
overall pooled effect size with the outlier included was large but not
significant, (g = 1.91, 95% CI [-1.47, 5.30], p = .22), with high het­
erogeneity (I2 = 93.20; 95% CI [88.90, 95.80]). Results suggest that the
outlier had a significant influence on the pooled effect size and a large
heterogeneity contribution (for a summary of subgroup effects, see
Table 3b).
To further examine emotion regulation, DERS scores (k = 5) were
analysed pre- and post- treatment. A large, non-significant effect was
found for the DBT skills training compared to active and waitlist controls
(g = 2.70, 95% CI [-3.82, 9.21], p = .31) with considerable heteroge­
neity (I2 = 96.00; 95% CI [93.00, 97.70]). One outlier was identified
(Rahmani et al., 2018) which, when removed, decreased the effect size
to a marginally significant small-to-moderate effect (g = 0.47, 95% CI
[-0.01, 0.96], p = .05), with low heterogeneity (I2 = 0.00; 95% CI [0.00;
81.60]).
2.5.2. Depression
The trimmed pooled effect of depression outcomes (k = 8) was a
moderate (g = 0.50, 95% CI [0.25, 0.75], p = .002) in studies of DBT
skills groups compared to waitlist, active skills training and medication
only control groups. The untrimmed effect was large but not significant
(g = 0.85, 95% CI [-0.05, 1.76], p = .062). After removing the outlier,
heterogeneity was not significant, suggesting the outlier had a large
heterogeneity contribution (I2 = 0.00; 95% CI [0.00, 52.30]).
2.5.3. Binge eating and bulimia
The pooled effect of DBT skills groups on eating disorder outcomes
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Journal of Affective Disorders 300 (2022) 305–313
for participants with BED/bulimia (k = 6) was large (g = 0.83, 95% CI
[0.49, 1.17], p = .001) with low heterogeneity (I2 = 31.10; 95% CI
[0.00, 72.00]) compared to waitlist and unguided self-help control
groups. No outliers were identified.
2.5.4. Anxiety
The pooled effect of anxiety outcomes in the DBT skills groups (k = 4)
was small-to-moderate (g = 0.45, 95% CI [0.08, 0.83], p = .03) with low
heterogeneity (I2 = 0.00; 95% CI [0.00, 61.40]) compared to waitlist,
active skills training and minimal attention control groups. No outliers
were identified.
2.5.5. Additional analyses
The meta-regression results showed treatment length was not a sig­
nificant predictor of effect size (F1,9 = 1.37, p = .27).
2.6. Addressing sources of bias
2.6.1. Risk of bias assessment
Of the 12 identified studies, the risk of bias was low for most studies
(see Table 2). Most studies reported adequate sequence generation
(92%), adequate allocation concealment (83%), adequate blinding of
outcome assessors (83%), low risk of incomplete outcome data (83%)
and low risk of selective outcome reporting (100%). Four studies had
some concern of bias, but for the remaining eight studies, risk of bias was
low. Overall interrater reliability was 80% across all domains. For each
of the five domains, Cohen’s kappa ranged from κ = 0.54 – 0.88, sug­
gesting acceptable interrater reliability.
2.6.2. Publication bias
A trimmed publication bias test was conducted. Egger’s test was not
significant (p > .46). The Duval-Tweedie trim-and-fill procedure did not
fill any studies. No asymmetry was observed in the funnel plot. Thus,
publication bias was not identified.
3. Discussion
We assessed the effects of DBT skills training groups on common
mental health disorders in 12 studies employing RCT methodology.
Results suggest that DBT skills groups are effective at overall symptom
reduction (moderate effect), and improving emotion regulation (small-
C.P. Delaquis et al.
to-moderate effect), depression (moderate effect), BED/bulimia (large
effect), and anxiety outcomes (small-to-moderate effect). This is the first
meta-analysis examining the effectiveness of DBT skills training for
common mental health disorders. We provide emerging evidence for
DBT skills training groups as an effective transdiagnostic treatment
modality for various mental health disorders, building on research
demonstrating the efficacy of DBT skills for individuals with BPD and
high suicide risk (Linehan et al., 2015).4
Consistent with previous research, we found that targeting emotion
regulation with DBT skills training effectively reduces symptoms of
overall psychopathology (Neacsiu et al., 2014). Our results yielded a
moderate effect on symptom reduction for clients with depression, a
large effect for clients with bulimia nervosa and BED, and a
small-to-moderate effect for clients with anxiety. The trimmed effect size
of DBT skills training for depression is comparable to depressive symp­
tom improvements seen with cognitive behaviour therapy (CBT;
adjusted for publication bias; g = 0.53, 95% CI 0.43, 0.62, k = 94;
Cuijpers et al., 2013) and the Unified Protocol (UP; g = -0.57 95% CI
-0.92, -0.21, p = .002, k = 5; Sakiris and Berle, 2019). Effect sizes for
BED/bulimia are comparable to CBT for BED (g = 0.82, 95% CI 0.41,
1.22, p < .05, k = 5; Vocks et al., 2010). Additionally, DBT skills training
had a small-to-moderate effect on reducing anxiety symptoms compa­
rable to the UP versus a waitlist control group (g = 0.56, p = .034, n =
26). The effect was slightly larger with the UP, suggesting clients with
anxiety disorders may benefit from an additional clinical focus on
exposure therapy or cognitive aspects of DBT (e.g., “thoughts are not
facts”), which may help clients with persistent co-occurring anxiety
symptoms (Harned et al., 2014). Future research should explore whether
DBT skills training groups can be amended to more effectively treat
clients with anxiety, and which variables mediate this relationship (e.g.,
length of treatment, specific modules [e.g. mindfulness], or presence of
co-occurring disorders).
To avoid overestimating the effect of DBT skills groups, we focused
on sensitivity analyses in which the two outliers with very large effect
sizes (>2 standard deviations) were excluded (Rahmani et al., 2018;
Sahranavard and Miri, 2018). Notably, both outlier studies were con­
ducted in Iran, indicating potential cultural differences including dif­
ferences in outcome measures and treatment delivery. Additionally,
differences in population or protocol may explain the extremely large
effects with participants from both studies exhibiting elevated psycho­
social distress at baseline. The first outlier study (n = 30) of BED re­
ported very high baseline DERS scores (M = 148) and an increased
therapeutic focus on emotion regulation skills (Rahmani et al., 2018).
The second outlier study (n = 10) included participants with substance
use (outcomes not reported) and high baseline depression scores (Sah­
ranavard and Miri, 2018). When clients present with higher distress at
baseline, there is naturally more room on the given mental health scale
for symptoms to decrease, indicating a possible ceiling effect (Salkind,
2010).5
While our hypothesis that improving emotion regulation is a mech­
anism underlying the treatment effectiveness of DBT skills groups was
supported, alternative hypotheses that were not investigated are also
plausible. For example, mindfulness training is a core component of DBT
and was a common module across included studies. Mindfulness based-
interventions have been shown to be superior to no treatment control
groups for anxiety, depression and weight/eating-related concerns
(Cohen’s d = 0.45–0.89; Goldberg et al., 2018). The development of
mindfulness skills, such as nonjudgmental observation and description
of emotional states, may also be a mechanism underlying clinical im­
provements. Future research should separately examine the components
4
Note: Studies of DBT skills for BPD include intensive case management with
small caseloads, and enhanced suicide risk assessment and management
training
5
Study authors have not responded to requests for clarifying information.
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Journal of Affective Disorders 300 (2022) 305–313
of DBT to isolate the effects of different modules and identify key skills
leading to specific symptom reduction.
3.1. Strengths and limitations
Strengths of this analysis include its adherence to PRISMA guidelines
(Moher et al., 2009), including pre-registration of the study protocol,
and the novelty of this summative research on DBT skills training for
common mental health disorders. Further, this study only assessed high
quality RCTs, and highlighted several gaps in the literature, including
the transdiagnostic potential of DBT skills training groups, the need for
further research exploring DBT for common disorders with larger sam­
ples, and a strong evidence base for stand-alone DBT skills groups for
future research to address.
Unfortunately, insufficient evidence from RCTs supporting the use of
DBT skills training for ADHD, trichotillomania (k = 1 of each), PTSD and
substance use disorders (although included in our search, none were
identified) limited our ability to conduct moderator analyses and
generalize findings to other common mental health disorders. Due to the
small sample size, we examined all depression and anxiety outcomes,
including outcomes in samples where they were not the primary
outcome. While this may be a limitation, it lends support to the hy­
pothesis that DBT skills training can treat both primary and co-occurring
depression and anxiety. Additionally, we selected studies that were
designed to treat disorders without co-occurring personality disorders,
with many studies including BPD or BPD traits as an exclusionary cri­
terion. However, most studies did not directly assess BPD, leaving the
possibility of comorbidity.
Further, the samples were primarily female and Caucasian, limiting
generalizability to other populations. At the same time, there were two
studies that included uniquely Iranian populations and one study of
Brazilian participants, which adds to the cross-cultural generalizability
of DBT skills groups. Lastly, a limitation of the included studies is that
most control groups were waitlist controls. This limited our ability to
compare DBT skills training to current gold-standard treatments for
common mental health disorders such as CBT. However, our analysis
comparing DBT skills groups to waitlist control groups allows us to
examine the effect of DBT skills training on symptom reduction and its
effectiveness in treating common mental health disorders as a stand­
alone treatment, which is the aim of this meta-analysis. Taken together,
these limitations highlight the need for further research on the efficacy
of DBT skills training groups as a transdiagnostic treatment.
3.2. Conclusions and future directions
Future research should determine the benefits of DBT skills training
groups for a wider range of mental health disorders with larger sample
sizes, as well as comparing the effectiveness of DBT skills training to
other gold standard treatments such as CBT. The benefits of treatment
length across different clinical diagnoses is also of interest. Future
research should also assess BPD traits in the study sample, either as an
exclusionary criterion or as a covariate. This meta-analytic evidence
suggests DBT skills training is effective in small doses (Mdn = 12.5
sessions), thus full model DBT (48 sessions) may not be required for
optimal treatment outcomes for clients without BPD. This has important
implications for treatment accessibility and dissemination, including
reduced training hours, treatment costs and clinician burden. The
reasonable treatment length (approximately 12 sessions) and group
format of DBT skills training make it an excellent candidate for effective,
accessible and cost-effective treatment for a range of disorders. Further,
it would be valuable to narrow in on baseline sociodemographic and/or
clinical characteristics linked to treatment success with DBT compared
to other therapies to tailor services from a personalised therapy
approach. Additional research on the effectiveness of DBT skills training
in more heterogenous clinical populations with mental health comor­
bidities, or for unique populations, such as veterans, incarcerated
C.P. Delaquis et al. Journal of Affective Disorders 300 (2022) 305–313

Table 3b
Meta-Analysis of Studies Comparing DBT Efficacy for Psychiatric Outcomes by Disorder.
Study Outcomesa Ni g 95% CI gpooled Q I2

Emotion Regulation 0.48** 5.11 0.00

DERS only 0.47* 2.49 0.00
Masson, 2013 DERS 30 0.75 0.23; 1.28
Hill, 2011 NMR 18 0.49 0.02; 0.97
***Rahmani, 2018b DERS 30 12.29 9.96; 14.61
Keuthen, 2012 DERS 18 0.43 -0.48; 0.38
Neasciu, 2018 DERS 15 0.14 -0.68; 0.97
Safer, 2001 NMR 14 0.18 -0.31; 0.67
Cancian, 2017 DERS 14 0.54 -0.18; 1.26
Harley, 2008 EPS 10 1.19 0.19; 2.19
Depression 0.50** 4.76 0.00
Hill, 2011 BDI-II 18 0.90 0.16; 1.63
Keuthen, 2012 BDI-II 18 0.84 0.13; 1.56
Harley, 2008 BDI / HAM-D 10 0.84 0.13; 1.56
Lynch, 2003 BDI / HAM-D 15 0.25 -0.33; 0.83
Fleming, 2015 BDI-II 17 0.44 -0.26; 1.12
Neasciu, 2018 PHQ-9 15 0.60 -0.36; 1.56
Safer, 2001 BDI 14 0.33 -0.40; 1.07
Cancian, 2017 DASS-Depression 14 0.78 0.04; 1.52
Sahranavard, 2018b BDI 10 4.46 2.69; 6.24
Eating Disorders 0.83*** 7.26 31.1
Masson, 2013 EDQLS / EDE-Q 30 0.83 0.42; 1.22
Carter, 2019 EDE-Q 24 0.40 -0.18; 0.97
Hill, 2011 EDEQ/MACR/PEWS 18 0.92 0.45; 1.39
Rahmani, 2018 BES 30 1.44 0.87; 2.01
Safer, 2001 EES 14 0.76 0.25; 1.27
Cancian, 2017 EES / BES / IES-2 14 0.66 0.11; 1.20
Anxiety 0.45* 1.19 0.00
Keuthen, 2012 BAI 18 0.64 -0.04; 1.31
Fleming, 2015 BAI 17 0.57 -0.13; 1.27
Neacsiu, 2018 OASIS 12 0.06 -0.84; 1.31
Cancian, 2017 DASS - Anxiety 24 0.37 -0.34; 1.09

Note: Ni = number of participants in intervention condition; 95% CI = 95% confidence interval. BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory;
BES = Binge Eating Scale; DASS – Depression Anxiety Stress Scale; DERS = Difficulties in Emotion Regulation Scale; EDE-Q = Eating Disorder Examination Ques­
tionnaire; EDQLS = Eating Disorder Quality of Life Scale; EES = Emotional Eating Scale; EPS = Emotional Processing Scale; HAM-D = Hamilton Depression Rating
Scale; IES-2 = Intuitive Eating Scale; MACR = Mizes Anorectic Cognitions Scale – Revised; NMR = Negative Mood Regulation; PEWS = Preoccupation with Eating
Weight and Shape Scale; PHQ-9 = Patient Health Questionnaire
a
For references see Appendix B;
b
Outlier removed
*
p < .05.
**
p < .01.
***
p < .001

persons, or parents with family conflict, is of interest to further extend
DBT’s potential application.
Collectively, DBT skills training groups appear to be a promising
treatment candidate for multiple mental health disorders, with emerging
evidence supporting its transdiagnostic applicability for emotion dys­
regulation broadly, as well as BED/bulimia, depression, and possibly co-
morbid anxiety. Results highlight the potential of DBT skills training
groups to make meaningful advances in addressing mental health needs
for clients that may experience limited benefits from other therapies.
Future research should continue to explore DBT skills training as a
transdiagnostic tool for treating emotion dysregulation and gain preci­
sion on both the mechanisms of change and critical components for best-
practice guidelines across disorders Table 3b.
original draft. Kayla M. Joyce: Supervision, Investigation, Writing –
review & editing. Maureen Zalewski: Conceptualization, Writing –
review & editing. Laurence Y. Katz: Conceptualization, Writing – re­
view & editing. Julia Sulymka: Investigation, Writing – review &
editing. Tayla Agostinho: Investigation. Leslie E. Roos: Conceptuali­
zation, Supervision, Writing – review & editing.
Declaration of Competing Interest
Laurence Katz is a Dialectical Behaviour Therapy trainer for Behav­
ioural Tech. All other authors report no conflict of interest.
Acknowledgments

Funding
Funding for the study was provided by the University of Manitoba
via the Psychology Undergraduate Research Experience award and
Research Manitoba. The funding source had no involvement in study
design, collection, analysis or interpretation of the data, writing the
manuscript, or the decision to submit the manuscript for publication.
CRediT authorship contribution statement
Chantal P. Delaquis: Methodology, Data curation, Writing –
The authors wish to thank Eva Vandenbossche, who assisted in the
screening of articles in the preliminary stages.
Appendix A
Articles for this meta-analysis were identified within the following
electronic databases in September of 2019: PsychINFO, PubMed,
Embase, The Cochrane Library (CENTRAL), and Google Scholar. Search
terms included combinations of: “dialectical behavio(u)r(al) therapy,”
“DBT,” “Axis I,”, “substance use disorder”, “SUD”, “PTSD,” “post-trau­
matic stress disorder,” “depression,” “dysthymia,” “MDD,” “major

311
C.P. Delaquis et al.
depressive disorder,” “anxiety,” “GAD,” “generalised anxiety disorder,”
“bipolar disorder,” “eating disorder,” “bulimia,” “anorexia,” “binge
eating disorder,” “BED,” “ADHD,” “attention-deficit hyperactivity dis­
order,” “emotion dysregulation,” “randomised control trial,” and “RCT”.
Appendix B
References for outcomes measures used in the included studies.
Adair, C. E., Marcoux, C. G., Cram, B. S., Ewashen, C. J., Chafe, J.,
Cassin, S. E., … & Brown, K. E. (2007). Development and multi-site
validation of a new condition-specific quality of life measure for
eating disorders. Health and Quality of Life Outcomes, 30(5), 23. 10.1186/
1477-7525-5-23
Arnow, B., Kenardy, J., & Agras, W. S. (1995). The development of a
measure to assess coping with negative affect by eating. International
Journal of Eating Disorders, 18(1), 79–90. 10.1002/1098-108X(199507)
18:1<79::AID-EAT2260180109>3.0.CO;2-V
Baker, R., Thomas, S., Thomas, P., Gower, R., Santonastaso, M., &
Whittlesea, A.(2009).The emotion processing scale: Scale refinement
and abridgement (EPS-25). Journal of Psychosomatic Research, 68(1),
83–88. 10.1016/j.jpsychores.2009.07.007
Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An in­
ventory for measuring clinical anxiety: Psychometric properties. Journal
of Consulting and Clinical Psychology, 56, 893–897. 10.1037/0022-
006X.56.6.893
Beck, A., Steer, R., & Brown, G. (1996). BDI-II, Beck depression in­
ventory: Manual (2nd ed.) San Antonio, Texas: Psychological
Corporation.
Beck, A., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961).
An inventory for measuring depression. Archives of General Psychiatry, 4,
561–571. 10.1001/archpsyc.1961.01710120031004
Catanzaro, S. J., & Mearns, J. (1990). Measuring generalised ex­
pectations for negative mood regulation: Initial scale development and
implications. Journal of Personality Assessment, 54(3–4), 546–563.
10.1080/00223891.1990.9674019
Fairburn, C. G., & Beglin, S. J. (1994). Assessment of eating disor­
ders: Interview or self-report questionnaire? International Journal of
Eating Disorders, 16(4), 363–370. 10.1002/1098-108X(199412)
16:4<363::AID-EAT2260160405>3.0.CO;2-%23
Gormally, J., Black, S., Daston, S., & Rardin, D. (1982). The assess­
ment of binge eating severity amongst obese persons. Addictive Behav­
iour, 7(1), 47–55. 10.1016/0306-4603(82)90024-7
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Neurology, Neurosurgery and Psychiatry, 23, 56–62. 10.1136/
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Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9:
Validity of a brief depression severity measure. Journal of General In­
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Luce, K., & Crowther, J. (1999). The reliability of the eating disorder
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Appendix C
Citations for all studies included in the meta-analysis. Cancian, A.,
312
Journal of Affective Disorders 300 (2022) 305–313
Souza, L., Liboni, R., Machado, W., & Oliveira, M. (2019). Effects of a
dialectical behaviour therapy-based skills group intervention for obese
individuals: A Brazilian pilot study. Eating and Weight Disorders - Studies
on Anorexia, Bulimia and Obesity, 24(6), 1099–1111. 10.1007/s40519-
017-0461-2
Carter, J. C., Kenny, T. E., Singleton, C., Van Wijk, M., & Heath, O.
(2019). Dialectical behaviour therapy self-help for binge-eating disor­
der: A randomised controlled study. International Journal of Eating
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Feldman, G., Harley, R., Kerrigan, M., Jacobo, M., & Fava, M. (2009).
Change in emotional processing during a dialectical behaviour therapy-
based skills group for major depressive disorder. Behaviour Research
and Therapy, 47(4), 316–321. 10.1016/j.brat.2009.01.005
Fleming, A., Mcmahon, R., Moran, L., Peterson, A., & Dreessen, A.
(2015). Pilot randomised controlled trial of dialectical behaviour ther­
apy group skills training for ADHD amongst college students. Journal of
Attention Disorders, 19(3), 260–271. 10.1177/1087054714535951
Harley, R., Sprich, S., Safren, S., Jacobo, M., & Fava, M. (2008).
Adaptation of dialectical behaviour therapy skills training group for
treatment-resistant depression. The Journal of Nervous and Mental
Disease, 196(2), 136–143. 10.1097/NMD.0b013e318162aa3f
Hill, D., Craighead, L., & Safer, D. (2011). Appetite-focused dialec­
tical behaviour therapy for the treatment of binge eating with purging: A
preliminary trial (clinical report). The International Journal of Eating
Disorders, 44(3), 249–261. 10.1002/eat.20812
Keuthen, N., Rothbaum, B., Fama, J., Altenburger, E., Falkenstein,
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Behavioural Addictions, 1(3), 106–114. 10.1556/JBA.1.2012.003
Lynch, T., Morse, J., Mendelson, T., & Robins, C. (2003). Dialectical
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Neacsiu, A. D., Eberle, J. W., Kramer, R., Wiesmann, T., & Linehan,
M. M. (2014). Dialectical behaviour therapy skills for transdiagnostic
emotion dysregulation: A pilot randomised controlled trial. Behaviour
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Neacsiu, A., Rompogren, J., Eberle, J., & Mcmahon, K. (2018).
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Behaviour Therapy, 49(3), 344–359. 10.1016/j.beth.2017.10.004
Rahmani, M., Omidi, A., Asemi, Z., & Akbari, H. (2018). The effect of
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Sahranavard, S., & Miri, M. (2018). A comparative study of the
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women substance abusers. Psicologia: Reflexão e Crítica, 31(1), 1–8.
10.1186/s41155-018-0094-z
Safer, D., Telch, C., & Agras, W. (2001). Dialectical behaviour ther­
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