Personality Disorder Services in NHS Highland: Challenges and
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Personality Disorder Services in NHS Highland: Challenges and Developments Dr Tim Agnew, Consultant Psychiatrist and Lead in NHS Highland Personality Disorder Service.
Overview
NHS Highland Services available as of 2009 Challenges Recent developments Future developments Questions
NHS Highland
41% of landmass of Scotland 33,000km² Only 6% of Scottish population (300 000) Two thirds in very low population densities Biggest centre of population Inverness (40 000) Difficult terrain Limited infrastructure
NHS Highland
4 Community Health Partnerships (CHPs) Services for North, Mid and South-East Highland CHPs Argyll and Bute CHP has its own major process of service redesign ongoing including psychological therapy services
Situation in 2009 in 3 Northern CHPs
Specific services for Borderline PD Generic services for all other PDs
Specific services for BPD
Structured admission program Dialectical Behaviour Therapy (DBT) CBT-BPD (Davidson)
Services for all PDs
Clinical psychology Primary care CMHTs In-patient services Liaison psychiatry
DBT service
DBT has been mainstay for BPD First group of therapists trained in 2006 Three groups trained to date (24 in total) 18 therapists amounting to 2 WTE Anyone meeting DSM IV criteria offered 1 year of DBT Very intensive
DBT service Problems with increasing waiting times Limited capacity, large referral numbers Situation unsustainable
DBT Service
BPD is a polymorphic disorder 256 varieties Severity was measured using number of DSM IV criteria DBT is over-intensive intervention for some
DBT service
Evidence suggests DBT is best at reducing parasuicidal behaviour and hospital admissions Stage 1 DBT – behavioural stabilisation Decided to prioritise on basis of:
parasuicidal behaviour psychiatric hospital admissions
DBT service
Allows quicker response for these individuals What to offer everyone else? Some patients seemed to prefer skills groups to individual work Skills group work twice as efficient in terms of therapist time as individual work
What about a skills group standalone?
Oft-quoted (but unpublished) study by Linehan does not suppport utility of skills training alone Some emerging evidence for DBT-ST (Soler, 2009)
Single centre, randomised, two-group trial DBT-ST or “Standard Group Therapy” for 13 weeks 63 patients Seemed to have an impact on affective symptoms No effect on parasuicidal behaviour
Other considerations
STEPPS (Systems Training for Emotional Predictability and Problem Solving) RCT All DBT therapists already trained to deliver skills groups Existing supervision system (DBT consult groups) Theoretical coherence
Drawbacks
No really robust evidence for approach No individual therapy
Formulation Skills generalisation Validation Dialectics Problem solving
No individual therapist
4 individual sessions before group work
Extra module (Foundation module)
Crisis plan Written formulation Psycho-education Validation, dialectics, problem solving
3 final group sessions
Agenda set by group
No RCT evidence
Service-based evidence Same regular assessment/ outcome tools as full DBT Pilot only Re-evaluate after one run-through
Skills Training Program (STP)
Starts next week 33 week run (plus 4 weeks individual work) Closed group of 8 patients 2 skills trainers Good feedback for individual sessions
Personality Disorder Service
Name change from DBT service PDS offers:
DBT STP CBT-BPD
Still only for people with BPD as primary presentation Allows flexibility to develop further
Life after DBT
Some feedback from individuals that there is a service gap after completion of DBT What is available after finishing DBT?
User-led “graduate” group not active Possible DBT skills informed “graduate” group, CPN input
Some people wish to move away from this type of service after completing DBT
Other perspectives
Recent visit by Tom Mullen Multidisciplinary and service user attendance Stakeholders meeting planned OTs keen to adapt Journey program locally Multidisciplinary visit to Leeds being planned Volunteering Highland
Future
PDS to expand educational role to CMHTs, primary care and in-patient wards PDS to offer consultation service to CMHTs, in-patient wards Expand CBT-PD provision within PDS Specific provision in the localities Training in other approaches
Don’t forget
Administration
Overhaul of referral process Overhaul assessment process Revised prioritisation Standardised admin guidance New computerised database
Main challenges
Too much geography Not enough therapists with not enough time Increasing referrals
Main developments
Revision of prioritising factors Skills Training Program Database and admin overhaul
Thank you
Questions or comments?
Reference
Soler J. et al, Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: A 3-month randomised controlled clinical trial. Behaviour Research and Therapy 47 (2009) 353-358 Blum et al., Systems Training for Emotional Predictability and Problem Solving (STEPPS) for Outpatients With Borderline Personality Disorder A Randomized Controlled Trial and 1-Year Follow-Up. American Journal of Psychiatry 165 (4) 468 -- Am J Psychiatry K. Davidson, J. Norrie, P. Tyrer, A. Gumley, P. Tata and H. Murray et al., The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial, Journal of Personality Disorders 20 (2006), pp. 450–465. M.M. Linehan, H.E. Amstrong, A. Suarez, D. Allmon and H.L. Heard, Cognitive-behavioral treatment of chronically parasuicidal borderline patients, Archives of General Psychiatry 48 (1991), pp. 1060–1064
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