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. Author manuscript; available in PMC: 2024 Nov 1.
Published in final edited form as: J Clin Psychol. 2023 Jul 18;79(11):2556–2565. doi: 10.1002/jclp.23564

Drug Use and Suicidal Ideation in the Daily Lives of Individuals in a Dialectical Behavior Therapy Program

Matison W McCool 1, Kirk D Mochrie 2, John E Lothes 3,4, Eric Guendner 3,4, Jane St John 4, Nora E Noel 3
PMCID: PMC10592253  NIHMSID: NIHMS1921107  PMID: 37462923

Abstract

Objectives:

Substance use disorders and borderline personality disorders (BPD) often co-occur and may be concurrently treated by Dialectical Behavior Therapy (DBT). However, there is limited information on how drug use and suicidal ideation may interact in the daily lives of individuals receiving DBT treatment.

Methods:

This study examined the DBT diary cards of 47 individuals in a community mental health center’s partial hospital and intensive outpatient program. Multilevel modeling techniques were used to examine the moderating effects of borderline personality disorder symptom severity on the relationship between same day, one, two, and three day lagged drug use and suicidal ideation.

Results:

Results indicated a significant relationship between same-day, one day lagged, two day lagged drug use and suicidal ideation. BPD was a moderator for the relationship between one day lagged drug use and suicidal ideation.

Conclusion:

Limitations of the study include the measure for borderline personality disorder symptom severity was only collected pre-treatment and the results are likely limited to the effects of cannabis use on suicidal ideation. Clinicians may need to consider the prolonged effects of drug use on suicidal ideation when conducting chain analyses on suicidal behaviors.

Keywords: Dialectical Behavior Therapy, Drug Use, Cannabis Use, Suicidal Ideation

Substance use is a primary risk factor for suicidal ideation, suicidal behaviors, and completed suicide (Esang & Ahmed, 2018; López-Goñi et al., 2018; Poorolajal et al., 2016). Moreover, individuals with borderline personality disorder (BPD) are also at increased risk of both suicidal behaviors (Martino et al., 2018; Paris, 2018; Temes et al., 2019) and substance use (Trull et al., 2018). A range of problems can arise from the use of alcohol and other drug use; consequently, there is no single intervention approach for all patients. Dialectical Behavior Therapy (DBT) is comprehensive therapy with considerable empirical support for treating BPD and patients with complex problems related to emotional dysregulation (Linehan & Wilks, 2015). More recently, evidence has accumulated suggesting the efficacy of DBT for a variety of patient populations in numerous settings, including the use of DBT skills as a partial hospital program (Lothes et al., 2021; Mochrie et al., 2019; Panos et al., 2014). Thus, it stands to reason that DBT concepts and skills may also help treat individuals with Substance Use Disorders (SUDs) with and without co-occurring BPD (Dimeff & Linehan, 2008).

On average, the prevalence of BPD amongst individuals with a SUD is approximately 33.8% and the average prevalence of a current diagnosis of a SUD amongst individuals with BPD is approximately 45.46% (Trull et al., 2018). In short, many substance using patients will likely exhibit the emotional and behavioral dysregulation targeted in DBT. Additionally, substance use is a major risk factor for suicide (Crump et al., 2021), a problem that has increased since the COVID-19 pandemic and resulting lockdowns (Jadir & Anderson-Carpenter, 2022). The relationship between substance use and suicide is evident across many substances including opioids (Rizk et al., 2021), alcohol, cocaine, and cannabis (Armoon et al., 2021; Crump et al., 2021). The relationship between cannabis use and suicide behaviors is particularly important as various states and territories are increasingly legalizing cannabis for recreational use (Weinberger et al., 2022). Specifically, cannabis use is associated with increased suicidal ideation and planning for suicide (Hill et al., 2021). Additionally, the positive relationship between cannabis use and suicidal ideation appears to strengthen over time (Halladay et al., 2020; Han et al., 2021). With high comorbidity between SUDs and BPD, individuals with both disorders are likely at an even higher risk for suicide than those with only one of the diagnoses (Trull et al., 2018; Yuodelis-Flores & Ries, 2015). Therefore, individuals with a SUD, BPD, and co-occurring BPD and SUD may benefit from a DBT-informed treatment approach (Cavicchioli et al., 2019).

Comprehensive DBT includes individual therapy that uses a hierarchy of behavioral targets, including substance use, and provides strategies for therapy-interfering behaviors (see Chapman & Rosenthal, 2016). The first focus of treatment within the hierarchy is to decrease life-threatening behaviors including suicide planning, nonsuicidal self-injury, and suicidal ideation (Linehan, 1993). Next, the focus moves to decreasing behaviors that interfere with therapy stemming from both the client (e.g., showing up late to session, refusal to work on therapy assignments) and therapist (e.g., feeling unmotivated, showing up late to appointments; Koerner, 2012). The third focus of the stage-1 hierarchy is behaviors that interfere with the patient’s quality of life and includes substance use (Linehan, 1993). Lastly, DBT focuses on increasing behavioral skills needed to make change (Koerner, 2012). Unless explicitly established as a pattern that leads to suicidal behavior or if the patient arrives to group or individual sessions intoxicated substance use is considered at the third level of the hierarchy (Dimeff & Linehan, 2008). Thus, for a substance-using patient that also exhibits suicide behaviors and suicidal ideation, treatment would focus first on the suicidal behaviors before targeting substance use (Linehan, 1993).

Evidence on DBT treatment has related changes in emotional dysregulation to differences in substance use (Axelrod et al., 2011) and DBT outcomes to skill usage (Neacsiu et al., 2010). DBT treatment for substance use encourages relatively extensive treatment involvement and supports relapse prevention (Dimeff & Linehan, 2008). Furthermore, some symptoms and related difficulties of BPD also relate to substance use difficulties, such as impulsive behaviors and difficulty regulating emotions (Trull et al., 2018). For example, individuals with BPD typically have a slow return to baseline after experiencing a prompting event that leads to an intense emotion (Selby & Joiner, 2013). Individuals engaging in substance use behaviors may substitute skillful behaviors with their drug of choice as a means of coping with difficult emotions (Gold et al., 2020). Within the Biosocial model, these substance use behaviors become reinforcers in themselves as they likely work to reduce emotion dysregulation in the moment (Volkow et al., 2019). Additionally, DBT framework proposes substance use as a vulnerability to experiencing unwanted emotions, which means that emotions may take more time for individuals with BPD to regulate (Linehan, 1993).

The slow return to baseline for individuals with BPD has predominately been examined through the polyvagal theory (Porges, 2009) where decreases in markers of the parasympathetic nervous system are associated with a slower return to emotional baseline (Yeh & Lin, 2022). The slow return to baseline for individuals with BPD may be due to reductions in cardiac vagal control when faced with emotional cues, resulting in fewer self-regulatory resources available to quickly regulate emotions (Austin et al., 2007). Research surrounding individuals with BPD’s slow return to baseline is mixed. Individuals with BPD tend to recover more slowly from emotions (Eddie et al., 2018), particularly those surrounding shame (Gratz et al., 2010) and anger (Fitzpatrick & Kuo, 2015). However, other studies have found less consistent results for a slow return to baseline hypothesis (Santangelo et al., 2016). Additionally, individuals that use substances also tend to experience increased emotional dysregulation as their substance use quantity and frequency increase (Garke et al., 2021). Taken together, the available evidence suggests that high sensitivity and reactivity within the emotional regulatory systems of the brain as well as possible slow return to baseline are likely related to substance use, particularly among individuals with comorbid BPD and SUDs. However, research is needed to confirm this.

The present study aimed to examine the relationship between suicidal ideation, daily drug use, and BPD when controlling for length of stay, or how many days individuals remained in treatment at the clinic. Specifically, we aimed to test the same day and subsequent day associations between drug use and suicidal ideation as measured by self-report on participant daily diary cards (formally used in comprehensive DBT programs). In addition, we set out to examine the potential for a slow return to baseline for suicidal ideation on days following drug use.

Therefore, we tested the following Apriori hypotheses:

  1. BPD symptom severity will be positively associated with self-reported suicidal ideation on the diary cards.

  2. When controlling for length of stay, on days participants used drugs, their self-reported suicidal ideation will increase.
    1. This relationship will be moderated by BPD symptom severity such that patients with higher BPD symptom severity scores will have greater increases in suicidal ideation on the days they report drug use.
  3. The days patients report drug use will be followed by days with increased suicidal ideation when controlling for length of stay.
    1. This relationship will be moderated by BPD symptom severity such that patients with high BPD symptom severity scores will see greater increases in suicidal ideation on days after they report drug use.

Method

Participants.

Participants included 47 individuals from a community mental health clinic in the Southeastern U.S. that provided a DBT adherent partial hospital program and intensive outpatient program. The sample was predominately white (N = 40), females (N = 38), with an average age of 36.04 (SD = 11.40). Some participants stepped down from the partial hospital setting into an intensive outpatient setting, while others were discharged to an outpatient provider. Eight individuals were diagnosed with SUD, and four had an official BPD diagnosis. Only one individual was officially diagnosed with both a SUD and BPD. The average length of stay within the sample was 68 days (SD = 45.85) and ranged from 22 to 232 program days.

Materials.

Baseline BPD Symptom Severity.

Patients completed the Borderline Symptom List-23 (BSL-23; Bohus et al., 2009) during their first treatment day. The BSL-23 is a well validated 23-item questionnaire used to measure BPD symptom severity, with higher scores indicating more severe BPD symptoms.

DBT Diary Cards

The diary card included questions asking patients to rate their suicidal ideation on a scale of 0 to 10 and whether they used illicit substances or not. Patients’ use of illicit substances was coded as “yes” or “no”; obtaining a quantity measure of substances via self-report was difficult as participants did not know the dosage and exact weight of their illicit substance use. In terms of suicidal ideation, patients responded to 2,306 out of a possible 3,243 days, achieving a response rate of 71%.

Procedure

An institutional review board at a local university approved the study (#19-0005). Patients gave informed consent for their de-identified data to be used in research during their intake into the clinic. Patients completed the BSL-23 during their orientation to the program on their first treatment day. Patients then completed the rest of their treatment, filling out diary cards each treatment day. Patients did not receive any experimental manipulation in their treatment and were not randomly assigned to their treatment group. The partial hospital and intensive outpatient programs are DBT adherent programs; meeting the five modes of DBT as set forth by Marsha Linehan (1993) where individuals attending the program have access to skills groups, individual DBT therapists, skill coaching via coaching phone, case management, and all therapist working within the programs belonged to a DBT consultation team. All therapists underwent DBT training provided by intensively trained and DBT board certified clinicians at the community clinic. The partial hospital program met for four hours, five days per week. Some patients stepped down from the partial hospital program into an intensive outpatient program. Patients in the intensive outpatient program met for three hours a day, three days per week. Participant diary cards were only collected if the individual began in the partial hospital program. Diary cards were collected and included in analyses until the individual was discharged entirely from the community mental health clinic. For a more in-depth description of these programs, please consult prior publications (Lothes et al., 2021, Mochrie et al., 2020).

Data Analysis

Multilevel modeling procedures (Raudenbush et al., 1995; Raudenbush & Bryk, 2002) were used to account for the nested structure of the data. To decrease the impact of individual-level differences on level-1 estimates, the daily substance use variable (level-1 predictor) was person-centered (Nezlek, 2011). Person centering of a binary predictor variable is recommended to best approximate the within cluster intercept and related variance in the outcome (Enders & Tofighi, 2007). Additionally, BPD symptom severity at treatment entry (level-2 variable) and length of stay in programs (level-2 covariate) were grand-mean centered (Nezlek, 2011). As part of the third hypothesis, we continued to lag drug use by one day until the drug use was no longer significant in the models. For example, we examined the effects of drug use on SI two days after drug use. In this model, we entered two-day lagged drug use (level-1 predictor), one-day lagged drug use (level-1 covariate), length of stay (level-2 covariate), and BPD symptom severity (level-2 predictor) into the model. Lastly, we probed the cross-level interactions on models where both BPD symptom severity and the previous day’s drug use were significant. In the case of a significant interaction effect, we substituted grand-mean centered BPD symptom severity for plus and minus 1 SD-centered BPD symptom severity. Centering in this way allowed us to test the simple slopes of previous day drug use on suicidal ideation at plus and minus 1 SD of BPD symptom severity. To conduct the analyses, we used the lme4 (Bates et al., 2015) package in R, which accounts for missing data through maximum likelihood estimation. Our data and R code can be found at the following link: https://osf.io/mecya/?view_only=304542dfca234d8cbb2be822c91ccc83.

Results

Results from Materials.

In the study sample, the BSL-23 achieved good reliability (Cronbach’s α = 0.93). Overall, the sample achieved a mean BSL-23 score of 55.28 (SD = 18.76), indicating on average our participants had a high severity of BPD symptoms (Kleindienst et al., 2020). Overall, patients reported 157 days of illicit substance use (M = 3.34, SD = 9.00). Of those 157 days, patients reported cannabis use on 124 days and did not report the type of substance on 33 days. No other illicit drug use other than cannabis were reported on the patient diary cards. Additionally, out of a possible 491 weeks, the community clinic conducted urinalysis tests on 86 weeks. In all, 23 tests were positive for cannabis, two were positive for benzodiazepines, and three were positive for amphetamines.

To examine the relationship between BPD symptom severity, same-day drug use, and suicidal ideation, we entered same-day drug use (level-1 predictor), BPD symptom severity (level-2 predictor), and length of stay (level-2 covariate) into the model. The results indicated a main effect of same-day substance use (β = 0.422, t = 2.015, p = 0.044) and BPD symptom severity (β = 0.034, t = 2.431, p = 0.015) but not length of stay (β = 0.009, t = 1.505, p = 0.132). Next, we added the cross-level interaction between same-day drug use and BPD symptom severity into the model. The results did not indicate a significant interaction between same day drug use and BPD symptom severity (β = 0.015, t = 1.274, p = 0.203).

Next, we examined the relationship between the previous day’s drug use, BPD symptom severity, and self-reported SI. We entered previous day drug use (level-1 predictor), BPD symptom severity (level-2 predictor), and length of stay (level-2 covariate) into the model. The results indicated a main effect of previous day drug use (β = 0.689, t = 3.128, p = 0.002) and BPD symptom severity (β = 0.035, t = 2.455, p = 0.014) but not length of stay (β = 0.009, t = 1.530, p = 0.126). Next, we added the cross-level interaction between the previous day’s drug use and BPD symptom severity into the model. The results of the cross-level interaction between previous day substance use and BPD symptom severity approached significance (β = 0.023, t = 1.899, p = 0.058).

To examine whether the relationship between previous day substance use and suicidal ideation is most robust for those with sample high BPD symptom severity, we substituted grand mean centered BPD severity for sample low (−1SD) centered and sample high (+1SD) centered BPD symptom severity in separate models. In these models, the main effect of previous day substance use provides the simple slope of previous day substance use for individuals at sample low and sample high BPD symptom severity. In the model examining the relationship between previous day drug use and SI at low BPD symptom severity, previous day drug use did not achieve significance (β = 0.208, t = 0.618, p = 0.537). However, the relationship between previous day drug use and suicidal ideation at high BPD symptom severity did achieve significance (β = 1.099, t = 3.565, p < 0.001).

Lastly, we examined the potential for longer-lasting effects of drug use on suicidal ideation. First, we entered two-day lagged drug use (level-1 predictor), previous day drug use (level-1 covariate), BPD symptom severity (level-2 predictor), and length of stay (level-2 covariate) into the model. The results indicated significant main effects of previous day drug use (β = 0.676 t = 2.782, p = 0.005), BPD symptom severity (β = 0.036, t = 2.504, p = 0.012), and two-day lagged drug use (β = 0.681, t = 2.758, p = 0.006). We then entered the interaction effect between two-day lagged drug use and BPD symptom severity. The results did not indicate a significant interaction (β = 0.008, t = 0.566, p = 0.571). We also entered a model with three-day lagged drug use (level-1 predictor), two-day lagged drug use (level-1 covariate), previous day drug use (level-1 covariate), BPD symptom severity (level-2 predictor), and length of stay (level-2 covariate). The results did not indicate a significant main effect of three-day lagged drug use (β = 0.446, t = 1.666, p = 0.096).

Discussion

Our results indicated a significant relationship between same, previous day, and two-day lagged drug use and suicidal ideation. Additionally, we found that BPD symptom severity at intake moderated the relationship between previous day drug use and suicidal ideation. Specifically, as BPD symptom severity increased, so did the strength of the relationship between previous day drug use and suicidal ideation. The effects of drug use on suicidal ideation also continued for two days after the initial use of illicit substances. However, the two-day continued effects of drug use on suicidal ideation did not interact with BPD symptom severity. Thus, the slow return to baseline hypotheses were only partially supported.

Of note is the proportion of positive urinalysis tests and self-reported drug use attributed to cannabis. Cannabis is not legal for medicinal or recreational purposes in the state the data was collected. The tested models aimed to examine a broad range of self-reported drug use. However, our results are likely more indicative of the effects of cannabis use on suicidal ideation within our clinical sample and may not generalize to other substance use.

More states within the U.S. are legalizing cannabis for recreational and medicinal use. The increased availability of cannabis and the use of substances as an emotion regulation strategy (Axelrod et al., 2011) could have unforeseen consequences for patients in a DBT setting, particularly among those with BPD. Specifically, our data suggest that there may be a link between cannabis use and suicidal ideation in the day-to-day lives of patients receiving DBT treatment. These results fit with recent trends linking a relationship between cannabis use, depression, suicidal ideation, having a suicide plan, and suicide attempts (Han et al., 2021). The relationship between cannabis use and suicidal ideation could become increasingly challenging for clinicians as attitudes towards cannabis are trending positive (Carliner et al., 2017) with the increasing legality of it across the United States.

Additionally, DBT clinicians examining diary cards and administering chain analyses may not notice a pattern between substance use and suicidal ideation in the days following substance use. Chain analyses are typically focused on the events immediately preceding the behavior that is being targeted. While chain analyses do examine potential vulnerability factors that could contribute to the targeted behavior, it is unlikely that clinicians would ask about substance or cannabis use two days before the behavioral event that prompted the chain. Based on the present study results, it may be useful for DBT therapists to be mindful of cannabis use as a vulnerability factor up to two days before increased suicidal ideation and conduct a chain analysis that focuses on the consequences of cannabis use.

Limitations

The present study was conducted at a single site in a state that does not have legalized medicinal or recreational cannabis. Therefore, our generalizability is limited by the small number of participants in a single geographic region. The region the data was collected also suffers from frequent hurricanes, two of which impacted the data collection during the study. A patient could have missed treatment days for multiple reasons, including being out of town due to holidays or other family functions. Of note, diary card information was also collected during two major hurricanes, which likely contributed to a decrease in the response rate. During these times, the clinic shut down, and some patients may have opted to leave town for an extended time.

Additionally, due to the legal status of cannabis in the state, it could be that the individuals that use cannabis have additional factors related to suicidal ideation, such as shame stemming from purchasing an illegal drug. Thus, our analyses do not account for whether the effects of substance use on suicidal ideation could be accounted for other variables, such as increased negative affect.

Another study limitation is the measures used to examine suicidal ideation and substance use. The DBT diary card uses a single item per day to assess suicidal ideation on a scale from 0 to 10 and a single item for drug use coded as a binary variable. Single item measures cannot be examined for internal consistency, limiting our analyses’ accuracy. Additionally, a single item for drug use limited us from understanding the relationship between the quantity of the drug used and the subsequent effects on suicidal ideation. Lastly, our models did not account for the change in BPD symptoms severity over the course of treatment, as our measure for BPD symptoms severity was collected at the beginning of treatment.

Future Directions

While the present study has limitations, it is one of the first to examine the daily relationship between drug use and suicidal ideation in a group of individuals receiving DBT adherent treatment. Future studies are warranted to more closely examine the relationship between drug use and suicide behaviors in the day-to-day lives of individuals and individuals with mental health disorders that put them at a higher risk for completed suicide. Particularly, future studies examining the relationship between daily substance use and other suicide behaviors (e.g., suicide planning) would be particularly helpful to disentangle the relationship between BPD, substance use, and suicide behaviors. These studies should focus on using validated scales and methods to examine suicidal and the quantity and frequency of substance use. Studies focusing on suicidal ideation and substance use would be beneficial if conducted within treatment settings administering DBT.

Conclusion

Overall, the present study aimed to examine the relationship between a broad range of substance use and suicidal ideation in a clinical sample. The sample primarily endorsed using cannabis. Cannabis is increasingly becoming a legal (at the state level) substance in the United States and the use of cannabis may also come with increases in suicidal ideation for individuals already at risk due to other comorbid disorders. The present study raises important considerations for DBT clinicians that work with populations with comorbid BPD and substance use. Particularly for clinicians to be aware of cannabis and other substance use in the days preceding an event that prompts a chain analysis, and consider discussing ways to repair, correct, and overcorrect cannabis use.

Funding Statement:

Matison McCool was supported in part by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health [AA018108]. The content is the sole responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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